The Appreciation Matrix

“By the way, thanks.”

It was a crumb, but I savored it.

Over an irregular and protracted course of physical therapy treatment, most sessions had begun with “My pain isn’t any better,” consisted of complex re-evaluation and treatment all the time fielding skeptical questions like “do you really think this will help?” and ending with more questions about unrelated and vague orthopedic issues “so why do you think my pelvis feels shifted when I walk”.  Over the months we had worked together, I had come to recognize that I often felt fatigued after these sessions and I chalked it up to the mental work of the case and the flat affect of my client. These sessions had been hard. She rarely smiled. I often didn’t know if I was helping. And then I received a simple thank you, delivered with a stone face.

Later a wave of gratitude would come in an email, sharing how I made a huge difference in her life, and how much more I had helped than all the other people she had seen. Reading this I was taken aback, having thought all along that I she kept seeing me more out of desperation than out of any appreciation of my services.

Meanwhile other sessions bubbled with gratitude from all sides, as we both appreciated the significant progress made by our efforts. But the amount of gratitude I received from a client, wasn’t always proportional to the progress. Sometimes I was baffled as to why people were thanking me at all. I wasn’t even sure I had done anything to help them. Other times I saw incredible progress but somehow my client failed to appreciate it.

From the time when I first started seeing patients as physical therapist. I recognized some cases were much harder than others. But they could be hard for different reasons. A pleasant person with a difficult problem was always more rewarding to work with than a difficult person with a simple problem. It wasn’t until years later, when I started my own practice and branched out into wellness training and nutrition, that I began to recognize that I gratitude from my clients was a major part of what fueled me.

Along my journey from a physical therapist focused only on injury, to a holistic wellness health cares provider, I discovered a whole body of research on the relationship between well-being and gratitude. Not only doing grateful people report a greater sense of well being, and recover from injury faster, but acts of gratitude such a writing a thank you letter improve well being, even if the letter is never sent [1,2].

After reading this research, I began to make a more conscious effort to express gratitude in my daily life. But the word gratitude felt both inprecise and constrained. It led me to ask the question, grateful to whom? There are many things such as a clear blue sky that I appreciated but had no specific person to thank. I found the word appreciation better describes what was so critical to feeling fulfilled in my work and personal life. My clients can appreciate the progress they have made by working with me without specifically being grateful to me and I still find that quite satisfying. This contemplation led me to form a 2×2 matrix of appreciation in the professional/client relationship. Where appreciation refers to a appreciation of the overall value of the relationship consisting of a combination of appreciation of the value of the services themselves as well as the value of the progress achieved through those services.

The most satisfying relationships are ones that fall in the top right corner. These are the sessions I most look forward to, even when the outcome is uncertain and the case is challenging.

The bottom left corner are the tough ones, I don’t know if i am helping or they are getting better and they don’t either. Several sessions in the corner and the relationship becomes fragile and it is sometimes best to suggest seeking another provider.

In the bottom right corner are those clients who are highly appreciative even when its not clear to me I did much for them. Working with these clients feels great, but can be intellectually less stimulating as I know that whatever I do they will appreciate it and be satisfied with the outcome.

In the top left corner are those cases where I know I won’t receive much appreciation from my client but I can appreciate the progress. In these situations I focus on the results for my source of satisfaction but never give up trying to get my client to appreciate their progress. This corner also includes those clients who don’t directly show appreciation such as very young children and my clients with severe dementia.

I work hard to get results with all my clients, even in the rare cases where they don’t see or appreciate the progress. I used to believe it was those results that made me stand out from other providers, particularly when I was able to help someone improve their health in a way other providers had not. But now I believe that it is my clients appreciation of those results that has built my reputation, and my appreciation of those results  that keeps me so engaged in my work. I know that whether any individual client gives me a lot or a little thanks for my efforts, my own ability to find things to appreciate in the interaction enhances my well being and ultimately makes me a better practitioner.

Besides simply thanking my clients, I now more actively search for things I appreciate in my interaction with them. This goes beyond appreciating their progress towards their goals to appreciating their efforts, intentions and the relationship itself. I am grateful to my clients who seek me out as a partner to improve their health by overcoming an injury, increasing their fitness, improving their nutrition or all the above. I hope you have appreciated reading this article as much as I have writing it. And finally, to all my past, present and future clients, Thank You.



Bryan Ausinheiler PT,DPT,CSCS,OCS,FNS



  1. 2010 Wood, Froh, & Geraghty. Gratitude and well-being: a review and theoretical integration. Clin Psychol Rev.
  2. 2012 Toepfer & Cichy. Letters of Gratitude: Further Evidence for Author Benefits. Journal of Happiness Studies



2 thoughts on “The Appreciation Matrix

  1. This is so insightful and SO true for me as well. I realize now that my last job left me on in the bottom half of your matrix; no wonder I was burned out. Thank you for taking the time to think about this and for thoughtfully creating a visual aid. I appreciate your brain. 🙂

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