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Selected Scholarly Articles

Theoretical Foundations of Positive Psychology:

Positive Psychology: An Introduction , Seligman & Csikszentmihalyi, 2000

APA President’s Address, Seligman, 1998

American Psychologist: Special Issue on Positive Psychology, 2000

Positive Psychology FAQs , Seligman & Pawelski, 2003

A Balanced Psychology and a Full Life, Seligman , Parks, & Steen, 2004

What (and Why) is Positive Psychology?, Gable and Haidt, 2005

Dynamic Spread of Happiness in a Large Social Network: Longitudinal Analysis over 20 Years in the Framingham Heart Study , Fowler & Christakis, 2008

Happiness Can Spread Among People Like a Contagion, Study Indicates , Washington Post, 2008

Non Zero: The Logic of Human Destiny , Robert Wright, 2001

Ordinary Magic: Resilience Processes in Development , Masten, 2001

The Better Angels of Our Nature , Pinker 2011

Enlightenment Now: The Case for Reason, Science, Humanism, and Progress , Pinker, 2018

PERMA and the Building Blocks of Well-Being, Seligman, 2018

Positive Psychology: A Personal History , Seligman, 2019

Agency in Greco Roman Philosophy , Seligman, 2020

Agency in Ancient China , Zhao, Seligman et al., 2021

Psychological History and Predicting the Future , Seligman, 2022

Well-Being Research:

Beyond Money , Diener and Seligman, 2004

Subjective Well-Being: Three Decades of Progress , Diener at al., 1999

Subjective Well-Being: The Science of Happiness and a Proposal for a National Index , Diener, 2000

Using Well Being for Public Policy: Theory, Measurement, and Recommendations , Adler and Seligman, 2016

If, Why, and When Subjective Well-Being Influences Health, and Future Needed Research, Diener, Pressman, and Delgadillo-Chase, 2017

Social Media and Well-Being Research :

Limiting Social Media Decreases Loneliness and Depression , Hunt, Marx, Lipson, & Young, 2018

Detecting Depression and Mental Illness on Social Media: An Integrative Review , Guntuku et al., 2017

Predicting Individual Well-Being Through the Language of Social Media , Schwartz et al., 2016

Gaining Insights from Social Media Language: Methodologies and Challenges , Kern et al., 2016

Psychological Language on Twitter Predicts County-Level Heart Disease Mortality , Eichstaedt et al., 2015

Personality, Gender, and Age in the Language of Social Media: The Open-Vocabulary Approach , Schwartz et al., 2013

Optimism Research :

Association between Predeployment Optimism and Onset of Postdeployment Pain in US Army Soldiers, Hassett et al, 2019

Optimism and Physical Health: A Meta-analytic Review , Rasmussen, Scheier & Greenhouse, 2009

Pessimistic Explanatory Style Is a Risk Factor for Physical Illness: A Thirty-Five-Year Longitudinal Study , Peterson & Seligman, 1988

Explanatory Style Change During Cognitive Therapy for Unipolar Depression, Seligman et al., 1988

Explanatory Style as a Predictor of Productivity and Quitting Among Life Insurance Sales Agents , Seligman and Schulman, 1986

Explanatory Style as a Mechanism of Disappointing Athletic Performance , Seligman et al., 1990

Explanatory Style and Academic Performance Among University Freshmen , Peterson & Barrett, 1987

Attributional Style in Depression: A Meta-Analytic Review , Sweeney, Anderson & Bailey, 1986

Learned Helplessness in Children: A Longitudinal Study of Depression, Achievement, and Explanatory Style, Nolen-Hoeksema, Girgus, & Seligman, 1986

Causal Explanations as a Risk Factor for Depression: Theory and Evidence, Peterson & Seligman, 1984

Learned helplessness in Humans: Critique and Reformulation, Abramson, Seligman, & Teasdale, 1978

Learned Helplessness: Theory and Evidence ,  Maier & Seligman, 1976

Learned Helplessness , Seligman, 1972

Positive Psychology Interventions Research:

Positive Psychology Progress: Empirical Validation of Interventions , Seligman, Steen, Park, & Peterson, 2005

Pursuing Happiness in Everyday Life: The Characteristics and Behaviors of Online Happiness Seekers , Parks et al., 2012

Disseminating Self-Help: Positive Psychology Exercises in an Online Trial , Schueller & Parks, 2012

Building Resilience , Harvard Business Review, Seligman, 2011

Character Strengths Research :

Christopher M. Peterson (Memoriam), Park & Seligman, 2013

Character Strengths Predict Subjective Well-Being During Adolescence, Gillham et al., 2011

Character Strengths: Research and Practice , Park & Peterson, 2009 

Strengths of Character, Orientations to Happiness, and Life Satisfaction , Peterson et al., 2007

Character Strengths in Fifty-Four Nations and the Fifty US States , Park, Peterson, & Seligman, 2006

Shared Virtue: The Convergence of Valued Human Strengths Across Culture and History, Dahlsgaard, Peterson, & Seligman, 2005

Strengths of Character and Well-Being , Park, Peterson & Seligman, 2004

Chris Peterson's Unfinished Masterwork: The Real Mental Illnesses , Seligman, 2013

Research on the VIA Institute Website

Positive Emotions Research :

Positive Emotions Broaden and Build , Fredrickson, 2013

Counting Blessings Versus Burdens: An Experimental Investigation of Gratitude and Subjective Well-Being in Daily Life , Emmons & McCullough, 2003

The Grateful Disposition: A Conceptual and Empirical Topography , McCullough & Emmons, 2002

The Psychology of Forgiveness , McCullough & vanOyen Witvliet, 2001

Interpersonal Forgiving in Close Relationships: II. Theoretical Elaboration and Measurement , McCullough et al., 1998

Mindfulness Training Modifies Subsystems of Attention , Jha, Krompinger & Baime, 2007

Witnessing Excellence in Action: The ‘Other-Praising’ Emotions of Elevation, Gratitude, and Admiration , Algoe & Haidt, 2009

The Varieties of Self-Transcendent Experience , Yaden, Haidt, Hood, Vago, and Newberg, 2017

A Four-Factor Model of Perceived Control: Avoiding, Coping, Obtaining, and Savoring , Bryant, 1989

Engagement Research :

Flow Theory and Research , Nakamura & Csikszentmihalyi, 2009

Relationships Research :

What Do You Do When Things Go Right? The Intrapersonal and Interpersonal Benefits of Sharing Positive Events , Gable et al., 2004 

Meaning Research :

On the Meaning of Work: A Theoretical Integration and Review , Rosso, Dekas & Wrzesniewski, 2010 

Crafting a Job: Revisioning Employees as Active Crafters of Their Work , Wrzesniewski & Dutton, 2001

Jobs, Careers, and Callings: People’s Relations to Their Work , Wrzesniewski et al., 1997

The Development of Purpose During Adolescence , Damon, Menon & Bronk, 2003

Achievement Research :

The Science and Practice of Self-Control , Duckworth & Seligman, 2017

Self-Control and Grit: Related but Separable Determinants of Success , Duckworth & Gross, 2014

Grit: Perseverance and Passion for Long-Term Goals , Duckworth et al., 2007 

Self-Discipline Outdoes IQ in Predicting Academic Performance of Adolescents , Duckworth & Seligman, 2005

The Role of Deliberate Practice in the Acquisition of Expert Performance , Ericsson, Krampe & Tesch-Romer, 1993 

A Social-Cognitive Approach to Motivation and Personality , Dweck & Leggett, 1988

School-Based Resilience Interventions Research :

Positive Education  Seligman & Adler 2019

Positive Education, Seligman & Adler, 2018

Positive Education: Positive Psychology and Classroom Interventions , Seligman, Ernst, Gillham, Reivich, & Linkins, 2009

Group Prevention of Depression and Anxiety Symptoms , Seligman, Schulman, & Tryon, 2007

The Prevention of Depression and Anxiety , Seligman, Schulman, DeRubeis, & Hollon, 1999

Teaching Well-Being increases Academic Performance: Evidence from Bhutan , Mexico, and Peru, Adler, 2016

Physical Health Following a Cognitive-Behavioral Intervention , Buchanan, Gardenswartz, & Seligman, 1999

School-Based Prevention of Depressive Symptoms: A Randomized Controlled Study of the Effectiveness and Specificity of the Penn Resilience Program, Gillham et al., 2007

Prevention of Depressive Symptoms in School Children: Two Year Follow-Up , Gillham, Reivich, Jaycox, & Seligman, 1995

Prevention of Depressive Symptoms in School Children, Jaycox, Reivich, Gillham, & Seligman, 1994

A Meta-Analytic Review of the Penn Resiliency Program's Effect on Depressive Symptoms , Brunwasser, Gillham, & Kim, 2009

Primal World Beliefs:

Primal World Beliefs , Clifton et al., 2019

Parents Think, Incorrectly, that Teaching their Children the World is a Bad Place is Best for Them , Clifton & Meindl, 2021

Well-Being and the Arts:

Art Museums as Institutions for Human Flourishing , Cotter and Pawelski, 2021

Imagination Research :

Creativity and Aging: What We Can Make with What We Have Left , Seligman, Forgeard, & Kaufman, 2017

Openness/Intellect: The Core of the Creative Personality , Oleynick et al., 2017

How Social-Emotional Imagination Facilitates Deep Learning and Creativity in the Classroom ,, Gotlieb, Jahner, Immordino-Yang, & Kaufman, 2017

Cultivating the Social-Emotional Imagination in Gifted Education: Insights from Educational Neuroscience , Gotlieb, Hyde, Immordino-Yang, & Kaufman, 2017

Post-Traumatic Growth Research :

Posttraumatic Growth: Conceptual Foundations and Empirical Evidence , Tedeschi & Calhoun, 2004

Doors Opening: A Mechanism for Growth After Adversity, Roepke & Seligman, 2015

Positive Psychology and Therapy Research:

Cognitive Therapy and Research Special Issue: Positive Emotions and Cognitions in Clinical Psychology , June 2017

Positive Psychology in Clinical Practice , Duckworth, Steen, & Seligman, 2005

Positive Psychotherapy , Seligman, Rashid, & Parks, 2006

Positive Health Research : 

Positive Health , Seligman, 2008

Positive Health and Health Assets: Re-analysis of Longitudinal Datasets , Seligman et al., 2013

The Person-Event Data Environment: Leveraging Big Data for Studies of Psychological Strengths in Soldiers. Vie, Griffith, Scheier, Lester & Seligman, 2013

The U.S. Army Person-Event Data Environment: A Military-Civilian Big Data Enterprise, Vie et al., 2015

Initial Validation of the U.S. Army Global Assessment Tool , Vie, Scheier, Lester, & Seligman, 2016

Protective Effects of Psychological Strengths Against Psychiatric Disorders Among Soldiers, Shrestha et al., 2018

Association Between Predeployment Optimism and Onset of Postdeployment Pain in US Army Soldiers, Hassett et al., 2019

PTSD: Catastrophizing in Combat as Risk and Protection, Seligman et al., 2019

Comparison of Cardiovascular Health Between US Army and Civilians. Shrestha et al., 2019

Optimism and Risk of Incident Hypertension: A Target for Primordial Prevention , Kubzansky et al., 2020

Development of Character Strengths Across the Deployment Cycle Among U.S. Army Soldiers , Chopik et al., 2020

Happy Soldiers are Highest Performers , Lester et al., 2021

Prospective Psychology:

We Aren't Built to Live in the Moment , Seligman & Tierney, 2017

Navigating into the Future or Driven by the Past , Seligman, Railton, Baumeister, & Sripada, 2013

Depression and Prospection , Roepke & Seligman, 2016

  • Research article
  • Open access
  • Published: 08 February 2013

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.

Conclusions

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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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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  • Positive psychology
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The effect of positive psychology interventions on well-being and distress in clinical samples with psychiatric or somatic disorders: a systematic review and meta-analysis

  • Farid Chakhssi   ORCID: orcid.org/0000-0001-6929-0331 1 , 2 ,
  • Jannis T. Kraiss 2 ,
  • Marion Sommers-Spijkerman 2 &
  • Ernst T. Bohlmeijer 2  

BMC Psychiatry volume  18 , Article number:  211 ( 2018 ) Cite this article

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Although positive psychology interventions (PPIs) show beneficial effects on mental health in non-clinical populations, the current literature is inconclusive regarding its effectiveness in clinical settings. We aimed to examine the effects of PPIs on well-being (primary outcome), depression, anxiety, and stress (secondary outcomes) in clinical samples with psychiatric or somatic disorders.

A systematic review and meta-analysis was conducted following PRISMA guidelines. PsycINFO, PubMed, and Scopus were searched for controlled studies of PPIs in clinical samples between Jan 1, 1998 and May 31, 2017. Methodological quality of each study was rated. We used Hedges’ adjusted g to calculate effect sizes and pooled results using random-effect models.

Thirty studies were included, representing 1864 patients with clinical disorders. At post-intervention, PPIs showed significant, small effect sizes for well-being (Hedges’ g  = 0.24) and depression ( g  = 0.23) compared to control conditions when omitting outliers. Significant moderate improvements were observed for anxiety ( g  = 0.36). Effect sizes for stress were not significant. Follow-up effects (8–12 weeks), when available, yielded similar effect sizes. Quality of the studies was low to moderate.

These findings indicate that PPIs, wherein the focus is on eliciting positive feelings, cognitions or behaviors, not only have the potential to improve well-being, but can also reduce distress in populations with clinical disorders. Given the growing interest for PPIs in clinical settings, more high quality research is warranted as to determine the effectiveness of PPIs in clinical samples.

Trial registration

PROSPERO CRD42016037451

Peer Review reports

Positive psychology is a relatively new field that focuses on enhancing well-being and optimal functioning rather than ameliorating symptoms, and complements rather than replaces traditional psychology [ 1 ]. Common themes in positive psychology include savoring, gratitude, kindness, promoting positive relationships, and pursuing hope and meaning [ 2 ].

Now that it has been repeatedly shown that well-being and psychopathology are two moderately correlated yet independent constructs of mental health [ 3 , 4 , 5 , 6 ], well-being receives growing attention in clinical research and practice. Even after successful treatment of psychopathology, low levels of well-being may persist in individuals, which, in turn, form a substantial risk factor for psychological distress [ 7 ]. In the light of a substantial body of evidence demonstrating that high levels of well-being buffer against psychological symptomatology, including relapse or recurrence of symptoms, besides enhancing quality of life and longevity [ 5 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 ], we anticipate that clinical samples could greatly benefit from positive psychological interventions (PPIs) which explicitly aim to enhance well-being, that is, positive feelings, cognitions or behaviors [ 15 ].

Although PPIs have been mostly examined in non-clinical samples [ 16 ], some preliminary evidence exist for their efficacy in clinical samples [ 16 , 17 ]. Independent lines of research have shown that PPIs improved well-being and decreased psychological distress in mildly depressed individuals [ 18 ], in patients with mood and depressive disorders [ 19 , 20 ], in patients with psychotic disorders [ 21 ] and improving quality of life and well-being in breast cancer patients [ 22 ]. Thus, PPIs may have the potential to be of value to clinical samples but their effectiveness in these samples is not well established.

To date, two meta-analyses have been published that examined the effectiveness of PPIs in predominantly non-clinical samples. First, Sin and Lyubomirsky [ 17 ] included 49 controlled studies with 4235 individuals examining the effectiveness of PPIs on well-being and depression. They found that PPIs were significantly more effective than comparators (i.e. active control or treatment as usual) for enhancing well-being ( r  = .29) and decreasing depression ( r  = .31). Second, to address several methodological issues in Sin and Lyubomirsky’s meta-analysis [ 17 ] such as lack of methodological quality assessment of the included studies, Bolier and colleagues [ 16 ] re-examined the literature. Using more stringent methodological and inclusion criteria, they systematically collected and synthesized the findings of 39 randomized controlled studies with 6139 individuals. Small but significant effects of PPIs on subjective well-being, psychological well-being and depression were found, with Cohen’s d effect sizes of 0.34, 0.20 and 0.23, respectively.

However, these previously published meta-analyses are inconclusive regarding the effectiveness of PPIs in improving well-being and alleviating psychological distress in clinical samples. Although both meta-analyses included a number of studies with clinical samples, 12 out of 49 studies [ 17 ] and 4 out of 39 studies [ 16 ], respectively, these were limited to psychiatric samples with depressive or anxiety symptoms. To our knowledge, no attempt has been made to systematically examine the effects of PPIs in samples with somatic disorders who may benefit from improvements in well-being [ 23 ].

Since there is growing interest in the application of PPIs targeting clinical samples, the aim of the study was to add to the existing literature on the effectiveness of PPIs in primarily non-clinical samples [ 16 , 17 ] through meta-analytically testing the effects of PPIs on well-being and distress across a broad range of clinical samples with psychiatric and somatic disorders.

This study was prepared and conducted according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines [ 24 ] and registered on April 29, 2016 in PROSPERO (#CRD42016037451), an international prospective register for systematic reviews.

Search strategy

The electronic databases PsycINFO, PubMed, and Scopus were searched from 1998 (the start of the positive psychology movement) to March 31, 2016, and an update of the search was conducted on May 31, 2017. For each database, text word search terms, medical subject headings (PubMed) or thesaurus terms (PsycINFO) were used relating to ‘well-being’ and ‘positive psychology’, in combination with terms related to ‘interventions’, ‘disorders and illness’ and ‘outcome’ (see Additional file  1 for more detailed information on the search terms). Studies cited in the previously published meta-analytic reviews [ 16 , 17 , 22 ] were cross-checked. Additionally, three clinical trial registers ( www.clinicaltrialsregister.eu , www.clinicaltrials.gov , www.isrctn.com ) were searched on August 31, 2016, to detect trials with unpublished results available.

Selection of studies

Potentially eligible studies were screened on title in the first phase, on abstract in the second phase, and on full paper in the third phase. Studies were included in the meta-analysis if they: 1) examined the effects of an intervention developed in line with the theoretical tradition of positive psychology cfm. Sin and Lyubomirsky (2009), that is, a psychological intervention (i.e. training, exercise, therapy) aimed at raising positive feelings, cognitions or behaviors; 2) included adult participants (18 years or older) with clinical psychiatric or somatic disorders [according to the International Classification of Diseases and Related Health Problems; [ 25 ]; 3) used an outcome measure of social, emotional or psychological well-being; 4) used a control condition; and 5) provided an effect size or sufficient information to calculate an effect size. Studies were excluded if they: 1) were not published in an English language peer-reviewed journal; 2) examined physical exercises aimed at improving well-being; or 3) used an intervention that is primarily based on reminiscence, mindfulness and/or meditation. With regard to the third exclusion criterion, extensive meta-analyses have already been published for these types of interventions [ 26 , 27 , 28 , 29 , 30 ]. Published abstracts and/or study protocols were also excluded.

The first (FC) and second author (JTK) independently conducted the screening of titles. The interrater reliability was high (kappa = 0.84; n  = 1000). Disagreements between raters during the screening of abstracts and full texts were discussed until consensus was reached. Any remaining ambiguity was resolved with the third (MSS) and fourth author (ETB).

Data extraction

Data were collected on: 1) population characteristics, including age, gender, disorder, and sample size (per condition); 2) intervention characteristics, including type of PPI, delivery mode, number of sessions, duration in weeks, retention rate, and guidance (i.e. with or without therapist); 3) methodological characteristics, including study design, type of control group, assessment points (i.e. pre, post and/or follow up), and outcome measures. Eight authors were contacted because information regarding study characteristics or to calculate effect sizes was lacking, of whom six provided additional data on request.

Quality assessment

All studies were rated on methodological quality using criteria based on the Cochrane Collaboration’s tool for assessing risk of bias [ 31 ] and the Jadad scale [ 32 ]. This rating consists of seven items that are rated as 0 (“absent”) or 1 (“present”), resulting in a maximum quality score of 7 points. Studies were identified as “good” when all seven criteria were met, “fair” when five or six criteria were met, and “poor” when four or less criteria were met [ 33 ]. The included items cover: 1) random sequence generation and allocation concealment (i.e. sufficient description of the method used to generate and conceal the allocation sequence); 2) blinding of outcome assessments (i.e. outcome assessments are either administered online or by an independent person who is not involved in the study), 3) reporting incomplete outcome data (i.e. dropout analysis is conducted or reasons for drop-out are reported), 4) using intention-to-treat analysis, 5) group similarity at baseline regarding prognostic factors (e.g. demographics) or adjustments were made to correct for baseline imbalance, 6) adequate sample size/power analysis (i.e. an adequate power analysis was conducted or the study included 50 or more persons in the analysis), and 7) reliability of the diagnostic assessment (i.e. assessment was conducted by a professional and not based on self-report or screening or there were no diagnostic assessments). The first (FC) and second author (JTK) independently conducted the quality assessment, whereby disagreements were discussed until consensus was reached.

Primary and secondary outcomes

The primary outcome was the mean well-being score at the end of the intervention, assessed with validated measures of social, emotional, and/or psychological well-being. In the absence of well-being measures, measures, constructs related to well-being such as hope, happiness, life satisfaction, personal growth, optimism or positive affect were included if available. If more than one measure for well-being was used, we used the most validated measure, to ensure each study had one primary outcome for the analysis. Secondary outcomes included depression, anxiety and stress.

Statistical analysis

For each study, means and standard deviations were extracted, where possible based on the intention-to-treat method; otherwise, the reported means and standard deviations for the patients that completed the interventions were used. Effect sizes were calculated in three steps. First, standardized pre-post effect sizes were calculated per condition (i.e. PPI or control condition) by subtracting the average pre-intervention score from the average post-intervention score and subsequently dividing this score by the pooled standard deviation. Second, the difference in effect size (Δ d ) between PPI condition and control condition was computed. Third, Δ d was adjusted for small sample bias, indicated as Hedges’ g . Where possible, pre-to-follow-up effect sizes were calculated in a similar manner, thereby only using studies with a follow-up period between 8 and 12 weeks.

Using Comprehensive Meta-Analysis version 2.2.064, separate meta-analyses were performed for 1) well-being, 2) depression, 3) anxiety, and 4) stress in which data were pooled using the random-effects model accounting for diversity across studies (e.g. in terms of populations, types of PPIs and outcome measures). Effect sizes of 0.56 to 1.2 can be considered large, effect sizes of 0.33 to 0.55 moderate, and effect sizes of 0 to 0.32 small [ 34 ].

Heterogeneity of effect sizes was examined using Q and I 2 statistics. The Q-test assesses whether the observed effect sizes are significantly more different from one another than would be expected based on chance alone. A significant Q-statistic indicates heterogeneity. The I 2 statistic captures the percentage of the total variance across the included studies attributable to heterogeneity. A value of zero indicates true homogeneity, while values of 25, 50, and 75% indicate low, moderate, and high levels of heterogeneity, respectively [ 35 ].

Publication bias was assessed using funnel plots, Egger’s Test, Duval and Tweedie’s trim-and-fill procedure, and fail-safe N. First, a funnel plot was created by plotting the overall mean effect size against study size. Whereas a symmetric distribution of studies around the effect size indicates the absence of publication bias, a higher concentration of studies on one side of the effect size than on the other indicates publication bias [ 36 ]. Second, Egger’s test [ 37 ] was used to examine the symmetric distribution of studies around the effect size with a quantitative test statistic (considered significant funnel plot asymmetry if p  < 0.05). Third, Duval and Tweedie’s [ 38 ] trim-and-fill procedure was applied. This procedure imputes the effect sizes of missing studies and produces an adjusted effect size accounting for these missing studies. Adjusted values were only reported for pooled effect sizes when these were statistically significant. Finally, a fail-safe N, a test of funnel plot asymmetry, was calculated for each analysis. The fail-safe N indicates the number of unpublished non-significant studies that would be required to lower the overall effect size below significance [ 37 ]. The findings were considered robust if the fail-safe N  ≥ 5n + 10, where n is the number of comparisons [ 39 ].

Pre-specified exploratory subgroup analyses were performed to examine differences in effect sizes based on: 1) population type: psychiatric vs somatic disorders; 2) intervention type: individual vs. group format, with vs. without therapist guidance; and 3) duration of the intervention: short (≤ 8 weeks) vs long (> 8 weeks). Mixed effects analysis was used to tests for differences between subgroups. Additional ad hoc analyses were performed to explore differences in effect sizes based on: 1) type of PPI: PPI therapy programs (e.g. meaning-centered group approach, well-being therapy) vs single PPIs (e.g. three good things/signature strengths); and 2) control group: no intervention (i.e. did not receive any intervention at all)/waitlist (i.e. did receive the intervention after the experimental group) vs. active/treatment-as-usual. Finally, meta-regression analysis was performed to investigate if effect sizes were moderated by study quality.

A total of 10,886 studies were produced in the electronic database searches. After the exclusion of duplicates ( n  = 1578) and the removal of studies at the title screening phase ( n  = 9069), 239 abstracts were reviewed (Fig.  1 ). Of the 101 articles identified for full text review, 30 controlled studies were included. The 30 studies comprised 33 comparisons for well-being, 26 comparisons for depression, 14 comparisons for anxiety and 6 comparisons for stress [ 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 ]. Fourteen studies were conducted in the United States, three each in Iran, Canada, and Spain, two each in the United Kingdom and Italy, and one each in Australia, Germany, and Taiwan. The characteristics of the included studies are presented in Table  1 .

figure 1

Flowchart of the study selection process

Population characteristics

The included studies comprised 1864 adult participants, 960 in the PPI conditions and 904 in the control conditions. The mean age of the participants at pre-intervention was 47.8 years ( SD  = 11.5, range 26.4–68.9), and more than half were women (61.5%). In 16 studies, clinical samples with somatic disorders were included, with cancer being the most prevalent disorder (8 out of 16 studies). Other somatic disorders included cardiac diseases ( n  = 4), HIV ( n  = 1), brain injuries ( n  = 1), diabetes ( n  = 1) and chronic pain ( n  = 1). The remaining 14 studies included samples with psychiatric disorders, with depressive disorder as the most prevalent disorder (7 out of 13 studies), followed by anxiety disorders ( n  = 2), severe emotion dysregulation ( n  = 1), psychotic disorders ( n  = 1), post-traumatic stress syndrome ( n  = 1), and various mental health problems ( n  = 2).

Intervention, comparison and outcome characteristics

In 20 studies, PPIs were compared to treatment as usual or an active control condition, such as supportive psychotherapy [ 44 ], cognitive behavioral therapy [ 47 ], dialectical behavior therapy [ 69 ] or mood monitoring [ 57 ]. Ten studies compared PPIs to a no intervention/waitlist condition. The names of the PPIs as provided by the authors of the studies are also displayed in Table 1 . All interventions were explicitly aimed at raising positive feelings, cognitions or behaviors. The 24 studies used empirically validated PPIs (see [ 2 , 18 ]) or programs that have incorporated PPIs such as positive psychotherapy [ 67 ] or well-being therapy [ 51 ]. In 24 studies, therapist guidance was part of the PPI. The intervention duration varied from 3 days to 16 weeks. The mean retention rate, based on dropouts at post-intervention, was 81.4% (available for 26 studies). For the PPI conditions, the mean retention rate was 81.0% and for the control conditions 81.8%. For the 12 studies that included follow-up measurements, the average follow-up time was 12.9 weeks after post-intervention.

Quality of studies

The quality scores of the studies are displayed in Table  2 . If a criterion was not reported in the paper, it was labeled “unclear”, and the criterion was rated as not met. All studies were either of medium quality ( n  = 12) or of low quality ( n  = 18). None of the included studies met all quality criteria. The use of intention-to-treat analyses was the most poorly rated, with only 11 studies meeting this criterion.

Meta-analyses

Table  3 summarizes findings from the meta-analyses per outcome, i.e. well-being, depression, anxiety, and stress. The meta-analyses were run separately for all studies at post-intervention with the outliers included, with the outliers excluded and with the low quality omitted. The meta-analyses at follow-up were run including outliers and low quality studies. The effect sizes of the individual studies at post-intervention are plotted in Figs.  2 , 3 , 4 and 5 .

figure 2

Post-intervention effects of positive psychology interventions on well-being. The square boxes show Hedges’ g effect size in each study, and the line the 95% confidence interval. The diamond reflects the pooled effect size and the line the width of the 95% confidence interval

figure 3

Post-intervention effects of positive psychology interventions on depression. The square boxes show Hedges’ g effect size in each study, and the line the 95% confidence interval. The diamond reflects the pooled effect size and the line the width of the 95% confidence interval

figure 4

Post-intervention effects of positive psychology interventions on anxiety. The square boxes show Hedges’ g effect 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 5

Post-intervention effects of positive psychology interventions on stress. The square boxes show Hedges’ g effect 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

Post-intervention effects on well-being

For well-being (33 comparisons), a significant, small effect was observed ( g  = 0.28, 95% CI: 0.07 to 0.48, p = 0.008) at post-intervention. The level of heterogeneity was high ( I 2  = 78.20). Four outliers were detected [ 41 , 46 , 52 , 61 ]. After omitting these studies from the analysis, we found a similar effect, with g = 0.24 (95% CI: 0.13 to 0.35, p  < 0.001), and heterogeneity reduced substantially ( I 2  = 20.29). When studies scored as low quality were excluded from the analysis (including outliers), again a small significant effect size was observed ( g  = 0.19, 95% CI: 0.02 to 0.37, p  = 0.030), with a moderate level of heterogeneity ( I 2  = 40.88).

Post-intervention effects on depression

Based on 26 comparisons, we found a significant, small effect of PPIs on depression, with g  = 0.27 (95% CI: 0.09 to 0.45, p  = 0.003) at post-intervention. The level of heterogeneity was moderate ( I 2  = 62.34). Five outliers were detected [ 45 , 51 , 56 , 68 , 69 ]. After removal of the outliers, a small effect size was observed ( g  = 0.23, 95% CI: 0.11 to 0.34, p  < 0.001). The level of heterogeneity was low ( I 2  = 10.16). After removal of low quality studies, the effect size for depression was not significant with g  = 0.07 (95% CI: -0.19 to 0.32, p  = 0.598), and heterogeneity was moderate ( I 2  = 66.08).

Post-intervention effects on anxiety

For anxiety (14 comparisons), a significant, moderate effect was found ( g  = 0.47, 95% CI: 0.23 to 0.71, p  < 0.001) at post-intervention. Heterogeneity was moderate ( I 2  = 62.34), and one outlier was detected [ 52 ]. After removal of the outlier, the effect size dropped to g  = 0.36 (95% CI: 0.20 to 0.53, p  < 0.001), but still remained in the moderate range, and the level of heterogeneity was low ( I 2  = 10.16). After removal of low quality studies from the analysis, the effect size for anxiety was small and not significant ( g  = 0.22, 95% CI: -0.05 to 0.49, p  = 0.233), with moderate heterogeneity ( I 2  = 40.39).

Post-intervention effects on stress

The overall mean effect size for 5 comparisons on stress was not significant ( g  = 0.00; 95% CI: -0.62 to 0.62, p  = 0.999) at post-intervention. After the removal of one outlier [ 41 ], the effect size increased to the small range ( g  = 0.27; 95% CI: -0.19 to 0.73, I 2  = 43.89) but remained non-significant ( p  = .247). Only 1 study that included stress as an outcome had a medium quality rating (see Table 1 ).

Effects at follow-up

At follow-up, a significant, moderate effect was observed for well-being ( g  = 0.41, 95% CI: 0.08 to 0.74, p  = 0.014), a significant, small effect for depression ( g  = 0.21, 95% CI: 0.05 to 0.37, p  = 0.011), and a significant, moderate effect for anxiety ( g  = 0.35, 95% CI: 0.12 to 0.59, p  = 0.004). There were no follow-up assessments conducted between 8 to 12 weeks with stress as outcome.

Subgroup analyses

Exploratory subgroup analyses are presented in Table  4 . For well-being ( Q  = 6.412, df  = 1, p  = 0.011) a significantly higher effect size was found for PPIs with therapist guidance ( g  = 0.39) than for PPIs without therapist guidance ( g  = − 0.12). For stress, PPIs were found significantly more effective in studies using a no intervention/waitlist control condition ( g  = 1.12 vs g  = − 0.21; Q  = 8.283, df  = 1, p  = 0.004) than in studies using an active or treatment-as-usual control condition. Effect sizes did not significantly vary based on population type (i.e. psychiatric vs somatic disorders), intervention format (i.e. individual vs group), intervention duration (i.e. shorter vs longer than 8 weeks) and/or type of PPI (i.e. PPI therapy programs vs single PPIs). For depression and anxiety, no significant differences between subgroups were found.

Meta-regression analysis

Using meta-regression analysis, we found no evidence that effect sizes for well-being and stress were moderated by study quality. The study quality had a significant negative influence on the effect size for depression and anxiety, with lower study quality scores resulting in lower effect sizes for depression (slope: -0.17, Z  = − 3.23, p  = 0.001) and anxiety (slope: -0.28, Z  = − 3.25, p  = 0.001).

Publication bias

First, inspection of the funnel plots showed that only for stress the funnel plot was skewed in favor of studies with a positive outcome at post-intervention. Second, Egger’s test statistic showed no significant funnel plot asymmetry for all analyses (all p -values > .05). Third, after adjusting for potential publication bias with Duval and Tweedie’s trim-and-fill procedure, the effect sizes for well-being and stress remained the same. However, for depression, four studies were trimmed and the adjusted effect size was g  = 0.15 (95% CI: 0.05 to 0.25). Also for anxiety, four studies were trimmed and the adjusted effect size was g  = 0.27 (95% CI: 0.14 to 0.39). Finally, the fail-safe N indicated that the findings for well-being and anxiety were robust, whereas the fail-safe numbers for depression (132) and stress (0) were lower than required (140 and 35, respectively). After omitting outliers, the findings for anxiety remained robust. The fail-safe N for well-being (137), depression (66) and stress (0) were lower than required (respectively 155, 115 and 35). At follow-up, the fail-safe N for well-being (28), depression (4) and anxiety (10) were lower than required (respectively 45, 35, and 30).

To our knowledge, this is the first meta-analysis examining the effects of PPIs on well-being and distress in clinical samples with psychiatric and somatic disorders. When excluding outliers, our analyses suggest that PPIs have a small but significant effect on well-being compared to control conditions. At follow-up, a significant moderate effect size of PPIs on well-being was observed. For the secondary outcomes, a small but significant effect size was found for depression at post-intervention and follow-up and moderate significant effect sizes for anxiety at post-intervention and follow-up. Effect sizes for stress were not significant. These findings suggest that PPIs not only have the potential to improve well-being, but can also reduce distress in populations with clinical disorders.

The effect sizes at post-intervention and follow-up for well-being and distress were comparable with those found in Bolier et al's meta-analysis of controlled PPIs studies in predominantly non-clinical samples [ 16 ], but were lower than those in the earlier meta-analysis of Sin and Lyubomirsky [ 17 ]. However, in the meta-analysis conducted by Sin and Lyubomirsky [ 17 ] less stringent inclusion criteria were used and other interventions such as mindfulness and life-review were included that are commonly not regarded as PPIs [ 2 , 16 ]. Nonetheless, our findings show promise for PPIs in samples with psychiatric and somatic disorders, and suggest that PPIs, wherein the focus is on eliciting positive feelings, cognitions or behaviors, may also be relevant for clinical populations.

In the field of psychology, especially clinical psychology, the focus lies primarily on examining distress-reducing treatment approaches. As PPIs explicitly aim to improve well-being, the findings of the current study are important because well-being is often impaired in individuals with clinical disorders [ 23 ] and low levels of well-being form a substantial risk for relapse or recurrence of symptoms [ 5 , 7 ]. More importantly, recent studies suggest that well-being and psychological distress are two separate constructs, and that the treatment of symptoms does not necessarily result in improved well-being (e.g., [ 6 , 14 ]). In the light of these findings, we encourage researchers to further establish the effectiveness of well-being enhancing approaches including PPIs.

Explorative subgroup analyses suggest that guided PPIs are more effective in improving well-being compared to unguided PPIs, such as self-help. Similar findings were found in earlier meta-analytic reviews [ 16 , 17 ] regarding PPIs in predominantly nonclinical samples, where larger effect sizes were found in therapist-guided interventions (compared with unguided self-help), when the interventions were offered to people with mental health problems. This is also in line with findings regarding supported versus unsupported conventional psychological treatments, such as cognitive behavioral therapy (e.g., [ 70 , 71 ]) where significant larger effect sizes are observed for supported psychological treatments. Therapist guidance may potentially improve outcomes of PPIs on well-being in samples with psychiatric and/or somatic disorders. However, based on the explorative nature of the subgroup analyses, these findings should be treated with caution and future research should examine the effect of therapist guidance compared to self-help in controlled studies.

No other significant pre-specified moderators of outcome were observed. There was no significant effect of disorder type (i.e. psychiatric vs somatic disorders) and intervention format (i.e. individual vs group). Although, the moderating effect of intervention duration was not significant, the results showed that PPIs with a shorter duration than 8 weeks did not have a significant effect on well-being whereas PPIs with a longer duration had a significant effect on well-being. This finding is in line with earlier meta-analytic reviews [ 4 , 5 ] and suggests that PPIs are more effective when offered during a longer period of time (more than 8 weeks). In the additional moderator analyses, no significant differences in effect sizes were found for empirically validated PPIs vs other PPIs. For stress, a significantly higher effect size was found for PPIs that had no intervention/waitlist as control condition than for PPIs that had an active control condition or treatment-as-usual as control condition. However, the sample sizes were relatively small in the exploratory subgroup analyses, which limits the interpretation of the differences between groups, and the results should therefore be considered with caution.

The current systematic review and meta-analysis highlights the need to improve the research methodology and reporting within the field of PPIs. The quality of the included studies was low to medium. Although the quality of the studies may have been underestimated since we rated a criterion as not met if it was not reported in the paper, it seems that the methodological quality of studies in this field could be considerably improved if authors routinely report on sequence generation, allocation concealment and blinding of assessors. Furthermore, only one third of the included studies reported using the intention-to-treat principle to analyze the results and almost half of the included studies did not report using a power analysis to determine the sample size. Inadequate statistical power and not adhering to the intention-to-treat principle introduces bias into the results of individual studies, and distorts the results from meta-analyses [ 72 ]. This was reflected in the meta-regression analysis which indicated that the effects of PPIs on depression and anxiety were moderated by the methodological quality of the studies, with a lower study quality resulting in smaller effect sizes. Therefore, we recommend researchers conducting studies on PPIs in clinical samples to comply with the quality criteria when designing studies, in order to perform more high quality research to accurately determine the effectiveness of PPIs in clinical samples with psychiatric and somatic disorders. Moreover, the number of studies including post-treatment follow-up measures is relatively low (12 out of 30). We encourage researchers in the field to include follow-up measurements as to determine whether possible favorable effects of PPIs can be sustained in the long run.

Our systematic review and meta-analysis focused on controlled studies of PPIs in clinical samples. We identified a number of studies in different clinical disorders, age groups and settings. Drawing upon these findings in one place has generated the first evidence-based overview of the effectiveness of PPIs in clinical populations. However, several limitations should be noted. One important limitation is that well-being was not always the primary outcome in the included studies. Also, different definitions of well-being were used across the included studies. Incorporating validated measures of well-being, preferably ones that encompass emotional, psychological, and social dimensions of well-being [ 73 ], in future studies of PPIs is recommended. Second, the effects of the PPIs may also have been overestimated due to publication bias. Although the results of this meta-analysis point at significant but small effects of PPIs, after adjustment for publication bias, caution is needed. Third, our conclusions are based on the overall effect after the exclusion of outliers, including studies of low quality. When considering only studies of at least medium quality, the effects of PPIs are substantially lower but the sample size of the studies also decreases substantially. Since this is the first study meta-analyzing the effects of PPIs in clinical samples, we based our conclusions on the analyses (i.e. after excluding outliers) with the largest sample size to present a more comprehensive representation of the field. Fourth, we observed a broad range of PPIs in our meta-analysis that varied in delivery mode and intensity. Future research should examine which clinical populations may benefit from PPIs, in terms of type, delivery mode and intensity, and whether there are differential mediators of outcome. Still, this is one of the first meta-analyses in this field providing an overview of PPIs in clinical samples.

Conclusions

In conclusion, this systematic review and meta-analysis provides evidence that PPIs are effective in improving well-being as well as in alleviating common psychological symptoms, including depression and anxiety, in clinical samples with psychiatric and somatic disorders. At present, the most promising PPIs seem to be those that are guided. Given the growing interest for PPIs in clinical settings [ 15 , 16 ], it is timely and important to further establish the potential of PPIs in the context of clinical populations using large-scale and methodologically sound trials.

Abbreviations

Authentic happiness index

Beck anxiety inventory

Beck depression inventory-II

Center for epidemiologic studies depression scale

Confidence interval

Clinical interview for depression - anxiety subscale

Clinical interview for depression - depression subscale

Dialectical behaviour therapy

Distress tolerance scale

Emotional well-being scale

Functional assessment of chronic illness therapy - spiritual well-being scale

Hospital anxiety and depression scale

Hospital anxiety and depression scale – anxiety scale

Hospital anxiety and depression scale - depression scale

The hope scale

Life orientation test – revised

The meaning in life questionnaire

Number of comparisons

The positive and negative affect scale - positive affect scale

Posttraumatic stress diagnostic scale

Positive psychological intervention

Positive psychotherapy inventory

Preferred reporting items for systematic reviews and meta-analyses

Perceived stress scale

The Ryff scales of psychological well-being

Psychological Well-Being Scale

Personal well-being index

Quick inventory of depressive symptomatology, self-report

Symptom checklist 90 – anxiety subscale

Symptom checklist 90 - depression subscale

Symptom questionnaire - anxiety subscale

Spielberger state – trait anxiety inventory

Subjective units of distress scale

Subjective well-being

Spiritual well-being scale

Satisfaction with Life Scale

Treatment-as-usual

Warwick-Edinburgh mental well-being scale

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Chakhssi, F., Kraiss, J.T., Sommers-Spijkerman, M. et al. The effect of positive psychology interventions on well-being and distress in clinical samples with psychiatric or somatic disorders: a systematic review and meta-analysis. BMC Psychiatry 18 , 211 (2018). https://doi.org/10.1186/s12888-018-1739-2

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Enhancing mental wellbeing by changing mindsets? Results from two randomized controlled trials

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BMC Psychology volume  12 , Article number:  77 ( 2024 ) Cite this article

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Improving mental wellbeing is often targeted with behavioral interventions, while mindset interventions might be more appealing as they require less time and effort. In addition to recent experimental studies demonstrating that attributional beliefs can be changed to improve emotional wellbeing and performance, the current study examines whether a positive change in people’s beliefs about stress and life philosophy enhances emotional, social and psychological wellbeing using brief educational interventions. Two parallel double-blind randomized controlled trials were conducted. Study 1 ( N  = 106; 62.3% female, mean age 36.0) compared an educational video about the benefits of a stress-is-enhancing mindset versus an active control video. In Study 2 ( N  = 136; 57.4% female, mean age 35.7), educational texts about the benefits of a stress-is-enhancing mindset and holding a life-is-long-and-easy mindset were compared to an active control text. Results of multilevel growth curve modeling showed that a stress mindset could be significantly changed using an educational video or text, while the change in the philosophies of life mindset did not significantly differ between conditions. Furthermore, none of the manipulations were able to sustain the positive change in mindset which might explain why there was no significant increase in mental wellbeing compared to control. To have a lasting effect on people’s mental wellbeing, a change in mindset might need to be embodied in everyday life. Future research should investigate simple versus intensive interventions with longer follow-up time to examine whether and how a mindset can be sustainably changed to promote flourishing mental health in the general population.

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Improving mental wellbeing in the general population seems a major challenge in the 21st century. Performance pressure in education and occupation, the COVID-19 pandemic, and the rise of mental health problems are only some of the hindering factors to experience wellbeing (e.g., [ 1 , 2 , 3 ]). Although North and West European countries dominate the world ranking of the most happiest countries [ 4 ], much less of their citizens are able to flourish in life [ 5 , 6 ]. Flourishing mental health can be viewed as the highest end of the mental wellbeing continuum, which consists of emotional wellbeing (i.e., happiness, life satisfaction, positive affect) [ 7 ], social wellbeing (e.g., social contribution, social acceptance) [ 8 ] and psychological wellbeing (e.g., personal growth, autonomy, self-acceptance) [ 9 ]. Hence, flourishing means more than feeling happy and satisfied with life [ 10 ]; people who flourish are also doing good for themselves and society [ 11 , 12 ]. Cross-sectional studies have shown that flourishing is related to better work performance, fewer physical health complaints and lower health care costs [ 13 , 14 ]. More importantly, longitudinal evidence revealed that flourishing reduced the risk of mortality and the onset and persistence of common mental disorders [ 15 , 16 , 17 , 18 ].

According to the Eudaimonic Activity Model, the most optimal path towards sustainable wellbeing and flourishing is to pursue growth-promoting goals and intentional behaviors with consistent effort [ 19 , 20 , 21 , 22 ]. An increase in happiness and positive affect is then thought to automatically follow. Nowadays, a wide variety of positive behavioral interventions have been developed which can effectively improve mental wellbeing in the general population [ 23 , 24 , 25 , 26 ]. Whether an individual can successfully change towards positive behavior depends, however, on aspects such as intrinsic motivation, time, effort, character traits like grit (i.e., a combination of being perseverant and having a passion for long-term goals), and social support [ 20 , 27 ]. For example, a study among 340 undergraduate and postgraduate university students showed that those with higher levels of grit also scored higher on growth mindset and mental wellbeing [ 28 ]. Therefore, a more cost-effective approach might be to first endeavor altering people’s beliefs which in turn can affect their behavior. Indeed, positive beliefs could directly influence the way people behave, or they might align with (intended) positive behaviors in such a way that the actual behavior change can be achieved with less time and effort [ 29 , 30 ]. As a consequence, disseminating how people can change their mindset might be more appealing for a wider population. While targeting people’s beliefs to enhance their wellbeing seems promising, to date, little is known about the impact and changeability of wellbeing related attributional beliefs.

Influential theoretical frameworks such as the Health Belief Model [ 31 ], the Theory of Planned Behavior [ 32 , 33 ], the Cognitive Dissonance Theory [ 29 ] and more specifically, the Growth Mindset theory [ 34 , 35 ] postulate that people’s beliefs influence their implicit and intentional behaviors. According to the latter theory, a mindset is “a mental frame or lens that selectively organizes and encodes information, thereby orienting an individual towards a unique way of understanding an experience and guiding one towards corresponding action and responses” ([ 36 ], p. 717 adapted from [ 35 ]). The theory and studies of Dweck focus on the belief that human traits and attributes are relatively stable (fixed mindset) versus the belief that human traits and attributes can develop and change incrementally through a person’s effort (growth mindset) [ 35 ]. The majority of studies on mindsets have focused on the malleability of intelligence and personality (e.g., [ 35 , 37 ]), but scientific interest in the adaptability of other attributes is growing (e.g., [ 38 , 39 ]). In particular, two types of mindsets might have the potential to influence people’s wellbeing, namely a stress mindset [ 36 ] and a philosophies of life mindset [ 40 ].

The stress mindset was introduced by Crum and her colleagues [ 36 ] and defined as “the evaluation of the nature of stress itself as enhancing or debilitating” (p. 718). In the following years, studies found that a stress-is-enhancing mindset is associated with increased life satisfaction and less symptoms of depression, anxiety and perceived stress compared to holding a stress-is-debilitating mindset (e.g., [ 36 , 41 , 42 , 43 , 44 ]). Research also showed that a stress mindset could be changed successfully by means of a simple intervention [ 36 , 41 , 45 ]. By presenting a short video with evidence in favor of a stress-is-enhancing mindset, Crum and her colleagues [ 36 ] were able to change participants’ mindsets from a stress-is-debilitating mindset to a stress-is-enhancing mindset. More importantly, the change towards a more stress-is-enhancing mindset was accompanied by positive changes in individuals’ work performance and symptoms of anxiety and depression [ 36 ]. In another study, the stress mindset of university students was successfully changed to a more stress-is-enhancing mindset, but this change led only to improved positive and negative affect, perceived distress, proactive behavior and academic performance when perceived distress at baseline was high [ 41 ]. Yet, it is unknown whether a change to a stress-is-enhancing mindset could enhance people’s mental wellbeing rather than sole happiness or life-satisfaction.

Another mental frame that may be related to wellbeing is the life philosophy mindset. Based on a philosophical debate about Hobbes view that life is “nasty, brutish and short”, Norton and colleagues [ 40 ] explored whether people endorse the belief that life is short versus long and the belief that life is hard versus easy. Prior research regarding the belief that life is enduring has shown that if people were willing to donate some of their time to volunteer for a charity organization, they were also more likely to donate more money [ 46 ]. Similarly, a study showed that older employees with a higher subjective life expectancy had the intention to work longer [ 47 ]. In contrast, results from research about the perceived difficulty of life is less clear. For instance, despite the realization that effort often brings more pleasure in life [ 22 , 48 ] and that a certain level of difficulty is needed for flow and personal growth [ 49 ], laypersons still desire an easy – yet meaningful – life [ 22 ]. Taken endurance and difficulty of life into account, Norton and colleagues [ 40 ] demonstrated that most participants from both North America and India held the belief that life is short and hard (45–61% across studies). Interestingly, the least popular view was that life is long and easy (6–15% across studies), while this mindset was associated with higher levels of happiness, life-satisfaction, volunteering, charitable donations and optimism about the future [ 40 ]. To our knowledge, the malleability of the philosophy of life mindset has not yet been investigated and potential effects of a shift to a life-is-long-and-easy mindset are unknown.

To summarize, the majority of people seem to hold a stress-is-debilitating mindset and a life-is-short-and-hard mindset. Based on the Eudaimonic Activity Model, Cognitive Dissonance Theory and the Growth Mindset Theory, it can be argued that a change in people’s beliefs might directly have an influence on their level of mental wellbeing. Consequently, this implies the potential efficacy of widespread, easy-to-administer, and cost-effective interventions targeted at reshaping prevailing belief systems to positively impact mental wellbeing. In fact, empirical evidence has shown that holding a more positive mindset is associated with several mental health related benefits, albeit mental wellbeing defined as having optimal levels of emotional, social and psychological wellbeing has not yet been investigated.

Therefore, the aim of the current paper is to examine whether a positive change in people’s beliefs about stress and life philosophy induced by simple educational interventions enhances mental wellbeing (i.e. emotional, social and psychological wellbeing). A series of two studies was conducted to test interventions with different delivery modes of information (i.e., video versus text), offering insights into the efficacy of different mediums in changing mindsets. In Study 1, an educational video in favor of a stress-is-enhancing mindset is compared to an active control video condition up to 4-weeks follow-up. It is hypothesized that people in the experimental condition significantly improve more towards a stress-is-enhancing mindset compared to people in the control condition. Furthermore, this shift towards a stress-is-enhancing mindset in the experimental condition is hypothesized to be accompanied by a significant increase in mental wellbeing, positive affect and locus of control, and a significant decrease in negative affect and perceived stress over time when compared to control. In Study 2, educational texts in favor of a stress-is-enhancing mindset or a life-is-long-and-easy mindset are compared to a control text condition up to 1-week follow-up. Hypotheses are that people in the experimental conditions improve significantly more towards a stress-is-enhancing mindset or a life-is-long-and-easy mindset respectively, and attain significantly higher levels of mental wellbeing over time compared to people in the control condition.

A parallel double-blind randomized controlled trial was conducted in which participants were randomly allocated to either an experimental stress mindset manipulation video or an active control video condition (allocation ratio 1:1). Online surveys were assessed at four different time points to capture both adaptive and sustainable responses to the interventions: at baseline, at posttest directly after the manipulation, and at 1 and 4 weeks follow-up. All methods were carried out using the CONSORT and JARS guidelines [ 50 , 51 ], and the experimental protocols were approved by the Ethics Committee of the University of Twente (no. 190,218 and no. 191,189).

Participants and procedure

Participants were recruited by six students of the University of Twente using convenience sampling. Participants had to be at least 18 years old and German-speaking. A power analysis in G*Power yielded a total required sample size of 124 participants to detect a small effect size (β = 0.80, α = 0.05, d  = 0.30) for a 2*4 repeated measures analysis. Eligible participants ( N  = 184) received an email with the link to the informed consent procedure and the baseline assessment. 134 participants completed the baseline assessment and were randomly assigned to the stress mindset video ( n  = 67) or control video condition ( n  = 67) by an independent researcher using random numbers from randomizer.org. The final sample consisted of 106 participants because 28 participants were excluded for not watching the video. Drop-outs were significantly younger ( M dropout = 28.2, SD  = 10.7; M completers = 35.8, SD  = 16.1; t (134) = 2.43, p  = .017) and experienced more stress ( M dropout = 14.97, SD  = 6.88; M completers = 12.22, SD  = 5.70; t (134) = -2.23, p  = .028) compared to completers.

The final sample consisted of 54 participants in the stress mindset condition and 52 participants in the control condition. Mean age was 36 years ( SD  = 16.20) and slightly more than half of the participants were female (62.3%), higher educated (54.7%) and in paid employment (55.7%). No significant differences were found between the two conditions on demographics and baseline outcome measures except for perceived stress; participants in the stress mindset condition ( M  = 13.31, SD  = 6.35) experienced significantly higher levels of perceived stress at baseline compared to those in the control condition ( M  = 11.08, SD  = 5.70; t (104) = 2.05, p  = .043).

At follow-up, the majority of the participants completed the surveys 1 week (94.3%) and 4 weeks (84.9%) after posttest. There were no significant differences between completers and drop-outs at any timepoint on any demographics or baseline measures ( p s > 0.109).

Both conditions received a 3-minute educational video aiming to deliver comprehensive and persuasive information to laypersons. While both videos were in German and similar in length and form, containing images and music, their content differed.

Stress mindset condition

The stress mindset condition received an educational video in favor of a stress-is-enhancing mindset. The video was originally developed by Crum, Akinola (45). For the purpose of the present study, German subtitles were added. In the video, scientific examples are given explaining how stress can enhance performance, health and mental wellbeing, and how this effect can be increased when believing in the positive aspects of stress. The video aimed to persuade participants to perceive stress as enhancing rather than debilitating.

Control condition

The control condition received an educational sham video about Kant’s ethical theory of the categorical imperative. The video was retrieved online from YouTube and states that according to the categorical imperative, people should act in such a way, that their behavior could become a general ethical rule. By giving the participants neutral yet scientific information about the categorical imperative, the video aimed to pose a neutral, non-manipulative equivalent to the experimental stress mindset condition.

  • Mental wellbeing

The 14-item Mental Health Continuum Short Form (MHC-SF) was used to measure emotional, social and psychological wellbeing [ 52 ]. Due to a mistake in designing the survey in Qualtrics, the MHC-SF was only administered at pretest, 1-week FU and 4-week FU, and not at posttest. Answers on items such as “During the past month, how often did you feel happy?” and “During the past month, how often did you feel that you liked most parts of your personality?” range from never (0) to every day (5). Higher total mean scores (0–5) indicate higher levels of mental wellbeing. The MHC-SF is frequently used due to its comprehensibility and good psychometric properties (α > 0.80) as shown among various samples of adolescents and adults in studies from all continents (e.g., [ 52 , 53 , 54 , 55 ]) as well as in the present study (α = 0.88).

  • Stress mindset

To check whether the experimental manipulation of participants’ stress mindset was successful, the Stress Mindset Measure (SMM) was used [ 36 ]. The 8-item questionnaire measures the extent to which an individual holds the mindset that the effects of stress are debilitating or enhancing. The SMM evaluates the participants’ general stress mindset (e.g., “The effects of stress are negative and should be avoided”) and signs and symptoms related to the debilitating and enhancing consequences of stress in the field of health and vitality, learning and growth, and performance and productivity (e.g., “Experiencing stress improves health and vitality”). The participants answered the items by rating the extent to which they agree or disagree with the given statements on a five-point Likert scale ranging from strongly disagree (0) to strongly agree (4). Total summed scores ranged from 8 to 40, with lower scores indicating a stress-is-debilitating mindset and higher scores a stress-is-enhancing mindset. The SMM proved to have good psychometric properties in the current study (α = 0.88).

Positive and negative affect

The 20-item Positive and Negative Affect Schedule (PANAS) was used to assess the extent to which an individual experienced positive affect (e.g., excited; proud) and negative affect (e.g., irritable; upset) in the last 24 h [ 56 ]. The items are rated on a five point scale, ranging from not at all (1) to extremely (5). Total summed scores ranged between 10 and 50 on each subscale, higher scores indicating higher levels of positive or negative affect. In the current study, acceptable reliability was found for negative affect (α = 0.75) and good reliability for positive affect (α = 0.85).

Locus of control

The 9-item Internal Locus of Control subscale of Levenson’s Multidimensional Locus of Control Scale [ 57 ] was used to assess individual’s degree of perceived internal control (e.g., “My life is determined by my own actions”). The items are rated on a seven-point Likert scale, ranging from strongly agree (0) to strongly disagree (6). Higher summed scores (0–54) indicate a higher tendency towards perceived internal locus of control. The questionnaire demonstrated acceptable reliability in the current study (α = 0.77).

Perceived stress

The 10-item Perceived Stress Scale (PSS-10) developed by Cohen [ 58 ] was used to assess the degree in which people consider events in their lives as stressful in the past month (e.g., “In the last month, how often have you felt nervous and stressed?”). Answers ranged from never (0) to very often (4) with higher summed scores (0–40) indicating higher levels of perceived stress. The questionnaire showed good psychometric properties in the present study (α = 0.84).

Statistical analyses

Changes in the outcome measures over time were examined using multilevel growth curve modeling in R (version 0.99.902, NLME package) to account for repeated measures nested within individuals [ 59 ]. It was hypothesized that changes would be nonlinear over time because participants watched a brief video only once. An unconditional growth curve model was specified with linear and quadratic changes over time, which was then compared with hypothesis-testing models. Time was centered on the second time point (posttest).

Results and discussion

Results demonstrated that the stress-is-enhancing mindset increased significantly more over time in the stress mindset condition compared to control, γ 11  = 0.25, S.E. = 0.05, t (292) = 4.57, p  < .001; γ 21 = -0.19, S.E. = 0.04, t (292) = -4.76, p  < .001 (see Table  1 ). This effect of the educational video was mainly visible directly at posttest ( d  = 0.64, see Fig.  1 ). However, no linear or quadratic changes were found for mental wellbeing, positive affect and negative affect ( γ s < 0.38, p s > 0.362). By contrast, linear changes over time were found for locus of control, γ 11  = 1.12, S.E. = 0.49, t (292) = 2.28, p  = .023 and perceived stress, γ 11 = -1.17, S.E. = 0.48, t (289) = -2.42, p  = .016, in favor of the stress mindset condition. Within this condition, locus of control gradually increased over time, while perceived stress reduced most strongly between pretest and posttest (see Fig.  1 ). Notably, between-group effect sizes per time point were not significant for locus of control and perceived stress (see Table  1 ). Overall, the findings indicate that the stress-mindset video had a positive – but small and temporary – effect on stress or mindset related outcomes, but no effect on mental wellbeing and general affect.

The findings of Study 1 underscore earlier findings about the changeability of stress mindsets [ 36 , 41 , 45 ]. As seen before [ 45 ], a sharp increase towards a stress-is-enhancing mindset was visible directly after watching an educational video in favor of this mindset compared to control. This sharp increase could perhaps have been more stronger when those participants with higher levels of stress at baseline were also included in the whole study, but for some unknown reasons they did not watch the manipulation videos and had to be excluded from the analyses. Although the overall stress-mindset trajectories over time differed between conditions in favor of the stress mindset condition, they only differed significantly at posttest and not at 1-week and 4-week follow-up. Hence, it seems that a mindset can quite easily be changed [ 36 , 41 , 45 , 60 , 61 ], but that a simple video manipulation might not be sufficient to sustainably maintain this change over a longer period of time.

In addition, Study 1 showed that the change towards a stress-is-enhancing mindset did not significantly led to more improvements in mental wellbeing compared to control. A possible explanation for this unexpected finding is that a potential steep increase in mental wellbeing immediately after the manipulation was missing from the growth curve analysis due to a constructional error at posttest. However, positive and negative affect, an important dimension of emotional wellbeing, did also not change significantly over time compared to control. Accordingly, a change in one’s mindset might merely fuel changes in proximal variables such as perceived stress and work performance when changing one’s stress mindset [ 36 ], or motivation and academic achievement when changing towards a growth mindset [ 62 ]. Because mental wellbeing consists of emotional, social and psychological wellbeing, it might be too distal from the belief that stress can be beneficial for one’s (physical) health and performance.

Therefore, in Study 2, we added a philosophy of life mindset condition, which seems more proximately related to mental wellbeing. We also used actively reading educational texts instead of passively watching videos because studies from other mindset types have shown that using educational or persuasive texts were successful in changing people’s mindset [ 38 , 39 ]. Such texts may be exemplary to slightly increase participants’ effort in order to change their mindsets without approaching the effort that is usually needed to modify behavior. Moreover, educational texts have not yet been used in the field of stress mindset.

figure 1

Average changes in mental wellbeing, stress mindset, locus of control and perceived stress by video condition (Study 1)

In the second study, a randomized controlled trial was conducted in which participants were randomly allocated to reading an educational text about either a stress-is-enhancing mindset, a life-is-long-and-easy mindset or about personality traits (active control condition) with an allocation ratio of 1:1:1. Online surveys were assessed at three different time points: at baseline, at posttest directly after reading the educational text and at 1-week follow-up. A 4-week follow-up was omitted due to disappointing recruitment for the available time and more attrition than anticipated.

Participants were recruited by eight students of the University of Twente using convenience sampling. The preconditions and procedure were similar to Study 1. The initial power analysis in G*Power yielded a total required sample size of 222 participants to detect a small effect size (β = 0.80, α = 0.05, d  = 0.25) for a 3*4 repeated measures analysis. Of the 204 eligible participants, 155 participants completed the baseline survey and were randomly assigned to the stress mindset condition ( n  = 52), the life philosophy mindset condition ( n  = 51) or the active control condition ( n  = 52). The final sample consisted of 136 participants because 19 participants were excluded for not reading the text. Drop-outs were significantly younger ( M dropout = 25.5, SD  = 7.3; M completers = 35.7, SD  = 16.5; t (152) = 4.57, p  = < 0.001) compared to completers, but they did not differ on any other demographics or outcome measures ( p s > 0.112).

The final sample consisted of 45 participants in the stress mindset condition, 47 participants in the philosophy of life mindset condition, and 44 participants in the control condition. The mean age of the final sample was 35.7 ( SD  = 16.5) and slightly more than half of the participants were female (57.4%), intermediately educated (61.0%) and in paid employment (58.8%). No significant differences were found between the three conditions on demographics and baseline outcome measures ( p s > 0.337). The majority of the participants completed the 1-week follow-up (90.4%) and no significant differences were found between drop-outs and completers although those in paid employment were marginally less likely to drop-out at follow-up, χ 2 (2) = 5.53, p  = .063.

All three conditions received a text to read, aiming at delivering comprehensible and convincing information to laypersons. All three texts were in German and similar in length, but their content differed (see Supplemental Material for full details).

Participants were instructed to read an educational text in favor of a stress-is-enhancing mindset. By referring to scientific evidence about the beneficial effects of stress on energy levels, workplace performance, life satisfaction and psychological symptoms the text aimed to persuade participants to believe in the positive nature of stress and to perceive it as enhancing rather than debilitating. This educational text was based on results from a study by Crum and colleagues [ 36 ].

Philosophy of life mindset condition

Participants in this condition were instructed to read a text about the benefits of holding a life-is-long-and-easy mindset in contrast to a life-is-short-and-hard mindset on wellbeing, relationship satisfaction and happiness. This educational text was based on results from a study by Norton and colleagues [ 40 ], aimed to change participants mindset, but regarding a positive life philosophy rather than positive beliefs about stress.

Participants in the active control condition received a neutral, educational text about the Big Five. Participants were informed that the Big Five are not only game animals in Africa but also the core traits used to describe people’s personality. By providing scientific information about the Big Five personality dimensions, it was expected that this text was of interest to participants but unlikely to change participants mindset about stress or life philosophies.

Similar to Study 1, mental wellbeing was measured with the MHC-SF (α = 0.90) and stress mindset with the SMM (α = 0.87) at all time points.

In addition, the philosophies of life mindset was measured with two items derived from Norton and his colleagues [ 40 ] at all time points. First, “Is life short, or long?” and second, “Is life easy, or hard?”. This resulted in four different life philosophies: (1) life is long and easy, (2) life is short and easy, (3) life is long and hard, and (4) life is short and hard [ 40 ]. In the present study, a change score was calculated by assigning participants to one of the following two groups. First, an optimistic change group was created including those who stayed in the life-is-long-and-easy philosophy or changed to this philosophy at posttest. Second, a pessimistic change group consists of those who stayed in one of the other three philosophies or changed to one of those three philosophies (i.e., life-is-short-and-easy, long-and-hard, or short-and-hard).

To assess changes over time, the same statistical analyses were conducted as described in Study 1. In addition, chi-square tests and planned contrasts were used to examine the changes in life philosophies over time and in relation to mental wellbeing between conditions.

Results of multilevel growth curve modeling showed that the stress-is-enhancing-mindset significantly increased in the stress mindset condition, but mainly compared to the philosophies of life condition, γ 11  = 0.14, S.E. = 0.06, t (253) = 2.50, p  = .013; γ 21 = -0.19, S.E. = 0.08, t (253) = -2.35 p  = .019, and only marginally compared to control γ 11  = 0.09, S.E. = 0.06, t (253) = 1.48, p  = .140; γ 21 = -0.16, S.E. = 0.08, t (253) = -1.93, p  = .055 (see Table  2 ). Participants stress-is-enhancing mindset increased most strongly directly after reading the text ( d  = 0.59; see Fig.  2 ) and gradually decreased up to 1-week follow-up ( d  = 0.15).

A Pearson chi-square test revealed that most participants endorsed the life-is-short-and-hard philosophy (37.5%), while the popularity of the life-is-long-and-easy philosophy (22.1%) was comparable to having a short-and-easy (21.3%) and long-and-hard philosophy (19.1%), c 2 (1) = 4.02, p  = .045. At posttest, mainly those in the philosophies of life mindset condition changed their life philosophy to long-and-easy from 19.1% at pretest to 36.2% at posttest and 38.6% at follow-up (see Table  2 ). However, optimistic changes did not significantly differ between conditions at posttest, c 2 (2) = 2.80, p  = .247, or follow-up, c 2 (2) = 2.00, p  = .368, probably a result of an optimistic change in the control condition as well.

In line with expectations, mental wellbeing was significantly higher among those endorsing a life-is-long-and-easy philosophy at pretest ( M  = 3.47, SD  = 0.57) compared to those endorsing a life-is-short-and-hard philosophy ( M  = 2.79, SD  = 0.97), t (79) = 3.99, p  < .001 (see Table  3 ). Similar results were found at posttest, t (132) = 2.73, p  = .009, and at 1-week follow-up, t (119) = 3.27, p  = .001. However, mental wellbeing was not significantly higher among participants who optimistically changed their philosophies of life mindset directly after reading the educational text, t (134) = 1.38, p  = .171. By contrast, one week after reading the text, those who optimistically changed towards a life-is-long-and-easy philosophy had higher levels of mental wellbeing ( M  = 3.59, SD  = 0.75) compared to those with a pessimistic change ( M  = 3.15, SD  = 0.96), t (121) = 2.50, p  = .014. Nevertheless, when comparing the three conditions in multilevel analyses, no linear or quadratic changes for mental wellbeing were found in favor of any of the conditions ( γ s < 0.12, p s > 0.103).

Study 2 adds to prior literature [ 36 , 41 , 45 ] that a stress mindset can also be changed by reading an educational text. Effect sizes of Study 1 and 2 are comparable, but direct comparison between a manipulative video and text is needed to examine whether and when a certain delivery mode is preferred in order to change one’s mindset successfully. Expanding on prior results, the current study also showed that participants who held a life-is-long-and-easy mindset possessed higher levels of mental wellbeing rather than sole happiness and life satisfaction [ 40 ].

However, the manipulation did not led to a significant change towards a life-is-long-and-easy mindset in comparison with control. Additionally, mental wellbeing did not significantly increase more over time in favor of any of the experimental conditions which is in line with Study 1. Brief educational videos and texts seem, therefore, not sufficient to change one’s mindset in a way that it could enhance people’s mental wellbeing. A possible explanation might be the relatively low number of participants per condition which might have resulted in reduced statistical power. More likely is that the text about personality in the control condition – perhaps in combination with completing surveys about mindsets and mental wellbeing – might unintentionally have been effective in the control condition as indicated by more favorable life philosophies and increased mental wellbeing over time within this group. For example, the recurring assessments about life philosophies might have triggered respondents in the control condition to reflect on whether life is long, short, easy or hard. Unconscious beliefs or deliberate reflection might have evoked a shift in mindset, and might have limited sufficient comparison between the three conditions.

Another explanation is that the baseline beliefs about the philosophy of life were already more favorable in the current study compared to baseline beliefs in the study of Norton and colleagues [ 40 ]. More specifically, less participants in the current study believed that life is short and hard (38% vs. 45–61%) and more participants thought of it as long and easy (22% vs. 6–15%). Thus, fewer participants in the present study had room to optimistically change their philosophies of life mindset – and assumed corresponding levels of mental wellbeing – compared to prior research. Taken together, Study 2 implies that a stress mindset can be changed with minimal effort, but that the use of simple texts are insufficient to change people’s mental wellbeing.

figure 2

Average changes in mental wellbeing and stress mindset by text condition (Study 2)

General discussion

The current study adds to prior research by examining the efficacy of changing people’s mindset beyond emotional wellbeing and performance, by including not only a stress mindset condition but also determining the possibilities of changing one’s life philosophy mindset, and by including different modes of delivery, namely educational videos and texts. The results confirm that most people endorse a stress-is-debilitating mindset and a life-is-short-and-hard mindset. The study also implies that a stress mindset can be changed quite easily, with an educational video or text, and that holding a life-is-long-and-easy mindset is associated with enhanced mental wellbeing. However, we did neither find evidence for a sustainable change in mindsets nor an improvement in people’s mental wellbeing over time compared to control. In fact, these results seem intertwined as participants’ shift towards a stress-is-enhancing mindset or a life-is-long-and-easy mindset receded within the first week after the manipulation, a time span which might have been too short for the shift in mindsets to have an effect on people’s mental wellbeing [ 25 , 26 ]. Since flourishing mental wellbeing is a conjunction of expedient feelings, thoughts and behaviors, the impact of a newly acquired mindset on mental wellbeing related behaviors might become visible only after people have embodied this mindset in everyday life. This is supported by the finding that those who possessed more positive mindsets at baseline showed higher levels of mental wellbeing when compared to those who did not.

A possible explanation for not finding a sustainable change in mindsets is that the manipulation tasks may have been too easy for participants, resulting in minor or temporary feelings of cognitive dissonance. Theoretically, a change in peoples mindset could lead to inconsistencies when the newly acquired belief encounter old beliefs or behaviors [ 29 ]. To re-enforce harmony, people are likely to change these dissonant beliefs and behaviors by either adapting towards the newly acquired mindset (e.g., “Life is long and easy, so why shouldn’t I just take the time to read the newspaper this morning”), or to discard the new mindset and revert to their initial beliefs and behaviors (e.g., “I was right, life is indeed short and hard, so I really start with my bucket-list now”). The effort-justification paradigm in particular states that people are more likely to adapt their old beliefs into a new mindset when this mindset is obtained by engaging in more unpleasant and effortful activities [ 30 ].

In line with this, a previous study maintained a beneficial shift in participants stress mindset up to two weeks after the manipulation [ 63 ] by using a more demanding experiment that consisted of watching a series of videos, two mental imagery exercises and a writing task about the positive consequenses of stress. In contrast, an experimental study determining the malleability of people’s healthy eating mindset revealed that a more intensive workshop in which participants experienced the sensory attributes of healthy nutrition (e.g. indulgent, pleasurable, social) was only successful directly after the workshop and not at follow-up [ 39 ]. Thus, the current knowledge yield contradicting results regarding the dose-response relationship of interventions targeting changes in mindsets. Indeed, there is also some promising evidence that simple educational text interventions can be effective in sustainably changing mindsets [ 38 , 39 ]. Hence, these inconsistencies in the dose-response relationship limit a firm conclusion about people’s effort needed when aiming for a lasting change in mindsets.

Another possible explanation for not finding a sustainable change in mindsets and assumed corresponding flourishing mental health could be the unilateral exposure to the mindsets under study. Life can be hard and stressful at times, and certain situations legitimate a debilitating view on stress or life in general [ 64 ]. Participants might have disregarded the merely positive side of stress or life manipulations and may have considered it as unrealistic based on personal negative experiences. More balanced educational interventions displaying more naturalistic beliefs about stress and life philosophy might promote a change in people’s mindsets more deliberately and sustainably [ 41 , 65 ]. For instance, a prior study demonstrated that a sole focus on either positive or negative outcomes of stress reduced the use of effective coping strategies in comparison with those who learned about a balanced view on stress [ 65 ]. Such balanced views could also facilitate cognitive dissonance in participants because they could become more consciously aware of the gap between their own black-and-white beliefs versus more beneficial and nuanced beliefs.

Limitations

The two experiments should be interpreted in light of the following limitations. Firstly, the current sample sizes were sufficient but minimal, especially after excluding participants who did not watch the manipulative video or read the manipulative text. Secondly, participants were all recruited via the network of several students from the same academic study program, which limits the generalizability of the findings. Lastly, the manipulative texts have not been tested in a pilot study, for example by using the think-aloud method [ 66 , 67 ]. As a result, it is unclear how participants understood, interpreted and processed the information.

Directions for future research

More research is needed to establish effective ways to sustainably change people’s beliefs which could facilitate more eudaimonic behaviors and subsequent mental wellbeing. A first step is to encourage researchers to use longer follow-up periods within mindset research to examine how long a change in mindset can last with associated benefits for people’s mental health. To date, the majority of studies are cross-sectional or lack follow-up measurements after an experiment [ 36 , 42 , 45 , 68 , 69 ]. A second avenue for future mindset studies is to investigate the ideal parameters of manipulations to facilitate sustainable changes in mindsets. Thus, comparing more different manipulation tasks such as varying between more or less effort and pleasurable activities. Examples are exposure to a severe stress activity or solving impossible puzzles before a reading and writing task about the positive consequences of stress or life philosophy and a repetition of brief educational videos, texts or workshops with more balanced knowledge on stress or the philosophy of life. A third direction for future research is to conduct ecological momentary assessment studies to examine how people perceive stressful situations before, during and after a manipulative video, text or intervention program in the real-life context. Finally, examples from nudging and in particularly priming research in other fields such as education, might inspire research within the field of psychological mindsets as well [ 70 ].

In conclusion, motivating people to change their beliefs towards a stress-is-enhancing mindset and in particular a life-is-long-and-easy mindset could be a fruitful direction to enhance mental wellbeing in the general population. In particular can the stress mindset be changed relatively easy using simple video and text manipulations albeit more effort is needed to change mindsets sustainably to ensure a change towards flourishing mental health as well. Future mindset scholars should prioritize the use of longitudinal assessments along a wide variety of simple and advanced mindset interventions. Researchers in this field should also consider mental wellbeing as primary outcome rather than sole aspects of emotional wellbeing.

Availability of data and materials

The data used for this study is available via https://doi.org/10.17026/SS/DFEXWO . Questions about these open source data files can be addressed to the corresponding author.

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Acknowledgements

We thank the following students for recruiting participants for the studies conducted: Helen Brand, Morticia Boroch, Miriam Kebernik, Felizia Wellinger, Pia Hulsmann, Lara Watermann, Natascha Berden, Jan-Niklas Girnth, Marleen Jansen, Katharina Meyer, Clemens Cholewa, Sare Danaci, Nils Hatger.

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Schreiber, C., Schotanus-Dijkstra, M. Enhancing mental wellbeing by changing mindsets? Results from two randomized controlled trials. BMC Psychol 12 , 77 (2024). https://doi.org/10.1186/s40359-023-01470-2

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A qualitative study of positive psychological experiences and helpful coping behaviours among young people and older adults in the UK during the COVID-19 pandemic

Roles Formal analysis, Investigation, Methodology, Project administration, Writing – original draft

Affiliation Research Department of Behavioural Science and Health, Institute of Epidemiology & Health Care, University College London, London, United Kingdom

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Roles Conceptualization, Writing – review & editing

Roles Conceptualization, Funding acquisition, Writing – review & editing

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* E-mail: [email protected]

  • Liyann Ooi, 
  • Elise Paul, 
  • Alexandra Burton, 
  • Daisy Fancourt, 
  • Alison R. McKinlay

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  • Published: January 23, 2023
  • https://doi.org/10.1371/journal.pone.0279205
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Table 1

While much research has focused on challenges that younger and older people have faced during the COVID-19 pandemic, little attention has been given to the capacity for resilience among these groups. We therefore explored positive psychological experiences and coping behaviours that protected mental health and well-being. Participants were 40 young people (aged 13–24) and 28 older adults (aged 70+) living in the UK during the COVID-19 pandemic. Interviews were held between May 2020 and January 2021. We generated six themes using qualitative thematic analysis, including: engagement in self-fulfilling activities, increased sense of social cohesion, personal growth, use of problem-focused strategies to manage pandemic-related stressors, giving and receiving social and community support, and utilising strategies to regulate thoughts and emotions. While all six themes were relevant both to younger and older adults, there were nuances in how each was experienced and enacted. For example, many older adults adjusted their routines given worries about virus vulnerability, while some young people experienced greater personal growth amidst increased awareness of mental health as they navigated the various lockdown restrictions.

Citation: Ooi L, Paul E, Burton A, Fancourt D, McKinlay AR (2023) A qualitative study of positive psychological experiences and helpful coping behaviours among young people and older adults in the UK during the COVID-19 pandemic. PLoS ONE 18(1): e0279205. https://doi.org/10.1371/journal.pone.0279205

Editor: Eleni Petkari, Universidad Internacional de La Rioja, SPAIN

Received: August 10, 2022; Accepted: December 2, 2022; Published: January 23, 2023

Copyright: © 2023 Ooi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The full dataset cannot be shared publicly because of the ethical risk that this would compromise participant confidentiality and anonymity. The minimal dataset containing a summary of anonymised participant quotes can be accessed in Supplementary material for this research article.

Funding: This research was supported by Nuffield Foundation [WEL/FR-000022583], but the views expressed are those of the authors and not necessarily the Foundation. The study was also supported by the MARCH Mental Health Network funded by the Cross-Disciplinary Mental Health Network Plus initiative supported by UK Research and Innovation [ES/S002588/1], and by the Wellcome Trust [221400/Z/20/Z]. DF was funded by the Wellcome Trust [205407/Z/16/Z]. DF is the Principal investigator, award manager, etc of all funding mentioned in the financial disclosure statement The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors declare no competing interests.

Introduction

During the novel coronavirus (COVID-19) pandemic, the first UK lockdown was imposed in March 2020 [ 1 ], with people being ordered to stay at home unless for essential reasons such as grocery shopping or exercise. People aged over 70 were at first classified as especially vulnerable to the virus [ 2 ] and advised to stay at home earlier than other age groups at the start of the pandemic, while young people faced their own unique challenges owing to closures of schools, universities, and workplaces. Evidence suggests that many people in the UK experienced heightened levels of stress, anxiety and fear during the pandemic [ 3 , 4 ]. However, younger people on average scored highest on measures of loneliness, depression, anxiety, while older adults scored the lowest [ 5 ]. Nonetheless, many older adults still experienced complex and adverse psychological responses to events, including depression linked to loneliness [ 6 ] and fear arising from perceived lack of health service availability during the pandemic [ 7 ]. Concerns have been raised regarding the disproportionate, long-term psychosocial impacts of COVID-19 on both younger and older adults [ 8 , 9 ]. Taken together, these factors point to a need for further exploration into the factors that helped buffer the consequences resulting from the pandemic affecting these groups. Such research is important for understanding why some people managed to cope better than others, and for preparing for potential future pandemics.

A narrative review on other infectious disease outbreaks over the last two decades indicated that while adverse psychological consequences were common in previous pandemics, positive psychological experiences were also reported and various coping strategies were used to help deal with the unique challenges of an outbreak [ 10 ]. Such positive psychological experiences may include positive emotional, cognitive, social, and behavioural functioning [ 11 ]. For example, amid the SARS pandemic, it was reported that some people engaged in healthier lifestyle behaviours and cared more for their own mental health [ 12 , 13 ]. In the early stages of the COVID-19 pandemic, quantitative findings indicate that people had more opportunities to explore new hobbies, enjoyed more time outdoors and developed greater gratitude for personal relationships [ 14 , 15 ].

Qualitative research also highlights how people may interpret their pandemic experience positively, including having a greater sense of solidarity with others [ 16 ], and a sense of empowerment from increased lifestyle flexibility [ 17 ]. The PERMA model of positive psychology [ 18 ], which encapsulates positive emotion, engagement, relationships, meaning and achievement, has been used to describe aspects of positive well-being and may be useful when interpreting the positive responses people have reported during the COVID-19 pandemic. However, it has been argued that the model’s conceptualisation of well-being does not explicitly address the management of negative emotions pertinent to adverse circumstances of the pandemic [ 19 ]. Therefore, recognising positive psychological experiences across domains of the PERMA model in tandem with how individuals deal with negative stressors, may provide a more holistic understanding of well-being of people in younger and older age groups during the pandemic.

How people deal with stressors reflect the concept of coping—crucial psychological and behavioural factors for how individuals draw on behavioural and cognitive efforts to manage stress [ 20 ]. Various coping strategies have been theoretically identified [ 21 ], including problem-focused coping (i.e., use of planning, restraint, or social support for practical reasons) and emotion-focused coping (i.e., acceptance, denial, positive reinterpretation, or social support for emotions). In the COVID-19 pandemic, the use of socially supported coping (i.e., drawing on social support) has been found to be especially linked with greater improvements in mental health during earlier stages of lockdown restrictions [ 22 ], which highlights the key role of social networks in the maintenance of well-being [ 23 ]. Moreover, some individual behaviours, such as those involving outdoor activities, have been shown to predict better well-being during the pandemic [ 24 ]. Hence the coping behaviours that people engaged in during the pandemic may protect well-being in a way that cuts across and transcends certain coping styles. Furthermore, understanding coping behaviours that individuals perceive as helpful in managing the unique challenges of the pandemic may offer valuable insights into resilience levels during the pandemic.

An evolving body of research suggests that the positive psychological experiences and coping behaviours which protect mental health and well-being during the pandemic may differ across age. In one UK study, young people demonstrated a significantly higher level of positive lifestyle changes than older adults across several domains, such as increased quality time with family, and increased physical exercise [ 15 ]. However, when compared to older adults, young people reported greater psychosocial difficulties and more adverse mental health consequences[ 25 , 26 ], and some have postulated that part of this is due to significant lifestyle changes owing to the pandemic [ 27 ], precarious employment [ 28 ] and education interuptions affecting long-term career planning [ 29 ]. Nonetheless, it has been observed that young people appeared to show quicker recovery from their symptoms compared to older adults during the initial stages of pandemic restrictions in the UK [ 30 ], thereby reflecting the potential for resilience of young people and the need to understand how older adults can be better supported over the longer term. Emerging qualitative findings have lent support to the premise of resilience of older adults and young people respectively as both groups drew on pre-existing and new coping strategies to protect their well-being during the pandemic [ 31 ]. Greater sense of coherence (SOC), which encapsulates an individual’s ability to comprehend, manage and make sense of a new health threat, has been found to support well-being [ 32 ]. While it has been argued that SOC strengthens with age, adverse health impacts in old age may moderate SOC among older adults [ 33 ], hence age-related factors may influence capacity to cope with some of life’s adversities.

Limited studies to date have explored in depth the experiences of young people and older adults during the COVID-19 pandemic through a positive psychology lens, to investigate the resources that people draw on to support themselves through pandemic-related distress. To address these gaps in the literature, we sought to answer the following question: “what were the positive psychological experiences or coping behaviours that protected mental health and well-being of young people and older adults living in the UK during the COVID-19 pandemic?”

This study forms part of the University College London (UCL) COVID-19 Social Study (CSS), which was the largest panel survey and qualitative interview study of the psychological and social experiences of people in the UK during the COVID-19 pandemic [ 34 ]. For the current study, we performed secondary qualitative analysis of 68 interview transcripts reporting the perspectives and experiences of young people (aged 13–24) and older adults (aged 70+). This paper follows the Standards for Reporting Qualitative Research (SRQR) reporting guidelines [ 35 ].

Participants were recruited through the CSS e-newsletter, social media, personal contacts, and partner organisations (i.e., third sector services) working with older adults or young people. Eligibility criteria included: aged 70+ or 13–24, living in the UK, and fluent in English. Given the link between certain demographic factors and mental health during the pandemic [ 30 ], convenience and purposive sampling strategies were employed to include individuals of diverse age, ethnicity, sex, marital status, living situation and employment status. All participants completed a self-report demographics questionnaire on age, ethnicity, sex, marital status, living situation, employment status, physical and mental health conditions. Semi-structured, one-to-one interviews, lasting between 14 to 85 minutes ( M = 45 minutes) were conducted between May 2020 and January 2021, which included the first and second national lockdown in the UK where people experienced cycles of tightened and eased pandemic-related measures (see S1 Table ). Interviews were conducted by postgraduate-level, male and female, qualitative health researchers via telephone or video call.

Interviews followed a Topic Guide (see S1 Fig ) designed to encompass a range of topics which have been covered in other papers with young people and older adults [ 7 , 29 , 36 ]. The Topic Guide was developed from supporting theory regarding social networks and SOC [ 23 , 32 ]. Specific questions were asked to elicit responses on positive experiences during the pandemic and behaviours that helped people cope (see S2 Fig ), which formed the focus of this study–although participants also spoke of factors negatively impacting well-being which are reported elsewhere [ 7 , 29 ]. Participants were offered a £10 shopping voucher as a token of gratitude.

Research ethics

Ethical approval for the study and research procedure was obtained from the UCL High Risk Ethics Committee (ProjectID:14895/005). We followed best practice guidelines outlined by the Health Research Authority for research involving children and young people when developing our research protocol for obtaining participant consent [ 37 ]. We sought written informed consent from participants aged 16 and over. In cases where participants were aged 13–15, they were asked to provide their verbal and written assent and have a parent provide their verbal and written informed consent. All data were held securely and confidentially. Our research protocols were aligned with the principles of the Declaration of Helsinki [ 38 ].

Data analysis

Interviews were audio-recorded, then transcribed verbatim. Transcripts were checked before importing into NVivo 12 [ 39 ]. We carried out qualitative thematic analysis with a predominantly deductive and theory-driven orientation during theme and code development [ 40 ]. In contrast to “Big Q” qualitative research, which tends to be more exploratory and inductive in nature [ 41 ], our analysis practices aligned more closely with structured, postpositivist-leaning “small q” qualitative research as distinguished by Braun and Clarke (2021) [ 42 ]. The lead author (LO) read through all transcripts to ensure completeness of data analysis. While LO coded all transcripts, a second researcher (AM) double-coded three transcripts at the beginning of data analysis and both authors reviewed these identified codes to ensure consistency before completing the remainder of the coding. A deductive coding approach was initially used, whereby a coding framework was first established based on supporting theory on positive psychology and coping [ 18 , 21 ], and this framework was applied to each transcript through line-by-line coding. The coding framework was then refined iteratively as new concepts were identified by LO. Contradictory remarks and context surrounding codes were noted to draw out subtle nuances. Codes that share a common meaning or concept relevant to the research question were clustered to create themes. Themes and subthemes were developed and regularly discussed between three researchers (LO, EP and AM) throughout the analysis stage to ensure appropriate categorisation of codes. NVivo Crosstab query was used to facilitate analysis of themes across the two age groups.

Participants were 28 older adults aged 70 to 93 years ( M = 77.1, SD = 5.9) and 40 young people aged 13 to 24 years ( M = 18.3, SD = 3.4). The majority of participants were White British (75%) and female (57%). Among younger participants, most were in secondary school or university (76%) and living with parent(s) (73%). Among older participants, most were retired (79%) and half were living with a partner/spouse (50%). Forty participants reported having existing physical ( n = 31) and/or mental health condition(s) ( n = 12). Participant characteristics are summarised in Table 1 .

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https://doi.org/10.1371/journal.pone.0279205.t001

Themes and corresponding sub-themes on positive psychological experiences and helpful coping behaviours are illustrated in Tables 2 and 3 respectively and described below. Many participants described several positive psychological experiences including engagement in self-fulfilling activities, increased sense of social cohesion and greater personal growth. In addition, many spoke of engaging in various helpful coping behaviours including use of problem-focused strategies to manage pandemic-related stressors, strategies to regulate thoughts and emotions, as well as giving and receiving social and community support.

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https://doi.org/10.1371/journal.pone.0279205.t002

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https://doi.org/10.1371/journal.pone.0279205.t003

Positive psychological experiences

1 engagement in self-fulfilling activities..

1 . 1 Opportunity for leisure and exploration of new skills . Many participants described enjoying more free time for leisure and to develop new skills, leading to feelings of improved well-being and satisfaction levels. Among older participants, some found that a slower pace of life during the pandemic allowed them to rekindle old hobbies and immerse themselves in leisure activities: ‘I’ve always loved reading so I’ve been able to get on with as much reading as I want . …to actually just sit for a couple of hours reading and not feel guilty . ’ (P06, aged 70–74)

Among younger participants, some expressed a renewed sense of competence being able to sharpen their skills, ‘I think I’ve improved on my music a lot more because I had more time to practice’ (P50, aged 13–17). Some quoted reduced academic pressure or being financially secure as facilitators for being able to learn new skills.

I haven’t needed to worry about doing a job so I have money next month . So in a way , I’ve been able to relax a bit which has been really nice and not focused everything on my work . So that is where I’ve been able to dedicate time to help with anything outside and I actually produce video content for those and learn new skills when it comes to software … (P26, aged 18–24)

1 . 2 Opportunity to organise affairs . Some older adult participants described having the opportunity to catch up on overdue tasks in their personal life including home fixes and ‘sort(ing) out paperwork’ for their finances and medical care concerning their end of life.

It (the pandemic)’s given me the focus to get into the garden and get on with that because for seven years I was at best maintaining it . Last year I made a big effort to get on top of it . …and the lockdown has enabled me to get on with that . (P06, aged 70–74)

Both young and older people found opportunities to incorporate time for more wellness activities in their life as they began to value their health and well-being more.

I suppose kind of a sense of satisfaction that it’s giving me the space to finally get around to fixing certain aspects of my life . Sorting out routines and getting finally around to doing the exercise… meditating , the sort of general wellness personal admin stuff . I’m glad that’s happened … (P56, aged 18–24)

2 Increased sense of social cohesion .

2.1 Heightened compassion and connectedness . More than half of participants reported feeling closer to family and friends as a result of more frequent or consistent contact, given a ‘greater spirit of loneliness’ and heightened sense of compassion for others. Many young and older participants discussed the desire to be more intentional about strengthening or rekindling relationships into the future; ‘So , it’s going to be worth making more of in the future , making more effort about in the future . Family , it makes me realise that I do really love them and miss them . ’ (P07, aged 70–74)

Among young participants, some described increased closeness through consolidated friendship networks as ‘it (the pandemic) was like a friends filter’ (P27, aged 18–24); ‘There are some people I haven’t necessarily missed not seeing them .… I’ve connected with the people I’ve needed to . So , in a way my network it’s become clearer and seems closer . ’ (P37, aged 18–24)

2.2 Greater sense of community . With the shared experience of going through a pandemic, many participants described a greater sense of community, especially during the first national lockdown; ‘ During the initial bits of lockdown , there was quite this sense of solidarity , wasn’t it ? This general feeling of… this sucks , but we’re all in this together . …That was really nice . ’ (P39, aged 18–24)

Several young and older participants discussed a greater sense of belonging through the “Clap for Carers” (a social movement in appreciation of people working for the UK’s National Health Service) and increased interactions with neighbours; ‘We relate a bit more to the local neighbours . … They all come out and clap every Thursday night at 8 o’clock… So , chatting more to the neighbours is probably the main positive . ’ (P13, aged 80–84)

3 Greater personal growth .

3.1 New outlook on gratitude . Several young and older participants described a new outlook on gratitude, as they had come to ‘appreciate all the smaller things’ in view of restrictions that were imposed during the pandemic, including greater appreciation for outdoor activities, use of digital tools to keep in touch with friends and family, and favourable living conditions (i.e., having a garden). Several older participants described feeling fortunate to be retired and financially secure in comparison to many younger, working adults who may be struggling with job security during the pandemic.

We’re retired so we have our pensions , so we’re not having to worry about losing our jobs , losing our income or finding a way in which to work in order to be able to earn some money when there can’t be any contact between people . So I feel very fortunate that we’re not faced with that problem . (P03, aged 70–74)

Among young participants, many discussed a greater sense of gratitude towards their existing friendships or romantic relationships, given the challenges faced with meeting new people during the pandemic.

I think one of the downsides of the pandemic was meeting new people wasn’t really possible . And one thing I was really grateful for was that I am in a happy relationship with someone for the past two years . But some friends of mine who were single were struggling with this idea of trying to meet new people to date . …that made me very grateful that I do have a partner and three different people in my household I can rely on . (P27, aged 18–24)

3.2 Increased feelings of resilience . Having navigated the unexpected challenges of the pandemic, some young and old participants found that they felt more resilient; ‘I think I’m stronger than I thought I was , and that I can do things , possibly , I didn’t think I would be able to do , and I’ve coped better than I thought I’d be able to cope . ’ (P08, aged 70–74). Some young participants reported having gained the ability to take better care of themselves, thereby feeling more prepared to face future hardships; ‘I now know how important it is to have good mental health , constantly . So , that if anything like this were to happen again , I would be prepared . ’ (P51, aged 13–17) Some participants with physical or mental health conditions discussed feeling proud of their capacity to manage their condition amidst the challenges of the pandemic.

I’m probably proud of myself , how I’ve dealt with it (a heart attack) … Sort of managing my own symptoms , managing my own time , and in a way , being strong enough to say , I’m going to go to bed today . Rather than doing the socially acceptable thing of pushing myself … So , I’m quite proud of myself that I’ve been able to do that . (P65, aged 70–74)

Helpful coping behaviours

4 use of problem-focused strategies to manage pandemic-related pressures..

4 . 1 Managing intake of pandemic-related news . Given the changing circumstances during the pandemic, some participants (both younger and older) acknowledged that ‘cutting down on news bulletins but nevertheless , making sure that one is in touch with what is happening , is probably advantageous’ (P04, aged 85–90). Some found it helpful to intentionally minimise consumption of news in view of adverse impacts on their mental health; ‘whenever I read the news it’s always just bad things . It always makes me worry , so just staying away from that helped as well . ’ (P50, aged 13–17)

4 . 2 Adopting a new routine . As the pandemic resulted in restrictions to usual activities, participants reported having to adapt their lifestyle to ‘a socially distant world’ . Around one-third of young participants described how adopting a new routine during the pandemic afforded a sense of structure and helped them feel ‘more under control’ , mitigating the potentially negative impact of remote studying/working from home which blurred study/work-life boundaries; ‘ I think the important things to me over lockdown have been actually to give myself a bit of a schedule and wake up by around 7 : 00 , 7 : 30 in the weekdays than actually have a lie-in . ’ (P26, aged 18–24). Furthermore, some discussed how online platforms facilitated self-paced learning which afforded better flexibility and ability to sustain a routine.

Some older adult participants described a new sense of purpose and achievement in keeping up a routine as similar as possible to that of pre-pandemic times while allowing themselves the flexibility to ‘swap things around’ .

I do make myself behave as if , yes , I’m going out to do something . Even if it’s only to go for a walk , or do the garden , that is my thing and I’m going to do it properly . … and I feel , therefore , positive that I have done things , and achieved things . (P08, aged 70–74)

5 Use of strategies to regulate thoughts and emotions.

5 . 1 Engaging with online arts and digital mental health apps . Many participants, especially older adults, missed engaging with arts and cultural activities in-person but most found it helpful being able to continually engage in such activities from home through virtual means during the pandemic. Participants reported that engaging in arts activities such as watching performances online or via television, participating in a “Zoom choir” and listening to music helped soothe feelings of anxiety or worry and elicited positive emotions.

And from Sky Arts on my big TV that has a few programmes a week . …compared with how often I might have been going to the theatre or cinema . I’ve been able to get performances there . It’s kept me happy . (P11, aged 70–74)

Several young people reported worries about uncertainty of their studies and future career; however, digital mental health apps assuaged some of these feelings by helping them to become more aware of strategies to improve their mental health.

I now have a mood tracking app (MindDoc) on my phone …so that I can track my mood and see what it affects . …it can give you very personalised advice . So that’s something I’ve taken up which I think I’m going to keep doing , because I think it’s very helpful . (P61, aged 13–17)

5 . 2 Being outdoors and connecting with nature . The majority of participants reported heeding government guidance that allowed outdoor exercise during lockdown and found it helpful to get ‘fresh air’ outdoors, with several describing easy access to green spaces as a facilitator for these coping behaviours. Some young participants spoke about how getting out helped them unwind after a long day of working or studying from home; ‘I did go out for the once-a-day exercise . I usually tried to do it after work just to give me that break to change my mindset from work mode to coming back to relaxing . ’ (P36, aged 18–24)

While the pandemic seemingly brought everyday life to a standstill, several participants, young and old, found it ‘therapeutic’ connecting with nature, where some participants described that seeing plants grow symbolised a sense of time passing.

Having plants grow within the house is an amazing way to keep track of time when it all seems so monotonous because it changes , it grows , and you are there . It’s a little project and I found that it’s so fantastic for me . I’ve really loved having my plants . (P26, aged 18–24)

6 Giving and receiving social and community support.

6 . 1 Engaging with interest-based social groups . Many participants found it rewarding to engage in interest-based social activities. Among these participants, several older adults reported engaging in groups such as walking groups, online writing groups or photography groups to keep their mind and/or body active while maintaining social connections.

Oh , and the other one I’m sort of involved , I was before lockdown , in a creative writing group… we’ve been doing that on Zoom .… . So that’s as a little social thing and keeping the mind active as well . Keep that going , yes . (P22, aged 75–79)

Amongst young participants, many described how engaging in online multiplayer games strengthened their relationships with friends or expanded their social circle as such games facilitated ‘friendly competition’ and allowed them to enter into a lot of discussions; ‘Since lockdown started , I’ve been involved in playing a lot more social board games online…and really built a wonderful community of people from all around the world who are really interesting people . …It’s a nice , different tangent . ’ (P26, aged 18–24)

6.2 Volunteering and community participation.

Several young participants sought out in-person volunteering, such as with foodbanks and delivering essentials to people who are shielding, as ‘another excuse to get out of the house’ (P57, 18–24) while also feeling helpful and needed.

The only thing that I wasn’t doing that was fully rigid with the routine of lockdown was volunteering at the foodbank . And that was because I thought I would just absolutely go crazy if I had to stay in the house the whole time… I just genuinely feel like everything that I do at the moment is really worthwhile to someone , it’s always helping someone else in some way … (P40, aged 18–24)

Among older adult participants, some discussed finding a sense of usefulness while keeping their mind busy by participating in surveys/studies.

My way of doing my bit … is participating in studies like yours… because I can’t go out there and deliver meals to people… but what I can do is contribute to a body of knowledge , that hopefully will be helpful to people in the future . (P18, aged 70–74)

In this qualitative study, we investigated positive psychological experiences and helpful coping behaviours perceived by young people and older adults in the UK in the first year of the COVID-19 pandemic. There were many similarities in the broad types of psychological experiences that younger and older adults had, as well as similarities in the broad coping behaviours employed, although the details of how these experiences and behaviours were perceived and enacted varied by age. Nonetheless, we identified several common potential components of future interventions to support both young people and older adults in times of pandemics, including activities that foster a sense of community and connectedness (such as “Clap for Carers”), resources that support a stable routine (such as self-paced online learning) and platforms that offer digital means of engaging with hobbies (either on the internet or via mobile phone apps).

One of our salient findings was an increased sense of social cohesion across age groups, congruent with evidence indicating greater gestures of solidarity [ 16 ] and the heightened value of personal relationships during the COVID-19 pandemic [ 14 ], which reinforce the value of platforms that foster these activities to take place. Our results build on previous research by suggesting how a heightened sense of loneliness and engaging in collective action may encourage a greater community spirit across the age groups amidst social distancing restrictions. While it has been suggested that many young people suffered from loss of social connections during the pandemic [ 29 ], a novel finding from our study is that some young participants acknowledged how social restrictions have inadvertently weakened some social ties yet strengthened other key friendships, which facilitated a sense of increased relational closeness. Results suggest that many participants felt that their social networks evolved towards strengthened relationships and stronger community ties, which in turn, improved perceptions of overall well-being.

Several pandemic-related experiences reported by participants appeared to be shaped by their different life stages (i.e., young versus older adulthood) and these factors further shaped subsequent coping behaviours. For instance, younger participants highlighted reduced academic pressure or being financially secure as enablers to exploring new skills. Emerging evidence suggests that younger people, as compared to older adults, had more financial worries during the pandemic [ 43 ] and having financial support has been shown to be a protective factor for coping among young people [ 44 ] –hence there is additional need for financial and occupational support toward young people in the future, coming out of the pandemic. The protective role of financial security also resonated with some older participants who described feeling grateful to be retired and financially secure compared with other groups. Moreover, many participants across both age groups discussed a greater sense of appreciation for smaller things in life during the pandemic, reflecting a sense of gratitude which can encourage psychological resilience [ 45 ]. Furthermore, our finding that some participants felt a greater sense of resilience within themselves supports the argument that adverse circumstances of living (such as those present during the COVID-19 pandemic) may encourage personal growth and resilience [ 46 ]. Our results expand previous findings of personal growth among young people during the pandemic [ 47 ] by suggesting that young participants experienced personal growth from having recognised and developed their ability to protect their own mental health in the future.

With regards to helpful coping behaviours, we noted some similarities and differences across age groups. Several young and older participants expressed mental health benefits of engaging in arts and cultural activities remotely, consistent with existing evidence for the use of arts to help cope with emotional experiences during the pandemic [ 48 ]. Our results further suggest how increasing digital access to arts during the pandemic is especially valuable to older adults who may otherwise be less likely to engage in arts through digital means as compared to young people. Among young people, our results on the use of digital mental health apps in supporting mental health highlights the promise of such tools in equipping individuals with self-care skills in the future [ 49 ]. Evidence suggests that engaging with nature is linked with more positive emotions and fewer symptoms of anxiety, particularly amid stringent lockdown measures during the pandemic [ 50 ]. We found that the main differences in this and with several other coping behaviours between young and older age groups were attributed to work-related stress. For instance, some young participants specifically highlighted how spending time outdoors helped them de-stress while adapting to remote working and learning during the pandemic. This could be taken into account by employers and education providers in the event of future social distancing restrictions.

In view of evidence which suggests increased volunteering behaviours in the UK during the COVID-19 pandemic [ 51 ], our findings highlight potential age differences in one aspect of volunteering whereby in-person volunteering was especially prominent among young participants. Erikson’s stage theory of psychosocial development [ 52 ] posits that adolescent years present a conflict of identity versus role confusion whereby adolescents navigate their independence and develop a sense of self. In-person volunteering may have facilitated such aspects of growth as young participants described gaining a sense of being useful while escaping the confines of home during the pandemic. Additionally, young people may have been less worried about their risks from COVID-19 when compared with older adults [ 53 ], hence readily sought out in-person volunteering opportunities. Furthermore, a novel finding of our study is that some older adult participants found it beneficial for their wellbeing to volunteer for research surveys during the pandemic, highlighting how volunteering opportunities must be accessible to all age groups. This extends existing literature that being useful in this manner could add meaning to individuals’ lives [ 54 ], by potentially helping people to make sense of life during the pandemic.

Strengths and limitations

This is the first known study that qualitatively explored positive psychological experiences and helpful coping behaviours perceived by young people and older adults in the UK during the COVID-19 pandemic. Purposive sampling enabled greater demographic diversity among participants, which facilitated rich nuances about the experiences of participants that could be targeted in future public health interventions. However, the socioeconomic background of participants was not known, and this may have biased certain findings. While in the present study (where participants were predominantly White British) we found a greater sense of community, some studies indicated reduced sense of social cohesion among some ethnic minority groups in the UK, as the pandemic had more adverse impacts in these communities [ 55 ]. Our data collection period may also have influenced the results of our study, given that interviews concluded in January 2021, less than one year since the start of the pandemic as declared by the WHO [ 56 ] –hence young and older adults’ experiences may be different at later stages of the pandemic. Moreover, the sample may be biased towards people who were less severely impacted by adversities during the pandemic or coping better than others who were unable to participate. Therefore, we cannot assume the transferability of our results to all other contexts and the coping behaviours may not reflect that of the broader population of older or young people.

Implications

This study highlights some key implications for coping during a pandemic and beyond. First, digital mental health apps may be a valuable tool to support mental health during crisis situations where access to formal mental health support is limited, therefore, further research on their potential is warranted. Second, the benefits of spending time outdoors and connecting with nature may have policy implications for access to green spaces during the pandemic as well as implications for green social prescribing to support well-being [ 57 ]. Third, present findings on positive psychological experiences and coping behaviours that protect well-being suggest scope for an extended version of the PERMA model of positive psychology: PERMA-H model [ 58 ], which incorporates the facet of positive health. Our findings support the idea that a positive psychology model that includes physical and psychological health may be especially relevant in the context of an infectious disease pandemic to understand well-being more holistically. Moreover, further research is warranted to understand the experience of various socioeconomic groups and ethnic backgrounds and capture experiences over time given the fluctuating nature of the pandemic.

Conclusions

While the COVID-19 pandemic has presented many challenges in various aspects of life of young people and older adults, participants’ use of various coping strategies reflect their resilience. In brief, participants described coping behaviours that protect their well-being, with older participants adapting lifestyles in the context of worries about their vulnerability to COVID-19. Moreover, this study highlights positive psychological experiences during the pandemic such as heightened connectedness and increased feelings of resilience. While all six themes were relevant both to younger and older adults, there were nuances in the experience and enactment of behaviours between each age group. These findings may be useful to guide tailored support for well-being among young and older age groups during a pandemic and post-pandemic recovery.

Supporting information

S1 fig. interview topic guide..

https://doi.org/10.1371/journal.pone.0279205.s001

S2 Fig. Interview guide example questions and prompts pertinent to the research question.

https://doi.org/10.1371/journal.pone.0279205.s002

S1 Table. Timeline of COVID-19 restrictions in UK between 2020 and 2021 and proportion of study interviews conducted in each month.

https://doi.org/10.1371/journal.pone.0279205.s003

S2 Table. Minimal data set.

https://doi.org/10.1371/journal.pone.0279205.s004

Acknowledgments

The researchers are grateful for the support of AgeUK, Alzheimer’s Society, Healthwise Wales and British Youth Music Theatre during recruitment. We are grateful to Anna Roberts, Joanna Dawes, Louise Baxter, Sara Esser, Rana Conway and Tom May for their help with conducting interviews. The authors extend thanks to study participants for their valuable contributions.

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Effects of gratitude intervention on mental health and well‐being among workers: A systematic review

1 Department of Mental Health, Graduate School of Medicine, The University of Tokyo, Tokyo Japan

2 Japan Society for the Promotion of Science, Tokyo Japan

Kazuhiro Watanabe

3 Department of Public Health, Kitasato University School of Medicine, Sagamihara Japan

Daisuke Hori

4 Faculty of Medicine, University of Tsukuba, Tsukuba Japan

Kyosuke Nozawa

5 Department of Psychiatric Nursing, Graduate school of Medicine, The University of Tokyo, Tokyo Japan

Kotaro Imamura

Norito kawakami, associated data.

Data sharing not applicable—no new data generated.

Gratitude intervention, which requires participants to engage regularly in brief activities designed to cultivate a sense of gratefulness, is known as one of the most effective positive psychological interventions. Although numerous meta‐analyses and systematic reviews have been conducted on gratitude intervention, no studies have focused on the working population. This study aimed to systematically summarize the effectiveness of gratitude interventions on workers' mental health and well‐being.

Systematic search was conducted in February 2021 using five databases. Eligible studies included randomized controlled trials implementing gratitude activities among healthy workers and measuring mental health or well‐being indicators and original articles or thesis in English.

Nine out of 1957 articles met the inclusion criteria. Eight studies adopted gratitude list interventions, showing a significant improvement in perceived stress and depression; however, the effects on well‐being were inconsistent. Interventions with gratitude list four times or less did not report significant changes in any outcomes.

Conclusions

Most gratitude interventions incorporated a gratitude list, and some studies included gratitude activities as a part of the combined program. On the other hand, no studies focused on only behavioral gratitude expression among workers. Gratitude interventions might be effective in improving mental health, but their effects on well‐being remain unclear. The total number of gratitude lists and reflections might influence the effect on mental health and well‐being; however, due to the high heterogeneity of the studies, further studies are needed.

1. INTRODUCTION

Positive psychology has spent the past two decades investigating human strengths and virtues, solidifying the “science of positive subjective experience, positive individual traits, and positive institutions”. 1 Since its inception, positive psychology has influenced various disciplines, including education, health care, and economics. 2 , 3 Positive psychology interventions have accumulated evidence of their effects on mental health and well‐being. 4 In recent years, positive psychology interventions have also been introduced in the occupational health field. A meta‐analysis conducted in 2019 has demonstrated their effectiveness in improving work‐related outcomes, including job stress, engagement, and organizational prosocial behavior. 5 Gratitude emerged from the study of positive psychology as a multidimensional concept involving an emotion, a personality trait, or a coping response. 6 Especially in the academic context, much research has been done on the two concepts of gratitude: trait gratitude and state gratitude. 7 Trait gratitude refers to the predisposition to be aware of situations in which one receives benefits from others and represents between‐person differences in the threshold to experience gratitude without specific events/experiences. 8 Separately, gratitude as a state‐level emotion is a discrete experience that occurs when one perceives themselves as the recipient of a positive outcome, triggering a subsequent desire to reciprocate or otherwise engage in prosocial behavior. 9 , 10 Several studies have found an association between trait gratitude and more frequent and intense state gratitude experiences. 11 , 12 Many studies have demonstrated the positive moderate to large associations between gratitude and well‐being, such as positive affect, happiness, and life satisfaction. 7 , 13 , 14 Regarding these mechanisms, Wood et al. introduced two gratitude specific hypotheses, 7 (a) the schematic hypothesis (grateful people have characteristic schemas that influence their interpretation of situations more positively) and (b) the coping hypothesis (grateful people make more positive coping appraisals, and less likely to behaviorally disengage, deny the problem exists) along with two more general hypotheses, (c) the positive effect hypothesis (positive emotions, including gratitude, have a protective effect on various mental disorders, leading to improved well‐being) and (d) the broaden and build hypothesis (positive affective states broaden people's momentary thought‐action repertoires to help them develop additional resources to enhance long‐term well‐being).

Two strategies, called gratitude interventions, have been generally used to promote gratitude. 15 One is a gratitude list (gratitude journal), which involves the participants making written lists of several things for which one is grateful regularly. 7 Another strategy, a behavioral expression of gratitude, 7 encourages the participants to express their grateful feelings to others. 7 The most cited behavioral expression conducted by Seligman is called gratitude letter, in which participants write gratitude letters to their benefactors and read the letters to them. 16 These interventions aim to increase state gratitude through activities; however, because state gratitude is a short‐term phenomenon that is difficult to assess, trait gratitude is often measured as an outcome. Gratitude interventions have several strengths. The objectives of the exercises are easy to understand and implement, as they are time and cost‐effective, tend to have lower dropout rates, and do not require experts in psychology. 15 , 17 The previous meta‐analyses and systematic reviews have indicated positive effects of gratitude intervention on well‐being (e.g., life satisfaction, happiness, and positive affect), 15 , 17 physical health (e.g., blood pressure, glycemic control, and inflammatory markers), 18 , 19 and mental health (e.g., depression and anxiety) 20 , 21 among various populations, including clinical, resident, and school.

Gratitude is also important for workers. A gratitude trait at work is defined as the tendency to recognize and be thankful for how various aspects of a job affect one's life. 22 Worker's gratitude has a significant favorable correlation with well‐being (e.g., positive affect and life/job satisfaction), mental health (e.g., depressive symptoms and distress), and work‐related outcomes (e.g., job performance, organizational commitment, and citizenship behavior). 22 , 23 Furthermore, a meta‐analysis of positive psychology interventions among workers indicated that employee gratitude interventions for desirable work outcomes were shown to have stronger mean effect sizes (g = 0.34) compared to other interventions, such as psychological capital interventions or well‐being interventions, even though the differences between them were non‐significant. 5 Although numerous meta‐analyses and systematic reviews have been conducted on gratitude intervention, 15 , 17 , 18 , 19 , 20 , 21 no studies have focused on the working population. Furthermore, since positive psychology and gratitude interventions at work have been suggested to be effective for mental health, well‐being, and work‐related outcomes, 5 it would be worthwhile to qualitatively summarize the intervention methods and their effectiveness. In addition, gratitude intervention among workers may have characteristics varying from other populations. For example, workplace mindfulness training programs often differ from the standard protocols supported by scientific evidence. 24 , 25 These variations include reduced time commitment (or dose) of training and the use of flexible delivery methods to meet the demands of contemporary work environments. 26 Similarly, gratitude intervention among workers might be tailored due to their limited time to devote to the working tasks. According to the review of 64 gratitude intervention studies, 18 the most common intervention durations were 4 and 6 weeks, with some of them lasting from four to eight months. On the other hand, the gratitude intervention among workers conducted by Neumeier et al. lasted a week, arguing the importance of that it could be easily combined with various work schedules and could be flexibly integrated into daily work routines with relatively little effort. 27 The findings relevant to the working population would be meaningful for developing and validating further gratitude intervention.

The current study aimed to systematically summarize randomized controlled trials to examine the effect of gratitude interventions on improving mental health and well‐being among workers. We searched the latest studies published until February 2021 to qualitatively summarize (1) the types of gratitude interventions conducted among workers, (2) the effectiveness of gratitude interventions in improving mental health and well‐being among workers, and (3) conditions and settings that are effective for improving mental health and well‐being among workers.

2. MATERIALS AND METHODS

2.1. study design.

The present study is a systematic review of randomized controlled trials (RCTs) to provide a qualitative summary of gratitude interventions implemented among workers and examine their effects on mental health and well‐being. This manuscript was written following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. 28 The study protocol was registered at the UMIN Clinical Trials Registry (ID = UMIN000039785).

2.2. Eligibility criteria

Participants, interventions, comparisons, and outcomes (PICO) of the eligible studies were defined. Participants included all healthy workers. Interventions were defined as any interventions that included gratitude activities. Based on previous meta‐analyses, 15 , 17 we categorized gratitude interventions into three types, gratitude list, behavioral gratitude expression, and others (such as drawing a picture of something one is thankful for or taking psychoeducation). Three good things (TGT) exercise was also included as a gratitude list intervention, consistent with previous studies. 15 , 17 TGT exercise is similar to making the gratitude list, except that the participants are instructed to write down three good things that happened in a specified period. 16 This is known as an activity to induce gratitude. 29 Although the previous meta‐analyses excluded the mixed intervention that also contained other activities besides gratitude, 15 , 17 , 18 , 19 , 20 , 21 we broadly included these programs because we thought that including both would provide more practical knowledge. In this study, we defined mixed intervention as a program that contains gratitude and other activities and defined plain interventions as programs containing only gratitude activities. Comparison groups of the review were those conducted other activities or measurements only. Outcomes were mental health and well‐being indicators. In this study, mental health included anxiety, perceived stress, depression, and mental disabilities, such as burnout measured using standardized psychological symptom measures. Regarding well‐being, we included outcomes along with the definitions by Steptoe et al. 30 Steptoe classified well‐being into three aspects, evaluative (how satisfied people are with their lives, such as job satisfaction and life satisfaction), hedonic (feeling or moods such as happiness or positive affect), and eudemonic (judgment about the meaning and purpose of life). In addition, eligible studies were (1) RCTs (adopting random assignment), (2) written in English, and (3) original articles or thesis.

2.3. Search and information sources

A systematic search was conducted in February 2021 using PubMed, Embase, PsycINFO, PsycARTICLES, and Web of science. The first author (YK) developed search terms based on the previous studies, 15 , 17 , 31 , 32 , 33 and subsequently, coauthors discussed these terms and agreed with them. The search terms used were (1) keywords related to gratitude (e.g., gratitude, grateful, thankful, blessing), (2) participants (e.g., worker, employee, organization), and (3) study design (e.g., randomized controlled trial). The search terms are described in detail in Table  1 .

Search terms used in each database

2.4. Study selection

We entered all identified studies in a Microsoft ® Excel (Washington, USA) file. After YK excluded duplicate records, the remaining articles were distributed among the three authors (YH, MI, and KN), who independently in pairs assessed the title and abstract of each article to identify eligible studies according to the eligibility criteria (sifting phase). At this phase, we excluded studies that did not meet the eligibility criteria. In the next phase, a full‐text review was conducted. The pairs of investigators independently reviewed the full texts that passed the previous shifting phase. When the pairs of investigators disagreed then all investigators discussed and solved disagreements. The reasons for excluding studies were recorded during the full‐text review phase.

2.5. Data collection process and data items

Three investigators (YK, MI, and DH) independently extracted information from each included study. The year of publication, country, study design, the characteristics of the participants, response rate at baseline, follow‐up period after the intervention, follow‐up/dropout rate of the survey, the details of the gratitude intervention, the experimental and control conditions, outcomes, and the results of the mental health and well‐being were extracted. After extraction, all authors confirmed the collected information to reach a consensus in this process.

2.6. Risk of bias in individual studies

Three investigators (YK, MI, and DH) assessed the included study quality independently using the revised Cochrane risk of bias tool for randomized trials (RoB2), 34 which evaluates randomized controlled study based on nine items: (1) random sequence generation, (2) allocation concealment, (3) blinding of participants and personnel, (4) blinding of providers, (5) blinding of outcome assessment, (6) blinding of data analysis, (7) incomplete outcome data, (8) selective reporting, and (9) other biases (e.g., cross over bias). Each item was then graded as high, some concerns, or low. Any discrepancies were settled by discussion among the investigators.

2.7. Synthesis of results

The data extracted from the included studies were summarized qualitatively. Based on the previous study, 17 gratitude interventions were categorized into three types, gratitude list, behavioral expression of gratitude, and others. Gratitude intervention types were also categorized into two types, plain and mixed. The importance of considering the control conditions has been argued to rigorously discuss the effectiveness of the gratitude intervention. 7 We categorized the control groups into three groups, positive, negative, and neutral, according to the previous study. 15 Positive activities included performing random acts of kindness and identifying strengths, which were presumed to affect mental health and well‐being. Negative activities included listing daily/weekly hassles or misfortunes, which were presumed to affect the outcomes negatively. Neutral activities included listing daily/weekly activities, events, or measures‐only control, which were presumed to be psychologically inert. The consequences of the interventions were classified into three categories: significantly favorable effects (+), significant adverse effects (−), and insignificant effects (n.s.).

3.1. Study selection

Our initial search of five databases resulted in 1957 articles overall. After removing duplicates and adding four articles using a hand search, 1470 articles proceeded to the sifting phase. Among these, 1443 articles were excluded, and 27 articles proceeded to full‐text review. Following this process, nine articles were included in the qualitative review (Figure  1 ).

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PRISMA flow diagram

3.2. Study characteristics

The characteristics of the included studies are summarized in Table  2 . Four gratitude intervention studies were conducted in the US 35 , 36 , 37 , 38 and three in China. 39 , 40 , 41 One study was conducted in Japan 42 and one in Australia. 27 The participants included in the study were mostly health care professionals ( n  = 2) 39 , 41 or teachers ( n  = 2). 37 , 40 Four studies conducted a follow‐up survey after one week, 35 one month, 36 , 42 and three months after the interventions, 41 and the other five studies conducted a follow‐up survey immediately after the intervention. 27 , 37 , 38 , 39 , 40 Regarding the response rate to the baseline survey (proportion of people who agreed to participate in the study out of the total number of people asked to participate), two studies had response rates above 80%, 39 , 41 and seven other studies did not report this. The follow‐up rates ranged from 50% to 97%. The completion rate of the intervention was not summarized in any studies.

Design and settings of the studies included in the systematic reviews: N  = 9

Abbreviations: NR, Not reported; RCT, Randomized controlled trial.

3.3. Intervention strategies

Table  3 shows the summary of intervention methods and their effect on outcomes. Nine interventions reported in eight studies adopted gratitude list, 27 , 35 , 36 , 38 , 39 , 40 , 41 , 42 while one study conducted psychoeducational group sessions. 37 No studies conducted incorporated only behavioral gratitude expression among workers. In studies using gratitude lists, six of eight studies asked participants to record "work‐related gratitude". 27 , 35 , 36 , 39 , 41 , 42 Five studies were web‐based, 27 , 35 , 36 , 39 , 40 two studies were paper‐based, 41 , 42 and in the remaining studies, the participants could choose one of the two. 38 Ki incorporated a web‐based gratitude list to 161 health care workers, including nurses, doctors, physical therapists, and occupational therapists, in China. 39 Participants were asked to write down gratitude lists twice a week for 4 weeks, totaling eight lists. A negative activity was offered to the control group, which asked the participants to write down at least one hassle event at work.

Interventions, outcomes, and results of the studies included in the systematic reviews: N  = 9

+, significant favorable effects; −, significant adverse effects; n.s., non‐significant effect; NA, not applicable.

The difference between gratitude interventions between study ID 5A and 5B in general/Work‐related subjective well‐being was non‐significant.

Summary of the scales and other information. CAS, Chinese Affect Scale 65 ; CES‐D 10, Center for Epidemiologic Studies Depression Scale 67 , 68 ; JAWS, Job‐Related Affective Well‐being Scale 72 ; JIG, Job In General scale 70 ; MBI‐GS, Maslach Burnout Inventory 74 ; NA, Negative affect; PA, Positive affect; PANAS, Positive and negative affect schedule 69 ; PSS, Perceived Stress Scale 64 ; SHS, Subjective Happiness Scale 71 ; SWLS, Satisfaction with Life Scale 66 ; SWWS, Satisfaction with Work Scale. 73

Baker incorporated a web‐based gratitude list to 163 employees recruited from a public university in the US. 35 Participants were asked to wire four gratitude lists related to their job once a week for 4 weeks. The study adopted a neutral control group that measured the outcomes only.

Otsuka et al. incorporated a paper‐based gratitude list to 38 employees in a local government in Japan. 42 Participants were asked to write four gratitude lists once a week for 4 weeks. They listed five people at work or in one's personal life to whom the participant was grateful during the past week. The study set a neutral comparison that asked the participants to write up to five events at work or in one's personal life during the past week in a journal for 4 weeks.

Chan et al. incorporated a web‐based gratitude lists to 78 schoolteachers receiving in‐service training for postgraduate degrees in China. 40 The author disseminated that this is an eight‐week self‐improvement project to enhance their well‐being through self‐reflection. Participants were asked to write three good things or events that happened to the participants once a week for 8 weeks. They also had at least 15 min to think about the meanings of these events at the end of the week. The control group was offered a negative activity that asked the participants to write down three bad things or events that happened to the participants and think about these events' meanings.

Kaplan et al. incorporated a web‐based gratitude list to 112 staff members from two large public universities in the US. 36 The participants were told that the purpose of the study was to explore avenues to increase well‐being at work. Participants were asked to create six gratitude lists, recording grateful things related to their job three times a week for 2 weeks. The control group completed a positive activity that asked the participants to engage in specific strategies to increase their social ties at work three times per week and document those experiences on a secure Web site.

Cheng et al. incorporated a paper‐based gratitude list to 102 health care workers, including physicians, nurses, physiotherapists, and occupational therapists recruited in five hospitals in China. 41 Participants were asked to create eight lists by writing diaries about work‐related thankful events twice a week for 4 weeks. Two control groups were included. One group completed a negative activity, writing diaries about work‐related hassle events (Control A), while the neutral comparison group completed only the measurements (Control B).

Neumeier et al. incorporated a web‐based gratitude list to 303 participants recruited via social media, newspapers, and radio in Australia 27 and assigned to three groups (plan gratitude group, mixed gratitude group, and neutral control group). In the plan gratitude group, participants were asked to create seven lists by writing down grateful things about work or the workplace. Subsequently, they reflected on the grateful events during the following 7 days at work. In the mixed gratitude group, participants were asked to complete seven positive exercises during the consecutive 7 days at work: "practicing gratitude” (the same exercise the plain gratitude group), "savoring the moment” (mindfully savoring a pleasurable activity by paying attention to your immediate experience), “you at your best” (writing a story about a time when you were at your best at work and reflecting on your personal strengths displayed in the story), “random acts of kindness” (performing three acts of kindness in your workplace to benefit others or make others happy), “visualizing your best possible self” (thinking and writing about your best possible professional self/working life and defining specific goal that would help you to attain this best possible future scenario), “wearing a smile” (relaxing, finding something that makes you laugh, and frequently wearing a smile over the day), and “brainstorming meaningfulness” (brainstorming about tasks or elements in your work that you find meaningful or that are significant to you, and creating a mind map about sources of meaningful experiences in your job). The participants in the control group completed only the measurements.

Cook et al. conducted psychoeducation that included gratitude activities in group sessions. 37 The participants were 44 high and middle school teachers from a single educational service district in the US. They completed five 2.5‐h group sessions. The program was developed as an intervention promoting the well‐being of teachers, helping them become resilient educators by focusing on eight practice areas: (1) increasing awareness and empowerment through mindfulness‐based practices, (2) paying attention to the positive and practicing gratitude, (3) helping and doing good deeds for others, (4) identifying unhelpful thoughts and altering them to be more helpful, (5) developing good sleep habits, exercising regularly, and eating well, (6) clarifying values and committing to them, (7) establishing good social support, role models, and a mentor (relationships), and (8) rewarding oneself through relaxation and recreation. Practicing gratitude requires three specific activities: (1) writing and delivering a gratitude letter, (2) weekly gratitude journaling that identifies 3–5 things one is grateful for and why, in addition to imagining what the week would be like if the things did not happen, and (3) paying attention to the small things and writing thank you notes to life (e.g., thankful for being able to take a warm shower and getting clean because it makes me feel better; thankful for being able to take walks and having time to think and getting healthy all at once). The control group underwent five neutral 2.5‐h group sessions to discuss topics related to their daily work.

In a more recent study, Ligon incorporated gratitude list to 148 mental health and customer service call centers in the US. 38 It was both allowed to make gratitude list by paper‐based or web‐based. The participants were told that the purpose of the study was to examine whether three different work activities effectively reduce stress and increase hope, positive thinking, mental toughness, and confidence. The study lasted for 2 weeks, and the participants were asked to create two gratitude lists, one for each week, spending 10 min each week on the day of their choice to write about three lifetime events for which they were grateful. The comparison groups completed two other activities. In the positive activity group, the participants wrote about one's best possible future self once a week for 2 weeks. In the neutral group, they wrote about typical daily work activities once a week for 2 weeks.

3.4. Effects of the intervention programs on the outcomes

The included study adopted various mental health and well‐being outcomes. Mental health included perceived stress ( n  = 3), 37 , 39 , 41 depression ( n  = 2) 39 , 41 and burnout ( n  = 1). 38 Well‐being encompassed positive affect ( n  = 5), 35 , 36 , 39 , 40 , 42 negative affect ( n  = 4), 35 , 36 , 39 , 40 life satisfaction ( n  = 4), 35 , 39 , 40 , 42 job satisfaction ( n  = 2), 35 , 37 happiness ( n  = 2), 27 , 42 and happiness at work ( n  = 1). 27 Perceived stress and depression improved significantly in all three studies, 37 , 39 , 41 while burnout did not. 38 Furthermore, positive affect increased significantly in two studies 36 , 39 but did not change in three studies. 35 , 40 , 42 Negative affect declined significantly in two studies 39 , 40 but did not change in two studies. 35 , 36 Life satisfaction increased significantly in one study 39 but not in three studies. 35 , 40 , 42 Job satisfaction significantly increased in one study 37 but did not change in another study. 35 Happiness and happiness at work increased significantly in Neumeier et al. 27 but not in Otsuka et al. 42 No significant adverse effects were observed.

3.5. Effects of the gratitude list by duration and frequency of the programs

In the studies that adopted gratitude list as the intervention, 27 , 35 , 36 , 38 , 39 , 40 , 41 , 42 the number of gratitude lists ranged from two to eight. The frequency with which the participants wrote gratitude lists ranged from once a week to every seven workdays. The duration of the interventions ranged from 7 days to 8 weeks. The most commonly adopted intervention duration was 4 weeks. 39 , 41 , 42 The studies that did not report significant changes on any outcomes required the participants to complete gratitude lists four times or less during intervention. 35 , 38 , 42 The other studies reported significant improvement on at least one of the outcomes. 27 , 37 , 39 , 40 , 41

3.6. Effects of the intervention by types of control groups (positive, negative, and neutral)

One of the included studies offered positive activities to the control group to increase their social ties at work and yielded inconsistent results on well‐being (significant for positive affect and insignificant for negative affect). 36 Neumeier et al. compared plain gratitude intervention and mixed gratitude intervention with no significant differences in well‐being (happiness and happiness at work). 27 In the study conducted by Ligon, although the positive intervention was provided, the intervention effect was not compared with the gratitude intervention group. 38 Three of the included studies offered negative activities that asked participants to regularly write down hassle or bad events. 39 , 40 , 41 The setting of these control groups was consistent with the most cited gratitude intervention study implemented by Emmons et al. 6 The studies showed significant improvement in mental health (perceived stress and depression) and inconsistent results for well‐being. Specifically, Ki showed a significant increase in positive affect, negative affect, and life satisfaction 39 Chan et al. showed no effects on positive affect and life satisfaction and reported a significant decrease in negative affect, 40 while Cheng et al. showed a significant decrease in depression and perceived stress. 41 However, the effectiveness may have been exaggerated because gratitude's benefits, adverse effects of negativity, or both might have maximized the observed differences. 15

Six studies adopted neutral control. 27 , 35 , 37 , 38 , 41 , 42 In one neutral condition, the participants were asked to write down events that occurred at work or in one's personal life regularly or to participate in group sessions to discuss topics related to their daily work, while the other neutral condition included only the measurement. These two studies showed significant improvement in perceived stress and depression 37 , 41 and non‐significant improvement in burnout 38 while the results on well‐being were inconsistent. Two studies reported insignificant changes, 35 , 42 and two studies reported a significant increase in job satisfaction, 37 happiness, and happiness at work. 27

3.7. Risk of bias within studies

Table  4 summarizes the risk of bias assessed using the revised Cochrane risk of bias tool for randomized trials (RoB2). 34 Cheng et al. 41 rated random sequence generation, allocation concealment, and incomplete outcome data as low risk and selective reporting as some concerns. In the study by Ligon, 38 selective reporting was rated as low risk, while random sequence generation was rated as some concerns. All other domains of the studies were rated as high risk, resulting in all nine studies being rated as high risk of bias overall.

Risk of bias, assessed by the revised Cochrane risk of bias tool for randomized trials (RoB 2): N  = 9

4. DISCUSSION

This study systematically reviewed gratitude intervention studies on mental health and well‐being among workers. Many studies were conducted with health care professionals and teachers, while only a few studies were conducted with general workers. Most gratitude interventions were incorporated a gratitude list. No studies focused on only behavioral gratitude expression among workers. Although the studies consistently showed significant improvement in perceived stress and depression, effects on well‐being were inconsistent. The studies that did not report any significant changes in the outcomes instructed the participants to create four gratitude lists or less during the intervention. The other studies reported significant improvement in at least one of the outcomes. The most frequently adopted intervention duration was 4 weeks, consistent with the previous meta‐analysis. 18 Three out of nine studies included negative activity groups, such as recording bad events, as a comparison. Compared to other populations, no distinct differences in the frequency or duration of the interventions were observed, although the characteristics of the recorded objects differed, with most studies asking the participants to record "work‐related" gratitude. This study updated the evidence of gratitude interventions by adding three studies 27 , 37 , 38 that were never included in the previous review studies.

4.1. What kind of gratitude interventions were conducted among workers?

Consistent with the previous meta‐analysis, 17 gratitude list was the most common strategy adopted with workers, seen in eight of nine studies. This is known as the classic and basic gratitude intervention. 6 This approach may be suitable even for busy workers because it is easy to understand and complete, without much time or special materials. 15 It was observed in both cases that less frequently completed gratitude list over a longer period (once a week for 8 weeks) 40 and more frequently completed gratitude list over a shorter period (daily for a week). 27 The follow‐up rate for each was over 70%, indicating that both methods are acceptable for workers.

On the other hand, behavioral gratitude expression was only included as part of a combined positive psychological program, 37 there were no studies that incorporated behavioral gratitude expression only. This may be attributed to the difficulty of implementing it. The previous study found that college students felt less adept at writing a gratitude letter compared to keeping a gratitude list, which in turn predicted lower rates of completing the activities. 43 Similarly, workers may hesitate to participate in gratitude intervention, including expressing their grateful feelings to others. However, a previous study utilizing the RCT design reported that outcomes were significantly improved in the group that combined gratitude list and behavioral gratitude expression compared to the group that completed only the gratitude list. 44 To introduce behavioral gratitude expressions to workers, it may be necessary to provide a practice guide for conducting the activity. Cook et al. provided instructions to include a specific person to give the gratitude letter to, concrete steps for writing, the approximate number of words (~300 words), and steps for delivering the letter. 37 Among workers, gratitude activities were often incorporated on a stand‐alone basis, but a few studies included them as part of a combined intervention, showing a high degree of adaptability in implementation methods.

4.2. Do gratitude interventions effectively improve mental health and well‐being among workers?

Gratitude interventions for workers might effectively improve perceived stress and depression; however, the effects on well‐being might be unclear. The effects of depressive symptoms on mental health outcomes were consistent with a meta‐analysis conducted by Cregg et al. among the general population. 21 Three possible mechanisms have been discussed. First, gratitude was associated with interpreting various stimuli and life events in positive terms, which is inconsistent with the selective attention to negative qualities of the self, the world, and the future that characterize depression and anxiety. 45 , 46 Second, it was argued that a less critical, less punishing, and more compassionate view of oneself account for the inverse relationship between gratitude and symptoms of depression and anxiety. 47 Finally, researchers have also found an association of gratitude with greater relationship connection and satisfaction, 48 well‐established buffers against psychopathology. 49 The basis of these mechanisms (interpretation of events, views of oneself, relationship connections, and satisfaction) is also closely related to workers, leading to consistent results. On the other hand, the effect of the gratitude intervention on burnout was not consistent with a previous pre‐post single‐arm study among workers (teachers). 50 It was argued that the symptoms of burnout would be reduced when they experience professional growth, self‐efficacy, and perceived success in their career progression. 51 More research is needed to conclude the effect of gratitude intervention on burnout.

Regarding well‐being, contrary to previous meta‐analyses, 15 , 17 inconsistent results were obtained. The most critical reason would be the high heterogeneity of intervention methods. The intervention effects on well‐being tended to depend on the intervention method rather than on the kind of well‐being indicators. In other words, effective studies showed improvements in multiple measured outcomes, while less effective studies failed to show any significant effects. To consider the effects of gratitude intervention on well‐being among workers, it is necessary to pay attention to whether effective conditions and settings are adopted, in addition to taking care of the control group (assigned activities are positive or negative, or neutral), as pointed out in the previous study. 7 The existing studies introduced various theories to explain the mechanism underlying the relationship between gratitude intervention and mental health or well‐being outcomes. For example, Ki, Baker et al, and Neumeier et al. cited the Broaden and Build Theory. 27 , 35 , 39 , 52 Additionally, Cheng et al. proposed the coping hypothesis, 41 while Kaplan et al. explained applied the model of happiness (happiness is a function of three major factors: life circumstances, temperament/disposition, and positive cognitive or behavioral activities). 36 , 53 Since the gratitude intervention can affect multiple dimensions, including cognition, mood, behavioral tendencies, coping, traits such as prosociality, and relationships with others, 7 , 17 , 32 several mechanisms may have a combined effect among workers as well.

4.3. What conditions and settings effectively improve mental health and well‐being among workers?

A key moderator of positive psychology interventions is the number of times a participant engages in an activity. 17 , 54 For example, in prior work in positive psychology, more time spent working on forgiveness activities resulted in larger effect sizes for forgiveness. 55 From this perspective, the total number of gratitude lists might affect outcomes among workers differently. Studies that recorded gratitude lists six times or more showed significant effects at least on one outcome, 27 , 37 , 39 , 40 , 41 while studies that recorded gratitude four times or fewer did not show significant results on any outcomes. 35 , 38 , 42 This can be explained by the schematic hypothesis of gratitude introduced by Wood et al. as the mechanism underlying the relationship between gratitude and well‐being. 7 The hypothesis suggests that grateful people go around in life with a particular interpretive lens, seeing help as more costly, valuable, and altruistic. Equally, ungrateful people view the help they see as lower on these dimensions. According to the Network Theory of Emotion, 56 , 57 emotional schemas develop linearly through repeated pairings of stimuli and emotions. 58 The schema hypothesis of gratitude has also been supported in an occupational context. 59 Thus, for a grateful schema, "repeated stimulation" would be necessary. Accordingly, less than four activities would not suffice. Whether the intervention duration is one week 27 or 8 weeks 40 or whether the frequency is high (daily) or low (once a week) does not seem to affect the formation of schemas, as long as the total number of gratitude activities are sufficient.

Considering differences in intervention content, six out of eight gratitude list studies asked participants to record "work‐related gratitude" while the remaining studies did not. In this study, the effect of these differences on mental health and well‐being has been inconsistent. However, whether the gratitude is work‐related might affect its effects. The gratitude list can also function as a reframing, specifically, positive reappraisal. 60 Therefore, it may be desirable to promote positive reappraisal in the work domain, especially when targeting work‐related outcomes. In a study conducted by Ligon, where gratitude lists were not "work‐related" but "life‐related," no significant improvement in burnout was found. 38 In the future, it will be important to investigate the relationship between the content of the gratitude recorded and the outcome. As another point in the gratitude list studies, both paper‐based and web‐based interventions were present, but it was seemed to be inconsistent differences in effectiveness by intervention medium. This is in line with the previous study that found no significant difference in performance between paper‐based and web‐based homework assignments among students. 61 It would be desirable to choose a medium depending on employees’ work style to reduce the burden on workers. 35 Two studies required the participants to reflect on and keep gratitude lists, and both showed improvement in one or more of the outcomes. 27 , 40 Reflecting on the gratitude list may enhance the intervention effect by "savoring." Savoring is a construct in positive psychology that refers to using one's cognitive or behavioral responses to regulate the emotional effect of positive events. 62 The previous diary study showed that savoring mediated and moderated the effect of daily positive events on happiness and mood. 63

Therefore, it might be useful to incorporate elements of savoring into gratitude intervention. In conclusion, the total number of gratitude lists and reflections might influence the effect on mental health and well‐being; however, due to the high heterogeneity of the studies (the content of the intervention, timing of measurement, subjects, etc.), further studies are needed.

4.4. Risk of bias within studies applying gratitude interventions

Based on our assessment of the risk of bias, all nine studies were rated as high risk of bias overall. While bias can occur in some domains due to the nature of the intervention (e.g., blinding of participants, personnel, and provider), it is necessary to study higher quality RCTs targeting workers. For example, randomization should be done by independent researchers, the process should be clearly stated, intention to treat (ITT) analysis should be employed, and protocol papers or registries should be opened in advance.

4.5. Limitations

The present systematic review has several limitations. First, we did not conduct a meta‐analysis because it was deemed inappropriate due to the large variability in mental health and well‐being indicators. Therefore, it is not possible to quantitatively verify the effects of the gratitude intervention among workers. Second, this review was limited to studies written in the English language. Third, it is possible that there was overlooked mixed intervention regardless they include gratitude activities substantially due to the reason it was not mentioned as gratitude activities clearly in the paper. Fourth, additional unpublished studies, especially those with negative consequences, were omitted. Therefore, publishing bias could not be ruled out. Fifth, generalizations have been limited because many studies were conducted on health care professionals and teachers, and few studies were conducted on general workers.

5. CONCLUSIONS

Most gratitude interventions incorporated a gratitude list, and some studies included gratitude activities as a part of the combined program. On the other hand, no studies focused on only behavioral gratitude expression among workers. Although studies in this review showed significant improvement in perceived stress and depression, the effects on well‐being were inconsistent. The total number of gratitude lists and reflections might influence the effect on mental health and well‐being; however, due to the high heterogeneity of the studies, further studies are needed.

Ethical approval : Ethical approval is not needed because data from previous studies in which informed consent was obtained by primary investigators were retrieved and included. Informed consent : N/A. Registry and the Registration No. of the study/Trial : The study protocol was registered at the UMIN Clinical Trials Registry (ID = UMIN000039785). Animal Studies : N/A. Conflict of interest : Yu Komase, Kazuhiro Watanabe, Daisuke Hori, Kyosuke Nozawa, Yui Hidaka, Mako Iida, Kotaro Imamura declare no competing interests. Norito Kawakami reports grants from Fujitsu LTD., SB At Work Corp., personal fees from Occupational Health Foundation, Japan Dental Association, Sekisui Chemicals, Junpukai Health Care Center, Osaka Chamber of Commerce and Industry, non‐financial support from Japan Productivity Center, outside the submitted work.

AUTHOR CONTRIBUTIONS

YK, KW, DH, KN, YH, MI, KI, and NK contributed substantially to the paper's conception, design, screening and evaluating studies, and writing and approved the manuscript for submission.

ACKNOWLEDGMENTS

This work was supported by The Japan Society for the Promotion of Science KAKENHI Grant Number JP1119140. The funding body has not been involved in the study's design and collection, analysis, and interpretation of data and in writing the manuscript.

Komase Y, Watanabe K, Hori D, et al. Effects of gratitude intervention on mental health and well‐being among workers: A systematic review . J Occup Health . 2021; 63 :e12290. doi: 10.1002/1348-9585.12290 [ CrossRef ] [ Google Scholar ]

DATA AVAILABILITY STATEMENT

An emotional regulation advantage in people with high psychological Suzhi—evidence from ERP research

  • Published: 26 February 2024

Cite this article

  • Zhaoxia Pan   ORCID: orcid.org/0000-0001-9573-133X 1 &
  • Dajun Zhang 2  

Emotional regulation, a key mechanism for promoting emotional health, has been found to play an important mediating role between psychological suzhi and emotional health, and there is a close relationship between psychological suzhi and emotion regulation effects. However, most studies on the relationship between psychological suzhi and emotion regulation effects have focused only on subjective experiences and changes in peripheral nervous system indicators, failing to examine central neurophysiological indicators of emotion regulation effects. The close relationship between psychological suzhi and emotion regulation has not yet been sufficiently revealed, and this has, to some extent, limited the in-depth exploration of the mechanisms of psychological suzhi. Therefore, to examine the relationship between psychological suzhi and changes in the nervous system surrounding emotion regulation, we aimed to deepen the research on the relationship between psychological suzhi and emotion regulation and thus to further reveal the mechanism of the role of psychological suzhi. This study used event-related potential (ERP) technology with a high temporal resolution to examine the electrophysiological differences in the use of two emotion regulation strategies, cognitive reappraisal and expressive inhibition, for negative emotion regulation among college students. The results showed that the late positive potential (LPP) amplitude of the high psychological suzhi group was significantly decreased beginning in the early time window (500–1000 ms), while the LPP amplitude of the low psychological suzhi group was significantly decreased beginning in the middle time window (1000–1500 ms). In the early, middle and late time windows, the negative emotion regulation effect of cognitive reappraisal in the group with high psychological suzhi was significantly better than that of the group with low psychological suzhi. The regulatory effect of cognitive reappraisal of negative emotion was significantly greater in college students with high psychological suzhi than in college students with low psychological suzhi.This study has enlightening significance for further research on the mechanism of psychological suzhi.

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The dataset analysed for the present study and the photographs used in the photograph rating are available from the corresponding author on reasonable request.

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Acknowledgements

We thank the students and teachers who participated, and we are grateful to faculty and staff at the Research Center of Mental Health Education of Southwest University for their generous support and valuable advice.

This research was supported by the Southwest University Research-Oriented Faculty Construction Project (2020–2021).

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ORIGINAL RESEARCH article

The hummingbird project year 2: decreasing distress and fostering flourishing in a pragmatic pre-post study.

Ian A. Platt

  • 1 University of Bolton, Bolton, United Kingdom
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Multi-component Positive Psychology Interventions (mPPIs) in secondary schools have been shown to improve mental health outcomes for young people. The Hummingbird Project mPPI – a six-week program of workshops designed to introduce a variety of positive psychology concepts to secondary school-aged children in schools improved well-being, resilience, and hope. The effects on mental distress, however, were not explored. The current study, therefore, was designed to replicate the effects of the Hummingbird Project mPPI on positive mental health and to also explore the effects on symptoms of mental distress. Secondary school-aged children (N = 614; mean age = 11.46 years) from a sample of secondary schools located across the North West of England (N=7) participated in the study; the majority of children were in Year 7 (94%). The Positive Psychology concepts explored included happiness, hope, resilience, mindfulness, character strengths, growth mindset and gratitude. The results showed significant improvements associated with the mPPI in; well-being (as measured by the World Health Organization Well-Being Index; WHO-5); hope (as measured by the Children's Hope Scale; CHS) and symptoms of mental distress (as measured by the Young Person’s Clinical Outcomes in Routine Evaluation; YP-CORE) from pre- to post-intervention. Whilst acknowledging the limits due to pragmatic concerns regarding the implementation of a control group, the effectiveness of the Hummingbird Project mPPI on wellbeing was replicated alongside reducing the symptoms of mental distress. Future evaluation, however, will need to implement more robust designs and consider follow-up duration to assess the longer-term effects of the Hummingbird Project mPPI.

Keywords: School, Well-being, Positive Psychology, Child, Adolescent, intervention

Received: 17 Jul 2023; Accepted: 26 Feb 2024.

Copyright: © 2024 Platt, Hochard, Kannangara, Tytherleigh, Carson, McFaul and North. 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) or licensor 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: Ian A. Platt, University of Bolton, Bolton, United Kingdom

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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