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Can Gratitude and Kindness Interventions Enhance Well-being in a Clinical Sample?

Authors:
RESEARCH PAPER
Can Gratitude and Kindness Interventions Enhance
Well-Being in a Clinical Sample?
Shelley L. Kerr Analise O’Donovan Christopher A. Pepping
Published online: 19 January 2014
ÓSpringer Science+Business Media Dordrecht 2014
Abstract Grounded in Fredrickson’s (Rev Gen Psychol 2(3):300–319, 1998) broaden
and build model of positive emotions, the current study examines the efficacy of 2-week
self-administered gratitude and kindness interventions within a clinical sample on a
waiting-list for outpatient psychological treatment. Results demonstrate that we can reli-
ably cultivate the emotional experiences of gratitude but not kindness in this brief period.
Further, both the gratitude and kindness interventions built a sense of connectedness,
enhanced satisfaction with daily life, optimism, and reduced anxiety compared to a placebo
condition. These brief interventions did not impact on more overarching constructs,
including general psychological functioning and meaning in life. These findings demon-
strate that gratitude and kindness have a place in clinical practice; not just as end states, but
as emotional experiences that can stimulate constructive change. Further, these strategies
can serve as useful pre-treatment interventions that may reduce the negative impact of long
waiting times before psychological treatment.
Keywords Gratitude Kindness Interventions Treatment
Clinical sample Broaden and build
Positive psychological interventions have much to offer the field of clinical psychology
(Duckworth et al. 2005; Lyubomirsky and Layous 2013; Wood and Tarrier 2010). Recent
S. L. Kerr A. O’Donovan (&)C. A. Pepping
School of Applied Psychology, Griffith University, 176 Messines Ridge Road, Mt Gravatt, Brisbane,
QLD 4122, Australia
e-mail: a.odonovan@griffith.edu.au
A. O’Donovan C. A. Pepping
Griffith Health Institute, Griffith University, Gold Coast, Australia
A. O’Donovan C. A. Pepping
Behavioral Basis of Health, Griffith University, Brisbane, Australia
123
J Happiness Stud (2015) 16:17–36
DOI 10.1007/s10902-013-9492-1
research indicates that even very brief self-administered positive psychological interven-
tions can have beneficial outcomes for clinical samples (Layous et al. 2012; Mitchell et al.
2010). A significant problem for clinical psychology is the difficulties caused to clients by
the need to wait unaided before they can access treatment. The aim of the present study
was therefore to evaluate the efficacy of brief self-administered positive psychological
interventions in a clinical sample on a waiting list to receive psychotherapy. Participants
completed either a gratitude intervention, a kindness intervention, or a mood-monitoring
placebo control intervention across a 2-week period to explore whether these interventions
might serve as a valuable pre-treatment intervention for clients waiting to enter treatment.
1 The Need for Intervention Whilst Waiting for Therapy
The long period clients are often required to wait before they can access psychological
intervention presents a substantial challenge for the field of clinical psychology. The little
research available on the waiting period prior to entering therapy indicates that a long
waiting period is linked with client dissatisfaction and even pre-intake drop out (Carpenter
et al. 1981; Kokotovic and Tracey 1987; Orme and Boswell 1991; Paige and Mansell 2013;
Peeters and Bayer 1999; Shueman et al. 1980). Perhaps more important is that lengthy
waiting times potentially affect clients’ attempts to seek help (May 1991), and the majority
of people who drop out of therapy prior to initial appointment do not go on to seek help
elsewhere (Archer 1984; Christensen et al. 1975; May 1990; Peeters and Bayer 1999; Sparr
et al. 1993). Furthermore, the adverse consequences of lengthy delays in receipt of therapy
appear more pronounced for clients with more severe or urgent concerns (May 1990).
Thus, it is critically important to explore possible ‘pre-treatment’ strategies to reduce the
negative impact of long waiting times.
Several clinical and administrative strategies have been trialled with clients on waitlists
for therapy to reduce pre-intake attrition and increase timeliness of service provided. Pre-
training procedures including education on the therapy process, allaying fears, increasing
optimism (Lawe et al. 1983), motivational telephone interventions (Parker et al. 2002) and
making pre-intake therapy groups available to clients on waitlists (Collins et al. 1973;
Stone and Klein 1999) have each demonstrated some efficacy. Drawing from Fredrickson’s
(1998,2000a) broaden and build theory of positive emotion, the present research inves-
tigated the efficacy of self-administered positive psychological interventions for clinically
distressed people on a waiting list to receive treatment.
2 Broaden and Build Theory of Positive Emotion
The broaden and build theory of positive emotion posits that ‘‘experiences of positive
emotions broaden people’s momentary thought-action repertoires, which in turn serves to
build their enduring personal resources’’ (Fredrickson 2001, p. 218). For example, the
positive emotion of joy broadens by generating the urge to play. This play then builds
more enduring personal resources, such as long-lasting social relationships (Fredrickson
1998,2001). Thus, the experience of short-term positive emotion may set the stage for long
term benefits, and Fredrickson (Fredrickson 1998,2000b) argues that positive affect may in
fact be the best way to resolve problems associated with negative emotions. Positive
emotion has an ‘‘undoing effect’’ on damaging negative mood states (Fredrickson and
Levenson 1998; Fredrickson et al. 2000), and is self-perpetuating, such that the experience
18 S. L. Kerr et al.
123
of positive emotion can lead to an upward spiral of positive emotion (Fredrickson and
Joiner 2002; Tugade and Fredrickson 2004). Thus, in the context of positive emotion, one’s
habitual ways of thinking are thus expanded and broadened, as opposed to a tendency to
act in a specific or habitual way (Fredrickson 1998,2000b).
It is this broadening that enables the second adaptive process of the broaden and build
model: ‘building’ personal skills and resources. The model suggests that the flexible,
broadened thinking characteristic of positive affect readies an individual to become more
engaged with their environment and their goals. People are then better able to acquire new
skills, build lasting personal resources, and prepare themselves for future challenges
(Fredrickson 2001). Importantly, the broaden and build model is accumulating increasing
empirical support (Fredrickson and Branigan 2005; Strauss and Allen 2006).
The broaden and build model provides a strong argument in favour of including positive
emotions in the treatment of psychological problems. From a clinical perspective, the model
underscores the importance of positive emotions in stimulating positive clinical change. The
undoing effect indicates that even those people who are experiencing significant distress and
negative emotion could benefit from positive emotion (King 2000). Fredrickson (2000b)
argues that during moments of feeling good, however fleeting, perceived safety and satiation
take precedence over perceived threat and need, therefore making possible the more lasting
positive consequences of positive emotion. Furthermore, the broaden and build model is
hopeful in its promise of lasting and self-perpetuating positive change.
2.1 Gratitude
Gratitude is a positive emotional response to a perceived benefit bestowed by another
(Emmons and Crumpler 2000; Emmons and McCullough 2003; Peterson and Seligman
2004; Tsang 2006). Gratitude magnifies the positives in life, and has a positive impact on
well-being, interpersonal relationships, and prosocial behaviour, Bartlett and DeSteno 2006;
Dunn and Schweitzer 2005; Janoff-Bulman and Berger 2000; Langston 1994; Tsang 2006;
Wood et al. 2010). The broaden and build model is particularly relevant to gratitude
(Fredrickson 2004), as the emotional experience of gratitude may facilitate the development
of lasting personal resources. Consistent with this proposition, research indicates that
gratitude increases the likelihood one will engage in prosocial behaviour, increases trust in
others, and helps to build and reinforce social bonds (Bartlett and DeSteno 2006; Dunn and
Schweitzer 2005; McCullough et al. 2001; Tsang 2006). Gratitude may also enhance
optimism, connectedness with others, meaning in life, motivational drive, empathy, stra-
tegic planning abilities, strengthened spirituality and faithfulness, and resilience and coping
during adversity (Emmons and Crumpler 2000; Emmons and Shelton 2002; Kashdan et al.
2006; McCullough et al. 2002; Miley and Spinella 2006; Ventura and Boss 1983).
Growing evidence attests to the positive effects of gratitude interventions on psycho-
logical health (Bolier et al. 2013; Wood et al. 2010). Several randomised controlled trials
have found beneficial effects of cultivating gratitude interventions (Chan 2010; Emmons and
McCullough 2003; Froh et al. 2008; Seligman et al. 2005; Sheldon and Lyubomirsky 2006;
Watkins et al. 2003). Sheldon and Lyubomirsky (2006) found that a 4-week self-adminis-
tered gratitude intervention led to a reduction in negative mood in a sample of undergrad-
uates. Lyubomirsky et al. (2011) examined the efficacy of an 8 month gratitude intervention
on well-being, and found that participants who self-selected into the study displayed
improved well-being. Further, a 6-week gratitude intervention has been shown to lead to
improvements in life satisfaction compared to a control condition (Boehm et al. 2011).
Finally, Geraghty et al. (2010) investigated whether a 2-week self-directed internet gratitude
Can Gratitude and Kindness Interventions Enhance Well-Being? 19
123
intervention would reduce body dissatisfaction in a sample of community volunteers. Results
revealed that not only did the gratitude intervention reduce body dissatisfaction compared to
a control condition, but that attrition from the intervention was very low, suggesting that self-
directed gratitude interventions may be a useful approach. In brief, the studies reviewed
above clearly demonstrate that enhancing gratitude has beneficial effects. It would therefore
be useful to explore whether self-administered gratitude interventions can assist clinical
samples waiting to receive psychotherapy. Also in the spirit of the broaden and build model
of positive emotions, kindness interventions hold much promise.
2.2 Kindness
Kindness is a combination of emotional, behavioural, and motivational components (Otake
et al. 2006). Whilst kindness is greater than an emotional experience alone, it has been
demonstrated to have a clear emotional undercurrent; namely, compassion. The momen-
tary thought-action tendency sparked by kindness is clearly an altruistic motivation or the
urge to act prosocially. Acts of kindness can build trust and acceptance between people,
encourage social bonds, provide givers and receivers with the benefits of positive social
interaction, and enable helpers to use and develop personal skills and thus themselves
(Bartlett and DeSteno 2006; Musick and Wilson 2003; Wills 1991).
Lyubomirsky et al. (2004, cited in Lyubomirsky et al. 2005) examined a behavioural
kindness intervention in which university students were asked to complete five acts of
kindness per week across a 6 week period. The authors found that performing acts of
kindness led to greater well-being. Similarly, several studies have demonstrated that
meditations that cultivate feelings of loving-kindness (directed toward the self and others)
enhance a range of positive outcomes including enhanced positive affect, purpose in life,
social support, and mindfulness, and reduced negative affect and symptoms of illness
(Cohn and Fredrickson 2010; Fredrickson et al. 2008; Hoffman et al. 2011), and even
reduce negative symptoms of schizophrenia (Johnson et al. 2011). Otake et al. (2006)
examined the importance of kindness in augmenting subjective happiness by comparing a
kindness intervention with a no-treatment control group. In the kindness condition, hap-
piness of students increased following the intervention, and the most substantial increases
in happiness were observed in participants who had completed the most kind acts, whereas
no increase in happiness was observed for the control group.
In summary, the positive emotions underpinning both gratitude and kindness lead to a
range of positive outcomes, and may stimulate a constructive process of broadening and
building. It is notable that although growing evidence converges to indicate that gratitude
and kindness interventions are beneficial, remarkably little research has examined the
efficacy of these interventions in clinical samples. As mentioned earlier, a critical problem
in clinical psychology is the potentially negative impact of long waiting times to receive
psychological assistance. Given that even very brief self-administered gratitude and
kindness programs lead to positive psychosocial outcomes, it is possible that these self-
administered interventions may be valuable ‘pre-treatment’ activities that clients can
engage in while waiting to begin therapy.
3 The Present Research
The aim of the present study was twofold: Firstly, we sought to evaluate the efficacy of a
gratitude intervention and a kindness intervention compared to a mood-monitoring placebo
20 S. L. Kerr et al.
123
control condition in a clinical population. Secondly, we aimed to explore whether these
interventions might serve as a valuable pre-treatment intervention for clients waiting to
enter treatment. Clients on a wait-list to receive psychological treatment were offered the
‘Pre-Treatment Program’ as a means of doing something constructive whilst they were
waiting to enter treatment proper.
4 Hypotheses
4.1 Gratitude Intervention
We predicted that gratitude (Hypothesis 1) would increase in the gratitude condition and
not in the control condition. Based on the broaden and build model of positive emotions, it
was predicted that this gratitude intervention would further stimulate improvements in
psychological functioning (Hypothesis 2; hedonic well-being, eudaimonic well-being,
general psychological functioning, negative mood states, and connectedness with others)
and no such effects would be observed in the control condition.
4.2 Kindness Intervention
It was predicted that kindness (Hypothesis 3) would increase in the kindness condition and not
in the control condition. Again, based on the broaden and build model of positive emotions, it
was predicted that this kindness intervention would lead to improvements in psychological
functioning (Hypothesis 4) in the kindness condition and not in the control condition.
5 Method
5.1 Participants
Participants were 48 adults (36 females and 12 males) ranging in age from 19 to 67 years
(M=43 years, SD =11.1) currently seeking individual psychological treatment at one of
seven outpatient psychology clinics in Queensland, Australia. Self-reported presenting
problems included depression, anxiety, relational problems, posttraumatic stress, substance
use disorders, and eating disorders. Fifty four percent of participants reported having
previously seen a therapist. Table 1displays means and standard deviations of demo-
graphic information and outcome measures at time 1 by condition.
5.2 Measures
5.2.1 Gratitude and Kindness
Participants were asked to list either things they were grateful for (gratitude intervention),
or to list the kind acts they had committed (kindness intervention), and to rate the intensity
of gratitude or kindness felt on a scale of 1 (somewhat grateful) to 7 (extremely grateful)
each day of the 14-day intervention. This provided a measure of gratitude/kindness fre-
quency (number of discrete daily situations that elicited gratitude/kind acts committed) and
mean episodic intensity (mean gratitude/kindness intensity).
Can Gratitude and Kindness Interventions Enhance Well-Being? 21
123
As a measure of gratitude in participants’ daily moods, we obtained a composite
measure of three gratitude related words (grateful,thankful, and appreciative), as in
Emmons and McCullough (2003), McCullough et al. (2004) and Kashdan et al. (2006).
These words were integrated into the PANAS list above to reduce demand characteristics.
Participants rated the extent to which they had experienced each of these emotions during
the past day using a 1–5 Likert scale. This composite displayed high internal consistency in
the present sample (a=.96). As a measure of kindness in participants’ daily moods, three
kindness related words (kind,compassionate, and considerate) were integrated into the
PANAS. Individuals rated the extent to which they had experienced each of these emotions
during the past day using a 1–5 Likert scale. Internal consistency in the present sample was
high (a=.95).
5.2.2 Hedonic Well-Being
As a measure of positive and negative affect in daily mood, we employed the version of the
Positive and Negative Affect Schedule (PANAS; Watson et al. 1988) used by Emmons and
McCullough (2003). Each day, participants were asked to rate the extent to which they had
experienced each emotion during the day. From these daily reports, two indices of hedonic
well-being were constructed in line with prior studies (Diener et al. 1985; Kashdan et al.
2006). The daily affect balance was calculated by subtracting total negative affect from
total positive affect for each days so that higher scores indicated greater well-being. The
percent of happy days was calculated by examining the percentage of days that positive
affect exceeded negative affect during the assessment period.
Two additional global life appraisals were included in the daily diary to tap individuals’
current and future life satisfaction, as employed by Emmons and McCullough (2003).
Participants were asked to rate how they felt about their life as a whole today [from -3
(terrible) to ?3 (delighted)]. Internal consistency across the 14 days was high (a=.91).
Finally, anticipated future satisfaction, or optimism, was assessed with the question: Please
Table 1 Means and standard deviations in parentheses for demographic and 14-day composite outcome
measures by condition
Measure Condition
Gratitude (n =16; 3
male)
Kindness (n =16; 4
male)
Control (n =15; 5
male)
Age 46.06 (12.15) 41.81 (10.48) 41.53 (10.77)
Gratitude composite 10.19 (1.08) 9.16 (2.87) 8.58 (1.53)
Kindness composite 9.63 (1.43) 9.68 (2.51) 8.36 (1.62)
Hedonic well-being
Percent happy days 69.20 (24.15) 59.38 (30.50) 50.00 (31.84)
Daily affect balance .75 (.87) .60 (1.30) .12 (.61)
Satisfaction with life 4.95 (.80) 4.91 (1.22) 4.11 (.68)
Optimism 5.12 (.79) 5.25 (1.07) 4.38 (.74)
Relational functioning
Connectedness with
Others
5.33 (.63) 5.20 (1.26) 3.96 (.69)
22 S. L. Kerr et al.
123
rate your expectations for tomorrow. Respondents rated their answers using a scale ranging
from -3 (pessimistic, expect the worst) to ?3 (optimistic, expect the best). Again, internal
consistency across the 14 day period was high (a=.91).
5.2.3 Eudaimonic Well-Being
The Purpose in Life test (PIL; Crumbaugh and Maholick 1964) was used to assess eu-
daimonic wellbeing, and is a 20-item scale designed to assess how meaningful one judges
one’s own life to be. The PIL evidences good psychometric properties (Crumbaugh 1968;
Reker 1977), and demonstrated high internal consistency in the present sample (a=.93).
5.2.4 General Psychological Functioning
The Outcome Questionnaire-45.2 (OQ-45; Lambert et al. 2002) is a widely used self-report
symptom and distress inventory that has demonstrated clinical usefulness in assessing
psychological functioning over time. The OQ-45 consists of three subscales: Subjective
distress, interpersonal relationships, and performance with one’s social role. The OQ-45 is
a reliable and valid measure (Lambert et al. 1998) and demonstrated high internal con-
sistency in the present sample (a=.90) for the total score.
The Depression Anxiety and Stress Scale (DASS-21) is a 21-item self-report instrument
designed to measure the negative emotional states of depression, anxiety and stress an
individual has experienced within the past week (Lovibond and Lovibond 1995). The
DASS-21 is a reliable and valid measure (Lovibond and Lovibond 1995; Henry and
Crawford 2005), and is sensitive to meaningful clinical change (Ng et al. 2007). The
DASS-21 had high internal consistency in the present sample (a=.91, .80, and .87 for
depression, anxiety and stress scales respectively).
5.2.5 Interpersonal Functioning
Participants rated how connected they felt with others each day using a rating scale ranging
from -3 (isolated) to ?3 (well connected). The measure was modelled on that used by
Emmons and McCullough (2003). Internal consistency across the 14 days was high
(a=.96).
5.3 Design and Overview of Interventions
Participants were randomly assigned to one of three intervention conditions (gratitude,
kindness, or placebo) prior to first contact. There were no significant differences in
demographic characteristics between individuals who did not complete all measures to
those who did. Non-completers were significantly more distressed, depressed, and reported
lower meaning in life compared to individuals who did complete the program and/or
returned all materials. Participants in each of the three intervention conditions received a
14-day diary intervention designed to cultivate gratitude, cultivate kindness, or a mood-
monitoring placebo group. Purpose in life, the OQ-45, and the DASS-21 were administered
at pre- and post-intervention, whereas all other measures were completed daily across the
14-day period.
Can Gratitude and Kindness Interventions Enhance Well-Being? 23
123
5.3.1 Gratitude Intervention
On each daily monitoring form provided in the 14-day diary, participants in the gratitude
group were instructed: ‘‘There are many things in our lives, both large and small, that we
might be grateful about. Think back over the past day and write down on the lines below up
to five things in your life that you are grateful or thankful for’’. These five things could be
either things that have occurred during that particular day, or could be more general factors
that the participant felt particularly grateful for on that particular day. This diary was
modelled on the measure used within studies conducted within student samples and with
those suffering from neuromuscular disorders (Emmons and McCullough 2003; McCul-
lough et al. 2004). This intervention has proved successful in manipulating felt gratitude,
and increasing emotional, behavioural, and physical benefits.
5.3.2 Kindness Intervention
On each daily monitoring form provided in the 14-day diary, participants in the kindness
group were provided with the following instructions: ‘‘Kind acts are behaviours that benefit
other people, or make others happy. They usually involve some effort on our part. On the
lines below describe as many as five acts that you did for someone else today. Be sure to
include at least one kind act that you did intentionally’’. This diary was modelled on the
committing kindnesses intervention trialled by Lyubomirsky et al. (2004, cited in Lyubo-
mirsky et al. 2005) and the counting kindnesses intervention introduced by Otake et al.
(2006). Thus respondents received both a committing and counting kindnesses intervention.
5.3.3 Mood-Monitoring Placebo Control Intervention
Participants in all three conditions were asked to make daily ratings of their mood, their
connectedness with others, expectations for tomorrow, and overall satisfaction with life.
This mood diary served a dual purpose. Firstly, it provided the outcome measures of
positive and negative affect in daily mood and overall life appraisals for all participants.
Secondly, it served as the placebo intervention for those respondents in the control group.
Mood diaries are often a component of the initial stages of therapy (e.g. in cognitive
behaviour therapy) and can themselves have therapeutic effects by increasing awareness
and providing concrete and accurate information regarding progress (Kirk 1989). However,
monitoring mood in this way was unlikely to manipulate the degree of positive affect, and
in particular gratitude and kindness experienced, thus providing an effective placebo
control condition for the study.
5.4 Procedure
Recruitment information was provided to several outpatient clinics, and seven sites agreed
to offer the program to clients. The program was offered to clients who were required to
wait for 1 month or more prior to beginning therapy. Clients who indicated interest in the
program were mailed an information package containing information sheets and consent
forms. Prior to contacting participants, clients were randomly assigned to one of the three
interventions described above. Participants were contacted by telephone, and were
informed that the present ‘pre-treatment’ program was completely separate from any
individual therapy they would ultimately receive at the clinic, and that the present program
was designed to make a difference whilst they were waiting for therapy. Participants were
24 S. L. Kerr et al.
123
mailed diary forms, the pre-intervention questionnaire package, and reply paid envelopes.
Respondents were offered SMS or email reminders to aid the completion of the daily diary.
In time for their completion of the 2-week diary intervention, clients were mailed the post-
intervention questionnaire package with a reply paid envelope. A telephone call was made
to clients at the completion of the intervention to debrief participants and receive feedback
of their experiences of the pre-treatment intervention.
6 Results
6.1 Preliminary Analyses
The groups did not differ on any of the pre-intervention measures (p[.16), nor did they differ
according to gender (p=.72) or age (p=.45). On average and prior to intervention the clients
who participated in the pre-treatment program reported a ‘moderate’ degree of depression,
anxiety, and stress symptoms on the DASS-21 (Lovibond and Lovibond 1995). Levels of
overall psychological functioning reported on the OQ-45 (M=88.02; SD =20.77) were
above the clinical cut off score of 63, indicating that the sample experienced a clinically
significant level of distress. Across the groups, clients completed an average of 13.21 days of
the diary (SD =2.12). Table 1displays14-day composite outcome measures bycondition, and
Table 2displays pre and post intervention outcome measures by condition.
6.2 Gratitude and Kindness
6.2.1 Gratitude Intervention
For the gratitude group, the mean number of gratitude-eliciting events listed per day was
2.70 (SD =1.28), and the mean intensity of the grateful emotion associated with each of
these events was 5.46 (SD =.81). To check that the gratitude intervention successfully
manipulated the degree of gratitude experienced in daily mood, we conducted between
group comparisons on the gratitude composite measure. Welch’s adjusted F ratio was
employed to correct for a violation of the assumption of homogeneity of variance. This
Table 2 Means and standard deviations in parentheses for pre and post intervention outcome measures by
condition
Measure Pre Post
Gratitude
(n =16;
3 male)
Kindness
(n =16;
4 male)
Control
(n =15;
5 male)
Gratitude
(n =16;
3 male)
Kindness
(n =16;
4 male)
Control
(n =15;
5 male)
Eudaimonic well-being
Meaning in
life
79.38 (23.79) 86.38 (23.47) 77.31 (15.29) 81.13 (22.49) 88.40 (23.61) 76.46 (19.73)
Psychological functioning
OQ-45 89.69 (23.77) 84.06 (19.75) 90.64 (19.02) 77.19 (25.93) 73.57 (18.40) 82.94 (19.62)
DASS-
depression
18.63 (12.43) 14.50 (11.49) 22.38 (9.99) 15.13 (13.06) 13.60 (9.30) 20.25 (8.03)
DASS-anxiety 14.00 (11.10) 14.88 (9.58) 15.00 (10.61) 9.38 (9.57) 9.07 (4.89) 16.75 (11.24)
Dass-stress 22.50 (11.58) 21.38 (10.87) 23.13 (10.12) 18.00 (11.84) 17.20 (10.02) 23.25 (8.64)
Can Gratitude and Kindness Interventions Enhance Well-Being? 25
123
analysis revealed a significant difference between groups, Welch’s F(2, 25.21) =4.60,
p\.05, g
2
=.10. Pairwise comparisons that do not assume equal variances (Games–
Howell tests) showed that the gratitude group gave higher composite ratings of gratitude
than the control group, p\.05, indicating that the gratitude intervention did indeed
enhance degree of gratitude experienced. No differences emerged between the kindness
and control conditions with regards to gratitude (p=.79). Cohen’s dwas 1.23 for the
mean difference between the gratitude and control group, .52 between the gratitude and
kindness conditions, and .27 between the kindness and control conditions, indicating a
large effect size for the gratitude intervention relative to the control intervention, and a
medium effect size between the gratitude and kindness conditions.
6.2.2 Kindness Intervention
For the kindness group, the mean number of kind acts committed or counted per day was
2.58 (SD =1.11), and the mean intensity of the kind emotion associated with each of these
events was 4.50 (SD =1.47). To check that the kindness intervention successfully
manipulated the degree of kindness experienced in daily mood, we conducted between
group comparisons on the kindness composite measure. This analysis revealed no signif-
icant differences between the groups in ratings of average kindness, F(2, 41) =2.12,
p=.13, g
2
=.09.
6.3 Outcome Measures
6.3.1 Hedonic Well-Being
Between groups comparisons were made on the daily ratings of clients’ PANAS score.
Two one-way ANOVA’s were conducted on the frequency (percentage) and intensity
(daily affect balance) of happy days across the 14-day period. No significant main effect
for condition emerged for the frequency (p=.19) or intensity (p=.17) of positive
emotion.
Between groups comparisons were made on the mean satisfaction with life score across
the 14-day period. There was a significant main effect for condition, F(2, 45) =4.18,
p=.02. Post-hoc Scheffe’s tests revealed that clients who completed the gratitude
intervention rated their satisfaction with life significantly higher than those in the control
condition, p\.05, Cohen’s d=1.13. There was a trend towards higher life satisfaction
ratings for clients in the kindness intervention compared to those in the control condition,
p=.06, Cohen’s d=.81. No differences emerged between the gratitude and kindness
conditions, p=.99.
Finally, to determine whether the three conditions differed in optimism, a one-way
ANOVA was performed on the 14-day mean optimism rating. The main effect of condition
was significant, F(2, 45) =4.55, p\.05. A post hoc Scheffe’s test revealed that clients in
the kindness intervention displayed higher optimism compared to those in the control
condition, p\.05, Cohen’s d=.95. Clients in the gratitude intervention displayed a trend
towards higher optimism than the control group, p=.07, Cohen’s d=.97. No differences
were observed in optimism between the gratitude and kindness conditions, p=.92.
26 S. L. Kerr et al.
123
6.3.2 Eudaimonic Well-Being
A392 mixed ANOVA was conducted to examine pre- and post-intervention differences
in meaning in life as measured by the PIL between the three experimental groups. How-
ever, no significant main effect for time (p=.67), group (p=.38) or interaction between
condition and time (p=.79) emerged.
6.3.3 General Psychological Functioning
To examine change in general psychological function as assessed by the OQ-45, we per-
formed a 3 92 mixed ANOVA, using OQ-45 scores as the dependent variable and
experimental group (gratitude, kindness, placebo) and time (pre, post) as independent vari-
ables. Results revealed a significant effect of time, F(1, 41) =23.66, p\.001, such that all
participants experienced significantly improved psychological functioning over the course of
the intervention. This was a small effect, with g
p
2
=.37. There was no main effect of group,
F(2, 41) =.78, p=.47, or interaction between group and time, F(2, 41) =1.10, p=.34;
suggesting that the gratitude, kindness, and placebo interventions were each equally effective
in improving global psychological functioning over the 14-days of the intervention.
Aseriesof392 mixed ANOVAs were conducted using the subscales of the DASS-21
(depression, anxiety, and stress) as the three dependent variables. For DASS depression, there
was no main effect for time (p=.17), group (p=.10) or interaction between condition and
time (p=.52) suggesting that clients’ ratings of depression did not change significantly during
the 14 days of the intervention period. For DASS anxiety, the significant main effect of time,
F(1, 44) =7.15, p\.05, g
p
2
=.14, was qualified by a significant interaction between group
and time, F(2, 44) =4.89, p\.05, g
p
2
=.18. When the effect of time was examined sepa-
rately for each group, it was observed that significant reductions in anxiety were reported by
the gratitude (p\.05) and kindness (p\.01) groups, but not the control group (p=.30)
during the 14 days of the intervention period. For DASS stress, there was a significant effect of
time, F(1, 44) =5.54, p\.05, g
p
2
=.11, but no main effect of group, F(2, 44) =.73,
p=.49, or interaction between time and group, F(2, 44) =1.58, p=.22, suggesting that all
groups in the study reported a reduction in stress levels during the 14 days of the intervention
period. To summarise, whereas all groups reported a reduction in stress levels, only the
gratitude and kindness groups reported a reduction in anxiety levels.
6.3.4 Relational Functioning
Mean daily rating of connectedness with others was compared between groups using a one-
way ANOVA. Welch’s adjusted F ratio was employed to correct for a violation of the
assumption of homogeneity of variance. This analysis revealed a significant difference
between groups, Welch’s F(2, 25.25) =19.90, p\.01. Pairwise comparisons that do not
assume equal variances (Games–Howell tests) showed that, relative to the control group,
both the gratitude (p\.01, Cohen’s d=2.07) and kindness groups (p\.01, Cohen’s
d=1.27) reported higher levels of connectedness with others.
7 Discussion
The present research represents the first attempt of which we are aware to examine the
effects of cultivating gratitude and kindness in a clinically distressed sample on a waiting
Can Gratitude and Kindness Interventions Enhance Well-Being? 27
123
list to receive treatment. Results demonstrate that we can reliably cultivate gratitude
(Hypothesis 1), and that enhancing gratitude leads to enhanced satisfaction with life and
connectedness with others, higher optimism, and reductions in anxiety (Hypothesis 2).
Results showed that we cannot cultivate kindness in just 2 weeks in a clinical sample
presenting for outpatient psychological treatment (Hypothesis 3). With regards to related
outcomes, participants in the kindness intervention displayed greater satisfaction with life,
increased optimism and connectedness with others, and lower anxiety (Hypothesis 4). In
brief, results from this research indicate that self-administered gratitude and kindness
interventions may be valuable for clients whilst waiting to receive treatment.
7.1 Enhancing Gratitude and Kindness
Results from the present research demonstrate that we can cultivate gratitude in a 2 weeks
intervention in a clinically distressed sample. A daily, conscious focus on things clients
were thankful for generated a significantly stronger experience of gratitude in daily life, as
compared to a conscious focus on acts of kindness or monitoring mood. These results
suggest that gratitude strategies may be useful for clinical populations. In contrast, we were
not able to reliably cultivate kindness using a 2-week counting and committing kindnesses
intervention. The large amount of individual variability in response to the kindness
intervention may have impacted on this finding. This increased variability in response to
the kindness intervention suggests that there may be a differential benefit from such an
intervention. Uncovering the specific nature of these individual differences would be an
important pursuit for further research.
The efficacy of similar kindness interventions has previously been demonstrated within
student samples (Otake et al. 2006; Lyubomirsky et al. 2004, cited in Lyubomirsky et al.
2005). In the current study we offered this intervention to people in the height of their
distress when presenting to therapy. Perhaps kindness interventions would be more helpful
after some of the initial groundwork in therapy has been accomplished. Because kindness
strategies require a focus on others’ well-being, rather than one’s own, it is possible that the
required behavioural enactment may function as an added burden rather than benefit at this
stage of therapy. Finally, it could be that the particular strategy used to cultivate kindness
in the current study is not suited to clinical samples. This may not preclude other kindness-
cultivating strategies.
7.2 Impact of Gratitude and Kindness on Psychological Functioning
Based on the broaden and build model of positive emotion, we predicted beneficial out-
comes for cultivating the positive emotions of gratitude and kindness into two key areas:
personal and relational well-being. As hypothesised, the current study demonstrated that
both gratitude and kindness interventions can build psychological and interpersonal
functioning within a clinical sample. Individuals in both the gratitude and kindness
intervention reported more daily satisfaction with their lives than those in the placebo
intervention, and higher levels of optimism, as well as lower anxiety compared to the
control group. These results are consistent with previous research for both gratitude (Chan
2010; Emmons and McCullough 2003; Froh et al. 2008; Seligman et al. 2005; Sheldon and
Lyubomirsky 2006; Watkins et al. 2003) and kindness (Cohn and Fredrickson 2010;
Fredrickson et al. 2008; Hoffman et al. 2011; Otake et al. 2006) interventions. These
findings suggest that even when starting from a baseline of distress and negative emotion, a
28 S. L. Kerr et al.
123
conscious focus on gratitude or kindness has adaptive benefits to well-being, in the form of
increased optimism and greater satisfaction with life.
In contrast to previous research in student populations, we did not find that these
interventions significantly increased the frequency or intensity of positive or negative
affect. Relatively consistently, gratitude interventions have been demonstrated to have a
positive impact on affect (Watkins et al. 2003; Emmons and McCullough 2003; Seligman
et al. 2005; Sheldon and Lyubomirsky 2006). Whilst cultivating kindness research is in its
infancy, Otake et al. (2006) demonstrated that a kindness intervention can increase sub-
jective happiness. That we were unable to reliably replicate these findings may relate to the
distinct nature of our clinical population. The majority of participants in the current study
presented with affective disorders. In that affect is the metric of the distress of this pop-
ulation, it may well be that shifts in affect would be small and gradual. The time period
under study prevents any conclusions regarding the more enduring or progressive nature of
these strategies for a clinical sample.
It is interesting that the kindness intervention had greater impact on optimism than the
gratitude intervention. In past research gratitude has been linked to greater optimism (e.g.
Emmons and McCullough 2003). In explaining the difference, we refer to prior arguments
that helping constitutes a proactive means of preventing helplessness (e.g. Midlarsky
1991), and research findings that kindness is associated with an increased sense of mastery
and self-efficacy (e.g. Fagin-Jones and Midlarsky 2007; Oliner and Oliner 1988). Thus, if
someone feels able to do something for others that will make a difference in their lives,
they perhaps feel more optimistic that they can be an active agent of self change in the
future.
With regards to eudaimonic well-being, contrary to our hypotheses, neither the gratitude
or kindness interventions influenced meaning in life in this period, nor was there change to
general psychological functioning above that of the placebo group.
7.3 Impact of Gratitude and Kindness on Relational Well-Being
In line with our hypotheses regarding the relational benefits of gratitude and kindness, we
found that both gratitude and kindness interventions increased clients’ sense of con-
nectedness with others to a significantly greater degree than a placebo intervention. This
result suggests that it is not just contact with a professional that helps someone in distress
feel more connected, as this contact was equal across each of the three interventions.
Instead, it appears that the positive, outward focus afforded by gratitude and kindness
interventions mobilised the existing support that people have in their lives, enabling them
to forge new, or strengthened connections with others. This finding is consistent with
prior research indicating an association between gratitude, kindness, and elements of
improved relational functioning (Bartlett and DeSteno 2006; Bono and McCullough 2006;
Dunn and Schweitzer 2005; Worthington et al. 2005; Zahn-Waxler et al. 1983) as well as
with outcomes of similar gratitude interventions with non-clinical samples (Emmons and
McCullough 2003). This result also fits within the build component of the broaden and
build model of positive emotion (Fredrickson 1998,2000b). For both gratitude and
kindness, this model predicts the acquisition of positive relational resources, such as new
or strengthened relationships. The current study confirms that repeated experience of
gratitude or kindness over a 2 week period can in fact strengthen one’s relational
resources.
Can Gratitude and Kindness Interventions Enhance Well-Being? 29
123
7.4 Extent of the Current Findings: A Dose–Effect Relationship?
Overall, results in the predicted directions were seen for a number of daily measures of
personal and relational well-being (i.e. optimism, satisfaction with life, connectedness with
others) whilst the impact on larger constructs measured prior to and following the inter-
vention were not consistent with our predictions (i.e. general psychological functioning as
measured by the OQ45). This may reflect a dose–effect relationship, such that the greater
one’s distress the larger the dose of intervention required to achieve the same effect (e.g.
Howard et al. 1986). In this way a dose–effect is relevant to translating therapeutic
strategies to clinical populations. Such an effect implies that an equivalent dose provided to
non-clinical and clinical samples may demonstrate a smaller effect for the clinical sample.
In some of the initial work examining the impact of gratitude interventions on well-being,
Emmons and McCullough (2003) examined the impact of offering a cultivating-gratitude
intervention over differing time periods; weekly for 10 weeks or daily for 2 weeks.
Interestingly, they found that whilst the shorter more intense intervention had a larger
effect on experienced gratitude, the prolonged but less frequent intervention demonstrated
an effect on health behaviours, such as time spent exercising, quality of sleep, and extent of
substance use. The authors speculated that this difference in effects may have been a result
of the time period in question; such that it was possible to detect changes to more lasting
habits in the context of the longer time period. One possible explanation of the significant
effect of the gratitude and kindness interventions on daily measures of well-being in the
current study, but non-significant effect on the larger constructs measured pre- and post-
intervention, is that the brief duration of our intervention precluded the observation of
significant changes to such overarching constructs as meaning in life, and negative mood
states. A similar argument was made by Sheldon and Lyubomirsky (2006, p. 81) following
introducing a gratitude intervention to a group of students; with these authors suggesting
gratitude may have ‘‘deferred effects’’ on various measures of interpersonal functioning.
It is acknowledged that this was an ambitious program to introduce, given the clinically
significant degree of distress experienced by our sample and the brevity of the intervention
itself. We presented a brief, general intervention designed to make a constructive differ-
ence whilst they were waiting for therapy proper. It is important to contextualise our results
in the reality that we would not expect this intervention to bring about a happy state for this
sample by just offering these brief interventions. However, despite the brevity of inter-
vention, we have demonstrated that such an intervention can make a positive difference for
a clinical sample, particularly with regard to daily experiences. That these findings dem-
onstrate the same pattern of associations between gratitude and kindness with well-being,
lends further support to Frederickson’s (1998,2000a) broaden and build model, in that it
applies equally well to persons who are and are not experiencing clinically significant
distress.
7.5 Duration of the Building Process for a Clinical Sample
Frederickson’s (1998,2000b) broaden and build model of positive emotion predicts that
the experience of positive emotion enables the building of positive resources that are
themselves durable and lasting. There has been further suggestion that these resources are
self-perpetuating, such that the resources beget yet more positive emotion, and thus further
acquisition of beneficial skills and resources (Frederickson 2000b). We have demonstrated
that both gratitude and kindness interventions can stimulate the acquisition of resources
such as optimism, satisfaction with life, and connectedness with others.
30 S. L. Kerr et al.
123
As further explanation for this apparent discrepancy between daily indices of well-being
and more over-arching constructs, we speculate that this building process may take some
time to appear; exactly how much time we do not yet know. In this way, the current
findings may indicate the beginnings of an upward spiral. Thus, the initial boost clients in
our interventions gained in optimism, life satisfaction, and connectedness, may make larger
changes more likely, in an incremental fashion. This requires longer term follow-up, and
examination of lengthier interventions; however, we suggest that the current positive
findings provide the impetus for further investigation. To exemplify this speculation, we
refer to gains in relational functioning; the clients in our study who were allocated to the
2 weeks focus on kindness or gratitude experienced an initial boost in their sense of
connectedness with others. This greater sense of connectedness may with time further
strengthen these clients’ existing relationships, increasing the degree to which their life is
intertwined with that of others, gradually increasing their sense that they are adequately
socially supported. With these improved relationships, periods of distress are less likely,
and positive emotional experiences more likely; thus predicting further gains. Furthermore,
with this enhanced building of relationships may come the sense that life is more mean-
ingful. If building resources is incremental, we would expect this building of resources to
mediate gains in eudaimonic well-being.
7.6 Implications, Limitations, and Future Directions
The present research has several important implications for clinical practice. Firstly, the
finding that clients can benefit from these self-administered positive psychological activ-
ities whilst waiting for therapy is of particular importance given the substantial problems
associated with long waiting times to receive treatment (Carpenter et al. 1981; Orme and
Boswell 1991; Paige and Mansell 2013; Peeters and Bayer 1999). If self-administered
positive psychological interventions serve as useful pre-treatment activities for clients
whilst waiting for therapy, it is possible that pre-treatment drop-out can be reduced, and
therapy outcome can be increased by using these simple interventions. Future research
should investigate these possibilities. Secondly, given that much of the research regarding
gratitude and kindness interventions has been conducted with student samples, the present
research reveals that these strategies are helpful in clinical populations, even at the height
of their distress when presenting for therapy.
There are some limitations of the present research that need to be acknowledged.
Firstly, the small sample is a limitation of the current research as it may have reduced the
power to detect some effects. Thus, it is possible that some of the null results observed in
the present research may reflect Type II error. However, it also needs to be acknowledged
that small sample sizes can lead to overestimates of effect sizes, and thus it is possible that
some results may reflect Type I error. In brief, it is acknowledged that the small sample
size does limit the extent to which definitive conclusions can be drawn from the present
research, and it is critically important that these findings are replicated with larger samples.
Furthermore, the small sample limits the extent to which analyses investigating moderators
of treatment effects can be performed. Nonetheless, the results from the present research do
provide some encouraging preliminary evidence that gratitude and kindness interventions
may be of benefit to clinical samples on a wait-list to receive therapy.
The attrition rate in the current study was high. Approximately half of the clients who
signed up for the pre-treatment program did not start or did not complete the program.
Available data for clients who did not complete the program or did not return all measures
suggested that they were significantly more distressed, depressed, or lacking meaning in
Can Gratitude and Kindness Interventions Enhance Well-Being? 31
123
life, compared to those clients who completed the program. This raises the possibility that
the intervention is less helpful for those who are highly distressed, as these individuals may
be less able to sustain the 2-week self-administered intervention. Due to the small sample
size in the present research, it was not possible to conduct subsidiary post hoc analyses to
examine this possibility. The differential efficacy of the program at different levels of
distress should be investigated in future research. However, despite this limitation, results
do indicate that gratitude and kindness interventions are more effective than a placebo
control condition, at least for those who completed the interventions. It is also important to
acknowledge that due to the absence of long-term follow-up, it is not possible to examine
the long-term stability of the effects fond in the present research. It is possible that once
participants receive the treatment they were on the wait-list to receive, participants across
all conditions may improve to the same extent. However, it is also possible that the
gratitude and/or kindness intervention may have additional long-term benefits. Future
research should examine these possibilities empirically.
Finally, given that participants were asked to retrospectively report events and mood in
the daily diaries, it is possible that participants’ current mood while completing the diary
may have influenced results. Although this is a possible limitation that needs to be
acknowledged, the use of random assignment limits the extent to which this issue might be
a limitation. Specifically, participants in all conditions were asked to retrospectively report
on events and mood each day, and differential results were found based on the condition
participants were randomly assigned to. Thus, it seems unlikely that the results can be
totally explained by mood-dependent memory.
Future research should explore whether attrition rates may be reduced if the program
was presented by the treating clinician, which could also start to build the relationship
between clinician and client and make the program follow a more natural progression from
waitlist to therapy. As a final note, we also wish to echo a caveat offered by McCullough
et al. (2004); that the interventions offered in this research represent a relatively minimal
strategy. We believe this caveat is particularly applicable to our clinical sample, in which a
host of other variables would be expected to impact on well-being. Our interventions
requested that participants reflect on either the things in their lives they are grateful for or
their kind acts towards others, for a duration of 2 weeks, and we anticipated that this would
affect their personal and relational well-being. In the context of the many factors that may
influence well-being, both individually as well as in combination, it is remarkable to reflect
that the single factors targeted in our intervention had a significant impact on these clients’
daily lives. Future research should also examine the effects of a longer-term intervention
for clinical populations focussing on gratitude or kindness, and explore what the optimal
dose of these interventions is.
8 Conclusion
The aim of the present research was to investigate whether brief, self-administered positive
psychological strategies may assist clients whilst on a waiting list to receive treatment.
Based on the broaden and build model of positive emotion, we argued that kindness- and
gratitude-cultivating strategies are well placed to stimulate positive change in well-being
for a clinically distressed sample waiting to receive treatment. The present research
demonstrated that gratitude and kindness have a place in clinical practice; not as end states,
but as emotional experiences that themselves have the capacity to stimulate positive
change to daily individual and relational well-being. Further, these strategies may serve as
32 S. L. Kerr et al.
123
useful pre-treatment interventions that reduce the negative impact of long waiting times to
receive treatment.
Acknowledgments We gratefully thank Jennifer Wilson for her helpful statistical advice.
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Article
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The effect of a grateful outlook on psychological and physical well-being was examined. In Studies 1 and 2, participants were randomly assigned to 1 of 3 experimental conditions (hassles, gratitude listing, and either neutral life events or social comparison); they then kept weekly (Study 1) or daily (Study 2) records of their moods, coping behaviors, health behaviors, physical symptoms, and overall life appraisals. In a 3rd study, persons with neuromuscular disease were randomly assigned to either the gratitude condition or to a control condition. The gratitude-outlook groups exhibited heightened well-being across several, though not all, of the outcome measures across the 3 studies, relative to the comparison groups. The effect on positive affect appeared to be the most robust finding. Results suggest that a conscious focus on blessings may have emotional and interpersonal benefits.
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This chapter examines the feeling of being grateful. It suggests feeling grateful is similar to other positive emotions that help build a person's enduring personal resources and broaden an individual's thinking. It describes various ways by which gratitude can transform individuals, organizations, and communities in positive and sustaining ways. It discusses the specific benefits of gratitude including personal and social development, community strength and individual health and well-being.
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In this article, the author describes a new theoretical perspective on positive emotions and situates this new perspective within the emerging field of positive psychology. The broaden-and-build theory posits that experiences of positive emotions broaden people's momentary thought-action repertoires, which in turn serves to build their enduring personal resources, ranging from physical and intellectual resources to social and psychological resources. Preliminary empirical evidence supporting the broaden-and-build theory is reviewed, and open empirical questions that remain to be tested are identified. The theory and findings suggest that the capacity to experience positive emotions may be a fundamental human strength central to the study of human flourishing.