The Virtues in Psychiatric Practice. Oxford University Press. Mature Gratitude in Positive Psychiatry Dr. Lilian Jans-Beken “After a severe seizure of cluster headache, I sat upright in my bed and thought that I had to find something to be grateful for, otherwise I wanted to end my live. So, I picked up a piece of paper and started writing. The first words were the names of my sons and I got angry at myself because there had to be more in life to be grateful for than just my children. So, I looked around and started writing, and I wrote and wrote until my paper was filled with gratitudes. There felt a flow inside of me and it was for the first in a long time that I really ‘felt’. I felt that I still could be grateful, despite my severe condition. After this realization, I fell asleep peacefully.” As a scientist, I am studying gratitude for almost ten years now. Stories as the one above are shared with me on a regular basis when I tell people that my research interest is in the association between gratitude and mental health. People in dire circumstances or just struggling with day-to-day life confide in me about how gratitude is a light in the dark for them. It is fascinating to see how a feeling, a way of thinking or an attitude of gratitude can be of such help in times of adversity. The aim of this chapter is to present the reader with case studies and scientific research on the beneficial association between gratitude and symptoms of psychopathology. Gratitude Gratitude has been omnipresent in religious, spiritual, and philosophical ideologies since ancient times. All these ideologies believed that gratitude contributes to the well-being of individuals, to strong relationships between people and to societal cohesion, and it is seen as an essential part of living a meaningful life. The scientific focus on gratitude is relatively new; the first scientific publication on gratitude was published in 1968 1. Scientists agree that gratitude is a positive emotion that arises when people are aware that someone or something has given them a benefit. Before gratitude can arise, four ingredients are required. First, there is the intention of the benefactor. If the benefactor is forced to help or has a double agenda - and this is clear to the beneficiary - then it is hard to feel grateful. It is important that someone is willing to help and that the benefit is given voluntarily; this makes someone feel seen and valued. Second are the costs for the other. Does someone receive $10 from a mother of four on welfare or from Bill Gates? More gratitude will be felt for the mother because the amount of money is a greater sacrifice for her than for Mr. Gates. Costs are not only about money but also include energy and time spent for the benefit of someone else. Third, gratitude depends on the value of the benefit to the beneficiary. Those $10 are welcome for a poor student if, thanks to this money, they can buy food at the end of the month. This money becomes no more than a nice gesture if the beneficiary has a generous salary. The last ingredient of gratitude is responsiveness. This means that the benefit someone wants to give or do must fulfill a need or wish of the beneficiary. We can help an old lady cross the street, but if she did not want to be across the street, she will not be The Virtues in Psychiatric Practice. Oxford University Press. grateful for the help. The positive emotion of gratitude arises when these four ingredients are present and in balance with each other 1,2. Mature gratitude In positive psychology, gratitude as a trait or virtue is viewed as a general tendency to recognize small to large benefits, to experience sufficiency, and to acknowledge anything in the world, both human and non-human, with grateful emotion; expression of this emotion promotes one’s own well-being and the well-being of others 3. In this broad definition of gratitude – mature gratitude – two dimensions are recognizable: a horizontal and a vertical dimension. The horizontal, immanent dimension includes gratitude for prosperity and adversity that is conceived consciously and within earthly borders. The horizontal dimension of mature gratitude is directed at material and natural objects, expected and unexpected events, and the people with whom we interact. Being grateful for the good things in life is the easier part; we all are able to do so. Being grateful for broken objects, disheartening events, and people who are annoying or hurtful, is a more difficult, but not impossible task. For this it is necessary to accept and transform our frustration, our feelings of powerlessness, and the hurt that we experience. The vertical, transcendent dimension of mature gratitude is a spiritual dimension, with gratitude directed at phenomena that cannot be precisely and mentally located in space and time. Illustrations of this vertical gratitude are cosmic gratitude 4, gratitude to God, or spiritual gratitude that can be elicited by, for example, gratitude for ancestors or spirits, but also cultural expressions such as music or art, or an awareness of being part of something big such as the universe. The vertical, transcendent dimension of mature gratitude can assist the experience of the horizontal gratitude but it is not necessary 5. Positive psychology 2.0 An important aspect of mature gratitude is the ability to be grateful for broken belongings, hurtful people, or any other kind of adversity. This premise is derived from positive psychology 2.0 (PP 2.0); the successor of positive psychology 1.0 6. Whereas PP 1.0 focusses on the pursuit of happiness, it becomes clear to us that we cannot avoid or ignore unpleasant issues like suffering and human weaknesses. Our mental health is not immune to adverse effects and we need a way to cope with disruptive issues, acknowledging that suffering is part of living. PP 2.0 posits that life is a struggle in a difficult and dangerous world, and the only way to achieve sustainable wellbeing and a good mental health is to embrace and transform our suffering and human weaknesses into an advantage for personal growth, happiness, and success. PP 2.0 focusses on the buffering effects of positive emotions and character strengths in stressful events, but also on harnessing positive capabilities from negative facets of live 6–8. The acceptance of negative affect appears to be necessary for healthy functioning 9. This can be achieved through learning how to make the best use of the dynamic and dialectic interplay between positive and negative life experiences in each context 10. Positive psychiatry The Virtues in Psychiatric Practice. Oxford University Press. The tenets of PP 2.0 are recognizable in the development of positive psychiatry. Psychiatry used to be a medical profession directed by the illusion that the client’s happiness is manufacturable and measurable for the benefit of an economically driven model. However, this disease curing model collides more and more with the values and virtues of the people who need psychiatric help. Psychiatry is changing to a client value motivated model that not only focusses on the cure of distressing symptoms but also on the client’s virtues, values, and development of resilience in a personal recovery model. This paradigm shift is based on two changes 11. The first change concerns putting the client at the center of treatment instead of the disease as the focus. Psychiatry should no longer be the place where only problems and complaints are discussed and treated, but also the place where the focus is on what works in patients' lives, where their competences and resilience are discovered and deployed, positive emotions are strengthened, and hope, gratitude and optimism are nurtured. The second change adds the paradigm of synthesis to the analysis of the client’s needs for care. The reductionist medical model can be supplemented by the functional solution-oriented model. This model is about designing and building an outcome that did not exist before, namely enhanced mental well-being. Symptom reduction is not sufficient when dealing with a complex phenomenon such as mental health. The experience of mental well-being is the result of many factors with interdependent interactions. These factors lie within the categories of bodily functions, mental well-being, meaningfulness, quality of life, societal participation, and daily functioning 12. Health and well-being cannot be understood merely by analysis of the individual psychopathological symptoms but by the synthesis of all the important categories of mental health 11,12. Gratitude and well-being Well-being has several domains, each of which is associated with gratitude: physical well- being, psychological well-being and social well-being 13. Gratitude is able to contribute more or less to each of these areas. Regarding physical well-being, many articles suggest that gratitude can play an important part in improved physical health. However, not much is known yet about the measurable effects of gratitude on physical functions. There are so few studies published on topics such as brain function, cortisol levels and oxytocin levels, that strong conclusions cannot be drawn yet. Outcomes of some of these studies suggest that keeping a gratitude diary or inducing gratitude in another way seems to lower blood pressure and to reduce inflammatory markers. More replication studies are necessary to strengthen the evidence about the direct health benefits of gratitude. However, some studies do show that gratitude turns out to be beneficial for a good night's sleep. By paying attention to positive things before going to sleep, people will worry less and therefore fall asleep better.