Atlas›Domain XV · Nature, philosophy, social & rites of passage›Guide 126
Guide XV-126

Gratitude practice

Emmons, McCullough, Seligman, Steen2003
A 27 · L 57 · M 1620 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the research protocols as their authors published them (Emmons and McCullough 2003, "counting blessings"; Seligman, Steen, Park and Peterson 2005, "three good things in life" and the "gratitude visit"; Koo, Algoe, Wilson and Gilbert 2008, mental subtraction of positive events; Wong et al. 2018, gratitude letter writing added to psychotherapy), with practice instructions as the Greater Good Science Center's Greater Good in Action (GGIA) site publishes them. Where the GGIA wording and the original studies differ (especially on how often to write), both are named.

Gratitude practice is not a psychotherapy and has no guideline-recommended clinical protocol. It is a family of brief, mostly written, self-administered exercises (positive psychology interventions) that a therapist can teach, assign, rehearse and debrief inside ordinary treatment. Its proposed route to change, as its authors and the GGIA describe it, is attentional and relational: people tend to dwell on what goes wrong and take good things for granted; deliberately noticing, writing down and elaborating good events, their causes and the people behind them shifts attention, lets the person savour positive experience, and, in letter and visit forms, strengthens a relationship [source: GGIA Gratitude Journal; GGIA Three Good Things; Emmons and McCullough 2003]. Mental subtraction works by contrast: imagining a good event never happened makes its presence feel less taken for granted [source: GGIA Mental Subtraction; Koo et al. 2008].

Evidence status in one line: a meta-analysis of 27 studies (N = 3,675) found a small effect of gratitude interventions on combined depression and anxiety symptoms (g = -0.29 at post-test, -0.23 at follow-up), smaller against active than waitlist controls, and its authors advise people seeking relief from depression or anxiety to choose interventions with stronger evidence for those symptoms [source: Cregg and Cheavens 2021, via IDEAS/RePEc and Proof Positive abstract pages; Ohio State news release]. An earlier meta-analysis (Davis et al. 2016) is cited by Cregg and Cheavens as suggesting well-being gains may partly reflect placebo effects [uncertain: not verified]. Use gratitude practice as an adjunct, never in place of an evidence-based treatment for a diagnosed disorder [source: Ohio State news release; synthesis].

Related guides: behavioural activation (Domain II 040); journalling (XV 127; VIII 129, 130); sleep (XV 123; II 069 CBT-I) where gratitude is used near bedtime.

2. Framework

There is no official phase model. The structure below is a clinical sequence for using the published exercises within therapy [synthesis], with the published protocol lengths given where the sources state them.

Published protocol formats [source: as named]

  • Counting blessings, weekly: up to five things the person felt grateful for over the past week, written at the end of a weekly report; 10 weekly reports in the student study [source: Emmons and McCullough 2003, Study 1].
  • Counting blessings, daily: the same listing done each evening; about two to three weeks of daily forms in Studies 2 and 3 (students; adults with neuromuscular disease) [source: Emmons and McCullough 2003].
  • Three good things and gratitude visit: each assigned for one week, delivered online without a therapist, followed up to six months [source: Seligman et al. 2005].
  • Gratitude letter writing as an add-on to university counselling-centre psychotherapy, compared with expressive writing and psychotherapy alone; follow-ups about 4 and 12 weeks after the writing ended. The number of writing sessions is [uncertain: not verified] [source: Wong et al. 2018].
  • Positive Psychotherapy (Rashid and Seligman) places a gratitude journal in its first session, "Positive Introduction and Gratitude Journal"; the rest of that manual's session plan is not described here [source: OUP chapter page; uncertain: not verified].

Clinical sequence [synthesis]

  1. Assess and formulate. Goal: decide whether a gratitude exercise fits this client now, and which one. Move on when you have a clear target (e.g. low positive affect, rumination on what is missing, relationship withdrawal, residual symptoms after treatment) and no contraindication in section 5.
  2. Orient and choose. Goal: a collaborative, non-moralising rationale; client picks the exercise. Move on when the client can say in their own words what they will do and why.
  3. Rehearse in session. Goal: a first entry written together so the client experiences the specificity and pace the exercise needs. Move on when the client can produce one specific, elaborated entry.
  4. Trial between sessions and review. Goal: try the exercise for a defined, short trial, then debrief at each session. Move on when you and the client can judge whether it is helping (section 4, monitoring).
  5. Adjust, vary or stop. Goal: change frequency, form or target, add a different positive activity, or drop the practice if it is not helping or is causing harm.
  6. Consolidate and maintain. Goal: the client decides whether to continue on their own; in Seligman et al. 2005, participants who continued voluntarily after the assigned week did best [source: Seligman et al. 2005].

Format: individual delivery produced larger effects than group or self-administered positive psychology interventions in a practice-oriented meta-analysis that did not analyse gratitude separately [source: Sin and Lyubomirsky 2009].

3. Guiding principles

  • Adjunct, not treatment. Gratitude exercises sit alongside, not instead of, evidence-based care for depression and anxiety. Practical meaning: never offer "try being more grateful" as the answer to a disorder [source: Cregg and Cheavens 2021; Ohio State news release].
  • Write it down. The GGIA versions stress writing over merely thinking. Practical meaning: assign a written (or typed) record and bring it to session [source: GGIA Gratitude Journal; GGIA Three Good Things].
  • Specific and deep beats long and general. Practical meaning: one well-elaborated item is preferred to a quick list [source: GGIA Gratitude Journal; Marsh 2011 citing Emmons].
  • People over things. Practical meaning: steer entries toward people and what they did, which the GGIA reports has more impact than possessions or circumstances [source: GGIA Gratitude Journal; Marsh 2011].
  • Guard against habituation. Practical meaning: the GGIA journal page suggests writing daily or every other day, while Marsh's GGSC article reports a study in which writing once a week outperformed three times a week; set frequency with the client and change it if entries go stale [source: GGIA Gratitude Journal; Marsh 2011].
  • Motivation and choice matter. Practical meaning: self-selected, motivated participants gained more; let the client choose and build motivation before assigning [source: Sin and Lyubomirsky 2009; Marsh 2011].
  • Variety helps. Practical meaning: rotate content within a journal and consider several positive activities rather than one [source: GGIA Gratitude Journal; Sin and Lyubomirsky 2009].
  • Cultural fit. Practical meaning: other-focused, prosocial forms (letters, thanks to others) may suit clients from collectivist backgrounds; ask how gratitude is expressed in the client's family, culture and faith [source: Sin and Lyubomirsky 2009; synthesis].
  • Validation first. Practical meaning: gratitude never replaces acknowledging pain, injustice or loss; the client is never told what they "should" be grateful for [synthesis].
  • The client chooses the object of gratitude. Practical meaning: never suggest thanking a person who harmed them, and never set up contact the client does not want [synthesis].
  • Gratitude can carry costs. Practical meaning: Emmons and McCullough note gratitude may have an aversive side, such as feeling indebted; ask about it [source: Emmons and McCullough 2003].
  • Collaborative empiricism. Practical meaning: treat each exercise as an experiment; keep it if it helps, drop it if not [synthesis].
  • Stay in scope. Practical meaning: gratitude work does not include advice on diet, exercise, sleep schedules or medicines; route those to the client's physician, a qualified exercise professional, sleep medicine or a registered dietitian as relevant [synthesis].

4. Intervention inventory

The published sources describe six core exercises (counting blessings, gratitude journal, three good things, gratitude visit, gratitude letter within psychotherapy, mental subtraction). The remaining entries are therapist-side procedures for assessment, preparation, rehearsal, debriefing and integration, marked [synthesis] where no source describes them.

4.1 Suitability assessment

  • Purpose / when: Before any assignment, to decide whether gratitude work fits and to screen out situations where it may invalidate or harm [synthesis].
  • Steps: (1) Clarify the target: low positive affect, a habit of overlooking what goes well, relationship withdrawal, residual symptoms or relapse prevention (Sin and Lyubomirsky 2009 suggest positive interventions may help with residual symptoms) [source: Sin and Lyubomirsky 2009]. (2) Check current severity: moderate to severe depression, active suicidality, acute grief, ongoing abuse or a recent trauma call for the primary treatment first [synthesis]. (3) Ask what "gratitude" means in the client's family, culture and faith, and whether they were told to be grateful when they were hurting. (4) Ask about indebtedness, guilt and obligation (an aversive side of gratitude flagged by Emmons and McCullough 2003). (5) Decide together: proceed, defer, or choose another approach.
  • Example language (illustrative): "Before we try anything like this, I want to check whether 'be grateful' has ever been used to shut you down. For some people it has, and then this exercise would be the wrong tool."
  • Watch for: relief or eagerness (good fit); a flinch, sarcasm or "I should be grateful" (explore before assigning); any sign of risk (stop and assess risk using standard practice).

4.2 Orientation and choice of exercise

  • Purpose / when: After assessment, to give a rationale and let the client choose, since motivation predicts benefit [source: Sin and Lyubomirsky 2009; Marsh 2011].
  • Steps: (1) Explain the idea in plain terms: attention tends to stick to problems; this is practice in noticing and staying with what went well and who helped [source: GGIA Three Good Things]. (2) Be honest about the evidence: modest effects, an adjunct, not a cure [source: Cregg and Cheavens 2021]. (3) Describe two or three options in one sentence each (journal, three good things, letter, subtraction). (4) Ask which appeals and which feels off. (5) Agree a short trial and a review date.
  • Example language (illustrative): "The research on these exercises shows small but real effects for many people. It won't replace the work we're doing, but it might add something. Which of these sounds most like you?"
  • Watch for: compliance without interest (revisit choice); the client picking the hardest option to prove something (suggest starting lighter) [synthesis].

4.3 Counting blessings (gratitude listing)

  • Purpose / when: The original experimental exercise; a simple entry point for clients who like brief structure [source: Emmons and McCullough 2003].
  • Steps (as published, paraphrased): (1) Look back over the period (the past week in the weekly version; the day in the daily version). (2) List up to five things, large or small, the person feels grateful or thankful for. (3) In the studies the listing sat at the end of a brief mood and well-being report. Weekly and daily versions both exist; choose with the client [source: Emmons and McCullough 2003].
  • In therapy [synthesis]: have the client keep the list with any mood rating you already use, and bring it to session.
  • Example language (illustrative): "At the end of the week, jot down up to five things you were glad of. Small counts: a decent coffee is allowed."
  • Watch for: identical lists every time (habituation; see 4.4 tips); lists that only contain things the client feels they "ought" to list. Note that the original studies found the comparison against a downward social comparison condition was not significantly different for positive affect in Study 2, so avoid framing it as "others have it worse" [source: Emmons and McCullough 2003; synthesis].

4.4 Gratitude journal (GGIA version)

  • Purpose / when: A fuller written practice for clients who like journalling; adds depth and specificity to the listing [source: GGIA Gratitude Journal].
  • Steps (paraphrased from GGIA): (1) Choose a format: paper, phone notes or a document. (2) Write up to five things, small or large. (3) For each, be specific and concrete. (4) Prefer depth: explore one person or event in detail rather than a quick list. (5) Prefer people to things. (6) Treat good things as gifts rather than givens. (7) Note surprises, which tend to produce stronger gratitude. (8) Vary the content; the same person can reappear with different details. (9) Optionally add subtraction (imagine life without it; see 4.8) [source: GGIA Gratitude Journal; Marsh 2011].
  • Frequency: versions differ. The GGIA practice page gives roughly three sessions a week for at least two weeks and also suggests writing daily or every other day; Marsh's 2011 GGSC article, citing a study by Lyubomirsky and colleagues, recommends once or twice a week because people adapt to what they focus on constantly [source: GGIA Gratitude Journal; Marsh 2011]. Agree a frequency with the client and adjust.
  • Example language (illustrative): "Rather than five quick bullet points, try picking one thing and writing what exactly happened, who was involved, and what it meant to you."
  • Watch for: entries turning into chores; staleness (lower frequency or vary focus); writing that drifts into self-criticism ("I don't deserve this").

4.5 Three good things in life

  • Purpose / when: A daily evening exercise that adds causal reflection; in Seligman et al. 2005 its effects appeared later than the gratitude visit's but lasted through six months [source: Seligman et al. 2005].
  • Steps (paraphrased from Seligman et al. 2005 and GGIA): (1) Each day, write three things that went well. (2) Give each a short title. (3) Describe what happened in detail: where, what was said and done. (4) Note how it felt then and how it feels on rereading. (5) Write why it happened, what caused it. (6) Style, spelling and length do not matter. (7) If attention slides to negative content, steer it back to the good event. The study assignment was one week; GGIA suggests at least one week, often before bed [source: Seligman et al. 2005; GGIA Three Good Things].
  • Example language (illustrative): "Then the key bit: why did it go well? Was it something you did, something someone else did, or luck? All three answers are useful."
  • Watch for: causal answers that are always external ("just luck") or always self-crediting; both are material for cognitive work (4.11). If evening writing stirs rumination or affects sleep, move it earlier [synthesis; cross-refer XV 123 and II 069 for sleep problems].

4.6 Gratitude visit

  • Purpose / when: A relational exercise; in Seligman et al. 2005 it produced the largest short-term gains of the exercises tested, which had faded by three months [source: Seligman et al. 2005].
  • Steps (paraphrased): (1) Choose a living person who was especially kind and was never properly thanked. (2) Write a letter of thanks. (3) Deliver it in person [source: Seligman et al. 2005]. Some later descriptions add reading it to the recipient [source: Ohio State news release].
  • In therapy [synthesis]: (4) Draft and redraft in session. (5) Plan the visit: timing, privacy, what the client will do if the recipient reacts awkwardly. (6) Debrief at the next session.
  • Example language (illustrative): "Who comes to mind who did something important for you and never really heard what it meant? Let's draft what you'd want them to know."
  • Watch for: recipient choice driven by obligation; anticipatory anxiety (rehearse; delivery is optional in 4.7); a recipient connected to harm (stop and redirect); disappointment if the reaction is muted.

4.7 Gratitude letter as an adjunct to psychotherapy

  • Purpose / when: For clients already in psychotherapy; in an RCT with 293 adults at a university counselling service, adding gratitude letter writing produced better mental health at about 4 and 12 weeks than psychotherapy alone or psychotherapy plus expressive writing [source: Wong et al. 2018].
  • Steps: (1) Client writes letters expressing gratitude to others [source: Wong et al. 2018]. (2) Whether letters must be sent, how many are written and when are not stated on the abstract page [uncertain: not verified]; offer sending as optional [synthesis]. (3) Review the letter's language in session: Wong et al. report that a lower proportion of negative-emotion words in the writing mediated the benefit over expressive writing [source: Wong et al. 2018]; you can notice, without editing for the client, where the letter shifts to complaint [synthesis].
  • Example language (illustrative): "You don't have to send this. The writing itself seems to be part of what helps."
  • Watch for: letters becoming apologies or self-blame; letters to the therapist (accept warmly, keep boundaries, and explore what it means within the work) [synthesis].

4.8 Mental subtraction of positive events

  • Purpose / when: For clients who take good things for granted or find listing flat; in Koo et al. 2008 it increased positive feelings and gratitude more than simply thinking about the event [source: Koo et al. 2008, via GGIA].
  • Steps (paraphrased from GGIA): (1) Pick a positive event (an achievement, a relationship, a trip). (2) Recall the circumstances that made it happen. (3) Identify how it might never have happened. (4) Write the large and small choices and chance events that could have gone otherwise. (5) Imagine present life without it and what followed from it. (6) Return to the present, reflect on what the event brought, and notice gratitude that it happened. GGIA suggests a different event each week [source: GGIA Mental Subtraction].
  • Example language (illustrative): "Let's imagine, just for a few minutes, that you'd never taken that job. What else wouldn't be in your life now? Then we'll come back."
  • Watch for: GGIA acknowledges imagining an important event's absence can be painful, and one commenter reported feeling worse for lacking such events [source: GGIA Mental Subtraction]. Avoid with recent bereavement or with events that are now lost (e.g. a relationship that ended) unless the client chooses it [synthesis].

4.9 In-session rehearsal of a first entry

  • Purpose / when: At assignment, so the client experiences the specificity the exercises call for [synthesis].
  • Steps: (1) Ask for one good thing from the past few days. (2) Slow down: who, where, what was said. (3) Ask what it felt like then and now. (4) For three good things, ask why it happened. (5) Have the client write it themselves. (6) Ask what got in the way and what made it easier.
  • Example language (illustrative): "Let's do one right now. Tell me something from this week that went a little better than expected. What exactly happened?"
  • Watch for: speed and vagueness (prompt for detail); visible shift in affect when the client elaborates (a sign the exercise can work for them).

4.10 Debriefing entries in session

  • Purpose / when: At each review, to deepen, savour and troubleshoot [synthesis; detail and savouring emphasis from GGIA].
  • Steps: (1) Ask whether the client did it and how it went, without praise or blame. (2) Invite them to pick one entry to read or describe. (3) Elaborate it: details, feelings, the people involved. (4) Ask what they notice across entries (themes, who keeps appearing). (5) Ask about any discomfort: guilt, indebtedness, "fake" feelings. (6) Agree any change.
  • Example language (illustrative): "Which entry stays with you most? Read me a line, and let's stay with it a moment."
  • Watch for: entries that are performances for the therapist; themes that point to values or relationships worth working on; signs of worsening mood (see section 5).

4.11 Working with causal attributions from "why it happened"

  • Purpose / when: When three-good-things entries show a fixed pattern of explaining good events (always luck, always others, never the client) [synthesis built on the causal step in Seligman et al. 2005 and GGIA].
  • Steps: (1) Collect the "why" answers from several entries. (2) Sort them with the client: own effort or qualities, other people, circumstances. (3) Ask what the pattern says about how the client sees themselves. (4) Use ordinary cognitive methods to test it (evidence for and against). (5) Add a prompt to future entries: "What part did I play?"
  • Example language (illustrative): "Every one of these says 'I got lucky'. I'm curious whether you'd accept that much luck as an explanation if a friend wrote it."
  • Watch for: the exercise turning into self-criticism; aim for balanced, not inflated, attributions.

4.12 Redirecting attention when negative content intrudes

  • Purpose / when: When the client reports that writing about good things pulls up what is wrong [source: GGIA Three Good Things, step on redirecting attention].
  • Steps: (1) Normalise: GGIA notes redirecting attention takes effort at first [source: GGIA Three Good Things]. (2) Agree a brief way of noting the intrusion (e.g. a margin mark) and then returning to the good event [synthesis]. (3) Bring the intruding material to session rather than suppressing it [synthesis]. (4) If intrusions dominate, pause gratitude work and address the underlying problem [synthesis].
  • Example language (illustrative): "If the worries crowd in, it's fine to note them in the margin for us to talk about, and then go back to the good thing for a minute."
  • Watch for: rumination or trauma memories triggered by the exercise; a client using the practice to push away grief or anger (see section 5).

4.13 Gratitude expressed within close relationships

  • Purpose / when: For couple or family work or relationship goals, using the other-focused direction the sources favour (people over things; letters and visits) [source: GGIA Gratitude Journal; Seligman et al. 2005]. In Study 2 of Emmons and McCullough, the gratitude group was more likely to report offering emotional support to others [source: Emmons and McCullough 2003].
  • Steps [synthesis]: (1) Each partner or family member notes something specific the other did. (2) They tell the other person, briefly and specifically, outside of conflict times. (3) Review in session how it felt to give and to receive. (4) Never use it to paper over an unaddressed injury or a safety concern.
  • Example language (illustrative): "Not 'thanks for everything', but one thing: what they did, and what difference it made to you."
  • Watch for: gratitude used as currency ("I thanked you, now you owe me"); a partner's coercive control (stop; safety assessment comes first).

4.14 Integrating gratitude with behavioural activation

  • Purpose / when: When activity scheduling is under way (Domain II 040) and the client is not noticing the good parts of what they do [synthesis].
  • Steps: (1) Alongside the activity record, add a line for one thing that went well in the activity and who or what made it possible. (2) Review these lines when choosing next activities. (3) Keep activity choices to the client's values and to their clinicians' advice; physical activity goals go to the client's physician or a qualified exercise professional [synthesis].
  • Example language (illustrative): "When you write down the walk with your neighbour, add one thing about it you're glad happened."
  • Watch for: gratitude notes replacing the activity itself; anhedonia making notes empty (keep the activity work primary).

4.15 Cultural, religious and spiritual adaptation

  • Purpose / when: When the client's tradition already has gratitude practices (blessings, thanksgiving prayers, offerings) or when gratitude carries cultural obligations [synthesis; cultural-fit point from Sin and Lyubomirsky 2009].
  • Steps: (1) Use the DSM-5-TR Cultural Formulation Interview and its supplementary module on spirituality, religion and moral traditions to learn what gratitude means to the client [synthesis]. (2) Ask whether they want to use a practice from their own tradition; if so, the client and their tradition shape it and the therapist does not teach religious content [synthesis]. (3) Where obligation to family or elders is heavy, explore the difference between felt thanks and owed duty. (4) If a loss of faith or conflict with a tradition is the problem, the DSM-5-TR category "Religious or Spiritual Problem" may be recorded with code Z65.8; ICD-10-CM lists religious or spiritual problem under the Includes of Z65.8 "Other specified problems related to psychosocial circumstances" [source: ICD-10-CM Z65.8 (Unbound Medicine); DSM-5-TR wording uncertain: not verified]. (5) With consent, collaborate with the client's religious leader.
  • Example language (illustrative): "In your family, how was thankfulness shown? Is there a practice from your own tradition you'd rather use than a journal?"
  • Watch for: imposing a secular template on a religious client, or a religious one on a secular client; gratitude tied to shame ("ungrateful child").

4.16 Choosing several positive activities and adding variety

  • Purpose / when: When one exercise has gone stale or the client benefits and wants more; Sin and Lyubomirsky recommend assigning multiple different positive activities and GGIA recommends variety within a journal [source: Sin and Lyubomirsky 2009; GGIA Gratitude Journal].
  • Steps: (1) Review which forms helped. (2) Rotate (e.g. journal one period, subtraction another, a letter when a recipient comes to mind). (3) Keep a record of what was done [source: Sin and Lyubomirsky 2009]. (4) Drop forms that feel forced [synthesis].
  • Example language (illustrative): "The lists have gone a bit automatic. Want to swap to the 'imagine it never happened' exercise for a while?"
  • Watch for: overload; too many homework tasks reduce adherence to the core treatment [synthesis].

4.17 Monitoring whether it is helping

  • Purpose / when: Throughout the trial; the research protocols paired the exercise with mood, well-being and symptom ratings [source: Emmons and McCullough 2003; Seligman et al. 2005].
  • Steps [synthesis]: (1) Use the outcome measures already in use in the therapy. (2) Add a brief client rating of how the exercise felt (helpful, neutral, unpleasant). (3) Review after the agreed trial. (4) Keep, change or stop.
  • Example language (illustrative): "On a simple scale, did doing this tend to leave you feeling better, the same or worse?"
  • Watch for: working signs: more specific entries, warmer affect when describing them, more noticing of others' help, reports of savouring. Warning signs: lower mood after writing, guilt, avoidance of session.

4.18 Maintenance and relapse prevention

  • Purpose / when: Near the end of treatment or after symptom remission; Seligman et al. found voluntary continuation was associated with the longer-term benefits, and Sin and Lyubomirsky suggest positive interventions may help with residual symptoms and relapse prevention [source: Seligman et al. 2005; Sin and Lyubomirsky 2009].
  • Steps: (1) Ask whether the client wants to keep a form of the practice. (2) Help them turn it into a habit tied to an existing routine [source: Sin and Lyubomirsky 2009 on habits; synthesis on details]. (3) Include it in the relapse plan as one coping resource among others, with clear signs that mean returning for help [synthesis].
  • Example language (illustrative): "If you want to keep this going after we finish, where in your week would it naturally fit?"
  • Watch for: the practice becoming a test the client "fails"; frame it as optional and adjustable.

4.19 Gratitude work alongside chronic illness or disability

  • Purpose / when: With clients living with long-term health conditions, where a daily gratitude list has been tested (adults with neuromuscular disease reported more positive affect, less negative affect, better sleep ratings and more connection; pain and function did not differ) [source: Emmons and McCullough 2003, Study 3].
  • Steps [synthesis]: (1) Acknowledge the illness burden fully first. (2) Offer the listing as optional, never as a coping requirement. (3) Allow entries about people, care received and small daily things. (4) Coordinate with the medical team; give no advice on treatment, medicines, diet or exercise.
  • Example language (illustrative): "This isn't about pretending the illness is fine. It's about whether noticing some good bits alongside it makes the days any different for you."
  • Watch for: feeling pressured to appear positive for carers or clinicians; grief for lost function (address directly).

4.20 Integration within a structured positive psychotherapy

  • Purpose / when: For therapists trained in Positive Psychotherapy (Rashid and Seligman), which introduces a gratitude journal in its first session [source: OUP chapter page "Session One: Positive Introduction and Gratitude Journal"].
  • Steps: follow the manual's own session structure; details of later sessions are not described here [uncertain: not verified].
  • Example language (illustrative): "Alongside getting to know each other, I'll ask you to start noticing and noting good things each evening, and we'll look at them together."
  • Watch for: as for 4.4 and 4.5; obtain training in the manual before delivering it as a protocol [synthesis].

5. Handling problems

The research sources say little about clinical difficulties; except where a source is named, the guidance below is [synthesis].

  • "It feels fake" or nothing comes (depression, anhedonia). Cheavens notes people find these exercises hard to enact fully when depressed or anxious [source: Ohio State news release]. Response: lower the bar to one small, concrete item; rehearse in session (4.9); accept neutral entries; if still empty, pause and prioritise the evidence-based treatment for the depression rather than pressing on.
  • Invalidation and "toxic positivity". The client hears the assignment as "stop complaining". Response: name the risk openly, validate the pain first, and say explicitly that gratitude and grief or anger can coexist; never use gratitude to close down a complaint about real mistreatment, discrimination or poverty.
  • Guilt and "I should be more grateful". Response: separate felt appreciation from moral duty; drop "should" language; explore where the rule came from (often family or faith messages); with religious clients see 4.15.
  • Indebtedness and obligation. Emmons and McCullough flag feeling indebted as a possible aversive side [source: Emmons and McCullough 2003]. Response: explore whether thanks feels like a debt; switch to entries about impersonal good things or the client's own actions; avoid letters to people the client feels beholden to.
  • Gratitude toward someone who caused harm. A client may feel pressure, or volunteer, to thank an abuser or controlling partner or relative. Response: do not support contact; explore the pressure; with ongoing abuse, follow safety assessment and safeguarding duties; never set up a gratitude visit with a person connected to harm.
  • Grief and loss. Thanking a dead person in a letter can be meaningful, but mental subtraction of a lost relationship can intensify pain [source: GGIA Mental Subtraction on painful subtraction; synthesis]. Response: let the client lead; follow grief assessment practice, including prolonged grief disorder as described in DSM-5-TR and ICD-11 [uncertain: not verified]; see the death and mourning guides in this domain.
  • Habituation and boredom. Entries become repetitive. Response: reduce frequency (Marsh 2011 reports once a week outperformed three times a week in one study), add variety or switch exercise [source: Marsh 2011; GGIA Gratitude Journal].
  • Non-adherence. Response: check that the client chose the exercise; shrink it; link it to an existing routine; ask what got in the way without blame; accept that some clients will not want it and move on. Motivation and effort predict benefit, so do not coerce [source: Sin and Lyubomirsky 2009; Grazer 2009 GGSC article].
  • Perfectionism and scrupulosity. Entries become a test of being a good person, or the client fears missing something they "should" have listed. Response: cap entries, allow trivial ones, and treat the perfectionism or obsessional pattern directly; stop the exercise if it becomes a compulsion.
  • Rumination or intrusive memories triggered. Response: use 4.12; move writing earlier in the day if bedtime writing disturbs sleep; with trauma, return to trauma-focused care first.
  • Comparison and superiority. "At least I'm not as badly off as X." The downward social comparison condition in Emmons and McCullough 2003 was designed to look positive [source: Emmons and McCullough 2003]. Response: redirect from comparison to the specific good thing and the person behind it.
  • Letter or visit goes badly. The recipient is awkward, dismissive or brings up old conflict. Response: rehearse possible reactions in advance (4.6); debrief promptly; make clear the value lay in the client's act of thanks, not the reply.
  • Ruptures. The client feels the therapist is pushing positivity or not hearing distress. Response: acknowledge it directly, apologise for the misfit, return to the client's own agenda, and ask whether to drop the exercise.
  • Cultural or religious mismatch. Response: see 4.15; adapt to the client's own forms, or drop it.
  • Risk. If writing reveals hopelessness, self-harm or suicidal thinking, stop the exercise and assess risk using current standard practice. Crisis resources: 988 Suicide and Crisis Lifeline (US); Samaritans 116 123 (UK and Ireland).
  • Body, food and eating. If gratitude entries centre on food, weight or body control, screen for disordered eating and refer to a registered dietitian or eating-disorder service; in the US, eating-disorder support is available via the National Alliance for Eating Disorders. Give no diet, weight or exercise advice.
  • Lifestyle spill-over. Emmons and McCullough's Study 1 group reported more exercise [source: Emmons and McCullough 2003]; do not turn gratitude work into exercise, sleep or diet coaching. Physical-activity guidance belongs with the client's physician or a qualified exercise professional (behavioural-activation framing, Domain II 040); sleep problems go to CBT-I (Domain II 069, 068) and sleep medicine; never advise starting, stopping or changing a medicine.
  • Children and adolescents. Get parental consent and the young person's assent; make letters and visits optional; keep any school use within safeguarding procedures. GGIA notes much of the research comes from narrow populations and more is needed with other groups [source: GGIA Three Good Things; GGIA Gratitude Journal].

Sources

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