The Unacknowledged Thank You. Many years ago, when I was still a beginning therapist in the hospital, feeling like a very small cog in a very big wheel, I worked with a little girl I'll call N. N was extremely familiar with the hospital, having "recovered" from a life-threatening illness only to endure recurrent long-term hospitalizations for the ongoing, irreversibly damaging side effects inflicted by the original treatment. At first, I intensely disliked N. Her voice was whiney, her face scarred, her body misshapen, and her behavior ungrateful and dismissive. After years of being in "the system," N and her mother knew everyone, in every relevant department. If one physician or nurse said No, they would work their way up the chain until they got to someone who would give them a Yes, in writing. Then, only then, would they praise that person up the wazoo, while cursing all the rest.
Many of our school staff members worked with N throughout her hospitalizations, and I myself worked with her over a period of seven years. At first her artwork was perseverative, lacking creativity and originality. She stuck with variations of the same image, drawing it over and over, in different media, sizes, and colors, but always sticking with the one theme she knew and loved and could trust to stay consistent in her rocky world. Even as N grew, reached majority and was transferred to the adults' unit, we continued our regular art sessions, until slowly, she began to branch out and blossom. She began asking me to teach her new art techniques. She requested additional images to study and work from, until reaching a point where she rarely returned to her earlier, repetitive theme. She began to feel better physically, and worked feverishly through an endless list of staff members and friends for whom she prepared thoughtful gifts in the form of her own original artwork.
All the while, N tended to express her wishes to me in the form of commands, with the please added on as an afterthought, an external politeness she was taught would work to get her what she wanted. Bring me this, Get me that, Maybe you could buy such-and-such a kind of [very expensive] paint? On occasion, she did remember to say thank you. Despite this, I grew to feel close to her and appreciate many of her positive characteristics, and and I looked forward to our sessions.
Throughout the years, N was the beneficiary of many expensive and scarce medical treatments that the hospital went out of its way to provide. On the last day of her hospital stay (after which she was released to live at home and continue her treatment as an outpatient) the hospital staff held a party for her, during which she and her mother distributed cards and gifts to every last medical staff member and social worker in the room.
At the time I felt it ironic and insulting that among all her acknowledgements, there was no mention whatsoever of me, who was present at the party, nor of any of the many additional school staff members who had accompanied N throughout all those years. Nothing. Not even a thank you.
At first I didn't know how to interpret her behavior. I thought, Could she really have forgotten all of our time together, all the work she had done, and how much meaning it held for her? Did she really think it was of that little value?
Then I stopped to think. As a form of closure, I went over my session notes. I talked to colleagues. I did some research on the psychological implications of showing, or not showing, appreciation within the therapeutic relationship. All of this helped me make sense of N's behavior. N and her mother, were simultaneously furious at, and indebted to, the medical establishment, whose original treatment had "caused" her handicaps, and whose later treatment had, at least partially, redeemed her from them. This family had always made their way through the system by showing people genuine gratitude, contaminated by their feelings of anger at the system which was responsible for all of this in the first place.*
N's involvement with the hospital school, on the other hand, was a perk, an option, a factor she did not associate directly with her medical condition or its treatment. By extension, it remained an element of her hospital stay for which she could choose to show appreciation, or not. We were one body within the hospital to whom N did not owe the debt of her life. In that light, I now understood just what our role was. We were the only form of hospital "treatment" she could like or dislike, thank or not thank, accept or reject. And she had chosen, for all that, to accept us. What bigger thanks could we ask for?
Keep the balance,
* I do not mean to suggest malpractice on the part of the hospital. The side effects that afflicted N were the unfair and unpreventable results of the life-saving treatment she received for an illness she suffered as a young girl.