I’ve lost count of the times I’ve been described as ‘reasonably well-kempt’ by a psychiatrist. This probably has more to do with my slightly scruffy but socially acceptable personal style than with my mental health. But all patients who have read clinic letters about themselves will recognise this psychiatric preoccupation with appearance.

"Why use words like ‘denies’ or ‘claims’ in relation to what a patient says?"

Mental health clinic letters are written by a health professional to the patient’s GP, and since 2004 the Department of Health has recommended that patients receive a copy of this correspondence if they wish, although in practice this doesn’t always happen. Their level of detail varies, but their basic function is to provide the professional’s assessment of the patient, a working or firm diagnosis, and the treatment plan. Frequently, however, they come over as plain character assassination. Value judgements about a patient are concealed within medical or psychological argot, insignificant details are recorded without explanation, and inaccuracies, misinterpretations and distortions are abundant. I’m often left wondering if they’re describing the same appointment I attended.

Promoting the patient's perspective

The DearGP hashtag was born out of these frustrations. One woman tweeted how their recent clinic letter had stated ‘has no hair’. She questioned the value of this information to her or her GP, both of whom are, of course, fully aware of the hair situation. In the ensuing discussion, people began writing satirical letters to their GPs, describing their mental health professionals in the style of a clinical evaluation. The original poster began her own with ‘Thank you for referring me to this meticulously dressed young doctor. He was average build, with hair.’

Women in particular are used to their hair and clothing being taken as indicative of their mental state. A woman with make-up and smart clothes couldn’t possibly be depressed — ignoring the fact that women are socialised to present this way, no matter how they feel. Similarly, a woman who changes her hairstyle must’ve had a corresponding change in mental state — she can’t have just decided it’s time for an update. And if she changes her hair too often? A sure sign of mental illness. Of course being unable to care for yourself can be an important part of the picture, but context and the patient’s perspective is notably absent. For example, a person who’s spent a month unwashed might have managed to get themselves together for one day, but this is not recorded.

Another recurring theme in these letters is premature and inaccurate diagnosis, particularly of controversial diagnoses like borderline personality disorder, often considered a ‘dustbin diagnosis’ (a term used for vague, catch-all, usually pejorative classifications). Patients often discover these hurriedly-applied diagnoses only when they have been committed to paper and sent to their GP to be entered into their general medical record. One Dear GP letter diagnoses BPD (Bad Psychiatrist Disorder) due to the doctor's poor communication and lack of empathy. Other common complaints of mental health professionals have been their ‘reluctance to engage’ on certain topics, inappropriate prescribing of medication, and ‘mind reading’ — assigning a motivation or a belief to a person without factual basis.

The hashtag has also highlighted problems with clinical language and letter-writing more broadly. The language is often dehumanising, and the mental health professional’s own subjective analysis is privileged over anything the patient might say. Why use words like ‘denies’ or ‘claims’ in relation to what a patient says? Is it any surprise that ‘eye contact was poor’ if you failed to build a rapport? Perhaps you mistook a genuine concern for an ‘overvalued belief’? How much time is lost on ‘compulsive information-seeking’, and how much of it is important to the person in front of you? The letters ask professionals to re-examine their perceptions and use of language, while hopefully making you laugh along the way. ‘We need to laugh and then get angry at this’ is how one Twitter user responded.

#DearGP has highlighted some of our worst encounters with mental health services, and it has been cathartic to write about and share these experiences. It has revealed a community that is tired of having these letters drop through the door to insult us in our own homes, while also becoming the official record of How Things Really Happened. The power dynamics in clinical relationships are rarely recognised, and it isn’t often they can be subverted in this way — returning the medical gaze back to the professional.

A group of us are collecting these letters for a zine, in the hope of extending the solidarity we have found on Twitter to others offline who know this experience so well. And of course we hope some copies will make their way to the desks, and consciousness, of the mental health professionals who routinely write these documents with such profound consequences.

Find us: @Dear_GP on Twitter