I let my therapist know via email or I might verbally tell her how much I appreciate her.. but it's difficult in person depending on what I want to say. About two years ago while visiting Cape Cod I took a really picturesque photo of a lone seagull near some dunes on the beach.. I printed it and put it in a nice frame and gave it to her. I struggled before giving it to her because I didn't know if she would be receptive to a gift from a client. I left it in the kitchen area with her name on the package. She emailed me and thanked me for it, I was so happy! Another time I made her some black beans and yellow rice. She loved it! The thing is, I don't do these things all of the time, just every so often.