Positive psychology: looking back and looking forward.

\r\nCarol D. Ryff*\r\n

  • Department of Psychology, Institute on Aging, University of Wisconsin-Madison, Madison, WI, United States

Envisioning the future of positive psychology (PP) requires looking at its past. To that end, I first review prior critiques of PP to underscore that certain early problems have persisted over time. I then selectively examine recent research to illustrate progress in certain areas as well as draw attention to recurrent problems. Key among them is promulgation of poorly constructed measures of well-being and reliance on homogeneous, privileged research samples. Another concern is the commercialization of PP, which points to the need for greater oversight and quality control in profit-seeking endeavors. Looking ahead, I advocate for future science tied to contemporary challenges, particularly ever-widening inequality and the pandemic. These constitute intersecting catastrophes that need scientific attention. Such problems bring into focus “neglected negatives” that may be fueling current difficulties, including greed, indifference, and stupidity. Anger, which defies easy characterization as positive or negative, also warrants greater scientific study. Going forward I advocate for greater study of domains that likely nurture good lives and just societies – namely, participation in the arts and encounters with nature, both currently under study. Overall, my entreaty to PP is to reckon with persistent problems from its past, while striving toward a future that is societally relevant and virtuous.


I have studied psychological well-being for over 30 years ( Ryff, 1989 , 2014 , 2018 ), seeking to define its essential features as well as learn about factors that promote or undermine well-being and probe how it matters for health. I bring this past experience and expertise to thinking about positive psychology (PP), noting that I have never considered myself a positive psychologist, mostly because it has always seemed misguided to me to partition science by valence. Everything that interests me involves complex blends of good and bad things, what Rilke called the beauty and terror of life. With these ideas in mind, I reflect about the future of PP by first looking at its past to highlight what it has, or has not, contributed over the last two decades. My views represent personal observations from an outsider who, from the outset, was dubious about the point of launching the PP movement.

I begin with a look at early critiques, including my own, that distilled various concerns about the launching of PP. Some of those problems have endured, such as the failure to embrace the deeper history of psychology and related fields that have long addressed optimal human functioning. This distortion undermines the building of cumulative and coherent knowledge, while also contributes to insularity within PP. Additional past critiques, some from within PP, emphasized the need to put negative and positive experience together, as in dialectical approaches. I made similar points along the way. For this essay, I describe work outside the PP umbrella doing exactly that, drawing largely on the Midlife in the United States (MIDUS) national longitudinal study 1 , which I have led over the past two decades.

Returning to PP, on the topic of scientific progress I highlight select contributions over the past 20 years, but again underscore that most of these topics predated PP. On the downside, two notable problems are discussed: (1) poorly constructed measures of well-being and problematic findings, which contradict the claim that PP rests on solid science; and (2) widespread use of homogeneous research samples (white, well-educated, Western) in PP, thereby ignoring how race/ethnicity, socioeconomic status, and culture matter for positive human functioning. Linked to these problems is widespread pursuit of financial profit, purportedly grounded in rigorous scientific findings. Such commercialization, illustrated by products and shopping carts on websites, makes clear that PP has become a major business. Money-making, I observe, is a strange counterpoint to the recurring emphasis on character strengths and virtue. Financial gain raises additional issues of ethical oversight and quality control in what is being sold.

Going forward, PP and the human sciences in general need to address contemporary societal problems. I focus on ever-widening inequality, now compounded by the pandemic. What we know is that the suffering is not occurring equally, but is happening disproportionately among those who were already vulnerable. These difficulties bring into high relief topics that psychology has largely neglected. Among pernicious negatives of our era that may be fueling the problems we see are greed and indifference, especially among the privileged, as well as stupidity, which seems to cut across educational strata. Anger is another important contemporary emotion that defies easy characterization as positive or negative. These topics stand in marked contrast to what PP was meant to correct – namely, the preoccupation with psychopathology, weakness and damage ( Seligman and Csikszentmihalyi, 2000 ).

Looking ahead, I examine factors that may be key in nourishing good lives and just societies, such as active engagement with the arts, broadly defined. Widespread initiatives are moving in this direction, though few emphasize the critical role of the arts in understanding human suffering, which I bring into high relief. A key question is whether great literature, music, poetry, painting, and film can activate caring and compassion, particularly among the advantaged. Encounters with nature constitute another domain for nourishing good lives, while also strengthening commitments to take care for our planet. I note currently unfolding work along these lines.

Looking Back

Early critiques of positive psychology.

Most cite Seligman and Csikszentmihalyi (2000) as the definitive statement of what PP was about and why it was needed. The essay began with the authors describing what led each of them to believe that psychology as a discipline was preoccupied with “pathology, weakness, and damage” (p. 7). These assertions were remarkably at odds with extensive literatures on the positive in clinical, developmental, existential, and humanistic psychology – decades of prior work, much of which I drew on to formulate an integrative model of psychological well-being ( Ryff, 1989 ). Instead, most of the foundational exegesis was devoted to describing the 15 articles that followed. All represented longstanding programs of research on such topics as evolution, subjective well-being, optimism, self-determination, maturity, health, wisdom, creativity, and giftedness. These realms were themselves notably at odds with the assertion that psychology was preoccupied with the negative, a point strangely missed by the founders of PP.

Three years later Psychological Inquiry published a target article titled “Does the Positive Psychology Movement Have Legs?” ( Lazarus, 2003 ), followed by numerous commentaries. Ryff (2003) found fault with many aspects of the Lazarus critique (e.g., subjectivism, dimensional versus discrete models of emotion, and cross-sectional research), most of which I clarified were not problems specific to PP. On the topic of emotion, however, I argued for joint focus on negative and positive emotions because “…bad things happen to people, and the healthy response is to feel the sadness, pain, frustration, fear, disappointment, anger, or shame resulting from the adverse experience. However, good things also happen to people, and the healthy response is to feel joy, pride, love, affection, pleasure, or contentment from such experience positive experiences. Thus, the capacity for experiencing and expressing both realms of emotion is central to healthy functioning.” (p. 154).

The unsatisfactory Lazarus critique meant that the central strengths and limitations of PP had not been addressed. On the credit side of the ledger, I praised the special issue for bringing together in the same forum research programs that addressed positive, healthy, adaptive features of human functioning, but underscored that everything assembled came from longstanding programs of prior research. Nothing meant to exemplify this new movement was new : “This myopia about past and present is damaging not for the superficial reason of taking credit for advances already contributed by others but for more serious problems of increasing the likelihood of reinventing wheels, both conceptual and empirical, such that science fails to be incremental and cumulative” ( Ryff, 2003 , p. 155).

To illustrate historical precursors, I drew on Coan’s (1977) Hero, Artist, Sage, or Saint. It described centuries of scholarly efforts to depict the more noble attributes of humankind, such as the ancient Greeks’ emphasis on reason and rationality, St. Augustine’s emphasis on close contact with the divine, the Renaissance emphasis on creative self-expression, and the poets and philosophers of the Enlightenment. I also noted James (1902/1958) eloquent writings about healthy-mindedness juxtaposed with the sick soul, along with others who formulated individuation ( Jung, 1933 ; Von Franz, 1964 ), ego development ( Erikson, 1959 ), maturity ( Allport, 1961 ), self-actualization ( Maslow, 1968 ), the fully functioning person ( Rogers, 1961 ), and positive mental health ( Jahoda, 1958 ).

My own work on well-being ( Ryff, 1989 ) had drawn extensively on these sources, while Ryan and Deci’s (2001) review of hedonic and eudaimonic well-being distilled other philosophical precursors. I noted other contributions on positive topics, such as studies of ego development ( Loevinger, 1976 ), adult personality development ( Helson and Srivastava, 2001 ), generativity ( McAdams and St. Aubin, 1998 ), the human quest for meaning ( Wong and Fry, 1998 ), effective coping and self-regulation ( Carver and Scheier, 1998 ), and proliferating research on human resilience and post-traumatic growth ( Tedeschi et al., 1998 ; Luthar et al., 2000 ). My point: “Taken as a whole, this impressive array of current and past research on the upside of human condition leaves one wondering what all the fanfare has been about. Positive psychology is alive and well, and it most assuredly has legs, which stretch back into the distant history of the discipline. It is only from particular vantage points, such as clinical or abnormal psychology that the positive focus constitutes a novelty. For other subfields, especially life-span developmental and personality psychology, there has always been a concern for healthy, optimal human functioning. Perhaps the main message in the positive psychology initiative is thus how deeply entrenched and divided are the subfields within which psychologists work” ( Ryff, 2003 , p. 157). Unfortunately, this failure to consider relevant wider literatures has persisted through time. More than a decade later, the positive in PP was defined entirely from “Three Foundational Documents” ( Pawelski, 2016 ), which included Seligman (1999) and Seligman and Csikszentmihalyi (2000) , and an unpublished paper from a 2000 conference in Akumal, Mexico organized by Seligman. Effectively, all meanings of the positive in PP emanated from its founder, thus more deeply entrenching the historical myopia.

My 2003 essay concluded with a call for psychology to organize its house of strengths and to be circumspect about generating new assessments: “Those who would add to the many tools already available need to be clear that they are not contributing to clutter – that is, generating instruments that are redundant with extant measures.” (p. 157). The concern went unheeded, as I detail later.

Calls to Put Negative and Positive Realms Together

Wong (2011) advocated for a balanced and interactive model of the good life: “the development of character strengths and resilience may benefit from prior experience of having overcome negative conditions” (p. 70). The call to maximize positive affect and minimize negative affect could also create a “happy person as a well-defended fortress, invulnerable to the vicissitudes of life” ( King, 2001 , p. 53). New to the discourse, Wong called for a balance between individualist and collectivist orientations, thereby signaling the need to address cultural issues. Similarly, Lomas and Ivtzan (2016) called for second wave positive psychology to recognize the insufficiency of the admonition of first wave PP to go beyond a psychology preoccupied with disorder and dysfunction. Negative states could be conducive to flourishing, calling again for recognition of the dialectical nature of wellbeing. Five dichotomies were examined: optimism versus pessimism, self-esteem versus humility, freedom versus restriction, forgiveness versus anger, and happiness versus sadness. Within each, the value of both sides was described. These ideas aligned with other prior work, such as Carver and Scheier’s (2003) observation that doubt and disengagement play critical roles alongside commitment and confidence as well as Larsen et al. (2003) emphasis on co-activation of positive and negative emotions that allow individuals to make sense of stressors and gain mastery over them.

At the 6th European Conference on PP in Moscow, I spoke about “Contradiction at the Core of the Positive Psychology Movement: The Essential Role of the Negative in Adaptive Human Functioning” ( Ryff, 2012 ), beginning with a quote from Dostoyevsky’s Notes From the Underground: “And why are you so firmly and triumphantly certain that only what is normal and positive – in short, only well-being is good for man? Is reason mistaken about what is good? After all perhaps prosperity isn’t the only thing that pleases mankind. Perhaps he is just as attracted to suffering. Perhaps suffering is just as good to him as prosperity.” I then drew on Mill’s (1893/1989) Autobiography: “Those only are happy, I thought, who have their minds fixed on some object other than their own happiness, on the happiness of others, on the improvement of mankind, even on some art or pursuit, followed not as a means, but as itself an ideal end. Aiming thus as something else, they find happiness by the way.”

Arguing that psychology should not be partitioned by valence because all lives encompass both positives and negatives, I provided three examples of how they might come together. In the first, the positive is construed as an antidote to the negative, such as how positive emotions can help undo negative emotions ( Fredrickson, 1998 ), or how psychological well-being can help prevent relapse of depression or anxiety ( Fava et al., 1998 ; Ruini and Fava, 2009 ). In the second, the negative is seen as the route or path to the positive, as in trauma contributing to personal growth ( Tedeschi et al., 1998 ), or the expression of negative emotion fostering relational intimacy ( Reis, 2001 ), or the expression of negative emotion in childhood contributing, via skilled parenting, to emotional development ( Gottman, 2001 ). In the third, the positive and negative emotions are inextricably linked, such that embedded within every negative is a positive and within every positive is a negative. This dialectical perspective is more common in interdependent cultural contexts, with our findings ( Miyamoto and Ryff, 2011 ) showing that Japanese adults report experiencing both positive and negative affect, whereas United States adults report mostly positive affect. The dialectical emotional style was also linked with better health (fewer physical symptoms) in Japan compared to the United States.

Around the same time, McNulty and Fincham (2012) issued an important new challenge to PP: to consider that psychological traits and processes are not inherently positive or negative, but can be either depending on the context in which they occur. This insight was illustrated with interpersonal research (longitudinal studies of marital partners). Four putatively positive processes (forgiveness, optimism, benevolent attributions, and kindness) were shown to be beneficial, or harmful, depending on the context in which they occurred. For example, whether forgiveness was linked with self-respect differed by levels of agreeableness of one’s partner. Martial satisfaction over time also varied depending on whether attributions for spouses’ undesirable behaviors were more or less benevolent. This work, including numerous other examples, offered compelling evidence that simplistic characterizations of phenomena as positive or negative are misguided.

Integrative Work Outside the Positive Psychology Umbrella

Extensive research not part of PP has brought negative and positive aspects of human experience together. To illustrate, I describe select findings from the MIDUS (Midlife in the United States) national longitudinal study (see text Footnote 1), which is based on diverse probability samples, thereby facilitating analyses of how well-being and health vary by age, race, gender, and socioeconomic status. A counterpart study in Japan (MIDJA) has illuminated cultural differences in well-being and health. MIDUS has unprecedented depth in high quality measures of hedonic well-being (life satisfaction, positive, and negative affect), eudaimonic well-being (autonomy, environmental mastery, personal growth, positive relations with others, purpose in life, and self-acceptance), optimism, sense of control, personality traits, generativity, social responsibility, and social ties with spouse/significant other as well as parents during childhood. Deeply multidisciplinary in scope, MIDUS has facilitated linkage of all of the above variables to epidemiology, biology, neuroscience, and genetics. Most importantly, MIDUS data are publicly available and are widely used by scientists around the world.

Many findings have combined positive and negatives. For example, Morozink et al. (2010) showed that those with lower educational attainment had elevated levels of IL-6 (interleukin-6, an inflammatory marker implicated in numerous diseases) but higher psychological well-being buffered against such effects. Miller et al. (2011) showed that those from lower socioeconomic backgrounds had increased risk for metabolic syndrome in adulthood, but maternal nurturance buffered such risk. Resilience findings (see Ryff et al., 2012 ) showing that positive psychosocial factors afforded protection against poor health and physiological dysregulation in the face of various challenges (aging, inequality, early life adversity, cancer, loss of spouse). Breaking new ground, multiple studies have documented that higher purpose in life predicts increased length of life and better health behaviors ( Ryff and Kim, 2020 ). Regarding underlying mechanisms, Heller et al. (2013) showed that sustained activation of reward circuitry in the brain predicted higher eudaimonic well-being as well as better diurnal regulation of cortisol. Personality researchers have studied “healthy neuroticism,” with findings from multiple international studies showing that neuroticism is less strongly linked with poor health behaviors (smoking, inactivity) among those who are high in conscientiousness ( Graham et al., 2020 ).

With regard to race, MIDUS has advanced knowledge of the Black-White paradox in health ( Keyes, 2009 ) – i.e., despite inequality and discrimination, Blacks show higher levels of flourishing and lower levels of mental disorders than Whites. Keyes (2005 , 2007) also revealed neglected types of mental health in the general population by jointly examining mental distress (depression and anxiety) and well-being (emotion, psychological, and social). In contrast to those who are flourishing (high well-being and no mental distress) are those who are languishing, defined as not suffering from mental distress but having low well-being. Declining well-being over time also predicted increased subsequent risk of mental distress ( Keyes et al., 2010 ), while positive mental health predicted subsequent recovery from mental illness ( Iasiello et al., 2019 ). Space does not permit the details, but many findings from MIDUS and MIDJA have documented cultural differences in how emotion and well-being matter for health and biological risk ( Miyamoto and Ryff, 2021 ).

To reiterate, I include the above glimpse at MIDUS research is to underscore the need for greater interplay and exchange between the field of PP and much parallel science being done by those who do not view themselves as positive psychologists and are not publishing in journals aligned with PP or happiness.

Recent Work in Positive Psychology

This section first below examines select areas of research that represent forward progress of PP over the past two decades. Then I note recent evaluative overviews of PP from those within the field. Some of their concerns are elaborated in the next sections on what I see as problems within PP science: first, the promulgation of poor instruments for assessing well-being, and second, the reliance on largely privileged, homogeneous samples for conducting PP research.

Forward Empirical Progress

Whether the science of PP is moving constructively forward can examined in various ways. Rather than conduct a systematic review of empirical findings, I choose to focus on chapter-writing, mostly from 3rd Edition of the Oxford Handbook of Positive Psychology ( Snyder et al., 2021 ). Unlike journal articles, chapters allow authors to combine many advances on particular topics over time thereby offering a narrative overview of multiple findings. The book includes 68 chapters written by 153 authors, 86% of whom were from the United States.

In the study of emotion, multiple lines of progress are evident. The broaden and build theory continues to evolve by showing short- and long-term benefits of positive emotions in multiple domains, including thoughts, actions, stress, health, physiological and neurological connections ( Tugade et al., 2021 ). Studies of positive affectivity, a trait composed of different components (joviality, self-assurance, and attentiveness) have also progressed via linkages to other constructs (extraversion, happiness, and well-being) as well as psychological disorders, health, marital and job satisfaction, and cultural issues ( Naragon-Gainey and Watson, 2021 ). Positive affect has been linked to longer life, lower incidence of disease, better recovery from disease and better overall health ( Hunter et al., 2021 ), with calls for further work on mechanisms, culture, and technology. The emotional approach to coping (EAC) shows evidence on the intentional use of emotional processing and expression to manage adverse circumstances, such as infertility, sexual assault, diabetes, cancer ( Moreno et al., 2021 ), while calling for more work on interventions, including who benefits (which contexts).

Happiness studies have examined ways in which happy and unhappy people respond to social comparisons, make decisions, and reflect ( Boehm et al., 2021 ), along with strategies (experiments and activities) to improve happiness and formulation of underlying mechanisms. Veenhoven (2021) reviewed differences in happiness across nations and linked them to important questions about what governments can or cannot do to raise levels of happiness, thus reaching toward issues of public policy. A unified model of meaning in life was advanced, underscoring the need for conceptual integration in this growing area of science ( Steger, 2021 ). Positive aging was covered via multiple positive formulations that have been extensively studied, in some cases with interventions ( Nakamura and Chan, 2021 ).

Shifting to life outlooks, how the future is construed was covered with work on optimism showing that those who expect good things to occur have higher well-being, better health, and higher quality social ties, partly attributable to how they cope with adversity ( Mens et al., 2021 ). Detrimental consequences of hope were considered, while calling for greater work on the origins of hope and cultural issues. Hope, defined as the perceived ability to achieve desired goals via pathways and agency, was examined with a goal pursuit process model and linked to academic and athletic performance, health and well-being, social relationships, and work ( Rand and Touza, 2021 ). Resilience, the capacity for positive adaptation in the face of significant adversity, was examined in models that illuminated self-regulation skills, good parenting, community resources and effective schools ( Cutuli et al., 2021 ). Strategies for reducing risk, building strengths and mobilizing adaptive systems were future directions.

Positive mental health was covered with a thoughtful historical perspective and overview of current conceptualizations and measures ( Delle Fava and Negri, 2021 ), examined from life course and cultural perspectives. Illustrating methodological novelty, Tarragona (2021) considered the benefits of personal narratives and expressive writing on mental health and physical health (immune function and cardiovascular health), particularly in the context of trauma. Dominant approaches to mental health interventions (psychotherapy, counseling, and coaching) were examined for commonalities and differences in time perspectives, therapeutic strategies and recipients ( Ruini and Marques, 2021 ), while emphasizing the need for professional regulation and oversight.

Several chapters covered interpersonal themes. Attachment theory was presented as a framework for studying positive relationships ( Mikulincer and Shaver, 2021 ) via links between mental representations of attachment security and how they matter for diverse outcomes (health, social adjustment or interpersonal conflict, and personal growth). Relationship complexities were examined, underscoring both meaningful rewards and substantial risks of close social ties ( Gable and Maisel, 2021 ). They highlighted positive processes, involving positive emotions, intimacy, growth of self-concept, and benefits of sharing positive events. Past research on empathy was reviewed and emerging work on the neuroscience of empathy described ( Duan and Sager, 2021 ). How empathy relates to racial/ethnic diversity, multiculturalism, and social justice were future directions. Forgiveness was described in terms of the methods used and the differentiation of various antecedents, some intrapersonal (empathy, personality, attributions, and religion) and others interpersonal (closeness and conciliatory behavior) ( Tsang and Martin, 2021 ). Whether forgiveness is uniformly positive was considered.

Pawelski and Tay’s (2021) described efforts to connect PP to the humanities through new conceptual analyses and various interventions. Silvia and Kashdan (2021) examined curiosity and interest, framed as recognizing, seeking out, and preferring things outside one’s normal experience. How these tendencies matter for well-being is under study in the laboratory and everyday life. Courage, defined as facing personal risks in pursuit of worthy goals, was examined historically and via modern theory and measurement tools focused on volition, goals, and risk ( Pury et al., 2021 ). Humility, formulated as accurate and modest self-presentation and being other-oriented, showed steady progress in empirical findings from 2000 to 2015 ( Worthington et al., 2021 ).

In sum, considerable evidence reveals forward progress on important topics in PP. Even though most areas of inquiry predated PP, it is useful to bring such contributions together to convey the range and diversity of topics on adaptive human functioning. At the same time, several chapters in the collection were not current in coverage, and some had a paucity of empirical findings. All ended with future questions. An interesting question is whether these have evolved over the past 20 years, or are largely similar to where the field was back then. Before addressing problematic areas of PP science, I next examine evaluative reviews from within the PP field.

Overarching Concerns About Positive Psychology

Lomas et al. (2021) call for PP to broaden toward complexity – go beyond the individual toward analysis of groups, organizations, and broader systems as well as to embrace diverse methodologies. Better understanding of context (historical, social, cultural, and institutional) was also emphasized. Contextual approaches were illustrated with positive organizational scholarship ( Cameron et al., 2003 ), positive educational approaches in schools ( Waters et al., 2010 ), and family-centered positive psychology ( Sheridan et al., 2004 ; Henry et al., 2015 ). Lomas et al. (2021) called for greater ethical oversight of the ever-expanding cadre of PP practitioners from applied programs: “…unless practitioners are affiliated to a particular profession, they may be operating outside the advice and provisions of any set of ethical guidelines” (p. 16).

Kern et al. (2020) contrasted the rapid growth of PP with concern about exaggerated claims, inflated expectations, disillusionment, and possibly, unintentional harms. Issues of over-promising and under-delivering in programs with individuals, schools, the workplace, and communities were noted. To help the field mature, they advocated for systems informed PP, which would clarify epistemological, political, and ethical assumptions and commitments. The implications of such ideas for research and practice were examined.

van Zyl (2022) reviewed criticisms and concerns about PP, including the lack of a unifying metatheory that underpins the science as well as fundamental ideas for how positive psychological phenomena should be researched. Related criticisms were that PP has borrowed most of its theories from social, behavioral and cognitive psychology, thereby advancing few of its own unique perspectives. There is the problem of terminological confusion – e.g., using terms like flourishing or well-being interchangeably when operationalizations of them are notably different, or failing to recognize the possible overlap among putatively distinct topics, such as grit, conscientiousness, or diligence. Inconsistency in the factorial structures of various measurement models is a further problem. The fact that most PP has failed to produce significant or sustainable changes was noted, along with its cultural (Western) biases.

Taken together, I agree with most of the above assessments and further illustrate them below.

Problems in Positive Psychology Science: Flawed Conceptualization and Measurement of Well-Being

I bring my expertise in the study of psychological well-being to how some have approached this topic in PP. As noted above, I foresaw problems of measurement clutter at the dawning of PP ( Ryff, 2003 ). My prediction was prescient and needs attention, given growing interest in the measurement of well-being across scientific disciplines. A recent edited volume ( Lee et al., 2021 ) included scrutiny of multiple measurement approaches along with an animated exchange among contributors ( Ryff et al., 2021a , b ; VanderWeele et al., 2021a , b ) on the pluses and minuses of various assessment strategies. What came into high relief was concern about the proliferation of thin, poorly validated measures that are undermining quality science in the study of well-being.

Although not considered in the above volume, Seligman and his collaborators have contributed to this problem. I offer two examples of the promulgation of poorly constructed and poorly validated measures of well-being that are at odds with claims that PP rests on rigorous science. A first study ( Seligman et al., 2005 ) sought to validate five different interventions (gratitude visit, three good things, you at your best, using signature strengths in a new way, and identifying signature strengths). Internet-based samples were recruited through the authentic happiness website 2 ; most participants were white and highly educated.

All completed baseline assessments and five follow-up assessments over a 6-month period after completion of the intervention assignment. As a general observation, the findings were overstated – most comparisons between the control group and intervention groups were not significantly different across time, nor was there coherence in when such effects were evident. There was also insufficient attention given to pre–post comparisons, which are central for demonstrating intervention effectiveness. My primary focus, however, is on the outcomes assessed – specifically, the measure of happiness.

Described as “scientifically unwieldy” (p. 413) happiness was “dissolved” into three distinct components: “(a) positive emotion and pleasure (the pleasant life), (b) engagement (the engaged life), and (c) meaning (the meaningful life).” I note the redundancy in defining each component. The source for this tripartite formulation was Seligman’s (2002) trade book, Authentic Happiness , which was operationalized with the Steen Happiness Index (SHI), an unpublished 20-item inventory. No evidence was provided that the inventory measures three distinct components of well-being, nor is it likely such evidence could be assembled. Many items lack face validity – i.e., they pertained to other constructs, such as optimism, positive self-regard, frustration, energy, social connection, making good choices. Adding to the befuddlement was this statement: “We continue to use the word happiness, but only in the atheoretical sense of labeling the overall aim of the positive psychology endeavor and referring jointly to positive emotion, engagement, and meaning” (p. 413). All analyses focused the atheoretical construct of happiness – i.e., the component parts were nowhere to be seen.

Next came PERMA, defined by Seligman (2011) in Flourish , another popular book. Added to the prior components of positive emotion, engagement, and meaning, were now two additional components: relationships and accomplishment. Again, none were explicitly defined, nor was the pronouncement about what happiness entails theoretically grounded in anything , nor was it linked with the extensive prior empirical literatures on subjective and psychological well-being as well as research on positive emotions (exemplified by the diverse MIDUS measures). Such obliviousness to what the field had been investigating for decades made inevitable that there would be redundancy with already validated approaches and assessment tools. Such duplication became a certainty given how PERMA was operationalized – namely, by taking items from prior instruments ( Butler, 2011 ). These were transformed into the PERMA-Profiler ( Butler and Kern, 2016 ) via multiple studies (none clearly defined) involving a large samples recruited mostly through online systems; most participants were well-educated.

Missing from the reported analyses were key preliminaries required to develop quality assessments. For example, of central importance was whether the item pools for the five components were empirically distinct (i.e., did each item correlate more highly with its own scale than another scale?). In subsequent tests of convergent validity with other measures, a further problem, not addressed, was the degree of item-overlap (redundancy), given that all PERMA items came from prior instruments. Additional analyses correlated PERMA scales with 20+ measures. For many (e.g., organizational practices, political orientation, work performance, social capital, burnout, values, self-efficacy, perceived stress, and gratitude), the relevance of these analyses was unclear.

Subsequent work showed that PERMA and subjective well-being are indistinguishable ( Goodman et al., 2018 ). Seligman (2018) responded by calling for the need to “transcend psychometrics,” accompanied by an exegesis on the psychometrics of baseball pitching. Also offered was the observation that “SWB probably is the useful final common path of the elements of well-being” (p. 1) – presumably an effort to deflect evidence away from the clear empirical redundancy of PERMA with subjective well-being. Most incoherent was the following: “All of this is to say that a good theory of the elements of well-being helps to build well-being and that the psychometric findings that the elements correlate perfectly with overall well-being and that the elements correlate very well with each other is not very instructive when it comes to building well-being” (p. 2).

Other findings have shown questionable support for the putative five-factor structure of PERMA ( Watanabe et al., 2018 ; Ryan et al., 2019 ; Umucu et al., 2020 ). Data from German speaking countries Wammerl et al. (2019) supported for the five-factor model but also bifactor models ( Reise, 2012 ). My observation is that these latter methodological studies examining various multivariate structures are largely disconnected from substantive issues of what well-being is, or critical questions needed to advance the field. Those are not about dimensional structures of recycled items, but about the antecedents and consequents well-being, whether well-being is protective in the face of adversity, and whether interventions can promote well-being. On all of these questions, the above two efforts to articulate a meaningful, conceptually grounded theory of happiness that works empirically (i.e., the data support the claimed multifactorial structure) AND that is distinct from what was already in the field, have failed.

Problems in Positive Psychology Science: Samples and Contexts

A second major problem in PP research, already illustrated in preceding sections, is the overwhelming reliance on homogeneous, privileged samples . This lack of diversity pervades subfields of psychology that have tended to conduct their research with readily available college students or community volunteers. Others call this the WEIRD phenomenon ( Henrich et al., 2010 ) – doing research with western, educated, industrialized, rich, and democratic societies. Minorities and socioeconomically disadvantaged individuals are missing in such inquiries, although population research makes clear that well-being and health are linked with sociodemographic factors ( Ryff et al., 2021c ). Our review, which included findings from MIDUS and other large studies, made clear that numerous aspects of well-being (hedonic and eudaimonic) do, in fact, differ by age, socioeconomic status, race, and gender. These differences also predict diverse health outcomes, assessed in terms of symptoms, chronic conditions, biological risk factors, and mortality. Thanks to the MIDJA (Midlife in Japan) study, we have illuminated cultural differences in many of these same topics ( Miyamoto and Ryff, 2021 ).

Closer to PP, I note that Frontiers in Psychology issued a recent call for papers to address with PPI (positive psychology interventions) work in non-WEIRD contexts ( van Zyl et al., 2021 ). Their bibliographic analyses showed that only about 2% of PPIs to date have been conducted with vulnerable groups, or in multi-cultural contexts. Clearly, a major need going forward is the importance of reducing the bias toward Western (often United States) samples of privileged people whose lives are clearly not representative of those from other cultural contexts as well as focusing on disadvantaged groups within such contexts.

The Commercialization of Positive Psychology: Needed Oversight

It is without question that PP has become a big business ( Horowitz, 2018 ). Happiness promotion involves billions of dollars spent on popular books, workshops, counseling/coaching, apps, websites, and social media platforms. PP has entered the corporate world through happiness consulting companies that claim to “bridge the gap between cutting-edge research in the field of positive psychology and best practices within corporate and community cultures around the globe” (p. 244). Horowitz wryly observes that few promoting happiness as the route to success consider the alternative – i.e., that success leads to happiness. There is also a marked failure to address the needs of lower echelon workers, such as better wages and benefits. Instead, motivational speakers cheer on executives, managers and workers with messages consonant with positive psychology and neoliberalism. Via apps and other gadgets happiness has become a “measurable, visible, improvable entity” (p. 246), thus replacing global commitments to combat stress, misery, and illness was with relaxation, happiness, and wellness.

I will not detail the dizzying array of websites promoting happiness, flourishing, and positive psychology; they are easily found online. Instead, I ask whether the for-profit cart has gotten seriously ahead of the scientific horse. This is a matter the scientific community cannot afford to ignore because it addresses whether the evidential basis behind the proliferation of products is truly there, or has been glossed over in the frenzy to sell. Prior to the commercialization of PP, scientists had shared understanding of what is required to demonstrate intervention effectiveness, as in randomized clinical trials, a staple of the National Institutes of Health. These guidelines exist to protect the public from products that are not credible. That the advertised promise of happiness promotion may be overstated is intimated by the “Earnings Disclaimer and Statement of Individual Responsibility” from the Flourishing Center 3 . It states that “the Flourishing Center, Inc. makes no guarantees that you will achieve results similar to ours or anyone else’s.” Additional text in this format follows: YOU FULLY AGREE AND UNDERSTAND THAT YOU AND YOU ALONE ARE RESPONSIBLE FOR YOUR SUCCESS OR FAILURE. NO REFUNDS ARE AVAILABLE UNLESS STATED OTHERWISE ON A PROGRAM’S SALES PAGE.

Closer to the heart of PP, we need to ask what it means when character strengths are being sold, when virtue has become a commodity, and when PP scientists have shopping carts on their websites. There is also the matter of pricing. Horowitz (2018) describes some who are receiving $25,000 speaker fees – are these defensible in academia? Many believe we have a responsibility to share our knowledge and expertise, but not to do so in pursuit of personal profit. Scrutiny also is required regarding the content of educational programs. Here I focus on the flagship program that is presumably leading the field – namely, the Master’s in Applied Positive Psychology (MAPP) at the University of Pennsylvania, described with no shortage of hubris, as Medici II ( Seligman, 2019 ). MAPP offers two semesters (nine courses) and a summer capstone project for a price of over $70,000. The curriculum is thinly described on the website, but if students are being taught that the theory, history, and meanings of PP (Introduction to Positive Psychology) began with Seligman and Csikszentmihalyi (2000) and other foundational documents ( Pawelski, 2016 ), they are not getting what they paid for. Further, if PERMA is being taught as a credible tool for measuring well-being (Research Methods and Evaluation), they are being miseducated. The theoretical, empirical, and experiential nature of positive interventions (Foundations of Positive Interventions) are not detailed on the website, but if Seligman et al. (2005) , reviewed above, is presented as credible evidence that PP interventions work, they are being misled.

Amidst these questions, it is important to underscore that high quality teaching materials for such programs do exist, such as the recent book on Positive Psychology Through the Life Span: An Existential Perspective ( Worth, 2022 ) and another on Positive Psychology in the Clinical Domains ( Ruini, 2017 ). Both offer thoughtful, historically comprehensive perspectives in their respective domains, which are essential features of quality education in PP.

The larger issue is the quality of what PP is marketing, not just in master’s programs, but also certificate programs and short-term seminars. Horowitz (2018) notes those who have expressed concerns about ethical oversight, calling for standardized nomenclature, formal training and certification guidelines, given uneven credentialing among those doing this work. Central concerns are whether the teaching in some programs is superficial and short-term practices lack scientific evidence of effectiveness. Stated otherwise, the commercialized end of PP appears to be fundamentally unregulated. “Despite all the research carried out in the field, what remains too often neglected are the who, why, and with what results ordinary consumers gain from all the money and time they spend on pursuing positive psychology by reading books, attending workshops, and carrying out recommended exercises.” (Horowitz, p. 274).

Looking Forward: Suggested New Directions for Positive Psychology

Societal ills as research imperatives.

Two major challenges of our era, ever-widening inequality and the world-wide pandemic, need scientific attention. Together, they constitute intersecting catastrophes ( Ryff, forthcoming ). Among those who were already disadvantaged, the pandemic has aggravated difficulties many were already facing plus added new challenges (unemployment, loss of healthcare, evictions due to unpaid rent, and food lines/hunger). MIDUS has been a prominent forum for investigating health inequalities, given its rich psychosocial, behavioral, and biological assessments ( Kirsch et al., 2019 ). Our findings have linked lower education and incomes to compromised well-being, greater psychological distress, poorer health behavior, higher stress exposures, elevated biological risk factors, greater morbidity and earlier mortality (see Text Footnote 1). A unique feature of the study has been recruitment of two national samples situated on either side of the Great Recession. Over the period covered by these two samples, educational attainment in the United States improved.

Despite such educational gains, the post-Recession refresher sample reported less household income (after adjusting for inflation), lower financial stability, worse health (multiple indicators) and lower well-being (multiple indicators) than the pre-Recession baseline sample. Further work compared the two samples on measures of negative and positive emotions, showing more compromised mental health in the later refresher sample, particularly among those with lower socioeconomic standing (measured with a composite of education, occupation, income, and wealth) ( Goldman et al., 2018 ). This worsening of mental health among disadvantaged Americans has occurred in the context of the opioid epidemic, growing alcoholism and increased death rates, including suicide, among middle-aged white persons of low SES standing ( Case and Deaton, 2015 ; Kolodny et al., 2015 ; Grant et al., 2017 ; Schuchat et al., 2017 ), a phenomenon known as deaths of despair ( Case and Deaton, 2020 ).

Positive psychologists need to engage with these societal changes. I note promising work already underway ( Waters et al., 2021 ). Although human strengths constitute important protective resources in the face of adversity, it is also the case that significant challenge can sometimes disable pre-existing strengths ( Shanahan et al., 2014 ). We found evidence of such disablement among those exposed to high levels of hardship in the Great Recession ( Kirsch and Ryff, 2016 ). Going forward, it is critical that studies of psychological strengths in the face of pandemic stress include assessment of key sociodemographic variables such as socioeconomic status in national samples. Vazquez et al. (2020) illustrated such work in a representative sample of Spanish adults. It is critical that future PP contributions to understanding impacts of the pandemic not perpetuate the longstanding prior focus on privileged, homogeneous samples.

Neglected Negatives Behind the Current Societal Problems

The founders of PP advocated that psychology should encompass more than psychopathology (depression and anxiety) and other forms of dysfunction. Hence, the call to elevate positive aspects of human functioning. I observe that psychology as a discipline has neglected something else: namely, a category of negative characteristics that may be implicated in the societal problems we now face. These include greed, indifference, and stupidity ( Ryff, 2017 , 2021a ), along with anger, which is not inherently positive or negative. I cover these topics below because they reveal a possibly pernicious blind spot in the larger vision of PP: namely, that the well-being and positive human functioning of some (especially those who are disadvantaged) may be compromised by the priorities and actions of others (especially those who are advantaged). To the extent that PP ministers primarily to the better educated and economically comfortable in conveying how to get the most out of life and achieve personal potential, PP may, itself, be part of the problem.

To illustrate, I note the widespread marketing of mindfulness meditation, including to CEOs as described by Horowitz (2018) in Happier? Purser (2019) offers more, observing that “mindfulness programs do not ask executives to examine how their managerial decisions and corporate policies have institutionalized greed, ill will, and delusion. Instead, the practice is being sold to executives as a way to de-stress, improve productivity and focus, and bounce back from working 80-h weeks. They may well be ‘meditating,’ but it works like taking an aspirin for a headache. Once the pain goes away, it is business as usual. Even if individuals become nicer people, the corporate agenda of maximizing profits does not change.”

Following from the above quote, we must consider that among the malevolent forces contributing to ever-widening inequality are behaviors of excessive self-interest orchestrated by those in positions of power. These problems are empirically evident when corporate profits soar, but worker paychecks lag ( Cohen, 2018 ), a problem described by economists as “monopsony power” – the ability of employers to suppress wages below the efficient or perfectly competitive level of compensation ( Kruger and Posner, 2018 ). Human history shows longstanding concern about problems of greed. The ancient Greeks saw greed and injustice as violating virtues of fairness and equality, and thereby, contributing to civic strife ( Balot, 2001 ). Dante’s Divine Comedy ( Dante’s, 1308/2006 ) placed sins of greed and gluttony, along with fraud and dishonesty, in his nine circles of hell. Adam Smith’s Wealth of Nations ( Smith’s, 1776/1981 ) made the case for self-interest and capitalism, but recognized the problem of greed, framed as the limitless appetites of the vain and insatiable.

Some within psychology are addressing what lies behind the worship of money and selfish wealth gratification, sometimes orchestrated through fraudulent tactics ( Nikelly, 2006 ). Motivational psychologists have studied “the dark side of the American Dream” ( Kasser and Ryan, 1993 ), showing that those motivated by primarily extrinsic factors (financial success) have lower well-being and adjustment compared to those motivated by less materialistic values. Social psychologists have shown that those with higher social class standing have increased sense entitlement and narcissism compared to those from lower class backgrounds; those in the upper-class are also more likely to behave unethically than those in the lower-class ( Piff et al., 2012 ; Piff, 2013 ). A large study of United States students examined what lies behind the widespread acceptance of inequality ( Mendelberg et al., 2017 ) by asking them to indicate their agreement or disagreement with the statement: “Wealthy people should pay a larger share of taxes than they do now.” The main finding was that students from affluent colleges (defined by family SES background) were more likely than those from public or less affluent colleges and universities to disagree with the statement – i.e., the most privileged were also the most strongly opposed to having the wealthy pay more taxes. In addition, such tendencies were most pronounced among those who were active in college fraternities and sororities.

The seamy underside of philanthropy, usually thought of as elites doing good in the world, is also under scrutiny ( Giridharadas, 2018 ). The Sackler family, well-known for their philanthropy in art museums around the world, offers a singular example. They owned Purdue Pharma, which created oxycontin, the highly addictive opioid painkiller that was aggressively marketed, thereby leading to massive over-prescribing. To date, more than 500,000 have died from overdose deaths. A 2021 HBO documentary, Crime of the Century , revealed the widespread individual actions behind this public health tragedy – within drug companies, political operatives, and government regulators, all of whom backed the reckless distribution of this deadly, but highly profitable, drug.

Some might argue that the above examples are isolated actions of those of extreme wealth and do not represent most of the rest of us. Stewart’s (2021) recent look at the new American aristocracy suggests otherwise. With a solid evidential basis, he shows that a much larger segment of the population is involved in warping our culture – i.e., how those laser-focused on career success are relying on an underpaid servant class to fuel their forward progress, while also making personal fitness a national obsession, even as large segments of the population lose healthcare and grow sicker. The privileged also segregate themselves in exclusive neighborhoods and compete relentlessly in getting their children into elite schools, which has contributed to ever-more extreme costs of higher education. Perhaps most troubling is the ethos of merit they have created to justify their advantages. Stewart powerfully distils that these people are not just around us, they are us.


On this topic I have little to say other than to quote Elie Wiesel, Nobel Prize winning author and Holocaust survivor: “I believe that a person who is indifferent to the suffering of others is complicit in the crime. And that I cannot allow, at least not for myself. The opposite of love is not hate, it’s indifference.” In the present era, such indifference to the widespread suffering of others must be studied and documented. It is a character weakness that psychologists should try to understand – where does it come from? How is it enacted? What are its consequents?

Marmion’s (2018) tongue-in-cheek edited collection on the Psychology of Stupidity warrants consideration, given psychology’s long preoccupation with studying intelligence (of multiple types) and cognitive capacities (also of multiple types). The book offers a taxonomy of morons and links stupidity with established topics (cognitive bias, narcissism, and negative social networks). Wisely, Marion asserts: “No matter what form it takes, stupidity splatters us all. Rumor has it that we ourselves are the source of it. I am no exception” (p. ix). The kind of stupidity that most interests me and needs critical study is the swallowing of lies, or being duped by others. Lies are perpetrated by people in high or low places, but the essential question is why they have impact – why they are believed. Some in the clinical realm have examined such questions, focusing on those who lie with impunity, sometimes revealing clear sociopathy ( Peck, 1983 ; Stout, 2006 ). We need more science about these assaults on the truth and why they have become such pervasive part of contemporary life. My hypothesis is that all levels of human experience (personal ties, the workplace, communities, and societies) are damaged by the swallowing of lies, whether knowingly or unknowingly.

Often depicted as toxic, anger is sometimes legitimate as Aristotle understood. He reminded that at the right time, to the right degree, and for the right reasons, anger can be a powerful and needed response. Indeed, its neural underpinnings look more like positive affect than depression or anxiety ( Harmon-Jones et al., 2011 ). Anger may be uniquely justified vis-à-vis profoundly unequal life opportunities. Mishra’s Age of Anger ( Mishra’s, 2017 ), offers an astonishing integration of history, philosophy, literature, politics, economics, and cultural studies on the topic. He begins with this: “Individuals with very different pasts find themselves herded by capitalism and technology into a common present, where grossly unequal distributions of wealth and power have created humiliating new hierarchies. This proximity is rendered more claustrophobic by digital communications and the improved capacity for envious and resentful comparison” (p. 13). Drawing on Arendt, Mishra describes existential resentments that are poisoning civil society and fueling authoritarianism.

Most powerful is Mishra’s portrayal of the distinct philosophies of Rousseau and Voltaire, eighteenth century interpreters of life. Voltaire praised material prosperity and consumerism, boldly professing his love of conspicuous consumption. Rousseau reminded that the ancients spoke incessantly about morals and virtue whereas the French philosophes spoke only of business and money. He saw the new commercial society as acquiring features of class division, inequality, and callous elites whose members were corrupt, hypocritical and cruel. According to Mishra: “What makes Rousseau, and his self-described ‘history of the human heart,’ so astonishingly germane and eerily resonant is that, unlike his fellow eighteen-century writers, he described the quintessential inner experience of modernity for most people: the uprooted outsider in the commercial metropolis, aspiring for a place in it, and struggling with complex feelings of envy, fascination, revulsion, and rejection” (p. 90). Although Rousseau’s books were best sellers in his era, they are rarely invoked in current discourse. He castigated the Enlightenment philosophes for their self-love and self-interest, writing that amour propre ( McLendon, 2009 ) was a dangerous craving to secure recognition for self over others and an insatiable ambition to raise personal fortunes. These observations need serious examination vis-à-vis the thriving business of PP – to what extent are self-interest and personal ambition the central motives behind what is being sold?

Returning to empirical science, I note that MIDUS includes multidimensional assessments of anger, from over 20 publications have been generated (see Text Footnote 1). Anger expression has been linked to multiple indicators of health (sleep, cognitive function, inflammation, and allostatic load) as well as to race/ethnicity, socioeconomic status, early life adversity, and cultural context.

What Nurtures Our Better Selves: The Arts and Humanities

To those who find my views to be overly negative, I end this section with more hopeful topics. I note that my career journey has reflected this dual focus on the forces that both undermine as well as nurture positive psychological functioning ( Ryff, 2022 ). As stated at the outset and multiple times long the way, I have always believed both are fundamental parts of the human experience. I begin this part with distant observations from Matthew Arnold, who in Culture and Anarchy ( Arnold, 1867/1993 ), emphasized that freedom should be employed in the service of higher ideals and further noted that these ideals are critically important during times of great peril, such as pandemics and wars. For him, culture was the study of perfection tied to the moral and social passion for doing good.

I have long believed that the arts (broadly defined) and humanities (history and philosophy) can help us discern how to do good and be well ( Ryff, 2019 ). Growing research is now linking diverse art (music, literature, poetry, art, film, and dance) to health ( Fancourt, 2017 ; Fancourt and Finn, 2019 ). To maintain a thread to current societal challenges, I here consider the arts in a somewhat different way – namely, whether they might be venues for nurturing compassion and insight about human suffering, which has become so widespread. Starting with contemporary film, multiple examples (e.g., The Florida Project, American Honey, Paterson, Parasite , and Nomadland ) reveal the lived experience of inequality, including descending into prostitution to feed a child, growing up with addicted parents, having dreams of self-realization stymied, experiencing homelessness, and working in physically-difficult, mind-numbing jobs. These works also portray the poetry in disadvantaged lives, including cleverness and resourcefulness vis-à-vis insensitive elites. The relevance of these domains for contemporary science, largely unstudied, is whether such inputs increase quotients of caring and compassion, and possibly challenge the complacency and indifference among those who are not suffering. Such questions elevate themes of social justice in ongoing research on well-being and health, while pointing to the arts as possible venues for informing and mobilizing individual and societal action.

The visual arts may also powerfully activate compassion vis-à-vis the pandemic or contemporary conflicts. The self-portrait of the Austrian artist, Egon Schiele, painted in 1912 and looking gravely ill before his death at age 28 from the Spanish flu, which also took his wife and their unborn child, is an example. Kandinsky painted Troubled in 1917, an abstract work of turbulence and trauma created during the Russian revolution when he was lived in Moscow and had a child die of malnourishment. A last visual example comes from over 1,000 watercolors painted from 1940 to 1942 and brought together in Charlotte Salomon: Life? Or Theater? ( Salomon, 2017 ). Born in 1917, this woman experienced multiple suicides in her family during her brief lifetime. She was a student at the Berlin Fine Arts Academy and in 1938 fled to southern France where an intense period of creativity unfolded. Next to a series of paintings depicting multiple faces with dramatic eyes and sad countenances, she wrote: “I realized that no heaven, no sun, no star could help me if I did not contribute by my own will. And then I realized that actually I still had no idea who I was. I was a corpse. And I expected life to love me now. I waited and came to the realization: what matters is not whether life loves us, but that we love life.” This insight about loving life had tragic salience: she was transported to Auschwitz in 1943 where, at age 26 and 5 months pregnant, she died.

Literature is another powerful realm for revealing travesties of the human condition. In A Tale of Two Cities ( Dickens, 1859/2004 ), Charles Dickens brought horrors of the French Revolution to the hearts and minds of his readers. We learned of the awful lives of those imprisoned within the Bastille, and after it was stormed, the executions by guillotine at the Place de La Concorde in Paris. The bloodbath of class retribution took more than 1,200 lives, including the French Queen and King. Here is how Dickens described the context: “…the frightful moral disorder born of unspeakable suffering, intolerable oppression, and heartless indifference” (p. 344). At the core of the book is Madame DeFarge, the tigress quietly knitting, observing, and overseeing the acts of vengeance. Near the end, we have insight into her fury, learning that her younger sister was the victim of shameless male aristocrats who carelessly exploited her and destroyed her life and family.

Two contemporary books of fiction address the current migration crisis. Mohsin Hamid’s Exit West ( Hamid’s, 2017 ) describes the awful realities of refugees whose lives have been stolen out from under them, only to be subjected to endless trauma as they try to find another home. Another recent work, Call Me Zebra ( Van der Vliet Oloomi, 2018 ), winner of the 2019 PEN/Faulkner award for fiction, tracks a family escaping from Iran by foot. The mother dies along the way, but the father and daughter eventually make their way to New York. The family is a group of anarchists, atheists, and autodidacts who took refuge in books; their distilled philosophy: “Love nothing except literature, the only magnanimous host there is in this decaying world…. The depth of our knowledge, the precision of our tongues, and our capacity for detecting lies is unparalleled” (p. 8). Memorization is key; thus, sprinkled throughout the book are quotes from Nietzsche, Omar Khayyam, Dante, Goethe, Rilke, Kafka, Cervantes, Garcia Lorca, Dali, and Picasso – “These writers’ sentences deposited me at the edge of the unknown, far from the repulsive banality of reality others refer to as life” (p. 205).

I conclude with examples of satire vis-à-vis experiences of oppression and want. Jonathan Swift’s, A Modest Proposal , written in Swift’s (1729) , was put forth with the stated intent of preventing the children of the poor people in Ireland from being a burden to their parents or the country, as well as to make them beneficial to the wider public. Swift began by describing female beggars in Dublin followed by their many children, all in rags, importuning every passing person for alms. He elaborated on the numerical scope of the problem and then observes that these young children cannot be fruitfully employed until they are around age twelve. Swift thus suggests that these children, if well nursed for their first year, be sent to England to provide “a most delicious nourishing and wholesome food, whether stewed, roasted, baked, or boiled; and I make no doubt that it will equally serve in a fricassee, or a ragout” (p. 3). Calculations were included to show the financial benefits that would follow. This satirical hyperbole mocked the heartless attitudes toward the poor among the British as well as their policies toward the Irish in general. The book is widely recognized as one of the greatest examples of sustained irony in the history of the English language.

Moving to the present, Paul Beatty’s The Sellout ( Beatty’s, 2015 ) won the Man Booker Prize and was praised as “Swiftian satire of the highest order.” The book covers race relations in the fictional township of Dickens (meaningfully named), California, a place where residents are left to fend for themselves. With masterful humor, Beatty parodies everything – from contemporary psychology to “slapstick racism” to public transportation to depict the obstacles of being poor and black in racist America. Sister cities for Dickens are identified: Chernobyl, Juárez, and Kinshasa – all known for their pollution, poverty, and dysfunction. The satire and razor-sharp wit reveal what it means to exist in a culture saturated with negative stereotypes.

To summarize, I have emphasized the role of the arts in awakening the wider public to human suffering. Central questions for science and praxis are whether these inputs can effectively increase needed supplies of compassion and empathy, while perhaps also provoke awareness of complacency among those who are comfortable, if not indifferent. Such topics can and should be studied, including in experimental and educational contexts. The National Endowment for the Humanities regularly tracks who partakes of the arts and further shows variation therein by educational status. Such practices are fundamentally not different from studying health behaviors (smoking, drinking, and exercise). These parts of living, focused on the content of what people are taking in, need to part of large epidemiological studies, where they could be linked with other important topics such as reported levels of social responsibility and caring ( Ryff and Kim, 2020 ) as well as their views about who should be taxed at what levels ( Mendelberg et al., 2017 ).

What Nurtures Human Flourishing: The Natural Environment

Nature is powerfully present in the visual arts and music as well and has been throughout human history. I have recently covered these topics elsewhere, including nature’s role in nurturing the human spirit ( Ryff, 2021b ) and here highlight some of that work. My overall messages are that those interested in understanding influences that nurture good lives as well as a concern for our planet need to bring encounters with nature into their scientific studies, including interventions designed to promote diverse aspects of well-being and health.

Vibrant research is now investigating how nature contributes to human flourishing ( Capaldi et al., 2015 ; Mantler and Logan, 2015 ). These ideas take on greater salience as more of the world’s population live in nature-impoverished urban milieus. Multiple theories have been invoked to explain how we benefit from nature, such as the biophilia hypothesis from evolutionary thinking, which suggests that our human ancestors depended on connecting with nature to survive ( Kellert and Wilson, 1993 ), or stress-reduction theory ( Ulrich et al., 1991 ), which proposes that past exposures to unthreatening natural environments contributed to survival via stress-reducing physiological responses. Other perspectives consider roles of the natural environment in addressing existential anxieties, such as meaning in life, isolation, freedom, and death ( Yalom, 1980 ). Eco-existential positive psychology ( Passmore and Howell, 2014 ) thus describe how restorative experiences with nature might contribute to sense of identity, multiple forms of happiness, meaning, social connectedness, freedom, and awareness of one’s mortality.

Empirical evidence has linked encounters with nature to high hedonic well-being, both short and long-term, and to aspects of eudaimonic well-being ( Capaldi et al., 2015 ; Mantler and Logan, 2015 ; Triguero-Mas et al., 2015 ). Some inquiries have examined intervening mechanisms, such as increased physical activity, increased social contact, stress reduction and restoration of cognitive attention. The focus on green spaces underscores growing concerns about urbanization, loss of biodiversity, and environmental degradation. Increasingly dire consequences of climate change (droughts, wildfires, and floods) have also led to research on pro-nature behaviors that support conservation of nature and biodiversity. Richardson et al. (2020) conducted an innovative population survey in the United Kingdom examining links between pro-nature actions with time spent in nature as well as knowledge of and concerns about nature.

Nature as a source of inspiration and uplift is pervasively present in poetry, literature, music, art, history, and philosophy. An example is the life of Alexander von Humboldt (1769-1859), beautifully written about in The Invention of Nature ( Wulf, 2016 ). Primarily a scientist, naturalist, and explorer (of South America and Siberia), Humboldt influenced many of the great thinkers of his day, including Jefferson, Darwin, Wordsworth, Coleridge, Thoreau, and Goethe. Humboldt was ahead of his time in thinking about the degradation and exploitation of nature, warning that humankind had the power to destroy the natural environment, the consequences of which would be catastrophic. He wanted to excite a ‘love of nature’ and thereby, revolutionized how the natural world was seen. He believed that nature speaks to humanity in a voice “familiar to our soul” (p. 61), thereby aligning himself with the Romantic poets of his time who believed nature could only be understood by turning inward.

The educator Mark Edmundson uses great literature and poetry to nurture well-being, including the ideals needed by the human soul such as courage, contemplation, and compassion ( Edmundson, 2015 ). In Why Read ( Edmundson, 2004 ). Edmundson elaborates what a liberal, humanistic education can contribute to personal becoming. Apropos of Humboldt and his contemporaries, Edmondson examined Wordsworth’s famous poem, “Lines Composed a Few Miles from Tintern Abbey” written in 1798. Wordsworth’s life had become flat – “he lived in a din-filled city, among unfeeling people, and sensed that he is becoming one of them …there is a dull ache settling in his spirit” (p. 57). Returning to a scene from his childhood, he remembered himself as a young boy, free and reveling in nature. The return to nature, which is the heart of the poem, reminds him of its role in nurturing his own vitality. “Wordsworth’s poem enjoins us to feel that it (the answer to one’s despondency) lies somewhere within our reach – we are creatures who have the capacity to make ourselves sick, but also the power to heal ourselves” (p. 49).

Wordsworth’s poetry served the same vital function in the life of John Stuart Mill (1893/1989) , who in early adulthood realized something deeply troubling – that he lacked the happiness central to the utilitarian philosophy in which he was immersed. Reflecting on his life, Mill described an early educational experience that was exceptional, but profoundly deficient. His father began teaching him Greek and Latin at a young age and then expanded the pedagogy to fields of philosophy, science, and mathematics. However, his father was deeply opposed to anything connected to sentiment or emotion. To escape the logic machine he had become, Mill began a quest to feel, and it was the poetry of Wordsworth, mostly about nature, that ministered deeply to the longings in his soul. He credited it for helping him recover from the crisis in his mental history.

To summarize, amidst the many interventions under study in PP, I lobby for a focus on encounters with nature, which some are already investigating. The preceding examples give us reason to believe that human lives may be enriched by such experiences. These can occur by being in nature as well as from reading about nature in poetry and literature, taking it in through film, or listening to music inspired by nature.

Concluding Thoughts

My observations about what PP has accomplished over the last two decades are clearly mixed. Some may see the criticism as unfounded, if not mean-spirited, while others may view the input as long overdue straight talk about problems with an initiative intended to be transformational. I have long believed that self-criticism is central to making progress, whether in our individual lives, or our collective pursuits. My hope is thus that the field of PP will grow and flourish going forward, but also come to grips with its limitations. How might this happen?

One way is to pay attention to the problem of overreach in what PP claims to have accomplished. This will require greater scrutiny of the science touted as the evidential basis that PP works. Peer review is all we have to monitor the quality of the work that we do, but alas, it is an imperfect system, such that seriously flawed work sometimes gets published, even in high visibility outlets. There is the related problem of PP taking credit for more than it can credibly call its own achievements – i.e., the impact of PP ( Rusk and Waters, 2013 ) has been overstated. As conveyed at the outset, extensive science on positive human functioning was happening well before PP declared its visionary new path. The upshot is that quantitative summaries of positive science unavoidably include many products that have nothing to do with the field of PP. Work from MIDUS is but one example of such wide-ranging science, much published in top-tier journals, showing protective benefits of psychological strengths. These studies were not created or nurtured by PP, and therefore, do not constitute evidence of its impact. Such distortion diminishes the stature of PP.

Relatedly there is need to recognize the insularity of PP, much seeming United States-centric, particularly in leadership. By creating its own professional society and journal, PP unfortunately removed itself from the wider discipline of psychology and its subfields, each with their own organizations and journals. While new groups can nurture comradery and a sense of identity, they can also create distance from related areas of inquiry. Most problematic, they can lead to insider peer reviewing that likely lowers rather than elevates the quality of the work generated.

On the matter of the commercialization of PP, I am perhaps an outlier in seeing this as a significant problem. However, it is construed, those who care about the long-term future of PP need to grapple with how to prevent the pursuit of profit from becoming a force that could ultimately take the enterprise down – on grounds that it is not scientifically substantiated, nor is it properly regulated, or doing lasting good, or is even creating harm. Without proper oversight, business pursuits could become the antithesis of the original promise and purpose of PP – to advance optimal human functioning.

Most of my essay has not been about these troublesome matters. Rather, I have tried to underscore the widespread consensus, from within PP and beyond, that thoughtful formulations are needed going forward, which put positives and negative together – i.e., research and practice that integrates human strengths and vulnerabilities. Parenthetically, one benefit of this shift may be that the adjective “positive” is less relentlessly present in titles of articles, books, and journals. As many have observed, greater attention must be given to diversity – i.e., how the wide array of topics being studied vary by numerous dimensions (e.g., age, gender, race/ethnicity, socioeconomic status, disability status, sexual orientation, and cultural context). It is also critical that societal relevance be a priority in the future science and practice that lies ahead. So doing demands attending to contemporary problems, and how they are negotiated in diverse life contexts. Our societal ills further call for study of negatives that have historically been neglected (greed, indifference, stupidity, and anger). Nonetheless, amidst the contemporary turbulence is the promise of the arts and of nature to help us be better – in seeing and caring about the suffering of others as well as in inspiring us to make the most of the lives we have been given and do so with commitment that encompasses families, schools, the workplace, communities, and the planet.

Data Availability Statement

Publicly available datasets were analyzed in this study. This data can be found here: .

Author Contributions

The author confirms being the sole contributor of this work and has approved it for publication.

National Institute on Aging Grants (P01-AG020166; U19-AG051426).

Conflict of Interest

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords : positive, negative, commercialization, inequality, greed, indifference, arts, nature

Citation: Ryff CD (2022) Positive Psychology: Looking Back and Looking Forward. Front. Psychol. 13:840062. doi: 10.3389/fpsyg.2022.840062

Received: 20 December 2021; Accepted: 21 February 2022; Published: 17 March 2022.

Reviewed by:

Copyright © 2022 Ryff. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Carol D. Ryff, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Positive psychology interventions: a meta-analysis of randomized controlled studies

  • Linda Bolier 1 ,
  • Merel Haverman 2 ,
  • Gerben J Westerhof 3 ,
  • Heleen Riper 4 , 5 ,
  • Filip Smit 1 , 6 &
  • Ernst Bohlmeijer 3  

BMC Public Health volume  13 , Article number:  119 ( 2013 ) Cite this article

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The use of positive psychological interventions may be considered as a complementary strategy in mental health promotion and treatment. The present article constitutes a meta-analytical study of the effectiveness of positive psychology interventions for the general public and for individuals with specific psychosocial problems.

We conducted a systematic literature search using PubMed, PsychInfo, the Cochrane register, and manual searches. Forty articles, describing 39 studies, totaling 6,139 participants, met the criteria for inclusion. The outcome measures used were subjective well-being, psychological well-being and depression. Positive psychology interventions included self-help interventions, group training and individual therapy.

The standardized mean difference was 0.34 for subjective well-being, 0.20 for psychological well-being and 0.23 for depression indicating small effects for positive psychology interventions. At follow-up from three to six months, effect sizes are small, but still significant for subjective well-being and psychological well-being, indicating that effects are fairly sustainable. Heterogeneity was rather high, due to the wide diversity of the studies included. Several variables moderated the impact on depression: Interventions were more effective if they were of longer duration, if recruitment was conducted via referral or hospital, if interventions were delivered to people with certain psychosocial problems and on an individual basis, and if the study design was of low quality. Moreover, indications for publication bias were found, and the quality of the studies varied considerably.


The results of this meta-analysis show that positive psychology interventions can be effective in the enhancement of subjective well-being and psychological well-being, as well as in helping to reduce depressive symptoms. Additional high-quality peer-reviewed studies in diverse (clinical) populations are needed to strengthen the evidence-base for positive psychology interventions.

Peer Review reports

Over the past few decades, many psychological treatments have been developed for common mental problems and disorders such as depression and anxiety. Effectiveness has been established for cognitive behavioral therapy [ 1 , 2 ], problem-solving therapy [ 3 ] and interpersonal therapy [ 4 ]. Preventive and early interventions, such as the Coping with Depression course [ 5 ], the Don’t Panic course [ 6 ] and Living Life to the Full [ 7 , 8 ] are also available. The existing evidence shows that the mental health care system has traditionally focused more on treatment of mental disorders than on prevention. However, it is recognized that mental health is more than just the absence of mental illness, as expressed in the World Health Organization’s definition of mental health:

Mental health is a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively, and is able to make a contribution to his or her community [ 9 ].

Under this definition well-being and positive functioning are core elements of mental health. It underscores that people can be free of mental illness and at the same time be unhappy and exhibit a high level of dysfunction in daily life [ 10 ]. Likewise, people with mental disorders, can be happy by coping well with their illness and enjoy a satisfactory quality of life [ 11 ]. Subjective well-being refers to a cognitive and/or affective appraisal of one’s own life as a whole [ 12 ]. Psychological well-being focuses on the optimal functioning of the individual and includes concepts such as mastery, hope and purpose in life [ 13 , 14 ]. The benefits of well-being are recorded both in cross-sectional and longitudinal research and include improved productivity at work, having more meaningful relationships and less health care uptake [ 15 , 16 ]. Well-being is also positively associated with better physical health [ 17 – 19 ]. It is possible that this association is mediated by a healthy lifestyle and a healthier immune system, which buffers the adverse influence of stress [ 20 ]. In addition, the available evidence suggests that well-being reduces the risk of developing mental symptoms and disorders [ 21 , 22 ] and helps reduce mortality risks in people with physical disease [ 23 ].

Seligman and Csikszentmihaly’s (2000) pioneered these principles of positive psychology in their well-known article entitled ‘Positive psychology: An introduction’, published in a special issue of the American Psychologist. They argued that a negative bias prevailed in psychology research, where the main focus was on negative emotions and treating mental health problems and disorders [ 24 ]. Although the basic concepts of well-being, happiness and human flourishing have been studied for some decades [ 12 , 25 – 27 ], there was a lack of evidence-based interventions [ 24 ]. Since the publication of Seligman and Csikszentmihaly’s seminal article, the positive psychology movement has grown rapidly. The ever-expanding International Positive Psychology Association is among the most extensive research networks in the world [ 28 ] and many clinicians and coaches embrace the body of thought that positive psychology has to offer.

Consequently, the number of evaluation studies has greatly increased over the past decade. Many of these studies demonstrated the efficacy of positive psychology interventions such as counting your blessings [ 29 , 30 ], practicing kindness [ 31 ], setting personal goals [ 32 , 33 ], expressing gratitude [ 30 , 34 ] and using personal strengths [ 30 ] to enhance well-being, and, in some cases, to alleviate depressive symptoms [ 30 ]. Many of these interventions are delivered in a self-help format. Sin and Lyubomirsky (2009) conducted a meta-analytical review of the evidence for the effectiveness of positive psychology interventions (PPIs). Their results show that PPIs can indeed be effective in enhancing well-being (r = 0.29, standardized mean difference Cohen’s d = 0.61) and help to reduce depressive symptom levels in clinical populations (r = 0.31, Cohen’s d = 0.65). However, this meta-analysis had some important limitations. First, the meta-analysis included both randomized studies and quasi-experimental studies. Second, study quality was not addressed as a potential effect moderator. In recent meta-analyses, it has been shown that the treatment effects of psychotherapy have been overestimated in lower quality studies [ 35 , 36 ]. The lack of clarity in the inclusion criteria constitutes a third limitation. Intervention studies, although related to positive psychology but not strictly developed within this new framework (e.g. mindfulness, life-review) were included in the meta-analysis. However, inclusion of these studies reduces the robustness of the results for pure positive psychology interventions.

Present study

The aim of the present study is to conduct a meta-analysis of the effects of specific positive psychology interventions in the general public and in people with specific psychosocial problems. Subjective well-being, psychological well-being and depressive symptoms were the outcome measures. Potential variables moderating the effectiveness of the interventions, such as intervention type, duration and quality of the research design, were also examined. This study will add to the existing literature and the above meta-analytical review [ 37 ] by 1) only including randomized controlled studies, 2) taking the methodological quality of the primary studies into account, 3) including the most recent studies (2009 – 2012), 4) analyzing not only post-test effects but also long-term effects at follow up, and 5) applying clear inclusion criteria for the type of interventions and study design.

Search strategy

A systematic literature search was carried out in PsychInfo, PubMed and the Cochrane Central Register of Controlled Trials, covering the period from 1998 (the start of the positive psychology movement) to November 2012. The search strategy was based on two key components: there should be a) a specific positive psychology intervention, and b) an outcome evaluation. The following MeSH terms and text words were used: “well-being” or “happiness” or “happy*”, “optimism”, “positive psychology” in combination with “intervention”, “treatment”, “therapy” and “prevention”. This was combined with terms related to outcome research: “effect*”, or “effic*”, or “outcome*”, or “evaluat*”. We also cross-checked the references from the studies retrieved, the earlier meta-analysis of Sin & Lyubomirsky (2009) and two other reviews of positive psychological interventions [ 38 , 39 ]. The search was restricted to peer-reviewed studies in the English language.

Selection of studies

Two reviewers (LB and MH) independently selected potentially eligible studies in two phases. At the first phase, selection was based on title and abstract, and at the second phase on the full-text article. All studies identified as potentially eligible by at least one of the reviewers during the first selection phase, were re-assessed at the second selection phase. During the second phase, disagreements between the reviewers were resolved by consensus. The inter-rater reliability (kappa) was 0.90.

The inclusion criteria were as follows:

Examination of the effects of a positive psychology intervention. A positive psychology intervention (PPI) was defined in accordance with Sin and Lyubomirsky’s (2009) article as a psychological intervention (training, exercise, therapy) primarily aimed at raising positive feelings, positive cognitions or positive behavior as opposed to interventions aiming to reduce symptoms, problems or disorders. The intervention should have been explicitly developed in line with the theoretical tradition of positive psychology (usually reported in the introduction section of an article).

Randomization of the study subjects (randomizing individuals, not groups) and the presence of a comparator condition (no intervention, placebo, care as usual).

Publication in a peer-reviewed journal.

At least one of the following are measured as outcomes: well-being (subjective well-being and/or psychological well-being) or depression (diagnosis or symptoms).

Sufficient statistics are reported to enable the calculation of standardized effect sizes.

If necessary, authors were contacted for supplementary data. We excluded studies that involved physical exercises aimed at the improvement of well-being, as well as mindfulness or meditation interventions, forgiveness therapy, life-review and reminiscence interventions. Furthermore, well-being interventions in diseased populations not explicitly grounded in positive psychology theory (‘coping with disease courses’) were excluded. Apart from being beyond the scope of this meta-analysis, extensive meta-analyses have already been published for these types of intervention [ 40 – 42 ]. This does not imply that these interventions do not have positive effects on well-being, a point which will be elaborated on in the discussion section of this paper.

Data extraction

Data extraction and study quality assessment were performed by one reviewer (LB) and independently checked by a second reviewer (MH). Disagreements were resolved by consensus. Data were collected on design, intervention characteristics, target group, recruitment methods, delivery mode, number of sessions, attrition rates, control group, outcome measures and effect sizes (post-test and at follow up of at least 3 months). The primary outcomes in our meta-analysis were subjective well-being (SWB), psychological well-being (PWB) and depressive symptoms/depression.

The methodological quality of the included studies was assessed using a short scale of six criteria tailored to those studies and based on criteria established by the Cochrane collaboration [ 43 ]: 1) Adequacy of randomization concealment, 2) Blinding of subjects to the condition (blinding of assessors was not applicable in most cases), 3) Baseline comparability: were study groups comparable at the beginning of the study and was this explicitly assessed? (Or were adjustments made to correct for baseline imbalance using appropriate covariates), 4) Power analysis: is there an adequate power analysis and/or are there at least 50 participants in the analysis?, 5) Completeness of follow up data: clear attrition analysis and loss to follow up < 50%, 6) Handling of missing data: the use of intention-to-treat analysis (as opposed to a completers-only analysis). Each criterion was rated as 0 (study does not meet criterion) or 1 (study meets criterion). The inter-rater reliability (kappa) was 0.91. The quality of a study was assessed as high when five or six criteria were met, medium when three or four criteria were met, and low when zero, one or two criteria were met. Along with a summary score, the aspects relating to quality were also considered individually, as results based on composite quality scales can be equivocal [ 44 ]. Table  1 shows the quality assessment for each study. The quality of the studies was scored from 1 to 5 (M = 2.56; SD = 1.25). Twenty studies were rated as low, 18 were of medium quality and one study was of high quality. None of the studies met all quality criteria. The average number of participants in the analysis was rather high (17 out of 39 studies scored positive on this criterion), although none of the studies reported an adequate power analysis. Also, baseline comparability was frequently reported (26/39 studies). On the other hand, independence in the randomization procedure was seldom reported (7/39 studies) and an intention-to-treat analysis was rarely conducted (3/39 studies).

  • Meta-analysis

In a meta-analysis, the effects found in the primary studies are converted into a standardized effect size, which is no longer placed on the original measurement scale, and can therefore be compared with measures from other scales. For each study, we calculated effect sizes (Cohen’s d ) by subtracting the average score of the experimental group (Me) from the average score of the control group (Mc), and dividing the result by the pooled standard deviations of both groups. This was done at post-test because randomization usually results in comparable groups across conditions at baseline. However, if baseline differences on outcome variables did exist despite the randomization, d’s were calculated on the basis of pre- post-test differences: by calculating the standardized pre- post change score for the experimental group (de) and the control group (dc) and subsequently calculating their difference as Δd= de – dc. For example, an effect size of 0.5 indicates that the mean of the experimental group is half a standard unit (standard deviation) larger than the mean of the control group. From a clinical perspective, effect sizes of 0.56 – 1.2 can be interpreted as large, while effect sizes of 0.33 – 0.55 are of medium size, and effects of 0 – 0.32 are small [ 45 ].

In the calculation of effect sizes for depression, we used instruments that explicitly measure depression (e.g. the Beck Depression Inventory, or the Center for Epidemiological Studies Depression Scale). For subjective and psychological well-being, we also used instruments related to the construct of well-being (such as positive affect for SWB and hope for PWB). If more than one measure was used for SWB, PWB or depression, the mean of the effect sizes was calculated, so that each study outcome had one effect size. If more than one experimental group was compared with a control condition in a particular study, the number of subjects in the control groups was evenly divided across the experimental groups so that each subject was used only once in the meta-analysis.

To calculate pooled mean effect sizes, we used Comprehensive Meta-Analysis (CMA, Version 2.2.064). Due to the diversity of studies and populations, a common effect size was not assumed and we expected considerable heterogeneity. Therefore, it was decided a priori to use the ‘random effects model’. Effect sizes may differ under this model, not only because of random error within studies (as in the fixed effects model), but also as a result of true variation in effect sizes between studies. The outcomes of the random effects model are conservative in that their 95% Confidence Intervals (CIs) are often broad, thus reducing the likelihood of type-II errors.

We tested for the presence of heterogeneity with two indicators. First, we calculated the Q-statistic. A significant Q rejects the null-hypothesis of homogeneity and indicates that the true effect size probably does vary from study to study. Second, the I 2 -statistic was calculated. This is a percentage indicating the study-to-study dispersion due to real differences, over and above random sampling error. A value of 0% indicates an absence of dispersion, and larger values show increasing levels of heterogeneity where 25% can be considered as low, 50% as moderate and 75% as a high level of heterogeneity [ 46 ].

Owing to the expected high level of heterogeneity, all studies were taken into account. Outliers were considered, but not automatically removed from the meta-analysis. The procedure of removing outliers which are outside the confidence interval of the pooled effect size is advised when a common effect size is assumed. However, in our meta-analysis, high dispersion was expected and therefore only the exclusion of Cohen’s d > 2.5 from the final sample was planned.

Subgroup analyses were performed by testing differences in Cohen’s d’s between subgroups. Six potential moderators were determined based on previous research and the characteristics of the investigated interventions and studies: 1) Self-selected sample/not self-selected: did the participants know that the aim of the intervention was to make them feel better?; 2) Duration: less than four weeks, four to eight weeks, or more than eight weeks; 3) Type of intervention: self-help, group intervention, or individual therapy; 4) Recruitment method: community (in a community center, local newspapers), internet, by referral/hospital, at university; 5) Psychosocial problems (Yes/none): was the data based on a group with certain psychosocial problems or was the study open to everyone?; 6) Quality rating: low (score 1 or 2), medium (score 3 or 4) or high (score 5 or 6). The impact of the duration and quality ratings was also assessed using meta-regression.

Results of meta-analysis may be biased due to the fact that studies with non-significant or negative results are less likely to be published in peer-reviewed journals [ 47 ]. In order to address this issue, we used three indices: funnel plots, the Orwin’s fail-safe number and the Trim and Fill method. A funnel plot is a graph of effect size against study size. When publication bias is absent, the observed studies are expected to be distributed symmetrically around the pooled effect size. The Orwin’s fail-safe number indicates the number of non-significant unpublished studies needed to reduce the overall significant effect to non-significance (according to a self-stated criterium) [ 48 ]. The effect size can be considered to be robust if the number of studies required to reduce the overall effect size to a non-significant level exceeds 5 K + 10, where K is the number of studies included. If asymmetry is found in the funnel plot, the Trim and Fill method adjusts the pooled effect size for the outcomes of missing studies [ 49 ]. Imputing missing studies restores the symmetry in the funnel plot and an adjusted effect size can be calculated.

For the reporting of the results of this meta-analysis, we applied Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 50 ].

Description of studies

The selection process is illustrated in Figure  1 . First, 5,335 titles were retrieved from databases and 55 titles were identified through searching the reference list accompanying the meta-analysis by Sin and Lyubomirsky (2009) [ 37 ] as well as two other literature reviews of positive psychological interventions [ 38 , 39 ]. After reviewing the titles and abstracts and removing duplicates, 84 articles were identified as being potentially eligible for inclusion in our study. Of these 84 articles, 40 articles in which 39 studies were described, met our inclusion criteria (of these, 17 articles describing 19 studies were also included in the meta-analysis by Sin and Lyubomirsky, 2009). In two articles [ 29 , 51 ] two studies were described, and one study [ 52 – 55 ] was published in four articles.

figure 1

Flow diagram.

The characteristics of the studies included are described in Table  2 . The studies evaluated 6,139 subjects, 4,043 in PPI groups and 2,096 in control groups. Ten studies compared a PPI with a no-intervention control group [ 29 , 51 , 56 – 63 ], 17 studies compared a PPI with a placebo intervention [ 29 , 30 , 32 , 34 , 52 – 55 , 64 – 75 ], seven studies with a waiting list control group [ 33 , 76 – 81 ] and five studies with another active intervention (care as usual) [ 51 , 82 – 85 ]. A minority of seven studies [ 51 , 57 , 76 , 77 , 82 , 83 ] applied inclusion criteria to target a specific group with psychosocial problems such as depression and anxiety symptoms. Half of the studies, 19 in total, recruited the subjects (not necessarily students) through university [ 29 , 32 , 34 , 51 , 56 , 58 – 61 , 64 – 68 , 70 , 72 , 75 , 80 , 85 ]. In seven studies subjects were recruited in the community [ 33 , 57 , 71 , 73 , 76 , 77 , 81 ], in four studies by referral from a practitioner or hospital [ 29 , 51 , 82 , 83 ], in three studies in an organization [ 62 , 78 , 79 ] and six studies recruited through the internet [ 30 , 52 – 55 , 63 , 69 , 74 , 84 ]. Twenty-eight studies measured subjective well-being, 20 studied psychological well-being and 14 studied depressive symptoms. Half of the studies (20) were aimed at adult populations [ 29 , 30 , 33 , 51 – 56 , 62 , 63 , 65 , 69 , 71 , 73 , 74 , 76 , 78 , 79 , 81 – 84 ]. A substantial number of studies (17) were aimed at college students [ 29 , 32 , 34 , 51 , 58 – 61 , 64 , 66 – 68 , 70 , 72 , 75 , 80 , 85 ] and two studies were aimed at older subjects [ 57 , 77 ]. In most studies (26) the PPI was delivered in the form of self-help [ 29 , 30 , 34 , 52 – 56 , 58 , 59 , 61 , 63 – 71 , 73 – 75 , 77 , 78 , 80 , 84 , 85 ]. Eight studies used group PPIs [ 32 , 33 , 51 , 57 , 60 , 62 , 72 , 76 ] and five used individual PPIs [ 51 , 79 , 81 – 83 ]. Intensity varied considerably across studies, ranging from a short one-day exercise [ 70 ] and a two-week self-help intervention [ 65 ] to intensive therapy [ 51 , 82 , 83 ] and coaching [ 33 , 81 ].

Post-test effects

The random effect model showed that the PPIs were effective for all three outcomes. Results are presented in Table  3 . The effect sizes of the individual studies at post-test are plotted in Figures  2 , 3 and 4 .

figure 2

Post-test effects of positive psychology interventions on subjective well-being. The square boxes show effect size and sample size (the larger the box, the larger the sample size) in each study, and the line the 95% confidence interval. The diamond reflects the pooled effect size and the width of the 95% confidence interval.

figure 3

Post-test effects of positive psychology interventions on psychological well-being. The square boxes show effect size and sample size (the larger the box, the larger the sample size) in each study, and the line the 95% confidence interval. The diamond reflects the pooled effect size and the width of the 95% confidence interval.

figure 4

Post-test effects of positive psychology interventions on depressive symptoms. The square boxes show effect size and sample size (the larger the box, the larger the sample size) in each study, and the line the 95% confidence interval. The diamond reflects the pooled effect size and the width of the 95% confidence interval.

A composite moderate and statistically significant effect size (Cohen’s d ) was observed for subjective well-being d = 0.34 (95% CI [0.22, 0.45], p<.01). For psychological well-being, Cohen’s d was 0.20 (95% CI [0.09, 0.30], p<.01) and for depression d = 0.23 (95% CI [0.09, 0.38], p<.01), which can be considered as small.

Heterogeneity was moderate for subjective well-being (I 2 = 49.5%) and depression (I 2 = 47.0%), and low for psychological well-being (I 2 = 29.0%). Effect sizes ranged from −0.09 [ 66 ] to 1.30 [ 64 ] for subjective well-being, -0.06 [ 78 ] to 2.4 [ 83 ] for psychological well-being and −0.17 [ 69 ] to 1.75 [ 83 ] for depression.

Removing outliers reduced effect sizes for all three outcomes: 0.26 (95% CI [0.18, 0.33], Z=6.43, p<.01) for subjective well-being (Burton & King, 2004 and Peters et al., 2010 removed) [ 64 , 70 ], 0.17 (95% CI [0.09, 0.25], Z=4.18, p<.01) for psychological well-being (Fava et al. (2005) removed) [ 83 ] and 0.18 (95% CI [0.07, 0.28], Z=3.33, p<.01) for depression (Fava, 2005 and Seligman, 2006 study 2, removed) [ 51 , 83 ]. Removing the outliers reduced heterogeneity substantially (to a non-significant level).

Follow-up effects

Ten studies examined follow-up effects after at least three months and up to 12 months (Table  3 ). For the purposes of interpretation, we used only those studies examining effects from three to six months (short-term follow-up), thus excluding Fava et al. (2005) [ 83 ] which had a follow-up at one year. The random-effects model demonstrated small but significant effects in comparison with the control groups for subjective well-being (Cohen’s d 0.22, 95% CI [0.05, 0.38], p<.01) and for psychological well-being (0.16, 95% CI [0.02, 0.30], p = .03). The effect was not significant for depression (0.17, 95% CI [−0.06, 0.39], p = .15). Heterogeneity was low for subjective well-being (I 2 = 1.1%) and psychological well-being (I 2 = 26.0%), and high for depression (I 2 = 63.9%).

Subgroup analyses

Subgroup analyses are presented in Table  4 . We looked at self-selection, duration of the intervention, type of intervention, recruitment method, application of inclusion criteria related to certain psychosocial problems, and quality rating.

For depression, five out of six subgroups of studies resulted in significantly higher effect sizes. Higher effect sizes were found for 1) interventions of a longer duration (only in the meta regression analysis), 2) individual interventions, 3) studies involving referral from a health care practitioner or hospital, 4) studies which applied inclusion criteria based on psychosocial problems and 5) lower quality studies. For subjective well-being and psychological well-being, there were no significant differences between subgroups, although for the latter there was a recognizable trend in the same direction and on the same moderators, except for quality rating.

Twenty-six out of 39 studies were self-help interventions for which we conducted a separate subgroup analysis. However, there was little diversity within the self-help subgroup: only six studies examined intensive self-help for longer than four weeks, self-help was offered to people with specific psychosocial problems in only one study and more than half of the self-help studies (n=14) recruited their participants via university. Consequently, there were no significant differences between subgroups for self-help interventions.

Publication bias

Indications for publication bias were found for all outcome measures, but to a lesser extent for subjective well-being. Funnel plots were asymmetrically distributed in such a way that the smaller studies often showed the more positive results (in other words, there is a certain lack of small insignificant studies). Orwin’s fail-safe numbers based on a criterium effect size of 0.10 for subjective well-being (59), psychological well-being (16) and depression (13) were lower than required (respectively 150, 110 and 80). Egger’s regression intercept also suggests that publication bias exists for psychological well-being (intercept=1.18, t=2.26, df=18, p=.04) and depression (intercept=1.45, t=2.26, df=12, p=.03), but not for subjective well-being (intercept=1.20, t=1.55, df=26, p=0.13). The mean effect sizes of psychological well-being and depression were therefore recalculated by imputing missing studies using the Trim and Fill method. For psychological well-being, three studies were imputed and the effect size was adjusted to 0.16 (95% CI 0.03-0.29). For depression, five studies were imputed and the adjusted effect size was 0.16 (95% CI 0.00-0.32).

Main findings

This meta-analysis synthesized effectiveness studies on positive psychology interventions. Following a systematic literature search, 40 articles describing 39 studies were included. Results showed that positive psychology interventions significantly enhance subjective and psychological well-being and reduce depressive symptoms. Effect sizes were in the small to moderate range. The mean effect size on subjective well-being was 0.34, 0.20 on psychological well-being, and 0.23 on depression. Effect sizes varied a great deal between studies, ranging from below 0 (indicating a negative effect) to 2.4 (indicating a very large effect). Moreover, at follow-up from three to six months, small but still significant effects were found for subjective well-being and psychological well-being, indicating that effects were partly sustained over time. These follow-up results should be treated with caution because of the small number of studies and the high attrition rates at follow-up.

Remarkably, effect sizes in the current meta-analysis are around 0.3 points lower than the effect sizes in the meta-analysis by Sin and Lyubomirsky (2009) [ 37 ]. We included a different set of studies in which the design quality was assured using randomized controlled trials only. Effectiveness research in psychotherapy shows that effect sizes are relatively small in high-quality studies compared with low-quality studies [ 35 ] and this might also be true for positive psychology interventions. In addition, we applied stricter inclusion criteria than those used by Sin and Lyubomirsky (2009) and therefore did not include studies on any related areas such as mindfulness and life review therapy. These types of interventions stem from long-standing independent research traditions for which effectiveness has already been established in several meta-analyses [ 40 , 41 ]. Also, the most recent studies were included. This might explain the overestimation of effect sizes in the meta-analysis by Sin and Lyubomirsky (2009).

Several characteristics of the study moderated the effect on depressive symptoms. Larger effects were found in interventions with a longer duration, in individual interventions (compared with self-help), when the interventions were offered to people with certain psychosocial problems and when recruitment was carried out via referral from a health care professional or hospital. Quality rating also moderated the effect on depression: the higher the quality, the smaller the effect. Interestingly, these characteristics did not significantly moderate subjective well-being and psychological well-being. However, there was a trend in the moderation of psychological well-being that was the same as that observed in the studies which included depression as an outcome. In general, effectiveness was increased when interventions were offered over a longer period, face-to-face on an individual basis in people experiencing psychosocial problems and when participants were recruited via the health care system.

Although it is clear that more intensive and face-to-face interventions generate larger effects, the effects of short-term self-help interventions are small but significant. From a public health perspective, self-help interventions can serve as cost-effective mental health promotion tools to reach large target groups which may not otherwise be reached [ 86 – 88 ]. Even interventions presenting small effect sizes can in theory have a major impact on populations’ well-being when many people are reached [ 89 ]. The majority of positive psychology interventions (in our study 26 out of 39 studies) are already delivered in a self-help format, sometimes in conjunction with face-to-face instruction and support. Apparently, self-help suits the goals of positive psychology very well and it would be very interesting to learn more about how to improve the effectiveness of PPI self-help interventions. However, a separate subgroup analysis on the self-help subgroup revealed no significant differences in the present meta-analysis. There was very little variation in the subgroups as regards population, duration of the intervention and recruitment method. As a result, this analysis does not give firm indications on how to improve the effectiveness of self-help interventions. It is possible that self-help could be enhanced by offering interventions to people with specific psychosocial problems, increasing the intensity of the intervention and embedding the interventions in the health care system. However, more studies in diverse populations, settings and with varying intensity are needed before we can begin to derive recommendations from this type of meta-analysis. Other research gives several additional indications on how to boost the efficacy of self-help interventions. Adherence tends to be quite low in self-help interventions [ 90 , 91 ] and therefore, enhancing adherence could be a major factor in improving effectiveness. Self-help often takes a ‘one size fits all’ approach, which may not be appropriate for a large group of people who will, as a consequence, not fully adhere to the intervention. Personalization and tailoring self-help interventions to individual needs [ 92 ] as well interactive support [ 93 ] might contribute to increased adherence and likewise improved effectiveness of (internet) self-help interventions.

Study limitations

This study has several limitations. First, the quality of the studies was not high, and no study met all of our quality criteria. For example, the randomization procedure was unclear in many studies. Also, most studies conducted completers-only analysis, as opposed to intention-to-treat analysis. This could have seriously biased the results [ 35 ]. However, the low quality of the studies could have been overstated as the criteria were scored conservatively: we gave a negative score when a criterion was not reported. Even so, more high-quality randomized-controlled trials are needed to enable more robust conclusions about the effects of PPIs. Second, different types of interventions are lumped together as positive psychology interventions, despite the strict inclusion criteria we applied. As expected, we found a rather high level of heterogeneity. In the future, it might be wise and meaningful to conduct meta-analyses that are restricted to specific types of interventions, for example gratitude interventions, strengths-based interventions and well-being therapy, just as has already been carried out with, for example, mindfulness and life review. In the present meta-analysis, studies on these specific interventions were too small and too diverse to allow for a subgroup-analysis. Third, the exclusion of non peer-reviewed articles and grey literature could have led to bias, and possibly also to the publication bias we found in our study. Fourth, although we included a relatively large number of studies in the meta-analysis, the number of studies in some subgroups was still small. Again, more randomized-controlled trials are needed to draw firmer conclusions. Sixth, the study of positive education is an emerging field in positive psychology [ 94 – 98 ] but school-based interventions were excluded from our meta-analysis due to the strict application of the inclusion criteria (only studies with randomization at individual level were included).

This meta-analysis demonstrates that positive psychology interventions can be effective in the enhancement of subjective and psychological well-being and may help to reduce depressive symptom levels. Results indicate that the effects are partly sustained at short-term follow-up. Although effect sizes are smaller in our meta-analysis, these results can be seen as a confirmation of the earlier meta-analysis by Sin and Lyubomirsky (2009). Interpretation of our findings should take account of the limitations discussed above and the indications for publication bias.

Implications for practice

In mental health care PPIs can be used in conjunction with problem-based preventive interventions and treatment. This combination of interventions might be appropriate when clients are in remission; positive psychology interventions may then be used to strengthen psychological and social recourses, build up resilience and prepare for normal life again. On the basis of the moderator analysis, we would recommend the delivery of interventions over a longer period (at least four weeks and preferably eight weeks or longer) and on an individual basis. Practitioners can tailor their treatment strategy to the needs and preferences of a client and can use positive psychology exercises in combination with other evidence-based interventions that have a positive approach and aim to enhance well-being, such as mindfulness interventions [ 40 ], Acceptance and Commitment Therapy [ 7 , 99 ], forgiveness interventions [ 42 ], behavioral-activation [ 100 ] and reminiscence [ 41 , 101 ].

In the context of public health, positive psychology interventions can be used as preventive, easily accessible and non-stigmatizing tools. They can potentially be used in two ways: 1) in mental health promotion (e.g. leaflets distributed for free at community centers, (mental) health internet portals containing psycho-education), and 2) as a first step in a stepped care approach. In the stepped care model, clients start with a low-intensity intervention if possible, preferably a self-directed intervention. These interventions can be either guided by a professional or unguided, and are increasingly delivered over the internet. Clinical outcomes can be monitored and people can be provided with more intensive forms of treatment, or referred to specialized care, if the first-step intervention does not result in the desired outcome [ 102 ].

Recommendations for research

Regarding the research agenda, there is a need for more high-quality studies, and more studies in diverse (clinical) populations and diverse intervention formats to know what works for whom. Standards for reporting studies should also be given more attention, for example by reporting randomized controlled trials according to the CONSORT statement [ 103 ]. In addition, we encourage researchers to publish in peer-reviewed journals, even when the sample sizes are small or when there is a null finding of no effect, as this is likely to reduce the publication bias in positive psychology. Furthermore, most studies are conducted in North America. Therefore, replications are needed in other countries and cultures because some positive psychology concepts may require adaptation to other cultures and outlooks (e.g. see Martinez et al., 2010) [ 68 ]. Last but not least, we strongly recommend conducting cost-effectiveness studies aiming to establish the societal and public health impact of positive psychology interventions. This type of information is likely to help policy makers decide whether positive psychology interventions offer good value for money and should therefore be placed on the mental health agenda for the 21 st century.

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Abbott JA, Klein B, Hamilton C, Rosenthal A: The impact of online resilience training for sales managers on wellbeing and performance. E-J Appl Psychol. 2009, 5: 89-95.

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Spence GB, Grant AM: Professional and peer life coaching and the enhancement of goal striving and well-being: an exploratory study. J Posit Psychol. 2007, 2: 185-194. 10.1080/17439760701228896.

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We are grateful to Toine Ketelaars and Angita Peterse for the literature search and Jan Walburg for his comments on the manuscript. We would also like to thank Deirdre Brophy for the English language edit.

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LB conducted the meta-analysis, including the literature selection and data-analysis, and wrote the manuscript. MH took care of selecting the articles and cross-checking the data. All authors contributed to the design of the study. EB, GW, HR and FS are advisors in the project. All authors provided comments and approved the final manuscript.

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Bolier, L., Haverman, M., Westerhof, G.J. et al. Positive psychology interventions: a meta-analysis of randomized controlled studies. BMC Public Health 13 , 119 (2013).

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research on positive psychology

Noam Shpancer Ph.D.

The Power of Imagination in Achieving Your Goals

Clear, detailed, vivid and positive mental simulations are linked to well-being..

Updated June 1, 2024 | Reviewed by Hara Estroff Marano

  • What Is Motivation?
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  • Goal setting and pursuit are linked to well-being.
  • Goal-directed simulations may also relate to well-being
  • Goals that are more attainable and under control predict greater well-being and fewer depressive symptoms.
  • Positive, clear, goal-directed simulations strongly predicted well-being at a two-month follow-up.

Goal setting and pursuit, both of which are linked to mental health and future success , involve the capacity for future-oriented thinking. Another way to use this capacity is by engaging in mental simulations, by imagining a future event or state, and the way to get there. The two are not mutually exclusive and can work in concert. We may be more able to achieve a goal if we mentally simulate (imagine) how to get there and how great it would be to achieve it.

Mental simulations--a uniquely human capacity to move forward (and backward) in time--have also been shown experimentally to relate to people's mood, sense of meaning in life, and even exercise behavior. Yet many simulation studies require participants to imagine non-personal future events, rather than having them focus on personally relevant goals. As a result, we know little about how mental simulations of personally important goals may relate to well-being.

A recent (2021) study by Australian psychologist Beau Gamble and colleagues sought to address this gap. The authors recruited 153 Australian adults (98 females) for a set of interview sessions and collected data on participants' demographics, well-being, mood, and cognitive abilities. In addition, they asked participants to think of goals they wanted to achieve in their life over three time periods (short-, medium-, long-term), after which the participants were asked to choose the two most important of those goals. (The process was repeated for medium- and then long-term goals).

Participants were then presented with questions about each of their six chosen goals, and the goals were later scored on additional six variables (goal specificity, life domain, whether the goals were intrinsically or extrinsically focused, whether goals and motives were approach or avoidance, and whether motives were autonomous or controlled) by a trained research assistant, blind to study hypotheses and the identity of participants.

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In the simulation phase, “participants were presented with each of their six important goals in random order and given three minutes to imagine and verbally describe a specific future scene or scenes in their life, related to that goal.” After each simulation, participants answered questions about the simulation, related to valance (positivity/negativity), vividness, detail, clarity, fragmentation, and perspective (first vs. third person). Transcriptions were later assessed for the degree to which the simulation was focused on the process or outcome of the goal.

Two months after the initial interviews, participants completed a brief follow-up survey examining their levels of well-being and mood and any progress they had made on each of the six chosen goals. This allowed the researchers to assess changes in participants' well-being between the time of the study (T1) and the follow up (T2).

The central findings revealed strong positive correlations between goal attainability and sense of control and well-being. as well as between the degree to which goals were central to participants’ identity and well-being. Goal attainability and sense of control correlated negatively with depressive symptoms. (Depressive symptoms positively correlated with perceived goal difficulty.) Self-reported goal clarity, detail, vividness, and positivity correlated positively with well-being and negatively with depressive symptoms. Those who scored higher on goal clarity “tended to report making greater progress in their goals over time.”

Further analysis found that “In general, higher attainability and importance of goals, and higher clarity and lower negativity of simulations at T1, were strongly associated with higher well-being, lower depressive symptoms, and greater goal progress at T2.”

Specifically, “lower negativity (and higher positivity) of goal simulations was predictive of well-being at T2, even after controlling for well-being at T1, and together these variables accounted for 73% of the variance in T2 well-being.”

The results overall suggest, as expected, strong links between some aspects of goal setting and pursuit and well-being. “Some of the strongest links with mental health were higher perceived attainability, sense of control, and lower expected difficulty in achieving one’s goals.” Perceived goal attainability was the strongest predictor of goal progress.

research on positive psychology

Regarding goal-directed simulations, “emotional valence of simulations also appears to be particularly important in the context of predicting mental health over time. As predicted, higher well-being and lower depressive symptoms were correlated with greater clarity, vividness, and detail.”

In sum, the study linked more attainable, under control, emotionally positive goals to higher well-being and lower depressive symptoms. In addition, clearer, more detailed, more positive, and less negative goal-directed simulations also predicted higher well-being and less depression . Finally, positive goal-directed simulations strongly predicted well-being at a two-month follow-up. The authors conclude: “These findings underscore the relevance of goal-directed imagination to well-being and depressive symptoms, and highlight potential targets for goal- and imagery-based interventions to improve mental health.”

More data from larger, more diverse samples are needed, and the study's correlational design precludes us from reaching conclusions about causality. Yet the study provides suggestive evidence to the possibility that our mental health may benefit from a practice of periodically taking time to imagine pursuing and achieving important, attainable, and positive future goals in clear and vivid detail.

Noam Shpancer Ph.D.

Noam Shpancer, Ph.D., is a professor of psychology at Otterbein University and a practicing clinical psychologist in Columbus, Ohio.

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Positive Psychology and Physical Health

Positive psychology is the scientific study of a healthy and flourishing life. The goal of positive psychology is to complement and extend the traditional problem-focused psychology that has proliferated in recent decades. Positive psychology is concerned with positive psychological states (eg, happiness), positive psychological traits (eg, talents, interests, strengths of character), positive relationships, and positive institutions. We describe evidences of how topics of positive psychology apply to physical health. Research has shown that psychological health assets (eg, positive emotions, life satisfaction, optimism, life purpose, social support) are prospectively associated with good health measured in a variety of ways. Not yet known is whether positive psychology interventions improve physical health. Future directions for the application of positive psychology to health are discussed. We conclude that the application of positive psychology to health is promising, although much work remains to be done.

‘. . . a happy, engaged, and fulfilling psychological and social life is not just a consequence of good health, it is what leads people to live a healthy and long life.’
Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. —World Health Organization 1

Most would agree with this statement, but over the years, it has been largely a slogan. More recently, theory, research, and applications from the perspective of positive psychology have helped articulate the meaning of health and well-being. Positive psychology is an umbrella term for the scientific study of the various contributors to a healthy and thriving life for the self and others (eg, positive emotions, life meaning, engaging work, and close relationships). 2 It is the study of strengths, assets, and positive attributes. The topics of concern to positive psychology are broad indicators of psychological, social, and societal well-being.

Research has shown that not only are physical, mental, and social well-beings important components for complete health, but they are also interconnected. Evidence is accumulating that a happy, engaged, and fulfilling psychological and social life is not just a consequence of good health, it is what leads people to live a healthy and long life.

This article provides a brief overview of what positive psychology is and addresses how theories, findings, and especially applications from positive psychology might pertain to physical health.

What Is Positive Psychology?

Positive psychology is a perspective within psychology that studies optimal experience, people being and doing their best. 2 - 4 It challenges the assumptions of the disease model. Positive psychology assumes that life entails more than avoiding or undoing problems and that explanations of the good life must do more than reverse accounts of problems. Someone without symptoms or disorders may or may not be living well. Positive psychology urges attention to what is taking place on the other side of the zero point of being problem-free. It calls for as much focus on strength as on weakness, as much interest in building the best things in life as in repairing the worst, and as much attention to fulfilling the lives of healthy people as to healing the wounds of the distressed. Research findings from positive psychology are intended to contribute to a more complete and balanced scientific understanding of human experiences and ways to foster thriving in individuals, communities, and societies.

One of the triggers for the introduction of positive psychology was the realization that since World War II, psychology as a field had devoted much of its effort to identifying, treating, and—occasionally—preventing problems such as anxiety and depression. 3 The yield of these problem-focused efforts has been impressive, but a myopic view of the human condition has resulted. It is as if psychology has viewed people as only fragile and flawed.

The goal of positive psychology is to complement and extend the problem-focused psychology, and an important idea from positive psychology is that one way to solve problems is by identifying and leveraging individual and societal strengths and assets. 5

The topics of concern to positive psychology can be divided into 4 related topics 2 , 3 :

  • Positive subjective experiences (happiness, gratification, fulfillment, flow)
  • Positive individual traits (strengths of character, talents, interests, values)
  • Positive interpersonal relationships (friendship, marriage, colleagueship)
  • Positive institutions (families, schools, businesses, communities)

The value of positive psychology is to use the scientific method to sort through various claims and hypotheses about what it means to live well or poorly and to identify the relevant circumstances in each case.

Positive Psychology and Health

Can physical health be clarified by a positive perspective in the same way that psychological well-being has been clarified? To return to the definition of health by the World Health Organization with which this article began, 1 a positive perspective urges us to look beyond the mere absence of disease and infirmity to define what it means to be healthy in positive terms. 6 - 8 Positive health can be characterized not only as a long and disease-free life but additionally in terms of

  • Less frequent and briefer ailments
  • Greater recuperative ability
  • Rapid wound healing
  • More physiological reserves
  • Chronic but nondebilitating diseases

Familiar within the field of epidemiology are the population-level concepts of DALYs (disability adjusted life years), HALYs (health-adjusted life years), and QALYs (quality-adjusted life years), which combine measures of morbidity and mortality into the same index. 9 Along these lines, HLEs (happiness-adjusted life expectancies) measure the quality of life in a nation by forming the product of the average life expectancy and the average happiness (aka subjective well-being, life satisfaction) in that nation. 10 Positive health concerns itself with the individual-level analogues of these constructs.

The field of positive health as we envision it overlaps with allied approaches concerned with disease prevention, health promotion , and wellness. The value of positive health as an approach in its own right is that it makes explicit the need to consider good health as opposed to the absence of poor health. Studies of “wellness” often end up being studies of illness, much as studies of mental “health” are often studies of mental illness.

Concern with positive health leads to an examination of health assets , individual-level factors that produce positive health in one or more of the ways that it might be defined, over-and-above the frequently studied risk factors for poor health, like high cholesterol, obesity, smoking, excessive alcohol use, and a sedentary lifestyle. 8 Among the psychosocial risk factors frequently examined with respect to poor health are anger, anxiety, depression, and social isolation. By the logic of a positive perspective, the mere absence of these negative states and traits is not all that matters for physical health. Important as well are positive states and traits, and the contribution of these in their own right needs to be studied, controlling for negative states and traits as well as other usual-suspect risk factors.

There have been extensive studies on negative psychological factors such as stress, depression, hostility, and their effects on increased risk of various health problems. 11 However, less known is whether certain positive psychological factors play a protective role against health risks. Research has shown that positive and negative emotions are not opposite and are only modestly correlated. 12 , 13 Experiencing each of those emotions is also involved in the activation of different brain regions. 14

For the past several years, researchers have examined the contributions of health assets, especially psychological ones, to good health, while they have controlled for established risk factors. Researchers need to examine both risk factors and health assets to understand relationships between both positive and negative psychological factors as they together contribute to health outcomes.

Carefully conducted research shows that positive health assets indeed predict good health assessed in a variety of ways. 15 Among the positive psychology health assets foreshadowing good health are

  • Positive emotions 16 , 17
  • Life satisfaction 17 , 18
  • Optimism 19 - 22
  • Forgiveness 23
  • Self-regulation 24
  • Vitality and zest 25
  • Life meaning and purpose 26 - 29
  • Helping others and volunteering 30 - 32
  • Good social relationships 33 - 35
  • Spirituality and religiosity 36 , 37

There has been growing evidence that positive psychological characteristics affect health and longevity using various research methods including longitudinal prospective and experimental designs.

Perhaps, among the most well-known long-term studies that showed the possible link between positive psychological assets and health outcomes is The Nun Study. 38 A group of American nuns who were members of the School Sisters of Notre Dame wrote autobiographical essays in their early 20s when they joined the Sisterhood. Six decades later, researchers who had accessed the convent archive scored the emotional content of 180 essays in terms of positivity, and investigated whether they were related to the mortality of nuns. Indeed, positive emotional content was significantly related to longevity. The nuns who expressed more positive emotions (those in the upper 25%) in their essays, strikingly, lived on average 10 years longer than those expressing fewer positive emotions (those in the bottom 25%). In other words, happier nuns lived longer than less happy (but not depressed) nuns. Putting this in context, unhealthy behavior like smoking costs on average 7 years of one’s life. 2

In another experimental study, Cohen and his colleagues examined the relationships between positive emotions and the vulnerability of catching the common cold. 39 With 334 healthy adult volunteers in the community, they first measured both positive emotional experience, such as happy, pleased, lively, and relaxed, and negative emotional experiences, such as depressed, anxious, and hostile, over a few weeks using self-reports. Afterward, participants were invited to the study lab and exposed to rhinoviruses through nasal drops and monitored in quarantine for the development of the common cold. The researchers found that higher positive emotional experiences were related to lower risk of developing a cold and fewer reports of symptoms, while negative emotional experiences were not significantly related to catching a cold, but associated with reports of more symptoms. In short, this study showed that experiencing positive emotions was linked to greater resistance to developing the common cold.

The health benefits of positive psychological assets have been documented in different cultural settings as well. For instance, in Japanese culture, the most commonly used indicator of subjective well-being is the sense of “life worth living” ( ikigai ). 29 In a population-based prospective cohort study with 43, 391 adults in Ohsaki, Japan, lack of the sense of “life worth living” ( ikigai ) was significantly associated with higher risk of all-cause mortality over time. Those who reported having an ikigai in their life in a survey were more likely to be alive at a 7-year follow-up compared to their counterparts who did not find a sense of ikigai . Interestingly, the increase in mortality risk was due to an increase in mortality from cardiovascular disease and external causes such as suicide, but not to morality from cancer. Having a sense of “life worth living” ( ikigai ) often means having a purpose in life and realizing the value of being alive which could serve as a motivation for living.

In our own study with US adults, having life purpose played a protective role for heart health. 27 At a 2-year follow-up, the higher level of life purpose was prospectively related to lower risks of incidence of myocardial infarction among people with coronary heart disease at the baseline.

One of the ways to achieve a sense of life meaning and purpose is through helping others and doing regular volunteer work in communities. Research has shown that among elders, people who volunteer regularly are healthier and live longer. 30 , 31 In a longitudinal study with a nationally representative sample of community-dwelling older US adults, a study found that volunteerism predicted a lower risk of hypertension 4 years later. 31 That is, those who had volunteered at least 200 hours in the previous 12 months were less likely to develop hypertension risk compared to those who did not volunteer. However, lower levels of volunteering did not decrease the health risk of hypertension. It seems that dosage and intentions of volunteering matters for its health benefits. In another study, people who regularly volunteered for self-oriented motives did not exhibit lower risk for mortality 4 years later, while those who regularly and frequently volunteered for other-oriented motives showed lower risk of subsequent mortality. 32 In conclusion, it is good to be good!

One of the well-studied health-related positive psychology topics is optimism. Optimism is sometimes seen as pollyannaism, a naively rosy view of the world coupled with a “don’t worry, be happy” attitude. However, optimism the way researchers study it is a disposition to an expectation that the future will entail more positive events than negative ones. 40 Optimists are neither in denial nor naive about challenges and difficulties in life. They simply attend to and acknowledge the positive.

Empirical research shows that optimism—usually assessed with self-report surveys—relates to good health and a long life. According to research, among asymptomatic men with HIV, optimism slowed the onset of AIDS over an 18-month follow-up. 41 , 42 Over an 8-year follow-up, optimism predicted better pulmonary function among older men, even when smoking was controlled. 43 In a longitudinal study of older men and women, optimism predicted not only better health but also lower levels of pain. 44 Our own research group recently reported a study of a large nationally representative sample of older adults (aged >50 years) in the United States showing that over a 2-year period, optimism predicted a lower likelihood of stroke, even after controlling for chronic illnesses, self-rated health, and relevant sociodemographic, biological, and psychological factors. 45

In addition, the importance of social support and positive relationships on good health and well-being has long been documented. Supportive social relationships were associated with longevity, less cognitive decline with aging, greater resistance to infectious disease, and better management of chronic illnesses. 33 - 35

Enough well-designed studies exist in support of the premise that health assets predict good health to warrant further investigation. Research so far provides compelling evidence that positive psychological health assets predict or are associated with various health outcomes and longevity among healthy populations. However, what is relatively unknown are the effects of positive health assets for recovery and long-term health outcomes among those with serious health problems such as cancer.

Furthermore, before we consider interventions that deliberately encourage these assets in order to reduce morbidity and mortality and to increase physical well-being, there are issues that need to be addressed. 46

First, assuming that health assets do play a causal role, what are the mechanisms? Research to date has often been stark, usually demonstrating an association over time but not clarifying how it happens. We assume the pathways are multiple, from biological to emotional to cognitive to behavioral to social. For example, in the case of optimism, biologically, it has been linked to better immune system functioning, and behaviorally, people who are optimistic engage in healthier behaviors. They eat healthy, exercise, do not smoke or drink, and seek medical care when they need. Socially, optimists have better and more frequent social contacts. All of these are associated with health benefits.

It is unknown which pathway bears the most traffic or whether the mechanisms vary as a function of the specific health outcome (eg, cardiovascular disease vs the common cold) or as a function of the individual’s age, gender, or lifestyle. Again, the best a researcher can do is to identify plausible mechanisms in a given study and explicitly investigate their role as mediators.

Second, are health assets a cause of good health or merely a correlated marker of its real causes? Indeed, the array of positive health assets is challenging for researchers, who cannot study or control all possible assets in the same investigation. No single study relying on correlational data can be definitive, so it is the overall body of research investigating health assets that must be examined to draw causal conclusions. 17

Third, do the apparent benefits of health assets generalize to all kinds of health outcomes? Much of the relevant research has ascertained general health and all-cause mortality, and some of this work has relied only on self-reported information about health status. When researchers look at specific health outcomes assessed in more objective ways, psychological health assets seem to be more predictive of cardiovascular health than they are of freedom from cancer. So the benefits of health assets may be disease specific. A wider variety of diseases needs to be investigated from the positive health perspective. Moreover, research is not clear about the relative contribution of health assets to disease onset, to disease progression, and/or to recovery.

Positive Psychology Interventions for Physical Health

Researchers and practitioners have begun to develop intervention strategies based on positive psychology to increase positive psychological assets such as positive emotions or life satisfaction to bolster physical health. Whether increasing positive psychological assets will turn to better health outcomes is inconclusive. These intervention efforts targeting health assets in order to lead to better health not only have practical significance but also theoretical importance because appropriately done intervention studies would strengthen the claim that health assets actually cause good health.

We refer to interventions informed by positive psychology as positive psychology interventions. Sometimes positive psychology interventions entail a specific technique, like counting one’s blessings at the end of the day or using one’s signature strengths of character in novels ways. 47 At other times, the intervention uses a more-elaborated therapy package that combines different techniques, such as “Well-Being Therapy,” 48 and Quality of Life Therapy , 49 among others.

Intervention studies allow us to conclude that interventions informed by positive psychology can indeed change positive psychological states and traits, sometimes in lasting ways. 47 , 48 An important qualification is that long-term benefits do not result from one-shot interventions unless these lead to a change in how someone habitually lives. 18 Perhaps, what is required is a sustained lifestyle change.

On the face of it, intervening to increase a health asset should also have benefits for physical health, given the association between health assets and health outcomes. However, this argument does not embody a syllogism. Health assets may not be direct causes of good health, and even if they are, changing them may not result in better health. Said another way, we do not yet know if the health benefits of deliberately cultivated happiness or optimism or life meaning have the same benefits as their naturally occurring counterparts. 50

Needed is intervention research that incudes physical health as an explicitly measured outcome. While it is interesting and important to show that a positive psychology intervention increases the psychological well-being of medial patients, the more exciting issue is whether the intervention also affects their physical health. If so, how quickly would health benefits be evident? And what is the mechanism by which the intervention has an effect?

In studying the mechanisms by which a positive psychology intervention influences physical health, the role played by mundane behavior should not be neglected. 46 There are well-documented “healthy” ways of behaving, 51 including sleeping 8 hours a night, eating balanced meals, not smoking, not drinking to excess, and exercising regularly.

We suspect that positive psychology interventions, when successful, lead people not only to think and feel in more positive ways but also to behave in more healthy ways. 40 , 46 For example, optimistic people are more actively engaged with the world and are better problem solvers than their pessimistic counterparts. They have more frequent and higher quality social contacts as well as more social support. All of these factors may lead to healthier behaviors and habits and eventually to better health.

Positive psychology intervention studies for better health outcomes are in their infancy. So far, nearly all positive psychology interventions primarily targeted changing health-related behaviors such as physical activity, not the health outcome directly. Researchers have shown that positive psychology interventions influence some of the biological and behavioral processes implicated in good health. For example, inducing positive emotions speeds cardiovascular recovery following a stressful event. 52 Training in mindfulness meditation can boost immune function. 53 Psychosocial resilience training targeting positive emotions, cognitive flexibility, social support, life meaning, and active coping reduces total cholesterol among middle-aged adults. 54 Researchers have begun to investigate how positive affect and affirmation influence physical activity and medication adherence among patients with coronary artery disease, 55 asthma, 56 and hypertension. 57 The next step in each case is to show that such interventions also increase good health as opposed to its possible precursors.

Using a randomized controlled clinical trial, a group of researchers recently developed an intervention strategy that enhances positive affect and self-affirmation (PA/SA) and applied it to 3 different high-risk clinical populations (eg, hypertension, asthma, coronary artery disease) to change their health-related behaviors. 55 - 57

In each clinical trial, patients were randomly assigned to either the patient education (PE) control group or the positive-affect/self-affirmation (PA/SA) intervention group. For the control group, each patient received an educational workbook, a pedometer, and a behavior contract for a physical activity goal. For the intervention group, each received PE control components and additionally, a PA/SA workbook chapter, bimonthly induction of PA/SA by telephone, and small mailed gifts. Patients in the PA intervention group were taught how to self-induce positive affect and self-affirmation using a workbook chapter, received bimonthly inducement of PA/SA by telephone, and unexpected small gifts (PA) mailed bimonthly several weeks before follow-up calls. During PA/SA induction phone calls, patients were told to “think about things that make you feel good” and take a moment each day to enjoy positive thoughts (PA), and to think about “proud moments” in their personal lives if they have a difficult time exercising (SA). For both groups, data were collected through a standardized bimonthly telephone follow-up for 12 months.

Using this research design, researchers conducted 3 parallel studies. In study 1, 55 patients were recruited right after percutaneous coronary intervention to increase physical activity among people with coronary artery disease. Compared to the control group, patients in the intervention group engaged in significantly more physical activities. In study 2, 56 physical activity among asthma patients who participated in the study was improved without differences between control and intervention groups. There was no significant effectiveness of intervention. In study 3, 57 the intervention effect on enhancing medication adherence among hypertensive African Americans was examined. Patients in both control and intervention groups received a culturally appropriate hypertension self-management workbook, a behavioral contract, and bimonthly telephone calls to help them better handle barriers to medication adherence. In addition, patients in the PA/SA intervention group received small gifts and bimonthly telephone calls to help them utilize positive thoughts into their daily routine and foster self-affirmation. At the 12-month follow-up, the intervention group showed a significantly higher level of medication adherence compared to the control group (42% vs 36%). The reduction of blood pressure was found among participants without significant differences across groups.

Mixed results from these intervention studies leave questions that need to be clarified with more studies to better understand the effectiveness of a positive psychology intervention on the different health outcomes before they are implemented in health practices.

Another line of positive psychology intervention research that attracted significant attention in recent years is applications of mindfulness meditation. It is assumed that meditations induce positive affect and lead to good health. A study led by a neuroscientist, Richard Davidson, demonstrated that mindfulness meditation produces changes in brain and immune function in a positive way. 53 In this study, 25 healthy employees at a work site received an 8-week intensive clinical training in mindfulness meditation. A weekly training class met for about 3 hours, and a silent 7-hour retreat was held during week 6 of the training. In addition, participants were instructed to perform home meditation practices for 1 hour each day, 6 days a week with the guided audiotapes. Brain electrical activity was measured at the baseline, the end of training, and 4 months after training. Also at the end of training, participants were vaccinated with influenza vaccine. Results from the meditation group were compared to those of the wait-list control group. Among the meditation group, brain activity in the left-sided anterior, associated with positive affect, was significantly increased. They also found significant increases in antibody concentrations to influenza vaccine in the meditation group. Interestingly, the size of increase in left-sided activation predicted the size of antibody concentration rise to the vaccine.

In sum, the effects of positive psychology interventions on health outcomes are inconclusive. As stated before, positive psychology interventions seem to be more effective on reducing health risks among healthy individuals in the short term. However, its long-term health effects, especially, on a population with different health problems, is not clear.


Positive psychology is a perspective that urges scientific attention to strengths and assets that contribute to health and a flourishing life. We have described what positive psychologists have learned about the relationships between positive psychological assets and physical health in the past decade.

To date, the application of positive psychology to health is promising, although much work remains to be done. On the positive side, research shows that what we call positive psychological health assets (eg, positive emotions, life satisfaction, optimism, positive relationships, life purpose) are prospectively associated with good health measured in a variety of ways. Also on the positive side, interventions have been developed that increase these assets; lasting effects require a lifestyle change.

Not yet known is whether positive psychology interventions improve physical health, reducing morbidity and mortality, speeding recovery from illness, and so on. Investigators are beginning to study the health effects of such interventions. Studies to date suggest that positive psychology interventions reduce some of the biological and behavioral processes that affect health, but the next step is to study good health per se.

We urge an open mind about the eventual success of such interventions. It is important not to get too far ahead of the data. Perhaps these interventions will work as intended, perhaps not. For example, the lesson from studies of psychological interventions targeting negative states and traits such as anger and depression in the hope of reducing cardiovascular disease, with which they are associated, is instructive. The success of these interventions is checkered at best. 46 Whether the deliberate cultivation of positive health assets such as positive emotions or life purpose will be more successful in promoting good health than the reduction of psychological risk factors is not known, but is a question worth addressing.

In conclusion, growing evidence suggests that positive psychological assets are linked to health and longevity. However, more studies are necessary to learn more about when, why, how, and for whom positive psychological assets plays a role in good health and whether interventions that enhance these assets will yield health benefits. We urge a skeptical yet fair-minded attitude on the part of researchers and practitioners and that they pay particular attention to underlying mechanisms. Meanwhile, freedom from disease and longevity are not the only goals of life. Quality of life matters in addition to quantity of life. It is clear from research that experiencing frequent positive emotions, having sense of life purpose, paying attention to what is positive in life, and living a more socially integrated life is linked to one’s quality of life across the lifespan. Thus, helping people cultivate positive psychological and social assets in life has potential for leading to happier, more meaningful, and healthier lives.


Christopher Peterson unexpectedly died on October 9, 2012, during the revision of this article. We are deeply indebted to his scholarly contributions and mentorship not only to this work but also to the foundation of positive psychology and its applications to various fields. His intellectual and personal contributions will continue to inspire and guide the positive psychology and positive health community.

Support for the preparation of this article was provided by the Robert Wood Johnson Foundation’s Pioneer Portfolio, which supports innovative ideas that may lead to breakthroughs in the future of health and health care. The Pioneer Portfolio funding was administered through a Positive Health grant to the Positive Psychology Center at the University of Pennsylvania, Martin Seligman, Director.

The role of affective states in the process of goal setting

  • Published: 03 June 2024

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  • Vahe Permzadian   ORCID: 1 &
  • Teng Zhao   ORCID: 2  

Given that employee performance goals are major determinants of work motivation and performance, examining the factors that influence goal setting has generated substantial research interest. Despite decades of work, however, the relationship between affect and goal setting is poorly understood. Based on mood-as-information and arousal-as-information theories, our study examines the extent that affective valence and affective arousal influence goal-setting processes and, in particular, the extent that the activation level moderates the effect of affective valence. Since theoretical perspectives that attempt to explain the process of goal setting are commonly based on an expectancy-value framework, we examined the effects of affective states on performance goal level and its antecedents of expectancy and valence. Participants were 142 university students, and the performance task was solving anagrams across two trials. Positive affective states were positively associated with expectancy and goal-level judgments, whereas negative affective states were negatively associated with expectancy and goal-level judgments. However, affective states were not found to be associated with valence judgments. Contrary to expectations, our findings did not support the moderating effect of affective arousal. We discuss the various implications of our findings for mood-as-information theory and arousal-as-information theory as well as for future research.

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We are all ordinary: the shared visual narratives of daily life promote the patients’ positive attitudes toward doctors

  • Xiaokang Lyu 1 , 2 ,
  • Shuyuan Zhang 3 ,
  • Chunye Fu 1 ,
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  • Tingting Yang 1 &
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BMC Psychology volume  12 , Article number:  311 ( 2024 ) Cite this article

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Current research on the doctor-patient relationship primarily focuses on the responsibilities of doctors, with relatively less emphasis on examining the contributions patients can make. As a result, there is an urgent demand for exploring innovative approaches that highlight the active role patients play in cultivating a robust doctor-patient relationship. The purpose of this study was to devise an intervention strategy centered around patients to enhance the doctor-patient relationship. Comics were developed to depict shared narratives encompassing challenging daily life experiences between doctors and ordinary individuals. The study aimed to assess the efficacy of this approach in cultivating positive attitudes toward doctors.

A 3-group design trial was conducted in Shanghai, China. A total of 152 participants were randomly assigned to one of three conditions: the parallel presenting group ( n  = 51), where narratives about a doctor and an ordinary employee were presented side by side in comics; the single presenting group ( n  = 50), where only narratives about a doctor were presented; and the control group ( n  = 51). The outcomes assessed in this study encompassed changes in identification with the doctor portrayed in the comics, perceived intimacy between doctors and patients in reality, and appraisal of the doctor in a prepared doctor-patient interaction situation.

The parallel presenting group exhibited significantly larger increases in identification with the doctor portrayed in the comics, perceived intimacy between doctors and patients in reality, and appraisal of the doctor in a prepared doctor-patient interaction scenario compared to the single presenting group. The observed enhancements in the appraisal of the doctor in a prepared doctor-patient interaction scenario can be attributed to the changes in identification with the doctor portrayed in the comics experienced by the participants.

Our study responds to the doctor-centric focus in existing research by exploring patients’ contributions to the doctor-patient relationship. Using comics to depict shared narratives, the parallel presenting group demonstrated significantly increased identification with the depicted doctor, perceived intimacy, and positive appraisal in prepared scenarios compared to the single presenting group. This underscores the effectiveness of patient-centered interventions in shaping positive attitudes toward doctors, highlighting the pivotal role patients play in fostering a resilient doctor-patient relationship.

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Chinese Clinical Trail Registry: ChiCTR2400080999 (registered 20 February 2024; retrospectively registered).

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In recent years, incidents of patient-initiated workplace violence targeting healthcare workers in China have garnered significant public attention [ 1 , 2 ]. These incidents highlight the underlying tensions between doctors and patients, posing a challenge to the improvement of healthcare system quality. Establishing a harmonious doctor-patient relationship is vital for the effective delivery of healthcare services. Traditionally, the responsibility for improving the doctor-patient relationship has primarily been attributed to doctors, with factors such as apathetic interactions and unprofessional approaches on the part of doctors identified as potential causes of tension [ 3 ]. Consequently, there is an increasing emphasis on the implementation of effective doctor-patient communication training [ 4 ], the enhancement of humanities education for doctors and medical students [ 5 ], and the integration of clinical empathy into clinical skills training courses [ 6 ] to address these challenges. Despite these efforts, a crucial aspect often overlooked is the proactive role patients can play in cultivating a robust doctor-patient relationship, prompting the need for innovative approaches that highlight and explore this aspect.

The patient population undeniably assumes a victim identity as they endure the suffering brought about by their illnesses. Conversely, healthcare providers, particularly doctors, also bear their own burdens. They are confronted with substantial responsibilities and face a significant disparity between their heavy workload and relatively low income [ 7 ]. Physician burnout is a prevalent systemic issue within the healthcare sector, profoundly impacting professional functioning and individual well-being [ 8 ]. Regrettably, physician burnout remains inadequately acknowledged and underreported. It manifests as a state of mental exhaustion, depersonalization, and diminished personal accomplishment, affecting numerous doctors [ 8 , 9 , 10 ]. Research suggests that younger physicians, those involved in high-risk procedures, and those experiencing work-life conflicts are particularly susceptible to burnout [ 11 ]. Major drivers include excessive administrative tasks, lack of autonomy, and unsustainable workloads [ 12 ] Clearly, physician burnout reaches across specialties and career stages, necessitating systemic solutions to this mounting problem.

Physician burnout is often overlooked or misunderstood by patients as simply the complaints of a privileged profession [ 13 ]. However, the reality is that both doctors and patients alike suffer under the strains of an overburdened healthcare system [ 7 ]. When burnout is perceived as merely a crisis of personal well-being impacting doctors’ work satisfaction, it can elicit limited public sympathy. But in truth, the well-being of physicians and patients is interdependent. By fostering greater empathy and understanding towards doctors, patients can help facilitate more effective doctor-patient communication and mitigate conflicts.

Anderson and colleagues [ 14 ] introduced an innovative concept of using comics to juxtapose the everyday experiences of doctors and patients, generating empathy through relatable narratives. For instance, these comics may depict a doctor feeling saddened by lack of time with his daughter, alongside a patient riddled with anxiety before an upcoming exam. This approach expands perspectives beyond the treatment setting, portraying doctors and patients as ordinary individuals balancing their own lives and burdens. Such narratives can provide a foundation for patients to actively contribute to improving doctor-patient bonds.

This concept aligns with the Common Ingroup Identity Model from social psychology. By establishing a common in-group identity between doctors and patients, positive emotions and preferences for one’s own group can extend to the broader shared identity. This shifts the dynamic from an “us versus them” mentality to a more inclusive “we” perspective [ 15 ]. Studies have confirmed that common in-group identity can positively predict intergroup help willingness, and is negatively correlated with real threats and negative stereotypes [ 16 ], increase the intimacy of group members [ 17 ], and shorten social and physical distance [ 18 ]. Within the Chinese cultural context emphasizing social harmony, embracing a common doctor-patient identity could prove even more effective in enhancing mutual understanding [ 19 ].

Informed by Anderson and colleagues’ [ 20 ] idea and the Common Ingroup Identity Model, the present study seeks to experimentally test the potential for visual narratives to improve doctor-patient relationships. We aim to expand the application of visual storytelling to foster a shared identity between doctors and patients beyond the clinical setting. Specifically, this research examines whether juxtaposing the everyday challenges faced by both doctors and ordinary people can enhance readers’ identification with physician characters, perceived intimacy between doctors and patients overall, and appraisals of doctors in simulated interactions. We hypothesize that depicting relatable out-of-office experiences for doctors and patients will establish a sense of common in-group identity, extending positive intergroup attitudes in line with previous findings [ 16 , 17 , 18 , 19 ]. Additionally, this study explores whether fostering this shared identity through comics can motivate more active, patient-driven efforts to strengthen doctor-patient bonds.

Study design

This was a randomized experiment in accordance with the Declaration of Helsinki and received ethical approval from Shanghai Hongkou District Jiangwan Hospital (JW201909) in China.

Many patients’ interactions with doctors are limited to consultation and treatment, which hampers their comprehension of the challenges faced by doctors, such as enduring long-term heavy workloads, navigating tense doctor-patient relationships, coping with prolonged overtime hours, encountering promotion difficulties, and struggling with work-life imbalances. By simultaneously presenting the stressful daily life events of doctors alongside those of ordinary employees, it becomes possible to foster patients’ understanding and identification with doctors, leading to increased tolerance during interactions with doctors. The present study employed comics as an intervention, showcasing the stressful daily life events of a doctor and an ordinary employee side-by-side, with the primary objective of investigating whether this intervention could enhance the doctor-patient relationship within a specific medical interaction setting.


The study was conducted at a hospital in Shanghai, with participants comprising inpatients and accompanying family members in the cardiology department. The patient participants were 2-3 individuals per group who had been hospitalized but were well enough to participate. The remaining participants in each experimental group were family members of the hospitalized cardiology patients. These individuals were selected as participants because the state of being in the hospital prompted them to have present personal experience of the doctor-patient relationship issues. This ensured the ecological validity of the study results. Each participant signed a written informed consent form agreeing to participate and confirming that they understood they could withdraw at any time and that their data would remain confidential.

A total of 180 participants were recruited, 28 participants were excluded for failing attention check questions designed to ensure respondents were reading comics carefully. Thus, 152 participants with valid complete data included in the analyses, M age = 35 years ( SD  = 10); age range is 18 to 65 years old; Male = 69, Female = 83. All participants were native Chinese speakers with sufficient language skills and received compensation of 15 yuan (RMB; approximately US $2) for their participation.

Power and sample size

No previous research was available as a reference for sample size estimation for this study. Therefore, our study was powered to detect medium effect sizes (i.e., Cohen’s d  = 0.50), with an α error of 5% and a power of 80% with the inclusion of a minimum of 48 participants in each group.


The content of the comics was derived from interviews conducted with ten doctors and ten ordinary employees. During the interviews, participants were specifically instructed to recollect daily work and life events that caused them stress or discomfort. Subsequently, we extracted similar events from the interviews of the ten doctors and ten ordinary employees, which were then adapted into the comics. To ensure the authenticity of the selected events, psychologists, physicians, and other professionals were consulted to evaluate their appropriateness for adaptation. Based on their feedback, ten events were identified and incorporated as the content of the intervention comics.

The comics were titled “A Day in the Life of a Doctor and an Office Worker” and were presented in a chronological order, depicting ten scenes that spanned from the morning awakening of the doctor or ordinary employee to their evening activities at home, respectively. The narratives of the doctor and the ordinary employee were presented side by side in parallel within the comics. Each set of parallel narratives was paired, such as the doctor facing criticism from a patient and the ordinary employee receiving negative feedback from a client. Participants who read these comics were divided into the parallel presenting group. Additionally, a single presenting group was established as a comparison in this study, where participants read the comic titled “A Day in the Life of a Doctor” featuring only the doctor’s portion from the parallel presenting group comic (Fig.  1 ).

figure 1

The example comics of the parallel presenting group

To minimize the influence of extraneous variables, sketching techniques were utilized in this study. Furthermore, we hired cartoonists to produce the comics to ensure compliance with copyright regulations and avoid potential disputes.


Appraisal of the doctors in reality.

Participants’ appraisal of doctors in real-life were assessed using a stereotype scale revised by Chinese researchers [ 20 ]. This measurement tool was based on the Stereotype Content Model [ 21 ], which evaluates individuals’ stereotypes of a particular group in terms of competence (e.g., competent), warmth (e.g., friendly), and ethics (e.g., honest). The scale comprised six adjectives and employed a 5-point Likert scale for scoring. A higher score indicated a more positive perception of doctors. In the present study, the internal consistency of the scale, as measured by Cronbach’s alpha, was 0.92.

Perceived intimacy between the doctors and the patients in reality

The Inclusion of Other in the Self Scale [ 22 ] was modified to assess the perceived intimacy between the doctors and the patients in reality. The scale is a single-item, pictorial measure of closeness, as the overlap of the circles, so does the closeness of the relation. Seven degree of overlap circles linearly were used for the 7-step, with higher scores indicating that participents perceived higher intimacy between the doctors and the patients in reality (Fig.  2 ). In the present study, this measurement was used twice for both intervention groups, once before and once after the intervention was delivered.

figure 2

The modified version of the Inclusion of Other in the Self Scale

Identification with the doctor in the comics

Identification with the character of the doctor in the comic was assessed using an adapted version of the rating scale employed by de Graaf and colleagues [ 23 ]in their research. The measurement consisted of eight items rated on a 7-point scale. Three items pertained to participants imagining themselves in the position of the doctor, for example, “During reading, I imagined what it would be like to be in the position of the doctor”. Two items focused on the participants’ experience of empathy towards the doctor, for instance, “I empathized with the doctor”. Additionally, three items gauged the sense of identifying with the character, such as “In my imagination it was as if I was the doctor”. The internal consistency of the scale, as indicated by Cronbach’s alpha, was 0.91 in the present study.

Appraisal of the doctor in a prepared doctor-patient interaction situation

The doctor-patient interaction situation utilized in this study was derived from a notable online conflict that occurred in 2015 between a doctor and a patient in China. The incident involved a celebrity who visited the emergency room due to eye discomfort. The doctor diagnosed the condition as keratitis and prescribed medication. However, the celebrity raised objections, claiming that the doctor did not listen attentively and engaged in a heated exchange with the doctor over the latter’s perceived curt and unresponsive demeanor. Subsequently, the celebrity took to social media to accuse the doctor of irresponsibility and questioned their suitability for the “white angel” title.

The incident generated mixed opinions, with some individuals viewing the celebrity’s actions as overly harsh while others criticized the doctor for being irresponsible. The incident underwent revisions, and experts with medical backgrounds assessed the professionalism of the materials, resulting in the development of an official version of the doctor-patient interaction situation. To ensure clarity and minimize confusion, the scenario materials were presented as a simplified comic strip with a distinct style different from the intervention materials (Fig.  3 ).

figure 3

The doctor-patient interaction situation. At ten o’clock in the middle of the night, Mr. Zhang suddenly felt pain in his eyes, and also kept running tears. In an emergency, he had to go to the local general hospital to see the emergency room. The emergency room was crowded, and Mr. Zhang waited in line for a while before his turn came. He had the following conversation with the doctor

Following the participants’ reading of the materials, they were asked to provide subjective evaluations of the doctor depicted in the materials. The evaluation employed the same measurement used to assess participants’ perceptions of real-life doctors, with the difference being that this time the evaluation pertained to the doctor featured in the scenario materials.

Figure  4 shows the participation flowchart. We conducted our experiment at a hospital in Shanghai, China, with the following steps.

figure 4

Flow Diagram of Participation and Data Collection

Upon obtaining informed consent, participants were requested to provide sociodemographic information, including gender, age, and education. Baseline questions were then administered, assessing participants’ initial appraisals of doctors and perceived intimacy between doctors and patients in reality. Subsequently, participants were randomly assigned to one of three groups: parallel presenting group, single presenting group, or control group.

Participants in the parallel presenting group and single presenting group were instructed to read the corresponding comics and respond to manipulation check questions. Those who did not pass the manipulation check were excluded from further analysis. Participants in both the parallel presenting group and single presenting group were then asked to answer questions regarding their identification with the doctor depicted in the comics and the perceived intimacy between doctors and patients in reality.

Following this, all participants were provided with a prepared doctor-patient interaction situation to read. After reading, participants were asked to answer manipulation check questions related to the interaction situation, and again, participants who did not pass were excluded. Finally, all participants were asked to appraise the doctor within the interaction situation.

After completion of the experiment, the responses were checked for completeness and paid to the participants.

Statistical analysis

Main outcomes.

Descriptive statistics (mean [ SD ] for continuous variables) of participant sociodemographic and control variables, as well as primary outcome measures, were calculated using SPSS, version 22 software (IBM Corporation). Comparisons of outcome measures were performed using independent samples t-test. The effect size, based on the Cohen’s d value, was also calculated and interpreted as small (Cohen’s d  = 0.20–0.49), medium (Cohen’s d  = 0.50–0.79), or large (Cohen’s d   ≧  0.80) [ 24 ].

Mediation of appraisal of the doctor by identification and perceived intimacy

A mediation analysis was conducted to examine whether identification with the doctor in the comic and perceived intimacy between the doctors and the patients in reality mediated the association between parallel presenting and appraisal of the doctor in the doctor-patient interaction situation, using the PROCESS macro procedure in SPSS, version 22 (IBM Corporation), with 5000 bootstrap samples published by Preacher and Hayes [ 25 ]. The unstandardized (B) and standardized (β) regression coefficients are presented for the following equations: (1) regressing the mediators (change in identification and perceived intimacy) on the independent variable (group), (2) regressing the dependent variable (change in appraisal of the doctor) on the independent variable (group), and (3) regressing the dependent variable on both the mediators and the independent variable. Indirect and total effect were also presented, and thus the percentage of the total effect was computed to explain how much of the total effect was explained by the mediation.

Sociodemographic and control variables

We analyzed the distribution of the three demographic variables of age, gender, and education, which found that with equal gender and education distribution and with no differences in age among the three groups. When analyzing the appraisal of doctors and perceived doctor-patient intimacy measured pre-test, there was no significant difference between the three groups. So it could be determined that the significance of the subsequent differences came mainly from the experimental intervention and not from the differences between the original groups. Table  1 illustrates the demographic variables for the three groups and provides descriptive results for the pre-test variables.

Primary outcomes

Table  2 ; Fig.  5 shows the descriptive statistics of outcome variables.

figure 5

Differences in identification, perceived intimacy, and appraisal of the doctor between or among the groups

Compared with the participants in the single presenting group, participants in the parallel presenting group: experienced significantly greater identification with the doctor in the comics ( t (99) = 4.33, p  < 0.001, Cohen’s d  = 0.86); perceived intimacy between the doctors and the patients in reality higher ( t (99) = 3.51, p  = 0.001, Cohen’s d  = 0.70); had an enhanced appraisal of the doctor in the doctor-patient interaction situation ( t (99) = 2.20, p  = 0.03, Cohen’s d  = 0.37).

For the appraisal of the doctor in the doctor-patient interaction situation, the two intervention groups were compared with the control group, and the results showed that the parallel presenting group appraised the doctors significantly higher ( t (100) = 3.38, p  = 0.001, Cohen’s d  = 0.67); while the single presentation group did not differ from the control group ( t (99) = 1.15, p  = 0.25).

Secondary outcomes

A mediating effect analysis was conducted to determine whether the changes of appraisal of the doctor between parallel presenting group and single presenting group was mediated by identification with the doctor in comics and perceived intimacy between the doctors and the patients in reality. The group (single presenting group = 0, parallel presenting group = 1) was used as the independent variable, identification and perceived intimacy were chain mediators, and appraisal of the doctor was the outcome variable.

The chain mediating effect of identification and perceived intimacy was not significant (indirect effect: β = 0.001 [95% CI, − 0.05 to 0.06). The analysis yielded a significant model only when identification as mediator (indirect effect: β = −0.21 [95%CI, − 0.43 to − 0.03). Changes in identification explained 47.9% of the improvements in appraisal of the doctor (Fig.  6 ).

figure 6

Mediation model of changes in identification mediated changes in appraisal of the doctor

Violence in healthcare settings has become a common occurrence worldwide [ 26 ], not only in China. How to establish a harmonious doctor-patient relationship has always been a challenge. By the importance to build trust in doctor-patients relationship as an interdependent phenomenon [ 27 ], we believe that solving this dilemma requires efforts not only from physicians but also from patients.

The utilization of comics portraying doctors and patients facing comparable hardships can effectively foster patient identification with healthcare professionals. This identification arises from a mutual recognition of the difficulties confronted by doctors, including long working hours, emotional strain, and the perpetual pursuit of knowledge. When patients perceive doctors as individuals who share their challenges, it establishes a profound connection that promotes empathy and trust. Patients often lack insight into the intricacies and demands of medical practice. By portraying doctors as dedicated, invested, and real individuals, patients develop a deeper understanding of the obstacles physicians encounter. This heightened comprehension can result in increased patience, empathy, and cooperation, ultimately enhancing the general doctor-patient relationship.

We construct the common “ordinary employee” identity of doctors and patients and then explore their influence and mechanism on patient attitudes. This idea is in line with the concept of the Common Ingroup Identity Model [ 28 ]. This model suggests that through cooperation, interaction, facing common problems, and emphasizing common destiny, two separate group representations can be transformed into a broader supergroup, i.e., recategorization into a common ingroup identity, which can reduce negative stereotypes and prejudices between the two groups [ 29 ]. Similarity increased identification and narrative transportation, which in turn reduced counterarguing, thus resulting in a more positive attitude towards the outgroup [ 30 ]. The use of comics to portray doctors as hard workers serve to challenge these stereotypes and reduce stigma. Patients who perceive doctors as fellow hard workers are more likely to view them with compassion and understanding, breaking down barriers that may hinder open communication and trust. Additionally, by highlighting the dedication and effort of doctors, this approach aims to inspire respect and appreciation for the medical profession as a whole.

Our goal is to work on developing interventions that can improve patients’ understanding of doctors in specific medical communication situations, which is not equivalent to a group-level improvement of attitudes toward groups of doctors. Our findings found that parallel presentation improves perceived intimacy at the group level, but that this change does not lead to better evaluations of physicians in specific medical treatments. That is, group-level relationship improvement may have a limited effect on context-specific doctor-patient communication. Further, this study found that identification played a mediating mechanism.

Identification is a vital component of the doctor-patient relationship, enabling public to understand doctors’ perspectives and concerns fully. When patients recognize the dedication and commitment of doctors through the depiction of their hard work, it humanizes healthcare professionals and reduces the perceived power imbalance. This, in turn, establishes a foundation of trust, enhancing communication, shared decision-making, and patient satisfaction. One of the key factors influencing the doctor-patient relationship is the inherent power dynamics within the healthcare system. Patients may feel powerless and intimidated, leading to communication gaps and hindered shared decision-making. By emphasizing the hard work and dedication of both parties, the comics aim to humanize doctors and reduce the perception of an imbalanced power dynamic. This can empower patients to actively engage in their healthcare, fostering a collaborative and equal partnership.

Furthermore, our study is informed by the conceptual framework proposed by Anderson et al. [ 16 ], which inspired the creation of a narrative that intertwines the lives of doctors and patients using comics as a medium. By immersing themselves in these cartoons, participants were able to gain a more concrete understanding of the day-to-day experiences of doctors and establish personal connections with their own lives. This experiential understanding is cultivated through a process of active engagement and empathy, enabling participants to “see” and “experience” rather than passively receive information.

It is important to note that graphic medicine represents a distinct genre within the realm of literature, serving as a means to address the communication needs of risk communication and health promotion [ 31 ]. Previously, graphic medicine has been utilized as a conduit for patients to express their experiences with specific illnesses, such as dementia [ 32 ]. Our research expands the application of graphic medicine by exploring its potential in facilitating improved doctor-patient communication and enhancing the doctor-patient relationship.

The doctor-patient relationship is the cornerstone of effective healthcare delivery, encompassing trust, communication, and collaboration. The doctor-patient relationship has faced several challenges, such as time constraints, communication barriers, and the power dynamics inherent in the healthcare system. Establishing a harmonious connection between doctors and patients has always posed a challenge, requiring mutual understanding and empathy. Moreover, physicians often experience burnout due to the demanding nature of their work, which can negatively impact patient care and the overall doctor-patient relationship. Addressing burnout on an individual level will not be enough in the current healthcare environment [ 33 ].

While efforts to improve this relationship have primarily focused on the role of physicians, our findings suggest that patient engagement is equally crucial. By portraying doctors and patients as equally hard-working individuals through the use of comics, this study highlights the potential to enhance patient identification with doctors, foster understanding, and promote recognition.

The study has several strengths, including enhancing doctor-patient relationship through patient engagement. By equating the hard work of both doctors and patients, this approach encourages patients to view healthcare professionals as individuals with their own struggles. Recognizing these challenges, it becomes crucial to explore innovative approaches that can alleviate these issues and promote a more harmonious connection between doctors and patients.


This study, however, has several limitations that should be acknowledged.

Firstly, in order to emphasize the burnout experienced by doctors and evoke empathy, the comic employed focus on negative narrative content. However, it is important to recognize that doctors and ordinary employee also encounter numerous positive events in their daily life. Therefore, further investigation is warranted to explore the impact of narratives with varying emotional value on the improvement of the doctor-patient relationship.

Secondly, although our study was conducted at a hospital site, the materials presented to participants and the examination of their effects on the enhancement of the doctor-patient relationship were carried out in a controlled context. This approach may limit the ecological validity of the findings, as the measurement of behavioral intentions was convenient and did not directly reflect real-life attitudes. Thus, it is recommended to conduct follow-up field experiments with higher ecological validity to gain a deeper understanding of the role of such interventions in real healthcare settings.

Lastly, caution should be exercised when interpreting the results of the mediation analyses, as both the proposed mediator and the outcome were measured concurrently. To establish a more robust causal relationship, future studies should consider employing longitudinal designs or experimental manipulations to examine the mediating role of identification with the doctor over time.

Implications to research, policy, and practice

The study’s findings carry profound implications across research, policy, and practical dimensions within the healthcare landscape. Research-wise, the demonstrated efficacy of patient-centered interventions, exemplified by the use of comics to portray shared narratives, underscores the imperative of exploring innovative methodologies that recognize and amplify the pivotal role patients play in shaping positive attitudes toward healthcare professionals. This underscores the need for continued exploration and refinement of patient-centric approaches in healthcare studies.

From a policy perspective, the study advocates for a more comprehensive and inclusive outlook in initiatives targeting the enhancement of the doctor-patient relationship. Policies should reflect an understanding of the intricate dynamics of healthcare interactions and actively involve patients in the collaborative development of strategies fostering a harmonious relationship. This suggests a paradigm shift towards policies that engage stakeholders in a more collaborative and patient-inclusive manner.

Practically, healthcare practitioners and educators stand to benefit by incorporating patient-centered communication strategies, as elucidated in this study, into training programs and clinical practices. This integration holds promise for elevating the overall quality of healthcare delivery and enhancing the patient experience. As a result, this study provides actionable insights for practitioners and educators seeking to implement effective and patient-focused communication strategies.

Furthermore, the study’s implications extend beyond the immediate doctor-patient relationship. Amid a burgeoning focus on improving the quality of life for healthcare professionals, the insights gleaned from this research contribute not only to fostering understanding between doctors and patients but also offer patients a valuable perspective on the daily challenges and pressures faced by healthcare providers. This heightened understanding has the potential to alleviate professional stress on doctors, thereby contributing to the creation of a more supportive and empathetic healthcare environment. In essence, the study not only directly benefits the doctor-patient relationship but also indirectly contributes to broader initiatives aimed at enhancing the overall well-being of healthcare professionals, aligning with the evolving landscape of healthcare priorities [ 34 ].


A parallel presenting of intervention the daily narratives of doctors and ordinary employees through comics can be effective in improvement of doctor-patient relationship. These results have relevance and implications for enriching patient-based intervention strategies to improve the doctor-patient relationship.

Data availability

Data will be made available on request.

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This work was supported by the National Social Science Foundation of China (20ASH015).

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Department of Social Psychology, School of Sociology, Nankai University, Tianjin, 300350, China

Xiaokang Lyu, Chunye Fu, Min Yang & Tingting Yang

Computational Social Science Laboratory, Nankai University, Tianjin, China

Xiaokang Lyu

Shanghai Hopemill Clinic, Shanghai, China

Shuyuan Zhang

Shanghai Hongkou District Jiangwan Hospital, Shanghai, China

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X.K.L prepared conceptualization, methodology, visualization and writing - original draft; S.Y.Z in charge of data curation and investigation; C.Y.F. prepared formal analysis, writing - original draft, interpretation, writing - review and editing; M.Y. and T.T.Y. proceeded writing - review & editing; F.D.X. proceeded project administration.

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Correspondence to Chunye Fu .

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The study was approved by the research ethics committee in the Shanghai Hongkou District Jiangwan Hospital (JW201909). Participants signed consent forms indicating that they understood what the study involved, that they could withdraw from the experiment at any time for any reason, and that their experimental data would be kept confidential and used for scientific purposes only.

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Lyu, X., Zhang, S., Fu, C. et al. We are all ordinary: the shared visual narratives of daily life promote the patients’ positive attitudes toward doctors. BMC Psychol 12 , 311 (2024).

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Received : 12 November 2023

Accepted : 27 May 2024

Published : 29 May 2024


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  • Doctor-patient relationship
  • Visual narratives
  • Identification
  • Common ingroup identity model

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