Gratitude and Well Being: The Benefits of Appreciation

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Gratitude and Well Being
and Lori A. Sansone , MD
Randy A. Sansone
Dr. R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio
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Lori A. Sansone
Dr. L. Sansone is a family medicine physician (government service) and Medical Director of the Family Health Clinic at Wright-Patterson Air Force Base, WPAFB, in Dayton, Ohio. The views and opinions expressed in this column are those of the authors and do not reflect the official policy or the position of the United States Air Force, Department of Defense, or US government.
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ADDRESS CORRESPONDENCE TO: Randy A. Sansone, MD, Sycamore Primary Care Center, 2115 Leiter Road, Miamisburg, OH 45342; Phone: (937) 384-6850; Fax: (937) 384-6938; E-mail: gro.krowtenhk@enosnas.ydnaR .
FUNDING: There was no funding for the development and writing of this article.
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Abstract
The word “gratitude” has a number of different meanings, depending on the context. However, a practical clinical definition is as follows—gratitude is the appreciation of what is valuable and meaningful to oneself; it is a general state of thankfulness and/or appreciation. The majority of empirical studies indicate that there is an association between gratitude and a sense of overall well being. However, there are several studies that indicate potential nuances in the relationship between gratitude and well being as well as studies with negative findings. In terms of assessing gratitude, numerous assessment measures are available. From a clinical perspective, there are suggested therapeutic exercises and techniques to enhance gratitude, and they appear relatively simple and easy to integrate into psychotherapy practice. However, the therapeutic efficacy of these techniques remains largely unknown. Only future research will clarify the many questions around assessment, potential benefits, and enhancement of gratitude.
Keywords: Gratitude, well being, psychotherapy, psychotherapy techniques
This ongoing column is dedicated to the challenging clinical interface between psychiatry and primary care—two fields that are inexorably linked.
Introduction
In this edition of The Interface, we discuss the subject of gratitude. While retaining slightly different meanings depending on the context, gratitude may be broadly defined as the appreciation of what is valuable and meaningful to oneself. The majority of available research studies indicate that gratitude is associated with an enhanced sense of personal well being. We review several of these studies, highlight some nuances related to the current research on gratitude, provide an overview of assessment approaches to gratitude, and suggest several simple techniques for enhancing the experience of gratitude in patients in the psychotherapy setting.
A Definition of Gratitude
Like most words, gratitude appears to have a number of different meanings, depending on the context. For example, gratitude has been conceptualized as a moral virtue, an attitude, an emotion, a habit, a personality trait, and a coping response. 1 A number of researchers have defined gratitude as a positive emotional reaction in response to the receipt of a gift or benefit from someone. 2 Gratitude has also been conceptualized both as a state phenomenon (i.e., an emotional reaction to a present event or experience) as well as a dispositional characteristic or trait phenomenon. 2 For our purposes, we would like to define gratitude in a much broader sense. Gratitude is the appreciation of what is valuable and meaningful to oneself and represents a general state of thankfulness and/or appreciation. This proposed definition transcends the interpersonal overtones attributed to the term (i.e., the construct of receiving something from someone) and allows for a more inclusive meaning (e.g., being thankful for experiences, such as being alive and coming into contact with nature). This definition also allows for both state and trait contexts.
Associations between Gratitude and Well Being
A number of authors have espoused a theoretical relationship between gratitude and well being. 3 – 6 In a very pragmatic way, this association seems logical. Experiencing gratitude, thankfulness, and appreciation tends to foster positive feelings, which in turn, contribute to one's overall sense of well being. Therefore, gratitude appears to be one component, among many components, that contributes to an individual's well being. However, in addition to theoretical postulation, there are a number of empirical endeavors that support this association—all from the first decade of this century.
Empirical evidence of a gratitude/well being connection. Emmons and McCullough examined gratitude and well being under three experimental conditions. 7 Participants were divided into three groups (i.e., one group was asked to journal about negative events or hassles, a second group about the things for which they were grateful, and a third group about neutral life events) and were required to journal either daily or weekly. Across the various study conditions, the gratitude subsample consistently evidenced higher well being in comparison with the other two study groups.
Dickerhoof 8 designed an experiment in which students could participant in one of two exercises—one that purportedly would boost happiness or another that consisted of “cognitive exercises.” To equalize the expectations of participants, the students were informed that participation in either group was likely to increase their overall sense of well being. The “happiness” paradigm required participants to either write about their best possible future selves (optimism exercise) or write letters of gratitude (gratitude exercise). In contrast, in the control paradigm, participants were required to write about the events of the past week. As predicted, compared with the control group, the happiness-paradigm group demonstrated increases in well being.
Froh et al 9 conducted a study in which 221 adolescents were assigned to either a gratitude exercise (i.e., counting one's blessings), a hassles condition, or a control condition. As predicted, the gratitude condition was associated with greater life satisfaction. The authors concluded from their experience that counting blessings seems to be an effective intervention for enhancing well being in adolescents.
In a sample of 389 adults, Wood et al 10 examined gratitude and well being in the context of personality style. In this study, gratitude was most strongly correlated with personality attributes related to well being, and the researchers concluded that gratitude has a unique relationship with life satisfaction.
Like the preceding authors, other studies have found similar findings. For example, among Taiwanese high school athletes, Chen and Kee 11 found that gratitude positively predicted life safisfaction. Tseng 12 found an association between gratitude and well being among 270 Taiwanese college students. Finally, Froh et al 13 examined 154 adolescents and confirmed associations between gratitude and life satisfaction.
Facets of the gratitude/well being relationship. In addition to the general association between gratitude and well being, a number of investigators have examined particular facets of this relationship. For example, Wood et al 14 found that coping styles did not seem to influence or mediate this relationship. 14 Verduyn et al 15 found that state, or current, gratitude could be enhanced by the importance of the stimulus, by the intensity of the emotion at onset, and through the physical or mental reappearance of the eliciting stimulus. Wood et al 16 determined that higher levels of gratitude predicted better subjective sleep quality and sleep duration. Gysels et al 17 found that, among cancer patients, gratitude was one of the motivations to participate in a research study related to palliative care. Froh et al 18 determined that participants with lower levels of positive feelings, in contrast to those with higher levels of positive feelings, were more likely to experience gratitude in a gratitude intervention. Finally, Polak and McCullough 19 found that gratitude may have the potential to reduce the negative effects of materialistic strivings. In summary, these findings indicate that the gratitude/well being association has a number of adjunctive aspects that warrant further study, particularly with regard to ways to enhance the experience of gratitude in the clinical setting.
Conflicting empirical data. As expected, not all investigators have confirmed associations between gratitude and well being. For example, Kashdan et al 20 examined veterans with and without posttraumatic stress disorder (PTSD). 20 Among the participants with PTSD, trait gratitude did demonstrate a relationship with well being, but not among nontraumatized veterans. Likewise, in college students, Gurel Kirgiz 21 compared a gratitude condition (i.e., composing a letter to someone who made a positive difference in the life of the participant) with a neutral emotional condition, but present levels of gratitude did not evidence a relationship with well being. (In this study, trait gratitude did evidence an association with well being.) Among divorced middle-aged women, Henrie 22 compared those who journaled gratitude experiences with those who read educational materials and those on a wait-list group; the treatment groups showed no improvement in their satisfaction with life. Finally, Mallen Ozimkowski 23 examined the effect of a “gratitude visit” (i.e., the writing and delivering of a letter of gratitude to someone in their lives who was never properly thanked) in children and adolescents. In this study, the gratitude exercise was not associated with enhanced well being. These findings suggest that there are conditions or circumstances that temper the association between gratitude and well being, which warrant further investigation if gratitude exercises are to be undertaken and be consistently effective in the clinical setting.
Assessment Measures for Gratitude
For interested readers, Emmons et al 24 have summarized the available assessment measures for gratitude. In addition, we were able to locate two questionnaires in the empirical literature, the Gratitude Questionnaire-Six-Item Form (GQ-6) and the Gratitude Resentment and Appreciation Test (GRAT).
Gratitude Questionnaire-Six Item Form. The GQ-6 is a brief, six-item, self-report measure that assesses one's disposition to experience gratitude ( Table 1 ). 25 With Likert-style response options (1 =strongly disagree and 7=strongly agree), the GQ-6 is positively related to optimism, life satisfaction, hope, spirituality/religiousness, forgiveness, empathy, and prosocial behavior, and negatively related to depression, anxiety, materialism, and envy. Two items are reverse scored to inhibit response bias. The GQ-6 has reportedly good internal reliability.
Table 1
The Gratitude Questionnaire-Six Item Form (GQ-6)
Using the scale below as a guide, write a number beside each statement to indicate how much you agree with it.
1=strongly disagree, 2=disagree, 3=slightly disagree, 4=neutral, 5=slightly agree, 6=agree, 7=strongly agree
____1. I have so much in life for which to be thankful.
____2. If I had to list everything that I felt grateful for, it would be a very long list.
____3. When I look at the world, I don't see much for which to be grateful.*
____4. I am grateful to a wide variety of people.
____5. As I get older I find myself more able to appreciate the people, events, and situations that have been part of my life history.
____6. Long amounts of time can go by before I feel grateful to something or someone.*
Reprinted with the permission of Dr. Emmons.
Scoring Instructions:
Add up your scores for items 1, 2, 4, and 5.
Reverse your scores for items 3 and 6. That is, if you scored a “7,” give yourself a “1,” if you scored a “6,” give yourself a “2,” ;etc.
Add the reversed scores for items 3 and 6 to the total from Step 1.This is your total GQ-6 score. This number should be between 6 and 42.
Interpretation:
25th Percentile: a score below 35 (bottom quartile)
50th Percentile: a score below 38 (bottom half)
75th Percentile: a score of 41 (higher than 75%)
Top 13%: a score of 42
Gratitude Resentment and Appreciation Test. There are three versions of the GRAT. The original GRAT consists of 44 items that contain the following three factors: abundance, simple appreciation, and appreciation of others. 26 There is also a Revised GRAT consisting of 16 items with Likert-style response options as well as a nine-item GRAT Short Form. This measure has shown good reliability, validity, and internal consistency.
Clinical Exercises that May Reinforce Gratitude
According to Bono and McCullough, 27 gratitude can be enhanced experimentally through relatively simple psychological interventions, which suggests that uncomplicated interventions may be reasonably effective in the clinical setting ( Table 2 ). 27 While few of the techniques listed in Table 1 have much empirical substantiation, the field of gratitude is in its infancy and validated techniques for clinical use may soon be available.
Table 2