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Abstract

The fields of positive psychology, health behavior change, and lifestyle medicine have evolved significantly over the past two decades, fostering a growing synergy within health care. Positive psychology, rooted in the philosophy of ancient Greeks, emphasizes flourishing, resilience, and well-being, while lifestyle medicine, involving the pillars of health—diet, exercise, sleep, social support, mind–body connection and substance avoidance—focuses on patient-prioritized action for better health. This paper reviews and explores the intersections of these fields, highlighting positive psychological interventions (PPIs) such as gratitude, savoring, and meaning-making as pathways to enhance health outcomes. Empirical evidence underscores the potential of PPIs, mediated through lifestyle medicine approaches, to influence physical and mental health. Yet challenges in research methodology, systemic barriers, and individual reluctance remain. By integrating robust psychological constructs with positive psychology and lifestyle medicine strategies, this review advocates for a unified approach that urges a system transition from sickness to flourishing, emphasizing both personal and systemic pathways to well-being.

Keywords

lifestyle medicine positive psychology health behavior change health coaching

“The onset and development of the COVID-19 pandemic led to innovative thinking about service delivery in many domains.”

Introduction

The fields of positive psychology and health behavior change have been frequent companions for over two decades. Together they undergird the practice of lifestyle medicine. The third (and 13th) president of the American Psychological Association (APA), William James, delivered a presidential address in 1904 observing that some individuals could use their own resources fully and others could not.¹ He proposed that additional research was required, examining the limits of human energy and the mechanism of stimulation of this energy, for optimal use.² By the middle of the 20th century, the American psychologist Gordon Allport (1897–1967), argued that the influences of the Greek philosophers Plato (c427–348 BCE) and Aristotle (384–32 BCE) were evident in all western thought. Also in 1954, the American psychologist Abraham Maslow³ (1908-1970) published the work Motivation and Personality. The final chapter of this work was titled “Toward a Positive Psychology.” In this chapter Maslow expressed some frustration with the preoccupation of psychology with mental illness and the shortcomings of people. Maslow believed that the field of humanistic psychology (emergent during the 1950s) ought to study healthy and creative individuals and should examine the lives of those who were self-actualized.⁴ He wrote:

The science of psychology has been far more successful on the negative than on the positive side; it has revealed to us much about man’s shortcomings, his illnesses, his sins, but little about his potentialities, his virtues, his achievable aspirations, or his full psychological height. It is as if psychology had voluntarily restricted itself to only half its rightful jurisdiction, and that the darker, meaner half.³

By the end of the 20th century, Martin Seligman (1942-) had become the 107^th president of the APA, just over a century since William James held the role. With his colleague Christopher Peterson, Seligman revived interest in the field of positive psychology, arguably dormant for much of the 50 years prior. Their work Character Strengths and Virtues: A handbook and classification⁵ was conceived as a counterpoint to the prevailing Diagnostic and Statistical Manual of Mental Disorders [in its 4th edition at the time].⁶ Seligman⁷ went on to develop the well-known model of positive psychology—PERMA—representing positive emotion, engagement, relationships, meaning and accomplishment. Along with work by Mihalyi Czikszentmihalyi (1934–2021) on Flow,⁸ Seligman’s model has become a prevailing model in the field of positive psychology.

Thus, the origins of positive psychology go back at least 120 years, and, arguably 2400 years. Through all this time, the field of behavioral change study has developed along its own pathways.

In the modern era, behavior change can be considered to have developed from the work of Watson⁹ and Skinner.¹⁰ This led to the classic “conditioning” experiments, including those of Pavlov.¹¹ The field of cybernetics began to emerge in the late 1940s, originally the work of Wiener,¹² which included concepts now considered central to behavioral change including feedback loops, self-regulation, adaptation and information processing.

Cognitive approaches to behavioral change soon followed with the work of Beck¹³ and these were in turn developed into cognitive-behavioral approaches by Ellis¹⁴ and Meichenbaum.¹⁵ Cognitive Behavioral Therapy (CBT) has since undergone several evolutions and now embraces approaches such as Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT) and Mindfulness-Based Cognitive Therapy (MBCT).¹⁶

This brief examination of the family tree of behavioral change must also acknowledge the work of Kurt Lewin’s Field Theory which led to the influential 3-step model for change: unfreezing current habits, making the desired change, and then refreezing the new behavior to stabilize it.¹⁷ In parallel, family therapy has made substantial contributions through a range of models, including Structural, Strategic and Milan Systemic.¹⁸ In the 21^st century, the field of behavioral change has become so vast and disparate, that there is not uniform agreement even on the number of extant theories and models. Some estimates range from 82¹⁹ through 117.²⁰

The intersection of behavioral change theories and positive psychology has drawn increasing attention over the past two decades. This intersection is represented by a focus on life-affirming behaviors, on well-being rather than diagnosis, focusing on strength and success as much as dysfunction and disorder, generating positive emotional states as much as addressing negative states, developing psychological and emotional capital as much as re-building damaged psyche, and bringing the experience of flow,⁸ self-compassion,²¹ and purpose²² to the heart of health and well-being.

This review aims to examine principles and practices in the intersecting fields of positive psychology and behavior change, in addition to the empirical evidence for their use and application in the context of lifestyle medicine. Challenges, limitations and future directions for this emergent field of study will be identified.

Theoretical Foundations

A challenge in the development of robust, testable ideas of positive psychology and behavioral change has been managing the imprecision of many everyday words common to the fields—well-being, happiness, strengths, resilience, vision, goal, support, autonomy and more. While these words have common meanings, they can be widely interpreted which makes the construction of theoretical foundations challenging.

Notwithstanding, there has been considerable work undertaken by several pioneers in both fields to establish a theoretical base, which will be reviewed here. The following review is not exhaustive; however, it is intended to highlight key contributions to the development of positive psychology.

The acronym “PERMA” was devised by Seligman⁷ to represent five conceptual pillars of positive psychology—Positive affect, Engagement, Relationship, Meaning and Accomplishment. Seligman uses this framework to describe the necessary and sufficient conditions for human flourishing—to experience positive affect daily (such as joy and gratitude); to be able to fully immerse oneself in an absorbing activity regularly; to be deeply bound in nurturing and meaningful relationships; to align one’s activities with a sense of greater meaning and purpose; and experience the sense of achievement that comes from using one’s strengths and talents to accomplish a meaningful goal. With his colleague Peterson, Seligman also endeavored to empirically conceptualize a framework for human virtue, consisting of Wisdom and knowledge; Courage; Humanity; Justice; Temperance and Transcendence.⁵

Working contemporaneously, the psychologist Csikszentmihalyi observed and named the concept of “flow,”⁸ colloquially “being in the zone” or working with energized focus. This concept forms the basis of “engagement” in Seligman’s PERMA model.

Other psychologists have added significant empirical and conceptual ideas to the field of positive psychology. Barbara Fredrickson’s²³ “Broaden and Build” theory conceptualizes the utility of positive emotions by seeking to explain how their existence provided, and provides, an evolutionary advantage. Lyubormirsky’s work on happiness argues that the experience of happiness can lead to many desirable life outcomes such as success and resilience. She has also established that while approximately half of the happiness experienced by humans is heritable, 40% is determined by the actions that we take (with the remaining 10% attributable to external events).²⁴ It is worth noting that while those possessed of a more pessimistic disposition might feel deflated that fully 50% of their own happiness is pre-determined, those possessed of an optimistic outlook may relish the idea that they can directly control nearly 50% of their own experience of happiness.

Ed Diener (affectionately known as “Dr. Happiness”) undertook significant research on subjective well-being. His work furthered psychological research exploring the factors that contribute to human happiness and flourishing rather than simply addressing disorder and dysfunction. One of his landmark contributions was the development of reliable and valid measures for assessing subjective well-being. He introduced the Satisfaction with Life Scale,²⁵ a widely used tool to evaluate individuals’ cognitive judgments of their overall life satisfaction. By emphasizing subjective experiences, Diener demonstrated that happiness is not only about material wealth or external circumstances but is deeply influenced by individual perceptions and evaluations.

Diener also conducted extensive cross-cultural studies, revealing that while cultural values influence what contributes to happiness, the desire for well-being is universal. His research underscored the importance of positive emotions, relationships, and a sense of purpose as key determinants of life satisfaction across diverse populations.^26,27

Todd Kashdan has contributed significantly to the development of key concepts in positive psychology, particularly focusing on psychological flexibility, curiosity, and the role of meaning in life. Psychological flexibility²⁸ refers to one’s ability to adapt to changing circumstances, manage emotions effectively, and align actions with personal values. This concept has become central in understanding resilience and mental health, highlighting that well-being is not the absence of discomfort but the ability to manage it effectively. Kashdan has demonstrated that curiosity supports exploration, learning, and connection, which enables individuals to engage with their environment in meaningful ways, contributing to happiness, positive relationships, and even physical health.^29-31 Notably, Kashdan has also been critical of the scientific basis of hedonic and eudaimonic happiness, as well as the “happiness-as-an-objective” narrative within positive psychology³² and has argued that embracing discomfort and negative experiences is essential for growth, creativity, and authentic happiness.³³

A complete examination of behavioral change theories is not possible. There exist a vast number of theories—Kwasnicka, Dombrowski, White and Sniehotta²⁰ estimated 116 at the time of publication in 2016. Many represent small variants of previously described models—for example, the Theory of Reasoned Action was subsequently developed into the Theory of Planned Behavior.³⁴ However, there are several theories that have significantly influenced practices of health coaching and health behavior change. With its five stages, the Transtheoretical Model of Change³⁵ seeks to normalize different degrees of readiness to change, thereby enabling practitioners to nuance their approaches to patients and clients to ensure that the patients’ desires, needs and concerns are addressed. Social Cognitive Theory³⁶ drew attention to the concept of self-efficacy in behavioral change—an individual’s reasoned belief in their capacity to engage in modification of behavior. Similarly, Self-Determination Theory³⁷ highlighted the importance of autonomy or choice in behavioral change, alongside the need for competence (related to self-efficacy) and the importance of social connection to others. Nudging or “Nudge Theory” has also been exploited in health behavior change^38,39 in an effort to facilitate health affirming choices for individuals.

The intersection of positive psychology and health behavior change theories lies in the ability of a positive psychology approach to focus on and affirm strengths, resources, capacities; to foster with the patient a sense of hope and optimism about a desired future state; to support patients to identify motivators that are supported by their own values; to note and build upon upward cycles of behavior and emotion; to develop strategies for resilience—based on learning—in order to overcomes barriers and setbacks; to place the patient at the center of their own choices; to harness social connection and support in the pursuit of challenging change and to focus less on moving away from sickness and languishing, and more on moving towards health and flourishing.

Positive Psychological Interventions (PPIs) in Health Behavior Change (HBC)

There are several types of PPI used in health behavior change, which can be broadly considered in seven categories—savoring, gratitude, kindness, empathy, optimism, strengths, and meaning.⁴⁰ Some seminal studies using these interventions include the “counting blessings” study of Emmons and McCullough,⁴¹ resulting in key findings across several study conditions including study participants reporting fewer physical symptoms, feeling generally better about their lives feeling more optimistic about the upcoming week, experiencing more alertness, enthusiasm, determination, attentiveness, and energy and feeling more connected to others. A similar intervention designed by Seligman (albeit with a limited effect duration) is the Gratitude Visit—writing, and delivering in person, a letter of gratitude to someone who had meaningfully influenced the life of the letter-writer.⁴² Another PPI—savoring interventions—may focus on the past, present or future. An intervention developed by Bryant, Smart and King⁴³ involved participants using souvenirs (such as photographs) to bring to mind pleasant reminiscences of a past event. Participants reported increased frequency of happy emotions when compared to the control group of the study. Simply adopting a more positive attentional focus to the present moment (e.g., by consciously noting pleasurable features of one’s immediate environment) has been shown to increase subjective happiness.^44,45 The practice of positive anticipation of future possibilities has also been linked to increases in happiness (when compared to efforts to imagine neutral or negative future events).⁴⁶ In a significant piece of research, Steger, Kashdan and Oishi⁴⁷ demonstrated that “doing good”—performing actions which were eudaimonically motivated—may be a pathway through which people create a sense of meaning and satisfaction in their lives.

Positive Psychology Interventions (PPIs) have been extensively studied for their effects on various health behaviors, demonstrating benefits in both physical and mental health domains.

For example, PPIs such as gratitude journaling and mindfulness practices, have been associated with improved physical health. In their systematic review, Paddon and Kampman⁴⁸ reported that from 74 studies involving 10 000 participants and spanning 24 years of research, positive psychology interventions showed a higher proportion of significant than non-significant effects on outcomes, across several domains of psychological well-being and physical health. In a similar review spanning published research from 1999 to 2022, Kukucska, Whitehall, Shorter, Howlett, Wyld and Chater⁴⁹ found that mindfulness-based interventions for police officers led to a significant improvement on several dimensions of psychological well-being such as depression, anxiety, negative affect and perceived quality of life, and some limited improvement on physical health domains including alcohol consumption.

PPIs have also shown promise in reducing stress in populations with diagnosed clinical disorders, including cancers, cardiac disorders, diabetes, brain injuries, and chronic pain. In one systematic review, statistically significant effect sizes were observed for both depression and anxiety in clinical populations.⁵⁰ This is significant because much of the published literature on PPIs focuses on non-clinical populations.

Through the use of a systematic review and the development of a logic model, Kletter, Harris and Brown⁵¹ concluded that PPIs can increase subjective well-being and interactional capacities in health care workers, thus supporting organizational improvement in health care systems and settings.

Although not strictly a PPI, a fascinating research design used biofeedback and smartwatches to provide feedback about predicted happiness. Participants who received feedback about their measurements modified their behavior and were 16% happier and 26% more active than the control group not receiving any such feedback.⁵²

Furthermore, the biological pathways for such effects are beginning to be studied. In a 2023 study,⁵³ researchers examined the effect of positive and negative emotional states on pro-inflammatory and anti-viral genes in adolescents. Increases in the strength of positive emotion were significantly associated with lower pro-inflammatory and anti-viral gene expression.

However, although much research suggests that PPIs may provide a useful pathway to improving health behaviors and health outcomes, other research suggests more work needs to be done to understand mechanisms of action; to compare PPIs with other interventions—psychological or otherwise; and to ensure that effect sizes are meaningful.

A recent systematic review suggests that there is currently insufficient evidence to support a claim that PPIs are superior to other interventions to improve symptoms of depression and increase happiness⁵⁴; however, there is support for the inclusion of PPIs as part of a suite of responses to treating depression. The current state of research on the impact of PPIs on health behavior change specifically is similar. In their systematic review, Feig, Madva, Millstein, Zambrano, Amonoo, Longley, Okoro, Huffman, Celano and Hoeppner⁵⁵ identified 27 studies examining PPIs for health behavior change. The most commonly targeted behavior was physical activity, followed by medication use, diet and smoking. Most examined studies found health behavior improvements; however, the review authors note that study methodologies were variable, and many studies were pilot studies. Therefore, further research is needed to establish the effective components of PPIs. In a “mega-analysis” published soon after, Carr, Finneran, Boyd, Shirey, Canning, Stafford, Lyons, Cullen, Prendergast and Corbett⁵⁶ reported that the 198 meta-analyses selected for their review showed a significant small to medium effect size on well-being, quality of life, strengths, anxiety, depression and stress.

While the research on PPIs and their impact on both physical and psychological dimensions of health has grown significantly, more research is needed to understand mechanisms of effect and to clarify the methods to ensure that effect sizes are meaningful.

The Psychological Constructs Underpinning PPIs and HBC

Although Positive Psychology as a discipline seeks to extend our understanding of psychological science and treatment, many PPIs are founded on existing and long-standing psychological theories and constructs. These constructs are significant in that they likely also contribute to the initiation and maintenance of behavioral change, the development of resilience and adaptation and the capacity for creativity to overcome challenges, setbacks and obstacles.

Self-Efficacy

Self-efficacy is a concept grounded in Bandura’s³⁶ Social Cognitive Theory. This theory describes an individual’s belief in their ability to do what is necessary to achieve specific outcomes which are meaningful to them. As a means of understanding action steps, this theory is useful in understanding the processes of initiating and maintaining health behavior change, as it predicts the extent to which an individual feels competent and confident to start and continue actions.

When individuals have high levels self-efficacy, they are more likely to approach challenges with confidence, set attainable goals, and persist in the face of difficulties. Some find this counter-intuitive—shouldn’t high levels of self-efficacy mean that structures such as goals, and the need to persist or show grit are unnecessary? On the contrary, self-efficacy appears to fuel efforts, likely through the mechanism of underlying confidence and belief in oneself.

As part of his theory, Bandura also outlined four pathways to the development of self-efficacy. Mastery experiences or simply a performance accomplishment is the first of these. The application of this construct reminds those working in the field of lifestyle medicine and PPIs to support patients to set achievable goals and to observe and amplify small successes. These cumulative successes build a sense of mastery. The second pathway is vicarious (modeled) experience. Such experience can be gained by observing the way in which a role model accomplishes something meaningful (e.g., a parent or close friend); however, vicarious experience can also be observed internally. If an individual has experienced success in one area of their life, then they can likely observe and extract from that the factors leading to success and apply them elsewhere. In the practice of lifestyle medicine, this enables clinicians to support patients to apply successes from one pillar of health to others. The third pathway to self-efficacy is verbal persuasion. When a person can identify and eliminate negative self-talk or reframe a perceived failure as an opportunity to learn and grow, they are harnessing this pathway. Finally, the mind–body connection or emotional and physiological state while performing an action can support or inhibit the development of efficacy. If an individual can learn to recognize and manage signs of stress and regulate emotion; if they can identify the physiological factor that support success (e.g. being rested and well-nourished); if they can reframe physiological arousal such as increased heart-rate from fear to excitement, then they are harnessing this pathway to self-efficacy. Understanding and applying these mechanisms is critical to the success of PPIs.

Hope and Optimism

Snyder’s Hope Theory⁵⁷ has three constructs: goals, pathways and agency. Snyder argues that hope consists of the ability to design pathways to goals and the motivation to engage in agency-thinking to follow those pathways. He, and colleagues, have also argued that hope correlates positively with physical and psychological health outcomes.⁵⁸ Optimism reflects an underlying belief that good things will happen. Significant conceptual exploration and research into optimism has been conducted by Scheier, Carver and Bridges.⁵⁹ Optimism and hope appear to be different but related constructs, which correlate positively with psychological well-being (including happiness) and negatively with indicators of illness.⁶⁰ The ability of the clinician to harness and develop hope and optimism for the patient appears to support mechanisms of action for PPIs and to potentiate health outcomes. In a 2021 review, Duncan, Jaini and Hellman⁶¹ argued that a hope-informed approach is crucial in the therapeutic encounter in medicine and that patients and clinicians alike benefit from such an approach. For example, hope appears to play a role in moderating the effect of depressed mood on suicidality⁶² and the agency component of hope theory supported primary care clinicians to achieve important patient care outcomes, despite having to navigate personal and organizational obstacles.⁶³

Resilience

Resilience, like many concepts in psychology, has a common language meaning in addition to more formal definitions. While there are a number of these formal definitions, it is generally considered to be the capacity to recover from adversity, conflict or failure; although Luthans⁶⁴ notes that it may also include the capacity to move forward in response to perceived positive events such as increased responsibility. Resilience enables individuals to navigate challenges and setbacks even if there might be transient fluctuations in motivation, commitment or momentum.

Individuals who have developed their capacity for resilience are more likely to successfully respond to plateaus in behavioral change or even reversals (such as bodyweight increasing while endeavoring to reduce it). Positive psychology interventions appear to be able to influence resilience, through interventions such as mindfulness training, fostering a growth mindset and cognitive re-framing.⁶⁵ In a circularly causal manner, those with higher levels of resilience are more likely to be able to persist with implementing strategies and interventions to improve their health and well-being.

Positive Affect

The experience of positive affect—pleasant emotions such as love, joy and satisfaction—have been shown to influence on health behaviors. Individuals who experience such emotional states appear more likely to engage in preventive health behaviors and positive health behaviors such as exercise.⁶⁶ Much of the research in this area also comes from Fredrickson²³ and her “Broaden and Build” theory. PPIs capitalize on this factor by seeking to amplify positive emotional states through activities such as gratitude journaling and savoring.

Integrating Psychological Constructs into Practice

A key perspective here is that positive psychology does not stand apart from the rest of the discipline of psychology, nor does it seek to supersede or even subvert other fields of study in psychology. Rather, it seeks to harness existing psychological theories and concepts, by understanding and enhancing factors which can support human flourishing, whole person health, and happiness. As a result, positive psychology remains grounded in robust theoretical foundations in psychology.

While the lifestyle medicine clinician need not have a detailed and deep understanding of these concepts, recognizing that many psychological constructs underpin the success and progress a patient might experience is important. As such, PPIs should not be applied simply as a “cookie-cutter” solution to a patient. Nor should the pursuit of superficial positivity dominate clinical interventions. Rather, integrating an understanding of key ideas such as self-efficacy, hope, resilience and optimism with carefully designed interventions which have been shown to support robust health and well-being is key to positive outcomes for individuals. Such an approach aligns well with the ethos of lifestyle medicine, capitalizing on the synergies between psychological and physical health to ensure that health is focused both on adding years to life and life to years. Recent studies suggest that positive psychology interventions show significant promise in this way. In one randomized pilot study,⁶⁷ participants with coronary artery disease were assigned to one of three PPIs (based on the work of three well-established PP researchers) or a wait-list control. The results showed that participants in all the PPI groups had significantly greater improvements in happiness and hope, and reduced depression compared to controls.

In a novel study, the effect of combining a PP intervention with a Motivational Interviewing (MI) intervention on physical activity—and other—outcomes for Type II Diabetes (T2DM) was examined.⁶⁸ Described as a “proof-of-concept” study, 12 adults with T2DM completed PP exercises involving gratitude, strengths and acts of kindness, alongside goal-setting activities based on MI. The intervention was reportedly well-accepted, with nearly 80% of planned sessions completed. At 16 weeks, significant improvements with large effect sizes were observed in self-reported physical activity, dietary adherence and general diabetes-related self-care. The study authors noted that the effect size MI alone tends to be modest in T2DM. Therefore, the addition of a PP component appears to be more powerful than MI alone.

In the last several years specifically, several studies have demonstrated the efficacy of PP interventions in community-based settings including rural-dwelling adults in Ghana with depression,⁶⁹ older African-American women with chronic pain,⁷⁰ adherence to health behaviors in patients with heart failure,⁷¹ and increases in physical activity among people with metabolic syndrome.⁷²

These, and many other, studies demonstrate the acceptability and efficacy not only of PPIs, but PPIs combined with existing therapies. When such an approach is considered in the context of lifestyle medicine—which aims to actively promote flourishing, thriving and high-levels of well-being (in contrast to a simple absence of disease or illness)—a blueprint for health care begins to emerge. Bohlmeijer and Westerhof⁷³ have already proposed the “Model for Sustainable Mental Health,” arguing that the integration of PPIs into mental health care, either as primary treatments or combination therapies offers a more balanced and person-centered approach to care.

Health Coaching

As an approach to supporting health behavior change, health coaching has grown considerably over the past two decades. Synergistically with lifestyle medicine and positive psychology, health coaching is collaborative, and patient centered. It aims not to treat disease directly, but to support patients to foster their own personally meaningful good health and well-being. This supports the goal of lifestyle medicine—to prevent, treat and reverse where possible, chronic disease.⁷⁴ Significant progress has been made in establishing clear practice standards with the establishment of the National Board for Health and Wellness Coaching (NBHWC). There are now thousands of NBHWC certified health coaches, mostly in the USA, and nearly 150 NBHWC approved training programs.⁷⁵

Health coaches harness many of the psychological and positive psychology principles described above, including self-efficacy and resilience. They use evidence-based interventions including goal-setting and motivational interviewing,⁷⁶ and they are trained to personalize support, making best use of the strengths, supports and successes that an individual has.

The evidence for the efficacy and impact of health coaching is now substantial. Across two publications,^77,78 the authors reviewed over 300 published papers on health coaching, concluding that the results supported health coaching as a promising intervention for chronic disease management. This perspective was further confirmed by a rapid systematic review (largely using the same studies) to examine durability of intervention. The authors found that 25 of the 28 reviewed studies demonstrated partially or fully sustained outcomes as a result of health and wellness coaching.⁷⁹

Challenges and Limitations in Integrating Lifestyle Medicine and Positive Psychology

Systemic Barriers

Lifestyle medicine practice has made significant progress in moving away from a disease-care or disease-management system. Positive psychology practices and their application through health coaching are therefore a congruent extension of this; however, much of health care delivery remains disease focused, and therefore there exists a misalignment of positive psychology and such a reactive approach to health. Perhaps one of the most significant systemic constraints is that of timed consultations. In one study, Irving, Neves, Dambha-Miller, Oishi, Tagashira, Verho and Holden,⁸⁰ reported consultation times across 67 countries varying from 48 seconds to 22.5 minutes. They noted that in 18 of the surveyed countries, representing about 50% of the global population, patients spent 5 minutes or less with their primary care physician. Such an interaction is clearly not conducive to the collaborative and reflective conversations which underpin much of the success of PPIs. Additionally, fragmented care models (likely linked to the predominant disease-care approach) tend to silo primary care, lifestyle medicine, health coaching, mental health and other specialist services. This impedes the integration of positive psychology interventions into routine patient care.^81,82

Individual Barriers

Patients and clinicians alike may be reluctant to incorporate lifestyle medicine and psychological practices into health care. Such reluctance may have several prequelae including lack of awareness and knowledge of the role that psychological well-being plays in physical well-being, minimal training in delivery of interventions, or a lack of understanding that such an approach can significantly influence health outcomes. While shifts in this lack of understanding are beginning to be evident in lifestyle medicine trained and certified physicians, those without such training may still diminish the importance of several lifestyle factors in their practice.⁸³ Some progress has already been made in considering implementation strategies for positive psychology and lifestyle medicine in health care.⁸⁴ Furthermore, a shift for patients to seeing themselves as “producers of health”⁸⁵ rather than consumers of health care may be necessary to fully respond to this barrier. Furthermore, individual cultural beliefs and practices influence perspectives on health care. For example, in some African American and South Asian populations, the presence of traits such as fatalism, collectivism and traditional gender roles correlates negatively with dietary adherence.⁸⁶

Limitations in Research

A major challenge in most social science research (incorporating positive psychology) continues to be the use of WEIRD populations—Western, Educated, Industrialized, Rich, Democratic—as samples. One study revealed that, between 2014 and 2017, 95% of all samples were drawn from this population.⁸⁷ Some progress has been made here. For example, there exists a growing body of research on positive psychology interventions in Arab populations.^88-90 A second limitation on many published studies is the absence of knowledge about durability of effect. Much research publishes “end-of-study” outcomes. Again, some progress has been made here, including by Durgante, Tomasi, Pedroso de Lima and Dell’Aglio⁹¹ who have tackled the WEIRD limitation head-on and researched long term effects of a PPI on Brazilian retirees.

Future Directions and Research Opportunities

The integration of lifestyle medicine and positive psychology into health care systems offer enormous potential for system-level change up to and including an inversion of health care spending to strongly favor prevention and well-being, rather than treatment of end-stage disease. In order to continue the incorporation of these approaches into health care delivery, several opportunities for development and further research exist. There is vast scope for the development of novel, evidence-based interventions. Much of the important work in establishing the validity of LM and PP has been done. What is required is further implementation research to understand how best to address factors as diverse as underserved populations, different age demographics and specific health conditions. Such research must also focus on scalability and sustainability of PPIs and LM in diverse contexts including primary care, specialist care, residential care, education settings and workplaces.

Such novel interventions could combine positive psychology, lifestyle medicine and behavior change in clinical settings. For example, there is already a large body of research supporting the efficacy of the “Best Possible Self” PPI,⁹² including in clinical settings. Primary Care settings typically involve waiting before seeing a physician. In 2020, the average wait time in US clinics was reported to be 18 minutes.⁹³ A 10-12 minute pre-consultation structured PPI module could be implemented by a practice nurse. This would first involve inviting the patient to respond to a Best Possible Self writing prompt. Following this, using an appreciative approach,⁹⁴ the practice nurse would invite the patient to reflect on “something you’ve done recently that used a strength you have,” or “something you’ve done that boosted your mood, even if only a little.” Finally, a small lifestyle action could then be paired with the patient’s identified strength(s) and provided as a printed “prescription.” Such an intervention could examine feasibility, patient engagement and impact on commitment to lifestyle medicine recommendations.

The onset and development of the COVID-19 pandemic led to innovative thinking about service delivery in many domains. The scope for continued development of digital PPIs exists.⁹⁵ In fact, with 90% of the US population owning a smartphone and 95% saying they use the internet,^96,97 to not intensively research digital PPIs and digital lifestyle medicine delivery would seem to be a major oversight, akin to not using the national road system to deliver goods. Finally, a focus on underserved and vulnerable populations must be prioritized. Not only does this avoid falling into the WEIRD trap yet again, it aligns strongly with what is arguably one of the most important of the World Health Organization’s Sustainable Development Goals—that of Universal Health Coverage.⁹⁸ Only when all have the opportunity to thrive and flourish will the true principles behind lifestyle medicine and positive psychology come to life.

Conclusion

The integration of positive psychology and lifestyle medicine represents a transformative approach in health care delivery, offering evidence-based strategies for improving physical and mental health. While research underscores the efficacy of positive psychological interventions in fostering resilience, motivation, and well-being, challenges such as structural barriers, cultural diversity, and unanswered questions about the durability of intervention effects must be addressed. Future efforts should prioritize inclusive research, scalability, and the development of innovative delivery models, particularly digital platforms, to ensure accessibility for diverse populations. By harnessing the synergies between positive psychology and lifestyle medicine, health care can shift from disease management to a more holistic, preventative, and patient-prioritized paradigm, ultimately advancing the goal of flourishing health for all.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Simon Metchette Matthews

References

Froh

. The history of positive psychology: truth be told. NYS Psychol. 2004;16(3):18-20.

Rathunde

. Toward a psychology of optimal human functioning: what positive psychology can learn from the “experiential turns” of James, Dewey, and Maslow. J Humanist Psychol. 2001;41(1):135-153.

Maslow

. Motivation and Personality. New York, NY: Harper Brothers; 1954:411.

Moss

. The roots and genealogy of humanistic psychology. In: Schneider

Bugenthal

JFT

Pierson

, eds. The Handbook of Humanistic Psychology: Leading Edges in Theory, Research, and Practice. London: Sage Publications Inc; 2001:5-20.

Peterson

Seligman

. Character Strengths and Virtues: A Handbook and Classification. 1st ed. Washington: American Psychological Association; 2004.

American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington: American Psychological Association; 2004.

Seligman

. Flourish: A Visionary New Understanding of Happiness and well-being. New York: Free Press; 2011.

Czikszentmihalyi

. Flow: The Psychology of Optimal Experience. New York: Harper & Row; 1990.

Watson

. Behaviorism. London: Routledge; 2017.

10.

Skinner

. Operant behavior. Am Psychol. 1963;18(8):503-515.

11.

Rescorla

. Behavioral studies of Pavlovian conditioning. Annu Rev Neurosci. 1988;11:329-352.

12.

Cybernetics

. Bulletin of the American academy of arts and sciences. 1950;3(7):2-4.

13.

Beck

. Thinking and depression: I. Idiosyncratic content and cognitive distortions. Arch Gen Psychiatry. 1963;9(4):324-333.

14.

Ellis

. Rational Emotive Behavior Therapy: It Works for me-it Can Work for You. New York: Prometheus Books; 2010.

15.

Meichenbaum

. Cognitive behaviour modification. Cogn Behav Ther. 1977;6(4):185-192.

16.

Jennings

Apsche

. The evolution of a fundamentally mindfulness-based treatment methodology: from DBT and ACT to MDT and beyond. Int J Behav Consult Ther (IJBCT). 2014;9(2):1-3.

17.

Burnes

. The origins of Lewin’s three-step model of change. J Appl Behav Sci. 2020;56(1):32-59.

18.

Walker

. Family therapy: concepts, models and applications. Nurs Times. 1995;91(38):36-37.

19.

Davis

Campbell

Hildon

Hobbs

Michie

. Theories of behaviour and behaviour change across the social and behavioural sciences: a scoping review. Health Psychol Rev. 2015;9(3):323-344.

20.

Kwasnicka

Dombrowski

White

Sniehotta

. Theoretical explanations for maintenance of behaviour change: a systematic review of behaviour theories. Health Psychol Rev. 2016;10(3):277-296.

21.

Neff

. Self-compassion and psychological well-being. Constr Hum Sci. 2004;9(2):27.

22.

Frankl

. Man's Search for Meaning. New York: Simon & Schuster; 1985.

23.

Fredrickson

. The broaden–and–build theory of positive emotions. Philos Trans R Soc Lond B Biol Sci. 2004;359(1449):1367-1377.

24.

Lyubomirsky

Sheldon

Schkade

. Pursuing happiness: the architecture of sustainable change. Rev Gen Psychol. 2005;9(2):111-131.

25.

Diener

Emmons

Larsen

Griffin

. The satisfaction with life scale. J Pers Assess. 1985;49(1):71-75.

26.

Diener

. Cross-cultural correlates of life satisfaction and self-esteem. J Pers Soc Psychol. 1995;68(4):653-663.

27.

Diener

Oishi

Lucas

. Personality, culture, and subjective well-being: emotional and cognitive evaluations of life. Annu Rev Psychol. 2003;54(1):403-425.

28.

Kashdan

Rottenberg

. Psychological flexibility as a fundamental aspect of health. Clin Psychol Rev. 2010;30(7):865-878.

29.

Kashdan

Fincham

. Facilitating curiosity: a social and self‐regulatory perspective for scientifically based interventions. In: Positive Psychology in Practice. Hoboken: John Wiley & Sons, Inc; 2004:482-503.

30.

Kashdan

Rose

Fincham

. Curiosity and exploration: facilitating positive subjective experiences and personal growth opportunities. J Pers Assess. 2004;82(3):291-305.

31.

Kashdan

Steger

. Curiosity and pathways to well-being and meaning in life: traits, states, and everyday behaviors. Motiv Emot. 2007;31:159-173.

32.

Kashdan

Biswas-Diener

King

. Reconsidering happiness: the costs of distinguishing between hedonics and eudaimonia. J Posit Psychol. 2008;3(4):219-233.

33.

Kashdan

Biswas-Diener

. The Upside of Your Dark Side: Why Being Your Whole self--not Just Your Good self--drives Success and Fulfillment. New York, NY: Penguin; 2015.

34.

Ajzen

Fishbein

. Theory of reasoned action-Theory of planned behavior. Florida: University of South Florida; 1988;67-98.

35.

DiClemente

Prochaska

. The Transtheoretical Approach: Crossing the Traditional Boundaries of Therapy. Homewood IL, USA: Dow Jones Irwin; 1984.

36.

Bandura

. Social foundations of thought and action. Englewood Cliffs, NJ: Prentice-Hall, Inc.; 1986:23-28.

37.

Ryan

Deci

. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol. 2000;55(1):68-78.

38.

Ledderer

Kjær

Madsen

Busch

Fage-Butler

. Nudging in public health lifestyle interventions: a systematic literature review and metasynthesis. Health Educ Behav. 2020;47(5):749-764.

39.

Matthews

. Nudging as a support for behavioral change in lifestyle medicine. Am J Lifestyle Med. 2023;17(6):775-781.

40.

Parks

Titova

. Positive psychological interventions: an overview. In: The Wiley Handbook of Positive Clinical Psychology. Hoboken, New Jersey, U.S: Wiley; 2016:305-320.

41.

Emmons

McCullough

. Counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life. J Pers Soc Psychol. 2003;84(2):377-389.

42.

Seligman

Steen

Park

Peterson

. Positive psychology progress: empirical validation of interventions. Am Psychol. 2005;60(5):410-421.

43.

Bryant

Smart

King

. Using the past to enhance the present: boosting happiness through positive reminiscence. J Happiness Stud. 2005;6:227-260.

44.

Bryant

Veroff

. Savoring: A New Model of Positive Experience. London: Psychology Press; 2017.

45.

Jose

Lim

Bryant

. Does savoring increase happiness? A daily diary study. J Posit Psychol. 2012;7(3):176-187.

46.

Quoidbach

Wood

Hansenne

. Back to the future: the effect of daily practice of mental time travel into the future on happiness and anxiety. J Posit Psychol. 2009;4(5):349-355.

47.

Steger

Kashdan

Oishi

. Being good by doing good: daily eudaimonic activity and well-being. J Res Pers. 2008;42(1):22-42.

48.

Paddon

Kampman

. A new lens on improving physical health with psychological interventions: a systematic review. Journal of Happiness and Health. 2023;3(2):49-92.

49.

Kukucska

Whitehall

Shorter

Howlett

Wyld

Chater

. A systematic review of positive psychology interventions (PPIs) to improve the health behaviours, psychological wellbeing and/or physical health of police staff. J Police Crim Psychol. 2023;38(3):728-742.

50.

Chakhssi

Kraiss

Sommers-Spijkerman

Bohlmeijer

. The effect of positive psychology interventions on well-being and distress in clinical samples with psychiatric or somatic disorders: a systematic review and meta-analysis. BMC Psychiatry. 2018;18:1-17.

51.

Kletter

Harris

Brown

. Outcomes, mechanisms and contextual factors of positive psychology interventions for health workers: a systematic review of global evidence. Hum Resour Health. 2021;19:1-14.

52.

Roessler

Gloor

. Measuring happiness increases happiness. J Comput Soc Sci. 2021;4(1):123-146.

53.

Rahal

Tashjian

Karan

, et al. Positive and negative emotion are associated with generalized transcriptional activation in immune cells. Psychoneuroendocrinology. 2023;153:106103.

54.

Lim

Tierney

. The effectiveness of positive psychology interventions for promoting well-being of adults experiencing depression compared to other active psychological treatments: a systematic review and meta-analysis. J Happiness Stud. 2023;24(1):249-273.

55.

Feig

Madva

Millstein

, et al. Can positive psychological interventions improve health behaviors? A systematic review of the literature. Prev Med. 2022;163:107214.

56.

Carr

Finneran

Boyd

, et al. The evidence-base for positive psychology interventions: a mega-analysis of meta-analyses. J Posit Psychol. 2024;19(2):191-205.

57.

Snyder

. Hope theory: rainbows in the mind. Psychol Inq. 2002;13(4):249-275.

58.

Snyder

Irving

Anderson

. Hope and health. Handbook of social and clinical psychology: The health perspective. 1991;162(1):285-305.

59.

Scheier

Carver

Bridges

. Optimism, pessimism, and psychological well-being. eds. Chang

In: Optimism & Pessimism: Implications for Theory, Research, and Practice. Washington. (pp. 189-216). American Psychological Association; 2001.

60.

Alarcon

Bowling

Khazon

. Great expectations: a meta-analytic examination of optimism and hope. Pers Indiv Differ. 2013;54(7):821-827.

61.

Duncan

Jaini

Hellman

. Positive psychology and hope as lifestyle medicine modalities in the therapeutic encounter: a narrative review. Am J Lifestyle Med. 2021;15(1):6-13.

62.

Huen

Yip

. Hope and hopelessness: the role of hope in buffering the impact of hopelessness on suicidal ideation. PLoS One. 2015;10(6):e0130073.

63.

Tennen

Cloutier

Wakefield

Hall

Brazil

. The buffering effect of hope on clinicians' behavior: a test in pediatric primary care. J Soc Clin Psychol. 2009;28(5):554-576.

64.

Luthans

. The need for and meaning of positive organizational behavior. J Organ Behav. 2002;23(6):695-706.

65.

Hulscher

. Positive Psychology Interventions to Improve Well-Being in Older Adults: A Systematic Review. Netherlands: University of Twente; 2020.

66.

Van Cappellen

Rice

Catalino

Fredrickson

. Positive affective processes underlie positive health behaviour change. Psychol Health. 2018;33(1):77-97.

67.

Nikrahan

Suarez

Asgari

, et al. Positive psychology interventions for patients with heart disease: a preliminary randomized trial. Psychosomatics. 2016;57(4):348-358.

68.

Celano

Gianangelo

Millstein

, et al. A positive psychology–motivational interviewing intervention for patients with type 2 diabetes: proof-of-Concept trial. Int J Psychiatr Med. 2019;54(2):97-114.

69.

Appiah

Wilson‐Fadiji

Schutte

Wissing

. Effects of a community‐based multicomponent positive psychology intervention on mental health of rural adults in Ghana. Appl Psychol Health Well Being. 2020;12(3):828-862.

70.

Janevic

Robinson-Lane

Courser

Brines

Hassett

. A community health worker-led positive psychology intervention for African American older adults with chronic pain. Gerontol. 2022;62(9):1369-1380.

71.

Celano

Beale

Freedman

, et al. Positive psychological constructs and health behavior adherence in heart failure: a qualitative research study. Nurs Health Sci. 2020;22(3):620-628.

72.

Millstein

Thorndike

Kim

Park

Huffman

. A community-based positive psychology group intervention to promote physical activity among people with metabolic syndrome: proof of concept results to inform a pilot randomized controlled trial protocol. Contemp Clin Trials Commun. 2020;19:100626.

73.

Bohlmeijer

Westerhof

. The model for sustainable mental health: future directions for integrating positive psychology into mental health care. Front Psychol. 2021;12:747999.

74.

ACLM . Become certified in lifestyle medicine practice. ACLM. 2025. https://lifestylemedicine.org/certification/

75.

NBHWC . What is a national board certified health and wellness coach? https://nbhwc.org/what-is-a-health-coach/. Accessed January 12, 2025.

76.

Miller

Rollnick

. Motivational Interviewing: Helping People Change and Grow. 4th ed. New York: The Guilford Press; 2023.

77.

Sforzo

Kaye

Harenberg

, et al. Compendium of health and wellness coaching: 2019 addendum. Am J Lifestyle Med. 2020;14(2):155-168.

78.

Sforzo

Kaye

Todorova

, et al. Compendium of the health and wellness coaching literature. Am J Lifestyle Med. 2018;12(6):436-447.

79.

Ahmann

Saviet

Conboy

Smith

Iachini

DeMartin

. Health and wellness coaching and sustained gains: a rapid systematic review. Am J Lifestyle Med. 2024;18(2):162-180.

80.

Irving

Neves

Dambha-Miller

, et al. International variations in primary care physician consultation time: a systematic review of 67 countries. BMJ Open. 2017;7(10):e017902.

81.

Rifkin

Fort

Patcharanarumol

Tangcharoensathien

. Primary healthcare in the time of COVID-19: breaking the silos of healthcare provision. BMJ Glob Health. 2021;6:e007721.

82.

Patel

Saxena

Lund

, et al. The lancet commission on global mental health and sustainable development. Lancet. 2018;392(10157):1553-1598.

83.

Bharati

Kovach

Bonnet

, et al. Incorporating lifestyle medicine into primary care practice: perceptions and practices of family physicians. Am J Lifestyle Med. 2023;17(5):704-716.

84.

Lianov

Fredrickson

Barron

Krishnaswami

Wallace

. Positive psychology in lifestyle medicine and health care: strategies for implementation. Am J Lifestyle Med. 2019;13(5):480-486.

85.

Fava

. Patients as health producers: the psychosomatic foundation of lifestyle medicine. Psychother Psychosom. 2023;92(2):81-86.

86.

Osokpo

Riegel

. Cultural factors influencing self-care by persons with cardiovascular disease: an integrative review. Int J Nurs Stud. 2021;116:103383.

87.

Apicella

Norenzayan

Henrich

. Beyond WEIRD: A Review of the Last Decade and a Look Ahead to the Global Laboratory of the Future. Netherlands: Elsevier; 2020:319-329.

88.

Basurrah

Di Blasi

Lambert

, et al. The effects of positive psychology interventions in Arab countries: a systematic review. Appl Psychol Health Well Being. 2023;15(2):803-821.

89.

Lambert

Warren

Schwam

Warren

. Positive psychology interventions in the United Arab Emirates: boosting wellbeing–and changing culture? Curr Psychol. 2021;42:1-14.

90.

Warren

Donaldson

Doiron

. Positive psychology research in the Middle East and North Africa. Middle East Journal of Positive Psychology. 2015;1(1):60.

91.

Durgante

Tomasi

LMB

Pedroso de Lima

Dell’Aglio

. Long-term effects and impact of a positive psychology intervention for Brazilian retirees. Curr Psychol. 2022;41(3):1504-1515.

92.

Heekerens

Eid

. Inducing positive affect and positive future expectations using the best-possible-self intervention: a systematic review and meta-analysis. J Posit Psychol. 2021;16(3):322-347.

93.

Collins

PBC

Joshua

Dinzeo

Lehrman

. Improving the waiting room experience. Fam Pract Manag. 2020;27(1):14-18.

94.

Cooperrider

Whitney

. Appreciative Inquiry: A Positive Revolution in Change. 1st ed. California: Berrett-Koehler; 2005:86.

95.

Parks

Boucher

. Positive psychological interventions (PPIs) in the age of COVID-19: on the potential impact of digital PPIs on loneliness. J Posit Psychol. 2020;15(5):569-571.

96.

Gelles-Watnick

. Americans’ Use of Mobile Technology and Home Broadband. Washington, DC, USA: Pew Research Center; 2024.

97.

Gottfried

. Americans’ Social Media Use. Washington, DC, USA: Pew Research Center; 2024.

98.

Ghebreyesus

. All roads lead to universal health coverage. Lancet Global Health. 2017;5(9):e839-e840.

Positive Psychology and Health Behavior Change in Lifestyle Medicine: A Narrative Review

Abstract

Keywords

Introduction

Theoretical Foundations

Positive Psychological Interventions (PPIs) in Health Behavior Change (HBC)

The Psychological Constructs Underpinning PPIs and HBC

Self-Efficacy

Hope and Optimism

Resilience

Positive Affect

Integrating Psychological Constructs into Practice

Health Coaching

Challenges and Limitations in Integrating Lifestyle Medicine and Positive Psychology

Systemic Barriers

Individual Barriers

Limitations in Research

Future Directions and Research Opportunities

Conclusion

Footnotes

Declaration of conflicting interests

Funding

ORCID iD

References