Paul J. Mills, Tiffany Barsotti, Meredith A. Pung, Kathleen L. Wilson,

Laura Redwine, and Deepak Chopra

Gratitude, along with love, compassion, empathy, joy, forgiveness, and self-knowledge, is a vital attribute of our wellbeing. While there are many definitions of gratitude, at its foundation, gratitude is a healing, life-affirming, and uplifting human experience that shifts us from focusing on the negative to appreciating what is positive in our lives. Gratitude provides us with a more intimate connection to ourselves and the world around us. In the feeling of gratitude, the spiritual is experienced.

For those who are ill, feelings of gratitude and awe may facilitate perceptions and cognitions that go beyond the focus of their illness, and include positive aspects of one’s personal and interpersonal reality in the face of disease. Such beneficial associations with gratitude have accelerated scientific interest in and research on gratitude and wellbeing. The number of publications on gratitude appearing in the biomedical literature in 5-year increments since 1960-1965 (http://www.ncbi.nlm.nih.gov/pubmed/) shows almost no publications until 1996-2000 with about 20 studies. That number doubled from 2001-2005. From 2006-2010 publications jumped to 150, and from 2011 to the present over 275 studies on gratitude have been published.

Much of this growth of scientific interest in gratitude can be traced to the early pioneering gratitude research of psychologists Robert Emmons and Michael McCullough. In general, studies find that the frequency with which one experiences the feeling of gratitude, as well as the depth of emotion when experiencing it, are linked to improvements in perceived social support as well as reduced stress and depression. Among groups seeking to support this work, the Greater Good Science Center (Berkeley, CA), in collaboration with the Templeton Foundation (West Conshohocken, PA), has been a strong advocate of advancing the science of gratitude and expanding that science into diverse areas of human health and wellbeing.

One area of research that has helped to elucidate our understanding of the science of gratitude and wellbeing is behavioral cardiology.  The field of behavioral cardiology augments traditional cardiology by examining psychosocial factors as they relate to cardiac health.  Traditionally, behavioral cardiologists focused more on traits such as anger expression and hostility. Cardiologists Friedman and Rosenman, who first described the Type A behavior pattern in the late 1950s, conducted some of the earliest and most systematic scientific work in this area. The Type A behavior pattern is characterized by a set of personality traits including free floating hostility, competitiveness and time urgency; with more of these traits being associated with worse disease. Research eventually suggested that it is anger coping styles, and not competitiveness and time urgency, that are the more pathogenic aspects of the behavior pattern, linking them to morbidity and mortality.

In contrast to these types of adverse influences of relatively negative psychological traits, studies of positive psychological attributes indicate potential beneficial effects on quality of life and physical health in cardiac disease. In several clinical populations, spirituality and/or religious wellness are often associated with better mental and physical health. In this literature, spiritual wellbeing is seen as distinct from religiousness. In individuals with symptomatic heart failure, for example, there is a positive relationship between spiritual wellbeing and better physical and mental wellbeing. These are important observations because heart failure is a major US public health concern affecting over 6 million Americans with rates expected to nearly triple over the next few decades as the population ages. Heart failure is the end stage of most cardiac anomalies, with the annual number of hospitalizations exceeding 1 million and US direct costs exceeding $40 billion/year. There is increasing recognition of the value of embracing multidisciplinary therapeutic approaches in heart failure (as well as other chronic illnesses) that include enhancing spirituality and positive psychological traits as part of more routine psychosocial support. Early studies report reduced depressive symptoms and better health-related outcomes among individuals with cardiovascular disease following spirituality-based interventions that include guided imagery, meditation, journaling, and nature-based activities.

A recent collaboration between the UC San Diego Center of Excellence for Research and Training in Integrative Health and the Chopra Foundation examined associations between gratitude and wellbeing in men and women with asymptomatic heart failure. We found that those patients with more dispositional or trait gratitude also slept better, were less depressed, had less fatigue, had more self-confidence to take care of themselves, and had less systemic inflammation.  We also took the opportunity in this study to examine the role that gratitude might have in the known beneficial effects of spirituality on wellbeing. We conducted what is called a mediation analysis (in statistics, a mediation model attempts to explain the underlying process by which one variable exerts its effect on another (in this case how spirituality might lead to enhanced wellbeing) by considering the effect of a third variable; in this case gratitude).  We found that gratitude fully or partially accounted for the beneficial effects of spiritual wellbeing on sleep quality, mood, confidence in self-care, and fatigue. That is, in this group of patients, the observed relationships between spiritual wellbeing and better mood and sleep quality were due to the contributions of gratitude as a fundamental component of spiritual wellbeing. Together, the findings from this study are confirmatory of gratitude’s relationships with better mental and physical wellbeing in cardiovascular disease.

Beyond observational studies relating trait gratitude to an array of measures of wellbeing, further work in the form of gratitude intervention studies has begun to demonstrate that when we are intentional with our gratitude and actually create time and space to regularly practice gratitude, other areas of wellbeing improve as well.  Though researchers consider gratitude to be a trait, this does not imply that it exists solely as a genetic setpoint that cannot be changed. Instead, engaging in intentional gratitude practices are associated with a variety of benefits and may, in fact, boost the frequency, depth, and range of circumstances for which we are grateful. Practices that actively cultivate a more conscious experience of gratitude take us beyond reciprocal gratitude, and greatly enrich our lives and our sense of connection to the life around us.  A recent gratitude intervention study, for example, found that when health care workers kept a work-related gratitude diary they had a decline in stress and depressive symptoms. As anthropologist and author of the book Living in Gratitude: A Journey That Will Change Your Life, Angeles Arrien wrote ‘Through conscious and sustained practice over a period of time, we can discover again how gratitude and all its related qualities—thankfulness, appreciation, compassion, generosity, grace, and so many other positive states—can become integrated and embodied in our lives’.  When gratitude is present in our awareness, everything changes, we can find ourselves transformed.

There are numerous practices to cultivate gratitude. At the Chopra Center for Wellbeing in Carlsbad CA., “What am I grateful for?” is one of four key questions that practitioners pose to themselves prior to entering into meditation. Such practices of gratitude bring awareness to and appreciation of the positive features within and around us, helping us to embrace life as it is with all of its imperfections.  Other practices to consciously cultivate a grateful life include journaling, counting blessings, savoring positive moments, and behavioral expressions of gratitude such as thank you notes, to name a few. By cultivating gratitude, we cultivate wellbeing.

For readers interested in learning about current biomedical studies examining gratitude and wellbeing in different states of illness, including cardiovascular disease, a description of these studies can be found at the US National Institutes of Health ClinicalTrials.Gov website (https://clinicaltrials.gov/ct2/home) by searching the word ‘gratitude’. ClinicalTrials.gov is a registry and results database of publicly and privately supported clinical studies of human participants conducted around the world.

 Additional Reading

Algoe SB, Haidt J, Gable SL. Beyond Reciprocity: Gratitude and Relationships in Everyday Life. Emotion, 8:425-9, 2008

Cheng ST, Tsui PK, Lam JH. Improving mental health in health care practitioners: randomized controlled trial of a gratitude intervention. J Consult Clin Psychol, 83:177-86, 2015

Dubois, C. M., Beach, S. R., Kashdan, T. B., Nyer, M. B., Park, E. R., Celano, C. M., & Huffman, J. C. Positive psychological attributes and cardiac outcomes: associations, mechanisms, and interventions. Psychosomatics, 53, 303-318, 2012

Mills P.J., Redwine L., Wilson K., Pung M.A., Chinh K., Greenberg B.H., Lunde O., Maisel A., Raisinghani A., Wood A., Chopra D. The Role of Gratitude in Spiritual Wellbeing in Asymptomatic Heart Failure Patients. Spirituality in Clinical Practice 2, 5-17, 2015

Mccullough, M. E., Emmons, R. A., & Tsang, J. A. The grateful disposition: A conceptual and empirical topography. Journal of Personality and Social Psychology, 82, 112–127, 2002

Sacco, S. J., Park, C. L., Suresh, D. P., & Bliss, D. Living with heart failure: psychosocial resources, meaning, gratitude and well-being. Heart Lung, 43, 213-218, 2014

Wood, A.M, Tarrier, N. Positive Clinical Psychology: a new vision and strategy for integrated research and practice. Clinical Psychological Reviews, 30, 819-29, 2010

 Authors

 Paul J. Mills, PhD, Professor of Family Medicine and Public Health, and Psychiatry at the University of California, San Diego; Director of Research at the Chopra Foundation

Tiffany Barsotti, MTh, C.Ht, Medical Intuitive, Counselor and Researcher at Heal and Thrive in Encinitas CA

Meredith Pung, PhD, Clinical Research Coordinator, University of California, San Diego

Kathleen L. Wilson, MS, Clinical Research Coordinator, University of California, San Diego

Laura Redwine, PhD, Assistant Professor of Psychiatry, University of California, San Diego

Deepak Chopra, MD, Co-Founder of The Chopra Center for Wellbeing, Carlsbad, CA; Assistant Clinical Professor of Family Medicine and Public Health, University of California, San Diego