Gratitude - more than just a platitude? The science behind gratitude and health

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British Journal of Health Psychology (2018)
©2018 The British Psychological Society
www.wileyonlinelibrary.com
Editorial
Gratitude –more than just a platitude? The science
behind gratitude and health
It is well established that gratitude is associated with better psychological well-being. Less
well understood is whether or how gratitude is associated with physical health outcomes.
Below, we review the limited research examining links between gratitude and physical
health suggesting that, for gratitude research to progress, models that help to identify the
underlying mechanisms through which gratitude may influence outcomes are needed.
We argue that the available research on gratitude does not clarify the causal mechanisms,
making it difficult to empirically test possible pathways. Of particular note, work has not
systematically considered the two key pathways –via health behaviours and biological
functioning –that appear likely to underpin this link. We make the argument that although
gratitude and other positive psychology constructs may have distinct indirect effects on
health, the pathways are likely to be similar at the behavioural and biological levels.
Ultimately, we advocate for the use of a unifying model of positive psychological
well-being, such as that developed in the context of cardiovascular disease (Boehm &
Kubzansky, 2012). An organizing model could be tested across different positive
psychology constructs (including gratitude) and across illness groups and used to advance
and refine specific theories and models of gratitude.
In psychological research, gratitude is conceptualized as both a trait and a state
(Emmons, 2004; McCullough, Emmons, & Tsang, 2002). At a trait level, gratitude is
characterized by individual differences in the average occurrence of feeling grateful in day-
to-day life while gratitude as a state or an emotion involves feeling gratitude as a response
to a beneficial experience (Wood, Maltby, Stewart, Linley, & Joseph, 2008). Altho ugh state
and trait gratitude may differ, reviews have highlighted consistent associations between
both forms and greater psychological well-being in healthy adult populations (Emmons &
Mishra, 2011; Lomas, Froh, Emmons, Mishra, & Bono, 2014; Wood, Froh, & Geraghty,
2010). Similarly, observational studies in groups with chronic health conditions have
found associations between gratitude, quality of life, increased social support, and
improved health behaviours and self-reported adherence (Eaton, Bradley, & Morrissey,
2014; Legler et al., 2018; Ruini & Vescovelli, 2012; Sirois & Wood, 2017; Wood, Maltby,
Gillett, Linley, & Joseph, 2008).
Findings from gratitude interventions are more mixed and demonstrate the lack of
clarity surrounding how interventions work. Gratitude interventions often take the form
of compiling a list of things to be grateful for in a journal (gratitude journals/lists; Wood
et al., 2010), brief grateful contemplation (Watkins, Woodward, Stone, & Kolts, 2003), or
writing letters of gratitude (Seligman, Steen, Park, & Peterson, 2005). As is evidenced
below, general positive psychology interventions (PPIs) often include components of
gratitude, adding to the challenges of identifying behaviour change pathways and teasing
DOI:10.1111/bjhp.12348
1

apart causal mechanisms. Some gratitude interventions or PPIs with a gratitude
component have demonstrated improvements in psychological well-being (e.g.,
increases in positive affect, reductions in depression; Seligman et al., 2005; Watkins,
Uhder, & Pichinevskiy, 2014; Wood et al., 2010) and, more recently, in improved
biological functioning (e.g., blood pressure) in healthy populations (Jackowska, Brown,
Ronaldson, & Steptoe, 2016). Others, notably when contrasting gratitude with another
positive psychology intervention (e.g., writing about best possible selves), have found
little evidence that gratitude interventions were superior (Kerr, O’Donovan, & Pepping,
2015; Manthey, Vehreschild, & Renner, 2016), begging the question of whether gratitude
interventions are distinct from other positive psychology interventions (Dickens, 2017).
Gratitude-based intervention studies in patients with chronic disease remain rare, a
consideration that is evident in reviews and meta-analyses of gratitude interventions that
have found limited evidence for their effectiveness in improving physical health out comes
(Dickens, 2017; Wood et al., 2010). There are several reasons to study gratitude in patient
samples. First, patient samples may yield larger effect sizes and greater variance in
outcomes, helping to clarify the links between gratitude and physical health outcomes
more broadly. Patient-based studies may also reduce the likelihood of ceiling effects (e.g.,
for positive affect; Froh, Kashdan, Ozimkowski, & Miller, 2009), which would, in turn,
help clarify cause and effect relationships in intervention studies and may further clarify
how different PPI constructs impact health. Equally, attempting to improve health and
well-being among patients is morally warranted, especially as gratitude-based interven-
tions are easy to administer, acceptable, low risk, and can be feasibly employed in busy
clinical settings.
To date, there are a few scattered investigations of gratitude interventions among
patients. One early study conducted among 65 people with neuromuscular disorders
found that writing gratitude lists improved positive affect and self-reported sleep relative
to a non-active control condition, but found no differences in pain, exercise, or functional
status (Emmons & McCullough, 2003). More recently, a positive affect skills intervention
that included a gratitude component was trialled in comparison with an emotion-
reporting control group in type 2 diabetes (n=49), with improvements in depression but
not in self-care behaviours (Cohn, Pietrucha, Saslow, Hult, & Moskowitz, 2014). A similar
intervention in HIV patients showed improvements in some health indicators (e.g.,
antidepressant use) but not in health behaviours or viral load (Moskowitz et al., 2017).
Another PPI for 67 cancer patients (based on practising optimistic thinking and writing
gratitude letters) demonstrated improvements in psychological adaptation to cancer in
comparison to an active control condition (Otto, Szczesny, Soriano, Laurenceau, & Siegel,
2016). Finally, relative to treatment as usual, a gratitude journaling intervention in a
sample of 70 asymptomatic heart failure patients improved parasympathetic heart rate
variability and reduced inflammation (Redwine et al., 2016). Despite their ease of use and
acceptability, 15 years has seen fewer than 10 trials of gratitude-based interventions in
patients with chronic health conditions.
There are likely several reasons for this lack. One possible reason is that the benefits of
gratitude for physical health outcomes may be seen as inconclusive based on the present
literature (Dickens, 2017). Another reason may reflect the lack of a model describing the
underlying mechanisms through which gratitude influences outcomes. Although several
general theories regarding gratitude exist (Fredrickson, 2004b; Watkins, 2014; Watkins
et al., 2014), these have not been specified into models depicting the hypothesized causal
relationships. Clearly specified models would allow the associations between the
different components proposed in these theories (e.g., positive affect, gratitude, social
2Editorial

support) and outcomes to be empirically examined and would guide the development and
implementation of more informed and effective interventions. Perhaps, the most
influential theory germane to understanding the positive effects of gratitude is the
broaden and build theory of positive emotion s (Fredrickson, 2001, 2004a,b). This theory
hypothesizes that positive emotions such as gratitude broaden the repertoire of thoughts,
actions, and attention (Fredrickson & Branigan, 2005; Le Nguyen & Fredrickson, 2017),
contributing to the development of long-term physical, psychological, social, and
intellectual resources (Fredrickson, 1998, 2004a; Fredrickson & Branigan, 2005; see
Figure 1). Despite the far-reaching impact of this theory (Fredrickson & Joiner, 2018), it
has been labelled a descriptive rather than a ‘mechanistic’ framework and may be limited
in its ability to identify causal mechanisms (Alkozei, Smith, & Killgore, 2017; Wood et al.,
2010).
With respect to the specific emotion of gratitude, there are at least three potential
mechanisms that are not clearly delineated within the broaden and build theory. First,
the original theory does not include a role for health behaviours, although health-
promoting behaviours are positively associated with gratitude (Hill, Allemand, & Roberts,
2013). While more recent iterations of the theory have expanded on the possible role of
health behaviours (Fredrickson, 2013; Fredrickson & Joiner, 2018; Van Cappellen, Rice,
Catalino, & Fredrickson, 2018; see Figure 2), health behaviours are not directly linked to
health outcomes. Rather, this model suggests that health behaviours work via positive
affect to influence biological function. Secondly, biological functioning is not depicted as
a mechanism, although this possibility has been acknowledged (Fredrickson, 2004a;
Fredrickson, Tugade, Waugh, & Larkin, 2003). Finally, while increased social connections
and increased positive emotions may also build physiologic al resources (e.g., cardiac vagal
tone; Kok et al., 2013; Le Nguyen & Fredrickson, 2017), these pathways are not clearly
represented. Therefore, although the broaden and build theory aids our general
understanding of how gratitude may increase well-being and, to some extent physical
Intellectual resources
Develop problem-solving skills
Learn new information
Broaden and build theory of
positive emotions
Physical resources
Develop coordination
Develop strength and cardiovascular
health
Social resources
Solidify bonds
Make new bonds
Psychological resources
Develop resilience and optimism
Develop sense of identity and goal
orientation
Figure 1. Broaden and build theory of positive emotions. Fredrickson (2003). Sigma Xi, The
Scientific Research Honor Society. Reprinted with permission.
Editorial 3

health outcomes, a causal model is needed to understand and model specific pathways.
Only by testing causal pathways are we able to refine and develop theories and thus
improve the frameworks we use to guide the development and implementation of
interventions.
While writers in this tradition have been understandably cautious in positing causal
links, there are several reasons to suspect that incorporating more causal pathways into
models would be useful. First, many behavioural scientists argue that the links between
positive psychological constructs and health-related outcomes reflect the actions of two
pathways: health behaviours (e.g., increased physical activity) and/or more adaptive
biological functioning (e.g., neuroendocrine functioning; Boehm & Kubzansky, 2012;
Kok et al., 2013; Pressman & Cohen, 2005; Steptoe, Dockray, & Wardle, 2009). Increasing
evidence can be used and built upon to further clarify how positive psychological factors,
such as gratitude, influence health. A second argument for using a broader, unifying model
is that positive psychological functioning encompasses many different constructs (e.g.,
positive affect, optimism, happiness, gratitude). Not only do such constructs overlap in
measurement, but they may also have similar effects on outcomes (Kashdan, Biswas-
Diener, & King, 2008).
While there are some early suggestions regarding mechanism in gratitude research
(Alkozei et al., 2017), these frameworks do not include both health behaviours and
biological functioning as mechanisms. A more global and inclusive model is found in the
model of positive psychological well-being (Boehm & Kubzansky, 2012). Developed to
organize thinking regarding the association between positive psychological well-being
and cardiovascular health, this model (see Figure 3) proposes that the link is mediated by
restorative processes (which protect against ill health) as well as by the absence or
reduction in deteriorative processes. In this view, restorative and deteriorative processes
include health behaviours (e.g., exercise, diet) as well as biological functions (e.g.,
Non-conscious
motives for health
behaviours
Positive affect
during health
behaviours
Built resources:
Biological &
psychological
Engagement in
health behaviours
Figure 2. Upward spiral theory of lifestyle change. Fredrickson and Joiner (2018). SAGE. Reprinted
with permission.
4Editorial

inflammation, cholesterol). This model allows for a clear visualization of the pathways
through which positive emotions may be related to health outcomes. If the model were
adapted to include gratitude, we propose that increased gratitude and positive affect
would directly influence restorative biological functioning and health behaviours as well
as indirectly via social support and stress (see Figure 4). Clearly identifying possible causal
candidates facilitates both their measurement and their being targeted in observational
and experimental research (see Boehm & Kubzansky, 2012 for specific candidates
identified in CVD research, something not yet available in gratitude research). In turn,
clear, mechanism-oriented measurement will help test hypotheses and build on existing
theories.
As has been intimated above, in using the above adapted model as a starting point to
organize gratitude research into a more causally oriented footing, we are not suggesting
that all constructs or measures of positive psychological well-being are identical. Indeed,
constructs such as gratitude may have discrete effects on health. Equally, we are not
suggesting that prominent, valuable theories should be discarded. Rather, we are arguing
for the merits of supplementing their ideas by delineating the pathways underlying
positive emotions and health outcomes: the behavioural pathway and/or the biological
Positive psychological
well-being
Eudaimonic
well-being
Optimism and
other measures
of well-being
Hedonic
well-being
Stress
+
–
–
Health behaviours
Biological function
Restorative
process
Deteriorative
process
Cardiovascular disease
–
–
+
+
Figure 3. Model of positive psychological well-being. Boehm and Kubzansky (2012). APA.
Reprinted with permission.
Editorial 5

pathway, as well as acknowledging other positive psychological constructs and their
probable overlap in future models. By using a unified model of positive psychological
constructs, the field can move towards a more causally oriented and mechanistic
theoretical framework which can also guide the development and implementation of
gratitude and other positive psychology interventions.
Although we believe gratitude is more than just a platitude, there is still much research
to do, particularly in clinical populations. This includes conducting carefully designed
experimental studies in which specific mediators (e.g., specific health behaviours and
specific health- and disease-related biomarkers) are tested, as well as improving study
design in general (Wood et al., 2010), a consideration that is beyond the scope of this
editorial. With the increased interest in positive psychological constructs such as
gratitude, more theory and model development needs to be undertaken so that the
mechanisms underlying gratitude–health links are identified and systematically investi-
gated. Adapted models based on the model of positive psychological well-being (Boehm
& Kubzansky, 2012) which depict many of the mechanisms which are likely to operate
across many different positive psychological constructs, including gratitude, may
represent a useful starting point.
Conflict of interest
The authors declare that they have no conflict of interests.
Positive affect
Positive psychological well-being
Gratitude
Health behaviours
Biological function
Restorative
process
Deteriorative
process
Illness
–
+
+
Social support
Stress
–
–
–
Figure 4. Adapted model of positive psychological well-being. Boehm and Kubzansky (2012)
reprinted [or adapted] with permission.
6Editorial

Kiralee Schache
1
, Nathan Consedine
1
, Paul Hofman
2
and Anna Serlachius
1
1
Department of Psychological Medicine, Faculty of Medical and Health Sciences,
University of Auckland, New Zealand
2
Liggins Institute, University of Auckland, New Zealand
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