9 Gift-of-life? The Psychosocial Experiences ... 229would evoke much gratitude, and for some this was the case: they spoke
of dialysis as a privilege, and were mindful of the many others, often
unknown, who had acted in ways that benefitted them. Focusing on
dialysis as a benefit that in different circumstances they might not have
received, they expressed much gratitude in relation to their access to
dialysis, the effects of the treatment on their health, the healthcare pro-
viders who delivered dialysis and those who supported them through it.
These participants tended also to acknowledge, but not dwell on, the
restrictions and impositions of dialysis. Lisa, for example, reported a
number of seriously debilitating conditions, and treatments for these,
before being diagnosed with kidney failure. She then had a sad and
unfortunate experience of transplantation; she received a kidney from
her brother but ‘it died’ a short time later. Although she spoke of the
difficulties she experienced in dealing with the loss of her kidney trans-
plant, Lisa went on to say that in some ways she considered herself
‘fortunate because at least with a kidney transplant you can get a sec-
ond go. Heart transplants and so forth, you’re not necessarily as lucky’.
Unprompted, Lisa spoke of some of the positive aspects of her trans-
plant experience and there was a sense that she sought a silver lining in
all that had occurred. When asked if there was anything in her life that
she was thankful or grateful for, she responded without hesitation: ‘At
the moment, I just say: “thank God I’m alive”’. Lisa went on to outline
a number of things for which she was grateful (e.g. her brother donating
a kidney to her, being able to go on the waitlist for a second transplant,
the ‘massive amount of support’ she received from friends) and made
several comparisons with those who were not in similar circumstances.
The comparisons Lisa made with others she considered to be less for-
tunate than herself represent downward counterfactuals, where focus is
placed on how the situation could be worse (e.g. she could have been
a heart recipient, and unable to ‘get a second go’ at transplant; or she
could be as ill as some of the people she saw at work, who were una-
ble to do the things she could do). This focus elicits an appreciation for
life and what one has (i.e. tangible and intangible assets) that is typical
of the grateful (Wood et al. 2008 ). Research has indicated that down-
ward counterfactuals play a powerful role in the activation of grati-
tude (Teigen and Jensen 2011 ), as gratitude, by virtue of its definition,
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