Sergio Ardis is Medical Director at USL Toscana Nordovest and lecturer in communication based on the Kalamazoo Consensus Statement, as well as National Secretary of ‘Gruppo italiano felicità e salute positiva’.
Could you introduce your work, your group, and your activities to our readers?
I am Sergio Ardis, national secretary and legal representative of the Italian Happiness and Positive Health Group. It is an association that does not have presidents, it only has secretaries because it is focused on operations and activity. The Italian Happiness and Positive Health Group was founded in July 2021; it is therefore a young group that has already done a lot, however, and has taken up the legacy of the Italian National Observatory of Subjective Wellbeing. It is an observatory aimed at measuring positive health, wellbeing, dimensions such as the one we want to talk about today. We have done a lot of meetings, but also promoted various research, including on gratitude, which we have studied as a very important aspect of positive health.
So I have to ask what is gratitude and why is it important?
If we open a dictionary we find a fairly straightforward definition of gratitude: an emotional state, a feeling, what we feel when we receive a gift, an unexpected benefit, not due. This is a form of gratitude that we like because we like receiving gestures, but it is a fairly limited definition since it does not include nuances of gratitude that we experience in different circumstances. For example, good weather when leaving the house in the morning or fresh, clean air.
Absolute gratitude, i.e. not directed towards a person or a gesture, is related to a personal disposition to experience gratitude. We can in fact experience gratitude for things that happen to us in our daily lives or even for deeper reflections, such as being born into a fortunate environment, into a family that allowed us to study, etc. All these are examples of circumstances that do not correspond to receiving an immediate and tangible gift, but are somehow the result of our tendency to decode as gifts the good things that happen to us during our lives.
Could you elaborate on this idea of gratitude as an attitude?
Defining gratitude as an attitude brings it closer to the concept of dispositional optimism, i.e. the tendency to be optimistic, which is not the tendency to expect positive things, but to interpret what happens to us in a favourable way. Similarly for gratitude, one can speak of dispositional gratitude: I expect positive things and am grateful for the things that happen to me.
But if gratitude is also something dispositional, does that mean it can be taught and cultivated?
Essentially yes, and it is important to do so. First of all, we have all learnt to be grateful, because it is a cultural approach, therefore acquired and not innate.
How can it be improved and how can it be taught? Here I quote a colleague, Enrica Brachi, a pedagogist an educator, who deals precisely with these dimensions. She, for example, teaches how to think of a positive thing that has happened to us every day, even in the most complex moments, and to express gratitude for that. She then also teaches how to say ‘thank you’ and thus not to interpret what happens to us always as something due. What can I be grateful for? Trivially, I feel strong gratitude for my morning shower. By cultivating the disposition to perceive gratitude, one can learn to be grateful even for small things, such as a morning shower. This, then, reflects in an attitudinal condition, a way of being, i.e. the tendency to experience gratitude.
And why is it important to cultivate the attitude of gratitude?
Gratitude has a strong effect on our subjective well-being, primarily because, like other positive emotional states of health, it has a social function. What does this mean? It means that feeling gratitude strengthens ties with other people.
We can imagine how gratitude came about when Australopithecines six million years ago began to walk upright in the bush and cooperate. Feeling part of the group and experiencing gratitude towards other members cemented the relationships between individuals. Over the next millions of years, until we became Homo sapiens, so up to 120-130 million years ago, this attitude developed more and more. Over the last 120,000 years, it has been crucial to the success of our species, because it has strengthened, along with other negative and positive emotional states, the group and thus enabled us to be supportive.
Gratitude has somehow given rise to solidarity; in fact, it provokes a certain sense of obligation: when we receive a gift, we are grateful for the gift received and at the same time we would like to reciprocate the gift received. So much so, however, that in some circumstances gratitude can also become problematic, i.e. it can arouse a negative emotion of embarrassment.
When we experience gratitude we secrete a hormone, oxytocin, which is the same hormone that, for example, is secreted during childbirth. It is the hormone of happiness, of bonding, of embracing, and of empathy. It is therefore a bonding, prosocial hormone. We can only imagine how important it was, throughout our evolution, and still is today, even though the cortex takes over. But we still experience gratitude, still feel strong pleasure. And feeling gratitude is good for us. In fact, the higher the gratitude scores, the higher the subjective well-being scores.
How is gratitude measured?
Gratitude has a very simple scale, with six questions in the Gratitude Questionnaire – Six Item Form asking people to express their agreement with statements such as ‘I have many things to feel grateful for’. When correlating gratitude scores with well-being scores, there is always a strong correlation: people who feel more gratitude are happier.
What role does gratitude play in health care?
Unfortunately, there is little attention paid to gratitude and in general to all dimensions of positive health in health care. Nowadays, people are treated so much with drugs, with psychotherapy, mostly aimed at resolving a state of malaise or illness, thus focusing on the negative aspects of life; on the other hand, little attention is paid to cultivating and promoting a positive approach, i.e. aimed at increasing one’s psycho-social well-being.
In the literature there are studies mainly on patients, few on doctors. Gratitude helps to heal better and to heal earlier, although there is no strong evidence for this. We do not know whether it actually promotes a more accelerated biological healing process in patients or only increases the feeling of well-being, but since health is not merely the absence of disease, we can still think that it plays a role.
For the time being there is more focus on, for example, hope, but I do not exclude that in the future there will be ample room for the application of positive psychology and gratitude as a tool to improve the condition of patients and also the working conditions of health professionals.
Is there anything else you would like to add?
We are repeating for the fourth time since 2018 the national study on the subjective well-being of health workers and the last three times we have included gratitude. It is very interesting to measure gratitude especially since after the start of the pandemic.
Speaking of gratitude and pandemic, we published an article hypothesising that this very dimension was responsible for maintaining the well-being of sanitarians during the lockdown. In fact, we saw that sanitarians fairly maintained subjective well-being compared to 2018 and especially increased job satisfaction.
This study was taken up in a scientific paper by Robert Emmons, a psychologist who deals with positive psychology and today perhaps the world’s foremost expert on gratitude, who uses our hypothesis as an example to say how gratitude could have played a role during the pandemic.
We are currently repeating this study, and eventually we will start to have a plot, a graph, a kind of measurement of the gratitude fever, and we expect unfortunately that right now the gratitude of health care workers is declining because we are suffering a difficult time.
