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Aging & Mental Health
ISSN: 1360-7863 (Print) 1364-6915 (Online) Journal homepage: http://www.tandfonline.com/loi/camh20
Gratitude and coping among familial caregivers of
persons with dementia
Bobo Hi-Po Lau & Cecilia Cheng
To cite this article: Bobo Hi-Po Lau & Cecilia Cheng (2017) Gratitude and coping among
familial caregivers of persons with dementia, Aging & Mental Health, 21:4, 445-453, DOI:
10.1080/13607863.2015.1114588
To link to this article: http://dx.doi.org/10.1080/13607863.2015.1114588
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Gratitude and coping among familial caregivers of persons with dementia
Bobo Hi-Po Laua
and Cecilia Chengb
a
Department of Social Work and Social Administration, University of Hong Kong, Hong Kong; b
Department of Psychology,
University of Hong Kong, Hong Kong
ARTICLE HISTORY
Received 13 August 2015
Accepted 27 October 2015
ABSTRACT
Objectives: Gratitude is widely perceived as a key factor to psychological well-being by different
cultures and religions. The relationship between gratitude and coping in the context of familial
dementia caregiving has yet to be investigated.
Design: This study is the first to examine the associations among gratitude, coping strategies,
psychological resources and psychological distress using a structural equation modelling approach.
Results: Findings with 101 Chinese familial caregivers of persons with dementia (mean age D
57.6, range = 40À76; 82% women) showed that gratitude was related to the greater use of emotionfocused
coping (positive reframing, acceptance, humour, emotional social support seeking, religious
coping) and psychological resources (caregiving competence and social support). Psychological
resources and emotion-focused coping in turn explained the association between gratitude and
lower levels of psychological distress (caregiving burden and depressive symptoms).
Conclusion: The present results indicate the beneficial role of gratitude on coping with caregiving
distress and provide empirical foundation for incorporating gratitude in future psychological
interventions for caregivers.
KEYWORDS
Gratitude; caregiving;
Alzheimer’s disease;
dementia; coping
Introduction
Gratitude has been proposed as a key factor for subjective
well-being by major religions (e.g., Christianity, Buddhism,
Muslim) and philosophers in different cultures (Confucius,
Marcus Tullius Cicero, Adam Smith; Emmons & Crumpler,
2000; Emmons & Shelton, 2002; Wood, Froh, & Geraghty,
2010). People characterized by a grateful personality tend to
be thankful and appreciative more frequently as well as to a
wider array of people and events in daily life (McCullough,
Emmons, & Tsang, 2002; Wood, Maltby, Stewart, Linley, &
Joseph, 2008). A rich corpus of studies has demonstrated
the robust associations between a grateful personality
(or gratitude) and indicators of subjective well-being, such
as life satisfaction and positive affect (Froh, Kashdan,
Ozimkowski, & Miller, 2009; McCullough et al., 2002; Watkins,
Woodward, Stone, & Kolts, 2003; Wood, Joseph, & Maltby,
2009). Gratitude was also inversely related to depressive
symptoms (Lambert, Fincham, & Stillman, 2012; McCullough
et al., 2002; Ruini & Vescovelli, 2013; Watkins et al., 2003;
Wood, Joseph, & Linley, 2007), anxiety (McCullough et al.,
2002; Vernon, Dillon, & Steiner, 2009), and a plethora of
negative emotions including exhaustion, disappointment,
and anger (DeWall, Lambert, Pond, Kashdan, & Fincham,
2012; Kashdan, Mishra, Breen, & Froh, 2009; Kashdan, Uswatte,
& Julian, 2006; McCullough et al., 2002). These negative
emotions are common among dementia caregivers (Pinquart
& S€orensen, 2003; Schulz, O’Brien, Bookwala, & Fleissner,
1995). However, the role of gratitude on relieving emotional
distress, such as perceived burden, has yet to be systematically
examined in the context of familial caregiving for persons
with dementia (PWDs).
The association of gratitude with distress through
resources and coping
Psychologists have proposed two hypotheses to explain the
salutary effects of gratitude. The first hypothesis (Fredrickson,
2004) puts forward that a grateful personality builds psychological
resources in halcyon times. These psychological resources
may include a greater sense of meaning, mastery, competence,
perceived, and received social support (Kashdan, Mishra, Breen,
& Froh, 2009; Lambert, Graham, Fincham, & Stillman, 2009;
Lanham, Rye, Rimsky, & Weill, 2012; Wood et al., 2009). In turn,
the accrued psychological resources may help reduce psychological
distress in stressful times.
Algoe’s (2012) find-remind-and-bind theory postulates
how gratitude fosters social support. Specifically, gratitude
signals the responsiveness of the benefactor to the beneficiary’s
needs. The grateful emotion elicited, therefore, enables
the beneficiary to locate high-quality social partners (i.e., the
benefactor) who care for their well-being, and forms supportive
interpersonal relationships. Algoe and her team replicated
the effect of gratitude on relationship quality and social support
among populations facing various stressors, including
college freshmen adjusting to their new school life as well as
women living with breast cancer (Algoe, Haidt, & Gable, 2008;
Algoe & Stanton, 2012).
Wood, Maltby, Stewart, Linley, and Joseph (2008) proposes
that grateful individuals are inclined to regard benefits from
others as more costly, valuable, and altruistic. Although this
socio-cognitive account is not formulated to explain specifically
how gratitude would facilitate appraisals of psychological
resources, these gift perceptions may enable grateful
individuals to perceive their lives as more favourably
CONTACT Bobo Hi-Po Lau bobolau12@gmail.com, hpbl@hku.hk
© 2015 Taylor & Francis
AGING & MENTAL HEALTH, 2017
VOL. 21, NO. 4, 445À453
http://dx.doi.org/10.1080/13607863.2015.1114588
endowed. The study by Wood et al. (2009) indicates that gratitude
is associated with enhanced autonomy, environmental
mastery, purposefulness, personal growth, and self-acceptance,
even after controlling for the effects of personality.
Gratitude has also been found to be associated with higher
levels of perceived mastery, internal locus of control, and perceived
competence (Kashdan et al., 2009; Kashdan et al.,
2006; Watkins et al., 2003).
Several literature reviews have also proposed coping strategies
as the mediator for the association between gratitude
and reduced psychological distress (Emmons & Mishra, 2011;
Wood et al., 2010). These reviews put forward that grateful
individuals tend to cope with stress using a more adaptive
repertoire of coping strategies (e.g., more positive reframing,
more social support seeking, less self-blame), and therefore
experience less distress in stressful encounters.
On the basis of the transactional model of stress and coping
(Lazarus & Folkman, 1984) and the categorization of coping
strategies proposed by Carver, Scheier, and Weintraub
(1989), Cooper, Katona, and Livingston (2008) validated a
scheme that comprised three subscales for categorizing an
array of coping strategies. Problem-focused coping refers to
efforts to define a problem, generate alternative solutions,
and conduct cost–benefit analysis for devising an action plan
(e.g., active coping, planning, seeking instrumental social support).
Emotion-focused coping is characterized by efforts to
change one’s feeling and perceptions about the situation
with the goal to lessen the emotional impact of the stressor
(e.g., positive reframing, acceptance, seeking emotional support).
Dysfunctional coping (e.g., denial, self-blame, behavioural
disengagement) describes a cluster of coping strategies
that may elicit adverse outcomes, especially when they are
used alone or over a prolonged period. The current paper
employed this framework to understand the role of coping
strategies in mediating the relationship between gratitude
and psychological distress.
Through the habitual deployment of emotion-focused
coping strategies (e.g., positive reframing, emotional social
support seeking), grateful individuals tend to experience less
emotional distress despite their stressful experiences
(Emmons & Kneezel, 2005; Lambert et al., 2009; Watkins, Cruz,
Holben, & Kolts, 2008). According to a study that investigated
the link between gratitude and various coping strategies
(Wood et al., 2007), gratitude was associated with seeking
instrumental and emotional social support, active coping,
positive reinterpretation and growth, and planning. Also, the
personality trait was related to less use of dysfunctional coping,
including behavioural disengagement, self-blame, and
denial. In addition, positive reinterpretation and growth partially
mediated the relationship between gratitude and perceived
stress.
Coping with dementia caregiving
The present study aimed to investigate the role of gratitude
on relieving caregiving distress among familial caregivers of
PWDs. Taking care of a PWD induces chronic strain among
caregivers, and this strain exerts a heavy toll on their mental
and physical health (Pinquart & S€orensen, 2003; Vitaliano,
Zhang, & Scanlan, 2003). Examining how gratitude facilitates
the coping process may advance the understanding of
researchers and practitioners on the individual differences in
coping with caregiving distress.
According to the caregiving and stress process formulated
by Pearlin, Mullan, Semple, and Skaff (1990), multiple
factors À the caregiving context, characteristics of stressor,
coping style, and coping resources À collectively influence
the physical and mental health impacts of caregiving.
Empirical evidence regarding the benefits of each category
of coping strategies is mixed. Li, Cooper, Bradley, Shulman,
and Livingston (2012) conducted a meta-analysis on the
relationship between coping strategies and psychological
morbidity among familial caregivers of PWDs based on 35
independent studies. Results showed that dysfunctional
coping was related to higher levels of anxiety and depression,
whereas emotion-focused coping was associated with
less psychological morbidity. Problem-focused coping was
related to neither depression nor anxiety. In contrast, subsequent
studies by Piercy and colleagues (2013) based on the
Cache County Dementia Progression Study data-set have
revealed that wishful thinking increased, but problemfocused
coping reduced depressive symptoms among
familial caregivers. Using semi-structured interviews, Au,
Shardlow, Teng, Tsien, and Chan (2013) found that Hong
Kong Chinese caregivers relied on internal self-regulation
and forbearance to cope with their caregiving burdens. This
finding resonates with Eastern philosophical teachings that
advocate changing one’s perception, rather than the external
environment, to tackle life stress.
Psychological resources, such as sense of mastery and
social support, are imperative to caregiver’s adjustment to
their caregiving role. An early study by Haley, Levine, Brown
and Bartolucci (1987) has demonstrated that social support
and self-efficacy in tackling caregiving loads were associated
with less depressive symptoms among dementia caregivers.
In examining the mediating pathways for the
relationship of caregiving stress with depressive symptoms,
Mausbach and colleagues (2012) found that personal mastery
and self-efficacy were robust mediators. The result is in
line with the findings of Chow and Ho (2012) on Hong
Kong Chinese caregivers, which demonstrated the predictability
of psychological resources on mitigating depression.
In a recent systematic review on models of burden in caregiving
with 56 reports, Van der Lee, Bakker, Duivenvoorden,
and Dr€oes (2014) underscored caregivers’ social functioning
and support as well as perceived competence and selfefficacy
as robust determinants of both burden and mental
health, amongst other stressors including PWDs’ behavioural
problems and mood disorders, self-care needs, and
cognitive function.
Numerous studies have examined the effects of other caregiver
characteristics (e.g., ethnicity, relationship with the PWD,
personality) on dementia caregiving experience (Hooker,
Monahan, Bowman, Frazier, & Shifren, 1998; S€orensen &
Pinquart, 2005). However, the current literature has largely
neglected the role of malleable character strengths in coping
with the caregiving role and tasks (Park, Peterson, & Seligman,
2004). Until recently have researchers begun to acknowledge
and investigate the positive aspects of caregiving experience,
such as personal growth (Cheng, Mak, Lau, Ng, & Lam, 2015;
Tarlow et al., 2004), apart from its negative aspects. Gratitude
may support the tendency of benefit finding and facilitate
adaptation to the caregiving role. Adopting a grateful orientation
to life (Wood, Froh, & Geraghty, 2010) may enable caregivers
to appreciate the positive moments of caregiving, from
the kind acts of a helpful neighbour to the tiny progress in
446 B. H.-P. LAU AND C. CHENG
self-care made by the PWD. An appreciative and thankful
caregiver is less likely to take these positive moments for
granted (Wood, Maltby, Stewart, et al., 2008). In other words,
gratitude may sharpen the sensitivity of the caregiver to
appreciate the positive aspects of caregiving. A grateful person
does not only recognize the occurrence of positive events
(e.g., happy moments with the PWD), but also generously
acknowledges the support from the people around or supernatural
power (e.g., God). Reciprocation of kind acts may foster
the relationship harmony between the grateful beneficiary
and the benefactor (Algoe & Stanton, 2012). The prosocial
nature of gratitude may, therefore, strengthen the perception
of social support (Wood, Maltby, Gillett, Linley, & Joseph,
2008), in addition to reminding the beneficiary of their existing
assets as well as their importance in the eyes of those
have offered help (Algoe, 2012; Lambert et al., 2009; Wood
et al., 2009).
This study extended the caregiving literature by investigating
the salutary role of gratitude in the coping process among
familial caregivers of PWDs. Specifically, we hypothesized that
gratitude was inversely associated with psychological distress
of caregiving, indicated by caregiving burden and depressive
symptoms. In addition, we posited that the beneficial role of
gratitude on distress was mediated by coping strategies as
well as psychological resources. The present findings, which
reveal multivariate associations among gratitude, coping, and
psychological distress of caregivers, may offer empirical support
for the future adoption of gratitude interventions to caregivers
of PWDs.
Method
Participant
Participants were recruited from nine local non-governmental
organizations (NGOs; see the Acknowledgement section
for the name). These NGOs were chosen based on their
extensive experience in dementia-related services and
capacity to commit to the case load of the current study
within the designated time frame of data collection. Chinese
caregivers were recruited if they were 40À80 years
old, provided care to a family member with dementia for
no less than two hours per day, and were able to understand
and speak Cantonese. Caregivers who were undergoing
cancer treatment or participating in any structured
counselling programmes were excluded. Except the age
restriction, these inclusion and exclusion criteria were identical
to those of a recent, territory-wide, multidimensional
caregiver program (REACH-HK; Cheung et al., 2015). The
age restriction was in place considering that local old-old
caregivers tend to have low literacy level and may find
some survey questions (e.g., coping strategies) too abstract
to answer. All participants were remunerated 30 Hong Kong
dollars for their participation.
One hundred and nine eligible caregivers provided consent
to participate in the study. Eight caregivers did not
complete the face-to-face interview, and hence the questionnaire.
They were either too distressed to answer the
questions or had substantial difficulty understanding the
survey questions. Their data were removed from the analysis.
The final sample thus comprised 101 caregivers. Table 1
presents the demographic characteristics of the caregivers
and PWDs.
Measures
Gratitude
Gratitude was measured by both the Gratitude Adjective
Scale (GAS; McCullough et al., 2002) and the Gratitude Questionnaire
(GQ; McCullough et al., 2002). For the GAS, participants
evaluated the extent to which the terms grateful,
thankful, and appreciative described their everyday feelings in
general. The GQ differs from the GAS in that the former does
not only measure the frequency of gratitude felt in everyday
life but also its span (the variety of gratitude-worthy events)
and density (the number of objects one is grateful for in each
specific event). In other words, the GQ complemented the
GAS by considering more dimensions of the affective disposition
(McCullough et al., 2002). Sample items of the GQ include
‘I have so much in life to be thankful for’ and ‘I am grateful to
a wide variety of people.’ In this study, participants evaluated
the extent to which the three GAS items described their
everyday feelings, as well as their agreement with the six GQ
items on a scale ranging from 1 (strongly disagree) to 7
(strongly agree).
A study on Taiwan college students, however, indicated
that Item 6 of the GQ (‘Long amounts of time can go by
before I feel grateful to something or someone’) loaded
poorly with other five items on a single gratitude dimension
on a confirmatory factor analysis (Chen, Chen, Kee, & Tsai,
2009). Hence, we also tested the factor loadings of the six
items on a single gratitude factor using confirmatory factor
analysis with our sample. Although the overall model-data fit
was good (x2
(9) D 8.67, p D .468, CFI D 1.00, TLI D 1.00,
RMSEA D .000, SRMR D .034), Item 6 loaded poorly on the
gratitude factor (factor loading D .13, p D .220), unlike the
rest of the five items (factor loadings D .54À.90, p < .000).
Table 1. Sample characteristics (N D 101).
Variables
CG characteristics n/Mean %/SD
CG proportion of female 83 82.2
CG age 57.6 7.95 (range D 40À76)
CG relationship with PWD
Spouse 29 28.7
Children/children-in-law 71 70.3
Others (i.e., sister-in-law) 1 1.0
CG cohabiting with PWD 60 59.4
CG working (full time/part time)a
25 24.7
CG monthly household
income (in HK dollar)b
5000 or below 26 25.7
5001À10,000 20 19.8
10,001À20,000 18 17.8
20,001À40,000 20 19.8
40,001 or more 10 10.0
CG education levelc
Primary or less 32 31.7
Junior secondary 16 15.8
Senior secondary 30 29.7
Degree or more 18 17.8
CG with religious affiliationd
51 50.5
CG married 70 69.3
PWD characteristics
PWD proportion of female 68 67.3
PWD age 81.7 9.36 (range D 59À100)
No. of years since the diagnosis 4.42 3.23
Notes: CG D caregiver; PWD D person with dementia.
a
One participant did not provide his/her work status.
b
Seven participants did not provide their income level.
c
Five participants did not provide their education level.
d
One participant did not provide his/her religious affiliation.
AGING & MENTAL HEALTH 447
Thus, following the practice of Chen et al. (2009), we removed
Item 6 from the GQ in the subsequent analysis. Responses on
the items were averaged to form the scale scores for each
measure.
Psychological resources
Participants’ recent caregiving competence was operationalized
as personal resources, whereas the receipt and satisfaction
with social support were operationalized as social
resources (Hobfoll, 2002). Caregiving competence was
assessed by a four-item scale (Pearlin et al., 1990). Participants
were asked to judge the accuracy of those items (e.g., ‘competent’,
‘self-confident’) as descriptions of themselves as caregivers
and to answer on a scale ranging from 0 (totally
inaccurate) to 3 (totally accurate). The average of the
responses on these items formed the scale score of caregiving
competence.
Social support was measured by three types of received
support (i.e., tangible, emotional, and informational) as well as
the satisfaction with each type of support (Krause, 1995;
Krause & Borawski-Clark, 1995). The receipt of social support
does not always confer satisfaction and a beneficial effect to
the well-being of the recipient. Support that compromises the
autonomy and preferences of the caregivers may be less welcomed
compared to the kind of assistance that is appropriate
and respects the dignity of the beneficiary (Smith & Goodnow,
1999). Thus, we constructed an overall social support
score by aggregating received social support and satisfaction
of caregivers to it in this study. Many participants remarked
that the first item of the received tangible support scale (‘provide
transportation’) was largely irrelevant to their caregiving
task because extremely few people in their social network
had the capacity to offer such support (e.g., without a car),
and they had restricted their daily activities (e.g., grocery
shopping, going to the elderly centre and doctors) to their
immediate vicinity. Thus, the item was removed, leaving the
received tangible support with two items (‘help with household
chores’ and ‘help with grocery shopping’). Both the
received emotional (e.g., ‘comfort you when you are stressful’)
and the received informational (e.g., ‘offer you information’)
support were evaluated by four items. Participants assessed
how often they received each type of support, and answered
on a scale ranging from 0 (never) to 3 (always). Participants
were also asked whether they were satisfied with the three
types of social support (tangible, emotional, informational)
they have received, and to respond on a scale ranging from 0
(totally dissatisfied) to 3 (very satisfied). The scores of the 13
items (2 on received tangible support, 4 on received emotional
support, 4 on received informational support, and 3 on
support satisfaction) were averaged to form the overall social
support score.
Coping strategies
The Brief COPE (Carver, 1997) was used to measure participants’
deployment of coping strategies in the recent two
weeks in response to the challenges encountered in caregiving.
Prior to the administration of the questionnaire, the centre
managers of two participating NGOs expressed concerns
regarding the substance abuse items (‘using alcohol and
other drugs to make myself feel better’ and ‘using alcohol
and other drugs to help me get through it’), and requested
removing them from the questionnaire in order to protect privacy
and reduce unnecessary stigmatization to their clients.
They remarked that the substance use items were too sensitive
considering the negative connotation of using these substances
to cope with caregiver stress, and the potential
elderly abuse cases that often occurred along with substance
abuse (Lachs & Pillemer, 2004). Thus, substance use was not
measured in the current study. The remaining 13 coping strategies
(active coping, planning, positive reframing, acceptance,
humour, religious coping, emotional social support seeking,
instrumental social support seeking, distraction, denial, venting,
behavioural disengagement, and self-blame) with a total
of 26 items were adopted. Each coping strategy was assessed
by two items. The framework of Cooper et al. (2008) included
three coping subscales. First, the problem-focused coping
subscale comprised active coping, planning, and instrumental
social support seeking. Second, the emotion-focused coping
subscale consisted of acceptance, emotional social support
seeking, humour, positive reframing, and religious coping.
Third, the dysfunctional coping subscale comprised behavioural
disengagement, self-blame, venting, denial, and distraction.
Participants answered on a scale from 1 (never) to 4
(always) regarding their use of each coping strategy. Strategy
scores and subscale scores were constructed by taking the
average of the responses on the items.
Psychological distress
Psychological distress was measured by both caregiving burden
and depressive symptoms. Caregiving burden, which
described the levels of strains in different domains of life as a
result of the caregiving role, was evaluated by a 12-item version
of the Zarit Burden Interview (Tang et al., 2015). Participants
evaluated the extent to which they had experienced
the symptoms described by the items (e.g., ‘feel angry when
you are around with CR’, ‘feel that your social life has suffered
because you are caring for CR’) in the recent two weeks, and
responded on a scale from 1 (never) to 5 (very often).
Responses on the 12 items were averaged to form the caregiving
burden score. Depressive symptoms were evaluated
by the seven-item Center for Epidemiologic Studies À Depression
Scale (CESD; Herrero & Meneses, 2006; Santor & Coyne,
1997). Sample items included ‘feel depressed’ and ‘have difficulty
sleeping’. Participants evaluated the frequency of which
they experienced each symptom in the previous two weeks
and answered on a scale from 1 (never) to 4 (always).
Responses on the seven items were averaged to form the
depressive symptoms score.
Procedures
This study employed a cross-sectional design. Each session
lasted for approximately one hour, and took place either in a
private counselling room of the participating elderly centre or
at the participant’s home. The items were shown on response
cards to facilitate participants’ responses. Written informed
consent was obtained before any questionnaire items were
asked. All the sessions were conducted in Cantonese. The
study materials were presented in traditional Chinese characters.
Back-translation by independent bilingual research assistants
was adopted to translate the English scale items into
Chinese (Brislin & Freimanis, 2001). This study has received
prior approval from the Human Research Ethics Committee
for Non-clinical Faculties of the University of Hong Kong.
448 B. H.-P. LAU AND C. CHENG
Analytic strategy
The associations among gratitude, psychological resources,
coping strategies, and psychological distress were first examined
using bivariate correlations. Structural equation modelling
(SEM) was then used to explore the interrelationships
among gratitude, psychological resources, coping strategies,
and psychological distress. The model-data fit was assessed
by multiple indices (Hu & Bentler, 1999). Specifically, in the
light of the small sample size, an acceptable model-data fit is
indicated by failing to reject the null hypothesis of the x2
test
of exact fit, attaining a standardized root-mean-square residual
(SRMR) of less than 0.09, as well as a comparative fit index
(CFI) of over .95. Other relevant indicators including TLI and
RMSEA with cut-offs at .95 and .060 were also used. The
SEM was performed using MPlus Version 6 (Muthen &
Muthen, 1998À2011), whereas all other analyses were conducted
with SPSS Version 19.0.0.
Results
Table 2 provides the descriptive statistics and reliabilities of
gratitude, psychological resources, coping strategies, and psychological
distress.
Table 3 presents the intercorrelations among gratitude,
psychological resources, coping strategies, and psychological
distress. As expected, GQ and GAC were strongly associated
with each other. GAC was positively related to social support
and emotion-focused coping. GQ was associated with problem-focused
coping as well as emotion-focused coping. Both
types of psychological resources (social support and caregiving
competence) were related to emotion-focused coping,
caregiving burden, and depressive symptoms. Burden and
depressive symptoms were related to dysfunctional coping,
but neither emotion-focused nor problem-focused coping.
We also examined the more nuanced relationships
between gratitude and individual coping strategies. Both GQ
and GAC were related to the enhanced use of positive reframing
(GQ: r D .29, p D .004; GAC: r D .25, p D 012), acceptance
(GQ: r D .30, p D .002; GAC: r D .26, p D 010), humour (GQ: r D
.32, p D .001; GAC: r D .30, p D 003), religious coping (GQ: r D
.24, p D .014; GAC: r D .24, p D 017), and emotional social support
seeking (GQ: r D .28, p D .005; GAC: r D .29, p D 004),
which all belong to the emotion-focused coping subscale. GQ
was also associated with greater use of planning (r D .23, p D
.024).
In the light of the small sample size relative to the broad
repertoire of coping strategies examined in this study, we
included only the constituent items of emotion-focused coping
into the tested model, as emotion-focused coping was
the only subscale that had significant correlations with both
GQ and GAC. Figure 1 displays the SEM results. The modeldata
fit was sufficient (x2
(98) D 119.35, p D .0703, x2
/df D
1.19, CFI D .945, TLI D .933, RMSEA D .047, SRMR D .085).1
The x2
test result indicated a sufficient model fit. The model
also fulfilled the criteria of good fit as required by SRMR. However,
marginal model fit was indicated by the CFI. The direct
effects from gratitude to both coping resources and emotionfocused
coping, and that from psychological resources to psychological
distress, were significant.2
Although the indirect
effect via emotion-focused coping (b D ¡0.05, p D .491) and
psychological resources (b D ¡0.17, p D .070) were non-significant,
the combined indirect effects via both mediators
were significant (b D ¡0.22, p D .016).
Discussion
This study examined the role of gratitude on the coping process
among a group of Hong Kong familial caregivers of
PWDs. The results suggest that gratitude is positively associated
with a higher level of psychological resources, as well as
emotion-focused coping. In turn, psychological resources and
emotion-focused coping together mediated the relationship
of gratitude with psychological distress.
The levels of gratitude among our participants are comparable
to those of other samples. Taking GQ as an example,
McCullough et al. (2002) recorded a mean score of 5.92 and
standard deviation (SD) of 0.88 among an American college
student sample. In a Taiwanese study applying the Chinese
version of GQ to the study of married couples, the mean
score was 6.01 (SD D 0.85) for wives (mean age D 37.5) and
5.64 (SD D 0.93) for husbands (mean age D 40.1). With the
current mean score of 5.60 and SD of 1.03, we contend that
the levels of gratitude for caregivers in the current study were
Table 2. Descriptive statistics and reliabilities of gratitude, psychological resources,
coping strategies, and psychological distress (N D 101).
Variables M SD a
Gratitude
Grateful Adjective Scale 5.40 1.10 .79
Gratitude Questionnaire 5.60 1.03 .86
Psychological resources
Caregiving competence 1.78 0.73 .88
Social support 1.52 0.56 .85
Coping strategies
Active coping 2.95 0.79 .73
Planning 2.57 0.95 .78
Positive reframing 2.72 0.92 .64
Acceptance 3.10 0.72 .50
Humour 2.40 0.84 .43
Religious coping 1.93 1.05 .88
Emotional social support seeking 2.29 0.83 .80
Instrumental social support seeking 2.38 0.80 .81
Distraction 2.43 0.92 .72
Denial 1.10 0.28 .21
Venting 2.19 0.70 .71
Behavioural disengagement 1.35 0.59 .72
Self-blame 1.72 0.65 .73
Coping strategies subscales
Problem-focused coping 2.63 0.65 .78
Emotion-focused coping 2.46 0.53 .71
Dysfunctional coping 1.76 0.35 .60
Psychological distress
Caregiving burden 3.24 0.69 .82
Depressive symptoms 2.07 0.85 .90
Table 3. Correlations among gratitude, psychological resources, coping strategies
subscales and psychological distress (N D 101).
1. GQ 2. GAS 3. CC 4. SS 5. PFC 6. EFC 7. DC 8. ZB 9. DS
2. .70ÃÃ
3. .11 .17
4. .05 .21Ã
.31ÃÃ
5. .23Ã
.17 .18 .08
6. .47ÃÃ
.43ÃÃ
.24Ã
.25Ã
.42ÃÃ
7. .06 ¡.11 ¡.14 ¡.18 .01 .05
8. ¡.03 ¡.10 ¡.25Ã
¡.22Ã
.19 ¡.13 .37ÃÃ
9. ¡.12 ¡.17 ¡.29ÃÃ
¡.34ÃÃ
.15 ¡.16 .42ÃÃ
.67ÃÃ
Notes: GQ D Gratitude Questionnaire; GAS D Grateful Adjective Scale; CC D
caregiving competence; SS D social support; PFC D problem-focused coping;
EFC D emotion-focused coping; DC D dysfunctional coping; ZB D caregiving
burden; DS D depressive symptoms.
Ã
p < .05; ÃÃ
p < .01.
AGING & MENTAL HEALTH 449
comparable with those for samples from other studies. There
was a reasonable spread in responses in the present sample.
The robust association between gratitude and emotionfocused
coping aligned with previous findings from studies of
other populations (e.g., Lambert et al., 2009; Wood et al.,
2007). In contrary to the results of Wood et al., dysfunctional
coping was not related to gratitude in the present sample. A
point to note is that the samples in Wood et al. (2007) have
very different characteristics from the present sample (e.g.,
age). Also, the former evaluated coping strategies in the context
of everyday lives, whereas the present study focused on
coping for dementia caregiving. There is so far little research
on the relationships between gratitude and coping strategies
other than emotion-focused coping and social support seeking.
Therefore, we call for future studies to further explore the
associations of dysfunctional coping and grateful personality.
The present findings highlight the benefits of gratitude in
coping with dementia caregiving, and suggest that gratitude
may facilitate the experience of positive aspects of caregiving
(Peacock et al., 2010; Tarlow et al., 2004). A recent qualitative
study found that Hong Kong familial caregivers of PWDs
spontaneously experienced several positive aspects of caregiving
in their daily lives (Cheng et al., 2015). These positive
aspects are highly relevant to the adaptive coping strategies
and psychological resources that were found to be associated
with gratitude in the current study. First, this study revealed
that caregivers experience relief by reinterpreting the behavioural
symptoms of PWDs as a consequence of disease progression.
Caregivers also tended to use humour to reframe
their experienced hassles. The habit of emotion-focused coping
among grateful caregivers may help them adroitly adopt
these adaptive reinterpretations. Second, a sense of purpose
and commitment, as well as a sense of mastery and emotional
calmness prevailed among the spontaneous reports of
positive aspects of caregiving in Cheng et al.’s study. Frequent
experiences of gratitude may support the accumulation of
psychological resources such as caregiving competence,
sense of meaning, and positive affect (Fredrickson, 2004).
Thus, grateful caregivers may demonstrate greater emotional
adjustment to their role. Moreover, grateful caregivers may
establish caring and loving relationships with family members,
friends, and practitioners through appreciating their
kind help and professional assistance. Through reciprocating
the kindness of the benefactors, grateful caregivers may, in
turn, experience a greater sense of mastery from their caregiving
role too. As reported by Cheng and colleagues, caregivers
were exhilarated by knowing that their works were appreciated
by their relatives and friends, as well as that their shared
experience has been beneficial to other caregivers. The ability
to respond with gratitude to the gratitude of others (friends,
relatives, other caregivers) is imperative to experiencing these
elating moments.
In the light of these findings, we propose that gratitude
may be a personality antecedent for experiencing higher levels
of positive aspects of caregiving. Specifically, gratitude may
facilitate the accrual of psychological resources eliciting caregiving
gains, such as caregiving competence and social support.
Gratitude may also foster emotion-focused coping
needed for experiencing caregiving gains, including positive
reframing, emotional social support seeking, and religious coping.
Frequent experiences of positive aspects of caregiving
may enhance role adjustment demonstrated by experiencing
less caregiving burden and depressive symptoms. Although
the findings of the current study have supported the hypothesized
positive link of gratitude with emotion-focused coping,
psychological resources, and psychological distress, future studies
are encouraged to investigate the role of positive aspects of
caregiving in the association of gratitude with mental health.
Figure 1. SEM model (N D 98).
Notes: Standardized coefficients were shown. Residuals of indicators were not shown on the diagram. The loadings from residuals to indicators were set at 1. Significant
direct effects were denoted by bold arrows (p < .05). Non-significant direct effects were indicated by dotted arrows. GQ D Gratitude Questionnaire; GAS D
Grateful Adjectives Scale; CC D caregiving competence; SS D social support; RE1 D item 1 on positive reframing; RE2 D item 2 on positive reframing; AP 1 D item
1 on acceptance; AP2 D item 2 on acceptance; HU1 D item 1 on humour; HU2 D item 2 on humour; RC1 D item 1 on religious coping; RC2 D item 2 on
religious coping; ES1 D item 1 on emotional social support seeking; ES2 D item 2 on emotional social support seeking; ZB D caregiving burden; DS D depressive
symptoms.
450 B. H.-P. LAU AND C. CHENG
Understanding the role of malleable character strengths,
such as gratitude, in dementia, caregiving may also help shift
the focus of non-pharmacological caregiver interventions
from one that emphasizes risks and losses to one that
empowers and capitalizes on caregivers’ strengths and gains
(Peacock et al., 2010). The current findings suggest that gratitude
interventions could be particularly useful for improving
participants’ perception of psychological resources as well as
enabling them to adopt more emotion-focused coping strategies,
such as emotional social support seeking and positive
reframing. Gratitude interventions that commonly involve
regular journaling or reflecting on gratitude-worthy events
have been found to result in robust improvement in life satisfaction
and emotional well-being (Emmons & McCullough,
2003; Ho, Yeung, & Kwok, 2014; Seligman, Steen, Park, &
Peterson, 2005). Cheng, Lau, Mak, Ng, and Lam (2014) have
reported preliminary success in a benefit-finding intervention
with dementia caregivers. Gratitude intervention, which enables
caregiver to appreciate the origin of benefits in addition
to acknowledging the presence of benefits, may engender
even greater results in terms of social support and relationship
satisfaction. Nonetheless, studies on the effect of gratitude
intervention for alleviating the physical and
psychological strains of dementia caregiving are scant. Gratitude
intervention has been found to fit well in multi-component
positive psychological interventions for elderly (Killen &
Macaskill, 2015; Proyer, Gander, Wellenzohn, & Ruch, 2014).
Future studies may explore the benefits of gratitude intervention
in non-pharmacological programmes that aims at
enhancing subjective well-being for caregivers (Schulz, 2000).
The person-centred approach (Kitwood, 1997) describes
dementia caregiving as a meaningful and dignified relationship
between the caregiver and the PWD. A common misconception
about dementia caregiving is that the relationship is
a one-way drive involving the caregivers giving without the
care recipients reciprocating. Dementia often involves a long
journey of gradual deterioration. Although caregivers in
Cheng et al.’s (2015) study reported experiencing the gratitude
of their family members with dementia as an elating
moment, few studies have investigated how individuals of
limited mental capacity express the love and care for their
caregivers, and how caregivers perceive this altered form of
(but not necessarily diminished) reciprocity. A recent study by
Monin, Schulz, and Feeney (2014) showed that compassionate
love of the PWDs and caregivers were associated with less
caregiving burden and greater positive aspects of caregiving.
Although gratitude was not included in the analysis, it is conceivable
that the expression and feelings of gratitude of the
PWDs and the caregivers may facilitate the experience of
compassionate love for each other, which in turn foster caregiving
gains and well-being. Understanding the grateful experience
of both parties of the dyadic caregiving relationship
may help researchers and practitioners appreciate the nature
and motivation behind the onerous but meaningful caregiving
role.
This study possesses several limitations. First, the cross-sectional
nature of the data-set precluded causal inferences on
the relationships among gratitude, psychological resources,
coping strategies, and psychological distress. Second, the
modest sample size may have limited the statistical power of
the SEM analysis (Anderson & Gerbing, 1988; MacCallum,
Browne, & Sugawara, 1996). Third, because the coping strategies
and social support variables were collected through selfreport,
they may not necessarily indicate actual behavioural
options. Future studies are encouraged to adopt longitudinal
cross-lagged designs to delineate the directions of causal relationships
and employ experience sampling paradigms to capture
actual behavioural options of caregivers. Lastly, the
current sample was homogeneous in terms of ethnic background
and was relatively young. They were also recruited
from centres that established track records in dementiarelated
care. The generalizability of the findings to caregivers
who are older, of other demographic characteristics, and not
reachable by established dementia-related social services
awaits confirmation. Nonetheless, we acknowledge the utility
of using qualitative studies to examine how gratitude facilitates
adaptation to the caregiving role, especially among
older caregivers who may have difficulties articulating their
experiences by quantitative measures.
Conclusion
This study examined the role of gratitude on the coping process
of caregivers of PWDs. The results demonstrate that gratitude
is related to higher levels of psychological resources as
well as emotion-focused coping. In turn, psychological resources
and emotion-focused coping mediated the relationship of
gratitude with lessening psychological distress. These findings
may provide empirical foundation for incorporating gratitude
into non-pharmacological interventions for caregivers of
PWDs. They may also facilitate researchers and practitioners
to appreciate the role of character strengths in the caregiving
process.
Acknowledgements
This study was supported by the HKU COA JMK Dementia Care Scholarship
awarded to the first author. The authors thank Prof. Terry Lum and
Dr Karen Cheung for their suggestions on the design of the study,
Mr Bobby Leung and Ms Iris Cheng for their assistance on data collection
and data preparation and the nine participating non-governmental
organizations (Baptist Oi Kwan Social Service, Hong Kong Alzheimer’s
Disease Association, Sik Sik Yuen, St. James Settlement, The Hong Kong
Society for Rehabilitation, The Salvation Army-Hong Kong and Macau
Command, The Evangel Lutheran Church of Hong Kong, Yan Chai Hospital
Social Service Department and Yan Oi Tong) for their efforts in recruiting
participants.
Disclosure statement
No potential conflict of interest was reported by the authors.
Notes
1. The SEM model was conducted on 98 participants. Two missing
responses were found on a positive reframing item, with another
missing response found on an emotional social support seeking
item.
2. The pattern of significant effects remained the same after controlling
for activities of daily living and problem behaviours of PWDs,
caregiver gender, caregiver age, caregiver’s religious affiliation, and
number of years of dementia diagnosis. Significant effects were
found for the association between gratitude and emotion-focused
coping, between gratitude and psychological resources, and
between psychological resources and psychological distress.
AGING & MENTAL HEALTH 451
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