Walking back to happiness

This article originally appeared in HIV Treatment Update, a newsletter published by NAM between 1992 and 2013.
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People with HIV, as endless studies attest, have higher rates of depression, addictions and other mental health problems than the general population. But even if we aren’t depressed, could we be happier? Gus Cairns investigates ‘positive psychology’, the study of happiness, which aims to transform ‘can’t complain’ into ‘on top of the world’.

People with HIV, as endless studies attest, have higher rates of depression, addictions and other mental health problems than the general population. But even if we aren’t depressed, could we be happier? Gus Cairns investigates ‘positive psychology’, the study of happiness, which aims to transform ‘can’t complain’ into ‘on top of the world’.

Dr Martin Seligman started his career as an expert on human misery. As a psychologist he had uncovered the phenomenon of ‘learned helplessness’ – thought to be at the core of depression.

Glossary

psychology

The study of the way people think, behave and interact. Psychological therapies are based on talking and working with people to understand the causes of mental health problems and develop strategies to deal with them. Psychologists have specialist training but are not medical doctors.

depression

A mental health problem causing long-lasting low mood that interferes with everyday life.

fatigue

Tiredness, often severe (exhaustion).

 

palliative care

Palliative care improves quality of life by taking a holistic approach, addressing pain, physical symptoms, psychological, social and spiritual needs. It can be provided at any stage, not only at the end of life.

stigma

Social attitudes that suggest that having a particular illness or being in a particular situation is something to be ashamed of. Stigma can be questioned and challenged.

However, he became disillusioned with his studies. He doesn’t disavow the strides that have been made in treating mental health problems, but he believes the focus on mental illness had costs.1,2 Firstly, it sometimes turned people into victims. Concentrating on the link between bad childhood experiences and subsequent problems could give the impression that one inevitably followed from the other. And it didn’t take on improving the abilities of people with average lives and talent.

The father of positive psychology, Abraham Maslow, noted that “Freud supplied us the sick half of psychology and we must now fill it out with the healthy half”.3  Seligman and others have investigated what happiness consists of and how people can increase their chances of feeling good.

What is happiness?

Psychologists tend not to talk a lot about happiness per se, but rather its components. There is general agreement that happiness/living well/good fortune is a very complex idea, not a simple, single emotional state.

The ‘happiness psychologists’ divide the state of happiness up into three main domains of experience:

Pleasure might be the experience you first think of when you think of happiness. Joy, sensuality, hilarity, orgasm: these are the sensations people crave and pursue. But pleasure fades; it is primarily caused by new sensations, and the brain simply won’t respond to the same thing with the same rush the second time round.

If people’s only understanding of happiness is pleasure, they’ll need more each time to get the same rush. Compulsively pursuing pleasure and nothing but is usually bad for the health and will eventually contribute to negative emotions.

Flow is a term invented by the Hungarian psychologist Mihaly Csikszentmihalyi4 to mean focused attention. Csikszentmihalyi describes it as "being completely involved in an activity for its own sake... Your whole being is involved, and you're using your skills to the utmost."

Depending on your personality and strengths, this could entail reading, writing or teaching, dancing, making love, having a rewarding conversation with a friend, rock climbing, closing a business deal...

Flow is not happiness in itself, any more than pleasure is. But studies have found that people who are able to achieve this state frequently are happier and healthier than people who find it difficult to focus attention.

Unlike pleasure, flow involves challenge: the task being accomplished must be sufficiently hard for its elegant performance to be a reward. Nonetheless, if your only way of achieving happiness is to achieve flow, you may have found something precious, but you may also have found a lonely obsession.

The third component of happiness is meaning. This is the factor that provides a framework around the other components of happiness and makes them permanent.

Meaning, as psychologists define it, is not mystical and not a set of external truths like a religion or a philosophy.

Abraham Maslow devised a pyramid or hierarchy of human needs: starting with physiological needs (food, shelter); then physical security and the feeling of safety; the need to feel loved and to belong; the need for self-esteem (feeling of value in the world). Finally, if a person has achieved all these needs, there is ‘self-actualisation’. This is only possible if all the other needs have been met: Maslow defined it as “a person's need to be and do that which the person was ‘born to do’.” Not everyone gets to this point.

Maslow’s self-actualisers:

  •  were all ‘reality-centred’, down to earth and could instinctively differentiate fraudulent from genuine.
  • were ‘problem-centred’, focusing on external problems rather than being self-absorbed.
  • typically had a few, close personal relationships rather than a large number of shallow friendships.
  • tended to be spontaneous and creative, not usually bound too strictly by social conventions.

These people achieved, permanently or intermittently, a sense that their lives had meaning and that they were living that meaning.

How do you measure happiness?

Even though you can’t measure emotions with a blood test (yet), you can measure other people’s feelings by asking them how they feel. If you ask one person how they feel, you have to take their word for it. But if you ask 10,000 people a set of identical questions about whether they are anxious or depressed or satisfied, and score the answers, and compare how reliably the answers tally with other indicators of mood and health – you can end up with some reliable instruments.

Some of these, like the Beck Depression Inventory, have been in use for nearly 50 years.5 Most list a series of multiple-choice statements and ask people which one tallies with “very like me” or “not at all like me” – for example:

0.      I do not feel sad.

1.      I feel sad.

2.      I am sad all the time and I can't snap out of it.

3.      I am so sad or unhappy that I can't stand it.

Psychologists Peter Hills and Michael Argyle at Oxford University tried to encapsulate happiness in a 29-item questionnaire.6 This is a series of statements ranging from “I am intensely interested in other people” to “I feel that I am not especially in control of my life”.

Self-assessed happiness, however, is a tricky thing to measure because it’s so tempting for people, however honest they are, to adjust their answers towards the way they would like to feel, or think the psychologist would like them to feel. One way to solve this problem is to try to ask more objective questions about a person’s life in a so-called quality-of-life survey.

Quality of life

‘Quality of life’, a vast area of social and psychological science, started off as a means of establishing the effect of physical illness, and now measures much more. Quality-of-life surveys are used by economic planners to predict market trends (happy people buy more) and by social scientists to measure the impact of unemployment.

Dr Richard Harding is Senior Lecturer in Palliative Care at King’s College London. He says: “Quality-of-life studies have been central to the study of the personal experience of chronic illness, especially in cancer care.

“However, even in cancer care, it was soon realised that people’s quality of life often did not only relate to their state of physical health. Modern questionnaires measure a lot more than just physical health. They measure patients’ physical, functional, cognitive, emotional, spiritual and social abilities, and their degree of burden from a range of physical and psychological symptoms such as fatigue, pain, and nausea, in order to determine their global health-related quality of life.”

Harding advocates for the same degree of investigation into the patient’s self-reported experience of disease to determine the quality of life of people with HIV.

“The assessment and care of people with HIV is arguably often focused on viral suppression and immune response, plus perhaps an assessment of whether they are depressed because that affects adherence, to the exclusion of understanding the patient experience of disease and their quality of life”, he says. “Although there has been some post-HAART research into HIV patients’ quality of life,7 it needs to be an essential component of clinical practice.”

Harding has applied quality-of-life methodology to studies of people with HIV, with sobering results.8 Many symptoms experienced by people with HIV went unreported because, he told the AIDS Impact Conference two years ago, “clinical encounters with HIV-positive patients concentrate on their CD4 count and viral load”.

I disagree with...arguing whether the glass is half-full or half-empty. The point is it's the same glass and we can help people recognise real resources.

Tom Warnecke, Vice-chair of UKCP

Harding and colleagues conducted two studies. In one, in collaboration with Professor Lorraine Sherr of University College London Royal Free Medical School, 904 patients, attending five HIV clinics in London and Brighton, were interviewed. In the second, with GMFA, 347 gay men with HIV were interviewed across the UK. He used a quality-of-life questionnaire called the Memorial Symptom Assessment Scale Short Form. Rates of as high as 80% were found for symptoms like ‘feeling worried’ and ‘feeling sad’. Harding commented that both the prevalence and the self-rated severity of these symptoms were comparable to findings from a study of patients with advanced cancer.

The GMFA study asked broader questions about treatment and health optimism, the respondents’ current job and financial status, future life plans, what their own expectations of their future health were and what they felt would support them to maintain good mental and physical health.

A number of themes emerged:

  • Less exclusive focus in healthcare appointments on CD4 and viral load and more on treatment side-effects and mental wellbeing.
  • More guidance on maintaining general health.
  • To quote a respondent: “A sympathetic partner who isn’t scared of having a positive boyfriend”.
  • Advice on rebuilding careers, including “employment outside the HIV field”.
  • More emphasis and publicity about combating anti-HIV stigma and discrimination.

“Messages from clinicians that patients can now expect to have a ‘near-normal life expectancy’ are not reflected in our respondents’ expectations”, Harding commented at the time.

Quality-of-life measuring instruments of an extremely sophisticated nature now exist, starting to match the complex definition of happiness. For instance, the World Health Organization’s quality-of-life assessment tool WHOQOL9 asks people about six ‘domains’ or areas of their life:

  • Physical health (e.g. energy and fatigue, pain, sleep quality)
  • Psychological health (e.g. body image, feelings, self-esteem, memory and concentration)
  • Independence (e.g. mobility, capacity to work)
  • Social relationships (friendships, social support, sex)
  • Environment (e.g. money, personal safety)
  • Religion, spirituality and personal beliefs.

All in all, a long way from defining a person’s health by their CD4 count.

How to be happier

Martin Seligman believes that we can improve our quality of life and happiness.

He does think there is a genetic component to happiness. However, there are a number of external influences on happiness that can be altered; and there are subjective changes we can make to improve satisfaction with our life.

Predictors of happiness

What are the determinants of happiness? Studies that relate subjective happiness to different people in different countries worldwide report some surprising results:

Health and happiness have remarkably little to do with each other. People with HIV may be an exception to this, but their high unhappiness scores, it appears, are not caused by HIV: they may have a lot more to do with other factors, such as social isolation.

Income matters a bit. On average, inhabitants of poor countries tend to be a little less happy than those of rich countries. But there are huge variations. Economic growth may be as important as absolute income. When it comes to individuals, very poor people tend to be less happy, but everyone on or above a basic level of income is as happy as each other; millionaires are only marginally happier than those who are comfortably off.

Age has an effect. Older people are generally calmer and more satisfied with their lives than young people. They don’t hit the heights of happiness so much, but neither do they plumb the depths of despair.

Race, education and climate on their own make no difference.

So what does make a difference? There are two consistent predictors of greater happiness:

Religion. Having a religion or strong spiritual belief is strongly associated with happiness, and the more fundamentalist the religion, the happier the individual person. Some may find this disconcerting, but religion could be seen as one example of the kind of cause that gives meaning to a life.

Marriage and friendship. The strongest predictor of happiness is a successful marriage or ‘primary’ relationship. Equally, one of the strongest predictors of unhappiness is an unhappy marriage. Happy people also tend to have a richer social life. Both of these could be because happy people tend to attract mates and friends, rather than because marriage or friendship as such make you happy.

If you can’t change your immediate circumstances, though, can you change your feelings? Positive psychologists feel that the answer is yes.

They believe there are two ways to do this.

Live in the present. People can try to pack their lives with pleasure, flow and meaning, but still be unhappy because they are preoccupied either with regretting the past or fearing the future.

Seligman recommends developing conscious gratitude to the people who have helped you along the way and conscious forgiveness of those who may have hurt you, in order to look back on the past with contentment and serenity, rather than bitterness and remorse.

When it comes to predicting the future, pessimists tend to generalise bad events (“I didn’t get the job because I’m bad at job applications” while attributing positive events to chance (“I was lucky, really, I only got the job because that other candidate dropped out”). Optimists do the reverse: for them, bad events are specific (“They were unclear about the presentation they wanted”) and good ones are general (“I got the job because I really know the field well”). It is possible to retune one’s habitual responses to avoid catastrophising bad events and minimising good ones.

Play to your strengths. By doing some anthropological research across a number of cultures, psychologist Katherine Dahlsgaard10 was able to generate a list of six key virtues, and 24 sub-characteristics, that all cultures, at all epochs of history, appear to have valued.

These were:

Wisdom and knowledge (curiosity, love of learning, critical thinking, originality, social intelligence, perspective)

Courage (bravery, perseverance, honesty)

Humanity and love (kindness and generosity, loving and receiving love)

Justice (fairness, teamwork, leadership)

Temperance (self-control, discretion, modesty)

Transcendence and spirituality (appreciation of beauty, gratitude, optimism, sense of purpose, forgiveness, playfulness and humour, enthusiasm).

A psychological questionnaire helps people measure how strong they are in a particular area (for instance, “I am always able to see the big picture” for perspective). This helps people understand their particular strengths and play to them, and to try harder in areas where they’re weaker.

Psychologists now aim to compile a diagnostic manual of mental strengths to pit against the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders), used to diagnose mental illness.

Is positive psychology useful?

I asked a couple of practising psychotherapists in the UK what they thought of the positive psychology movement.

Tom Warnecke is vice-chair of the United Kingdom Council for Psychotherapy (UKCP). “The field can be accused of prescribing rose-tinted glasses for everyone,” he says. “But on the other hand a lot of people in mental distress fail to appreciate the assets and strengths they do have. For instance a client of mine was in despair because her professional life was falling apart. But she had a good supportive relationship and was just taking it for granted. She wasn’t making best use of it because she ‘didn’t want to be a burden’.

“I disagree with putting a spin on things or arguing whether the glass is half-full or half-empty. The point is it’s the same glass, and we can help people recognise real resources.”

James Antrican is UKCP’s chair, and more sceptical. “I see positive psychology as a little like a placebo,” he says. “It can help people feel better enough that they can start to make real changes.

“But everyone needs a bit of pathology too: gloominess is sometimes the very thing that pushes us into making useful readjustments. I agree we should celebrate our strengths; but maybe sometimes we should use our discontent as a strength too.”

To read more

Want to know if you’re truly happy or a natural grump? Want to know what your strongest virtues are and your weakest points? For more on positive psychology, including a number of diagnostic questionnaires, go to: www.authentichappiness.sas.upenn.edu.

Where to get help

The best way to find a supportive psychotherapist is often through personal recommendation.

Alternatively you could contact a local HIV organisation for information on services they provide, or contacts they may have who provide counselling and psychotherapy.

London services are often funded to provide counselling to people in particular boroughs, so it’s a good idea to check with them directly to see if they can provide services to you directly, or if they can put you in touch with therapists they work with. You could start with the Terrence Higgins Trust (info.counselling@tht.org.uk), PACE (info@pacehealth.org.uk – for lesbian, gay, bisexual and transsexual people) and Shaka Services (info@shakaservices.org.uk – for African, African Caribbean and Asian people).

All counsellors and psychotherapists should be accredited by one of the two UK psychotherapy organisations. Check the ‘find a therapist’ buttons at UKCP (www.psychotherapy.org.uk) or BACP (www.bacp.co.uk).

Want to learn more? In London the City Lit (www.citylit.ac.uk) offers an introductory course on “Positive psychology and happiness” in December.

Dr Martin Seligman is in London to give a free lecture on Positive Psychology on Tuesday, 29 September from 5.30pm - 6.30pm at Friends House, 173 Euston Road, London NW1 2BJ. All welcome.

References

1. Seligman MEP. Authentic Happiness London, Nicholas Brealey Publishing, 2003.

2. For a video of Martin Seligman talking about positive psychology see www.youtube.com/watch?v=9FBxfd7DL3E.

3. Maslow AH. Toward a Psychology of Being. Princeton, NJ, Van Nostrand Reinhold, 1998.

4. Csikszentmihalyi, M. Flow: The Psychology of Optimal Experience. New York: Harper and Row, 1990.

5. Beck AT et al. An inventory for measuring depression. Arch. Gen. Psychiatry 4: 561–71. 1961.

6. Hills P, Argyle M. The Oxford Happiness Questionnaire: a compact scale for the measurement of psychological well-being. Personality and Individual Differences 33(7):1073-1082. 2002. Take the test at www.meaningandhappiness.com.

7. See for instance Grierson J, Bartos M. No pill for happiness: social correlates of mental health and psychological distress among HIV positive people. 13th International AIDS Conference, Durban, abstract no. ThPpD1457, 2000.

8. Harding R, Sherr L et al. The prevalence, burden and correlates of physical and psychological symptoms in HIV outpatient clinics. 8th AIDS Impact Conference, Marseilles, abstract 222, 2007.

9. See http://depts.washington.edu/yqol/docs/WHOQOL_Info.pdf

10. Dahlsgaard K et al. Shared virtue : The convergence of valued human strengths across culture and history. Review of General Psychology 9(3):203-213. 2006.