Writing therapy is known for promoting self-exposure, which leads to improved psychosocial well-being and physical functioning (Meshberg-Cohen et al., 2014; Meston et al., 2013; Travagin et al., 2015). The most common writing intervention is expressive writing, with numerous studies examining its effectiveness (Pennebaker, 2013; Travagin et al., 2015). Although expressive writing interventions initially focused on writing about thoughts and emotions related to traumatic experiences (Pennebaker, 2013), many researchers have modified expressive writing for use in diverse contexts and populations (Smyth et al., 2018). In particular, writing interventions based on self-regulation focus on positive aspects of a person's life or positive experiences. Self-regulation processes explain how people manage their emotional states and have taken many forms, such as writing about one's best possible self (BPS) or gratitude (Nazarian & Smyth, 2013; Reiter & Wilz, 2015; Suhr et al., 2017). Journaling about one's BPS or gratitude has resulted in improved mood, less severe depressive symptoms, higher mental and physical well-being, and more functional coping (Boehm et al., 2011; Lomas et al., 2014; O'Connell et al., 2017; Peters et al., 2013; Wong et al., 2018).
BPS writing is based on a self-regulation process that involves developing goals for and visualizing a best possible future self (Meevissen et al., 2011). The BPS intervention has its origins in the experimental findings that expressive writing about traumatic events can have beneficial effects for some individuals (Loveday et al., 2018). Writing about one's BPS (i.e., a narrative of one's goals) has shown the same long-term health benefits as writing about a trauma, but has been linked to increased satisfaction with life, positive affect, optimism, and overall well-being (Boehm et al., 2011; Peters et al., 2013). Layous et al. (2013) examined the effects of BPS writing once per week for 4 weeks in an experiment of 131 undergraduate students, finding that a BPS activity significantly boosted positive emotions and flow, and marginally increased a sense of relatedness. These researchers assigned participants to complete the BPS activities either online or in-person and found that there were no significant differences between these two randomly assigned groups (Layous et al., 2013). Recently, Heekerens and Heinitz (2019) randomized 128 undergraduate students to perform either the BPS intervention or a daily control activity to explain the effectiveness of the BPS intervention and found that the BPS intervention effectively increased thriving.
The mental health benefits of gratitude intervention have been well reported. O'Leary and Dockray (2015) examined the efficacy of a gratitude diary and grateful reflection intervention (four times per week for 3 weeks) and found that outcome variables of depression, stress, and happiness improved over time among participating women. Killen and Macaskill (2015) implemented a 2-week “three good things in life” gratitude intervention in 88 healthy adults age ≥60 years. Researchers reported that the intervention yielded significant differences in eudemonic well-being as measured by flourishing at three different times (baseline to Day 15 that was maintained at Day 45) (Killen & Macaskill, 2015). A cross-sectional study conducted among 86 male and 30 female police officers reported that participants who felt more grateful and practiced gratitude journaling were found to have higher life satisfaction and be emotionally stronger than others (McCanlies et al., 2018). Gratitude writing was also found to be effective with clinical samples receiving mental health treatment (Kerr et al., 2015; Wong et al., 2018).
The purpose of the current study was to determine if journaling focused on BPS and gratitude could improve physiological and psychosocial outcomes (i.e., emotional well-being and mental health) in a sample of affected parents who have teenagers or adult children with emotional and/or behavioral problems. The hypotheses were:
BPS and gratitude groups will exhibit decreases in blood pressure and cortisol levels after 6 weeks of diary writing.
BPS and gratitude groups will demonstrate improved emotional well-being (i.e., life satisfaction and gratitude) and mental health (i.e., decreased depression, anxiety, and somatic symptoms) after 6 weeks of diary writing.
A quasi-experimental design was used to examine changes in emotional well-being and mental health between pretest and posttest. Saliva samples and blood pressure were collected three times (baseline, after first journal entry, and after 6-week writing intervention). Saliva samples were collected using passive drool, a recommended method that is cost effective and approved for use with approximately all analytes. Salivary cortisol is frequently used as a biomarker of psychological stress and commonly used as a proxy measure for the hypothalamus–pituitary–adrenal axis (Hulett et al., 2018). Participants were instructed to refrain from eating food or drinking caffeinated beverages for 1 hour prior to saliva collection, and time periods of the final saliva collection were scheduled so collection did not differ more than 2 hours (pretest ± 2 hours) for each individual. Saliva samples were frozen at −20°C until assayed by an expert technician at the university's biobehavioral laboratory.
A convenience sample of 42 parents of teenagers or adult children with emotional and/or behavioral problems was recruited in the southeastern United States. A power analysis using the Gpower computer program indicated a sample of 34 was needed to detect large effects (d = 0.5) with 80% power using a paired t test between means of the pretest and posttest, with alpha at 0.05 (2-tailed).
A demographic questionnaire included data on age, race, residence, marital status, education, and living arrangement. Emotional well-being was assessed using the Satisfaction With Life Scale (SWLS) and Gratitude Questionnaire (GQ-6). A SWLS score is the total of the five items, ranging in score from 1 (strongly disagree) to 7 (stronglyagree). Scores are summed to evaluate an individual's life satisfaction, with higher scores indicating greater satisfaction (Cronbach's alpha = 0.86). A score of 30 to 35 indicates highly satisfied, 25 to 29 indicates things are mostly good, 20 to 24 indicates generally satisfied, 15 to 19 indicates slightly below average life satisfaction, 10 to 14 indicates dissatisfied, and 5 to 9 indicates extremely dissatisfied (Diener et al., 1985). The GQ-6 has six items, ranging in score from 1 (strongly disagree) to 7 (strongly agree), and a total score is the sum of item scores (Cronbach's alpha = 0.78). To calculate a total score, the scores for questions 1, 2, 4, and 5 are summed and then added to the values for questions 3 and 6, which are reverse scored. Higher scores reflect more gratitude and positive emotions, such as hope and optimism (McCullough et al., 2002).
Stress level was measured using the Perceived Stress Scale (PSS) to assess the degree participants believed their lives to be stressful in the past 1 month. The PSS is a 10-item, self-reported questionnaire with a 5-point Likert scale (0 = never to 4 = very often) that measures how often participants experienced a certain emotion based on a prompt (e.g., How often have you felt nervous and stressed?) (Cronbach's alpha = 0.77). Scores range from 0 to 40, with 0 measured as no stress, 1 to 13 as low stress, 14 to 26 as moderate stress, and 27 to 40 as high perceived stress (Cohen et al., 1983; Lee, 2012).
Mental health was assessed using the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and PHQ-15 to detect depression, anxiety, and somatization, respectively (Kroenke et al., 2010). The PHQ-9 can be used as a continuous measure with cut points of 5, 10, 15, and 20 representing mild, moderate, moderatelysevere, or severe levels of depressive symptoms, respectively. It has shown high internal consistency (Cronbach's alpha = 0.86 to 0.89). The GAD-7 was used as a screener for panic, social anxiety, and posttraumatic stress disorder, with cut points of 5, 10, and 15 representing mild, moderate, or severe levels of anxiety symptoms, respectively (Cronbach's alpha = 0.92). The PHQ-15 measures symptoms that account for >90% of those seen in primary care, such as pain, headache, and dizziness. Scores range from 0 to 30, with cut points of 5, 10, and 15 representing mild, moderate, or severe somatic symptom severity, respectively (Cronbach's alpha = 0.80) (Kroenke et al., 2010).
Perception of writing intervention was measured using two items from the modified version of the Credibility/Expectancy Questionnaire (CEQ) (Devilly & Borkovec, 2000). For the current study, the wording of the two CEQ items was modified slightly to assess participant perception of effectiveness about a journal writing intervention.
The study was approved by the university Institutional Review Board. All participants read and signed an informed consent. All potential participants were asked to complete the pre-test and posttest instruments at a local community healing center or university office. The pretest/posttest questionnaires were anonymous; participants were linked by a unique identification number.
Pretest. After participants completed the demographic data questionnaire, SWLS, GQ-6, PSS, PHQ-9, GAD-7, and PHQ-15, the investigator assessed blood pressure and collected saliva cortisol (passive drool). After saliva collection, participants were randomly assigned to either a BPS or gratitude writing (GW) group; however, three participants were allowed to choose a preferred group after random assignment to retain them in the program and accommodate their preference. The GW group had 22 (52.4%) participants and the BPS group had 20 (47.6%) participants. Participants were instructed to make a first journal entry (approximately 15 to 20 minutes). After participants completed the onsite journal entry, blood pressure and saliva were taken a second time.
In-Home Writing Intervention: A 6-Week Guided Journal. Participants were given a journal along with weekly writing instructions and prompts (approximately 15 to 20 minutes for each entry) and asked to make entries at least three times per week for 6 weeks. Each week had a domain with writing prompts (Week 1–family life; Week 2–health; Week 3–career and finances; Week 4–relationships; Week 5–hobbies; and Week 6–social life). Participants in the BPS group were asked to write about their best possible future self for each weekly domain. At the conclusion of the writing, participants were asked to extract the two most important qualities for each domain and formulate these as statements of future achievement (i.e., In the future I will be…). Participants in the GW group were instructed to focus on positive aspects of their lives and think of all the things for which they were grateful. They were asked to identify the three to five most important things they were grateful for in each domain and write statements beginning “I am grateful for….” The confidential journals were kept by participants.
Posttest. Participants returned to the data collection site after 6 weeks. Participants completed all posttest instruments and the investigator measured final blood pressure and collected saliva samples.
Paired t tests measured differences in outcome variables between pretest and posttest. t tests compared differences in mean scores of the outcome variables between the GW group and BPS group. Additional bivariate analyses of continuous variables were calculated using a Pearson correlation coefficient. Repeated measures analysis of variance (ANOVA) analyzed differences in blood pressure and cortisol level at three points in time. Due to the small homogenous sample, no attempt was made to adjust measures by demographic factors or other baseline measures. All analyses were performed using SPSS version 23.
The pretest sample comprised 42 parents. Of these parents, five were excluded from analysis because they either did not complete the posttest (n = 4) or stopped journal writing after Week 3 (n = 1). The age range of the final 37 parents was 37 to 71 years (mean age = 55.34, SD = 8.25). Most participants were mothers (n = 35, 94.6%), White (n = 33, 89.2%), and highly educated (n = 32 baccalaureate degree or higher, 86.5%). A majority were married (n = 28, 75.7%) and living with a spouse or partner (n = 17, 45.9%) and family members (n = 12, 32.4%). Participants identified as Protestant (n = 16, 43.2%), Catholic (n = 9, 24.3%), or other religion or atheist (n = 12, 32.4%).
Of 37 parents, 10 (27%) parents had teenagers and 27 (73%) had adult children. Twenty (54.1%) parents reported their children had emotional and/or behavioral problems and 17 (45.9%) parents reported their children had a problem with substance use. The most frequently reported emotional and/or behavioral problems in children were depression, anxiety, attention-deficit/hyperactivity disorder or attention deficit, and deviant behaviors, as well as high-risk sexual and health behaviors, including suicidal attempts. The substances used were alcohol, marijuana, opioids, heroin, cocaine/crack, and methamphetamine.
Frequencies of Journaling
Before the study, a majority of participants rarely or never made journal entries (n = 24, 64.9%); some participants journaled a few times per month (n = 4, 10.8%), once per week (n = 1, 2.7%), daily (n = 6, 16.2%), and more than once per day (n = 2, 5.4%).
Of an initial sample of 42 parents, 20 participants completed a GW journal and 17 completed a BPS journal. Participants made journal entries an average of 15 times over a 6-week period (mean = 15.43, range = 5 to 36, SD = 6.89). The GW group made an average of 16.5 journal entries, and the BPS group averaged 14.2; however, there was no significant difference in the number of journal entries between groups. Pearson correlations indicated no significant associations between number of journal entries and all psychosocial outcome variables.
At baseline, perceived stress level in participants was moderately high (mean = 16.71). Participants rated their mental health as fairly good. As shown in Table 1, the score of life satisfaction was relatively high (mean = 24.57), with a moderately high level of gratitude (mean = 33.49). The depression mean was 4.67 of the total PHQ-9, suggesting a mild level of depressive symptoms. The anxiety mean of the total GAD-7 was 4.47, indicating mild anxiety. The mean of the total PHQ-15 was 7.37, suggesting mild to moderate somatic symptom severity.
Baseline Measures of Emotional Well-Being, Stress, and Mental Health Variables
Except for somatic symptoms and life satisfaction, there were no statistical differences between the BPS and GW groups at baseline. Although perceived life satisfaction (SWLS) was higher among the GW group than the BPS group (p = 0.014), somatic symptoms (PHQ-15) were higher among the BPS group (p = 0.009). There were no differences in blood pressure and cortisol level between groups (Table 2).
Baseline Data of Best Possible Self (BPS) and Gratitude Groups
Changes in Physiological and Psychosocial Outcomes
Hypothesis 1: Blood Pressure and Cortisol. As shown in Table 3, systolic and diastolic blood pressure in both groups were in normal range. Repeated measures ANOVA indicated statistically significant mean changes in systolic blood pressure at three points in time (p = 0.016). Post hoc tests using a Bonferroni correction revealed a decrease in systolic blood pressure from the first journal entry to after the 6-week intervention (p = 0.021). Although not statistically significant, systolic blood pressure at 6 weeks showed a slight reduction in the BPS group (from 120 mmHg to 115.7 mmHg) and GW group (from 118.5 mmHg to 113.1 mmHg).
Blood Pressure and Cortisol Levels in Best Personal Self (BPS) and Gratitude Writing Groups
The results did not produce statistically significant mean changes in all participants for diastolic blood pressure. However, the GW group showed a statistically significant reduction from the first journal entry to after the 6-week intervention (p = 0.004). Specifically, the post-intervention diastolic blood pressure reduced to 72.84 mmHg, which was significantly different from baseline (p = 0.01) and after the first journal entry (p = 0.024).
The cortisol levels taken at three times were in normal ranges (0.108 [SD = 0.137] µg/dL vs. 0.144 [SD = 0.138] µg/dL vs. 0.092 [SD = 0.057] µg/dL). Although the cortisol level increased after the first writing, and decreased after 6 weeks in both groups, repeated measures ANOVA indicated the mean cortisol level did not significantly differ between time points for either group (Table 3).
Hypothesis 2: Changes in Emotional Well-Being and Mental Health. Paired t tests indicated statistically significant decreases in stress level (p < 0.001), anxiety (p < 0.001), somatic symptoms (p = 0.001), and depression (p = 0.01), as well as increased gratitude (p = 0.012) among participants. In the BPS group, in particular, there were statistically significant decreases in stress (p < 0.001), depression (p = 0.04), anxiety (p = 0.045), and somatic symptoms (p = 0.011), as well as increases in life satisfaction (p = 0.004) and gratitude (p = 0.009) after completing the writing intervention. In the GW group, there were statistically significant decreases in anxiety (p = 0.001) and somatic symptoms (p = 0.029) (Table 4).
Mean Differences of Mental Health Outcome: Pretest and Posttest
Perception of Journaling
Participants highly valued their journal writing experience. Using a 9-point scale, participants rated the writing intervention on two questions: (1) How useful do you think the writing journal would be for managing stress? (mean score = 7.92; 1 = not at all useful to 9 = very useful); and (2) At this point, how much do you really feel that the writing intervention helped you to improve your mood and alleviate your level of stress? (mean score = 7.43; 1 = not at all helpful to 9 = very much). There were no significantly different perceptions between the BPS and GW groups. The mean scores for the two questions for the BPS group were 7.88 and 7.29, respectively; and the mean scores for the GW group were 7.95 and 7.55, respectively.
The current study examined the effectiveness of a 6-week positive writing intervention on measures of blood pressure, cortisol levels, emotional well-being, and mental health for affected parents of troubled children. Baseline data of the current study found overall mental health scores (depression, anxiety, somatic symptoms) and emotional well-being (life satisfaction and gratitude) of participants to be relatively good, suggesting an ability to manage their parental stress. This finding may be due to the use of a small homogenous, highly educated sample.
Participants made an average of 15 entries over a 6-week period. Findings indicated no statistical correlations between the number of journal entries and psychosocial outcome variables. Pennebaker (2013) concluded writing expressively once per week for 1 month is likely to be most effective at creating improvements in physical and psychological health. Further research is needed to determine the effective number of journal entries to improve emotional health.
The first hypothesis was that the positive writing intervention would reduce blood pressure and cortisol levels. Repeated measures ANOVA indicated the 6-week writing intervention significantly reduced systolic blood pressure (p = 0.016); however, there was no significant change in diastolic blood pressure. Although the GW group had a significant reduction in diastolic blood pressure (p = 0.004), the BPS group did not. Cortisol level did not significantly differ between time points for both groups, but it was interesting that the cortisol level was increased after the first writing in both groups. These findings suggest a first journal entry may serve as a stressor while participants tried to follow the instructions of writing on positive aspects of life. Based on a previous literature review, Kirschbaum and Hellhammer (1989) reported cortisol levels typically peak approximately 20 to 30 minutes after introduction of a stressor. As reported, the investigator collected the second saliva sample immediately after the first writing was completed at the first visit. Therefore, a one-time writing intervention may not be effective.
The second hypothesis was that the positive writing intervention would improve emotional well-being and mental health outcomes. Previous research reported a positive writing intervention promoted increases in satisfaction with life, optimism, happiness, and overall well-being, and reduced stress and depression (Boehm et al., 2011; O'Leary, & Dockray, 2015; Peters et al., 2013). Overall, findings of the current study support the hypothesis that a 6-week journaling intervention reduces stress levels, somatic symptoms, anxiety, and depression in participants. In particular, the BPS group demonstrated more favorable outcomes (e.g., increases in life satisfaction and gratitude, and decreases in stress, depression, anxiety, and somatic symptoms) compared to the GW group (e.g., decreases in anxiety and somatic symptoms). This finding may be due to different characteristics of the groups in the baseline data. For example, the GW group had lower scores on the PHQ-15 (somatic symptoms) (p = 0.009). In addition, because of these characteristics and limited statistical power due to the small sample size, it is presumptive to suggest BPS journaling is more effective than GW journaling. However, these findings may suggest the efficacy of BPS writing. Peters et al. (2013) compared the effects of a 1-week BPS and GW intervention on life satisfaction and optimism in university students. They reported the BPS intervention was more effective for increased life satisfaction and optimism than GW. Dickens (2017) conducted a meta-analysis of 56 studies on gratitude intervention and concluded GW can lead to improved mental health outcomes, including happiness, but the benefits may be overemphasized. Malouff and Schutte (2017), who conducted a meta-analysis of 29 studies on diverse optimism interventions, reported BPS studies showed a significant effect, suggesting optimism-intervention researchers might wisely use a brief in-person BPS intervention, at least when seeking short-term effects.
The current research also explored the perceived benefit from parents' perspectives that writing interventions may be beneficial to manage stress in this population. The two-item analysis indicated participants considered journal writing highly useful to manage stress and believed writing improved mood and alleviated stress. Given the high rating of these items, the findings suggest journal writing is a practical means for stress management. Considering few resources are available for affected parents, diary writing could be used as a positive coping intervention for this population. Writing journal entries can be done anytime, anywhere, privately, without anyone knowing (Alexander et al., 2016).
The current study had several limitations. First, the study drew from a small homogenous sample, limiting general-izability. The sample was mainly highly educated White individuals. Further studies with larger samples with diverse educational and ethnic backgrounds are needed. Boehm et al. (2011) reported Anglo American individuals with the experiment conditions (i.e., expressing optimism, conveying gratitude) demonstrated larger increases in life satisfaction relative to Asian American individuals, whereas both cultural groups in the control condition (listing past experiences) showed the least improvement. Due to the homogeneous sample characteristics, the study did not control demographic extraneous variables. Future research needs to determine the effectiveness of writing intervention for large heterogeneous samples. In addition, the effectiveness of the writing intervention may have been caused, in part, by the self-selection of parents who participated in the intervention. Parents who chose to engage in the writing intervention may have been more proactive in efforts to cope with stressors. In addition, the study included only two fathers of troubled children. Studies involving more fathers would understand whether these findings generalize to men.
The small sample size yielded limited statistical power results. Although the current sample size was adequate to detect large effects (d = 0.5) with 80% power for a paired t test, it was not sufficient to detect mean differences for a group comparison. For example, 128 participants would be needed for the same large effect size (d = 0.5) to obtain statistical power at the recommended 0.80 level for a t test (Cohen, 1988). Therefore, the current study sample (N = 37) may have limited the significance of statistical comparisons between groups.
Finally, the timing of cortisol collection may have been a limitation. Cortisol levels fluctuate according to the time of day or night. The diurnal cortisol rhythm portrays lowest concentrations at night, slowly rising over pre-awakening hours, sharply rising to a peak 30 to 45 minutes after waking, known as the cortisol awakening response (CAR) (Stalder et al., 2018). Many saliva samples were collected between 9 a.m. and 11 a.m. near CAR. Dickerson and Kemeny (2004) reported cortisol collected after 12 p.m. had more consistent readings compared to cortisol collected before 12 p.m., suggesting cortisol levels are more stable in the afternoon. Ideally, the time of the saliva collection should have been the same for all participants, but this was not possible, although pretests/posttests were planned in a 2-hour block for each individual to reduce diurnal cycle influence.
The results of the study bear important implications for nurses who work in the community. Although preliminary, overall, the current research supports positive journal writing interventions to improve psychological health for parents who have teenagers or adult children with emotional and/or behavioral problems. The BPS and GW journals can be used to promote emotional well-being for affected parents without cost or burden. Considering limited resources are available for supporting family members in communities, nurses could recommend writing interventions to clients as a self-care tool for mental health, as well as stress management. The potential of using writing for patients is a valuable tool for nurses working in all areas of health care, as it is an accessible tool that may be incorporated into the treatment of patients across all racial, gender, ethnic, and socioeconomic classes. In addition, because there were no differences in online and paper delivery of the writing intervention, with many preferring online delivery (Killen & Macaskill, 2015), practitioners can make this intervention easily accessible by linking it to their practice websites.
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Baseline Measures of Emotional Well-Being, Stress, and Mental Health Variables
|Outcome Variable||Instrument||Total Items||Scale (Total Score Range)||Cronbach's Alphaa||Total Score (Mean, SD, Range)|
|Life satisfaction||SWLS||5||7-point (5 to 35)||0.86||24.57 (5.46) (7 to 32)|
|Gratitude||GQ-6||6||7-point (6 to 42)||0.59||33.49 (2.98) (28 to 41)|
|Stress||PSS||10||5-point (0 to 40)||0.76||16.71 (4.64) (9 to 30)|
|Depressive symptoms||PHQ-9||9||4-point (0 to 27)||0.81||4.67 (3.55) (0 to 17)|
|Anxiety||GAD-7||7||4-point (0 to 21)||0.79||4.47 (3.01) (0 to 10)|
|Somatic symptoms||PHQ-15||15||3-point (0 to 30)||0.94||7.37 (3.5) (0 to 14)|
Baseline Data of Best Possible Self (BPS) and Gratitude Groups
|Variable||Mean (SD)||t test|
|Instrument||BPS (n = 17)||Gratitude (n = 20)||p Value|
|Life satisfaction||SWLS||22.24 (6.2)||26.55 (3.89)||0.014*|
|Gratitude||GQ-6||33.53 (3.06)||33.45 (2.98)||0.94|
|Stress||PSS||17.8 (5.25)||15.9 (4.08)||0.24|
|Depressive symptoms||PHQ-9||5.94 (4.19)||3.65 (2.62)||0.053|
|Anxiety||GAD-7||4.75 (3.1)||4.25 (2.99)||0.627|
|Somatic symptoms||PHQ-15||9.14 (2.38)||6 (3.66)||0.009**|
|Blood pressure (mmHg)a|
| Systolic||120.01 (3.53)||118.47 (15.59)||0.912|
| Diastolic||78.08 (5.18)||77.37 (8.23)||0.952|
|Cortisol (μg/dL)||0.091 (0.082)||0.124 (0.173)||0.526|
Blood Pressure and Cortisol Levels in Best Personal Self (BPS) and Gratitude Writing Groups
|Measure||Mean (SD)||F||p Value|
|Baseline||After First Journal Entry||After 6 Weeks|
|Blood pressure (mmHg)|
| All||119.18 (14.58)||118.09 (15.12)||114.26 (14.76)||[1.586, 52.334] = 5.009||0.016*|
| BPS||120.01 (3.53)||119.93 (4.22)||115.73 (3.7)||[1.613, 22.58] = 1.646||0.217|
| Gratitude||118.47 (15.59)||116.63 (14.35)||113.11 (15.36)||[1.539, 27.703] = 3,585||0.052|
| All||77.68 (14.41)||80.21 (9.04)||76.26 (9.4)||[1.532, 50.556] = 2.307||0.065|
| BPS||78.08 (5.18)||82.6 (2.42)||80.60 (2.3)||[1.215, 17.012] = 0.745||0.051|
| Gratitude||77.37 (8.23)||78.32 (2.42)||72.84 (8.51)||[1.560, 28.083] = 7.707||0.004**|
| All||0.108 (0.137)||0.144 (0.138)||0.092 (0.057)||[1.197, 41.911] = 3.621||0.094|
| BPS||0.091 (0.082)||0.115 (0.082)||0.091 (0.072)||[1.375, 22] = 1.043||0.343|
| Gratitude||0.124 (0.173)||0.171 (0.171)||0.093 (0.082)||[1.134, 20.414] = 2.695||0.13|
Mean Differences of Mental Health Outcome: Pretest and Posttest
|Measure||Total (N = 37)||BPS (n = 17)||Gratitude (n = 20)|
|Pretest||Posttest||p Value||Pretest||Posttest||p Value||Pretest||Posttest||p Value|
|SWLS||24.67 (5.5)||26.08 (6.09)||0.134||22.24 (6.2)||25.29 (6.29)||0.004**||26.84 (3.76)||26.79 (5.98)||0.972|
|GQ-6||33.58 (2.96)||34.89 (1.65)||0.012*||33.53 (3.06)||34.88 (1.62)||0.009**||33.63 (2.95)||34.89 (1.73)||0.081|
|PSS||16.91 (4.71)||13.18 (5.33)||<0.001**||18.07 (5.34)||11.36 (6.59)||<0.001**||15.84 (4.32)||14.53 (3.82)||0.153|
|PHQ-9||4.51 (3.48)||2.89 (2.37)||0.01*||5.94 (4.19)||3.44 (2.78)||0.04*||3.32 (2.21)||2.42 (1.92)||0.122|
|GAD-7||4.33 (3.02)||2 (2.45)||<0.001**||4.87 (3.18)||2.8 (3.1)||0.045*||3.89 (2.89)||1.33 (1.68)||0.001**|
|PHQ-15||7.29 (3.52)||4.81 (3.73)||0.001**||9.14 (2.38)||5.64 (4.25)||0.011*||5.76 (3.63)||4.12 (3.22)||0.029*|