14.5 The Psychology of Health: Feeling Good

Two kinds of psychological factors influence personal health: health-relevant personality traits and health behavior. Personality can influence health through relatively enduring traits that make some people particularly susceptible to health problems or stress while sparing or protecting others. The Type A behavior pattern is an example. Because personality is not typically something we choose (“I’d like a bit of that sense of humor and extraversion over there, please, but hold the whininess”), this source of health can be outside personal control. In contrast, engaging in positive health behaviors is something anyone can do, at least in principle.

Personality and Health

Different health problems seem to plague different social groups. For example, men are more susceptible to heart disease than are women, and African Americans are more susceptible to asthma than are Asian or European Americans. Beyond these general social categories, personality turns out to be a factor in wellness, with individual differences in optimism and hardiness important influences.

Optimism

Pollyanna is one of literature’s most famous optimists. Eleanor H. Porter’s 1913 novel portrayed Pollyanna as a girl who greeted life with boundless good cheer, even when she was orphaned and sent to live with her cruel aunt. Her response to a sunny day was to remark on the good weather, of course, but her response to a gloomy day was to point out how lucky it is that not every day is gloomy! Her crotchety Aunt Polly had exactly the opposite attitude, somehow managing to turn every happy moment into an opportunity for strict correction. A person’s level of optimism or pessimism tends to be fairly stable over time, and research comparing the personalities of twins reared together versus those reared apart suggests that this stability arises because these traits are moderately heritable (Plomin et al., 1992). Perhaps Pollyanna and Aunt Polly were each “born that way.”

Adrianne Haslet was approximately four feet away from one of the bombs that exploded at the Boston Marathon in 2013. Although the explosion caused her to lose her left foot, Adrianne vowed that she will continue her career as a dancer—and will run the Boston Marathon in 2014. She is an optimist, and optimism can lead to positive health outcomes.

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An optimist who believes that “in uncertain times, I usually expect the best” is likely to be healthier than a pessimist who believes that “if something can go wrong for me, it will.” One recent review of dozens of studies including tens of thousands of participants concluded that of all of the measures of psychological well-being examined, optimism is the one that most strongly predicted a positive outcome for cardiovascular health (Boehm & Kubzansky, 2012). Importantly, the association between optimism and cardiovascular health remains even after statistically controlling for traditional risk factors for heart disease including depression and anxiety, suggesting that it is not just the absence of psychopathology, but the presence of positive expectancies for the future, that predict positive health outcomes. Does just having positive thoughts about the future make it so? Unfortunately not.

Rather than improving physical health directly, optimism seems to aid in the maintenance of psychological health in the face of physical health problems. When sick, optimists are more likely than pessimists to maintain positive emotions, avoid negative emotions such as anxiety and depression, stick to medical regimens their caregivers have prescribed, and keep up their relationships with others. Among women who have surgery for breast cancer, for example, optimists are less likely to experience distress and fatigue after treatment than are pessimists, largely because they keep up social contacts and recreational activities during their treatment (Carver, Lehman, & Antoni, 2003). Optimism also seems to aid in the maintenance of physical health. For instance, optimism appears to be associated with cardiovascular health because optimistic people tend to engage in healthier behaviors like eating a balanced diet and exercising, which in turn leads to a healthier lipid profile (i.e., higher levels of high-density lipoprotein cholesterol that help to prevent buildup in your arteries, and lower triglycerides, which are the chemical form of fat storage in the body), which decreases the risk of heart disease (Boehm et al., 2013). So being optimistic is a positive asset, but it takes more than just hope to obtain positive health benefits.

The benefits of optimism raise an important question: If the traits of optimism and pessimism are stable over time—even resistant to change—can pessimists ever hope to gain any of the advantages of optimism (Heatherton & Weinberger, 1994)? Research has shown that even die-hard pessimists can be trained to become significantly more optimistic and that this training can improve their psychosocial health outcomes. For example, pessimistic breast cancer patients who received 10 weeks of training in stress management techniques became more optimistic and were less likely than those who received only relaxation exercises to suffer distress and fatigue during their cancer treatments (Antoni et al., 2001).

Hardiness

Sometimes hardiness tips over the edge into foolhardiness. Members of the Coney Island Polar Bear Club take that plunge every Sunday of winter.

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Some people seem to be thick-skinned, somehow able to take stress or abuse that could be devastating to others. Are there personality traits that contribute to such resilience and offer protection from stress-induced illness? To identify such traits, Suzanne Kobasa (1979) studied a group of stress-resistant business executives. These individuals reported high levels of stressful life events but had histories of relatively few illnesses compared with a similar group who succumbed to stress by getting sick. The stress-resistant group (Kobasa labeled them hardy) shared several traits, all conveniently beginning with the letter C. They showed a sense of commitment, an ability to become involved in life’s tasks and encounters rather than just dabbling. They exhibited a belief in control, the expectation that their actions and words have a causal influence over their lives and environment. And they were willing to accept challenge, undertaking change and accepting opportunities for growth.

Can just anyone develop hardiness? Researchers have attempted to teach hardiness with some success. In one such attempt, participants attended 10 weekly hardiness-training sessions, in which they were encouraged to examine their stresses, develop action plans for dealing with them, explore their bodily reactions to stress, and find ways to compensate for unchangeable situations without falling into self-pity. Compared with control groups (who engaged in relaxation and meditation training or in group discussions about stress), the hardiness-training group reported greater reductions in their perceived personal stress as well as fewer symptoms of illness (Maddi, Kahn, & Maddi, 1998). Hardiness training can have similar positive effects in college students, for some even boosting their GPA (Maddi et al., 2009).

Health-Promoting Behaviors and Self-Regulation

Even without changing our personalities at all, we can do certain things to be healthy. The importance of healthy eating, safe sex, and giving up smoking are common knowledge. But we don’t seem to be acting on the basis of this knowledge. At the turn of the 21st century, 69% of Americans over 20 are overweight or obese (National Center for Health Statistics, 2012). The prevalence of unsafe sex is difficult to estimate, but 65 million Americans currently suffer from an incurable sexually transmitted disease (STD), and 20 million contract one or more new STDs each year (Satterwhite et al., 2013). Another million people live with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), 18.1% of whom are unaware of their infection, which is usually contracted through unprotected sex with an infected partner (Centers for Disease Control, 2012). And despite endless warnings, 21% of Americans still smoke cigarettes (Pleis et al., 2009). What’s going on?

Self-Regulation

Nobody ever said self-control was easy. Probably the only reason you’re able to keep yourself from eating this cookie is that it’s just a picture of a cookie. Really. Don’t eat it.

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Doing what is good for you is not necessarily easy. Mark Twain once remarked, “The only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you’d rather not.” Engaging in health-promoting behaviors involves self-regulation, the exercise of voluntary control over the self to bring the self into line with preferred standards. When you decide on a salad rather than a cheeseburger, for instance, you control your impulse and behave in a way that will help to make you the kind of person you would prefer to be—a healthy one. Self-regulation often involves putting off immediate gratification for longer-term gains.

Self-regulation requires a kind of inner strength or willpower. One theory suggests that self-control is a kind of strength that can be fatigued (Baumeister, Heatherton, & Tice, 1995; Baumeister, Vohs, & Tice, 2007). In other words, trying to exercise control in one area may exhaust self-control, leaving behavior in other areas unregulated. To test this theory, researchers seated hungry volunteers near a batch of fresh, hot, chocolate chip cookies. They asked some participants to leave the cookies alone but help themselves to a healthy snack of radishes, whereas others were allowed to indulge. When later challenged with an impossibly difficult figure-tracing task, the self-control group was more likely than the self-indulgent group to abandon the difficult task—behavior interpreted as evidence that they had depleted their pool of self-control (Baumeister et al., 1998). The take-home message from this experiment is that to control behavior successfully, we need to choose our battles, exercising self-control mainly on the personal weaknesses that are most harmful to health.

Sometimes, though, self-regulation is less a matter of brute force than of strategy. Martial artists claim that anyone can easily overcome a large attacker with the use of the right moves, and overcoming our own unhealthy impulses may also be a matter of finesse. Let’s look carefully at healthy approaches to some key challenges for self-regulation—eating, safe sex, and smoking—to learn what “smart moves” can aid us in our struggles.

Eating Wisely

One of the reasons that people in France are leaner than people in the United States is because the average French diner spends 22 minutes to consume a fast-food meal, whereas the average American diner spends only 15 minutes. How could the length of the average meal influence an individual’s body weight?

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In many Western cultures, the weight of the average citizen is increasing alarmingly. One explanation is based on our evolutionary history: In order to ensure their survival, our ancestors found it useful to eat well in times of plenty to store calories for leaner times. In postindustrial societies in the 21st century, however, there are no leaner times, and people can’t burn all of the calories they consume (Pinel, Assanand, & Lehman, 2000). But why, then, isn’t obesity endemic throughout the Western world? Why are people in France leaner on average than Americans, even though their foods are high in fat? One reason has to do with the fact that activity level in France is greater. Research by Paul Rozin and his colleagues also finds that portion sizes in France are significantly smaller than in the United States, but at the same time, people in France take longer to finish their smaller meals. At a McDonald’s in France, diners take an average of 22 minutes to consume a meal, whereas in the United States, they take under 15 minutes (Rozin, Kabnick, et al., 2003). Right now, Americans seem to be involved in some kind of national eating contest, whereas in France people are eating less food more slowly, perhaps leading them to be more conscious of what they are eating. This, ironically, probably leads to lower French fry consumption.

Short of moving to France, what can you do? Studies indicate that dieting doesn’t always work because the process of conscious self-regulation can be easily undermined by stress, leading people who are trying to control themselves to lose control by overindulging in the very behavior they had been trying to overcome. This may remind you of a general principle discussed in the Consciousness chapter: Trying hard not to do something can often directly produce the unwanted behavior (Wegner, 1994a, 1994b).

The restraint problem may be inherent in the very act of self-control (Polivy & Herman, 1992). Rather than dieting, then, heading toward normal weight should involve a new emphasis on exercise and nutrition (Prochaska & Sallis, 2004). In emphasizing what is good to eat, the person can freely think about food rather than trying to suppress thoughts about it. A focus on increasing activity rather than reducing food intake, in turn, gives people another positive and active goal to pursue. Self-regulation is more effective when it focuses on what to do rather than on what not to do (Molden, Lee, & Higgins, 2009; Wegner & Wenzlaff, 1996).

Avoiding Sexual Risks

People put themselves at risk when they have unprotected vaginal, oral, or anal intercourse. Sexually active adolescents and adults are usually aware of such risks, not to mention the risk of unwanted pregnancy, and yet many behave in risky ways nonetheless. Why doesn’t awareness translate into avoidance? Risk takers harbor an illusion of unique invulnerability, a systematic bias toward believing that they are less likely to fall victim to the problem than are others (Perloff & Fetzer, 1986). For example, a study of sexually active female college students found that respondents judged their own likelihood of getting pregnant in the next year as less than 10%, but estimated the average for other women at the university to be 27% (Burger & Burns, 1988). Paradoxically, this illusion was even stronger among women in the sample who reported using inadequate or no contraceptive techniques. The tendency to think “It won’t happen to me” may be most pronounced when it probably will.

Unprotected sex often is the impulsive result of last-minute emotions. When thought is further blurred by alcohol or recreational drugs, people often fail to use the latex condoms that can reduce their exposure to the risks of pregnancy, HIV, and many other STDs. Like other forms of self-regulation, the avoidance of sexual risk requires the kind of planning that can be easily undone by circumstances that hamper the ability to think ahead. One approach to reducing sexual risk taking, then, is simply finding ways to help people plan ahead. Sex education programs offer adolescents just such a chance by encouraging them, at a time when they have not had much sexual experience, to think about what they might do when they need to make decisions. Although sex education is sometimes criticized as increasing adolescents’ awareness of and interest in sex, the research evidence is clear: Sex education reduces the likelihood that adolescents will engage in unprotected sexual activity and benefits their health (American Psychological Association, 2005). The same holds true for adults.

Not Smoking

One in two smokers dies prematurely from smoking-related diseases such as lung cancer, heart disease, emphysema, and cancer of the mouth and throat. Lung cancer alone kills more people than any other form of cancer, and smoking causes 80% of lung cancers. Although the overall rate of smoking in the United States is declining, new smokers abound, and many can’t seem to stop. College students are puffing away along with everyone else, with 20% of college students currently smoking (Thompson et al., 2007). In the face of all the devastating health consequences, why don’t people quit?

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Nicotine, the active ingredient in cigarettes, is addictive, so smoking is difficult to stop once the habit is established (discussed in the Consciousness chapter). As in other forms of self-regulation, the resolve to quit smoking is fragile and seems to break down under stress. In the months following 9/11, for example, cigarette sales jumped 13% in Massachusetts (Phillips, 2002). And for some time after quitting, exsmokers remain sensitive to cues in the environment: Eating or drinking, a bad mood, anxiety, or just seeing someone else smoking is enough to make them want a cigarette (Shiffman et al., 1996). The good news is that the urge decreases and people become less likely to relapse the longer they’ve been away from nicotine.

Psychological programs and techniques to help people kick the habit include nicotine replacement systems such as gum and skin patches, counseling programs, and hypnosis, but these programs are not always successful. Trying again and again in different ways is apparently the best approach (Schachter, 1982). After all, to quit smoking forever, you only need to quit one more time than you start up. But like the self-regulation of eating and sexuality, the self-regulation of smoking can require effort and thought. The ancient Greeks blamed self-control problems on akrasia (weakness of will). Modern psychology focuses less on blaming a person’s character for poor self-regulation and points instead toward the difficulty of the task. Keeping healthy by behaving in healthy ways is one of the great challenges of life (see Other Voices box).

OTHER VOICES: Freedom to Be Unhealthy?

Robert H. Frank is an economics professor at the Johnson Graduate School of Management at Cornell University.

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In the chapter on Emotion and Motivation you learned about the health benefits and risks associated with what you eat. In this chapter, you learned that what you do (Do you exercise?) and what you think (Are you an optimist?) also can influence your experience of stress and health. The research is clear that people who eat right and exercise regularly have better mental and physical health outcomes. Is it our business, then, to try to get people to eat better and exercise more?

The mayor of New York City, Michael Bloomberg, recently advocated for a tax on large, sugary drinks, which has been nicknamed the “soda tax.” Some have praised this idea, believing that it is our responsibility to structure society in a way that improves the health of our citizens, and especially our children. Others have criticized this initiative, arguing that we live in a free country and people should be free to drink all of the soda and avoid all of the exercise they want. Economist Robert Frank recently weighed in on this issue, considering the pros and cons of a soda tax.

On narrow technical grounds, a New York State court recently rejected Mayor Michael R. Bloomberg’s proposed curbs on large sodas and other sugary drinks. The ruling is being appealed, but many people who viewed the proposal as a step down a slippery slope to a nanny state were quick to celebrate the court’s move. Beyond questioning the mayor’s legal authority to impose a 16-ounce limit on the size of sugary beverages sold in certain places, critics objected on philosophical grounds, arguing that people should be free to make such choices for themselves.

But while almost everyone celebrates freedom in the abstract, defending one cherished freedom often requires sacrificing another. Whatever the flaws in Mr. Bloomberg’s proposal, it sprang from an entirely commendable concern: a desire to protect parents’ freedom to raise healthy children.

Being free to do something doesn’t just mean being legally permitted to do it. It also means having a reasonable prospect of being able to do it. Parents don’t want their children to become obese, or to suffer the grave consequences of diet-induced diabetes. Yet our current social environment encourages heavy consumption of sugary soft drinks, making such outcomes much more likely. So that environment clearly limits parents’ freedom to achieve an eminently laudable goal.

The mayor’s critics want to protect their own freedom to consume soft drinks in 32-ounce containers. But pro-freedom slogans provide no guidance about what to do when specific freedoms are in conflict, as they are here. Nor do they alert us to the possibility that taxes or other alternative policies often render such tough choices unnecessary. Sensible policy decisions spring less reliably from slogans than from careful assessment of the pros and cons of the relevant alternatives.

Does frequent exposure to supersize sodas really limit parents’ freedom to raise healthy children? There’s room for skepticism, because people often believe that they’re not much influenced by others’ opinions and behavior. But believing doesn’t make it so.

As an Illinois state legislator in 1842, Abraham Lincoln deftly illustrated the absurdity of this particular conceit: “Let me ask the man who could maintain this position most stiffly, what compensation he will accept to go to church some Sunday and sit during the sermon with his wife’s bonnet upon his head?” Most men, Lincoln conjectured, would demand a considerable sum—not because wearing a woman’s bonnet would be illegal or immoral, obviously, but just because it would be so unseemly.

Even those who concede the obvious power of the social environment have little reason to worry about how their own choices might alter it. Collectively, however, our choices can profoundly transform the environment, often in ways that cause serious problems. And that makes the social environment an object of legitimate public concern.

Imagine a society like the United States before 1964, where unregulated individual choices produced high percentages of smokers in the population—more than 50 percent among adult men. Not even the staunchest libertarians should deny that their children would be more likely to become smokers in such an environment.

Smokers harm not only themselves and those who inhale secondhand smoke but also those who simply want their children to grow up to be nonsmokers. People can urge their children to ignore peer influences, of course, but that’s often a losing battle.

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No rational deliberation about smoking policies can ignore the fact that smoking harms others in this way. Such considerations helped give rise to a variety of policies that discourage smoking. In New York City, for example, smoking is no longer permitted in many public places, and state and city taxes on a pack of cigarettes are now near $6.

Such policies have reduced the national smoking rate by more than half since 1965, making it much easier for parents to raise their children to be nonsmokers. That’s an enormous benefit. Opponents of smoking restrictions must be prepared to show that those adversely affected by them suffer harm that outweighs that benefit. Given that the overwhelming majority of smokers themselves regret having taken up the habit, that’s a tall order.

Parallel arguments apply to sugary drinks. Unless we’re prepared to deny, against all evidence, that the environment powerfully influences children’s choices, we’re forced to conclude that rejecting Mr. Bloomberg’s proposal significantly curtails parents’ freedom to achieve the perfectly reasonable goal of raising healthy children. Why should opponents of the mayor’s proposal be permitted to limit parents’ freedom in this way, merely to spare themselves the trivial inconvenience of having to order a second 16-ounce soda?

Fortunately, society’s legitimate interest in the social environment needn’t be expressed by means of invasive prohibitions. The public policy goal that prompted the mayor’s proposal could also be served in more direct and less intrusive ways.

For example, we could tax sugary soft drinks. In 2010, the mayor himself praised a proposal for a penny-per-ounce tax on soda in New York State; the idea was dropped after heavy opposition from the beverage industry.

The case for reintroducing such a proposal is strong. We have to tax something, after all, and taxing soft drinks would let us reduce taxes now imposed on manifestly useful activities. At the federal level, for example, a tax on soda would permit a reduction in the payroll tax, which would encourage businesses to hire more workers.

Just as few smokers are glad that they smoke, few people go to their graves wishing that they and their loved ones had drunk more sugary soft drinks. Evidence suggests that the current high volume of soft-drink consumption has generated enormous social costs. So to those who have lobbied successfully against a soda tax, I pose a simple question: How do the benefits of your right to drink tax-free sodas outweigh the substantial costs of defending it?

Where do you stand? The research described in this textbook makes clear that healthier eating and behavior lead to better health outcomes—benefiting both the individual and society more generally in the form of greater productivity and lower health costs due to later illness. But does the government really have the right to penalize people for choosing to drink soda and other sugary drinks? On the other hand, does it really impinge upon people’s freedom to be charged a few more cents for drinks that are bad for them (and costlier to society in the form of health expenses)? How should the science of human health and behavior be used to influence actual human health and behavior?

From the New York Times, March 23, 2013 © 2013 The New York Times. All rights reserved. Used by permission and protected by the Copyright Laws of the United States. The printing, copying, redistribution, or retransmission of this Content without express written permission prohibited. http://www.nytimes.com/2013/03/24/business/soda-restrictions-and-a-clash-of-two-freedoms.html