The Grateful Heart: Reviewing the

literature on gratitude

By: Teri Crawford BrownAspen University

Attitude is everything. Gratitude is the ultimate attitude adjustment. Researchers have conducted numerous studies on the effect and benefits of gratitude. Gratitude, it turns out, is a very powerful and often overlooked emotion. Gratitude is a powerful force which instantly begins propelling people forward toward happiness, success, and health. Once established as a force within a person gratitude naturally begins radiating out toward others.

This literary review is designed to help nurses see the proven value of using gratitude in their daily lives to positively affect their attitude and to show the proven affects that gratitude can have on the patient’s outcomes and perceptions of their illness.

The idea of reviewing the available literature on gratitude began three years ago as I started on a personal journey to make me the best version of myself. This journey has led me to the realization that gratitude is the secret to happiness; it is the foundation of wanting what you have, and to being present in the moment with a happy heart. I made a vision board and every morning and night I gave gratitude for the things that were presently in my life and for the things that were coming into my life. I began to write in my journal three things I was grateful for everyday and I started making a conscious effort to give gratitude for every circumstance I was faced with: good or bad. I learned to have gratitude for the lessons that these circumstances came to teach me and not to view unpleasant situations as bad but rather as lessons

These small changes created a complete shift in my thinking and led me to a peace filled, joyful, life. During this time my uncle, that I was very close to, was diagnosed with and being treated for Metastatic Melanoma. He was 50 years old when he was diagnosed and from the beginning we realized that he had a very small chance of survival. Together we practiced positive thinking and gratitude throughout his treatment. As we all know, cancer is a cruel disease, and its treatments almost as cruel. It was a struggle for me to keep an attitude of gratitude seeing the amount of suffering that my uncle was going through. Then, on a Friday, the week before my uncle passed, I was driving him to the hospital to be admitted for rectal bleeding, he weighed 108 pounds, the cancer had come to the outside of his chest, neck, throat, it was horrible, he was in dreadful pain. As we were driving to the hospital my uncle said to me “you know Teri, I am so grateful for my vision, it would be awful to not be able to see” This sentence shook me to the core. He was grateful. Even with everything his body was suffering, all the pain, all the vomiting, deformity, and the certainty that his days were numbered, he still chose to be grateful.

Although gratitude has most often been conceived of as a discrete emotion, gratitude is also an affective trait. (McCullough, Emmons, & Tsang, 2002) The grateful disposition is a generalized tendency to recognize and respond with positive emotions to the role of other moral agents' benevolence. At the dispositional level, grateful people report higher levels of positive emotions, life satisfaction, vitality, optimism, and lower levels of depression and stress (Pozgar, 2013). They also experience relatively low levels of negative effects such as resentment, depression, and envy.

JudaismIn Judaism, gratitude is a vital component of worship and permeates every aspect of the worshipers’ daily life

. Thankfulness for everything is appropriate in Judaism because all things come from God. In the Hebrew worldview, the Jewish life is filled with thankfulness. A prayer is said upon hearing good or bad news, and God is praised for everything. In this way, a divine perspective on life is kept

Christianity Gratitude has always been central among the Christian virtues. Being created by a personal God, Christians are obligated to praise and thank the source of life. It is argued that gratitude molds and shapes the entire Christian life, thus being, inextricably, connected to mental, physical, and relational well-being. An indebtedness to others enables followers of Christ to share a common bond, which shapes not only emotions and thoughts, but actions and deeds. In Christian gratitude, God becomes the giver of all good gifts, the ultimate foundation of thankfulness, gratitude is a state of well-being and righteousness, these stem from a profound sense of indebtedness to the Creator, Sustainer, and Redeemer.

Islam

The Holy Koran repeatedly asserts the necessity for gratitude and thankfulness to God

throughout its chapters. For instance, in Sura fourteen, it is written “If you are grateful, I will

give you more” (14:7). A traditional Islamic saying states that, “The first who will be summoned

to paradise are those who have praised God in every circumstance.” The prophet Mohammad

also said “Gratitude for the abundance you have received is the best insurance that the abundance

will continue.” (Fadiman & Frager, 1997) True gratitude, it is taught, brings more abundance

upon the believer.

Psychological perspectives on gratitude

. Virtually ignored in psychology's past, the importance of gratitude for personality and social behavior has recently been rediscovered. In their analysis of gratitude, McCullough, Kilpatrick, Emmons, and Larson conceptualize gratitude as having three morally relevant functions, which of a moral barometer, a moral motivator, and a moral reinforcer. They hypothesized that by experiencing gratitude, a person is motivated to carry out prosocial behavior, energized to sustain moral behaviors, and is inhibited from committing destructive interpersonal behaviors. As a moral barometer, gratitude provides individuals with an affective readout that accompanies the perception that another person has treated them prosocially. As a moral motive, gratitude stimulates people to behave prosocially after they have been the beneficiaries of other people's prosocial behavior. As a moral reinforcer, gratitude encourages prosocial behavior by reinforcing people for their previous prosocial behavior.

Giving Thanks: Spiritual and Religious Correlates of Gratitude was published in 2005 in the Journal of Psychology and Christianity

This is the first empirical article on gratitude to appear in a journal of Christian psychology.

Outlines a study done on 199 people. The purpose of the study, according to the authors, is if there are sufficient theological and psychological reasons to anticipate that individuals who are religious report higher levels of gratitude compared to their less religious counterparts.

They predicted they would observe strong, positive associations between gratitude and religion/spirituality. In that spiritual issues are at the forefront of quality of life concerns for people with chronic disease, they employed a unique sample: Adults with congenital or later-onset neuromuscular diseases.

• The results of this study suggest one explanation for why religiously involved people are at a lower risk for depressive symptoms or other mental health difficulties

• The authors hope that future research will refine their understanding of gratitude within a spiritual and religious frame work and will lead to new and testable hypotheses concerning religion, emotion, and psychological well-being.

• The association between gratitude and religion may reflect the fact that people who are highly religious and/or spiritual tend to perceive positive circumstances in their lives that are not caused by human action (e.g., eyesight, a sunny day) as nevertheless resulting from the intentional behavior of a benevolent moral agent (i.e., God or a higher power). In contrast, less religious or spiritual individuals might attribute these same events as due to chance, and therefore, be less inclined to feel grateful in response.

The Role of Gratitude in Breast Cancer: Its Relationships with Post-traumatic Growth, Psychological Well-Being and Distress By: Chiara Ruini and Francesca Vescovelli

-The sample consisted of 70 consecutive women recruited from the Breast Cancer Center of the Santa Croce Hospital in Loreto (Italy). -The findings of this investigation provide confirmation of the strong association between gratitude and post-traumatic growth in oncological settings. Indeed, people’s recovery from potentially traumatic experiences is modulated by the extent to which they are able to discover some benefit in the experience. Focusing on these benefits and on the positivity that patients perceive, seems to be very important for activating growth processes that are related to a better psychological adaptation to the medical condition.

The efficacy of a character strengths and gratitude intervention for people with chronic back pain by Heidi Baxter, Malcolm Johnson and Debbie Bean in 2012

The efficacy of a character strengths and gratitude intervention for people with chronic back pain by Heidi Baxter, Malcolm Johnson and Debbie Bean in 2012 explores the efficacy of a character strengths and gratitude intervention to reduce pain and increase positive affect in people with chronic back pain. The following two questions guided the research: i) What is the efficacy of a character strengths and gratitude intervention significantly improving mood in people with chronic back pain? ii) To what extent would a character strengths and gratitude intervention significantly reduce the experience of pain in people with chronic back pain compared to an alternative positive memories intervention? Data were collected from eight participants (females = 4). The mean age was 54.63 (SD = 8.25)The findings of the present study offer partial support for the character strengths and gratitude intervention improving mood in people with chronic back pain.

The role of gratitude in medical settings remains largely under- investigated, as opposed

to post-traumatic growth, which has increasingly being studied in life-threatening illnesses. This

study hypothesis is that gratitude, conceived as a personality disposition, might be an important

ingredient for PTG and thus associated with a higher well-being and to lower distress also in a

life-threatening illness such as breast cancer. As far as the authors knew, this was the first study

in a breast cancer patient sample that aims to assess the role of gratitude in promoting post-

traumatic growth, well-being, and in reducing distress.

• The aims of this study were to: (a) examine the role of gratitude in a breast cancer sample and its correlations with post-traumatic growth, psychological well-being, and psycho- logical distress; (b) compare patients reporting higher levels of gratitude (High Gratitude Individuals, HGI) versus those reporting lower levels of gratitude (Low Gratitude Individuals, LGI) in the above measures, in order to determine if dispositional gratitude may contribute to better mental health indicators.

• The sample consisted of 70 consecutive women recruited from the Breast Cancer Center of the Santa Croce Hospital in Loreto.

• The findings of this investigation provide confirmation of the strong association between gratitude and post-traumatic growth in oncological settings. Indeed, people’s recovery from potentially traumatic experiences is modulated by the extent to which they are able to discover some benefit in the experience. Focusing on these benefits and on the positivity that patients perceive, seems to be very important for activating growth processes that are related to a better psychological adaptation to the medical condition.

The efficacy of a character strengths and gratitude intervention for people with chronic back pain

• 2012 explores the efficacy of a character strengths and gratitude intervention to reduce pain and increase positive affect in people with chronic back pain. The following two questions guided the research: 1) what is the efficacy of a character strengths and gratitude intervention significantly improving mood in people with chronic back pain? 2) To what extent would a character strengths and gratitude intervention significantly reduce the experience of pain in people with chronic back pain compared to an alternative positive memories intervention? The primary intent of the present study was to provide initial indications of the efficacy of a positive psychology intervention in a sample of people with chronic back pain.

• Data was collected from eight participants (females = 4). The mean age was 54.63 (SD = 8.25), ranging from 39 to 67. Participants had lived with chronic back pain for an average of 8 years (SD = 8.72), ranging from 1.50 to 27 years, in addition to a number of other concurrent medical conditions. The initial incidents associated with the onset of pain were varied.

• Visual examination of the daily ratings reflected in these figures showed that for six of the eight participants happiness was highest during the character strengths and gratitude intervention, while anger was lowest for all participants during this condition. No trends were apparent for anxiety, nor depression. There was a significant difference in anger ratings between the conditions in favor of the character strengths intervention (Friedman's test, F (2) = 11.267, p = 0.004). That means anger was lower in the character strengths and gratitude intervention than either the baseline or the positive writing comparison condition (both p <0.05). Anger did not differ during the baseline or positive writing comparison condition

• The present study showed that the character strengths and gratitude intervention significantly reduced anger and improved daily happiness for the majority of participants. While it was not effective in improving sadness, anxiety, depression, pain catastrophizing or pain, a number of factors were not controlled for. These included medication changes and adherence. Positive psychology intervention may be effective for people with chronic back pain.

How gratitude relates to burnout

and job satisfaction in mental health

professionals.

This study investigated how gratitude relates to burnout and job satisfaction in mental health professionals. Burnout has been linked to poor health outcomes. For instance, a 10-year prospective study of industrial workers found that burnout increased the risk of hospitalization due to cardiovascular disease after controlling for employee health at baseline. The goal of the present study was to examine how gratitude relates to burnout and job satisfaction. The authors hypothesized that dispositional and workplace-specific gratitude would predict burnout and job satisfaction after controlling for demographic and job-contextual variables, as well as another positive emotion, hope.Contrary to the hypotheses, workplace-specific gratitude did not predict personal accomplishment after controlling for hope, demographic/contextual variables (coworker support, education level, support from family/friends, client/provider relationship quality), and dispositional gratitude. Similarly, dispositional gratitude did not predict burnout or job satisfaction after controlling for hope and demographic/contextual variables. However, when analyses were rerun controlling for demographic/job contextual variables but not for hope, dispositional gratitude predicted personal accomplishment.

Dispositional gratitude did not predict burnout and job satisfaction after controlling for demographic/job contextual factors and hope. However, when controlling only for demographic/job contextual factors, dispositional gratitude predicted personal accomplishment. Thus, dispositional gratitude may play a role in the sense of personal accomplishment similar to that of other positive emotions, such as hope. Dispositional gratitude is more distal to workplace attitudes than workplace-specific gratitude, which may explain why it did not relate to emotional exhaustion and depersonalization. Also, it is possible to feel gratitude across a variety of situations but still have a particular aspect of life (e.g., work) where gratitude is more difficult to cultivate. These findings highlight the importance of measuring both dispositional and situational gratitude, because they may impact different aspects of well-being.

Gratitude and prosocial behavior: an experimental test of gratitude

• Prosocial responses to gratitude-operationalized as the distribution of resources to another-were paired with a self-report measure of gratitude to test the prosocial effect of gratitude. To investigate positive mood as an alternative explanation, this experiment compared responses of individuals receiving a favor to responses of individuals receiving a positive outcome by chance. A total of 40 participants were randomly assigned to either a Favor or Chance condition. Participants receiving a favor helped more and reported more gratitude compared to participants in the Chance condition.

• The current experiment creates a laboratory induction of gratitude using a larger favor, and includes a control group to compare the effects of gratitude with those of positive mood. Both behavioral and self- report measures of gratitude are included. If gratitude motivates individuals to act prosocially toward their benefactor, then participants receiving a favor should experience more gratitude and reciprocate more resources to their partners than participants who receive a positive outcome by chance.

• Participants were forty undergraduate psychology students at Baylor University

• The data support the prosocial nature of gratitude. Participants reported being more motivated by gratitude when they had received a favor, compared to individuals who had received the same positive outcome by chance. This emotion seemed to translate itself into different patterns of behavior toward their partner: Participants who believed they had received a favor from the other participant gave her more money than did participants who believed they had received the outcome by chance. These results are consistent with the prediction that grateful feelings motivate the individual to act prosocially toward his or her original benefactor.

These results also suggest that gratitude may have unique effects independent of positive mood. If gratitude's prosocial effect was due solely to the effects of positive mood, participants who also received a positive outcome by chance should have given similar amounts of resources to the other person as did participants who received the positive outcome as a favor.

Gratitude as a psychotherapeutic intervention

• A number of rigorous, controlled experimental trials have examined the benefits of gratitude. Gratitude has one of the strongest links to mental health and satisfaction with life of any personality trait—more so than even optimism, hope, or compassion. Grateful people experience higher levels of positive emotions such as joy, enthusiasm, love, happiness, and optimism, and gratitude as a discipline protects us from the destructive impulses of envy, resentment, greed, and bitterness.

• People who experience gratitude can cope more effectively with everyday stress, show increased resilience in the face of trauma-induced stress, recover more quickly from illness, and enjoy more robust physical health. Taken together, these results indicate that gratitude is incompatible with negative emotions and pathological conditions and that it may even offer protection against psychiatric disorders.

• A daily gratitude journal-keeping exercise with young adults resulted in higher reported levels of the positive states of alertness, enthusiasm, determination, attentiveness, and energy compared with a focus on hassles or a downward social comparison (ways in which participants thought they were better off than others

• In these studies, participants in the gratitude condition are given the following instructions: “We want to focus for a moment on benefits or gifts that you have received in life. These gifts could be simple everyday pleasures, people in your life, personal strengths or talents, moments of natural beauty, or gestures of kindness from others. We might not normally think about these things as gifts, but that is how we want you to think about them. Take a moment to really savor or relish these gifts, think about their value, and then write them down every night before going to sleep.”

• Importantly, these data showing that gratitude is correlated with beneficial outcomes are not limited to self-report. Notably, the family, friends, partners, and others that surround them consistently report that people who practice gratitude seem measurably happier and are more pleasant to be around. Grateful people are rated by others as more helpful, outgoing, optimistic, and trustworthy.

• By writing each day, we magnify and expand on these sources of goodness. Setting aside time on a daily basis to recall moments of gratitude associated with even mundane or ordinary events, personal attributes one has, or valued people one encounters has the potential to weave together a sustainable life theme of gratefulness just as it nourishes a fundamentally affirming life stance.

• One of the first steps in gratitude practice is attention. Attention is noticing and becoming aware of blessings that we normally take for granted. It is tuning into the many reasons for gratitude that already exist in our lives.

• The act of writing, of systematically recording blessings, translates a person’s thoughts into words, and writing has been shown to have advantages over just thinking the thoughts. Writing helps to organize thoughts, facilitate integration, and helps individuals accept their own experiences and put them into context

• Gratitude practice is systematically paying attention to what is going right in one’s life, to see the contributions that others make in these good things, and then expressing gratitude verbally and behaviorally. Gratitude practice is intentionally shifting your attention from the negative to the positive and allowing your inner voice to speak that truth. Gratitude practice is acknowledging that even difficult and painful moments are our teachers, and we can be grateful for them.

Does gratitude work as a psychotherapeutic intervention? The evidence to date suggests that it does. Gratitude is a key, underappreciated quality in the clinical practice of psychology, its relevance deriving from its strong, unique, and causal relationship with well-being, as well as its dynamic healing influence on the therapist-patient relationship.

The evaluated research shows gratitude is associated with happiness and well-being, indicative of an ability to adapt to life circumstances. Multiple studies have shown that long-term happiness varies only slightly in spite of life circumstances and supports the idea that positive attitudes, forgiveness, and gratitude contribute to longevity and satisfaction. The study by Emmons and McCullough investigated the possible links between gratitude and subjective well- being, the benefits suggesting that gratitude is a crucial component of happiness.

RecommendationThe research on gratitude has found over and over that people who remind themselves every day of the things they are grateful for demonstrate improved mental and physical health. Further, saying a meaningful "thank you" and counting your blessings plays a significant role in a person's sense of wellbeing and happiness. Participants in some of the studies who exhibited gratitude reported higher levels of alertness, enthusiasm, determination, optimism, and energy. They also experienced less depression and stress, and were more likely to help others, exercise more regularly, and make more progress toward personal goals. The results of these studies appear to be equally true whether for healthy college students or people with incurable diseases.

The research, to date, has usually been conducted from a non-spiritual focus. Moreover, the research is largely focused on correlations, leaving the direction somewhat unclear. This papers review of the relevant literature shows that a single, spirituality-oriented research, guided by theory, could potentially contribute a great deal to the field.

Across time, religious thought, and multiple cultures, the emotional mechanisms of gratitude and forgiveness have been viewed as positive and desirable aspects of society. Yet both are somewhat difficult to define or categorize. The evaluated research shows gratitude is associated with happiness and well-being, indicative of an ability to adapt to life circumstances. Multiple studies have shown that long-term happiness varies only slightly in spite of life circumstances and supports the idea that positive attitudes, forgiveness, and gratitude contribute to longevity and life satisfaction. The study by Emmons and McCullough investigated the possible links between gratitude and subjective well- being, the benefits suggesting that gratitude is a crucial component of happiness

The literature that has been reviewed shows different people using gratitude in their lives: the patients with breast cancer, people dealing with post-traumatic stress disorder, health care workers, and also just everyday people incorporating gratitude into their day to day lives. All of the studies showed an increase in measured happiness levels and lower levels of stress. The most interesting data came in the study of gratitude as a therapeutic intervention. This study showed that one of the first steps in gratitude practice is attention. Attention is noticing and becoming aware of blessings that we normally take for granted. It is tuning into the many reasons for gratitude that already exist in our lives. Simultaneously, directing our attention this way in a focused manner blocks thoughts and perceptions that are contrary to gratitude.

The emerging discoveries support knowledge of the value of a grateful disposition. Gratitude connects us to the kindness of others and intensifies interpersonal relationships. As we give to others, we strengthen ourselves. As we receive from others, we allow them to also grow. We reap what we sow. Feelings are very personal and only each person can determine what is significant for them. However, when one is conscious and purposeful in their emotions and their use of gratitude, they have the power to influence everyone.