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Many consumers ask us if it's OK to write a complimentary letter or give their psychiatrist a photo or present for Christmas with a thank you card.

People's diffidence arises for two reasons. Firstly, many of us are confused about the idea of boundaries and what this does or doesn't allow us to do.

Secondly, letters of thanks are rare in psychiatry - psychiatry is not obstetrics; both clinicians and consumers are much more used to complaints than they are compliments, especially in the public sector.


The issue of 'boundaries' presents a confusing dilemma for many consumers. The theory is straightforward enough: clinicians have an obligation to manage the therapeutic relationship in such a way that their patients/clients will remain emotionally and physically safe. They are required to manage all interactions to keep an emotional and physical line between themselves and us.

In reality, though, in some situations the relationship does become (and needs to become) quite intimate. The problem is, without due diligence these intimate relationships can turn into the wrong type of intimate relationship which will hurt us more than anything else and ruin any therapeutic value.

On the other hand, many consumers believe that 'boundaries' are often used by clinicians to control people, or as an excuse for poor communication.

Just as some clinicians seem all over the place in how they define appropriate 'boundaries', consumers' need for closeness and distance also vary enormously.

In private psychiatry these confusions can be worked through over time but in the come-and-go world of public psychiatry this is rarely a possibility. The most likely scenario is that consumers are being told that they need to keep proper boundaries without ever knowing what this means.

Saying thank you for the receipt of good practice is not in and of itself too intimate in relation to 'appropriate' consumer/clinician relations. However, some clinicians providing some sorts of therapeutic interventions will not accept anything and will refuse our gestures of kindness. These will probably only be clinicians working with a particular form of psychotherapy/psychoanalysis.

If you are concerned about what the reaction to an act of gratitude might be, maybe ask them first.

A shortlist of what it is OK to do (and not so OK)

Constructing a written message

In most instances, it's best if your words of thanks are expressed on a card. For one thing, it stops us from slipping into 'overdoing it' mode!

The exception to this rule is where you are writing to a unit manager or some other person where you want to reinforce good practice. In these cases, it can be useful to include dot points of all the things that you found to be good. (It is OK in such a letter to include a couple of practices that could be improved so long as the positive largely outweighs the negative.)

Because consumer-clinician relationships can be one-sided, power-based, tricky, and in some ways unknown, it's best to keep your words short, meaningful, individualised and genuine. Try to maintain your status as a 'patient'.

A couple of words of warning: in all cards and letters, we must be vigilant about confidentiality, especially third-party confidentiality. And keep a copy of all correspondence, just to be safe.