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To be useful, the above definition of health needs to be unpacked. Philosophers, psychologists, poets, songsters and others have had much to say about what makes a person feel well. A key concept is that of need satisfaction. In Maslow’s (1943) more academic hierarchy of needs (Figure 1.1), a person is healthy if all of their needs are satisfied, starting with the most basic needs for air, food, water, sex, sleep, homeostasis and excretion. Then as need satisfaction moves towards the top of the pyramid, the epitome of need satisfaction, a person becomes more and more ‘satisfied’, and thus physically and mentally healthy to the point of ‘self-actualization’.

Maslow’s hierarchy framework has been influential. It puts the concept of ‘self-actualization’ at the top of the pyramid, a state in which the person feels they have achieved a so-called ‘peak experience’ of meaningful and purposeful existence. Maslow’s needs hierarchy emphasizes the great importance of safety, love and belonging, and self-esteem. For every good principle in psychology, there are always exceptions, and human needs do not always fall into any fixed hierarchy. For example, an extreme sports enthusiast who is into mountain climbing may put ‘esteem’ and ‘self-actualization’ ahead of ‘safety’. We read about it in the news the next morning. Few would disagree about the existence of the five levels of need within the pyramid. However, there are also key elements of human fulfilment that are not explicitly mentioned in Maslow’s hierarchy, for example, agency and autonomy – the freedom to choose – and the often-neglected spirituality – the subjective intuition that lacks any hard empirical proof that not all that is significant is of the physical world.

Figure 1.1 Maslow’s hierarchy of human needs

Homeostasis is a core concept within Physiology, a regulating property of the organism wherein the stability of the internal environment is actively maintained. The function of cells, tissues and organs are organized into negative feedback systems. Homeostasis operates at cellular, organismic and ecosystems levels. At organismic level, homeostasis regulates core body temperature and the levels of pH, sodium, potassium and calcium, glucose, water, carbon dioxide and oxygen in the body.

In Chapter 2 we present a Homeostasis Theory of Behaviour which can be applied across all areas of health psychology. If homeostasis breaks down, a person can suffer a variety of life-threatening conditions, including diabetes, obesity, starvation, chronic thirst and insomnia (Marks, 2015, 2016a, 2016b). Homeostasis is not actually a ‘need’ as suggested by Maslow’s pyramid; it is the process that works towards the restoration of equilibrium, as we shall see in Chapter 2. A broad spectrum of evidence from many scientific fields suggests that homeostasis is an organizing principle of considerable generality, not simply at the level of physiological need, but throughout the psychological universe of regulation of thought, feeling and action (Marks, 2018).

Throughout history, philosophers have discussed the nature of a good and happy life or what, in health care, is termed ‘quality of life’ (QoL). For Aristotle, happiness was viewed as ‘the meaning and the purpose of life, the whole aim and end of human existence’. For utilitarians such as Jeremy Bentham, happiness was pleasure without pain. To individuals suffering from cancer or other conditions with pain, unpleasant physical symptoms and treatment options, and an uncertain prognosis, QoL has special relevance.

QoL has been defined by WHO as (take a deep breath):

An individual’s perception of their position in life, in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards, and concerns. It is a broad ranging concept, affected in a complex way by the person’s physical health, psychological state, level of independence, social relationships, and their relationship to salient features of their environment. (WHOQoL Group, 1995: 1404)

A sixth domain, concerning spirituality, religiousness and personal beliefs, was later added by the WHOQoL Group (1995). The Collins dictionary defines QoL more simply as: ‘The general well-being of a person or society, defined in terms of health and happiness, rather than wealth.’ The QoL concept overlaps with that of subjective well-being (SWB), which has been defined by a leader in the field, Ed Diener (‘Dr Happiness’), as: ‘An umbrella term for different valuations that people make regarding their lives, the events happening to them, their bodies and minds, and the circumstances in which they live’ (Diener, 2006: 400). The evidence linking SWB with health and longevity is strong and plentiful.

With a global population of more than seven billion unique individuals of diverse cultures, religions and social circumstances, one wonders whether QoL can ever be assessed using a single yardstick. A few courageous individuals and organizations have given it a try and, since the 1970s, many scales and measures have been constructed. A few examples are listed in Table 1.2.

By far, the most utilized scale to date has been the SF-36, which accounts for around 50% of all clinical studies (Marks, 2013). These ‘happiness scales’ are diverse and consist of items about what makes a ‘good life’. For example, Diener et al.’s (1985) brief Satisfaction with Life Scale (SWLS) uses a seven-point Likert scale with five items:

In most ways my life is close to my ideal.

The conditions of my life are excellent.

I am satisfied with my life.

So far I have gotten the important things I want in life.

If I could live my life over, I would change almost nothing.

Table 1.2

Using the 1–7 scale below, testees indicate their agreement with each item by placing the appropriate number on the line preceding that item. They are asked to ‘be open and honest’ in their responding.

7 Strongly agree

6 Agree

5 Slightly agree

4 Neither agree nor disagree

3 Slightly disagree

2 Disagree

1 Strongly disagree

For the vast majority of people, SWB is relatively stable over the long term. Using longitudinal data, Headey and Wearing (1989) reported that when the level of SWB changed following a major event, it tended to return to its previous level over time. To account for this, the authors proposed that each person has an ‘equilibrium level’ of SWB, and that ‘personality’ restores equilibrium after change by making certain kinds of events more likely. Restoration of equilibrium is nothing to do with personality; it’s a fundamental stabilizing process across all living systems, called ‘homeostasis’.

Diener and Chan (2011) review evidence that having high SWB adds four to ten years to life. The evidence for an association between SWB and all-cause mortality is mounting. As always, there could be a mysterious third variable influencing both SWB and mortality (e.g., foetal nutrition, social support, lifestyle) and, if the relationship between SWB and mortality did prove to be causal, the possible mediating processes would be a matter for speculation and further research. For the time being, it seems safe to assume that happy people live longer.