Designing for Health and Happiness David S. Sobel, MD, MPH Regional Health Education The Permanente Medical Group, Kaiser Permanente Northern California Telephone: 510.987.3579, david.sobel@kp.org Follow me on Twitter @KPhealthyfun Healthy Pleasures The Permanente Medical Group 2014

2 Questions 1. Are people unmotivated? 2. Does pleasure and happiness matter for health? 3. How can we design for happiness and amplify pleasure?

3 Are people unmotivated? Consequences: Attempt to increase motivation Prescribing behavior change (i.e. often failure) Frustration and cynicism But do we really know what motivates people? How can we make it easier for people to do what they already want to do? Have we identified and celebrated successes?

4 Shifting the Curve Target the Ready & Willing: Help people do what they already want to do. Where to focus? Which curve can you shift?

5 What do people really care about? Healthy Lifestyles Real Life Sleep Sex Stress Exercise and healthy diet Preventive screenings

6 n= 1064 The Unmentionables

7 Pleasure and Passion: Missing Ingredients in Motivation understand whole person screens for depression align with intrinsic motivation bright spot for clinicians What do you Really Enjoy?

8 Theres no improvement, Henry. Are you sure you have given up everything you enjoy?

9 Types of Pleasures Sensory Pleasures q 5 Senses Non-Sensory Pleasures q Achievement (competence*) q Autonomy* q Activity (process of activity, not outcome) q Neuromuscular (arousal and relaxation) q Esthetic (nature, beauty, etc.) q Humor q Social Pleasures (relatedness*) Frijda, N. (2010). On the nature and function of pleasure. In M. L. Kringelbach & K. C. Berridge (Eds.), Pleasures of the brain (pp. 99112). New York: Oxford University Press. Biswas-Diener, R. Pleasure: An Initial Exploration. J of Happiness Studies, 2014. *Self-Determination Theory

10 Finding Pleasure: Enjoyment as a Vital Sign List 10 activities that are fun for you. What brings you joy? What that makes you feel happy? It can be anything- walking the dog, talking with friends, working in the garden, listening to music, writing a letter to someone special, watching your children play, fixing a special meal What prevents you from doing more of the things you really enjoy? Pleasant Events Schedule Peter Lewinsohn320 items

11 Questions 1. Are people unmotivated? 2. Does pleasure and happiness matter for health?

12 Are Happier People Healthier? "During the past 4 weeks, have you been a happy person?" All things considered, how satisfied are you with your life? Siahpush Am J Health Promo 2008;23:18-26 People with higher happiness and life satisfaction 2 years later reported 50% better health and less long-term, limiting health conditions. n=10,000

13 Are Happier People Healthier? A long-term study of nuns discovered that those who wrote autobiographies at a young age reflecting happiness, love and hope had a 2.5 time lower risk of dying than their gloomier counterparts. Danner J Pers Soc Psych 2001;80:804-13

14 Health Benefits of Happiness Seven types of evidence are reviewed that indicate that high subjective wellbeing (such as life satisfaction, absence of negative emotions, optimism, and positive emotions) causes better health and longevity. the evidence is clear and compelling. Deiner, Applied Psych 2011

15 SAVOR YOUR SENSES: In Touch Infants (preterm and term) Pregnancy and childbirth Diabetic and asthmatic children Adolescent psychiatric patients Post-traumatic stress disorder Eating disorders Migraine headache and low back pain HIV+ adults Breast cancerTouch Research Institute, University of Miami School of Medicine Field TM Touch Therapy 2000.

16 When looking at Nature: More positive feelings Reduced negative emotion Lower physiological arousal Higher alpha brain waves Quicker recovery from stress SAVOR YOUR SENSES: Nature vs. Urban

17 Postsurgical patients in a room with a view of nature (vs. a brick wall) had: less distress required less pain medication discharged 1 day sooner Nature-Deficit Disorder -No Child Left Inside (R. Louv) Ulrich R: Science 1984:224:420 SAVOR YOUR SENSES: Looking at Nature

18 SAVOR YOUR SENSES: The Case for Wine (and Alcohol) C12 drinks per day for women C2-4 drinks per day for men is associated with: 18% lower total mortality 30% lower risk of coronary heart disease and type 2 diabetes higher good HDL cholesterol . Di Castelnuovo: Arch Intern Med 2006;166:2437, Koppes LL: Diabetes Care 2005;28:719, Mukamal KJ: JAMA 2010;303:2065

19 Chocolate eaters may enjoy: 27% lower relative risk of death and an extra year of life (Lee I, BMJ 1998) Lower blood pressure (Taubert D, Arch Intern Med. 2007) 47% lower mortality rate in men (Buijsse B: Arch Intern Med 2006) 35% less likelihood of hospitalization or death from heart disease in women over 70 (Lewis JR Arch Intern Med. 2010) 20% lower rate of stroke (Larsson, Neurology, 2012) decreased insulin resistance, high HDL and lower LDL cholesterol, reduced blood platelet adhesion, protection arterial wall lining, etc (Corti R: Circulation, 2011) SAVOR YOUR SENSES: Life is Sweet

20 CENSORED The risk of death in men who had sex twice or more a week is half that of men who had sex less than once a month.* Davey Smith G: BMJ 1997;315(7123):1641-44 SAVOR YOUR SENSES: The Benefits of Sex * After adjusting for age, social class, smoking, blood pressure, and existing heart disease

21 Men taking a siesta were 30-50% less likely to have a heart attack 24,000 people over 6 years: Occasional nap: 12% reduction in coronary mortality Frequent naps: 37% reduction Trichopoulas D: Lancet 1987;2:269 Naska, A: Arch Int Med 2007;167:296 PRACTICE HAPPINESS: Siestas

22 Hearty Laughter Heart attack patients Rx: 30 min/day humor video fewer irregular rhythms lower blood pressure lower stress hormones less medication one-fifth rate recurrent heart attacks Tan SA: Can J Cardiol 1997 PRACTICE HAPPINESS: Humor Matters

23 Pets In the year following a heart attack, pet owners have one-fifth the rate of recurrent heart attack. Friedmann E, Public Health Reports 1980;95:307 INDULGE IN ALTRUISM: Selfless Pleasures

24 INDULGE IN ALTRUSIM Giving Better than Receiving Mortality risk reduced by nearly half in seniors giving social support while increased in those receiving support.* Brown SL Psych Sci 2003 * After controlling for age, gender, health status, socioeconomic status, health behaviors, and personality

25 Questions 1. Are people unmotivated? 2. Does pleasure and happiness matter for health? 3. How can we design for happiness and amplify pleasure?

26 Think of a change you made q Did your plan out and write down specific small steps and/or have feedback of performance data? q Did a major life event trigger an epiphany/breakthrough change? q Did you change because your environment required or invited the change? q Did you just change the behavior because it felt good?

27 Roads to Behavior Change Incremental Planned Change Baby Steps Small Steps Simple Steps Tiny Steps Starter Steps Success Steps Mastery Experiences Breakthrough Change Environmental Change Pleasurable Change

28 Health Behavior Change What if small steps do not lead to sustained behavior change and health habits?

29 Small Steps to Health Small Steps Sustained Health Habit Improved Health Small Steps Success Experience Improved Health Confidence Optimism Self-Efficacy Mood/Affect Pleasure etc. Exercise Healthy Eating Smoking Preventive Care etc. Behavior Matters Mood Matters

30 Segar M et al. Rebranding Exercise. International Journal of Behavioral Nutrition and Physical Activity 2011, 8:94. http://www.ijbnpa.org/content/8/1/94 Failure and Success http://michellesegar.com/organizations/

31 Celebrate Design with Pleasure: Amplifiers Focus PrimeReframe

32 Celebrate Design with Pleasure: Amplifiers Reframe Prime Focus

33 Ingredients of Sensory Pleasures Good Sense+ Mindful Attention+ Pleasure!= What do you need for pleasure to happen? Good Stimulus

34 PRACTICE HAPPINESS A Wandering Mind is an Unhappy Mind What are you feeling, doing, and thinking right now? 2250 people Killingsworth, Gilbert: 2010. Science 330:932. www.trackyourhappiness.org Mind wandering: 50% People happier when their mind was NOT wandering during all activities, pleasant or unpleasant What people are thinking is better predictor of happiness than what they are doing

35 A Call to be Present TELEPHONE RING Distraction? Interruption? or Call to be present? ( First ring: Smile. Breathe. Listen, listen. This wonderful sound brings me back to my true self. ( Second ring: Smile. Breathe. ( Third ring: Be fully present as you answer. Thich Nhat Hanh, Peace is Every Step

36 Celebrate Design with Pleasure: Amplifiers Focus PrimeReframe

37 YOU ARE HERE

38 Amplifying Pleasure with Scarcity The last piece of chocolate on earth

39 Celebrate Design with Pleasure: Amplifiers Focus Reframe Prime

40 The Power of Priming Priming make us more sensitive to and aware of: opportunities events interactions triggers

41 What 3 things happened today that I am: grateful for? curious about? surprised by? learning something new? Emmons RA, J Pers Soc Psych, 2003 Emmons RA, Thanks! 2007 Priming for Gratitude, etc.

42 What do you take for granted?

43 What to call it? Priming Behaviors Ripple Behaviors Cascading Behaviors Domino Behaviors Keystone Behaviors

44 Design with Pleasure: Amplifiers Focus PrimeReframe Celebrate

45 Celebrating Unexpected Pleasures

46 Design with Pleasure Emphasize more proximal, immediate satisfaction, mood, and feelings Focus on present experience Dont be senseless (invite sensual pleasure) Celebrate (even small) successes Include unexpected surprises, delights Change the focus/perspective/filters/frames Identify priming and cascading behaviors

47 Thank you

48 Healthy Pleasures: 5 Part Online Video Program or search YouTube for Healthy Pleasures

49 Twitter @KPhealthyfun

50 Resources for Happiness

51 Can judge a book by its cover?

52 Resources and References (1) Ben-Shahar, Tal: Happier: Learn the Secrets to Daily Joy and Las@ng Fulllment. McGraw-Hill, 2007 Boronson, Mar;n: One Moment Medita@on. Winter Road Publishing, 2009. Burns, David: The Feeling Good Handbook. Morrow, 1989. David, Susan, et al. Oxford Handbook of Happiness. Oxford, 2013 Davis, Martha; Eshelman, E; McKay, M: The Relaxa@on & Stress Reduc@on Workbook. New Harbinger, 2008. Diener , Ed and Biswas-Diener, Robert . Happiness: Unlocking the Mysteries of Psychological Wealth. Wiley-Blackwell, 2008. Dunn EW, Akmin LB, Norton MI. (2008). Spending money on others promotes happiness. Science, 319,1687-89 Emmons RA, McCullough ME (Eds.) (2004). The Psychology of Gra@tude. Oxford Press. Emmons, RA (2007). Thanks!: How the New Science of Gra@tude Can Make You Happier. Houghton Miin Howell RT, et al: (2007). Health benets: Meta-analy;cally determining the impact of well-being on objec;ve health outcomes. Health Psychology Review 1(1),83-136 Kabat-Zinn, J: Wherever You Go There You Are: Mindfulness Medita@on in Everyday Life. Hyperion, 1994 Kringelbach, M (ed): Pleasures of the Brain. Oxford, 2010 Lyubomirsky, S . The How of Happiness. Penguin Press, 2008 Lyubomirsky, S . The Myths of Happiness: What Should Make You Happy, but Doesn't, What Shouldn't Make You Happy, but Does. Penguin Press, 2013 McKay M, Davis M, and Fanning P: Thoughts and Feelings: The Art of Cogni@ve Stress Interven@on. New Harbinger, 2007. Neele, Daniel: Happiness: The science behind your smile. Oxford University, 2005.

53 Resources and References (2) Ornstein, Robert and Sobel, David: Healthy Pleasures. New York: Addison-Wesley, 1989. Ornstein, Robert and Sobel, David: The Healing Brain. New York: Simon & Schuster, 1987. Pennebaker, James W. Opening Up: The Healing Power of Conding in Others. Guilford Press, 1997. Posi;ve Psychology Center, University of Pennsylvania. hep://www.ppc.sas.upenn.edu/ Seligman, Mar;n: Authen@c Happiness, Free Press, 2004 Seligman, Mar;n: The Op@mis@c Child. Mariner, 2007. Seligman, Mar;n: Flourish. 2011. Sheldon KM, Lyubomirsky S: Is It Possible to Become Happier? (And If So, How?) Social and Personality Psychology Compass 1/1 (2007): 129145, Siahpush M, Spieal M, Singh GK: Happiness and Life Sa;sfac;on Prospec;vely Predict Self-Rated Health, Physical Health, and the Presence of Limi;ng, Long-Term Health Condi;ons. American Journal of Health Promo;on: September/October 2008;23:18-26. Sobel, David and Ornstein, Robert: The Healthy Mind, Healthy Body Handbook (also published under the ;tle The Mind&Body Health Handbook), Los Altos, CA: DRx 1996. Sobel, David: Rethinking Medicine: Improving health outcomes with cost-eec;ve psychosocial interven;ons. Psychosoma@c Medicine 57:234-244, 1995. Sobel, David: The cost-eec;veness of mind-body medicine interven;ons. In The Biological Basis for Mind Body Interac@ons, Progress in Brain Research, Vol 122, E.A. Mayer and C.B. Saper (Eds.), Amsterdam: Elsevier Science, 2000:393-412. Wiseman, Robert: 59 Seconds: Think a Li^le, Change a Lot. New York: MacMillan, 2009.