Giving and receiving thanks: a mixed methods pilot study of a gratitude intervention for palliative patients and their carers

Abstract

Background Psychological research examining the nature and workings of gratitude has burgeoned over the past two decades. However, few studies have considered gratitude in the palliative care context. Based on an exploratory study which found that gratitude was correlated with better quality of life and less psychological distress in palliative patients, we designed and piloted a gratitude intervention where palliative patients and a carer of their choice wrote and shared a gratitude letter with each other. The aims of this study are to establish the feasibility and acceptability of our gratitude intervention and provide a preliminary assessment of its effects. Methods This pilot intervention study adopted a mixed-methods, concurrent nested, pre-post evaluation design. To assess the intervention’s effects, we employed quantitative questionnaires on quality of life, quality of relationship, psychological distress, and subjective burden, as well as semi-structured interviews. To assess feasibility, we considered patients and carers’ eligibility, participation and attrition rates, reasons for refusal to participate, appropriateness of intervention timeframe, modalities of participation, and barriers and facilitators. Acceptability was assessed through post-intervention satisfaction questionnaires. Results Thirty-nine participants completed the intervention and twenty-nine participated in interviews. We did not find any statistically significant pre/post intervention changes for patients, but found significant decrease in psychological distress for carers in terms of depression (median = 3 at T0, 1.5 at T1, p = .034) and total score (median = 13 at T0, 7.5 at T1, p = .041). Thematic analysis of interviews indicates that overall, the intervention had: (1) multiple positive outcomes for over a third of interviewees, in the form of positive emotional, cognitive, and relational effects; (2) single positive outcomes for nearly half of interviewees, who experienced emotional or cognitive effects; (3) no effect on two patients; and (4) negative emotional effects on two patients. Feasibility and acceptability indicators suggest that the intervention was well received by participants, and that it should adopt flexible modalities (e.g. writing or dictating a gratitude message) to ensure that it is feasible and adapted to individual needs and preferences. Conclusions Larger scale deployment and evaluation of the gratitude intervention, including a control group, is warranted in order to have a more reliable evaluation of its effectiveness in palliative care.

‘Thank you for loving me’: A qualitative study on perceptions of gratitude and their effects in palliative care patients and relatives

“…This paper examines material produced as part of a pilot study that sought to assess the feasibility, acceptability and effects of a gratitude letter-writing intervention in palliative care. 11 We analysed gratitude letters and semistructured interviews with palliative patients and relatives who took part in the intervention. We adopted a discourse analysis framework to make sense of participants' representations of gratitude and their effects, and conducted inductive thematic analysis of our material.…”

“…Participants could decide whether to share their letter with the addressee at any point after writing and in the way of their choosing. As this research was conducted as part of a larger study with a predetermined sample size of 30 participants, based on recommendations for pilot studies 11 , data saturation was not discussed.…”

“…This paper examines materials produced by 23 patients and 13 relatives -for the pilot study recruitment flowchart, see Bernard et al 11 Fifteen patients participated in the interviews and shared their gratitude letter with the researchers, 6 shared their letter only and 2 did the interview only; 11 relatives participated in the interviews and shared their letter, 1 shared a letter only and 1 participated in the interview only. All participants who wrote a letter agreed to share a copy with the research team during their post-intervention interview.…”

“…[8][9][10] In palliative care, our research team led a pilot gratitude intervention for patients and their family carers, based on writing a gratitude letter to each other and sharing it. 11 Quantitative results showed a reduction in psychological distress for carers, and qualitative analyses highlighted that the intervention could help patients and carers to experience emotional wellbeing, personal growth and improved relationships.…”

Positive psychology and palliative care: A call for an integrative approach

“…This aspect is crucial not only because the therapeutic alliance is a decisive factor of success in psychotherapy but also because of the "containing" role of this alliance when undesirable effects emerge. For example, we have identified anxiety and sadness resulting from a gratitudebased intervention (Bernard et al 2023;Poncin et al 2024). A further concern of some interventions is the lack of flexibility and adaptability to individual patient characteristics.…”