Gratitude when you’re in pain? You’ve got to be kidding!

ResearchBlogging.orgOr – introducing the “parent of all virtues” (Wood, Joseph & Linley, 2007).

For some time now I’ve been exploring the contribution of positive psychology on wellbeing in people with chronic pain.  Positive psychology is the ” scientific study of the strengths and virtues that enable individuals and communities to thrive”. (Seligman, ND). It strikes me that in chronic pain management, we’ve responded to the issues raised by people who don’t “live well” with their pain, leaving the group of people who do cope well largely ignored. We have much to learn, I believe, from those who have faced their situation and either been stoic – or in a surprising number, grown from their experiences.  Some excellent resources in the field of positive psychology in general can be found at The Positive Psychology Center and Authentic Happiness, and for Kiwi’s, the New Zealand Association of Positive Psychology.

Gratitude is an emotion that most people feel frequently and strongly (McCullough et al., 2002).  Most people say that feeling grateful makes them feel happy. And oddly enough, gratitude seems to emerge despite difficult circumstances – with some research suggesting that it is in times of intense personal challenge that gratitude is most prominent (Peterson & Seligman, 2003). Immediately after the earthquakes in Christchurch nearly a year ago, people frequently expressed gratitude for one another, for the workers who kept the city running, and for the simple things in life like water, shelter and social support.

The question then arises – is experiencing gratitude empirically related to psychological wellbeing? And the answer is, not unexpectedly, yes! One study showed that gratitude was associated with wellbeing more than the “big five” personality model (Wood, Joseph and Maltby, 2009). It appears that gratitude influences wellbeing in two ways: “directly, as a causal agent of well-being; and indirectly, as a means of buffering against negative states and emotions.” (Nelson, 2009).

The next question is – can we influence wellbeing by increasing gratitude? And so far, research seems to support it.  For instance, in Catherine Nelson’s 2009 review of gratitude interventions, she cites studies in which one group of participants were asked to write down five things they were grateful for each week over 10 weeks, while two other groups were asked to carry this out daily either for two weeks or three weeks. At the completion of the study, it was found that positive affect was increased, and that there appeared to be a dose-response effect. In other words, the more often gratitude was expressed, and the longer this was carried out, the more positively people felt (Emmons & McCullough,

Interestingly, although we think of gratitude as having an effect on emotion, expressing gratitude can have a direct influence on “physiological coherence”.  This is “increased synchronization between the two branches of the ANS, a shift in autonomic balance toward increased parasympathetic activity, increased heart-brain synchronization, increased vascular resonance, and entrainment between diverse physiological oscillatory systems. The coherent mode is reflected by a smooth, sine wave-like pattern in the heart rhythms (heart rhythm coherence) and a narrow-band, high-amplitude peak in the low frequency range of the HRV power spectrum, at a frequency of about 0.1 hertz.”(McCraty & Atkinson, 2003). What this means is that by expressing gratitude, we may be improving our physiological response to life events.

How do we introduce the idea of expressing gratitude when life is difficult? – for this part of my post today, I’m using my approach, because I haven’t yet found research that identifies “the best way” to do it!

My way is to begin with some mindfulness. Sitting with the person and asking them to be present with what is happening right now. This can be done through focusing the mind on breathing, really experiencing the sensations that occur while breathing – the rise and fall of the abdomen, the cool air in the nostrils when breathing in, the warmer air when breathing out, the heart beat, the weight of the body pressing against the surface of the chair or support, the warmth of hands on lap.

I then ask the person to think of something that they appreciate right then and there. I might say “What comes to mind when you think of something you’re grateful for right now.” If they seem stumped, I might suggest that they express appreciation for being able to breathe; or being able to hear – and I might guide them to sounds of nature; or having a chair to sit on – and I might guide them to experience the sensation of being supported by the chair.

I try to guide the person to identify at least four or five things they appreciate then and there, so they can experience what it feels like to mindfully notice the good that is around them, and to notice the emotions that arise from doing so.

Ongoing practice I then give people is to write down three things they appreciate or are grateful for at the end of each day just before going to sleep.  Research has shown that doing this can influence sleep quality (Wood, Joseph, Lloyd & Atkins, 2009).

So, here’s a thought: what about trying this strategy out for yourself? It’s easy, quick and has some surprising results. Let me know how it works for you.

Emmons, R.A. & McCullough, M.E. (2003). Counting blessings versus burdens: An experimental investigation of gratitude and subjective well-being in daily life. Journal of Personality and Social Psychology, 84(2), 377–389.

McCraty, R. & Atkinson, M. (2003). Psychophysiological coherence. Boulder Creek, CA: HeartMath Research Center, Institude of HeartMath, Publication No. 03-016.

Nelson, C. (2009). Appreciating gratitude: Can gratitude be used as a psychological intervention to improve individual well-being? Counselling Psychology Review, 24(3-4), 38-50.

Wood, A., Joseph, S., & Linley, A. (2007). Gratitude – Parent of all virtues. The Psychologist, 20(1), 18-21.

Wood, A. M., Joseph, S., Lloyd, J., & Atkins, S. (2009). Gratitude influences sleep through the mechanism of pre-sleep cognitions. Journal of Psychosomatic Research, 66(1), 43-48.

Wood, A. M., Joseph, S., & Maltby, J. (2009). Gratitude predicts psychological well-being above the Big Five facets. Personality and Individual Differences, 46(4), 443-447.
A Wood,, S Joseph, & A. Linley (2007). Gratitude – Parent of all virtues The Psychologist, 20 (1), 18-21


  1. Gratitude during pain is DEFINITELY a good thing. I have a group on Facebook called “The Blessing Within” that is about finding things to be grateful for every day, in hopes that other chronically ill people can learn an attitude of gratitude and increase their quality of life through improved outlook (hopefully ultimately increasing their activity and productivity levels because they will feel more positive even if their pain levels don’t actually change much. 🙂

  2. I believe that there are many problems with the concept of gratitude.While I might feel grateful that the weather is nice on a particular day, I should not feel gratitude that I have a roof over my head when so many do not. Food, shelter, clothing and stable finances are the right of all of us and to feel gratitude because I have all of those is, in many instances, to become complacent about issues of social justice. I do not feel grateful that I have fibromyalgia and in pain! This issue of gratitude has about it an air of religiosity which I am not comfortable with most of the time. It is certainly not an easy issue to debate and I did give it only a cursory overview on my latest blog. I doubt that gratitude can sustain and improve the quality of life for very long, but I am hopeful that those of us with pain can use mindfulness as a way of living a less painful life.

    1. I’m certainly not grateful for having fibromyalgia – but at the same time, I can find things to be grateful for despite having it! I was first drawn to the concept of gratitude when I read Victor Frankl’s work “Man’s Search for Meaning”, or his exploration of how surivors of the Concentration Camps managed to get through each day by looking for something, however small, to be grateful for. And there are many stories of people, when faced with adversity, not only survive but actually grow and flourish – in fact, Seligman has recently published his first book in about 10 years called “Flourish: A visionary new understanding of health and happiness”.

      I don’t view looking at gratitude, and being thankful for and appreciating what I have as a religious experience at all. I certainly recognise the similarities between the “count your blessings” lessons within my Christian heritage, and the gratitude activity described in this post, but I think it’s entirely possible to approach life with a view to identifying what is good and positive without any overtones of religion. I do feel gratitude that I have a roof over my head – I could so easily have lost it in the earthquakes here. I feel gratitude for having the opportunities I do – and out of this, I feel more responsibility to contribute to my world in the best ways I can.

      I don’t know the answer as to how being grateful can improve my life, but some of the theories about mechanisms thought to operate are explored in some of the articles I cited in the post. It might be food for future blogging for me!
      Thanks for taking the time to comment, as ever, it’s wonderful to know people read what I write.

      1. Hi Bronnie,
        I just stumbled across this entry and found the concepts and some of the responses intriguing. I am wondering about the effectiveness of promoting thankfulness in general (as a distinct and objectified methodology) or rather just seeking to harness it when it exists.

        In many ways Frankl sought an objectification of his experiences, but he also suggests his objectification was steeped in the teachings of his faith.

        If someone’s worldview precludes a level of comfort (for lack of a better term) with faith issues then how effective is ‘raw’ mindfulness. In other words, can mindfulness even be mindfulness when it is practiced as a brute experience? If it can, even to some degree, should we still call it mindfulness? And how effective is it?

        I rather like the idea of harnessing people’s faith practices where they exist – particularly if they are healthy practices. That can be anything from ‘counting your blessings’ to ‘samadhi.’ Both would seem to achieve the same thing – from my anecdotal experience. I have never felt uncomfortable speaking in terms that make faith-sense for the individual, and I think we can do that respectfully if we are educated enough to know what to respect.

        So the clinical problem is ‘what does one do with the person who does not have or find comfort in the notion of faith-sense?’ I think it might be important (from a research perspective) to separate out this group of people and measure faith-deconstructed brute ‘mindfulness’ to see if it has effects on pain relief. Otherwise we can make the errors of measuring how round something is when it is already rather round.

        My hypothesis is that one can not ‘brute force’ this concept effectively from a faith-deconstructed perspective. It would be interesting to find out though.

        Thanks as always for your thoughtful postings.


      2. As an experiencer of chronic pain since ’87, plus a therapist specializing in chronic pain treatment, I appreciate this discussion! My 2 cents:
        1. It’s safe to say that positive mind states make for less pain, and:
        2. Whatever works to create positive mind states is on: I pray out loud with my devout Christian clients (I’m of transpersonal view: there are many paths up one Mountain, many lenses through which to view the Truth; that view offends some folks, OK). I teach mindfulness to everyone; research and decades of practice tell me mindfulness works. Sometimes I adapt mindfulness for devout Christians: instead of “in breath, out breath,” I’ll have them pick a Christian phrase as a mantra.
        3. Mindfulness doesn’t work for everyone always: some respond better to humor a la Norman Vincent Peale, or artwork, or what have you.
        4. Gratitude’s been shown in research I believe, and practice to be great and timing’s everything:
        when someone’s really hurting, it can be offensive in my experience to say, “what are you grateful for?” Empathy is the bridge.
        Comments invited, it’s ongoing learning for us all, Charles Horowitz, Ph.D., Boulder, CO

      3. Thanks for taking the time to comment, Charles. Yes, timing is everything and I hope that no-one would be insensitive enough to counter someone being distress with “and now then, what are you grateful for?”! As you say, empathy is the bridge, and for me, an empathic response would be to sit “with” the person’s distress, giving them space to experience it (this is mindfulness) allowing it to peak and then ebb away, and in that peaceful space, then ask the person to consider what they might be also able to experience. I might suggest attending to other sensations like touch, scent, sound, colour, and guide them to consider what they might be able to also enjoy in the moments they sit with me. And in doing this I hope to help people move through the emotional landscape from distress through peace to some sort of positive emotion that can be brought to mind.
        For Christians I suggest meditating on a favourite psalm – this is a long-standing practice in most denominations and is usually readily accepted.

        I do think the greatest gift we can give to people is the willingness to walk alongside them, helping them to make room for emotions that can be difficult to experience.

      4. Thanks, Bronnie, I’m with you.
        For me, Shinzen Young’s book and CD set,
        Break Through Pain, plus David Butler’s Explain Pain have been best so far.

      5. Hi Charles
        I love Turk & Winter’s book “The Pain Survival Guide” – it has nothing on mindfulness or gratitude, but it is practical and comprehensive. Otherwise I tend not to use books much (literacy is a problem for many clients), so I generate my own visual aids and use experiential learning in session to help people develop confidence in their ability maintain focus in the “now”. Sometimes an aid like a taste sensation (a raisin or glass of water), or a tactile sensation like a feather or shell can be used.

      6. Thanks for your reply, Bronnie! I’m with you in approach.
        A question: how do you work differently, if you do, with someone when it’s a pretty clear case of somatization? I’ve got one now and tend to work it the same way: CBT, MBSR, relaxation skills.
        The client keeps seeking advanced medical help, i.e. seeing specialists, when she’s seen over 500 docs. Comments please, anyone?

      7. Thanks for your reply, Bronnie! I’m with you in approach.

        Here’s a link for Shinzen Young’s mindfulness approach to pain:

        Click to access artPain.pdf

        A question: how do you work differently, if you do, with someone when it’s a pretty clear case of somatization? I’ve got one now and tend to work it the same way: CBT, MBSR, relaxation skills.
        The client keeps seeking advanced medical help, i.e. seeing specialists, when she’s seen over 500 docs. Comments please, anyone?

  3. Great post, Bronnie. I love all the articles and supporting info that you have cited. I want to take more time to go through them. When I was in my pain place, for over 30 years, I know that being able to divert my attention away from what I could not control, my pain, esp. as a teen, to that which I could control, my attitude, gave me great strength. Focusing on what I could do rather than what I could not sustained me for years.
    It seems that if you give up your desire to “be well” you stay stuck in your pain. For me, gratitude is a marvelous tool I can, have and always will use to escape circumstances and allow myself to be in a better space. Pain has taught me what really matters in life. And for that I am grateful.
    Blessings, Mary

    1. Thank you so much for giving your experience Mary, it’s so good to hear that it has made a difference to you. I am grateful for what I have learned about myself as a result of pain, although from time to time I wish I could have learned it in a different way!

  4. BRONNIE, PLEASE CLARIFY your well written, bold, and valuable article: As Barbara responded previously, it’s hard to be grateful when you’re in pain. I work as a therapist doing CBT and mindfulness with folks in agony, i.e. with RSD and other forms of burning pain sensations. They are disappointed, frustrated, scared, and depressed with their conditions, usually. That and the sensations of pain are often so gripping of their awareness that it’s hard for them to look beyond to gratitude; my job includes getting them to both decrease their experience of pain and to look beyond it.
    Yes, your point is great: if they cultivated positive mind states i.e. gratitude, their experienced pain will be softened and their acceptance will be increased. Research shows it. Still, to ask them to be grateful initially is unthinkable.
    I love Viktor Frankl as an example, and: he came into that camp with attitudes shaped by decades of conditioning. His amazing attitude was not created I suspect not so much by choice as much as by pre-existing temperament. It’s very tough, though possible–I’ve done it over time with individuals–to influence a down person to become an up person.
    So overall I agree with you, but most of the pain cases I work with would not be ready for this. I came into this field from my own pain and might have brained you had you given your article to me 20 years ago.
    Your thoughts, please, Bronnie and anyone?
    Charles Horowitz, Ph.D.

    1. It’s interesting that the research into using gratitude to improve mood has used people with depression – not a group who would naturally find much to be grateful for! So while I understand that this post is somewhat disconcerting and might even appear heartless, it’s based on my own personal experience (having both depression and chronic pain), my experience working with people who have chronic pain (and have been referred to a tertiary treatment centre), and on my reading of how it seems that taking this approach affects people.

      I don’t begin treatment with gratitude practice. Like most clinicians working in the area I start with education about chronic pain – and I help people generate their own chronic pain “model” or formulation. By exploring the ways in which appraisals of pain influence mood and behaviour, and using traditional CBT Socratic and experiential discovery, I find that people are more open to reconsidering the way they approach life. I usually introduce it, as I said, via mindfulness practice, and in the form of an experiment. I suppose my overall approach is to acknowledge that I have no idea what will work for them individually, so all of our work together is a process of discovery and experimentation!

      I must add that over the past two years I’ve been increasingly moving away from CBT, and for many years now I’ve paid little to no attention to reducing pain intensity. It’s not our focus – but if it happens, and on occasion it does, that’s great. My focus is far more on getting on with life and doing what is important and valued despite the pain. This stance recognises that pain intensity fluctuates, and almost everyone who has chronic pain will have occasions when it flares up. If we try to control what can rarely be controlled, we are likely to expend more effort on the attempts to control than on doing and living according to our values. And as the three week pain management programme participants often comment “My pain hasn’t changed, but my attitude towards my pain has”.

  5. Has the idea of meditation and mindfulness-based therapy come up here yet? I am Canadian, but here is a link to a bookstore that specializes in psychological titles: I have used these tenants myself: I am both a clinician and have a chronic condition, and they have worked really well for me.

    1. Yes, I’ve written about it quite a lot on this blog – just go to the search blox and type in mindfulness. Not so much about meditation, because mindfulness and ACT are more my personal interest!
      btw, we don’t mind Canadians on here – I’m a Kiwi, so we’re both part of The Great British Empire!

  6. I found this post from “rhuematoid arthritis guy” quite riveting:

    He discusses a flareup, what went on in his head as he struggled with the sense of isolation it had generated; at the end he says, “I’m happy to share that I don’t feel the least bit defeated. In fact, I feel stronger, and more prepared, than ever before. Sure, I’d love to continue to not be in a flare…but learning to cope even better while I’m in the midst of a flare…well, this is a wonderful consolation prize that I’ll never turn down!”

    Sounds like he’s grateful.

  7. Awesome post (anjd responses) once again Bronnie.
    I totally understand that some people will not be able to follow this path, and that some following this path will not find the same benefits as others. A patient with profound CRPS found some improvement practising Metta (loving kindness meditation) when his daughter survived though with paraplegia a horrible hit and run pedestrian-car accident. His intention was to decrease the stress related to her circumstances, and it helped his signs and symptoms.
    Making the right guesses about when to introduce a practice with a person in pain is quite an art. Yogi’s having practised mindfulness, moving meditation, deep awareness, …, often suggest that making friends with pain is really helpful. Not for most people who have not practiced such things before. For them it is ridiculous and insulting. Yet at some time in their recovery process, this might be exactly the technique to help them move forward some more. As you point out Bronnie, by educating the person about pain science, we could provide some evidence that practising gratitude might be helpful from a physiology point of view. This helps foster motivation, and validates that the pain is a real thing (reality is that for most people, without pain education, practising gratitude would reinforce that the problem is in their head – not real).

    Did The Beatles have it right? “All you need is love”? Certainly our physiology is better off when when we live in love rather than in fear, and Buddhist practice would suggest that the most important love is for self.
    Maybe love and gratitude are not identical, but it would be interesting to look at how similarly the endocrine and immune systems and central and autonomic nervous systems respond when we practice the two.

  8. great post! This reminds me of the studies done on Meditation and the brain. The more wellbeing we offer ourselves, the more our happiness and contentment remain. Seligman has some great research out there and hopefully the new research coming out of Denmark with help perpetuate further support of what he is trying to do.

    It’s time we start to measure how to make people happy and what happiness is as opposed to how many people need or should be on medication.


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