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Assessing and encouraging enjoyable activities

What we've seen in our work is that most people don't give themselves permission to live until they've been given a terminal diagnosis.                 
Stephen Levine

I came across an interesting research study recently: Pressman, S. D., K. A. Matthews, et al. (2009). "Association of Enjoyable Leisure Activities With Psychological and Physical Well-Being." Psychosom Med 71(7): 725-732. [Abstract/Full Text] 
Objective: To examine whether engaging in multiple enjoyable activities was associated with better psychological and physiological functioning. Few studies have examined the health benefits of the enjoyable activities that individuals participate in voluntarily in their free time. Method: Participants from four different studies (n = 1399 total, 74% female, age = 19-89 years) completed a self-report measure (Pittsburgh Enjoyable Activities Test (PEAT)) assessing their participation in ten different types of leisure activities as well as measures assessing positive and negative psychosocial states. Resting blood pressure, cortisol (over 2 days), body mass index, waist circumference, and perceived physiological functioning were assessed. Results: Higher PEAT scores were associated with lower blood pressure, total cortisol, waist circumference, and body mass index, and perceptions of better physical function. These associations withstood controlling for demographic measures. The PEAT was correlated with higher levels of positive psychosocial states and lower levels of depression and negative affect. Conclusion: Enjoyable leisure activities, taken in the aggregate, are associated with psychosocial and physical measures relevant for health and well-being. Future studies should determine the extent that these behaviors in the aggregate are useful predictors of disease and other health outcomes.

The ten leisure activities assessed were: involvement in hobbies; actively engaging in sports; being in outdoor settings such as gardens, parks, countryside; going away on holiday; club, fellowship, and religious group participation; doing fun things with others; going out for meals with friends and/or relatives; visiting friends and/or relatives; spending time unwinding at the end of the day; and spending quiet time alone.  The ten activities weren't meant to be an exhaustive list of all enjoyable possibilities, but they were meant to cover activities that are done with others & alone, in a variety of locations, and both actively & passively.  Subjects surveyed were asked to estimate how often they were involved in each of these activities (that they enjoyed) during the previous month.  As can be seen, more frequent involvement in enjoyed activities was associated with a wide range of positive measures.  The total frequency score for the complete questionnaire was more strongly associated with these positive measures than was the individual frequency score for any specific enjoyable activity. 

For a downloadable copy of a PEAT questionnaire version that I've put together click here

The study authors anchored their frequency assessment from 0 (never, not applicable or not enjoyed) to 4 (every day).  They are less forthcoming as to their descriptive terms for scores of 1, 2 & 3.  I've linked these scores to "occasionally", "quite often", and "frequently", (rather than - for example - linking them to specific numbers of days on which the subject was involved in the activity) partly because an activity like "spending time unwinding at the end of the day" practised daily seems to carry a somewhat different weight to "going out for meals with friends and/or relatives" or "actively engaging in sports" practised daily (so what I mean by occasionally/quite often/frequently is a little different depending on the activity being assessed).

Why might the PEAT be a useful questionnaire to add to the bank of assessment instruments we already use?  As a therapist I consider using the PEAT as a way of highlighting the broad range of potentially enjoyable activities that clients might become involved in - and as a way of assessing how they're doing as compared with averages in a general population.  Mean score on the PEAT in this research was about 22.  Assuming a normal distribution, approximately 70% of those surveyed would fall in the range 16.5 to 27.5.  Disability measures (that measure the extent to which respondents are not currently active at a level that's "normal" for them) are also of considerable use.  See for example four different disability questionnaires listed on this website's page "Problem solving & behavioural activation", where there are also various activity scheduling forms.  For people struggling with depression and other psychological/physical disorders associated with excessive avoidance, encouraging progressive increase in activity is of great value (Cuijpers, van Straten et al. 2007).   In their excellent book "Manage your mood", David Veale and Rob Willson provide a helpful and practical introduction to using behavioural activation as a self-help (or guided self-help) treatment for depression.

Why might one encourage involvement in some activities more than others?  Veale and Willson make the excellent point that activities that are in line with one's personal values and goals are likely to be more helpful than activities that are selected more randomly.  The well-known Bus driver metaphor is often helpful here.  A second way of choosing activities to counteract depression and other painful psychological states is to assess whether there were any types of activity whose reduction might have contributed to the onset or exacerbation of the psychological disorder - for example loss of social activity after a divorce or bereavement, loss of physical activity after an injury, and so on.  One might then preferentially choose to increase activity involvement that helps to "plug the gap".  A third way to choose one type of activity over another is because one knows, from research or the subject's previous experience, that certain types of involvement are likely to be particularly helpful - to counteract psychological symptoms, or build physical health, or encourage wellbeing (or all three).  Exercise and social involvement immediately come to mind as probably relevant here.

Increasing involvement in enjoyable activities doesn't just counteract negative mood, it also builds positive mood.  Increased positive mood is of underestimated value.  See, for example Barbara Fredrickson's work on the broaden-and-build theory, or Sin & Lyubomirsky's systematic review this year on "Enhancing well-being and alleviating depressive symptoms with positive psychology interventions: a practice-friendly meta-analysis" or Chida & Steptoe's recent paper "Positive Psychological Well-Being and Mortality: A Quantitative Review of Prospective Observational Studies"

It makes sense for pretty much all of us to take an occasional look at whether we are giving ourselves enough of this kind of time off.  "All work and no play makes Jack a dull boy" is one way of putting it - or, more arrestingly - see Mary Oliver's beautiful poem "The Summer Day" which ends with the words: 

 

I don't know exactly what a prayer is.
I do know how to pay attention, how to fall down
into the grass, how to kneel down in the grass,
how to be idle and blessed, how to stroll through the fields,
which is what I have been doing all day.
Tell me, what else should I have done?
Doesn't everything die at last, and too soon?
Tell me, what is it you plan to do
with your one wild and precious life?

 

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