1. No category

The Effectiveness of
Gratitude Activities on
Increasing Mental
Wellbeing in Healthy
Adults: An Evidence
Based Review and
Meta-Analysis
By Brianna Munson
nature
exercise
friends
dessert
good night sleep
What are you thankful for?
http://theodysseyonline.com/sdsu/11-things-only-best-friendswould-understand/71534
learning
http://blogdailyherald.com/2014/10/07/providence-coffee-shopround/
Why Study Mental Wellbeing?
http://www.corrections.com/news/article/30549-mental-health-issues-in-county-corrections-vs-state-prisons
Relevance to PT:
Happier People Have:
Ankylosing spondylitis: 67%
Decreased Fatigue
Higher Levels of Physical
Activity
(Jones 1996)
Post stroke: 68% (Staub 2001)
Decrease obesity
(Avenell 2004)
Prevent Alzheimer's Disease
(Schlosser 2005)
Better Sleep
Decreased sleep causes
flares in fibromyalgia
(vincent 2015)
)
Relevance to PT: Happier
People Have:
Improved
immune
functioning
Slower disease
progression
and longer
survival
Increased
longevity
Improved
Cardiovascular
and respiratory
functioning
DECREASED
PAIN
Howell 2007
Clinical Problem and Purpose
biological
Social
PSYCH
OLOGI
PSYCHOLOGICAL
CAL
Pain
Physical Therapists:
• clear anatomical
and pathological
link (Foster 2011)
Low back
pain: acute
to chronic
(Foster
2011)
How Can We Address the
Psychological Part of the Model
Acts of
Kindness
Gratitude
Cultivating
Personal
strengths
Cultivating
Optimism
Positive
Psychology
Interventions:
(Southwell 2012, (Sin 2009)
Learning to
forgive
Mindfulness
meditation
Committing
to your
goals
15 minutes
writing a
letter
thanking
someone
Gratitude
Activities
Write
about
5
things
Think
about
5
things
http://www.australiancurriculumlessons.com.au/2014/12/30/identifying-parts-letter-english-lesson-plan-years-23/
http://alpinekleinbunch.blogspot.com/2013/03/how-to-write-missionary.html
http://joshuamhood.com/how-to-be-happier-in-5-minutes/
I am
satisfied
with my
life
I feel joyful
energetic
attentive
I don’t feel
sluggish
timid
sad
Why Would Cultivating Gratitude
Increase Mental Wellbeing?
increased
focus on the
positives in life
direct
attention
away from
what one does
not have
Positive
memory bias
Mental
Wellbeing
Watkins 2004
Gaps in the Literature
2 Meta-analysis: Positive Psychology
Interventions increase mental wellbeing
Correlation between gratitude and
mental wellbeing
(Wood 2010)
No meta-analysis on causative
relationship
Theoretical Construct
Mental
wellbeing has a
causal
relationship with
physical health
Then
gratitude
AND
interventions
positive
will have a
psychology positive effect
interventions on mental
IF research as a whole wellbeing
supports the have a
correlational causal
relationship relationship
with mental
between
wellbeing
gratitude
and mental
wellbeing
As Physical
Therapists this is
what we aim to
improve
Foreground Question
Are gratitude activities effective at
increasing mental wellbeing, satisfaction
with life, affect and gratitude?
• Population: healthy adults between
• Intervention:
• writing or thinking about things subjects are
grateful for
• writing letters of appreciation
• Control: neutral, negative or no control
• Outcome: mental wellbeing, satisfaction with life,
affect, gratitude
Hypothesis and Expected Findings
Null: Gratitude
activities will not
have an effect on:
Alternative:
Gratitude activities
will have an effect
on
Expected Findings:
Mental
Wellbeing
Mental
wellbeing
> 10 studies
Satisfaction
with life
Satisfaction
with life
All at least
3a level of
evidence
Affect
Affect
Reject the
null
Gratitude
Gratitude
Methods: Search Procedures
Inclusion
• adults, intervention either gratitude letters or thinking/writing
about what thankful for
Exclusion
• chronic diseases, psychiatric diagnosis, articles not in English,
other interventions besides gratitude utilized
Terms:
• Gratitude, thank*, awe appreciation, intervention, thankful,
thankfullness, acknowledgement, recognition
Statistics
Extraction
Calculated
per
Outcome
Heterogene
ity Q
statistic
Grand
Outcome
Convert
• Means and SD
• Effect sizes and 95% CI
• P value > .05 = fixed effect model
• P value < .05 = random effects model
• Grand ES and 95% CI calculated used weighted individual ES
• Clinical units
Prisma
Identification
Screening
Eligibility
Records
Identified
(n=309)
Abstracts
screened for
inclusion/excl
usion criteria
(n=60)
Full-text
articles
assessed for
eligibility (n =
30)
Primary Articles
Studies
included in
meta-analysis
(n=12 studies)
(n=15
experiments)
Study Quality
Study
Year
Emmons et al. experiment 1
and 2
2003
1b
Randomized Control Trial
Watkins et al. experiment 3
and 4
2003
2b
Randomized Control Trial
(post test only)
Watkins et al.
Experiment 4
2003
1b
Randomized Control Trial
Rash et al.
2011
1b
Randomized Control Trial
(double blinding)
Sheldon et al.
2006
1b
Randomized Control Trial
(single blinding)
Koo et al. experiment 1 and
2
2008
1b
Randomized Control Trial
(double blinding)
Toepfer et al., 2012
2012
1b
Randomized Control Trial
Lambert
2009
1b
Randomized Control Trial
Gander et al.
2014
1b
Randomized Control Trial
Toepfer et al.
2009
2b
Repeated Measures
Killen et al.
2014
1b
One group pre-post
Watkins et al.
2015
1b
Randomized Control Trial
Level
Design
Gratitude Activities
Study
Activity
Control
Length
Write- weeks events
1x/wk, 10 wks
Write- weeks hassles
Everyday for 2 wks
1x
1x
Rash et al.
gratitude thinking,
gratitude letter, gratitude
writing
Gratitude thinking
Write- events they wished
happened over summer
Write-living room layout
Write- weeks events
1x/wk, 2 wks
Sheldon et al.
Gratitude writing
Write-typical day
1x/wk, 4 wks
Koo et al. experiment 1
No activity
1x
No activity
1x
Toepfer et al. 2012
Write- positive event and
how it could have not
occurred
Write- positive event and
how it could have not
occurred
Gratitude letter
No activity
1x/wk, 3 wks
Proyer et al.
Gratitude letter
Write-early memories
1x
Peters et al.
Gratitude writing
Imagine-typical day
Everyday for 1 wk
Gander et al.
Gratitude letter
Write-early memories
1x-intervention
Emmons et al. experiment Gratitude writing
1
Emmons et al. experiment Gratitude writing
2
Watkins et al. experiment 3 Gratitude writing
Watkins et al. experiment
4
Koo et al. experiment 2
Sample
Size=1491
Toepfer et al., 2009
Gratitude letter
No activity
everyday for 1 wk-control
3x over 8 wks
Killen et al.
Gratitude writing
No control
Everyday for 2 wks
Synthesis Across Studies
Outcome
Studies included
Measurement
Tool
Statistically
Significant
Gratitude
Emmons experiment 1
3 affect terms
rated 1-5
yes
Emmons experiment 2
3 affect terms
rated 1-5
yes
Toepfer 2012
GQ6
no
Toepfer 2009
GQ6
yes
Killen
GQ6
no
Rash 2011
SWLS
yes
Toepfer 2012
SWLS
yes
Toepfer 2009
SWLS
yes
Killen 2014
SWLS
no
Satisfaction with Life
Synthesis Across Studies
Outcome
Study
Measurement
Tool
Statistically
Signicant
Positive Affect
Emmons
experiment 1
30 affect terms rated
1-5
yes
Rash 2011
PANAS
yes
Sheldon 2006
PANAS
yes
Watkins
experiment 4
Watkins
experiment 4
Watkins
experiment 3
Rash 2011
PANAS
yes
PANAS
yes
PANAS
yes
PANAS
yes
Sheldon 2006
PANAS
yes
Koo experiment
1
13 affect terms rated
1-7
yes
Koo experiment
2
13 affect terms rated
1-7
yes
Negative Affect
Combined Affect
Mental Wellbeing
Between Group
 Random Effect
 Small ES: 0.27
(0.09-0.45)
SIGNIFICANT
 Random Effect
 Small ES: 0.28
(0.05-0.51)
SIGNIFICANT
Favors Intervention
I am
satisfied
with my
life
I feel joyful
energetic
attentive
I don’t feel
sluggish
timid
sad
Satisfaction with Life
Between Group
 Fixed Effect
 Small ES: 0.36
(0.14-0.57)
 7% increase
on SWLS
SIGNIFICANT
 Fixed Effect
 Small ES 0.28
(0.11-0.45)
 5% increase
on SWLS
SIGNIFICANT
Favors Intervention
No MCID/MDC
Positive Affect
Between Group
 Fixed effect
 Small
ES=0.44
 7% increase
on PANAS
SIGNIFICANT
SIGNIFICANT
Favors Intervention
 Fixed effect
 Medium
ES=0.64(0.4
3-0.86)
 8% increase
on PANAS
No MCID/MDC
Negative Affect
Between Group
SIGNIFICANT
 Fixed Effect
 7% decrease
on PANAS
 Small ES=0.33
(0.25-0.60)
SIGNIFICANT
 Fixed effect
 5% decrease
on PANAS
 Medium
ES=0.63 (0.420.85)
Favors Intervention
No MCID/MDC
Gratitude
 Fixed Effect
 Small ES=0.43
(0.25-0.60)
 4% increase
on GQ6
SIGNIFICANT
 Fixed Effect
 ES=0.03 (-0.150.20)
 0.2% increase
on GQ6
Not significant
No MCID/MDC
Summary of Hypothesis
Gratitude activities will
have an effect on
Mental
Wellbeing
Satisfaction
with life
Affect
Gratitude
(Partially)
Positive Affect
Negative
Affect
Explanation of Results: Mental
Wellbeing
Variability
?
Dosing:
1-14x
Lack
true
control
(Watkins 2006)
Explanation of Results: Negative
Affect
I’m
grateful
for…
ENVY
https://images.search.yahoo.com/images/view;_ylt=AwrTcXhdkPhUWtQAWGeJzbkF;_ylu=X3oDMTIyaWVyaGliBHNlYwNzcgRzbGsDaW1nBG9pZAM4ZGE3NmZkMWVjZjc1YWIwNTY2NWUyYTY1MGQ2YWFiMARncG9zAzQEaXQDYmluZw-?.origin=&back=https%3A%2F%2Fimages.search.yahoo.com%2Fyhs%2Fsearch%3Fp%3Dshielding%2Bin%2Bsword%2Bfight%2Bcartoon%26n%3D60%26ei%3DUTF-8%26fr%3Dyhs-mozilla-001%26fr2%3Dsb-top-images.search.yahoo.com%26hsimp%3Dyhs001%26hspart%3Dmozilla%26tab%3Dorganic%26ri%3D4&w=1180&h=1300&imgurl=thumbs.dreamstime.com%2Fz%2Fcartoon-roman-legionary-sword-shield-19618242.jpg&rurl=http%3A%2F%2Fwww.dreamstime.com%2Fstock-photography-cartoon-roman-legionary-sword-shieldimage19618242&size=139.0KB&name=%3Cb%3ECartoon%3C%2Fb%3E+Roman+legionary+with+%3Cb%3Esword%3C%2Fb%3E+and+%3Cb%3Eshield%3C%2Fb%3E.+Isolated+on+white.&p=shielding+in+sword+fight+cartoon&oid=8da76fd1ecf75ab05665e2a650d6aab0&fr2=sb-topimages.search.yahoo.com&fr=yhs-mozilla-
Explanation of Results: Negative
Affect
Coping
Reframing
“living life to the fullest”
“having greater
appreciation of my friends
and family”
“valuing each day more”
2010)
http://lowres.cartoonstock.com/families-hip_operation-dodgy_hiphospital-visiting_hours-patients-lcan646_low.jpg
(Wood
Explanation of Results: Positive Affect
1 year
later
(Lyubomirsky 2005, Brickman 1978)
http://www.pd4pic.com/man-people-bored-unhappy-cartoon-human-face.html
Gratitude Across Populations
(Froh 2008, 2009)
(Geraghty 2010)
(Emmons 2003)
(Geraghty 2010)
http://www.hopeandhealingcenter.org/events/292/
http://miamioh.edu/student-life/student-counseling-service/resources/mental-health-topics/depression/index.html
https://mghocd.org/bdd-and-anorexia-nervosa-what%E2%80%99s-the-big-difference-is-there-a-difference/
http://schools-training.com/articles/growing-certified-healthcare-workers.html
(Emmons 2003)
(Cheng 2015, Lanham 2012, Estrada 1997)
Clinical Implications
Home Exercise Program
Activity: gratitude letter,
thinking or writing
Frequency: 1x/wk
Duration: 3+ wk
Motivation to improve mental
wellbeing
(Lybumirsky 2005)
Value gratitude
(Fordyce, 1977, 1983?? Lybomirsky 2005
Referral to Psychologist
http://psychcentral.com/blog/archives/2014/07/12/its-ok-to-have-anxiety/
http://www.cgepmd.com/home/2013/09/18/an-invitation-to-join-the-pink-ribbon-movement-at-the-7th-annualpineapple-saute-and-sip/breast-cancer-ribbon/
http://www.dreamstime.com/royalty-free-stock-photos-blank-clipboard-notepad-isolated-white-image8448708
Cost and Harm
Addressed in two studies
(Seligman et al, Killen et al): minimal costs
Free for individuals!
The How of Happiness
by Sonja Lyubomirsky
Harm: not addressed
• 12$ on amazon
No special training
needed for PTs
Limitations
Variation in age (18-89 years old)
Lack of blinding
Multiple studies by the same author
Searches conducted by a single person, in
English only, on a limited number of databases
Directions for Future Work
Meta analysis on other positive psychology
interventions
Direct effects of gratitude on physical health
Effect on participation in rehab
Gratitude in conjunction with PT (chronic
pain, FABQ)
Conclusion
Gratitude activities are effective at increasing
mental wellbeing.
Physical therapists should consider the use of
gratitude activities as one option to address the
psychological component of the
biopsychosocial model in order to improve the
effectiveness of their treatments.
Acknowledgements
 Amber
Fitzimmons
 Erica Pitsch
 DPT Class of 2015
 Michille Ho
 Andrew Tran
 Family and Friends
Primary References
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nature
friends
exercise
QUESTIONS???
dessert
good night sleep
learning