The Many Facets of Personal Development

The Personal Development circle involves all the ways that you can grow as a person.  It focuses on how you spend your time and energy during the day, and how you invest in what matters most to you.  The possibilities seem almost endless for ways Veterans can choose to focus on Personal Development when they are creating their Personal Health Plans (PHPs).  Working with Whole Health Partners and Coaches can certainly support Personal Development.  What are some other possibilities?

One option is to look at the “subtopics” related to the Personal Development self-care circle, as shown in Figure 7-1.  The subtopics were created for the self-care skill-building courses for Veterans, introduced in Chapter 5.  These subtopics encourage Veterans to think about options and focus in on which ones they want to use in their PHP.  Note that there is a “Make One Small Change” circle that leaves room for creativity, if Veterans do not see an option that interests them. 

This chapter will review 12 well-researched items, tied in with these circles, that can be considered when Personal Development is the focus:^[i]

1. Improve the Quality of Your Work Life 2. Foster Resilience 3. Increase Happiness 4. Cultivate Hope and Optimism 5. Develop Self-Compassion 6. Commit Random Acts of Kindness

7. Enhance Humor and Laughter 8. Build Creativity 9. Balance (Integrate) Work and Other Areas of Life 10. Explore Lifelong Learning 11. Volunteer 12. Improve Financial Health

Questions to Ask About Personal Development

These are just a few of the questions you might consider when you discuss Personal Development during personal health planning:

• What do you do during the day?
• Describe a typical day (at home or at work or both).
• Do you work outside the home? Where do you work?
• What sort of work did you do before you retired?
• How is your relationship with your co-workers?
• How do you feel about the amount of time you work? Is work balanced well with other aspects of your life?
• Do you enjoy your work?
• Is your work fulfilling?
• To what extent are you defined by our job?
• Is your job an expression of who you are?
• Do you have the job you want? If not, what is your ideal job?
• What are your greatest strengths? What has enabled you to make it this far?
• What gives you the strength to take on life’s burdens?
• What would help you to handle life’s challenges better?
• Who are your role models?
• Are you happy? What makes you happy?
• Are you hopeful about the future?
• Are you an optimist or a pessimist?
• Are you kind to yourself?
• How many times a day do you laugh?
• What do you do well?
• What would you like to learn more about?
• Do you do any volunteer work?
• What are you most proud of?
• What is your greatest talent?
• What creative and artistic pursuits do you enjoy?
• Is there anyone you feel you need to forgive?
• What are you grateful for?  What are your blessings?

Fourteen Key Elements of Personal Development

Most people spend over a third of their adult lives working.  We know Quality of Work Life (QWL) is important to health and discussing it can be an important aspect of personal health planning.  Improving job satisfaction, preventing workplace injuries, reducing work stress, improving relationships, and feeling that one’s work is meaningful are important contributors to health.⁸⁷ 

A large 2017 review of 37 studies found that high job demands, low control, high effort with little reward, bullying, role stress, and low social support are tied to a higher risk of developing common mental health problems.⁸⁸  Recent studies have also linked shift work to poorer health.  For the nearly 25% of people who do shift work, there are significant negative effects on sleep, substance use, cognitive function, mood (anxiety and depression), quality of life, and workplace safety and in a different 2023 study looking at U.S.⁸⁹ For manufacturing jobs, it was found younger, male, Hispanic or Black workers were disproportionately working more rotating shifts potentially resulting in health disparities.⁹⁰

 

A 1997 study of nurses found that the following workplace characteristics favorably influenced QWL.^[i]

• Autonomy. It is important to have some control over one’s work experiences.
• Low levels of stress. Chapter 12, “Power of the Mind” covers several options that might help with stress management.
• Good relations with supervisors.
• Low levels of role conflict. Everyone should be clear on their responsibilities.
• Appropriate feedback on performance. Good feedback is timely, constructive, and focused on personal and professional growth.
• Opportunities for advancement. What is a person’s long-term trajectory at work?
• Fair pay. Is a person receiving a salary comparable to others doing the same work?

In nursing, better QWL is tied to lower burnout rates, better working environments, and fewer injuries on the job.  They are tied to better patient outcomes as well.^[ii]  For some, “work life” might include working at home, doing volunteer work, or doing childcare.  Regardless of what sort of work a person does, discussing QWL can be helpful. 

Burnout

Burnout due to work can happen to anyone, and for people in the helping professions, it is a particularly high risk.  In Medscape’s Physician Burnout and Depression Report 2024, for example, a survey of 9,226 physicians across 29 different specialties, found that 49% of them were burnt out.^[iii]  In addition, as many as 60% of psychologists also struggle with burnout.^[iv]  A 2005 study of 751 practicing social workers found a current burnout rate of 39% and a lifetime rate of 75%.^[v]  In a survey of 257 RN’s, 63% reported burnout.^[vi]  In a 2018 meta-analysis of 21 studies focused on nurses, rates of compassion fatigue and burnout were 53% and 52%.^[vii]  A 2022 Gallup Poll found that 44% of American K-12 teachers reported burnout, and the rate was 35% for those teaching at the college level.⁹¹  At least 19% of police officers had at least one aspect of burnout.⁹²  Lawyers, first responders, clergy and many others are also at risk. 

For health care workers, burnout occurs in part because of poor QWL due to excess bureaucratic challenges and long hours (these were the main causes noted in the Medscape Survey)4 as well as workload, loss of autonomy, administrative burdens, and challenges balancing work demands with other aspects of life.^[viii]  Perfectionism, lack of stress-coping skills, unhealthy personal habits (such as substance use disorder), poor relationships with colleagues, poor self-care, and difficult patients can also contribute.^[ix],[x]  Burnout also affects teachers, lawyers, mental health professionals, social workers, and many other groups.  The Maslach Burnout Inventory (MBI) is a commonly used tool to assess burnout and measures three main aspects:⁹³

1. Emotional exhaustion
2. Cynicism and depersonalization
3. A sense of low personal accomplishment

Many burnout questionnaires are used in the research, but burnout can quickly be assessed using two questions.  They are worth asking routinely and include^[xi]:

1. Do you feel burned out or emotionally depleted by your work?
2. Have you become more callous toward people since taking this job—treating patients and colleagues as objects instead of people?

Burnout has been found to improve with various interventions, including mindfulness training.  In 2009, Krasner and colleagues³ evaluated how a course on mindful communication, offered to a group of 70 primary care physicians, improved all 3 aspects of burnout.^[xii]  A University of Wisconsin group conducted a pilot study that provided abbreviated, tailored mindfulness training (18 hours) to 30 primary care clinicians.^[xiii]  Data at nine months post-intervention showed statistically significant improvements in measures of job burnout, depression, anxiety, and stress.  Another study of 93 different types of health care clinicians, including nurses, social workers, and psychologists, also found that all three subscales of the Maslach Burnout Inventory (MBI) improved for participants after they took an eight-week Mindfulness-Based Stress Reduction course.^[xiv]  Recent studies indicate that mindfulness meditation is helpful to decrease stress and burnout in nurses and that loving-kindness and compassion meditation (in a review of 327 studies) decreased burnout in people working in many different types of jobs.^94,95  Positive psychology interventions also reduce burnout and stress, according to a study of health care workers.⁹⁶

Burnout can be reduced if a person has greater individual autonomy, a stronger sense of balance between work and other obligations, strong relationships with colleagues, and a sense of shared values at work.  It helps if support for burnout reduction is offered at an institutional level.^[xv]  Physical well-being, clinical variety (for health care professionals), boundary setting, realistic expectations, and feeling passion for one’s work can help people cope.  It is NEVER helpful to place the blame for burnout on the person who is experiencing it.  Some employers and institutions mistakenly do so.  Do not blame the victim.

The VHA’s goal for employees is to thrive and find purpose, fulfillment, and joy in their work while serving Veterans, their families, caregivers and survivors. In response to employee feedback, the VHA is implementing the REBOOT Initiative which stands for Reduce Employee Burnout and Optimize Organizational Thriving.  There are 7 priority focus areas:

• Implement Chief Clinician Wellbeing Officer
• Optimize Meeting Practices
• Optimize TMS Education and Training
• Strengthen Mental Health Support
• Address inefficiencies
• Maximize use of HR policies/Flexibilities
• Strengthen Culture of Servant Leadership
• Implement Chief Clinician Wellbeing Officer (CWO): The CWO’s role would be to engage, advocate for, and foster wellbeing among clinical staff.
• Optimize meeting practices: Encourage and incentivize the use of effective meeting practices, including the frequency and length of meetings.
• Optimize TMS education and training: Streamline approaches for employees to gain vital education and training, such as the use of test-out options.
• Strengthen mental health support: Increase investments in mental health resources, ensuring employees know what resources are available and how to ask for support.
• Address inefficiencies: Empower and reward leaders and teams at all levels to identify and eliminate inefficiencies to enhance the work environment for all staff.
• Maximize use of HR policies/flexibilities: Encourage and actively use all available HR flexibilities to boost employee wellbeing, retention, and recruitment efforts.
• Strengthen culture of servant leadership: Increase the practice of servant leadership principles (i.e., leaders strive to serve and support others) at all levels of the VHA organization.

“Employee Wellbeing is identifying ways to address employee mental health (fatigue, stress, low morale) by creating a culture of well-being. The workstream is working on ways to promote healthy work-life integration through a whole health approach, supporting employee wellbeing and strengthening VA’s supervisor and leadership culture to support employee wellbeing.” 

One simple method for decreasing burnout is the following exercise.  Have Veterans give it a try, and give it a try yourself.

End of the Day Exercise At the end of each day, on the way home from work, after dinner, or before you go to bed, ask yourself the following three questions: What did I learn today, and how will that change what I do tomorrow? What am I grateful for? Try to list at least 3 things. What do I need right now to take care of myself? Anything you do  to reduce burnout is a positive step in the direction of Whole Health.  Burnout is the “shadow side” of resilience, which is another fundamental aspect of personal development, for patients and clinicians alike.[i]

2.  Foster Resilience

Resilience involves being able to adapt to changing environments, identify opportunities, adapt to constraints, and bounce back from misfortunes and challenges.^[i]  Figure 7-2 is the Circle of Resilience, which explores how the Circle of Health might relate to fostering resilience. 

Anything that can foster resilience can be an invaluable part of a PHP, but how do we foster resilience?  Cultivating positive emotions can help with our adaptability in the face of change or disruption.  It has been noted that resilient people have negative emotions just as much as other people, but they generate many more positive emotions compared to those who are less resilient. 

Resilience-related research continues to expand.  Increased attention is being paid to Veterans’ experiences with post-traumatic growth (PTG), which includes the positive psychological changes that can occur as a result of a struggle with trauma.^[ii]  In Veterans, PTG was found to be independently associated with higher mental, cognitive, and psychosocial functioning.⁹⁷  It is linked to many positive changes, including self-confidence, flexibility, openness in relationships, and greater appreciation of what life has to offer.⁹⁸ 

Grit, described as a person’s passion and perseverance in attaining long-term goals, has been a focus of research in recent years.^99,100  The neurobiology of resilience is also garnering increased attention.^[iii],[iv]

 

The following are tips for increasing resilience in three different areas.  They can be used by patients and clinicians alike.  Many tie in with other parts of the Circle of Health as well.¹

1.  Attitudes and Perspectives

• Find a sense of meaning related to the work you do.
• Foster a sense of contribution.
• Stay interested in your roles.
• Accept professional demands.
• Come to terms with personal concerns (self-acceptance) and confront perfectionism.
• Work with thinking patterns.
• Develop a health philosophy for dealing with suffering and death.
• Exercise self-compassion.
• Give up the notion that you have to figure everything out.
• Practice mindful awareness.
• Interject creativity into work; consider an array of different therapeutic options, as appropriate.
• Treat everyone you see as though they were sent to teach you something important.
• Identify what energizes you and what drains you, seeking out the former.

2.  Balance and Priorities

• Be aware of both personal and work goals.
• Balance work life and other aspects of life effectively.
• Set appropriate limits.
• Maintain professional development.
• Honor yourself.
• Find time for recreation.
• Take regular vacations.
• Engage in community activities.
• Experience the arts.
• Cultivate a spiritual practice.
• Budget your time just as you might your finances, planning ahead when possible.

3.  Supportive Relations

• Seek and offer peer support.
• Network with peers.
• Find a supportive mentor or role model.
• See your primary care provider.
• Consider having your own psychologist or counselor.
• Nurture healthy family, friend, and partner relationships.

Studies indicate that specific interventions can be used to improve resilience, especially when targeted to people who have low resilience at baseline.¹⁰¹  Even digital interventions show some benefit.¹⁰²  Resilience can be increased through a number of means for people with cancer, children, older adults, and many other demographic groups.^103-105

3.  Increase Happiness

An important question to ask when using the Whole Health approach is simply, “Are you happy?”  Fostering happiness has, as you would expect, numerous benefits.^[i]  There are three main aspects of happiness that are described in psychology research.1

1. The pleasant life (positive emotions and pleasure).
2. The engaged life (pursuing work, relationships, and leisure).
3. The meaningful life (life has meaning, and one serves something one believes is bigger than oneself). This ties into the question of “what really matters.”  It can also tie into someone’s spirituality, as discussed in Chapter 11.

People who pursue all three aspects are the most satisfied,^[ii] and the meaningful life has the most impact.  (This ties in nicely with the way the Whole Health approach encourages a close look at what matters most to people.)  Happier people are more successful, more socially engaged, and healthier.^[iii]  People are happiest if they can identify and use their signature strengths.^[iv]  Family support is strongly linked to happiness as well.¹⁰⁶  Studies show that happiness is linked to positive outcomes such as financial success, supportive relationships, mental health, effective coping, physical health, and longevity.18^,107  What people see as contributing to a good life, a happy life, varies from person to person and changes based on phase of life.^108,109

It is important to remind people that the pursuit of happiness can be misdirected; people who equate money with happiness, for example, may end up less happy.^[v]  Ideally, happiness is one of an entire spectrum of healthy emotions people experience, when appropriate.  Happiness is a complex concept; a 2023 review, focused on countries and cultures from around the world, classed the determinants of happiness under 3 main categories of 1) Health, 2) Hope and 3) Harmony.¹¹⁰  There were multiple aspects of happiness sorted into those 3 areas. 

It is helpful, as part of the Whole Health approach, to explore on an individualized basis what brings a person happiness and how enhancing health might lead to a happier life for them.  A 2022 review concluded that “programs for mindfulness, contemplation, or stress reduction, including positive psychology and mind-body/behavioral medicine training, seem to be capable of influencing...happiness over time.”  In other words, it is possible to use various practices to enhance happiness. 

4.  Cultivate Hope and Optimism

The definition of hope involves three components.  These include the following:

1. Having goals related to a situation.
2. Believing you have the ability to reach those goals.
3. Sensing you can know the path to follow in order to achieve your goals in any situation. 

Hope, which is closely tied to resilience, is linked to a relatively stronger sense that life is meaningful,^[i] as well as to more positive emotions and productivity at work.  Optimism is a more general term, based around the idea that positive things will happen in the future.¹¹¹ 

Hope has been found to have numerous health benefits.¹¹²  Hope has been linked to favorable outcomes for cancer patients and may be influenced not only by personality characteristics and the environment, but also by a person’s physiology.¹¹³  It is important to palliative care patients, and has a potential benefit for people with chronic pain and other chronic illnesses.^114,115  Hope offers people a sense that life is meaningful and is linked to more positive emotions overall.¹¹⁶ In addition, it has significant potential benefit for helping people with mental health problems.¹¹⁷

Optimism has been linked to taking more proactive steps for one’s health, more effective coping, better physical health, and better socioeconomic status.  It is associated with persistence with educational pursuits, better income, and stronger relationships.^[ii]  Higher levels optimism correlate with decreased pain sensitivity and better adjustment to chronic pain as well.^[iii]  Optimism also has a positive effect on depression outcomes in young adults.¹¹⁸  A 2022 systematic review and meta-analysis found that optimism is associated with a lower risk of cardiovascular events and all-cause mortality,^[iv]  and it is linked to better outcomes following coronary artery bypass graft surgery.¹¹⁹

With practice, people can learn to be more hopeful and optimistic.¹²⁰  Hope Therapy exists as a specific protocol which has shown benefits for people in individual and group therapy settings.¹²¹  Mind-body skills training can be helpful in cultivating optimism, as noted in Chapter 12, “Power of the Mind.”  We are beginning to understand more about  the neurobiology of optimism, which may help us to cultivate it in ourselves and others even more effectively.¹²²

5.  Develop Self-Compassion

Self-compassion involves directing care, kindness, and compassion toward oneself.  It has six main elements:¹²³

1. Self-kindness, which includes positive self-talk, treating oneself well when something goes wrong, and not focusing criticism and anger at oneself
2. Common humanity, the recognition that one’s experiences are common to human beings and you are not alone
3. Mindfulness, which allows a balanced perspective and the ability to work skillfully with one’s thoughts and emotions.
4. Reduced self-judgment
5. Decreased isolation
6. Lower levels of overidentification

Mindful awareness is closely linked to self-compassion.  One of the mindful awareness practices featured in Chapter 10 is the loving-kindness meditation.  This practice begins by wishing oneself well.  After that, you extend the compassion out to others.  The practice also concludes with a moment of self-compassion.  It is not uncommon for compassion-based meditations to begin with focusing on self-compassion as the beginning and ending points of cultivating compassion for others.  Self-compassion can also be cultivated through dynamic psychotherapy and compassion-focused therapy, including the Mindful Self-Compassion course.¹²³  Online trainings focused on increasing self-compassion have also shown promise.¹²⁴

Research indicates that having more self-compassion is linked to optimism and happiness, as well as ? more successful romantic relationships and overall well-being.^[i],[ii]  Having more self-compassion is linked to greater levels of resilience.^[iii]  Self-compassion interventions reduce secondary traumatic stress in health care workers.¹²⁵  A 2011 meta-analysis of 20 different studies found a large effect size (should this just be large effect? Not sure large effect size) when self-compassion was used to treat stress, anxiety, and depression.^[iv]  *A 2020 systematic review also found benefits for anxiety, depression, stress, as well as for diabetes outcomes, such as  (lower)A1c levels.¹²⁶   It may reduce the likelihood of suicidal thoughts and self-harm as well.^[v]  Self-compassion was linked to having more happiness, optimism, curiosity, wisdom, exploration, and emotional intelligence, in addition to other qualities.34  It is also linked to better self-care and lower levels of negative affect.^[vi],[vii] 

Self-compassion is associated with other health benefits as well.  It is linked to well-being outcomes in older adults.^[viii]  A 2020 systematic review concluded that focusing on and using one’s strengths improved psychological well-being in people with chronic illness.^[ix]  Self-compassion is associated with lower levels of subclinical cardiovascular disease as well.¹²⁷  Building self-compassion is helpful for weight management, and shows promise in the treatment of PTSD, autism, eating disorders, low back pain, and insomnia, in addition to many other potential roles.^128-133

6.  Commit Random Acts of Kindness

Random acts of kindness (ROKs) involve doing something for an unknown person that you hope will benefit them.^[i]  Examples might include paying for the order of the person behind you at the drive through restaurant, holding the door for someone, leaving a kind note on someone’s car, or putting money in someone’s expired parking meter.  You can offer a stranger a flower, or write a kind note to someone about something you appreciate.  People can search “Random Acts of Kindness” online and find hundreds of other suggestions.  ROKs are linked to greater life satisfaction^[ii] and greater happiness.24^,134  Functional MRI studies indicate that imagining kindness activates the emotional regulation system of the brain.  More research is needed to gauge the degree of benefit that ROKs have, and in what situations.¹³⁵

Kindness can become a self-reinforcing habit that becomes easier over time as neural connections build in a positive way.^[iii]  Encourage Veterans to give them a try.  It can help to strategize in advance about what specific acts of kindness one could perform.  Some research indicates that people underestimate the value their acts of kindness will have on others.¹³⁶  Keep this in mind as you encourage people to incorporate ROKs into their health plans.

7.  Enhance Humor and Laughter

In the 1970s, word spread that journalist Norman Cousins had improved his symptoms of ankylosing spondylitis using humor.^[i]  Laughter affects us in many positive ways.^[ii]  It increases our pulse and breathing rates, enhances oxygen use, and decreases blood vessel resistance, all of which can be beneficial.  After we laugh, we feel more relaxed.  10-15 minutes of laughter daily can burn 10-40 extra calories.  Intense laughter relaxes muscle tone.  Humor seems to calm down the sympathetic nervous system, which is responsible for the ‘fight or flight’ response.  It lowers stress hormone levels, bumps up endorphins (the feel-good chemicals in the body) and helps immune system function. 

In terms of specific illnesses, laughter44:

• Decreases anxiety
• Lowers heart attack risk in high-risk diabetics
• Increases good cholesterol (HDL)
• Is linked to lower coronary heart disease and reduced arrhythmias and recurrent heart attacks for people in cardiac rehabilitation
• Increases pain tolerance
• Decreases body inflammation
• Relaxes the airways
• Reduces allergic reactions

The quantity of research on humor and laughter and their effects on health has grown dramatically in recent years.  Recent research indicates that humor is favorably linked to quality of life in people with chronic diseases.¹³⁷  Studies have found benefits from simulated laughter experiences (laughter yoga and laughter therapy) can have  positive effects in many circumstances.  It has been found to be useful in people receiving  palliative care, hemodialysis or cancer treatment, as well as those who have schizophrenia, obesity, type 2 diabetes, anxiety, depression, fecal ostomies, pregnancy symptoms (what is a pregnancy symptom? I.e. nausea? We might need to explain ], or an array of other health challenges.  For more details about studies of laughter and humor for these indications, see the Personal Development overview on the VA Whole Health Library.

The great thing about laughter is that there are many ways to make it happen.  Be sure to mention it to people during personal health planning, as appropriate, so they know it ‘counts’ as something they can do for their Whole Health.  Build up your own repository of jokes to use with patients, as appropriate.  (Contrary to popular belief, “Dad jokes” are not hazardous to one’s health!)  For more ideas on how to build your skills related to laughter medicine, including training in Laughter Yoga, refer to the Resources section at the end of this chapter. 

8.  Build Creativity

The American Psychological Association defines creativity as “...the ability to produce or develop original work, theories, techniques, or thoughts,” noting that creative individuals show expressiveness, imagination, and originality and can innovate in a variety of ways.¹³⁸  Creativity has many domains, or aspects; attitudes, skills, knowledge, motivations, and personality traits are all factors that lead to creative thinking and behavior.^[i]  We are just beginning to understand the neuronal basis of creativity.¹³⁹

It can be helpful to explore what creative pursuits someone enjoys, because that can help guide personal health planning recommendations.  Many creative activities can help a person relax, not to mention engage them socially.  Creativity is likely linked to well-being in the elderly.¹⁴⁰  The many benefits of creative art therapies are discussed in Chapter 12.  More studies focused on the health benefits of other types of creativity are needed. 

We  know creativity is enhanced by being in a supportive environment, having control over aspects of your life, and having internal motivation.^[ii]  Creativity engages  problem solving as well as the generation of new ideas.49  It can be enhanced through meditation.^[iii],141  Research suggests that creativity can be fostered by keeping a verbal or written record of ideas, putting yourself in novel and interesting circumstances, learning something outside your area of expertise, seeking out challenging tasks, or “sleeping on” tough problems.^[iv]

Encourage people to explore a variety of ways they could potentially make use of their creativity.  Examples range from writing or making art to building something,  performing  improv comedy, solving puzzles, or doing various crafts. 

9.  Balance (Integrate) Work and Other Areas of Life

Of course, not everyone is employed, but for those who are, many struggle with the age-old challenge of having their work responsibilities balance with other aspects of their lives. Most of the literature on this topic can be searched using the term “Work-Life Balance.”  However, this term implies that work is not a part of “life,” or perhaps that work must be time spent doing something negative, which is not true for many people.  As Swiss philosopher Alain de Botton put it, “There is no such thing as work-life balance.  Everything worth fighting for unbalances your life.”^[i]  Recently, people have begun to use the terms “work-life integration,” “work-life interface,” or even “work-life blend,” given that it is now possible, with technology, to take work with us wherever we go.  Perhaps the true focus is how you maintain an overall sense of harmony in your life. 

However you describe it, it is important to be aware of the following about the balance/integration of work and other aspects of life^[ii]:

• Balance is an important contributor to satisfaction and well-being for everyone; without it, quality of life and overall life satisfaction are adversely affected.^[iii] Lack of balance has been found to be associated with impaired mental health, family conflict, reduced job and life satisfaction, and burnout.¹⁴²  Resilience is decreased when there is work-life conflict.¹⁴³
• Work-life balance has been said to include three forms of balance, all of which are important:

1. Time balance—how much time is devoted to different activities.
2. Satisfaction balance—how much satisfaction different parts of your life give you.
3. Involvement balance—how much you engage in various responsibilities. It is not merely about balancing time; it is about being committed and present during the various aspects of your life.

 

The following tips can help people find more balance^,[iv],53,144:

1. Allow for This is not something you just plan; it is like walking across a stream on slippery rocks.  You have to keep reassessing and changing course.
2. Set boundaries. Respect your personal time, including while on leave, and prioritize your own self-care.  Take breaks during the day.  Find time for hobbies.
3. Ensure that every day you accomplish something. AND every day, be sure you find joy or fun.  AND every day, connect with another person in a positive way.  Ask yourself from time to time if your work feels meaningful.
4. Do not be trapped by delayed gratification. Allow yourself to experience positive aspects of life regularly.  Do not spend your time waiting until the next task is completed to enjoy your life.  Ideally, find ways to make the tasks enjoyable too. 
5. Check in with others for a perspective on how balanced you are. You may be enduring more than you realize or working harder than you think.  It can help to curate your own support circle, with people who inspire you and support you in reaching your goals.  It can help to have mentors who check in with you about how it is going with staying balanced.
6. Share experiences with others—friends, loved ones, and colleagues.
7. Advocate for institutional changes at work if there are threats to employees’ balance. Many experts note that work-life balance, like burnout, must be addressed not only at the individual level, but also at organizational and system levels.¹⁴⁵
8. Explore working from home. People who work from home report not only a higher level of work satisfaction, but also report improved work-life balance.¹⁴⁶

For more information, go to the Whole Health tools, “Work-Life Integration: Tips and Resources” and “Workaholism.” 

10.  Explore Lifelong Learning

Research shows education is a powerful influence on health and well-being.  It is linked to midlife cognitive abilities (how well you think as you age),^[i] as well as longer telomere length.^[ii]  Telomeres are areas on the ends of chromosomes; the longer they are, the lower a person’s risk of chronic disease and death.  More education corresponds with lower risk of mortality.^[iii]  Higher education is one of the most effective ways to raise family income.^[iv]  Education seems to decrease stress and slow aging, too.^[v]  Lifelong learning keeps us up to date in an era when technology and research are constantly advancing.  It can involve taking courses, completing a GED or degree program, working with vocational rehabilitation experts, or deciding how often to read up on new discoveries and innovations. 

Lifelong learning can also involve cultivating various life skills.  Research indicates life skills are important to health.  For example, a 2017 study of over 8,100 men and women over age 52 found that having five key life skills—conscientiousness, emotional stability, determination, control, and optimism—was favorably linked to wealth, income, mood, social connection, (lower)?incidence of a number of chronic diseases, activities of daily living, walking speed, (decreased )obesity, and ( improved?)self-rated health and well-being.^[vi]  Even lab results, like HDL cholesterol, vitamin D, and C-reactive protein were significantly better.  No one skill was responsible; it was having a combination of various skills that made the most difference.  Precision education (tailoring education to the specific characteristics of an individual learner- is transforming lifelong learning by making learning more personalized, efficient, and manageable, with just-in-time learning interventions and careful measurement of outcomes.¹⁴⁷

A lifelong learner ^[vii]:

• Is flexible
• Reflects on what has been learned
• Is aware of the need for lifelong learning
• Requests feedback
• Is able to share what has been learned
• Is highly motivated
• Clearly sees how to use what has been learned and apply it in daily life
• Is aware of resources that can help with making future improvements

Encourage Veterans to think about learning and how they would like to approach it .  Frame it in terms of work and financial well-being as well.  Vocational rehabilitation can be a great resource in many VA facilities.^[viii],[ix]

11.  Volunteer

In 2023 about 63 million people volunteered regularly (how often is “regularly”).  This is nearly 25% of the U.S. population.¹⁴⁸  In 2019, the value of volunteer work was estimated to be over  $167 billion.^[i]  At the height of the pandemic, 51% of the US population over age 16 reported helping their neighbors.¹⁴⁹  Veterans volunteer more than the general population.¹⁴⁸ 

The strong presence of volunteer programs in VA programs is not only health-promoting for the recipients of the volunteers’ efforts, but also for the volunteers themselves.  An umbrella review of 28 individual reviews found volunteering has social, mental, physical, and general health benefits.¹⁵⁰  More specifically, volunteering^{[ii],[iii],[iv],[v],[vi],[vii]}:

• Increases longevity
• Improves functional ability
• Lowers rates of depression, frailty, and loneliness in the elderly
• Decreases heart disease incidence and correlates with lower blood pressure levels
• Improves mental health and life satisfaction, as well as quality of life
• Increases a sense of personal accomplishment
• Enhances social connections
• Increases well-being for people with chronic illnesses compared to medical care alone
• Protects against cognitive aging (keeps the brain working well)
• Leads to a “helper’s high” in elderly women volunteers. Some also reported they felt stronger, calmer, and had fewer aches and pains.
• Decreases in inflammation (e.g., levels of C-reactive protein)

Veterans tend to enjoy working with other Veterans.  Encourage them to volunteer, noting that most of the benefits of volunteering do not occur if one simply donates money; personal contact with others is key.  If you do recommend volunteering to someone, it can be helpful to provide them with a list of options.

12.  Improve Financial Health

Financial health refers to the state of a person’s financial life or situation.  It can include the amount of savings people have, how much they spend on fixed expenses like mortgage or rent, or their ability to stay out of debt.1  Financial literacy, the ability to make informed judgments and manage money, is also important.^[i]

Ask Veterans about their financial health and revisit your own periodically too.  Remember that debt may cause some people to avoid health care visits because they cannot afford them. 

What else is there to know about money and health?1

• There is a small but positive link between income and happiness, but that decreases at higher income levels.
• Finances are a significant source of stress for 76% of Americans. Mindful awareness can help to reduce this stress.  Identifying stressors and creating a financial health plan can prove helpful.
• A financial planner may be a helpful member of someone’s Whole Health team.
• Enrolling in a course to build financial skills may be useful.
• Poverty is linked to lower quality of life, impaired social connection, and increased frailty in the elderly.¹⁵¹ It is also associated with biological markers for toxic stress.¹⁵²
• Income can have a direct impact on a person’s ability to attend to areas of self-care. For example, a lower income can lead to fewer food choices, less access to health care, poorer-quality surroundings, and fewer opportunities for personal growth.  When creating a personal health plan, be aware of these challenges.

Income, occupation and education can significantly impact health outcomes.  Individuals with higher incomes generally have healthier lifestyles and improved living conditions as well better access to health care.  When creating a personal health plan, it is important to address social determinants of health SDOH with Veterans so appropriate recommendations can be made.  Additional resources for fostering financial health are available in the Resources section at the end of this chapter.

Whole Health Tool: Forgiveness

What Is Forgiveness?

Forgiveness is a “…freely made choice to give up revenge, resentment, or harsh judgments toward a person who caused a hurt and to strive to respond with generosity, compassion, and kindness toward that person.”^[i]  When used therapeutically, forgiveness is a process—a series of steps to follow.  It is not just an isolated event. 

Forgiveness may also involve the need to forgive ourselves or to request forgiveness from another person for something we have done.  It may also involve accepting a request for forgiveness. 

The following are important points to keep in mind about forgiveness1:

• Forgiveness does not require us to reconcile with the offender and have continued contact. There are times when it is in our best interest to stay away from the offender.
• Forgiveness is a process that can take time; it is not just a decision we make quickly. To forgive generally requires emotional and mental energy on our part.
• To forgive means that we must fully accept what actually happened, how we were hurt, how our lives were affected by the offense, and even how we have changed as a result. This ties in with post-traumatic growth.
• When we do not forgive, we continue to give the negative experiences and the offender power over us. To forgive is to become free to move forward.
• We need never forget what happened; forgiveness does not have to involve forgetting. Despite our continued memory of the event, we nevertheless forgive so as to move from living in the past to living in the present.
• Forgiveness does not relieve offenders of their responsibility. If it is necessary to pursue justice, we can still take the actions that are needed, such as pressing charges, filing complaints, or otherwise appropriately addressing concerns.

How Forgiveness Works

Forgiveness reduces repetitive thoughts (ruminations) that may be begrudging, vengeful, or fearful.  It does NOT condone the behavior or event that caused harm, but rather, it frees the victim of that harm from continuing to suffer after the fact.  It has been said that forgiveness is “…giving up all hope of a better past.”

How to Use It

There are many forgiveness materials and books available to help people move through the forgiveness process.  However, this process could trigger emotions and memories.  It may be helpful to get help from  a licensed mental health professional.

The forgiveness process tends to move through stages.^[i] These include the following:

1. Recognize the need to forgive. Learn how an offense has affected us and how it has continued to preoccupy us.
2. Acknowledge and release emotions.
3. Decide to forgive. Making the decision to forgive is an important step.
4. Change old beliefs and patterns. Gain a deeper understanding and try to experience more empathy and compassion for ourselves and the perpetrator.
5. Emerge into greater wholeness.  Find meaning in the suffering, and recognize suffering is universal.

When to Use Forgiveness

Forgiveness can be used whenever a person needs to work with traumatic past experiences.  A 2019 meta-analysis found 128 studies including a total of more than 58,500 people that showed a positive relationship between forgiveness of others and physical health.^[i]  For example, research shows that it is associated with the following^[ii],153:

• Improved mental health, as well as reduced negative affect and emotions
• Satisfaction with life and, potentially, better psychological health^[iii]
• Fewer physical ailments and somatic complaints, as well as less medication use
• Reduced fatigue and better sleep quality
• Reduced depression, anxiety, and anger; recovery from sexual abuse
• Reduced risk of myocardial ischemia and better cholesterol numbers in patients with coronary artery disease
• Decreased vulnerability to chronic pain and fibromyalgia symptoms
• For people with substance use disorders, a lower likelihood of using illicit drugs
• Better work life if one practices forgiveness with co-workers; productivity, mental health, and physical health improve^[iv]
• A weakened relationship between negative experiences and self-harm (according to self-forgiveness research)35
• Better cognitive function (with self-forgiveness and decreasing one’s hostility)^[v]
• Prevention of adverse childhood experiences. Forgiveness in a parent reduces the chances that their children will have similar experiences.¹⁵⁴

What to Watch Out for (Harms)

Forgiveness is not a process that can be done in a hurry.  It requires time for reflection and, often, time to work with a clinician or coach to move through the emotions and other challenges that come up as one moves through the process.  A person should never be rushed through the stages of forgiveness. 

Tips from Your Whole Health Colleagues

• If you are going to recommend forgiveness to others, become as familiar as you can with the Resources at the end of this chapter.
• This process cannot be rushed. And it is completely worth the time investment.
• Self-forgiveness is also important to explore.^[i] It is linked to decreased risks of suicidal ideation and self-harm.35
• Use the Resources at the end of this chapter to take the process deeper, and if interested, go to the online Whole Health tool, “Forgiveness: The Gift We Give Ourselves.”

Whole Health Tool: Gratitude

What Is Gratitude?

Gratitude is a strong contributor to happiness and well-being.  Gratitude is universal; it is found across all cultures. It shares origins with the word “gratia,” which means grace.  Gratitude  is both an attitude and a practice, closely linked to thankfulness and appreciation.

How Gratitude Works

Gratitude practice is a direct cause of well-being, and it also protects against negative emotions and mental states.  Other  benefits include the following^{[i],[ii],[iii],155-164}:

• Higher levels of self-reported physical health
• Increased happiness, pride, life satisfaction, and hope
• Enhanced social connection and decreased loneliness
• Reduced risk of depression, anxiety, substance use disorders, hopelessness, and suicidal ideation (including for Veterans); increased caregiver self-efficacy
• Improved body image
• Higher likelihood of performing acts of kindness, generosity, and cooperation
• More resilience and better physical health, including cardiovascular and palliative cancer care outcomes
• Better sleep, cognitive function, and energy level
• Decreased prejudice

Gratitude influences our neural networks, including how the brain and heart connect with one another; this is revealed in studies that look for links between heart rate and activation of different parts of the brain on functional MRI.^[iv]  Keeping a gratitude journal leads to more regular exercise, greater optimism, and more alertness, enthusiasm, determination, attentiveness, and energy.  People also become more supportive of others.^[v]  Study participants who wrote about three good things that happened each day and why they happened felt happier and less depressed six months later.25

Gratitude from patients to their care teams also has benefits.  In a study of neonatal ICUs, medical teams performed better when patients’ families expressed gratitude.^[vi]

How to Use It

There are different ways to cultivate gratitude, and the following are just a few examples of exercises you can try yourself or suggest to others.25

Grateful Contemplation Exercise 1: Happy Moment Reflection.  Reflect on a happy moment that stays strong in your memory even though it may have happened years ago.  Relive it, using all your senses.  What about the experience stays with you?  Was gratitude part of it?  Write down your reflections.

Grateful Contemplation Exercise 2: Gratitude Attitude.  Practice having an attitude of gratitude throughout the day.  Think of cues you can use to remind you to be grateful.  Examples might be a phone alarm, starting your commute home, sitting down to a meal (many people “say grace” before meals), or passing through the doorway to a building or room.  Acknowledge—and enjoy—the positive things that happened during your day. 

Grateful Contemplation Exercise 3: A Written Gratitude Practice.  Find a regular time at the end of the day to reflect on the day and write down five things you are grateful for.  Take time to reflect on their value as you write them.  Writing them down is more powerful than just thinking about them.  Consider using a special journal or write what you are grateful for on a piece of paper and put it into a jar.  Consider listing simple everyday things, people in your life, personal strengths, moments of natural beauty, events that make you feel awe, and/or gestures of kindness from others.  Review your list (or open the jar) every so often, perhaps monthly or yearly, as a reminder. 

Grateful Contemplation Exercise 4: Gratitude Visits.25  Write and deliver a letter of gratitude to someone who has been very kind to you but whom you have never properly thanked.  This practice has been found to lead to increased happiness and reduced depression for the person writing the letter (and it helps the recipient too).

When to Use Gratitude

Gratitude practice can be used by anyone.  It may be particularly useful for those who do not routinely feel grateful or struggle with low mood or depression. 

What to Watch Out for (Harms)

Gratitude practices tend to be quite safe.

Tips from Your Whole Health Colleagues

The following tips are from the Whole Health tool “Creating a Gratitude Practice”:

• If you find your gratitude practice is getting stale, mix it up a bit; switch to another format to add to your gratitude ‘tool kit.’.
• Pick one co-worker each day, and express thanks for what they contribute.
• During group meetings (work, community groups, etc.) have each person take a moment to share one thing they are grateful for.
• Take turns going around the dinner table and have each person share one thing they are grateful for that happened that day.
• Express appreciation about what your partner, child, or friend does and who they are as a person.
• Go for a walk with a friend and talk about what you are most grateful for.
• Create an art project that focuses on your blessings and what is going well in your life.
• Write a thank you letter to yourself.
• Give thanks for your body.
• Pause to experience awe and wonder about some aspect of your life.
• Imagine your life without the good things in it, so as not to take them for granted.

Personal Development Resources

Websites

VA Whole Health and Related Sites

• A Patient Centered Approach To: Personal Development. Part of the Components of Health and Well-Being Video Series. https://www.youtube.com/watch?v=sYZfEA5RgNw&feature=youtu.be
• Veterans Whole Health Education Handouts.
  https://www.va.gov/WHOLEHEALTH/veteran-handouts/index.asp

• • An Introduction to Personal Development
  • Finding Balance
  • The Healing Power of Hope and Optimism
  • Create a Gratitude Practice
  • Forgiveness
  • What Matters Most? Exploring Your Values
  • Laughter Heals
• Personal Health Plan Template.  https://www.va.gov/WHOLEHEALTH/docs/PHI_Jan2022_Final_508.pdf
  

Whole Health Library Website

• Personal Development. Overview includes an extensive list of financial health resources.  https://www.va.gov/WHOLEHEALTHLIBRARY/overviews/personal-development.asp
• Values. https://www.va.gov/WHOLEHEALTHLIBRARY/docs/Values.pdf 
• Creating a Gratitude Practice. https://www.va.gov/WHOLEHEALTHLIBRARY/docs/Creating-A-Gratitude-Practice.pdf 
• Forgiveness: The Gift We Give Ourselves. https://www.va.gov/WHOLEHEALTHLIBRARY/docs/Forgiveness.pdf
• The Healing Benefits of Humor and Laughter.
  https://www.va.gov/WHOLEHEALTHLIBRARY/docs/Healing-Benefits-of-Humor-Laughter.pdf

• Taking Breaks: When to Start Moving, and When to Stop.
  https://www.va.gov/WHOLEHEALTHLIBRARY/docs/Taking-Breaks.pdf

• Work-Life Integration: Tips and Resources. https://www.va.gov/WHOLEHEALTHLIBRARY/docs/Work-Life-Integration-Tips-and-Resources.pdf
• Workaholism. https://www.va.gov/WHOLEHEALTHLIBRARY/docs/Workaholism.pdf
  Implementing Whole Health in Your Own Life: Clinician Self-Care.  https://www.va.gov/WHOLEHEALTHLIBRARY/overviews/clinician-self-care.asp

• Self-Management of Chronic Pain. https://www.va.gov/WHOLEHEALTHLIBRARY/professional-care/self-management-chronic-pain.asp
• Whole Health for Skill Building: Personal Development.
  https://www.va.gov/WHOLEHEALTHLIBRARY/courses/whole-health-skill-building.asp

• • Faculty Guide
  • Veteran Handout
  • PowerPoints
  • Mindful Awareness Script: A Mindful Awareness Experience to “Get Your Gratitude On”

Other Websites

• Laughter Yoga International. https://laughteryoga.org/
• Money Management International. Nonprofit agency that provides free education about credit and debt management.  https://www.moneymanagement.org/
• Money Smart. FDIC education program with online financial training materials. https://moneysmartcbi.fdic.gov
• Self-Compassion. Includes practices and other resources.  http://self-compassion.org
• Center for Mindful Self-Compassion. https://centerformsc.org. Training programs for beginners, graduates, and professionals.
• Forgiveness Resources
  • Fetzer Institute. https://fetzer.org/
  • International Forgiveness Institute. https://internationalforgiveness.com/
  • The Forgiveness Project. https://www.theforgivenessproject.com/

Books

• 21 Keys to Work/Life Balance: Unlock Your Full Potential, Michael Sunnarborg (2013)
• A Life at Work: The Joy of Discovering What You Were Born to Do, Thomas Moore (2009)
• Encore: Finding Work that Matters in the Second Half of Life, Marc Freedman (2008)
• Enjoy Every Sandwich: Living Each Day as If It Were Your Last, Lee Lipsenthal (2011) (Dr. Lipsenthal wrote this book shortly before his death from colon cancer.)
• Finding Balance in a Medical Life, Lee Lipsenthal (2007)
• Forgive: Why Should I and How Can I? Timothy Keller (2022)
• Forgive for Good: A Proven Prescription for Health and Happiness, Fred Luskin (2002)
• Forgiveness Is a Choice: A Step by Step Process for Resolving Anger and Restoring Hope, Robert Enright (2001)
• Forgiveness: A Bold Choice for a Peaceful Heart, Robin Casarjian (1992)
• Forgiveness: The Greatest Healer of All, Neale Walsch (1999)
• Hidden Potential: The Science of Achieving Greater Things, Adam Grant (2023)
• Life Is Not Work, Work Is Not Life: Simple Reminders for Finding Balance in a 24-7 World, Walker Smith (2001)
• No Regrets: A Ten-Step Program for Living in the Present and Leaving the Past Behind, Hamilton Beazley (2004)
• Off Balance: Getting Beyond the Work-Life Balance Myth to Personal and Professional Satisfaction, Matthew Kelly (2011)
• Resilience: The Science of Mastering Life’s Greatest Challenges, Steven Southwick (2012)
• Stop Living Your Job, Start Living Your Life: 85 Simple Strategies to Achieve Work/Life Balance, Andrea Molloy (2005)
• Striking a Balance: Work, Family, Life, Robert Drago (2007)
• The Book of Forgiving: The Fourfold Path for Healing Ourselves and Our World, Desmond Tutu (2015)
• The Forgiving Life: A Pathway to Overcoming Resentment and Creating a Legacy of Love, Robert Enright (2012)
• The Good Enough Job: Reclaiming Life from Work, Simone Stolzoff (2023)
• The Gratitude Project: How the Science of Thankfulness Can Rewire Our Brains for Resilience, Optimism, and the Greater Good, Jeremy Adam Smith (editor) (2020)
• The Medical Marriage: Sustaining Healthy Relationships for Physicians and Their Families, Wayne Sotile (2000)
• The One-Minute Gratitude Journal, Brenda Nathan (2016). There are now multiple widely-available journals like this available.
• Zen and the Art of Making a Living: A Practical Guide to Creative Career Design, Laurence Boldt (2009)

Special thanks to Shilagh Mirgain, PhD, and Janice Singles, PsyD, who wrote the original Whole Health Library materials on Personal Development that inspired content for much of this chapter.

Free Podcasts

• The Gratitude Attitude Podcast | thegratitudeattitudepodcast (podbean.com)
• Podcast | Greater Good (berkeley.edu)
• Podcast — Gratitude Blooming

References

1 Mirgain S, Singles J. Personal development. Whole Health Library website. https://www.va.gov/WHOLEHEALTHLIBRARY/overviews/personal-development.asp. 2018. Accessed July 17, 2019.

2 Sirisub P, Suwannapong N, Tipayamongkholgul M, Howteerakul N, Noree T. Intention to extend working life among thai registered nurses in ministry of public health: A national survey. Nursing Research and Practice. 2019;2019:1-11. doi:10.1155/2019/7919404.

3 Horrigan JM, Lightfoot NE, Lariviere MA, Jacklin K.  Evaluating and improving nurses' health and quality of work life. Workplace Health Saf.  2013;61(4):173-181. doi: 10.3828/21650799-20130327-18.

4 Medscape, Physician Burnout and Depression Report 2024: ‘We Have Much Work to Do,” Available at https://www.medscape.com/slideshow/2024-lifestyle-burnout-6016865#2. Accessed 4-15-24.

5 Irving JA, Dobkin PL, Park J. Cultivating mindfulness in health care professionals: a review of empirical studies of mindfulness-based stress reduction (MBSR). Complement Ther Clin Pract. 2009;15(2):61-66. doi: 10.1016/ctcp.2009.01.002. Epub 2009 Feb 28.

6 Wacek B. Factors Which Put Social Workers at a Greater Risk for Burnout. Social Work Commons . 2017:1-55.

7 Kronos survey finds that nurses love what they do though fatigue is a pervasive problem. Kronos website. https://www.medscape.com/viewarticle/879761. Published May 9, 2017. Accessed August 17, 2020.

8 Zhang YY, Han WL, Qin W, et al. Extent of compassion satisfaction, compassion fatigue and burnout in nursing: a meta-analysis. J Nurs Manag. 2018;26(7):810-819.

9 Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377-1385.

10 McKinley TF, Boland KA, Mahan JD. Burnout and interventions in PEDIATRIC residency: A literature review. Burnout Research. 2017;6:9-17. doi:10.1016/j.burn.2017.02.003

11 Rindfleisch A. Implementing whole health in your own life: clinician self-care. Whole Health Library website. https://www.va.gov/WHOLEHEALTHLIBRARY/overviews/clinician-self-care.asp. 2018. Accessed July 17, 2019.

12 West CP, Dyrbye LN, Sloan JA, Shanafelt TD. Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals. J Gen Intern Med. 24(12):1318–21. doi: 10.1007/s11606-009-1129-z. Epub 2009 Oct 3.

13 Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284-1293. doi: 10.1001/jama.2009.1384.

14 Fortney L, Luchterhand C, Zakletskaia L, Zgierska A, Rakel D. Abbreviated mindfulness intervention for job satisfaction, quality of life, and compassion in primary care clinicians: a pilot study. Ann Fam Med.  2013;11(5):412-420. doi: 10.1370/afm.1511.

15 Ratner P, Sawatzky R. Health status, preventive behaviour and risk factors among female nurses. Health Rep. 2009;20(3):53-61.

16 Rindfleisch A. Burnout and resilience: frequently asked questions. Whole Health Library website. https://www.va.gov/WHOLEHEALTHLIBRARY/tools/burnout-resilience.asp. 2018. Accessed July 17, 2019.

17 Nanda A, Wasan A, Sussman J.  Provider health and wellness. J Allergy Clin Immunol Pract. 2017. pii: S2213-2198(17)30388-4. doi: 10.1016/j.jaip.2017.05.025. [Epub ahead of print].

18 Cohn MA, Fredrickson BL, Brown SL, Mikels JA, Conway AM.  Happiness unpacked: positive emotions increase life satisfaction by building resilience. Emotion (Washington, DC). 2009;9(3):361-368. doi: 10.1037/a0015952.

19 Tsai J, Sippel LM, Mota N, Southwick SM, Pietrzak RH. Longitudinal course of posttraumatic growth among U.S. military veterans: results from the national health and resilience in veterans study. Depress Anxiety. 2016;33(1):9-18. doi: 10.1002/da.22371.

20 Kalisch R, Müller MB, Tüscher O. A conceptual framework for the neurobiological study of resilience. Behav Brain Sci. 2015 2015;38:e92. doi: 10.1017/S0140525X1400082X.

21 Feder A. Fred-Tores S, Southwick SM, Charney DS. The biology of human resilience: opportunities for enhancing resilience across the life span. Biol Psychiatry. 2019;86(6):443-453. doi: 10.1016/j.biopsych.2019.07.012.

22 Steptoe A. Investing in happiness: the gerontological perspective. Gerontology. 2019;65(6):634-639. doi: 10.1159/000501124.

23 Peterson C, Park N, Seligman ME.  Orientations to happiness and life satisfaction: The full life versus the empty life.  J Happiness Stud.  2005;6(1):25-41. doi: 10.1007/s10902-004-1278-z.

24 Lyubomirsky S, King L, Diener E. The benefits of frequent positive affect: does happiness lead to success? Psychol Bull. 2005;131(6):803-855.

25 Tandler N, Krauss A, Proyer RT. Authentic happiness at work: Self- and Peer-rated orientations to happiness, work satisfaction, and stress coping. Frontiers in Psychology. 2020;11. doi:10.3389/fpsyg.2020.01931

26 Gruber J, Mauss IB, Tamir M. A dark side of happiness? How, when, and why happiness is not always good. Perspect Psychol Sci. 2011;6(3):222-33. doi: 10.1177/1745691611406927.

27 Varahrami A, Arnau RC, Rosen DH, Mascaro N. The relationships between meaning, hope, and psychosocial development. Int J Existential Psychol Psychother. 2009;3:1-14.

28 Carver CS, Scheier MF, Segerstrom SC. Optimism. Clin Psychol Rev. 2010;30(7):879–889. doi: 10.1016/j.cpr.2010.01.006. Epub 2010 Feb 1.

29 Goodin BR, Bulls HW. Optimism and the experience of pain: benefits of seeing the glass as half full. Curr Pain Headache Rep. 2013;17(5):329. doi: 10.1007/s11916-013-0329-8.

30 Krittanawong C, Maitra NS, Hassan Virk HU, Fogg S, Wang Z, Kaplin S, Gritsch D, Storch EA, Tobler PN, Charney DS, Levine GN. Association of Optimism with Cardiovascular Events and All-Cause Mortality: Systematic Review and Meta-Analysis. Am J Med. 2022 Jul;135(7):856-863.e2. doi: 10.1016/j.amjmed.2021.12.023. Epub 2022 Feb 4. PMID: 35123934.

31 Neff KD, Kirkpatrick KL, Rude SS. Self-compassion and adaptive psychological functioning. J Res Pers.  2007;41(1):139-154.

32 Zessin U, Dickhäuser O, Garbade S. The relationship between self-compassion and well-being: a meta-analysis.  Appl Psychol Health Well Being. 2019;2(9):e1912200. doi:10.1001/jamanetworkopen.2019.12200.

33 Atkinson DM Rodman JL, Thuras PD, Shiroma PR, Lim KO. Examining burnout, depression, and self-compassion in veterans affairs mental health staff. J Altern Complement Med. 2017;23(7):551-557. doi: 10.1089/acm.2017.0087. Epub 2017 Jun 7.

34 Barnard LK, Curry JF. Self-compassion: Conceptualizations, correlates, & interventions. Rev Gen Psychol. 2011;15(4):289.

35 Cleare S, Gumley A, O’Connor RC. Self-compassion, self-forgiveness, suicidal ideation, and self-harm: a systematic review. Clin Psychol Psychother. 2019;26(5):511-530. doi: 10.1002/cpp.2372.

36 Dunne S, Sheffield D, Chilcot J. Brief report: self-compassion, physical health and the mediating role of health-promoting behaviors. J Health Psychol. 2018;23(7):993-999. doi: 10.1177/1359105316643377. Epub 2016 Apr 26.

37 Sirois FM. A self-regulation resource model of self-compassion and health behavior intentions in emerging adults.  Prev Med Rep. 2015;2:218-22. doi: 10.1016/j.pmedr.2015.03.006. eCollection 2015.

38 Brown L, Huffman JC, Bryant C. Self-compassionate aging: a systematic review. Gerontologist. 2019 Jul 16;59(4):e311-e324. doi: 10.1093/geront/gny108.

39 Yan T, Chan CWH, Chow KM, Zheng W, Sun M. A systematic review of the effects of character strengths-based intervention on the psychological well-being of patients suffering from chronic illness. J Adv Nurs. 2020;76(7):1567-1580. doi: 10.1111/jan.14356.

40 Buchanan KE, Bardi A.  Acts of kindness and acts of novelty affect life satisfaction. J Soc Psychol. 2010;150(3):235-237. doi: 10.1080/00224540903365554.

41 Andersen SM, Saribay A, Thorpe JS. Simple kindness can go a long way: relationships, social identity, and engagement. Soc Psychol. 2008;39(1):59.

42 Gilbert P. Compassion: From its evolution to a psychotherapy. Frontiers in Psychology. 2020;11. doi:10.3389/fpsyg.2020.586161

43 Cousins N. Anatomy of an illness (as perceived by the patient). N Engl J Med. 1976;295(26):1458-1463.

44 Rindfleisch A. The healing benefits of humor and laughter. Whole Health Library website. https://www.va.gov/WHOLEHEALTHLIBRARY/tools/healing-benefits-humor-laughter.asp. 2018. Accessed July 17, 2019.

48 Baer, J, Creativity doesn’t develop in a vacuum. New Dir Child Adolesc Dev. 2016;2016(151):9-20. doi: 10.1002/cad.20151.

49 Trunnell EP, Evans C, Richards B, Grosshans O. Factors associated with creativity in health educators who have won university teaching awards: a modified qualitative approach. J Health Educ. 1997;28(1):35-41.

50 Henriksen D, Richardson C, Shack K. Mindfulness and creativity: Implications for thinking and learning. Think Skills Creat. 2020;37:100689. doi:10.1016/j.tsc.2020.100689

51 Epstein R, Schmidt SM, Warfel R. Measuring and training creativity competencies: Validation of a new test. Creativity Res J. 2008 20(1): 7-12. doi: 10.1080/10400410701839876.

52 Schwingshackl A. The fallacy of chasing after work-life balance. Front Pediatr. 2014;2:26. doi: 10. 3389/fped.2014.00026.

53 Rindfleisch A. Work-life integration: tips and resources. Whole Health Library website. https://www.va.gov/WHOLEHEALTHLIBRARY/tools/work-life-integration-tips-and-resources.asp. 2018. Accessed July 17, 2019.

54 Feigon M, Block C, Guidotti Breting L, Boxley L, Dawson E, Cobia D. Work-life integration in neuropsychology: a review of the existing literature and preliminary recommendations. Clin Neuropsychol. 2018 Feb;32(2):300-317. doi: 10.1080/13854046.2017.1411977.

55 Yester M. Work-life balance, burnout, and physician wellness. Health Care Manag (Frederick). 2019 Jul/Sep;38(3):239-246. doi: 10.1097/HCM.0000000000000277.

56 Gampawar P, Schmidt R, Schmidt H. Leukocyte telomere length is related to Brain Parenchymal fraction and Attention/speed in the Elderly: Results of the Austrian stroke Prevention study. Frontiers in Psychiatry. 2020;11. doi:10.3389/fpsyt.2020.00100.

57 Pudas S, Josefsson M, Nordin Adolfsson A, et al. Short Leukocyte Telomeres, But Not Telomere Attrition Rates, Predict Memory Decline in the 20-Year Longitudinal Betula Study. J Gerontol A Biol Sci Med Sci. 2021;76(6):955-963. doi:10.1093/gerona/glaa322

58 Vaiserman A, Krasnienkov D. Telomere length as a marker of BIOLOGICAL Age: State-of-the-Art, open issues, and FUTURE PERSPECTIVES. Frontiers in Genetics. 2021;11. doi:10.3389/fgene.2020.630186

59 Douglas-Hall A, Chau MM. Parents' low education leads to low income, despite full-time employment. 2007. National Center for Children in Poverty. Available at: http://www.nccp.org/publications/pub_786.html. Accessed July 17, 2019.

60 Normando P, Bezerra FF, Santana BA, et al. Association between SOCIOECONOMIC markers and ADULT telomere length differs according to SEX: Pro-Saúde study. Brazilian Journal of Medical and Biological Research. 2020;53(11). doi:10.1590/1414-431x202010223

61 Steptoe A, Wardle J. Life skills, wealth, health, and wellbeing in later life. Proc Natl Acad Sci U S A. 2017;114(17):4354-4359.

62 Stephenson P, Brigden D, Dangerfield P. Lifelong learning for the modern day clinician. Br J Hosp Med (Lond). 2009;70(4):230-232.

63 Akhter-Khan SC, Hofmann V, Warncke M, Tamimi N, Mayston R, Prina MA. Caregiving, volunteering, and loneliness in middle-aged and older adults: a systematic review. Aging Ment Health. 2023 Jul-Aug;27(7):1233-1245. doi: 10.1080/13607863.2022.2144130. Epub 2022 Nov 23. PMID: 36417922.

64 Han SH, Park N. Heterogeneous Effects of Volunteering on Frailty in Later Life: A Panel Quantile Regression Approach. J Gerontol B Psychol Sci Soc Sci. 2024 May 1;79(5):gbae033. doi: 10.1093/geronb/gbae033. PMID: 38459929; PMCID: PMC10998351.

65 Bell MJ, Ferraro KF, Sauerteig-Rolston MR. Volunteer Engagement and Systemic Inflammation: Does Helping Others Benefit Oneself? Gerontologist. 2022 Nov 30;62(10):1477-1485. doi: 10.1093/geront/gnac073. PMID: 35640008; PMCID: PMC9710242.

66 Han SH, Roberts JS, Mutchler JE, Burr JA. Volunteering, polygenic risk for Alzheimer's disease, and cognitive functioning among older adults. Soc Sci Med. 2020 May;253:112970. doi: 10.1016/j.socscimed.2020.112970. Epub 2020 Apr 2. PMID: 32278238; PMCID: PMC7527033.

67 Kim S, Halvorsen C, Han SH. Volunteering and Changes in Cardiovascular Biomarkers: Longitudinal Evidence From the Health and Retirement Study. Innov Aging. 2023 Jun 4;7(5):igad048. doi: 10.1093/geroni/igad048. PMID: 37457805; PMCID: PMC10340447.

68 von Bonsdorff MB, Rantanen T. Benefits of formal voluntary work among older people. A review. Aging Clin Exp Res. 2011;23(3):162-169. doi: 10.3275/7200. Epub 2010 Jul 16.

69 Luks A. doing good: helper’s high. Psychol Today. 1988;22(10):39-40.

70 Yeung JWK, Zhang Z, Kim TY. Volunteering and health benefits in general adults: cumulative effects and forms. BMC Public Health. 2017;18(1):8.

71 Guiney H, Machado L. Volunteering in the community: potential benefits for cognitive aging. J Gerontol B Psychol Sci Soc Sci. 2018;73(3):399-408.

72 American Institutes for Research. Consumer education initiatives in financial and health literacy task 4: deliverable 4, final report. 2010. https://aspe.hhs.gov/sites/default/files/pdf/76156/index.pdf. Accessed July 17, 2019.

73 Enright R, Freedman S, Rique J. Psychology of interpersonal forgiveness. In: Enright RD, North J, eds. Exploring Forgiveness. Madison, WI: University of Wisconsin Press; 1998.

74 Rindfleisch A, Forgiveness. In Rakel D, ed, Integrative Medicine.  4th ed, Philadelphia: PA Saunders; 2017:940-944.

75 Lee Y-R, Enright RD. A meta-analysis of the association between forgiveness of others and physical health. Psychol Health. 2019;34(5):626-643. doi: 10.1080/08870446.2018.1554185.

76 Mirgain S, Singles J. Forgiveness: the gift we give ourselves. Whole Health Library website. https://www.va.gov/WHOLEHEALTHLIBRARY/tools/forgiveness-the-gift-we-give-ourselves.asp. 2018. Accessed July 17, 2019.

77 Rasmussen KR, Stackhouse M, Boon SD, Comstock K, Ross R. Meta-analytic connections between forgiveness and health: the moderating effects of forgiveness-related distinctions. Psychol Health. 2019; 34(5):515-534. doi: 10.1080/08870446.2018.1545906.

78 Toussaint L, Worthington EL, Van Tongeren DR, et al. Forgiveness working: forgiveness, health, and productivity in the workplace. Am J Health Promot. 2018;32(1):59-67. doi: 10.1177/0890117116662312. Epub 2016 Aug 25.

79 Toussaint LL, Shields GS, Green E, Kennedy K, Travers S, Slavich GM. Hostility, forgiveness, and cognitive impairment over 10 years in a national sample of American adults. Health Psychol. 2018;37(12):1102-1106. doi: 10.1037/hea0000686.

80 Griffin BJ, Worthington EL, Davis DE, Hook JN, Maguen S. Development of the self-forgiveness dual-process scale. J Couns Psychol. 2018;65(6):715-726.

81 Mirgain S, Singles J. Creating a gratitude practice. Whole Health Library website. https://www.va.gov/WHOLEHEALTHLIBRARY/tools/creating-gratitude-practice.asp. 2018. Accessed July 17, 2019.

82 Bartlett MY, Arpin SN. Gratitude and loneliness: enhancing health and well-being in older adults. Res Aging. 2019;41(8):772-793. doi: 10.1177/0164027519845354.

83 Ducasse D, Dassa D, Courtet P, et al. Gratitude diary for the management of suicidal inpatients: a randomized controlled trial. Depress Anxiety. 2019;36(5):400-411. doi: 10.1002/da.22877.

84 Kyeong S, Kim J, Kim DJ, Kim HE, Kim JJ. Effects of gratitude meditation on neural network functional connectivity and brain-heart coupling. Sci Rep. 2017;7(1):5058.

85 Emmons RA, McCullough ME. Counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life. J Pers Soc Psychol. 2003;84(2):377-389.

86 Raskin A, Bamberger P, Erez A, et al. Expressions of gratitude and medical team performance. Pediatrics. 2019;143(4):e20182043. doi: 10.1542/peds.2018-2043.

87 Guest, RH, Quality of Work Life - Learning from Tarrytown. Harvard Business Review, 1979. Available at https://hbr.org/1979/07/quality-of-work-life-learning-from-tarrytown. Accessed4-15-24.

88 Harvey SB, Modini M, Joyce S, Milligan-Saville JS, Tan L, Mykletun A, Bryant RA, Christensen H, Mitchell PB. Can work make you mentally ill? A systematic meta-review of work-related risk factors for common mental health problems. Occup Environ Med. 2017 Mar;74(4):301-310. doi: 10.1136/oemed-2016-104015. Epub 2017 Jan 20. PMID: 28108676.

89 Brown JP, Martin D, Nagaria Z, Verceles AC, Jobe SL, Wickwire EM. Mental Health Consequences of Shift Work: An Updated Review. Curr Psychiatry Rep. 2020 Jan 18;22(2):7. doi: 10.1007/s11920-020-1131-z. PMID: 31955278.

90 Jacqueline M. Ferguson, PhD,a,c Patrick T. Bradshaw, PhD,b Ellen A. Eisen, ScD,a David Rehkopf, ScD, MPH,c Mark R. Cullen, MD,c and Sadie Costello, PhDa. Distribution of Working Hour Characteristics by Race, Age, Gender, and Shift Schedule among U.S manufacturing workers. Published online 2023 Jan 24. doi: 10.1080/07420528.2023.2168200. PMID: 36691907

91 Marken S, Agrawal S. K-12 Workers Have Highest Burnout Rate in U.S. Gallup Eduction, June 13, 2022. Available at https://news.gallup.com/poll/393500/workers-highest-burnout-rate.aspx. Accessed 4-15-24.

92 Alves L, Abreo L, Petkari E, Pinto da Costa M. Psychosocial risk and protective factors associated with burnout in police officers: A systematic review. J Affect Disord. 2023 Jul 1;332:283-298. doi: 10.1016/j.jad.2023.03.081. Epub 2023 Mar 25. PMID: 36972850.

93 Maslach C, Leiter MP. Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry. 2016 Jun;15(2):103-11. doi: 10.1002/wps.20311. PMID: 27265691; PMCID: PMC4911781.

94 Green AA, Kinchen EV. The Effects of Mindfulness Meditation on Stress and Burnout in Nurses. J Holist Nurs. 2021 Dec;39(4):356-368. doi: 10.1177/08980101211015818. Epub 2021 May 17. Erratum in: J Holist Nurs. 2022 Sep;40(3):NP1-NP5. PMID: 33998935.

95 Wang R, Gu X, Zhang Y, Luo K, Zeng X. Loving-kindness and compassion meditations in the workplace: A meta-analysis and future prospects. Stress Health. 2024 Feb;40(1):e3273. doi: 10.1002/smi.3273. Epub 2023 May 23. PMID: 37221984.

96 Townsley AP, Li-Wang J, Katta R. Healthcare Workers' Well-Being: A Systematic Review of Positive Psychology Interventions. Cureus. 2023 Jan 23;15(1):e34102. doi: 10.7759/cureus.34102. PMID: 36843822; PMCID: PMC9946896.

97 Gower T, Fischer IC, Tsai J, Kang H, Na PJ, Tedeschi RG, Pietrzak RH. Functional significance of posttraumatic growth in U.S. military veterans. J Affect Disord. 2024 Apr 15;356:267-273. doi: 10.1016/j.jad.2024.04.046. Epub ahead of print. PMID: 38614442.

98 Dell'Osso L, Lorenzi P, Nardi B, Carmassi C, Carpita B. Post Traumatic Growth (PTG) in the Frame of Traumatic Experiences. Clin Neuropsychiatry. 2022 Dec;19(6):390-393. doi: 10.36131/cnfioritieditore20220606. PMID: 36627947; PMCID: PMC9807114.

99 Schimschal SE, Visentin D, Kornhaber R, Cleary M. Grit: A Concept Analysis. Issues Ment Health Nurs. 2021 May;42(5):495-505. doi: 10.1080/01612840.2020.1814913. Epub 2020 Sep 11. PMID: 32915678.

100 Lee DH, Reasoner K, Lee D. Grit: what is it and why does it matter in medicine? Postgrad Med J. 2023 Jun 15;99(1172):535-541. doi: 10.1136/postgradmedj-2021-140806. PMID: 37319151.

101 Calo M, Judd B, Peiris C. Grit, resilience and growth-mindset interventions in health professional students: A systematic review and meta-analysis. Med Educ. 2024 Apr 10. doi: 10.1111/medu.15391. Epub ahead of print. PMID: 38600797.

102 Schäfer SK, von Boros L, Schaubruch LM, Kunzler AM, Lindner S, Koehler F, Werner T, Zappalà F, Helmreich I, Wessa M, Lieb K, Tüscher O. Digital interventions to promote psychological resilience: a systematic review and meta-analysis. NPJ Digit Med. 2024 Feb 8;7(1):30. doi: 10.1038/s41746-024-01017-8. PMID: 38332030; PMCID: PMC10853230.

103 Ding X, Zhao F, Wang Q, Zhu M, Kan H, Fu E, Wei S, Li Z. Effects of interventions for enhancing resilience in cancer patients: A systematic review and network meta-analysis. Clin Psychol Rev. 2024 Mar;108:102381. doi: 10.1016/j.cpr.2024.102381. Epub 2024 Jan 12. PMID: 38278013.

104 Ramamurthy C, Zuo P, Armstrong G, Andriessen K. The impact of storytelling on building resilience in children: A systematic review. J Psychiatr Ment Health Nurs. 2023 Dec 12. doi: 10.1111/jpm.13008. Epub ahead of print. PMID: 38087837.

105 Toth EE, Ihász F, Ruíz-Barquín R, Szabo A. Physical Activity and Psychological Resilience in Older Adults: A Systematic Review of the Literature. J Aging Phys Act. 2023 Sep 12;32(2):276-286. doi: 10.1123/japa.2022-0427. PMID: 37699587.

106 Orth RJ, Holahan CJ, Moos RH, Cronkite RC. Family support, family income, and happiness: a 10-year perspective. J Fam Psychol. 2008;22(3):475-483.

107 Esch T, Stefano GB, Michaelsen MM. The foundations of mind-body medicine: Love, good relationships, and happiness modulate stress and promote health. Stress Health. 2024 Mar 5:e3387. doi: 10.1002/smi.3387. Epub ahead of print. PMID: 38442034.

108 Karwetzky C, Michaelsen MM, Werdecker L, Esch T. The U-Curve of Happiness Revisited: Correlations and Differences in Life Satisfaction Over the Span of Life-An Empirical Evaluation Based on Data From 1,597 Individuals Aged 12-94 in Germany. Front Psychol. 2022 Apr 28;13:837638. doi: 10.3389/fpsyg.2022.837638. PMID: 35572301; PMCID: PMC9096900.

109 Maximiano-Barreto MA, Leal LR, Pessoa RMP, Bomfim AJL, Morais D, Luchesi BM, Chagas MHN. Factors associated with happiness among community-dwelling older adults: a systematic review. Geriatr Nurs. 2024 Mar-Apr;56:124-137. doi: 10.1016/j.gerinurse.2024.01.004. Epub 2024 Feb 9. PMID: 38340433.

110 Singh S, Kshtriya S, Valk R. Health, Hope, and Harmony: A Systematic Review of the Determinants of Happiness across Cultures and Countries. Int J Environ Res Public Health. 2023 Feb 13;20(4):3306. doi: 10.3390/ijerph20043306. PMID: 36834001; PMCID: PMC9963575.

111 Conversano C, Rotondo A, Lensi E, Della Vista O, Arpone F, Reda MA. Optimism and its impact on mental and physical well-being. Clin Pract Epidemiol Ment Health. 2010 May 14;6:25-9. doi: 10.2174/1745017901006010025. PMID: 20592964; PMCID: PMC2894461.

112 Rasmussen HN, England E, Cole BP. Hope and physical health. Curr Opin Psychol. 2023 Feb;49:101549. doi: 10.1016/j.copsyc.2022.101549. Epub 2022 Dec 24. PMID: 36640676.

113 Corn BW, Feldman DB, Wexler I. The science of hope. Lancet Oncol. 2020 Sep;21(9):e452-e459. doi: 10.1016/S1470-2045(20)30210-2. PMID: 32888474.

114 Velić S, Qama E, Diviani N, Rubinelli S. Patients' perception of hope in palliative care: A systematic review and narrative synthesis. Patient Educ Couns. 2023 Oct;115:107879. doi: 10.1016/j.pec.2023.107879. Epub 2023 Jun 30. PMID: 37413808.

115 Katsimigos AM, O'Beirne S, Harmon D. Hope and chronic pain-a systematic review. Ir J Med Sci. 2021 Feb;190(1):307-312. doi: 10.1007/s11845-020-02251-1. Epub 2020 May 25. PMID: 32451764.

116 Gallagher MW, Lopez SJ. Positive expectancies and mental health: identifying the unique contributions of hope and optimism. J Posit Psychol. 2009;4(6):548-556.

117 Schrank B, Bird V, Rudnick A, Slade M. Determinants, self-management strategies and interventions for hope in people with mental disorders: systematic search and narrative review. Soc Sci Med. 2012 Feb;74(4):554-64. doi: 10.1016/j.socscimed.2011.11.008. Epub 2011 Dec 13. PMID: 22240450.

118 Uribe FAR, de Oliveira SB, Junior AG, da Silva Pedroso J. Association between the dispositional optimism and depression in young people: a systematic review and meta-analysis. Psicol Reflex Crit. 2021 Nov 29;34(1):37. doi: 10.1186/s41155-021-00202-y. PMID: 34842988; PMCID: PMC8630239.

119 Arsyi DH, Permana PBD, Karim RI, Abdurachman. The role of optimism in manifesting recovery outcomes after coronary artery bypass graft surgery: A systematic review. J Psychosom Res. 2022 Nov;162:111044. doi: 10.1016/j.jpsychores.2022.111044. Epub 2022 Sep 21. PMID: 36170801.

120 Luo J, Li L, Reangsing C, Schneider JK. Effects of Psychotherapy on Hope/Hopelessness in Adults with Cancer: a Systematic Review and Meta-analysis. Int J Behav Med. 2022 Dec;29(6):691-704. doi: 10.1007/s12529-021-10051-9. Epub 2022 Feb 8. PMID: 35137362.

121 Cheavens JS, Whitted WM. Hope therapy. Curr Opin Psychol. 2023 Feb;49:101509. doi: 10.1016/j.copsyc.2022.101509. Epub 2022 Nov 3. PMID: 36495712.

122 Erthal F, Bastos A, Vilete L, Oliveira L, Pereira M, Mendlowicz M, Volchan E, Figueira I. Unveiling the neural underpinnings of optimism: a systematic review. Cogn Affect Behav Neurosci. 2021 Oct;21(5):895-916. doi: 10.3758/s13415-021-00931-8. Epub 2021 Aug 2. PMID: 34341967.

123 Neff KD. Self-Compassion: Theory, Method, Research, and Intervention. Annu Rev Psychol. 2023 Jan 18;74:193-218. doi: 10.1146/annurev-psych-032420-031047. Epub 2022 Aug 12. PMID: 35961039.

124 Finlay-Jones AL, Parkinson A, Sirois F, Perry Y, Boyes M, Rees CS. Web-Based Self-Compassion Training to Improve the Well-Being of Youth With Chronic Medical Conditions: Randomized Controlled Trial. J Med Internet Res. 2023 Sep 13;25:e44016. doi: 10.2196/44016. PMID: 37703081; PMCID: PMC10534292.

125 Rushforth A, Durk M, Rothwell-Blake GAA, Kirkman A, Ng F, Kotera Y. Self-Compassion Interventions to Target Secondary Traumatic Stress in Healthcare Workers: A Systematic Review. Int J Environ Res Public Health. 2023 Jun 12;20(12):6109. doi: 10.3390/ijerph20126109. PMID: 37372696; PMCID: PMC10298083.

126 Misurya I, Misurya P, Dutta A. The Effect of Self-Compassion on Psychosocial and Clinical Outcomes in Patients With Medical Conditions: A Systematic Review. Cureus. 2020 Oct 17;12(10):e10998. doi: 10.7759/cureus.10998. PMID: 33209554; PMCID: PMC7669250.

127 Thurston RC, Fritz MM, Chang Y, Barinas Mitchell E, Maki PM. Self-compassion and subclinical cardiovascular disease among midlife women. Health Psychol. 2021 Nov;40(11):747-753. doi: 10.1037/hea0001137. PMID: 34914480; PMCID: PMC8926023.

128 Brenton-Peters J, Consedine NS, Boggiss A, Wallace-Boyd K, Roy R, Serlachius A. Self-compassion in weight management: A systematic review. J Psychosom Res. 2021 Nov;150:110617. doi: 10.1016/j.jpsychores.2021.110617. Epub 2021 Sep 16. PMID: 34560404.

129 Rushforth A, Durk M, Rothwell-Blake GAA, Kirkman A, Ng F, Kotera Y. Self-Compassion Interventions to Target Secondary Traumatic Stress in Healthcare Workers: A Systematic Review. Int J Environ Res Public Health. 2023 Jun 12;20(12):6109. doi: 10.3390/ijerph20126109. PMID: 37372696; PMCID: PMC10298083.

130 Cai RY, Edwards C, Love AM, Brown L, Gibbs V. Self-compassion improves emotion regulation and mental health outcomes: A pilot study of an online self-compassion program for autistic adults. Autism. 2024 Apr 7:13623613241235061. doi: 10.1177/13623613241235061. Epub ahead of print. PMID: 38584374.

131 Petersen JM, Barney JL, Capel LK, Woolley MG, Lensegrav-Benson T, Quakenbush-Roberts B, Twohig MP. Self-compassion and body image inflexibility as mediators of outcomes in a residential eating disorder sample. Eat Disord. 2024 Feb 22:1-18. doi: 10.1080/10640266.2024.2306440. Epub ahead of print. PMID: 38389388.

132 Greff Ballejos K, Calvetti PÜ, Schaab BL, Reppold CT. What are the benefits of cultivating self-compassion in adults with low back pain? A systematic review. Front Psychol. 2023 Nov 6;14:1270287. doi: 10.3389/fpsyg.2023.1270287. PMID: 38022933; PMCID: PMC10657904.

133 Butz S, Stahlberg D. The Relationship between Self-Compassion and Sleep Quality: An Overview of a Seven-Year German Research Program. Behav Sci (Basel). 2020 Mar 6;10(3):64. doi: 10.3390/bs10030064. PMID: 32155708; PMCID: PMC7139482.

134 Schienle A, Unger I. Non-Deceptive Placebos Can Promote Acts of Kindness: A Randomized Controlled Trial. Behav Sci (Basel). 2023 Aug 23;13(9):703. doi: 10.3390/bs13090703. PMID: 37753981; PMCID: PMC10525077.

135 Folk D, Dunn E. How Can People Become Happier? A Systematic Review of Preregistered Experiments. Annu Rev Psychol. 2024 Jan 18;75:467-493. doi: 10.1146/annurev-psych-022423-030818. Epub 2023 Aug 11. PMID: 37566759.

136 Kumar A, Epley N. A little good goes an unexpectedly long way: Underestimating the positive impact of kindness on recipients. J Exp Psychol Gen. 2023 Jan;152(1):236-252. doi: 10.1037/xge0001271. Epub 2022 Aug 18. PMID: 35980709.

137 Bartzou E, Tsiloni E, Mantzoukas S, Dragioti E, Gouva M. Humor and Quality of Life in Adults With Chronic Diseases: A Systematic Review. Cureus. 2024 Feb 29;16(2):e55201. doi: 10.7759/cureus.55201. PMID: 38562265; PMCID: PMC10983057.

138 American Psychological Association Dictionary of Psychology, Available at https://dictionary.apa.org/creativity. Accessed 4-15-24.

139 Malach R. The neuronal basis of human creativity. Front Hum Neurosci. 2024 Feb 27;18:1367922. doi: 10.3389/fnhum.2024.1367922. PMID: 38476979; PMCID: PMC10929679.

140 Cristini C, Colautti L, Vedova AD, Antonietti A. Creativity and humor in the elderly: Shared mechanisms and common functions to promote well-being. Neurosci Lett. 2024 Apr 3;828:137762. doi: 10.1016/j.neulet.2024.137762. Epub ahead of print. PMID: 38574850.

141 Hughes Z, Ball LJ, Richardson C, Judge J. A meta-analytical review of the impact of mindfulness on creativity: Framing current lines of research and defining moderator variables. Psychon Bull Rev. 2023 Dec;30(6):2155-2186. doi: 10.3758/s13423-023-02327-w. Epub 2023 Jul 13. PMID: 37442873; PMCID: PMC10728263.

142 Gropel P, Kuhl J. Work-life balance and subjective well-being: the mediating role of need fulfilment. Br J Psychol. 2009;100(Pt 2):365-375.

143 Bernuzzi C, Sommovigo V, Setti I. The role of resilience in the work-life interface: A systematic review. Work. 2022;73(4):1147-1165. doi: 10.3233/WOR-205023. PMID: 36093652.

144 Abuhalimeh B, Brunton NE. Rebalancing Work and Life for the Busy Physician. Ann Vasc Surg. 2024 Apr;101:80-83. doi: 10.1016/j.avsg.2023.12.008. Epub 2023 Dec 20. PMID: 38128693.

145 Yester, M. (2019). Work-Life Balance, Burnout, and Physician Wellness. The Health Care Manager, 38 (3), 239-246. doi: 10.1097/HCM.0000000000000277.

146 MacDonald LM. Impact of Working From Home on Addressing Practitioner Burnout and Work-Life Balance in Mental Health. Perm J. 2022 Jun 29;26(2):77-82. doi: 10.7812/TPP/21.186. Epub 2022 Jun 15. PMID: 35933659; PMCID: PMC9662233.

147 Desai SV, Burk-Rafel J, Lomis KD, Caverzagie K, Richardson J, O'Brien CL, Andrews J, Heckman K, Henderson D, Prober CG, Pugh CM, Stern SD, Triola MM, Santen SA. Precision Education: The Future of Lifelong Learning in Medicine. Acad Med. 2024 Apr 1;99(4S Suppl 1):S14-S20. doi: 10.1097/ACM.0000000000005601. Epub 2024 Jan 29. PMID: 38277444.

148 Volgistics, Volunteer Statistics of 2023, Available at https://www.volgistics.com/blog/volunteer-statistics-of-2023/. Accessed 4-15-24.

149 AmeriCorps, Volunteering and Civic Life in America. Available at https://americorps.gov/about/our-impact/volunteering-civic-life. Accessed 4-15-24.

150 Nichol B, Wilson R, Rodrigues A, Haighton C. Exploring the Effects of Volunteering on the Social, Mental, and Physical Health and Well-being of Volunteers: An Umbrella Review. Voluntas. 2023 May 4:1-32. doi: 10.1007/s11266-023-00573-z. Epub ahead of print. PMID: 37360509; PMCID: PMC10159229.

151 Hayajneh AA, Rababa M. The Association of Frailty with Poverty in Older Adults: A Systematic Review. Dement Geriatr Cogn Disord. 2021;50(5):407-413. doi: 10.1159/000520486. Epub 2021 Dec 20. PMID: 34929708.

152 Brisson D, McCune S, Wilson JH, Speer SR, McCrae JS, Hoops Calhoun K. A Systematic Review of the Association between Poverty and Biomarkers of Toxic Stress. J Evid Based Soc Work (2019). 2020 Nov-Dec;17(6):696-713. doi: 10.1080/26408066.2020.1769786. Epub 2020 Jul 12. PMID: 32657246.

153 Rindfleisch, Forgiveness. In Rakel D, Minichiello V. Integrative Medicine, 5th edition. Elsevier, 2022.

154 Skolnick VG, Lynch BA, Smith L, Romanowicz M, Blain G, Toussaint L. The Association Between Parent and Child ACEs is Buffered by Forgiveness of Others and Self-Forgiveness. J Child Adolesc Trauma. 2023 May 11;16(4):1-9. doi: 10.1007/s40653-023-00552-y. Epub ahead of print. PMID: 37359460; PMCID: PMC10173225.

155 Kumar SA, Taverna E, Borowski S, Smith BN, Vogt D. From posttraumatic stress symptoms to suicidal ideation among military veterans: Pathways founded on meaning in life and gratitude. J Trauma Stress. 2024 Mar 25. doi: 10.1002/jts.23033. Epub ahead of print. PMID: 38527914.

156 Golec de Zavala A, Keenan O, Ziegler M, Mazurkiewicz M, Nalberczak-Skóra M, Ciesielski P, Wahl JE, Sedikides C. Mindful-Gratitude Practice Reduces Prejudice at High Levels of Collective Narcissism. Psychol Sci. 2024 Feb;35(2):137-149. doi: 10.1177/09567976231220902. Epub 2024 Jan 17. PMID: 38232344.

157 Kerry N, Chhabra R, Clifton JDW. Being Thankful for What You Have: A Systematic Review of Evidence for the Effect of Gratitude on Life Satisfaction. Psychol Res Behav Manag. 2023 Nov 28;16:4799-4816. doi: 10.2147/PRBM.S372432. PMID: 38047154; PMCID: PMC10693196.

158 Jun WH. Influence of Gratitude and Sense of Meaning in Life on Caregiving Self-Efficacy of Family Caregivers of Persons With Mental Illness. West J Nurs Res. 2023 Dec;45(12):1104-1110. doi: 10.1177/01939459231206046. Epub 2023 Oct 18. PMID: 37853704.

159 Wang X, Song C. The impact of gratitude interventions on patients with cardiovascular disease: a systematic review. Front Psychol. 2023 Sep 21;14:1243598. doi: 10.3389/fpsyg.2023.1243598. PMID: 37809310; PMCID: PMC10551131.

160 Jeon SE, Ryu S, Lee JY, Kim JM, Kim SW, Kang YS. The Effect of Fear of COVID-19 Infection and Anxiety on Loneliness: Moderated Mediation Effects of Gratitude. Psychiatry Investig. 2023 Sep;20(9):870-879. doi: 10.30773/pi.2023.0170. Epub 2023 Sep 19. PMID: 37794669; PMCID: PMC10555511.

161 Diniz G, Korkes L, Tristão LS, Pelegrini R, Bellodi PL, Bernardo WM. The effects of gratitude interventions: a systematic review and meta-analysis. Einstein (Sao Paulo). 2023 Aug 11;21:eRW0371. doi: 10.31744/einstein_journal/2023RW0371. PMID: 37585888; PMCID: PMC10393216.

162 Borelli E, Bigi S, Potenza L, Gilioli F, Artioli F, Porzio G, Porro CA, Efficace F, Bruera E, Luppi M, Bandieri E. Gratitude among advanced cancer patients and their caregivers: The role of early palliative care. Front Oncol. 2022 Oct 24;12:991250. doi: 10.3389/fonc.2022.991250. PMID: 36353529; PMCID: PMC9639866.

163 Tani Y, Koyama Y, Doi S, Sugihara G, Machida M, Amagasa S, Murayama H, Inoue S, Fujiwara T, Shobugawa Y. Association between gratitude, the brain and cognitive function in older adults: Results from the NEIGE study. Arch Gerontol Geriatr. 2022 May-Jun;100:104645. doi: 10.1016/j.archger.2022.104645. Epub 2022 Jan 30. PMID: 35123174.

164 Newman DB, Gordon AM, Mendes WB. Comparing daily physiological and psychological benefits of gratitude and optimism using a digital platform. Emotion. 2021 Oct;21(7):1357-1365. doi: 10.1037/emo0001025. Epub 2021 Nov 15. PMID: 34780238; PMCID: PMC9070006.