Background
Prior research has focused mainly on the experience of gratitude among patients with fatal, potentially life-threatening diseases (i.e., cancer survivors, HIV infected). Until now, little attention has been given to the perception of gratitude among patients with chronic diseases that are not primarily fatal and life-threatening (i.e., multiple sclerosis and psychiatric disorders). Therefore, we were interested in how patients with chronic, nonterminal illnesses adapt to their situation and experience gratitude, awe, and beauty in life. Do these patients really perceive gratitude and awe despite their disease and its unpredictable course?
Patients with chronic disease are often burdened by their thoughts and feelings and tend to focus on symptoms and relief. Awareness of their thoughts and feelings is often considerably narrowed. Yet, patients may also at the same time become more aware of moments and experiences of (silent) well-being, interactions with others and care, which may lead to favorable feelings of gratitude and joy. Feelings of gratitude facilitate perceptions and cognitions that go beyond the focus of illness and include positive aspects of one’s personal and interpersonal reality, even in the face of disease. These feelings may help those with chronic or other illnesses to enjoy the beauty of nature, their surroundings, relationships with others, as well as the goodness of life. As such, they become a source of relief and even of lasting fulfilment, notwithstanding the limitations of the disease [
1]. The key issue here is awareness of such positive experiences and relationships. Hence, it is a matter of attention, of interpretation and of acceptance of the situation in the light of the beauty still found in the middle of a crisis [
2].
Gratitude is thought to be an “emotional state and an attitude toward life that is a source of human strength in enhancing one’s personal and relational well-being” [
3]. Gratitude in perception, feeling, cognition, motivation, and memory constitutes a counterbalance - or even counterforce - against physical and cognitive limitations of the disease. With regard to the past, gratitude is typically associated with memories of love and joy, both received and given. With regard to the present, gratitude enables the perception of enriching experiences in the midst and in spite of illness. Looking to the future, gratitude reinforces confidence and hope. Undoubtedly, gratitude is an essential dimension of one’s subjective quality of life, patients included [
4].
Feelings, cognitions and motivations related to gratitude are intrinsic psychological occurrences – they cannot be forced or commanded. Yet, they can be consciously trained and harbored [
4‐
7]. Feelings of gratitude can be, and clearly are, often thwarted by the immensity of disease and the physical, psychological and spiritual challenges it entails [
8].
In contrast, awe is an emotional perception of wondering astonishment and admiration, i.e., when facing either a breathtaking landscape, a starry sky, experiencing mystical experiences, etc. [
9,
10]. This overwhelming emotion is often accompanied by a sense of vastness and the feeling that time is standing still. Keltner and Haidt [
9] suggested that such emotions are experienced more often in “times of tremendous social change”. Patients with chronic, long-lasting, and thus a frustrating course of disease also undergo dramatic social changes. Thus, it is reasonable that awe may also be experienced more frequently during times of illness. The experience of beauty in life is a more general feeling that can but does not always result in feelings of gratitude or awe. It is simply the ability to recognize and perceive such beauty in nature, in beloved persons, etc.
While presumably all religious traditions try to come to grips with suffering, Abrahamic religious traditions underline that humans, nature and all living things stem from God, the loving creator of all that exists. This belief in a loving God can prevail against the negative experience of disease. Spirituality (either religious or non-religious) may facilitate sentiments of gratitude in the midst of an individual’s suffering. Openness to spirituality also opens people to perceive, receive, and respond to the fundamental goodness of creation and life. Such feelings and behaviors of gratitude are a basic expression of religion. Gratitude becomes a part of religious awe in relation to God (or, in other currents, to some transcendent power) both in feeling and prayer and behavior [
11‐
13]. Thus, is appears meaningful to ask whether the religious/spiritual attitudes of patients have an influence on their experience of gratitude and chronic disease. This will be one of the main research questions of this study.
Research on gratitude as a life orientation has shown that gratitude is correlated with positive emotional functioning, lower dysfunction, positive social relationships, and well-being (reviewed in [
14]). Interestingly, thankfulness was also associated with lower risk of major depression, generalized anxiety disorder, phobia, and drug abuse [
15]. The association between gratitude and fewer depressive symptoms seems to be mediated by positive reframing and/or positive emotion [
16].
Gratitude has been examined in the face of various chronic diseases, including cancer [
17‐
21] and HIV infection [
22]. Persons with prostate cancer sought to appreciate the “beauty and gifts of life” [
17]. Long-term breast cancer survivors expressed their “deep gratitude for being alive”; they reported “joy for life itself and for being present in their lives” and a “more positive approach to life” [
18]. The authors suggested that “this gratitude helped the women balance the challenges and discomforts; many of them endured as long-term survivors” [
18].
Due to the adaptive role of positive emotions under chronic stress, Algoe and Stanton [
21] suggested that gratitude could be regarded as a factor of resilience. In a study involving patients with metastatic breast cancer, feeling gratitude resulted in a readiness to accept help from supporting persons [
21]. Among skin cancer patients, however, those with malignant melanoma were more likely to “mention a sense of relief/gratitude following treatment and/or a commitment to enjoy life here on” than patients with non-melanoma skin cancer [
19]. Because the “realization of one’s mortality” and emotional relationships were more frequent in melanoma patients than in the non-melanoma skin cancer patients [
19], one may suggest that these factors might contribute to the higher proportion of relief/gratitude. Another study investigated cancer patients who experienced posttraumatic growth and found that their positive experience was associated with “cognitive reappraisal of emotion, gratitude finding, and openness to experience” [
20].
All of these specific findings were derived from patients with fatal, potentially life-threatening diseases, and gratitude was expressed either as renewed awareness of the gift of life (diagnosis and treatment), or as an appreciation of still being alive (survivors). However, what about patients with chronic diseases that are not primarily fatal and life-threatening, with symptoms that may appear “at random” or that may persist for longer periods of time? Will the experience of gratitude and awe differ with respect to specific forms of diseases?
To answer these questions, we intended to measure feelings of gratitude and awe, along with the experience of beauty in life in two rather diverse patient groups: one group with multiple sclerosis (MS) and another group with psychiatric disorders. We were particularly interested in associations between these variables and spiritual attitudes and life satisfaction. Patients with the aforementioned diseases were chosen (1) because one can expect a large fraction of relatively young individuals who have low specific interest in spiritual or religious issues [
23‐
25] (this provides a basis for comparison to those who do regard themselves as religious and/or spiritual), and (2) because they experience chronic diseases that are not primarily fatal and life-threatening. Patients with MS are faced with an illness that is characterized by an often unpredictable course of exacerbations and remissions with significant impairment of life goals and everyday life. Furthermore, there is no “cure”. Similarly, patients with psychiatric disorders cannot expect a specific “cure” in most cases, and thus they must also find strategies to adapt to their recurring symptoms.
For the purpose of this study, we therefore measured whether and how often these patients have experienced feelings of gratitude, wondering awe, and beauty in life. To measure these emotions and perceptions, we used specific items derived from a questionnaire for measuring the frequency of engagement in specific religious and secular forms of spirituality [
23], particularly the scale
Gratitude/Awe, which includes three items addressing the frequency of feelings of great gratitude, wondering awe, and experienced and valued beauty in life. We suggest that (1) the frequency of experience will differ with respect to specific forms of spirituality, particularly that religious/spiritual patients may experience gratitude, awe and beauty in life more often than non-religious/skeptical patients, (2) that the perceptions of these emotions differ with respect to gender and underlying disease, and (3) that these emotions are related to patients’ life satisfaction.
Discussion
We intended to analyze whether and how often patients with MS or psychiatric disorders experience feelings of
Gratitude, wondering
Awe, and
Beauty in life. Our data show that Gratitude and Awe were noticed and appreciated by a small group (34% and 23% often or frequently, respectively) of the individuals investigated. In contrast, most participants have experienced and appreciated
Beauty in life (64% often or frequently). The mean scores of the
Gratitude/Awe scale, which measures the frequency of these feelings and experiences, are in the lower intermediate range (42.4 ± 23.8). Previously, in a positively selected group of Catholic priests, we observed much higher mean scores of 70.1 ± 21.6 [
31]. Another sample of patients with chronic diseases (70% chronic pain diseases), reached mean scores of 50.3 ± 23.7 on the respective scale [
32].
With respect to our assumption that the perceptions of
Gratitude, and experience of
Beauty in life may differ according to gender, we indeed observed lower scores of
Gratitude/Awe in male patients. This finding is in line with the findings of other studies [
33]. This might not mean that men are less capable of experiencing feelings of gratitude or beauty, but, as found by Kashdan et al. [
33], women have a higher willingness to express their emotions than men.
Interestingly, there were no significant differences with respect to the underlying disease categories. The only exception was that patients with depressive orders had significantly lower experiences of Beauty.
Because one of our hypotheses was that religious/spiritual patients may experience
Gratitude,
Awe and
Beauty more often than non-religious/skeptical persons, we analyzed the respective variables with respect to the spiritual/religious self-categorization of the patients and their engagement in specific forms of spirituality. We found that persons lacking a spiritual/religious attitude (R-S-) had significantly lower
Gratitude/Awe scores than patients with spiritual/religious attitudes. In line with this finding,
Gratitude/Awe correlated most strongly with the frequency of engagement in
Religious practices, but also secular forms of spirituality, particularly
Humanistic practices. Both activities, religious and humanistic, are associated with relational activities. This can be expressed either through connectedness to a transcendent source (resulting in praying, church attendance, etc.) or connectedness to concrete others (resulting in a helping and caring attitude), and both religious and humanistic practices are primarily active. A previous study also showed that the best predictors of
Gratitude/Awe were religious trust (in terms of an intrinsic religiosity) [
23]. Among the three target items analyzed in this study, feelings of
Gratitude as well as Awe correlated most strongly with
Religious practices. Experienced Beauty was most strongly associated with
Humanistic practices and only weakly with
Religious practices. Thus, it is the experience of feelings of
Gratitude and wondering
Awe more than awareness of
Beauty in life that might have a positive spiritual/religious connotation.
Keltner and Haidt [
9] recommended that research should concentrate on similarities and differences between gratitude and awe. In our study, both were strongly interconnected (r = .59). However,
Awe was experienced less often than
Gratitude. Interestingly, significantly more women than men experience
Gratitude, whereas there were no significant gender differences with respect to
Awe.
Wood et al. [
34] argued that an “ungrateful person is less likely to notice help, and less likely to reciprocate the help, making their benefactor less willing to provide further aid”. In turn, grateful people benefit from “better social relationships, characterized by greater closeness and heightened reciprocal social support”. Patients with reduced experience of gratitude and awe, or low awareness of the (still existing) positive aspects in life (including beauty in nature, situations, and relationships) receive help to focus their attention on these aspects of their life. The persons investigated in this study (particularly those with psychiatric disorders) may benefit from such interventions, which have the potential to increase their life satisfaction and well-being. Gratitude interventions to increase well-being and decrease depressive symptoms might be a meaningful option [
14,
35].
Previous research has shown that gratitude is strongly related to well-being [
14]. However, in this study we measured satisfaction with various dimensions of life concerns and not simply well-being. We observed only a weak association between life satisfaction and
Gratitude, yet a moderate association with the experience of
Beauty in life. However, general life satisfaction was among the best predictors of
Gratitude/Awe. What is measured as life satisfaction or quality of life might differ from what patients and people in general consider as authentic happiness or as lasting personal fulfillment, and from what may constitute elements of personal “well-being”. Fagley [
36] found that awe correlated moderately with life satisfaction (r = .35) and only weakly with gratitude (r = .28); their hierarchical multiple regression analysis indicated that after controlling for demographic variables, personality factors and gratitude, a grateful attitude made a “significant unique contribution (11% of the variance, p < .001) to life satisfaction”. In our study,
Gratitude/Awe explained only a small amount of life satisfaction (4%), and thus it should be regarded as an independent dimension. Our findings emphasize the fact that more frequent experiences of
Gratitude/Awe will not necessarily result in higher life satisfaction with all its usually scored aspects, both objectively and subjectively. Rather, it may indicate an ability of patients with a spiritual/religious attitude to “look deeper” and to appreciate life as such – a trait or attitude which can be predicted best by an engagement in
Religious practices and
Humanistic practices.
Findings of Diener et al. [
37] showed that the association between religiosity and higher subjective well-being is mediated by social support, feeling respected, and meaning in life. Interestingly, the prevalence of religiousness was dependent on the characteristics of the society and underlying difficulties of life conditions. They found that in societies with more favorable circumstances, individuals’ religiosity was lower, and the level of well-being was similar among religious and non-religious individuals [
37]. Also, in the German patients investigated in this study, the percentage of religious individuals was low (65% non-religious), and their relatively low life satisfaction scores did not differ with respect to the underlying spiritual/religious self-perception. This means religious/spiritual patients from our sample are not more satisfied with their life concerns (as measured by life satisfaction scales) than non-religious patients.
Although religious self-perception appears to have no significant influence on life satisfaction, a study among healthy individuals showed that higher levels of trait gratitude are associated with “more positive beneficial appraisals” [
38]. Because previous studies found that positive spirituality/religiosity was significantly associated with positive appraisals of chronic illness [
32], one may suggest that patients in our sample also draw on spiritual/religious resources to cope with chronic illness (in terms of finding meaning and hope) and to value the moments of beauty and show gratitude for the positive aspects in life despite illness. This attitude might be a dispositional trait, which can be developed (i.e., gratitude interventions (reviewed by [
14]). Wood et al. [
14] stated that there might be a “higher order grateful personality” that exists beyond particular aspects of gratitude and may represent a “life orientation towards the positive”, involving a “worldview towards noticing and appreciating the positive in life”.
In cancer patients, Strack et al. [
20] reported that the “cognitive reappraisal of emotion, gratitude finding, and openness to experience” was associated with post-traumatic growth in patients’. In our study, we focused on two groups of patients with primarily non-fatal, chronic diseases, who have to find strategies to adapt to their often recurring symptoms. In this sample of non-cancer patients, we have evidence of relatively low life satisfaction, particularly in the patients with psychiatric disorders. Detailed analyses showed that
Gratitude and
Awe are not experienced or noticed very often. However, the participants have still experienced and valued
Beauty in life. One may hypothesize that patients lack reasons to be grateful because of their frustrations with the disease and associated dissatisfaction with life; or they give less attention to issues other than the symptoms of their illness. However, it seems that religious individuals are able to value other aspects in their life despite the disease – though they need not necessarily be more satisfied with their life in the
usual understanding of “life satisfaction”.
Limitations
This study was not designed to specifically measure gratitude as a short-term emotion. Rather, it is measured here as a disposition of gratefulness and an attention to beauty in life as a specific aspect of spiritual activities and experiences. Therefore, the three items of the Gratitude/Awe scale measure a specific aspect of patients’ experience of feelings of Gratitude, wondering Awe and perception of Beauty in life. These can be observed even in patients lacking any interest in spiritual or religious issues.
Further, the study was cross-sectional, and thus we cannot draw conclusions on the directions of causality in the observed associations. Thus, longitudinal studies are strongly needed. Moreover, the perceptions of patients with psychiatric disorders may be significantly different during their “silent” and asymptomatic phases. Similarly, the respective scores might also be lower in patients with MS during acute or relapsing phases of disease. In addition, we have no data on whether or not analyzed patients with MS had frontal lobe lesions or ideation/thought disturbances. Such neurological affections may have an impact on states of consciousness, ideations, and self-reflection. Further research might focus on such altering impacts which have not been pursued by our investigation. Moreover, it would be desirable that future research compares also non-clinical populations and different clinic al populations with regard to the variables at stake.
Nevertheless, the strength of this cross-sectional study is its focus on participants with primarily non-fatal diseases. Instead of choosing a sample of relatively young and healthy students and confronting them with hypothetical situations to induce feelings of gratitude, we chose a sample of patients that has had to deal with the ups and downs of chronic disease. However, we do not know any specific details about our patients’ concrete feelings of gratitude and awe or their specific causes.
Of course there are some additional findings on the putative association between patients’ spirituality and further health-related and psychological measures. Among patients with MS for example, their engagement in religious practices was only marginally associated with negative mood states such as grief, despair or tiredness (r < .20; p < .05), while there were no significant correlations with cognitive or motoric MS related fatigue (r < .10; n.s.) (Wirth et al., in preparation). These and other details will be topic of independent papers of the Freiburg group on patients with psychiatric diseases (Reiser et al., in preparation) and the Herdecke group on patients with MS (Wirth et al., in preparation).
Conclusions and outlook
Gratitude/Awe, as measured in this study, could be regarded as a “life orientation towards noticing and appreciating the positive in life” [
14]. This was significantly associated with specific spiritual/religious attitudes. Positive spirituality/religiosity seems to be a source of gratitude and appreciation of life in all its dimensions including “light and shadows”. In contrast, a non-religious/non-spiritual (R-S-) self-perception was associated with lower abilities or perceptions of
Gratitude and
Awe in life. Diener et al. [
37] confirmed an association between religiosity and higher subjective well-being, which is mediated by social support, feeling respected, and meaning in life. Thus, patients need access to available resources and strategies. However, not all patients are able to recognize and/or value such internal and external resources. It seems that the personality prior to illness has an influence on the ways individuals will adapt and cope. Moreover, a nationally representative, longitudinal study performed by the University of Manchester (using a shortened version of the “Big Five Inventory”), found that agreeable individuals adapt more easily and fully to health afflictions than disagreeable individuals [
39]. Spirituality/religiosity might also be one aspect that allows patients to cope more easily. Medical professionals should be aware of such personality differences because individuals lacking such resources for coping may need additional and specific support to adapt.
Further research should address the relationship between Gratitude/Awe as a dimension of spirituality/religiosity along with personality traits like the “Big Five” (openness, conscientiousness, extraversion, agreeableness, and neuroticism). Is agreeableness a predisposition for, or rather a consequence of gratitude – or are they mutually reinforcing?
Boyce and Wood [
39] have shown a critical predictive role of agreeableness prior to disability for the adaptation to and coping with disability as well as for the recovery of lost life satisfaction within four years. Whether the same might also be true for patients with neurological and/or psychiatric diseases remains to be shown.
Competing interests
The study was not financed by any organization; the authors did not receive financial support by organizations, companies etc. which could have influenced the interpretation of data.
Authors’ contributions
AB conceived the study, performed statistical analysis and drafted the manuscript. AGW, AZ, FR, and KB participated in the conception and design of the study. AZ, KH, KG, MH, and SS helped to recruit the patients. KB contributed to drafting the manuscript. All authors read and approved the final manuscript.