This section discusses the factors that influence our cognitive perceptions and their roles in wellness strategies. It helps us distinguish common misattributions (thinking traps) that interfere with optimizing happiness, and it reviews the evidence-based strategies for enhancing wellbeing. Moreover, it teaches us how to activate these strategies during residency training.


Do you see two profiles... or a vase?

This illustration shows us that different people can see the world in different ways - that is - we can have different cognitive perceptions.

Skill building exercise

Can you name at least four factors that influence cognitive perceptions? Find out...
Our cognitive perception are shaped by:
  • past experience and familiarity biases
  • personal, family and cultural expectations
  • language
  • psychological ”set”: genetic or learned tendencies to see things a certain way

The iceberg principle: it is the tendency of the human mind to perceive only a small piece (the "tip" of an iceberg's mass) of reality through a limited lens (see Figure 1). The lens can shift, and perspective can change!

Using the iceberg principle to our advantage will enable us to: (i) recognize that our viewpoint is a limited cognitive lens at any given moment, (ii) imagine and be aware of other perspectives, and (iii) develop cognitive flexibility.

Cognitive flexibility (or permitting our lens to shift) is a great life skill and is associated with many other adaptive qualities found in resilient thinking. Cognitive flexibility is related to a sense of wellbeing.

<strong>Figure 1.</strong> The iceberg principle

Figure 1. The iceberg principle

Skill building exercise

Can you think of an example where cognitive flexibility and taking perspective helped you in your own life?

From a historical perspective, Aristotle used the term “eudaimonia” in his work for highest human good. Eudaimonia is derived from Greek, where “eu” means good and “daemon” means spirit. It translates into having a good, indwelling spirit or ”human flourishing”.

Aristotle believed that happiness was related to good living, such as taking perspective on what aspects of our lives are meaningful and give us a sense of purpose (see Figure 2).

<strong>Figure 2.</strong> From <i>The School of Athens</i>, Raphael's 1509 fresco, showing Aristotle (right) and Plato (left)

Figure 2. From The School of Athens, Raphael's 1509 fresco, showing Aristotle (right) and Plato (left)

What does it mean for us to develop a positive cognitive set?

Click on the items below to find out.
Cognitive flexibility
The ability to focus on what is changeable in challenging situations and to shift focus away from ruminating about things we cannot change.
Not rose-coloured glasses, but a willingness to look beyond problems for what is good in ourselves and others and to look for what is meaningful in situations of distress.

How does it work?

Positive cognitive set is correlated with other key protective factors such as higher reported happiness, secure attachment relationships, and problem-solving skills (Kobau et al, 2011).

Skill building exercise

1. Do you know of a standard psychotherapeutic tool that can help tackle cognitive distortion? Find out...
Cognitive restructuring as a therapeutic tool of cognitive behavioural therapy
2. Can you name at least four well-known cognitive distortions? Find out...
  • All-or-nothing thinking
  • Catastrophizing/minimizing
  • Filtering
  • Overgeneralization
  • Disqualifying the positive
  • Disavowing the negative
  • Jumping to conclusions
  • Emotional reasoning
  • Should statements
  • Personalization

The cognitive triangle: first proposed by Aaron Beck in 1976, it depicts how thoughts, emotions, and behaviours all influence each other (see Figure 3) (Beck, 1976; Burns, 1980; Burns, 1989).

<strong>Figure 3.</strong> The cognitive triangle (Beck, 1976; Burns, 1980; Burns, 1989)

Figure 3. The cognitive triangle (Beck, 1976; Burns, 1980; Burns, 1989)


Misappraisals impact our wellbeing (see Figure 4 for common misappraisals). A misappraisal is the failing to perceive or value the things that have evidence to promote our wellbeing, focusing instead on things that have little evidence to support their role in improving a sense of wellbeing.

What contributes to a sense of wellbeing?

  • 50% is genetic tendency (glass half-full/empty)
  • 10% is attribution to environmental factors (e.g., material possessions, relationships, job, grades)
  • 40% is about attitudes and behaviours: SHAPEABLE!
  • (Lyubomirsky et al, 2005)

To learn more about the common misappraisals illustrated in Figure 4, click on the thinking traps below.

<strong>Figure 4.</strong> Common misappraisals

Figure 4. Common misappraisals

Trap #1: It’s all in my genes...

What percentage of perceived emotional wellbeing (happiness) is genetically determined by inherited family genes? What determines happiness?
Only about 50% of baseline happiness is genetically inherited as a ”happiness” trait. There is definitely a tendency to see the glass half-full or empty, but it is a tendency that is modifiable! Outside of extreme circumstances such as chronic abuse and failure to have basic safety and shelter, only about 10% of wellbeing appears to be attributable to environmental factors (see Figure 5) (Lyubomirsky et al, 2005).
<strong>Figure 5.</strong> Determinants of happiness (Data derived from Lyubomirsky et al, 2005)

Figure 5. Determinants of happiness (Data derived from Lyubomirsky et al, 2005)

Trap #2: It’s all in my environment...

Which event would produce a profound and long lasting impact on our overall happiness level?

A. Incorrect

We all dream of winning the lottery, but it will not buy us lifelong happiness. Researchers in Illinois in the 1970s interviewed lottery winners who won between $50,000 and $1,000,000 (remember, this is the 1970s) and found that only one year after winning, their happiness levels were no different than the group who did not win. In fact, the lottery winners noticed that they experienced less enjoyment from ordinary day to day activities compared to the non-winners. This difference was statistically significant (Brickman et al, 1978).

B. Incorrect

Marrying your soul mate is a good idea but it will not have long lasting effect on your happiness level. Although there were individual differences, on average, people experienced a happiness boost for two years after marriage, followed by return toward baseline levels (Lucas et al, 2003).

C. Incorrect

Although we may assume that severe medical illness will leave to unhappiness, the effect is not long lasting. It appears that hemodialysis patients adapt to their medical illness and new health status. Although they report their own health to be worse than others, this does not appear to have a significant impact on overall happiness (Riis et al, 2005).

D. Incorrect

Although accident victims did find everyday events less enjoyable than controls, this was not statistically significant. Ratings of past happiness and present happiness were significantly lower than controls, but there was no difference in ratings of future happiness (Brickman et al, 1978).

E. Correct

Positive psychology research shows that personal attitudes and behaviours can be more impactful for long-term sense of wellbeing than extremely positive/negative life events.

Traps #3 and #4: The “I should...” or “If only...”

Do any of these statements sound familiar to you?
I should...
  • Buy a bigger home
  • Work less
  • Work more
If only...
  • If had more time to myself, I would be happier...
  • If only I made 20% more money per year...
  • If only I could lose 10 lbs...

The good news is that 40% of our happiness level is dictated by intentional activity, and hence, it is under our control.

The bad news is that, in general, we do not have an accurate view of what increases happiness levels, and often what we think will make us happier in fact can do the opposite, or have no impact on overall happiness level.

So, why don’t these things make us happy as we think they will?

It is about hedonic adaptation! Hedonic adaptation is the observed tendency of humans to quickly return to a relatively stable level of happiness despite major positive or negative events or life changes. Or, in other words, no matter if we win the lottery or get a divorce, we go back to our usual level of happiness eventually (Brickman et al, 1978).

How does hedonic adaptation work?

The effect of hedonic adaptation is a form of emotional and cognitive habituation to positive or negative stimuli. Research shows that it seems to be stronger when related to changes in life circumstances, and a weaker effect is observed in the case of changes in activity. We habituate less easily to experiences than circumstances.

How can you hack the trap of hedonic adaptation with intentional behaviour?

For this, ensure your activity is:

  • Episodic (e.g., may adapt less readily, as by nature activity is transient)
  • Varied (e.g., engage in different manners, times of day, settings)
  • Choose activity that directly counteracts adaptation (e.g., intentionally draw attention to features that produced your initial happiness boost after a previous circumstantial change)

What specific strategies increase wellbeing?

So, if winning the lottery, finding love, and earning more money do not ultimately change our happiness level over the long term, then what does? Current data on wellbeing and power of resilient thinking has been well captured in The How of Happiness by Sonja Lyubomirsky (2008).

Evidence-based positive psychology skills to increase wellbeing comprise the following:

  • Focusing on kindness/doing things for others
  • Building on signature strengths
  • Savouring and gratitude practice
  • Cognitive reframing
  • Finding what is meaningful
  • States of flow
  • Mindfulness practice to stay in the here-and-now*
  • Valuing physical self-care*
       *Evidence-based strategies to reduce depression relapse  

1. Focusing on kindness/doing things for others

Dunn et al (2013) found that people who spent money on others instead of themselves were happier. Acts of kindness through money were found to increase happiness most when they involved feeling more socially connected and being able to see the impact of your act directly. This held true across different cultures and socioeconomic statuses.

2. Building on signature strengths

It is important to know our own character strengths and cultivating them in daily life. Figure 6 shows key character strengths as depicted by Martin Seligman (Park et al, 2004; Lyubomirsky, 2008). Visit to learn more.

Do you want to test your own character strengths?

Take a quiz: Character Strengths Survey. The Values In Action Character Strengths Inventory (VIA) survey is a free, online, scientifically validated survey of character strengths. The survey is a 240-question inventory, through which activation of your key strengths is linked to long-term wellbeing. Once identified, use your top strengths regularly by practicing them in daily life. This has been shown to increase your baseline wellbeing significantly (Park et al, 2004; Lyubomirsky, 2008).

<strong>Figure 6.</strong> Seligman’s signature character strengths (Data derived from Park et al, 2004; Lyibomirsky, 2007)

Figure 6. Seligman’s signature character strengths (Data derived from Park et al, 2004; Lyubomirsky, 2008)

3. Savouring and gratitude practice

This is a regular acknowledgement of what is going well in life and knowing what you are grateful for. Gratitude practice is correlated with an increased sense of wellbeing. Visualizing past positive events and anticipating future ones can increase your happiness baseline.


4. Cognitive reframing

This is about reframing situations in a more positive light, and pausing to count one’s blessings.

Example: “I’m so overloaded with work...” Reframing: “I am one of very few given this training. Whenever possible, I want to appreciate the opportunity to learn as much as I can...”

5. Finding what is meaningful

Stay focused on important personal goals that are meaningful to you, even when there are many external demands on your agenda. Focus on the journey, rather than the end point. Brunstein (1993) found that the process of working toward a goal or participating in a valued, challenging activity is as important to wellbeing as its attainment.

6. States of flow


This means a mental state of complete absorption.

”... the best moments of our lives are not the passive, relaxing times... the best moments usually occur if a person’s body or mind is stretched to its limits in a voluntary effort to accomplish something difficult and worthwhile” (Csikszentmihalyi, 1997).

Skill building exercise

  • How do we find flow? Based on Figure 7, what state do you find yourself in most at home? At work? How about during leisure?

  • When was the last time you remember experiencing flow?

“The metaphor of flow is one that many people have used to describe the sense of effortless action they feel in moments that stand out as the best in their lives. Athletes refer to it as "being in the zone," religious mystics as being in "ecstasy," artists and musicians as "aesthetic rapture.” It is the full involvement of flow, rather than happiness, that makes for excellence in life. We can be happy experiencing the passive pleasure of a rested body, warm sunshine, or the contentment of a serene relationship, but this kind of happiness is dependent on favorable external circumstances. The happiness that follows flow is of our own making, and it leads to increasing complexity and growth in consciousness.” (Csikszentmihalyi, 1997)

<strong>Figure 7.</strong> The Csikszentmihalyi’s flow model of the mental state based on challenge level and skill level 
    	                   (Data from <a href=''>Flow (psychology), Wikipedia/the free encyclopedia</a>)

Figure 7. The Csikszentmihalyi’s flow model of the mental state based on challenge level and skill level (Data from Flow (psychology), Wikipedia/the free encyclopedia)

7. Mindfulness practice to stay in the here-and-now

One of Canada's great artists, Maud Lewis, was introduced to the world in a 1965 CBC series portraying the artist at work in and around her house (to view the video, go to the CBC Archives). Maud Lewis and folk art truly captures the spririt of wabi sabi Nova Scotia style. She creatively prospered throughout her life, in spite of considerable adversity - look at her hands in the video (she had severe form of juvenile rheumatoid arthitis) and the size of her paintings, which reflected the fact that she only had a very limited range of motion of her arms... and in spite of this... limitation and imperfection, her art expresses a joy and optimism about the world around her, in spite of the very clear long-term imperfections and hardships she dealt with in her life.

Benefits of mindfulness practice include the following:

  • The impact of cognitive distortions linked to anxiety and depression can be reduced by practicing mindfulness and staying in the moment.
  • Catastrophizing, anticipating the worst, and ruminating about the past can all distort the present and interfere with wellbeing.
  • Mindfulness can reduce the risk of depression relapse.


States of focused attention also support chromosomal health. In the interest of learning new things, the chromosomal level is an interesting new place to talk about with respect to mind, mood, and health across our lifespan. Telomeres are DNA-protein structures found at the ends of chromosomes and they play a vital role in protecting the genetic material in our genome. When we are very young, these telomeres are 8,000-10,000 base pairs long (Blackburn et al, 2016).

So what do telomeres have to do with healthy aging? Telomeres act like plastic ends of shoelaces protecting the lace itself from unravelling. Telomeres do the same thing for chromosomes: they keep the active portions of the chromosome protected, and keep them from unravelling or abnormally crosslinking.

Telomere shortening is associated with aging and diseases of aging, including:

  • Depression
  • Heart disease
  • Stroke
  • Diabetes mellitus
  • Cancer

8. Valuing physical self-care

Behavioural activity: regular exercise was found to boost mood and vitality lasting up to six months afterwards.

Physical activity and mood regulation: in a Cochrane review of 38 randomized double blind studies (n = 2,326 subjects), exercise has shown significant benefit for mood regulation, including for mild and moderate depressive symptoms.

Physical activity is the number one recommendation for treatment of mild and moderate severity of depression, according to the Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines.

Neuronal firing with running: physical activity is known to be an excellent mood enhancer and even an effective treatment for clinical depression, because exercise activates neurochemistry.


In a meta-analysis of 193,166 subjects, sedentary behaviour has been correlated with a 25% increased risk of depression (Zhai et al, 2015). Staying active is probably the single most effective do-no-harm option for improving your mood, aside from ensuring you are not overconsuming an actual CNS depressant such as alcohol.

1 What percentage of our happiness level is dependent on intentional thinking/activity?
A. Incorrect
B. Correct
C. Incorrect
D. Incorrect

2 Which of the following is not a common misappraisal with negative impact on our sense of wellbeing?

3 Ariana is a second year resident who is finding the amount of work overwhelming. She also notes that her violin playing, which often provides her with stress relief, is not as enjoyable as it has been in the past. What should she do to increase her wellbeing?
A. Incorrect. Playing the violin at the same time every day would lead to hedonic adaptation.
B. Correct. Varying the circumstances under which you do an activity will decrease hedonic adaptation.
C. Incorrect. She should savour positive events whenever they happen.
D. Incorrect. Making a list of why the violin playing is not as enjoyable anymore focuses on the negative and not the positive aspects of the activity.

4 Noah is a fourth year resident who had an episode of major depression last year. He wants to continue his residency in a healthy manner. Which of the following are evidence based strategies to increase baseline happiness and wellbeing and reduce depression relapse?
A. Correct. Both mindfulness practice and exercise have evidence for increasing wellbeing and decreasing depression relapse.
B. Incorrect. Building on signature strengths is a strategy to increase happiness, but does not have evidence for decreasing depression relapse.
C. Incorrect. Increasing time spent in “flow” states is a strategy to increase happiness, but does not have evidence for decreasing depression relapse.
D. Incorrect. Identifying and addressing cognitive distortions is a strategy to increase happiness, but does not have evidence for decreasing depression relapse.

5 What strategies can we use to promote flexible resilient thinking in residency training? Choose one answer only.
A. Partially correct. This is one strategy to promote cognitive flexibility, but so is mindfulness and focused attention.
B. Partially correct. This is only one strategy to promote flexible resilient thinking.
C. Partially correct. Use signature strengths to make a project personally meaningful rather than a ”to-do” job, and to generate flow.
D. Partially correct. This is one strategy to promote cognitive flexibility, but so is managing cognitive distortions and generating flow.
E. Correct. All these are useful strategies to promote flexible resilient thinking.
  • Our cognitive perception is shaped by many factors including past experiences and cultural expectations.
  • The iceberg principle conveys that we perceive only a small piece of our reality.
  • Fortunately, we can develop cognitive flexibility and resiliency to see other perspectives and focus on what is changeable in any challenging situation.
  • Positive thinking is linked with happiness, secure attachment relationships, and problem-solving skills.
  • Cognitive behavioural therapy can help us change cognitive distortions and misappraisals.
  • Our sense of wellbeing is only 50% genetic; 10% is due to environment but, importantly, 40% is due to our attitudes and behaviours, and we can shape those!
  • Hedonic adaptation is our tendency to return to a stable level of happiness despite good or bad things happening to us. Making our behaviours episodic and varied challenges hedonic adaptation.
  • Specific behaviours that have been associated with happiness include:
    • Focusing on kindness
    • Building on signature strengths
    • Savouring and gratitude practice
    • Cognitive reframing
    • Finding what is meaningful
    • States of flow
    • Mindfulness practice to stay in the here-and-now
    • Valuing physical self-care

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  • Blackburn E, Epel E. The Telomere Effect. Grand Central Publishing. New York, NY, 2017.
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  • Burns DD. The Feeling Good Handbook. New York, NY, US: Morrow, 1989.
  • Csikszentmihalyi M. The Masterminds Series. Finding Flow: The Psychology of Engagement with Everday Life. New York, NY: Basic Books, 1997.
  • Csikszentmihalyi M. Finding flow. 1998. Accessed Sept 14, 2018.
  • Dunn E, Norton M. Happy Money: The Science of Happier Spending. Toronto, ON: Simon & Schuster, 2013.
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  • Lyubomirsky S. The How of Happiness. A New Approach to Getting the Life You Want. New York, NY: Penguin Group, 2008.
  • Park N, Peterson C, Seligman MEP. Strengths of character and well-being. J Soc Clin Psychol. 2004;23:603-19.
  • Riis J, Loewenstein G, Baron J, Jepson C, Fagerlin A, Ubel PA. Ignorance of hedonic adaptation to hemodialysis: A study using ecological momentary assessment. J Exp Psychol Gen. 2005;134:3-9.
  • Seligman M. Character Strengths Questionnaire. 2005. Accessed Sept 15, 2018.
  • Zhai L, Zhang Y, Zhang D. Sedentary behaviour and the risk of depression: a meta-analysis. Br J Sports Med. 2015;49(11):705-9.