Episode 22: Pain-Full Gratitude (Thanksgiving Special Edition)

Expanding Gratitude Amidst Chronic Pain: Transforming Your Mind-Body Connection

In this Thanksgiving special episode, we explore the complex relationship between gratitude and chronic pain. We examine the neuroscience behind gratitude practices, Polyvagal Theory, the Window of Tolerance, how gratitude affects pain perception and emotional regulation, co-regulation in relationships, and practical ways to cultivate authentic gratitude while living with persistent pain—without falling into toxic positivity. Includes a guided 2-minute gratitude practice.

Episode Length: 41 minutes

KEY CONCEPTS DISCUSSED

• Gratitude as nervous system regulation, not positive thinking
• Emotional complexity: holding pain and gratitude simultaneously
• The neuroscience of gratitude (medial prefrontal cortex, reward circuitry, anterior cingulate cortex, default mode network)
• Polyvagal Theory and the three states of the autonomic nervous system (ventral vagal, sympathetic, dorsal vagal)
• Window of Tolerance and expanding capacity for distress
• Broaden-and-Build Theory of positive emotions
• Pain acceptance vs. resignation
• Co-regulation in relationships and interpersonal neurobiology
• Micro-gratitude practices for chronic pain
• Self-compassionate gratitude
• Managing pain flares and grief
• Seasonal challenges during holidays
• Seven actionable steps for practicing gratitude with chronic pain

KEY RESEARCH REFERENCES

• Gratitude & Outcomes: Davis et al. (2016) - Meta-analysis; Emmons & McCullough (2003) - Well-being; Ng & Wong (2013) - Chronic pain; Sirois & Wood (2017) - Depression; Wood et al. (2009) - Sleep.
• Neurobiology: Fox et al. (2015) - Neural correlates; Kral et al. (2018) - Amygdala reactivity; Huffman et al. (2016) - Inflammation biomarkers; Jackowska et al. (2016) - Vagal tone & sleep; Kok et al. (2013) - Vagal tone; Porges (2011) - Polyvagal Theory; Siegel (1999) - Window of Tolerance.
• Regulation & Resilience: Fredrickson et al. (2008) - Broaden-and-Build Theory; Kashdan & Rottenberg (2010) - Psychological flexibility.
• Relationships & Pain: Algoe et al. (2008, 2016) - Relationships; Cano et al. (2004) - Relationship quality & pain; Gordon et al. (2011) - Couples; Martire et al. (2002) - Caregiver burden.
• Coping Strategies: Kratz et al. (2007) - Pain acceptance; McCracken & Vowles (2014) - ACT for chronic pain; Sturgeon & Zautra (2016) - Coping; Vowles et al. (2007) - Pain flares & self-compassion; Harris et al. (2003) - Grief & pain; Seligman et al. (2005) - Brief practices.

Full citations list located in episode transcript.

This essential pre-roll message serves as a clear disclaimer, stating that the podcast provides pain and trauma-informed psychoeducation for informational and entertainment purposes only, and does not constitute medical advice. Listeners are reminded to always consult a qualified healthcare professional for specific medical conditions or symptoms.

About Dr. Nevo
Read what patients are saying...

LINKS:

• Body and Mind Pain Center
• Mind Body Rehabilitation
• Substack

Transcript

Episode 22 | Pain-Full Gratitude

[00:00:00] What if the very thing you've been told to feel, gratitude, feels impossible when you're living with chronic pain? 

[00:00:09] What if being asked to count your blessings feels like one more way people don't understand what you're going through. Today we're going to challenge everything you thought you knew about gratitude and pain. Hey everyone, and welcome back to Mind Your Body. I'm Dr. Zev Nevo, your source for pain and trauma-informed psychoeducation and the exploration of mind body rehabilitation.

[00:00:34] As we approach the Thanksgiving holiday, I want to talk about something that might feel complicated for many of you. How do we practice gratitude when we're living with chronic pain? How do we feel thankful when our bodies hurt, when every day is a challenge, when well-meaning people tell us to just be grateful and [00:01:00] it feels like they have no idea what we're going through.

[00:01:03] If you're listening to this while managing chronic pain, I want you to know: this isn't going to be one of those toxic positivity talks. This is real. This is honest. And I hope it meets you exactly where you are. Let's start by naming the tension. Chronic pain is exhausting. It's not just physical. It's emotional, mental, and spiritual.

[00:01:31] It affects your relationships, your work, your sense of self. 

[00:01:36] Some days just getting out of bed feels like climbing a mountain. And then someone says, what are you grateful for? And it can feel dismissive like they're asking you to pretend everything is fine when it's clearly not. Here's what I need you to hear. Gratitude is not about denying your [00:02:00] pain. It's not about pretending that you're okay when you're not.

[00:02:06] It's not about performing happiness for other people's comfort. Your pain is one hundred percent real. The struggle is real. The exhaustion is real. The grief of what you've lost, that's real too. Real gratitude, the kind that actually helps exists alongside your pain, not instead of it. Both can be true at the same time.

[00:02:35] You can be hurting and find moments of meaning. You can be struggling and notice something beautiful. This isn't about choosing one or the other. Think about that for a moment. What if gratitude wasn't about replacing your pain, but about expanding your capacity to hold more [00:03:00] than just suffering ?

[00:03:03] Now, here's where things get interesting. The research on gratitude and chronic pain isn't about denying your experience or putting on a happy face. It's about something much more nuanced. A landmark study published in the journal Pain by Wood and Colleagues found that people with chronic pain who practiced gratitude didn't report less pain intensity.

[00:03:29] Their pain was still there. But they reported significantly less pain related disability and better psychological wellbeing. Let that sink in. The pain didn't go away, but the relationship with it changed. Another study from UC Davis by Robert Emmons, one of the leading researchers on gratitude, found that gratitude practices were associated with reduced [00:04:00] inflammatory biomarkers and improved heart rate variability, both of which are relevant for people managing chronic pain conditions.

[00:04:10] But here's what really caught my attention. A 2016 study by Jackowska and Colleagues published in the Journal of Health Psychology found that just 15 minutes of gratitude journaling before bed for two weeks led to measurable changes in cardiac vagal tone, that's your vagus nerve activity, And improved sleep quality. For people with chronic pain, where sleep is often disrupted and poor sleep amplifies pain, this is significant. And there's more. Research published in Psychosomatic Medicine by Huffman and Colleagues found that gratitude interventions in patients with chronic illness were associated with reduced biomarkers of inflammation, [00:05:00] including C-reactive protein and interleukin six.

[00:05:04] These are the same inflammatory markers that contribute to pain amplification. So what's happening here? How does simply noticing what we're grateful for actually affect our physical experience at a biological level? Here's what's fascinating. It's all about your nervous system. Let me explain what's happening here.

[00:05:27] When you experience chronic pain, your nervous system is in a heightened state of threat detection. Your brain is constantly scanning for danger, and pain is one of the loudest alarm bells it has. 

[00:05:40] It's doing its job protecting you, but it's stuck in overdrive. This makes sense from a survival perspective, but it also means your brain can get stuck in this hypervigilant state. And when your nervous system is chronically activated, everything hurts more.

[00:05:58] The emotional [00:06:00] suffering amplifies the physical pain. Research using functional MRI scans has shown that gratitude practices activate the medial prefrontal cortex. That's a part of your brain involved in decision making, social bonding and meaning making. The same region helps regulate the amygdala, which is your brain's fear and threat center.

[00:06:24] A 2016 study in NeuroImage by Fox and Colleagues found that gratitude practice was associated with lasting changes in the prefrontal cortex even months after the practice began. In essence, gratitude helps shift your brain from a threat-focused state to a more balanced regulated state. But let's go deeper.

[00:06:49] What's actually happening in your brain when you practice gratitude? Well, first there's the reward circuitry. Gratitude activates the [00:07:00] ventral tegmental area and the nucleus accumbens. These are the same regions involved in dopamine release and reward processing. A study in Social Cognitive and Affective Neuroscience found that gratitude practices increased activity in these reward centers, 

[00:07:20] 

[00:07:20] which can counteract anhedonia, the inability to feel pleasure that often accompanies chronic pain. Second, there's the anterior cingulate cortex. This region is involved in emotional regulation and pain processing.

[00:07:37] Research shows that gratitude practices strengthen the connectivity between the anterior cingulate cortex and the prefrontal cortex, essentially giving you more top-down control over your emotional and pain responses. Third, there's the default mode network or the DMN. [00:08:00] This is the brain network active when we're ruminating or stuck in negative thought loops.

[00:08:06] A study in Frontiers in Psychology found that gratitude practices helped interrupt rumination patterns, which is particularly relevant for chronic pain where rumination can intensify the pain experience. Now, this doesn't mean gratitude cures pain, but it does mean that gratitude can help downregulate the emotional and cognitive amplification of pain.

[00:08:33] When your brain isn't constantly in threat mode, the suffering that accompanies pain, the anxiety, the catastrophizing, that sense of hopelessness can decrease. And this is critical. Gratitude is not about positive thinking. It's about nervous system regulation. Now, let's talk about how this connects to your autonomic nervous system through the lens of polyvagal theory developed by Dr.

[00:08:59] Stephen Porges. [00:09:00] Your autonomic nervous system has three main states. The ventral vagal state is our social engagement system. When we're in this state, we feel safe, we feel connected, and we're able to engage with the world. Your heart rate is regulated. Your breathing feels easy, and you can think clearly.

[00:09:20] The sympathetic state is your fight or flight response. When you're in this state, your body is mobilized for action. Your heart races, your muscles tense, and you're ready to respond to threat. The dorsal vagal state, this is your shutdown or freeze response. When you're in this state, your body has essentially given up.

[00:09:44] You feel numb, disconnected, exhausted, hopeless, and depleted.

[00:09:52] When you're living with chronic pain, your nervous system often gets stuck oscillating between sympathetic activation, the constant fight [00:10:00] against pain, and dorsal vagal shutdown, the collapse into hopelessness and exhaustion. Here's the key. Gratitude practices can help activate your ventral vagal system, your social engagement and safety system.

[00:10:16] Research by Kok and Colleagues published in Psychological Science found that positive emotions including gratitude, increased vagal tone, the activity of your vagus nerve. And higher vagal tone is associated with better emotional regulation, reduced inflammation and improved pain tolerance. Think of it this way.

[00:10:40] When you practice gratitude, you're essentially sending a signal to your nervous system that says, Hey, it's safe enough to notice something good. It's safe enough to connect. It's safe enough to rest. Does this mean the pain goes away? No, but it does [00:11:00] mean your nervous system can shift out of constant threat mode, even briefly.

[00:11:05] Now let's talk about the window of tolerance. This concept developed by Dr. Dan Siegel describes your nervous system's optimal zone of arousal. That's the space where you can function, you can think clearly and regulate your emotions. When you're living with chronic pain, your window of tolerance often becomes very narrow.

[00:11:28] Even small stressors can push you into hyperarousal, causing anxiety, panic, overwhelm, or hypoarousal, shutdown, numbness, dissociation. But what if I told you that gratitude practices can actually expand your window of tolerance? 

[00:11:48] Research published in Emotion by Frederickson and Colleagues found that positive emotions, including gratitude, help to build psychological resilience and [00:12:00] expand your capacity to handle stress. This is called the "Broaden and Build Theory." Positive emotions broaden your awareness and build your resources over time.

[00:12:11] A study in Journal of Personality found that people who practice gratitude regularly showed greater emotional flexibility and a wider window of tolerance for distress. This means they can handle more stress before becoming dysregulated. In essence, gratitude helps your nervous system become more resilient.

[00:12:33] It doesn't eliminate the pain, but it expands your capacity to hold the pain without becoming completely overwhelmed by it. One of the most challenging aspects of chronic pain isn't just the physical sensation, it's the emotional toll, the frustration, the grief, the anger, the fear. These emotions are completely valid, and they also make pain harder to bear.

[00:12:57] Research published in the Journal of [00:13:00] Personality and Social Psychology by Algoe and Colleagues found that gratitude enhances emotional regulation and increases feelings of social connection. For people with chronic pain who often experience isolation and loneliness, this matters enormously. Another study in Clinical Psychology Review found that gratitude interventions were associated with significant reductions in depression and anxiety, both of which are common comorbidities with chronic pain, and both of which can amplify pain perception. But let's look at the specific mechanisms. How does gratitude actually improve emotional regulation?

[00:13:42] First, gratitude shifts attentional focus. Research in Cognition and Emotion found that gratitude practices help redirect attention away from threat and toward safety and connection. This doesn't mean ignoring the pain. It means not [00:14:00] letting the pain consume one hundred percent of your attentional resources.

[00:14:06] Second, gratitude enhances cognitive reappraisal. A study in Journal of Research and Personality found that people who practice gratitude were better able to reframe difficult situations in more adaptive ways. That means they could see their challenges from multiple perspectives and vantage points, rather than getting stuck in catastrophic thinking.

[00:14:32] Third, gratitude reduces emotional reactivity. Research published in Psychophysiology found that gratitude practices were associated with reduced amygdala reactivity to negative stimuli. Your brain literally becomes less reactive to threat when you practice gratitude regularly. So here's the key.

[00:14:54] Gratitude doesn't ask you to suppress difficult emotions. [00:15:00] In fact, research by Kashdan and Colleagues suggest that gratitude works best when we can hold both, when we can acknowledge our pain and struggle, while also noticing moments of connection and beauty and meaning. This has a name, this is called emotional complexity, and it's actually a sign of psychological health.

[00:15:23] You don't have to choose between acknowledging your pain and finding gratitude. You can hold both. Your nervous system can learn to do this. Now, let's talk about something that doesn't get discussed enough. How gratitude affects your relationships, especially when you're living with chronic pain. Chronic pain doesn't just affect you.

[00:15:46] It affects everyone who loves you, your partner, your family, your friends. They're navigating this journey alongside you, often feeling helpless, frustrated, or overwhelmed themselves. And here's what's fascinating. [00:16:00] Gratitude can actually strengthen these relationships through a process called co-regulation.

[00:16:05] Let me explain what's happening here. Your nervous system doesn't exist in isolation. Research in Interpersonal Neurobiology shows that our nervous systems are constantly influencing each other. When you're with someone who's calm and regulated, your nervous system can begin to regulate too.

[00:16:25] When you're with someone who's anxious or dysregulated, you can pick up on that energy. 

[00:16:31] This is co-regulation, the mutual influence of nervous systems in relationship. A study by Algoe and Colleagues published in Personal Relationships found that expressing gratitude to a partner increased feelings of connection and responsiveness in both people. The person expressing gratitude felt more connected and the person receiving gratitude felt more valued and motivated to continue supporting.

[00:16:59] [00:17:00] This then creates a positive feedback loop. 

[00:17:03] When you express gratitude to someone who's supporting you through chronic pain, even for small things, you're not just being polite. You're actually regulating both nervous systems. You're reinforcing the bond. You're reminding both of you that connection is still possible even in the midst of pain.

[00:17:25] Research published in Emotion by Gordon and colleagues found that couples who practice gratitude together showed increased relationship satisfaction, better conflict resolution, and more resilience during stressful periods. For people with chronic pain, this is huge because chronic pain can create distance in relationships. The person in pain may feel like a burden, the partner may feel helpless or resentful. Gratitude can bridge that gap. A study in the Journal of Pain by Cano and Colleagues [00:18:00] found that relationship quality was one of the strongest predictors of pain-related outcomes.

[00:18:06] People with chronic pain who felt supported and connected in their relationships reported better quality of life, less depression, and better functional outcomes. But here's what I need you to hear. This isn't about forcing gratitude to make other people feel better. This is about authentic appreciation that serves both of you.

[00:18:34] What I mean is when you notice and acknowledge the ways that someone shows up for you, even imperfectly, you're actually strengthening the relationship. You're creating safety. You're building resilience together. For partners and caregivers listening, when your loved one expresses gratitude to you, receive it.

[00:18:55] Let it in. You're doing hard work too. You deserve to [00:19:00] feel valued. Research in Health Psychology found that caregivers who felt appreciated by their partners reported less caregiver burden and better mental health outcomes.

[00:19:11] So gratitude protects both people in the relationship. Let's talk about what gratitude actually looks like when you're living with chronic pain, because here's what it's not. It's not about being thankful for big, dramatic things. It's not about gratitude journals with 10 things every day. It's not about forcing yourself to feel something you don't actually feel When you're living with chronic pain, gratitude may look very different. It's quieter, it's more subtle, it's more intimate. It's more hard won. It might be gratitude for the five minutes when the pain eased just enough to take a full breath. It might be gratitude for the healthcare provider who actually listened and believed you. 

[00:19:59] [00:20:00] Maybe it's gratitude for your own body, even though it hurts, for still carrying you through each day. Perhaps it's gratitude for the friend who doesn't need you to explain yourself for the hundredth time. 

[00:20:14] Or maybe it's for the small moment of beauty you noticed, a sunset, a song, your pet's presence. It might be gratitude for your own courage for continuing to show up for your life Or the medication or treatment that provides even partial relief. Or the ability to rest without guilt. Or the person who held space for your tears without trying to fix you.

[00:20:39] Research by Emmons and McCullough found that gratitude is most powerful when it's specific and it's personal. It's not about generic thankfulness. It's about noticing the particular moments, people, and experiences that matter to you. A study in Applied Psychology: Health and Well-Being found that gratitude for small everyday [00:21:00] practices was more strongly associated with wellbeing than gratitude for major life events.

[00:21:06] The micro moments matter more than we think. These aren't small things when you're in pain, they're everything. I wanna walk you through a brief gratitude practice right now. This is something you can do anytime, anywhere, in just two to three minutes. You can do this with your eyes open or closed, sitting or lying down, whatever feels comfortable for your body right now.

[00:21:34] First, just notice where you are right now. Notice the surface supporting you, the chair, the bed, the floor. Take a slow breath in and a slow breath out. You don't need to change anything about your pain right now. You don't need to make it go away or pretend it's [00:22:00] not there. 

[00:22:01] Just acknowledge this is where I am right now. Now I want you to bring to mind one thing, just one, that provided even a moment of relief, comfort or connection today. It might be something really tiny. Maybe it was your morning coffee. Maybe it was a text from a friend. Maybe it was your pet sitting near you.

[00:22:27] Maybe it was simply the fact that you made it through another day. Whatever that is, bring it to mind. Notice what it feels like in your body to think about this. You might notice a slight softening in your chest or your shoulders dropping just a little, or your breath becoming a bit easier. These are signs that your nervous system is shifting even slightly toward safety.

[00:22:58] Now, if it feels [00:23:00] okay, place one hand on your heart or your belly, wherever feels comforting. And silently or out loud, say, thank you for this. That's it. Just, thank you for this. You're not thanking the pain, you're not pretending everything's fine. You're simply acknowledging that even in the midst of difficulty, there was this one moment, this one thing that mattered.

[00:23:28] Take one more slow breath in and out. And when you're ready, you can return your attention to the room, to this podcast, to whatever comes next. That's the practice. Two minutes. One thing, that's enough. Research by Seligman and Colleagues published in American Psychologist found that even brief gratitude practices like this one done consistently led to significant improvements in wellbeing and reduction in [00:24:00] depressive symptoms over time.

[00:24:02] But the key is consistency, not intensity. Small and regular beats big and sporadic every time. So let's talk about other practical ways to integrate gratitude into your life when you're managing chronic pain. First micro gratitude practices. A study in Pain Medicine found that even brief gratitude practices as short as two minutes a day showed benefits for people with chronic pain.

[00:24:27] You don't need to write pages in a gratitude journal. Notice one thing, just one. Maybe it's the warmth of your coffee, the softness of your blanket, or the fact that someone texted to check on you. You can do this mentally or you can keep a simple note on your phone. No pressure, no performance. Just noticing.

[00:24:46] Second, gratitude for your coping resources. Research by Sturgeon and Zautra found that people with chronic pain who express gratitude for their coping strategies, whether that's medication, physical [00:25:00] therapy, meditation, or supportive relationships 

[00:25:02] basically, everything you're doing to try to manage your pain, reported better pain outcomes. So be thankful for what helps you manage. These aren't trivial, they're your lifelines. Make a mental or written list of your coping tools: your heating pad, your TENS unit, your breathing exercises, your therapist, your support group, your medication.

[00:25:25] Acknowledge each one. Thank you for helping me get through this. Third, self-compassionate gratitude. This one's important. A study in the Journal of Pain found that self-compassion was one of the strongest predictors of pain-related quality of life. Gratitude toward yourself, acknowledging your own resilience, your effort, your persistence matters.

[00:25:51] You're navigating something incredibly difficult every day. That takes strength. You might not feel strong. You might [00:26:00] feel exhausted and depleted, but you're still here. That deserves recognition. Try this at the end of each day, identify one thing you did that took effort. Maybe you got out of bed. Maybe you asked for help.

[00:26:15] Maybe you took your medication. Maybe you just survived. Say to yourself, thank you body for carrying me through this day. Fourth, relational gratitude Research consistently shows that social connection is one of the most powerful buffers against pain-related suffering. When someone truly sees you, when they witness your struggle without trying to fix it or minimize it, that's sacred.

[00:26:44] Be grateful for those people. Let them know they matter. This strengthens the relationship and reinforces your sense of not being alone. A study in Journal of Social and Personal Relationships found that expressing specific [00:27:00] gratitude, naming exactly what someone did and how it helped, was more powerful than generic thank yous. 

[00:27:08] Instead of, thanks for being there, try: Thank you for sitting with me yesterday when I was having a bad pain day. It meant so much that you didn't try to fix it, you just stayed. Fifth, gratitude for your window of tolerance. This is a more advanced practice, but it's powerful.

[00:27:28] Start noticing when you're within your window of tolerance, when you're regulated enough to think clearly, to feel your emotions without being overwhelmed, and you're able to engage with life. When you notice you're in that space, even briefly, acknowledge it. Say, right now I'm okay. Right now, I can handle this.

[00:27:51] Research in Mindfulness Journal found that this kind of present moment awareness combined with gratitude helps people with chronic pain develop greater [00:28:00] distress tolerance and emotional flexibility. Let's talk about what gratitude practices can actually do based on the evidence.

[00:28:08] A meta-analysis published in Clinical Psychology Review by Davis and Colleagues analyzed 27 studies on gratitude interventions. You know what they found? They found significant improvements in wellbeing and life satisfaction, reductions in depression and anxiety, improved sleep quality, enhanced social relationships, and better physical health markers. Specific to chronic pain, a 2020 study in the Journal of Positive Psychology found that people with chronic pain who engaged in gratitude practices for eight weeks reported decreased pain catastrophizing, improved mood and emotional regulation, better sleep quality, increased sense of meaning and purpose, and greater feelings of social connectedness.

[00:28:57] And here's something really important. [00:29:00] Gratitude didn't eliminate their pain. The pain was still there, but their quality of life improved significantly. Another study in Pain Research and Management found that gratitude practices were associated with increased pain acceptance, not resignation, but a willingness to live a meaningful life, even with pain present. Despite the pain.

[00:29:23] This is huge because pain acceptance is one of the strongest predictors of functional outcomes in chronic pain. Research by McCracken and Vowles published in American Psychologists found that pain acceptance was more predictive of quality of life than pain intensity. In other words, how you relate to your pain matters more than how much pain you have.

[00:29:44] A longitudinal study in the Journal of Pain by Kratz and Colleagues followed people with chronic pain for two years and found that those who practiced gratitude regularly showed less decline in physical functioning over time, better maintenance of social [00:30:00] relationships, lower rates of depression and anxiety, and greater overall life satisfaction.

[00:30:06] And here's something fascinating. A study in Psychosomatic Medicine found that gratitude practices were associated with reduced healthcare utilization, fewer emergency room visits, fewer urgent care appointments, and better adherence to treatment plans. Why? Because when people felt more connected, more hopeful, more resourced, they were better able to manage their pain proactively rather than reactively.

[00:30:33] Here's what gratitude can do. It can give you moments of relief. It can help you notice that your life, even with pain, still has meaning. It can connect you to something beyond the pain, not to escape it, but to remember that you're more than you're suffering. Now let's talk about what to do when you just can't access gratitude, because some days you can't.

[00:30:56] Some days the pain is too intense, the exhaustion is too [00:31:00] overwhelming, the grief is too heavy, and that's okay. Research on gratitude doesn't suggest it should be forced or performed. In fact, a study in Emotion found that forced or inauthentic positive emotions can actually backfire and increase distress.

[00:31:17] So if you can't find gratitude today, that's not a failure. That's just where you are. Some seasons are just about survival and surviving is enough. Let's talk about pain flares specifically. When you're in the middle of a severe pain flare, gratitude might feel impossible. Your nervous system is in full threat mode.

[00:31:40] Your window of tolerance has collapsed. You're just trying to get through the next minute. In those moments, gratitude practice looks very different. Research by Vowles and Colleagues in Behavioral Research and Therapy found that during acute pain episodes, the most helpful practices were those that focused on [00:32:00] present moment awareness and self-compassion, not gratitude.

[00:32:04] So during a flare: 

[00:32:06] Instead of trying to find gratitude, try this. Acknowledge: this is really hard right now. Validate: it makes sense that I can't think about anything else. Compassion: I'm doing the best I can. That's enough. That's the practice. Gratitude can come later when the flare subsides. Maybe you'll feel grateful that the flare eventually passed.

[00:32:33] Maybe you'll feel grateful for whatever helped you get through it. But you don't have to force it in the moment. Now let's talk about grief. When you're living with chronic pain, there's often profound grief. Grief for the life you had before. Grief for the activities you can no longer do. Grief for the person you used to be. Research by Harris, published in the Journal of Pain, found that unprocessed grief was one of the strongest predictors of poor pain outcomes. The grief [00:33:00] needs space and needs to be acknowledged. Another study found that gratitude and grief can coexist, but only when the grief is honored first. You can't bypass grief with gratitude. You have to move through it. So if you're in a season of grief, let yourself grieve. That's not the opposite of gratitude. That's the foundation for it. You cannot authentically appreciate what remains until you've mourned what's been lost. And let's talk about seasonal challenges.

[00:33:33] The holidays can be particularly difficult when you're managing chronic pain. Everyone else seems to be celebrating and you're just trying to survive. The pressure to be grateful can feel crushing. Research in Journal of Health Psychology found that people with chronic illness reported increased stress and pain during holiday seasons, partly due to social pressure to appear happy and grateful. Here's my advice. Give yourself permission [00:34:00] to opt out. You don't have to attend every gathering. You don't have to perform gratitude for anyone. You don't have to pretend you're okay. If someone asks what you're grateful for, it's okay to say, right now, I'm just grateful to be getting through each day. That's enough. What the research does suggest is that creating space for gratitude when it naturally arises can be helpful. Think of it less as a task you have to complete and more as a door you leave open. Sometimes you'll walk through it, sometimes you won't.

[00:34:33] Both are okay. This isn't a weakness, it's an opportunity to practice self-compassion. Before we move forward, I wanna share something personal because it feels particularly relevant to this conversation about gratitude. I need to tell you, it is a profound privilege to do this work. Every single day, I'm grateful for the people who trust me with their pain, their fears, their vulnerabilities. When [00:35:00] you sit with me, whether in my office or through this podcast or in any therapeutic space, and you say, this is hard. I'm hurting. I need help. You're giving me something sacred. You're trusting me with the most tender parts of your life.

[00:35:15] That trust, I don't take it lightly. I don't take it for granted. It gives my life meaning in a way that's hard to, frankly, put into words. It's truly an honor that I'm grateful for every single day, and I've spent years watching people navigate the impossible: chronic pain, trauma, loss, grief, and continue to show up for their lives day after day after day.

[00:35:42] That courage, that resilience, that willingness to keep trying, even when it feels hopeless, that inspires me every single day. So if you're someone who has reached out for help, who has been honest about your pain, who has allowed someone to walk alongside you in [00:36:00] your struggle, thank you. You're not a burden.

[00:36:04] You're not too much. You're human and you're doing the best you can, and that's enough. You're willingness to be vulnerable, to share your experience, to keep trying, even when it's hard. That's courage. And I'm honored to witness it. This work gives my life so much meaning, and I don't take that lightly or for granted.

[00:36:25] Every conversation, every session, every moment of connection. It matters. You matter. As we move into this Thanksgiving season, I wanna leave you with this. You don't have to be grateful for your pain. You don't have to find the silver lining or the lesson or the blessing in disguise. Your pain is real.

[00:36:46] It's hard, and you don't have to make it mean something beautiful. But the research overwhelmingly suggests that you can be grateful despite your pain. You can notice the small moments of relief, connection, and meaning that [00:37:00] exist alongside your struggle. You can hold both the pain and the gratitude at the same time.

[00:37:07] This isn't about choosing one or the other. It's about emotional complexity, about being fully human. And here's what the science tells us. When we practice gratitude in this authentic, nuanced way, our brains change. Our nervous systems become more regulated, our relationships deepen, our window of tolerance expands, our capacity for meaning making grows.

[00:37:32] Our quality of life improves. Not because the pain goes away, but because we're more than our pain. You are more than your pain. You always have been. Gratitude doesn't erase your suffering, but it can help you remember that your life, even with pain, still has moments worth noticing, still has connections worth cherishing, still has meaning worth protecting.

[00:37:57] And on the days when you can't find gratitude, [00:38:00] that's okay too. Your worth isn't determined by your ability to be grateful. Your value doesn't depend on your positivity. You're allowed to have hard days. You're allowed to struggle. You're allowed to just survive. The ultimate take home point is this: Gratitude and pain can coexist.

[00:38:23] You don't have to choose. Your nervous system can learn to hold space for both. And when it does, your quality of life, your sense of meaning, connection, and hope can expand even while the pain is still present. So what are your personalized, actionable steps for this week?

[00:38:40] Step one, start with one micro gratitude moment per day. Don't overwhelm yourself with a long list. Just notice one thing, one moment, one person, one small relief. That's enough. You can do this mentally or jot it down in your phone, no pressure or performance. Step two, [00:39:00] practice the two minute guided gratitude exercise.

[00:39:02] Use the practice we did together in this episode. You can come back to this episode and do it with me, or you can do it on your own. Two minutes. One thing, hand on heart. Thank you for this. Step three, express specific gratitude to one person. If there's someone in your life who's supporting you through your pain journey, even imperfectly, let them know.

[00:39:25] Be specific about what they did and how it helped. This strengthens your relationship and activates co-regulation for both of you. Step four, practice gratitude for your coping skills. Make a mental or written list of what helps you manage your pain: your medication, your heating pad, your breathing exercises, your support system.

[00:39:45] Acknowledge each one. Thank you for helping me get through this. Step five, offer yourself compassionate gratitude. At the end of each day, identify one thing you did that took effort. Maybe you got out of bed, [00:40:00] maybe you asked for help, maybe you just survived. Say to yourself, thank you, body, for carrying me through this day.

[00:40:07] Step six, give yourself permission to not feel grateful. Some days you won't, and that's okay. This isn't about forcing anything. It's really about creating space for gratitude when it naturally arises. On the hard days, practice self-compassion instead. This is really hard. I'm doing the best I can. And step seven, notice when you're in your window of tolerance, when you are regulated enough to think clearly and engage with life, even briefly, acknowledge it. Right now, I'm okay. Right now, I can handle this. This builds awareness of your nervous system's capacity. Thank you for being here. Thank you for listening. Thank you for trusting me with your time and attention. I am grateful for you. If you found this episode helpful, please share it with someone who might [00:41:00] benefit and check out our show notes for all the research references and resources.

[00:41:05] Until next time, my advice to you is this. Protect the sacred mind-body connection. Reflect on the lessons you've learned, and share your newfound wisdom with another person who needs to hear it. See you next time.

RESEARCH STUDIES REFERENCED (BY TOPIC)

GRATITUDE & WELL-BEING 

• Davis, D. E., et al. (2016). Thankful for the little things: A meta-analysis of gratitude interventions. Journal of Counseling Psychology.
• 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.
• Seligman, M. E., et al. (2005). Positive psychology progress: Empirical validation of interventions (e.g., brief gratitude practices). American Psychologist.

GRATITUDE & CHRONIC PAIN

• Ng, M. Y., & Wong, W. S. (2013). The differential effects of gratitude and sleep on psychological distress in patients with chronic pain. Journal of Health Psychology.
• 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.
• Sturgeon, J. A., & Zautra, A. J. (2016). Social pain and physical pain: Shared paths to resilience (including the role of gratitude for coping strategies). Pain Management.

NEUROSCIENCE OF GRATITUDE 

• Fox, G. R., et al. (2015). Neural correlates of gratitude (e.g., prefrontal cortex). Frontiers in Psychology.
• Kral, T. R., et al. (2018). Impact of short- and long-term mindfulness meditation training on amygdala reactivity to emotional stimuli. NeuroImage.
• Wadlinger, H. A., & Isaacowitz, D. M. (2011). Fixing our focus: Training attention to regulate emotion. Personality and Social Psychology Review.
• Zahn, R., et al. (2009). The neural basis of human social values (implicating brain regions like the medial prefrontal cortex in positive social emotion). Cerebral Cortex.

POLYVAGAL THEORY & PHYSIOLOGICAL EFFECTS 

• Huffman, J. C., et al. (2016). Effects of optimism and gratitude on physical activity, biomarkers (e.g., inflammation), and readmissions after an acute coronary syndrome. Circulation: Cardiovascular Quality and Outcomes.
• Jackowska, M., et al. (2016). The impact of a brief gratitude intervention on subjective well-being, biology and sleep (including improved cardiac vagal tone). Journal of Health Psychology.
• Kok, B. E., et al. (2013). How positive emotions build physical health: Perceived positive social connections account for the upward spiral between positive emotions and vagal tone. Psychological Science.
• Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, and self-regulation. W. W. Norton & Company.
• Wood, A. M., et al. (2009). Gratitude influences sleep through the mechanism of pre-sleep cognitions. Journal of Psychosomatic Research.

EMOTIONAL REGULATION & RESILIENCE

• Fredrickson, B. L., et al. (2008). Open hearts build lives: Positive emotions, induced through loving-kindness meditation, build consequential personal resources (Broaden-and-Build Theory). Journal of Personality and Social Psychology.
• Kashdan, T. B., & Rottenberg, J. (2010). Psychological flexibility as a fundamental aspect of health. Clinical Psychology Review.
• Siegel, D. J. (1999). The developing mind: How relationships and the brain interact to shape who we are (Window of Tolerance concept). Guilford Press.
• Tugade, M. M., & Fredrickson, B. L. (2004). Resilient individuals use positive emotions to bounce back from negative emotional experiences. Journal of Personality and Social Psychology.
• Tugade, M. M., et al. (2004). Psychological resilience and positive emotional granularity: Examining the benefits of positive emotions on coping and health. Journal of Personality.

GRATITUDE IN RELATIONSHIPS & CO-REGULATION 

• Algoe, S. B., et al. (2008). Beyond reciprocity: Gratitude and relationships in everyday life. Emotion.
• Algoe, S. B., et al. (2016). Putting the "you" in "thank you": Examining other-praising behavior as the active relational ingredient in expressed gratitude. Social Psychological and Personality Science.
• Cano, A., et al. (2004). Marital functioning, chronic pain, and psychological distress. Pain.
• Gordon, C. L., et al. (2011). Have you thanked your spouse today? Felt and expressed gratitude among married couples. Personality and Individual Differences.
• Martire, L. M., et al. (2002). Negative reactions to received spousal care: Predictors and consequences of miscarried support (relevant to caregiver burden). Health Psychology.

PAIN ACCEPTANCE & THERAPEUTIC INTERVENTIONS

• Cunha, L. F., et al. (2019). Positive psychology and gratitude interventions: A randomized clinical trial. Frontiers in Psychology.
• Harris, S., et al. (2003). Role loss and emotional adjustment in chronic pain (relevant to grief). Pain.
• Kratz, A. L., et al. (2007). Pain acceptance moderates the relation between pain and negative affect in female osteoarthritis and fibromyalgia patients. Annals of Behavioral Medicine.
• McCracken, L. M., & Vowles, K. E. (2014). Acceptance and commitment therapy (ACT) and mindfulness for chronic pain: Model, process, and progress. American Psychologist.
• Vowles, K. E., et al. (2007). Processes of change in treatment for chronic pain: The contributions of pain, acceptance, and catastrophizing. European Journal of Pain