Background

Gratitude, as a psychological construct, refers to the recognition and appreciation of positive things in one’s life. Think: relationships, circumstances, and acts of kindness received. Over the past two decades, researchers have operationalized it into structured, replicable interventions that are increasingly finding their way into clinical settings.

The most common formats of gratitude include:

● Gratitude journaling: Writing down three to five specific things one is grateful for, several times per week.
● Gratitude letters and visits: Composing a detailed letter of thanks to someone who has had a meaningful impact, and in some protocols, delivering it in person.
● Counting blessings: Reflecting on current circumstances compared to less favorable alternatives to counteract habituation to good things.
● Mental subtraction: Imagining life without specific positive elements as a way of reactivating appreciation for them.

In clinical and healthcare contexts, the formats above generally function as adjuncts to existing treatment, apparent in psychotherapy, palliative care, inpatient wellness programs, and staff well-being initiatives. Gratitude interventions studies yield benefits not just in patient-doctor rapport but are also low-cost, low-burden, and accessible to a wide range of patients, making them attractive from the outset, even before their efficacy is considered.

What the Research Actually Shows

The scientific study of gratitude gained momentum in the early 2000s. Emmons & McCullough’s landmark 2003 randomized controlled trial (RCT) found that participants assigned to gratitude journaling, rather than recording daily hassles and/or neutral events, reported higher well-being, greater optimism, and fewer physiological complaints.

Similarly, Seligman et al. (2005) later tested multiple positive psychology exercises. They found that the gratitude visit produced the largest short-term gains in happiness and reductions in depression. However, the “three good things” journaling exercise showed more durable effects over time.

Since then, the field has broadened considerably. A review by Wood et al. (2010) in Clinical Psychology Review found that practicing gratitude is associated with greater positive emotions and life satisfaction, with interventions highlighting a causal relationship.

In 2016, Kini and his team showed that gratitude letter writers had changes in brain activity months later, indicating lasting effects on areas related to social connections.

In clinical settings, Mills et al. (2015) found that heart failure patients with higher gratitude reported better sleep quality, were less fatigued, and had lower inflammatory markers.

Jackowska et al. (2016) demonstrated that just two weeks of gratitude journaling improved sleep quality, while Cheng’s (2015) study showed similar results in a Chinese adult sample, suggesting benefits extend beyond Western contexts.

Effect sizes across studies are small to moderate, consistent with findings from most behavioral interventions, and warrant consideration before making strong clinical claims.

Impact on Patient Outcomes and Mental Health

Depression and Anxiety

A multitude of randomized controlled trials have found tangible reductions in depressive symptoms followed by gratitude journaling. The evidence is potent for subclinical depression, referring to people who experience depressive symptoms but do not meet the full diagnostic criteria for a clinical depression diagnosis. Gratitude intervention study exercises are looked upon as supporting pillars rather than standalone treatments. Regarding anxiety, the findings are heterogeneous; gratitude appears to divert attentional bias away from threat, but effect sizes are smaller than those observed for mood outcomes.

Chronic Illness and Coping

Patients with heart failure, cancer, and chronic pain have been studied as well. The study by Mills and colleagues (2015) is particularly compelling because it used biological markers to examine gratitude. They found that people who felt more grateful had lower levels of IL-6 and TNF-alpha, which are substances linked to heart problems. It remains unclear whether gratitude directly improves health or helps people sleep better and feel less stressed, but the underlying pathway is biologically plausible. In oncology settings, patients who engage in gratitude practices consistently report greater meaning and
reduced existential distress, outcomes that pharmacological treatments do not address.

Sleep

Practicing gratitude has consistently been shown to enhance sleep quality across numerous studies. A proposed mechanism is reduced pre-sleep cognitive arousal, particularly rumination (habitually thinking and replaying past mistakes and negative thoughts) and worry, which hinders sleep onset. For patients whose illness or treatment impairs sleep, the intervention is clinically beneficial and actionable.

Health Behaviors and Adherence

Sirois & Wood (2017) found that grateful people are more likely to be proactive in engaging in preventive health behaviors and in maintaining their medical regimens, a pattern mediated by reduced negative affect and stronger future orientation. For providers working on adherence, it is worth factoring this into how they frame gratitude practices for patients.

Benefits for Healthcare Providers and Burnout Reduction

Burnout is documented at significant rates across the medical and nursing fields. Interventions that integrate easily into existing environments without spurring additional workload are in demand. This area is where gratitude research offers a viable framework, although the provider-specific evidence base is underdeveloped compared with the patient-facing literature.

Additionally, gratitude-related traits are frequently associated with higher compassion satisfaction and lower compassion fatigue, even after adjusting for environmental stressors. A 2023 study published in the Online Journal of Issues in Nursing (OJIN) found that a 21-day gratitude journaling intervention among acute-care health professionals produced substantial reductions in work-related stress that persisted at a 12-week follow-up. At the team level, new evidence suggests that expressing gratitude
among colleagues, bolsters communication and cohesion, with direct positive implications for patient safety and quality of care.

However, a crucial caveat here is that gratitude practices do not address the structural drivers of burnout, such as administrative burden, staffing ratios, and systemic pressure. Gratitude intervention studies and practices are best understood as one important part of a broader approach to well-being, not a simple one-size-fits-all remedy.

How to Actually Use These Practices in Clinical Settings

For Individual Patients

Gratitude journaling is by far the most accessible entry point. Writing three to five specific things to be grateful for, three to four times per week rather than daily (since novelty reduces the effect over time), requires no special materials and can be completed in minimal time. Specificity matters and goes a long way, for example: “My nurse explained my diagnosis clearly” is more effective than “I am grateful for my care team.” Gratitude letters thrive in environments where therapeutic relationships are already
established, such as in palliative care, outpatient mental health, and post-acute rehabilitation. Furthermore, in clinical conversations, simply asking patients what has gone well or what support they have received can prompt gratitude-related thinking without requiring a formal exercise.

For Care Teams and Managers

Beginning briefings or handovers by acknowledging something that went well serves as a deliberate counterweight to the default focus on problems. Peer recognition systems allow staff to formally acknowledge colleagues’ contributions, fostering a culture of gratitude without adding pressure on frontline workers.

Delivery Considerations

Research shows that people tend to benefit more from gratitude exercises when they choose to participate voluntarily rather than when required. That is why any program needs to be presented as an optional resource and, when possible, woven into the routines people already have. For patients dealing with severe depression, traumatic experiences, or complicated grief, introducing gratitude exercises too soon can feel like their feelings are not being acknowledged. It is essential to use clinical judgment to
assess when someone is ready for such exercises, just like with any other therapeutic approach.

Limitations, Gaps, and Where The Field is Heading

The majority of published studies rely on self-report outcomes, which remain susceptible to demand characteristics, and publication bias is a reasonable concern given that positive findings overwhelm the field and pre-registration remains uncommon. Sample characteristics also limit generalisability; the research overrepresents White, educated, Western adults in a non-clinical population, and evidence in patients with severe mental illness, cognitive impairment, or complicated comorbidities is sparse. Cultural adaptation is likely necessary in collectivist contexts, or in populations in which expressing positive emotion, and even overly positive emotion, carries social risk. The bulk of studies also follow participants for 8 weeks or less, and the few with longer follow-up periods show attenuating effects, raising the question of whether brief interventions produce lasting change or require ongoing practice.

Future research should concentrate on precision targeting, identifying who benefits most from which practice under what clinical conditions, a question current evidence cannot yet answer. Moreover, studies that use objective biomarkers, invest more in digital delivery formats, and formally evaluate gratitude components within provider well-being programs would all significantly advance the field. The crux of the challenge remains the shift from “Gratitude is associated with well-being” to “This practice, delivered this way, produces this outcome in this population.” This is an intricate question, and answering it is what will make these tools genuinely useful in clinical care.

References

1. Cheng, S. T., Tsui, P. K., & Lam, J. H. M. (2015). Improving mental health in health care practitioners: Randomized controlled trial of a gratitude intervention. Journal of Consulting and Clinical Psychology, 83(1), 177–186. https://doi.org/10.1037/cou0000033
2. 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. https://doi.org/10.1037/0022-3514.84.2.377
3. Jackowska, M., Brown, J., Ronaldson, A., & Steptoe, A. (2016). The impact of a brief gratitude intervention on subjective well-being, biology, and sleep. Journal of Health Psychology, 21(10), 2207–2217.
4. Kini, P., Wong, J., McInnis, S., Gabana, N., & Brown, J. W. (2016). The effects of gratitude expression on neural activity. NeuroImage, 128, 1–10. https://doi.org/10.1016/j.neuroimage.2015.12.007
5. Mills, P. J., Redwine, L., Wilson, K., Pung, M. A., Chinh, K., Greenberg, B. H., Lunde, O., Maisel, A., Raisinghani, A., Wood, A., & Chopra, D. (2015). The role of gratitude in spiritual well-being in asymptomatic heart failure patients. Spirituality in Clinical Practice, 2(1), 5–17.
6. Seligman, M. E. P., Steen, T. A., Park, N., & Peterson, C. (2005). Positive psychology progress: Empirical validation of interventions. American Psychologist, 60(5), 410–421.
7. Sirois, F. M., & Wood, A. M. (2017). Gratitude uniquely predicts lower depression in chronic illness populations: A longitudinal study of inflammatory bowel disease and arthritis. Health Psychology, 36(2), 122–132. https://doi.org/10.1037/0003-066X.60.5.410
8. Tully, S., Tao, H., Johnson, M., Lebron, M., Land, T., & Armendariz, L. (2023). Gratitude practice to decrease stress and burnout in acute-care health professionals. OJIN: The Online Journal of Issues in Nursing, 28(3).
9. Wood, A. M., Froh, J. J., & Geraghty, A. W. A. (2010). Gratitude and well-being: A review and theoretical integration. Clinical Psychology Review, 30(7), 890–905. https://doi.org/10.1016/j.cpr.2010.03.005