Counting your blessings? or looking on the bright side of life [whistles]
My family were big on the Andrews Sisters. One of my strong memories as a child is listening to the song ‘count your blessings, name them one by one…’ [no, I will not sing it ok?!]. And I remember the book Pollyanna (you can read it for free here!) and the ‘Glad game’ where she looked for the positive in her rather dire situation when she went to live with her strict Aunt Polly.

And guess what?  There is something in this approach to coping that makes a difference!

While on holiday, sad person that I am, I did spend one or two days reading journal articles.  Several of them were related to the theme of positive psychology in a special issue of Clinical Psychology Review.

While research into optimism, positive affect and even psychological flexibility has been around for a long time, and even been integrated into clinical practice, gratitude has been a bit of a forgotten sister.  Maybe it’s because of the slightly naive views expressed in books and films of the 1950’s and the effect of the cynicism that increased during the swinging 60’s, but whatever reason, gratitude hasn’t had nearly as much attention paid to it as other emotions like anger or sadness or even happiness.  I certainly can’t find a single paper on gratitude in chronic pain research, so this post is a little speculative.

Onto what is not speculative, in a paper by Wood, Froh and Geraghty (2010), the authors summarise some of the most recent findings about gratitude – is it a trait? a habit? what is the effect of looking for and expressing gratitude?

Firstly, gratitude is defined as   “…involving a life orientation towards noticing and appreciating the positive in life.” While some of us probably have more of a tendency towards this than others, these authors suggest that gratitude as a trait is an overarching construct that includes things like awe and respect, appreciation for what is happening right now, and so on.  These underlying components are not exactly the same as gratitude, but together contribute towards an overall ‘life orientation’ – a bit like the role neuroticism has as an overarching construct that includes things like anxiety, hostility, depression and so on.

Gratitude is found to correlate with “traits associated with positive emotional functioning, lower dysfunction, and positive social relationships. Grateful people were less angry and hostile, depressed, and emotionally vulnerable, experienced positive emotions more frequently.” It’s not entirely clear whether these findings are cause – or effect.  Similarly, gratitude is associated with aspects of wellbeing – negatively correlated with mental health problems such as depression, anxiety, as well as positively correlated with relationships with others, emotional wellbeing (happiness), and response to adverse events.

The research base is poor, however, in terms of the relationship between gratitude and physical health.  The few studies that have been conducted suggest that there is a relationship between gratitude and experiencing the physical effects of stress – and interventions to increase gratitude have shown positive effects on sleep.

Some of the clinical interventions that have been developed have provided a degree of hope that by developing gratitude it may be helpful for promoting wellbeing.  Twelve studies are cited in this paper, with three different interventions being studied.

The first is to simply list things for which a person is grateful. This can be carried out in different ways, but a common one is to write down three things at the end of the day for which the person is grateful, directly before bed.  The outcome from this in one study was a reduction in worry comparable to the intervention used in CBT, of recording automatic thoughts and working with those thoughts.  The advantage of the gratitude intervention was that people enjoyed it, completed it, and some even continued to use it after the study was over.

Another intervention involved ‘contemplating’ gratitude – by simply thinking of, or writing about things the person is grateful for.  This is a brief intervention, maybe over 5 minutes, and appears to be useful for raising mood in the short term – and might be useful for someone who comes into a session feeling particularly flat.

The final intervention involves ‘behavioural expression of gratitude’ – maybe writing a letter expressing gratitude to someone and delivering it, or visiting and speaking with someone to express gratitude.  In the studies exploring this, long-lasting increase in positive affect was found up to two months after the activity.

There are problems with the current research into gratitude as a clinical intervention.  None of the studies examined in this paper were thought, by these authors anyway, to involve adequate control conditions, and for people reading this blog, none of them were related directly to people experiencing chronic pain.  It’s clearly the early stages of developing this construct for the people we work with.

On the other hand, and being admittedly speculative, I think the gratitude research does hold out some interesting features that can be explored in pain management.

One of the most grim aspects of experiencing chronic pain is the loss of enjoyment and motivation to do everyday activities.  Low mood and pain, along with loss of quality sleep, are commonplace.  Gratitude interventions seem to have a positive affect on mood and sleep – so it might be reasonable to consider writing daily gratitude lists just before bed to foster more restful sleep, abort or disrupt the negative rumination that often occurs as people try to go off to sleep with pain, and to focus on what has been achieved during the day rather than what has not been achieved to help reinforce goal achievement and maintain forward momentum.

There is ongoing research into growth from traumatic experiences – many people have spoken and written about the new insights they have gained from going through difficult times.  Maybe something we can encourage people we work with to do is consider what they have gained from their chronic pain.  I know this sounds challenging – what could be positive about chronic pain?

For me, having chronic pain has helped me stop and slow down, helped me remember to have balance in my life and to measure my energy so I can be consistent and persistent.  For almost every negative I can also find a positive – if I look at things in a different way.  I can think of the need to ‘pace’ and ration my energy as a ‘have to’ or a ‘must’, and an imposition.  Or I can think of it as a way to experience and choose to do each activity in a mindful way, fully being present with each activity rather than flitting off and doing things in automatic.

I’d love to hear your thoughts on this – or better still, what about trying it for a couple of days? Write down three things you are grateful for just as you go to bed, and see what it’s like.

Wood, A., Froh, J., & Geraghty, A. (2010). Gratitude and well-being: A review and theoretical integration Clinical Psychology Review, 30 (7), 890-905 DOI: 10.1016/j.cpr.2010.03.005



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