Ethics, Cultural and Standard of Care Considerations
By Ofer Zur, Ph.D.
An Online Course: Gifts in Psychotherapy: Ethical and Clinical Considerations
Table Of Contents
Giving a gift is an ancient and universal way to express, among other things, gratitude, appreciation, altruism and love (Saad & Gill, 2003). Gifts have been defined as “something that is bestowed voluntarily and without compensation” (Dictionary.com, 2005). Anthropologists and psychologists have viewed gift behavior as a product of an interaction between psychological mechanisms and the environment (Toby and Cosmides, 1992).
Even though most therapists have regularly received gifts from clients (Borys & Pope, 1989; Grohol, 2010; Knox, et. al., 2009; Pope, Keith-Spiegel, & Tabachnick, 1986), the phenomenon of gifts in therapy has received minimal attention in the theoretical literature (Knox, 2008; Knox, et. al., 2003; Kritzberg, 1980, Spandler, et. al., 2000). Therapists have been reluctant to openly talk about it for fear of being accused of some sort of boundary violation or exploitation of clients (Lazarus & Zur, 2002; Zur, 2007, 2015, 2017). For the same reason many therapists are even less willing to discuss the gifts they give to clients. In the beginning of the 21st century there seem to be growing willingness to discuss issues of gifts in a more complex and less dogmatic ways (Barnett & Barteck, 2009; Brendel, et. al., 2007; Zur, 2007). The intention of this paper is to generate an open discussion of gift-giving among both therapists and clients; describe the various types of gifts given in therapy; articulate the clinical and ethical issues that relate to gift-giving (Newsome, 2015, Zur, 2012, 2015); emphasize the cultural and other context related factors effecting gift-giving; and finally, to provide psychotherapists with basic guidelines for dealing with gifts in psychotherapy.
Besides the question of whether therapists should accept or give gifts, psychotherapists have long debated the relative value of appropriate gifts from clients as simple and genuine expressions of gratitude. This debate has also been concerned with the meaning of the gifts and the potential benefit of interpretation or exploration of the meaning (Furman, 2014a; Grohol, 2010; Hahn, 1998; Knox, et. al., 2003; Knox, et. al., 2009; Kritzberg, 1980; Spandler, et. al., 2000; Zur 2015). Regardless of the variations in opinion about how to respond to gifts, there is agreement that the giving of a gift in therapy is an important event in the therapist-client relationship and should be handled thoughtfully and clinically appropriately (Corey, Corey, Callahan, 2003; Ladouceur, 2013; Spandler, et. al., 2000; Zur, 2007, 2012, 2017). Many if not most authors seem to agree that a gift in psychotherapy requires the therapist to express genuine appreciation and gratitude and, when appropriate, to also explore the meaning and conscious or unconscious intent of the gift with the client (Knox, et. al. 2003; Spandler, et. al., 2000). Hopefully, such exploration can be carried out without causing the client to feel rejected or insulted (Hahb, 1998). An additional challenge for the therapist is how to appropriately respond when presented with gifts that are inappropriate, ill-timed, excessive or very expensive. This paper asserts that both gratitude and exploration of the meaning of the gift, when appropriate, can be employed. The exploration of the meaning of a gift must be carried out only when relevant, potentially helpful and is not likely to shame or cause the client to feel rejected. On the most basic level gift-giving and the reciprocal appreciation of the gifts can enhance the therapeutic alliance. Beyond the expression of gratitude, exploring the meaning, intentions or patterns of the client’s gift-giving in psychotherapy can also enhance the clinical work and therapeutic outcome, especially when carried out with sensitivity and flexibility.
Gifts to Therapists and Clients
There are several types of gifts that are common in psychotherapy. Gifts can be given by therapists or clients. They can be symbolic (i.e., a poem) or concrete (i.e., a book) and they can be modest – homemade cookies or bread, a music CD, flowers, homegrown fruits or a framed picture – or more extravagant items, such as opera or baseball season tickets, or even truly excessive items like a piano, a car or a large sum of money (Knox, et. al., 2003). Gifts can be appropriate or inappropriate in their type, monetary value, timing, content, frequency, intent of the giver, perception of the receiver and their effect on the giver, receiver or anyone else that may be touched by the gift-giving (Knox, et. al., 2003; Spandler, et. al., 2003). Even small gifts can be inappropriate if, for example, they include violent or sexual or romantic themes (Koocher & Keth-Speigle, 1998). Smolar (2003) takes the concept of gift-giving in therapy further and describes several additional categories of therapists’ gifts to clients: the gift of a transitional object; the gift of self-disclosure; the gift of (extra) time; the gift of physical touch; and the gift of presence. Some scholars describe an overlap between gifts, favors and bartering and view most gifts as a form of unspoken quid pro quo (Gabbard & Nadelson, 1995). At times, especially in child therapy, therapists may be given gifts by the clients’ parents or other family members.
Sample Meds and Gifts by Pharmaceutical Companies
Another type of gift in psychotherapy is that made by a third party, most commonly by the pharmaceutical industry, as part of their multibillion dollar annual marketing efforts (Zur, 2007). Historically, primarily psychiatrists have been inundated by such gifts, but as psychologists start gaining prescription privileges, the drug companies have increasingly targeted them. These gifts can be anything from pens and note pads, sample medications, free dinners and season tickets, all the way to free exotic golf vacations combined with free continuing education seminars. Psychiatry has demonstrated some of the pitfalls associated with the powerful influence and financial resources of pharmaceutical marketing. The literature suggests that prescribing behavior is influenced by exposure to such marketing practices, even by small and seemingly insignificant gifts (Reist & VandeCreek, 2004). This type of gift-giving has raised numerous ethical and professional concerns regarding conflict of interest and how these gifts impact physicians’ professional integrity (Polster, 2001; Zur, 2007).
Gifts for Referrals
Gifts made in response to referrals of new clients have also been frowned upon and viewed as unethical conduct and a conflict of interest that should be avoided. The concern with such gifts, especially if they are of significant monetary value or are made on an ongoing basis, is that they are part of an implicit business relationship which creates a conflict of interest (Zur, 2007). It is basically a kickback, which has been deemed unethical and even illegal in many similar situations. These kinds of gifts that are likely to create indebtedness and conflict of interest for professionals have been recognized as a potentially problematic area by federal and state bodies and numerous organizations. Correspondingly, it has been addressed in federal and state laws, as well as in the by-laws and regulations of various organizations and corporations (i.e., Duke Energy’s, 2004). Many solutions for these concerns seem to focus on limiting the value of the gifts (i.e., below $50) and on the requirement for disclosures. A further discussion of these two types of gifts is beyond the scope of this chapter.
Gifts and Boundaries
Boundary issues mostly refer to the therapist’s self-disclosure, touch, bartering and fees, length and location of sessions, contact outside the office and to the exchange of gifts between therapists and clients (Guthiel & Gabbard, 1998). Boundary crossing in psychotherapy is an elusive term. A boundary, according to Gutheil and Gabbard (1993), is the “edge” of appropriate behavior. Lazarus and Zur (2002) define boundary crossing as any deviation from traditional analytic and risk management practices, i.e., the strict, ‘only in the office,’ emotionally distant forms of therapy. Appropriate gift-giving, by either clients or therapists, falls under the definition of boundary crossing.
While most analysts, ethicists, attorneys and “experts” may use a broad brush in describing boundary issues (Epstein, Simon & Kay, 1992; Simon, 1991; Strasburger, Jorgenson, Sutherland, 1992), it is important to differentiate between harmful boundary violations and helpful boundary crossings (Williams, 1997). A boundary violation occurs when a therapist crosses the line of decency and integrity and misuses his/her power to exploit and/or harm a client for the therapist’s own benefit (Guthiel & Gabbard, 1998; Lazarus & Zur, 2007, 2012). Boundary violations usually involve exploitive business or sexual relationships. Boundary violations are always unethical and are likely to be illegal. However, boundary crossings, such as appropriate gift-giving, non-sexual touch or self-disclosure are often part of an appropriate and healthy therapist-client relationship and, as such, can increase therapeutic effectiveness (Zur, 2004). Inappropriate gifts, such as very expensive gifts or sexually suggestive gifts (i.e., pornographic images, condoms, dozen red roses), are clearly boundary violations. Dual relationships involve the therapist in relationships that are additional to the therapeutic one. However, most common gift-giving by clients or therapists does not involve dual relationships.
Maintaining clear and firm boundaries is highly important in the analytic tradition (Simon, 1991). Such firm boundaries often include avoidance of any boundary crossing including accepting or giving gifts to clients. When it comes to gifts, the general traditional analytic rule is that clients’ gifts must be analyzed rather than received. Practitioners of traditional analysis are likely to view therapists who accept gifts as interfering in the transference analysis by acting out and gratifying an unconscious impulse (Audet & Everall, 2010; Bader, 1996; Bursten, 1959; Hahn, 1998; Kritzberg, 1980; Silber, 1969; Simon, 1991; Stein, 1965; Talan, 1989).
Unlike the analytic tradition, humanistic psychology and feminist therapy have emphasized the importance of congruent relationships between therapists and clients, which are often enhanced by giving and receiving gifts (Williams, 1997, 2003). Behavioral, cognitive, cognitive behavioral, family and group therapies are likely to support any boundary crossing, including appropriate gift-giving, if they are likely to enhance therapeutic effectiveness (Lazarus & Zur, 2002; Spandler, et. al., 2000; Zur, 2007).
Accepting, Rejecting and Hesitating
Even though there is some hesitation to discuss gifts openly, most psychotherapists view it neither as ethically problematic nor mind accepting gifts of small value, such as home baked cookies or bread, books or CDs or a potted plant (Borys & Pope, 1989; Knox, et. al., 2009; Newsome, 2015; Pope, Keith-Spiegel, & Tabachnick, 1986; Pope, Tabachnick, Keith-Spiegel, 1987; Reidbord, 2010; Shelton, 2016). Small and symbolic gifts from clients during the holiday season, at termination, after a particularly difficult emotional challenge or from young children have been the most common and largely uncontroversial types of gifts (Borys, 1992; Borys & Pope 1989). This level of acceptance of small gifts has also been reported among forensic professionals (M.D., PH.D., MSW, MA) by Gerson and Fox (1999). Generally, small and symbolic gifts have been viewed as enhancing the therapeutic alliance and are tied to positive clinical outcomes (Brendel, et. al., 2007; Corey, Corey, Callahan, 2003; Hahn, 1998; Spandler, et. al., 2000; Zur, 2004, 2007, 2015, 2017).
Most clinicians and ethicists also agree that rejecting appropriate gifts of small monetary value but of highly symbolic and relational value can be offensive to clients, cause clients to feel rejected and thus is detrimental to the therapeutic alliance and the therapeutic process (Geric, 2014; Knox, et. al., 2003; Spandler, et. al., 2000). Massoth, a member of the American Psychological Association Ethics Committee, reported in the Monitor of Psychology that “. . . psychologists may do more harm than good if they refuse a reasonable gift” (Bailey, 2004, p.62). In contrast, excessive gift-giving and clients’ gifts of high monetary value, insider stock market tips or gifts given as financial loans by clients have, understandably, been a concern for many therapists, ethicists and licensing boards (Corey, Corey, Callahan, 2003; Lazarus & Zur, 2002, William, 1997). There are also instances where even a very small and inexpensive gift, such as a nude calendar or condom, constitutes an inappropriate gift (Koocher & Keth-Speigle, 1998). Similarly, gifts with racist, sexist, pornographic, violent, sexually suggestive or any other offensive or bigoted themes, regardless of their monetary value, have been seen as inappropriate and unethical.
Gift as ‘buying’ love
A further concern is whether a client’s gift-giving is an attempt to influence or manipulate the therapist or is an effort to “buy” love. Many of our clients seek therapy because they do not feel appreciated, loved or cared for. Many others feel generally undeserving and have low self-esteem. One way that people who feel unworthy and not lovable can try to increase the chance of the therapist liking them is through gift-giving. These clients often repeat such patterns with their lovers, friends, teachers, supervisors or employers. It is the therapists’ challenge to identify patterns such as “buying love through gifts” and, when and if appropriate, to bring it to the client’s attention in a constructive manner, which will cause neither embarrassment nor any sense of rejection (Knox, et. al., 2003; Knox, et. al., 2009; Spandler, et. al., 2000). Rather than going along and uncritically accepting these gifts in such situations, therapists should use it as “grist for the therapeutic mill.” Gabbard and Nadelson (1995) caution that gifts are often an unspoken quid pro quo. They believe that “there is no free lunch,” and they encourage therapists to look for the tacit obligation that gifts may impose. Similarly, Spandler, et. al. (2000) invite therapists to look at the potential meaning of gifts, including concerns with power, hostility and erotic connotations.
Refusing Clients’ Gifts
A therapist’s hesitation, uneasiness or refusal to accept appropriate gifts can be experienced as rejection, an experience that many clients are already familiar with. Refusing a gift without attempting to understand the client’s subjective reason for giving the gift is, at the minimum, a lost clinical opportunity. Hahn (1998) adds, “Gift acceptance without some attempt to understand its meaning from the patient’s perspective may bypass an opportunity to illuminate the patient’s subjective experience” (p. 85).
Some therapists choose to include a “no gift policy” in their office policies (Corey, Corey, Callahan, 2003). Such procedures may be ethically and legally appropriate, but from a clinical point of view it does not resolve concern with the negative impact that rejecting a gift may have on a client (Welfel, 2002; Zur, 2007, 2012). At times, therapists may chose to accept small gifts that seem to try to buy their love in order not to shame or insult clients or to avoid causing a sense of rejection. Nonetheless, while they may accept such gifts, they must find a way to deal with the maladaptive gift-giving behaviors therapeutically. In this kind of situation Hahn (1998) suggests that they may say, “I will keep the gift for now, but I’m not going to do anything with it until we have a chance to understand what it might be about” (p. 84). Spanler, et. al. (2000) also support the option of “holding” the gift for the time being rather than immediately rejecting, accepting or interpreting. This approach is not likely to cause any feeling of rejection in the client and at the same time does not miss the opportunity to explore the clinical concerns regarding the client’s gift-giving patterns.
Gifts in Context
Each gift must be evaluated within the context that it is given. The nature of the therapeutic relationship, the setting, the client’s culture, history and presenting problem are some of the factors that determine the appropriateness of the gift (Barnett & Barteck, 2009; Brendel, et. al., 2008; Brown & Trangsrud; Hahn, 1998, Spandler, et. al., 2000). Besides gifts during the holidays and at termination, accepting a book, audiotape, CD, card or poem that has special meaning to a client is common and acceptable. A baker may bring a loaf of bread to each session and a farmer may do the same with some produce. A vet may offer a rescued puppy to a dog loving therapist and a winemaker may give a case of his or her own prime wine during the holidays. Similarly, artist clients often share their appreciation through gifts of their art. This may include a painting, sculpture, woven blanket, handmade candle, small wooden bench, a carved gourd, a lampshade or a poem. Many rural or ethnic settings often readily embrace gift-giving as a common expression of connection and gratitude (Shapiro & Ginzberg, 2002; Zur, 2006, 2007). As long as the gifts are neither overly expensive nor excessive or ill-timed, they are likely to enhance the therapeutic alliance and the clinical outcome. Over interpretation or needless discussion of the meaning of such naturally flowing gifts can be harming or insulting.
Gifts as Expression of Negative Feelings
Psychoanalytic literature has emphasized the possibility that gift giving can also be a way of acting out or a way to express negative feelings (Bader, 1996; Hahn, 1998; Knox, et. al., 2003; Kritzberg, 1980; Spandler, et. al. 2000). Such gifts are often given right after difficult sessions, when disagreements between therapists and clients arise or when clients feel slighted by the therapists. Such negative feeling should be explored in a clinically appropriate way.
Expensive Gifts and Wealthy Clients
Therapists who are offered gifts of cash, valuable stock tips, vacation homes or financial loans should not accept them regardless of how wealthy the client. The fact that very expensive gifts are not a financial burden for wealthy clients is not a good enough reason to accept such gifts. Such gifts are likely to impair therapists’ objectivity and interfere with their clinical judgment (Zur, 2007). Instead of accepting these often tempting gifts, therapists must find ways to discuss their professional concerns with clients and make clear that such gifts make them uncomfortable. Nor should therapists be tempted to uncritically accept less valuable, but still expensive gifts, such as theatre or baseball season tickets or a weekend at a patient’s vacation home, without discussing the meaning of the gifts with their clients and seeking consultation in regard to their potential interference in the therapeutic process. If clients insist on giving very expensive gifts, therapists, with the help of consultation, may come to creative arrangements with clients, such as making an anonymous donation to a mutually agreed upon charity.
Therapists must take into consideration that wealthy clients are most often aware, consciously or unconsciously, of the significant impact of their wealth on other people. They often know from first hand experience how power, influence and social desirability go hand in hand with wealth (Needleman, 1991). Giving presents has different meanings for wealthy people than ordinary people because people often have certain expectations, hopes or fantasies of what rich people can do for them. Gabbard & Nadelson (1995) articulated how giving expensive gifts can also be a way to manipulate and control. Gift giving by wealthy clients is complex, as inexpensive gifts can be seen as miserly or even disrespectful and expensive gifts can be viewed as controlling or inappropriate. As a result, wealthy clients and therapists are in a difficult bind when it comes to gifts. Awareness and, when appropriate, discussion of these concerns is of extreme importance and may be the only way to untangle these complicated webs. Additionally, due to the power of money in our culture and people’s expectations and projections upon the wealthy, the wealthy often develop a generalized distrust of others (Goldbart & DiFuria, 2002). The meaning and impact of money vis-à-vis wealthy people is often an important clinical issue that can be brought to the surface where it may generate discussion of the meaning of money in general, their wealth in particular and, when appropriate, their gift-giving. While many wealthy people may deny the importance of money and its effect on their lives, gift-giving can provide a precious opportunity for investigating such issues.
Some clients have attempted to give therapists financial or investment tips. Most licensing boards and ethics committees, because of the concern that therapists may use their influence on their clients to obtain such information, have frowned upon these kinds of gifts (Zur, 2007). Another concern is the fact that the monetary value of such gifts cannot be calculated. When such investment tips include inside information about a certain company stock, the matter becomes even more complicated due to the fact that it may be illegal and, therefore, a crime to give or receive inside information, as was recently illuminated by the Martha Stewart case.
Bequests, Inheritance and Wills
Gifts that are made through bequests also present complications that must be handled with care. If the gift is made while the patient is still alive, a lengthy discussion of the potential implication of such a gift should be carried out. Once the patient is dead it is too easy for relatives to claim undue influence. At this point the therapist may, unfortunately, need to respond to civil malpractice lawsuits or to licensing board complaints initiated by the heirs. Without the patient to set the record straight, the therapist is extremely vulnerable. In a case where the therapist’s identity was not known to the relative(s), confidentiality issues become highly relevant, which complicates the matter further and increases the therapist’s vulnerability significantly. An option that has been proposed (Harris, 2004) is that, if possible, therapists may suggest to the client to anonymously donate the money that was willed to the therapist to a charity that they both support. If the client is already dead and the therapist is surprised by the gift, he/she, if appropriate, can still consider the anonymous donation option.
Impact on others
When receiving a gift from a client, a therapist must also take into consideration its potential effect on other people in the client’s life (Zur, 2007). A precious family heirloom may have sentimental value for a client’s family members and accepting such a gift may cause stress and ill-feeling towards the client and the therapist. As was noted above, leaving the therapist large sums of money in one’s will may also result in negative feelings by the client’s family members. Similarly, expensive gifts may not only be unethical and clinically ill advised, they may also affect the client’s spouse or other family members.
Timing of the gifts has also been considered an important factor in determining the meaning and appropriateness of gifts (Corey, Corey, Callahan, 2003; Hahn, 1998). Most commonly, inexpensive gifts at holiday times and at termination have been deemed appropriate. A gift given by a client very early in therapy, after a difficult, confrontational or missed session, may require a further discussion with the client. Expensive gifts given on the way to the door at the last session or after termination have also been reported as presenting therapists with ethical and clinical quandaries (Koocher & Keith-Spiegel, 1998).
Besides the clinical-psychological aspects, gift-giving in psychotherapy must always be considered within its cultural context. More often than not, the meaning of gift-giving behavior derived from specific cultures can only be understood within this cultural context (Barnett & Barteck, 2009; Brendel, et. al., 2008; Brown & Trangsrud; Corey, Corey, Callahan, 2003; Koocher & Keth-Speigle, 1998; Trimble, 2002). Regardless of the therapist’s clinical or ethical stance on the subject of gifts, s/he must be aware that turning down a small gift may mean rejection or disrespect to an individual who comes from a culture which stresses hospitality, reciprocity or the importance of gift-giving rituals (Barnett & Bivings, 2003; Nathan, 1994; Spandler, et. al., 2000). A standard, pre-existing “no gift policy” is often meaningless and does not mitigate the sense of insult or humiliation for a non-Western client whose culture emphasizes the significance of gift-giving.
While in many Western cultures the verbal expression of gratitude seems appropriate and sufficient, in many non-Western cultures actual gifts and attendant rituals are the primary means of expressing gratitude, affirmation and an emotional bond (Otnes & Beltramini, 1996). In order for a therapist to successfully work with a client from a non-Western culture it is necessary to comprehend the specific meaning of the gift ritual for the culture in question (Saad & Gill, 2003). The wise therapist will learn about each client’s culture and their gift-giving traditions also, if possible, from the clients themselves.
In the Indian, Cambodian and many other Far Eastern cultures, there is greater focus on the meaning and rituals of gift-giving. In some of these cultures the gift is not given to the person but to the spirit in the person. In others of that region the gifts are perceived to be able to cure ailments or mental illness if the gifts appease the spirit of the ancestors carried by the sick person. According to this tradition, if the gift is not given, the sickness may return (Refugee Mental Health In The United States, 2004). Japanese, Indian and many other cultures have generally very proscribed rituals regarding what should be given, when, to whom and how. American Indian clients may give their therapist tobacco when asking for healing or, consistent with the rituals of giving gifts to healers, they may give some other kind of gift at the very first session (American Indian Mental Health Advisory Council, 2004). Similarly, Jewish clients have been known to give Jewish cooking books as a way to share a hearty custom with their therapists (Spandler, et. al., 2000).
In summary, therapists must be sensitive to different cultures’ gift-giving customs and rituals. Therapists’ ignorance of these cultural elements may very likely be perceived by such clients as disrespectful which, in turn, may interfere with developing trusting and helping therapeutic relationships. Rejecting or returning a present, regardless of the reasons, can be easily seen as a personal insult and personal rejection and is likely to result in a serious rupture in the therapeutic relationship. Employing protocols or guidelines, such as a “no gifts rule” and providing interpretation around gifts can easily interfere with the therapeutic alliance with non-Western clients. Cultural sensitivity, respect and knowledge of the culture’s gift-giving customs should be considered carefully and acknowledged openly.
Therapists’ gifts to clients has been given even less attention than clients’ gifts to therapists. Therapists’ gifts, like clients’, vary widely. They may include a symbolic gift (i.e., a Tarot card or a greeting card or small painting with an image that has meaning to the client, a gift that serves as a transitional object (i.e., a stone from the office rock-collection that the client can carry in his pocket or her purse affirming the connection with the therapist between sessions), a clinical aid (i.e., a note from the therapist with a specific phrase or mantra to help a client dealing with anxiety) or therapy-related educational material (i.e., a book, audiotape or CD on mood swings for a bi-polar patient or an educational brochure on stepfamilies for a newly wed couple) (Zur, 2007). The therapist may choose to follow social convention by giving gifts of affirmation or acknowledgment (i.e., a small graduation or wedding gift, flowers or a card to a hospitalized patient or a card for a grieving patient), a supportive, reassuring gift (i.e., giving a flashlight to a child-patient who is going on his first overnight camping trip) or gift of affirming the relationships (i.e., a souvenir from a trip abroad). Some other types of therapists’ gifts that have been reported are medication samples, a quarter for a parking meter (Koocher & Keth-Speigle, 1998) or sharing a lunch with a client or a ride to a nearby bus stop on a rainy day (Lazarus, 1994).
The question of therapists’ gifts has been minimally explored since Freud struggled with it early in his career. According to Blanton (1971), when Freud realized that one of his clients was planning to buy a set of his complete works, he gave it to the client as a gift. Immediately following the gift-giving, Freud noticed that the patient’s dreams seemed to be “drying up” and ever since, traditional analysis has held to the belief that gifts interfere with the natural course of analysis.
While analytically oriented therapists are likely to be concerned with the clinical effect of therapists’ gift-giving on the analytic process (Langs, 1974, Simon, 1991, Talan, 1989), there is wide agreement among most other therapists that following social conventions and giving appropriate small gifts for weddings or confirmations or giving gifts for clinical reasons is an acceptable practice (Corey, Corey, Callahan, 2003; Gutheil & Gabbard, 1993). As in any clinical intervention, therapists are cautioned to be aware of their own motives when giving the gift and to be especially careful that the gifts are not attempts to get the client to like the therapist or to avoid conflict. Gabbard (1994) wonders if a patient is truly free to express negative feelings following the receipt of a gift from the therapist. Therapists must also take into consideration that their clients, or those who are close to the clients, may misinterpret their gifts.
Supplying clients with medication samples is a very common practice among medicating psychiatrists, and there are authors (i.e., Gutheil & Gabbard, 1993) who put it in the category of therapists’ gifts to clients. Giving medication samples can amount to a very expensive gift if it involves expensive medication and is carried out over a long period of time. In fact it can amount to thousands of dollars’ worth of medication. The concern with medication samples is twofold. The potential conflict of interest in regard to the medicating psychiatrist’s relationships to the pharmaceutical companies and the clients are on ethically and even clinically problematic area (Polster, 2001; Reist & VandeCreek, 2004). The second concern is that besides gratitude, clients may feel indebtedness towards the therapist who provides them with such often expensive medications gratis. Because medications are important and can be very expensive, it is likely to increase the probability that clients feel they owe the therapists more than the agreed fee. Such concerns are hopefully addressed in therapy to reduce interference in the therapeutic process.
Despite the prevalent belief to the contrary, there are no code of ethics or guidelines of major organizations that specifically ban gifts in therapy (Zur, 2007, 2016). Except for the AAMFT, ACA and NAADAC Codes of Ethics, neither the major US professional organizations’ (i.e., APA, ApA, CAMFT, Feminist, NASW, NBCC), nor Canadian (i.e., CPA, CCPA) nor Australian (i.e., APS, AASW, AIWCW, PACFA) codes of ethics mention the topic of gifts. Instead, these codes do have the standard mandate to avoid harm and exploitation and to respect clients’ integrity, autonomy and privacy. The AAMFT Code of Ethics mentions the term ‘gift’ in Principle III of Professional Competence and Integrity, section 3.10, in which it states, “Marriage and family therapists pursue knowledge of new developments and maintain their competence in marriage and family therapy through education, training, or supervised experience.” (2015). For some reason NAADAC’s Code of Ethics includes the following gift related statement in the Dual Relationships section “The addiction professional avoids situations that might appear to be or could be interpreted as a conflict of interest. Gifts from clients, other treatment organizations or the providers of materials or services used in the addiction professional’s practice will not be accepted, except when refusal of such gift would cause irreparable harm to the client relationship. Gifts of value over $25 will not be accepted under any circumstances.” (2011, Standard 3).
Like its predecessor, the APA Code of Ethics of 2016 has taken a positive step in regard to boundaries in its revised Introduction and Applicability sections where it finally explains what some of the modifiers that are used in the code (e.g., reasonably, appropriate, potentially) mean. More specifically it states: “As used in this Ethics Code, the term reasonable means the prevailing professional judgment of psychologists engaged in similar activities in similar circumstances, given the knowledge the psychologist had or should have had at the time” (APA, 2016, Introduction). The importance of this clarification is that it articulates the importance of context, including culture and theoretical orientation in determining and assessing clinicians’ actions, such as receiving and accepting gifts and any other boundary crossings. The hope is that this clarification will prevent experts, courts and ethics committees from using the analytic or dominant-Western-Anglo culture yardstick to judge non-analytically oriented psychologists who thoughtfully and strategically engage in gift-giving or other appropriate boundary crossings.
American Counseling Association (ACA) revised code of 2014 takes a flexible stance of gifts and states in section A.10.f.: Receiving Gifts: “Counselors understand the challengesof accepting gifts from clients and recognize that in some cultures, small gifts are a token of respect and gratitude. When determining whether to accept a gift from clients, counselors take into account the therapeutic relationship, the monetary value of the gift, the client’s motivation for giving the gift, and the counselor’s motivation for wanting to accept or decline the gift.”
From a risk management point of view gift exchange, like self-disclosure, home visits and physical, non-sexual touch, has been placed quite high on the list of things to avoid. The reason is that in board or ethics committee hearings or in lawsuits, therapists who give or accept gifts may not be seen in a positive light (Guthiel & Gabbard, 1993; Williams, 1997).
Accepting even small gifts from clients has also been viewed by many risk ethicists and management experts as a potential first step on the slippery slope towards business, sexual or otherwise exploitive dual relationships (Strasburger, et. al., 1992). Similarly, the “Epstein Exploitation Index” also includes a gift-giving item in the questionnaire assessing the level of risk of exploitation (Epstein, et. al., 1992). According to the prevalent and unfounded belief in the ‘slippery slope’ argument, boundary crossings inevitably lead to boundary violations. It refers to the idea that failure to adhere to rigid boundaries and an emotionally distant form of therapy will ultimately foster exploitive, harmful and sexual dual relationships (Guthiel & Gabbard, 1993, Pope, 1990, Simon, 1991). This paranoid approach is based on the ‘snowball’ dynamic that asserts that giving a simple gift is the precursor to an exploitive business relationship; a therapist’s self-disclosure inevitably becomes an unhealthy social relationship; and a non-sexual hug will quickly devolve into a harmful sexual relationship. To allege that self-disclosure, a hug, a home visit or accepting a gift are likely to lead to sex and harm is, in Lazarus’ words, “an extreme form of syllogistic reasoning” (1994, p. 257).
The rigid attitude toward boundary crossings, including gift-giving, stems in part from what Dineen (1996) called “sexualizing boundaries.” This is a skewed view that sees all boundary crossings as sexual in nature, as illustrated in the above mentioned slippery slope argument. Simon (1991), for example, decrees that: “The boundary violation precursors of therapist-patient sex can be as psychologically damaging as the actual sexual involvement itself” (p. 614). Similarly, Pope (1990) states ” . . . non-sexual dual relationships, while not unethical and harmful per se, foster sexual dual relationships” (p. 688). These unreasonable beliefs link any deviation from risk management or analytic guidelines to sexual exploitation (Zur, 2004). The concern with sexualizing boundaries is amplified due to the fact that most gift-giving in our culture comes from women rather than from men (Spandler, et. al., 2000) and the risk management concern that women patients are the primary victims of exploitive male therapists.
The concern with rigid boundaries, such as the absolute non-acceptance of gifts, is that it is likely to interfere with the therapeutic alliance and with clinical effectiveness (Zur, 2007, 2015, 2017). As a result of this apprehension, many clients receive sub-standard care. Lazarus (1994) underscores that, stating, “One of the worst professional or ethical violations is that of permitting current risk-management principles to take precedence over human interventions” (p. 260). Additionally, outcome research has documented the importance of rapport and warmth for effective therapy, and that rigidity, distance and coldness are incompatible with healing. Appropriate boundary crossings and dual relationships are likely to increase familiarity, understanding and connection, hence increasing clinical effectiveness (Lambert, 1991; Lazarus & Zur, 2002, Norcross & Goldfried, 1992).
The standard of care is defined as qualities and conditions that prevail or should prevail in a particular mental health service and that a reasonable and prudent practitioner follows. The standard is based on community and professional standards, as well as on state laws, case law, licensing boards’ regulations, a consensus of professionals, ethics codes of professional associations and a consensus in the community (Reed, 1998; Zur, 2003, 2007, 2016). The standard of care is not an objective yardstick to be found in any textbook, nor is it closely tied to a theoretical orientation. Therapists’ acceptance and giving of appropriate presents is clearly within the standard of care of behavioral, humanistic, family, group and other non-analytic therapies. Obviously, gift-giving falls within the standard when one works with ethnic minorities and cultures that have an established tradition of gift-giving rituals.
Gifts are important social rituals, which are geared to the expression of gratitude and appreciation. Gifts in therapy can be given by clients and/or by therapists. Generally, gracious acceptance of appropriate gifts is important in order to avoid rupture of the therapeutic alliance or interference in the therapeutic process that is likely to result from rejection of clients’ gifts. The meaning of gifts should be noted and, when appropriate, explored and discussed with clients. The meaning of gifts can generally be understood within the context that they are given. Relevant factors for such understanding most often lie in the nature of the therapeutic alliance and therapeutic setting, clients’ culture, therapists’ culture, type and length of treatment and quality of the relationships. Additionally, clients’ history, problem, diagnosis and financial and racial background are also highly relevant. Each gift should be evaluated for its propriety considering timing, monetary value, frequency, etc. Inappropriate clients’ gifts, such as those that are very expensive, ill-timed or those with sexual or offensive themes, should not be accepted uncritically. Instead, therapists should discuss the meaning and intent of the gifts with the giver and seek consultation when necessary. At times, gracious acceptance of clients’ gifts is more important and poses less risk of harm then making the correct interpretation or having an extensive analysis in regard to its meaning. Ideally, gracious acceptance can go hand in hand with therapeutic discussion (when it is clinically called for) of the meaning of the gift.
- Major Points
- Giving a gift is an ancient and universal way to express, among other things, gratitude, altruism and love.
- Anthropologists and psychologists have viewed gift behavior as a product of an interaction between psychological mechanisms and the environment. Accordingly, different cultures have different rituals and traditions and apply different meanings and intentions around gift-giving.
- There are several types of gifts in psychotherapy:
- There are gifts from clients to therapists, therapists to clients, gifts by third parties, such as pharmacological companies, to medicating psychiatrists or psychologists and gifts from clients’ family.
- Gifts in therapy can be symbolic (i.e., a poem) or concrete (i.e., a book).
- Gifts can range from greeting cards, homemade bread or cookies, music CDs, flowers, home-grown fruits, a framed picture, puppy, case of wine, opera or baseball season tickets or even very expensive items, such as a car or a vacation home.
- Gifts can be appropriate or inappropriate in regard to their type, monetary value, timing, content, intent of the giver, perception of the receiver and their effect on the giver or the receiver.
- Gifts can be given at the very beginning, during or towards the end of therapy or after therapy. Some therapists receive their gifts in clients’ wills upon the death of the client.
- Gifts can be an expression of appreciation and gratitude, may also aim to enhance or cement a bond, level the playing field or can be a way to buy love, counteract negative feeling, create indebtedness or to manipulate and control.
- Most often, clinically and ethically appropriate and acceptable gifts from clients are small and rather inexpensive symbolic gifts around the holidays, before termination and symbolic gifts from children.
- Most therapists and ethicists agree that small, inexpensive, appropriate gifts, by either therapists or clients, are neither counter-clinical nor unethical.
- Appropriate gifts are likely to enhance the therapeutic alliance, the best predictor of therapeutic outcome.
- Understanding the meaning of gifts in therapy requires a look at the context of therapy and special attention to the client’s culture, timing of the gifts, client’s history, patterns in regard to gifts as they relate to the presenting problem and the nature of the therapeutic relationship.
- Cultural aspects of gift-giving must always be taken into consideration.
- While therapists should pay attention to the meaning of clients’ gifts, they must handle interpretation with clinical sensitivity. They must weigh the benefit of interpretation (rather than a simple “thank you”) against the clients’ potential feelings of rejection, shame or insult.
- Inviting clients to discuss the meaning of the experience of giving or receiving gifts rather than the meaning or symbolism of the gift itself is likely to be less threatening or insulting.
- Therapists’ hesitation, uneasiness or refusal to accept appropriate gifts is likely to be perceived as rejection and may harm the therapeutic alliance. A refusal of gifts without an attempt to understand the meaning of the gift-giving from the client’s subjective experience is, at the minimum, a lost clinical opportunity.
- A standard “No gift policies” may be ethically and legally appropriate but from a clinical point of view it does not resolve concern with negative impact on a client who is likely to experience it as rejection or even an insult.
- Timing of gifts is important. While an appropriate present at termination is common, a large present at the very beginning of therapy may need more careful examination. A gift following a confrontation or a difficult session may also invite exploration or discussion of its meaning.
- Very expensive gifts are often inappropriate and should not be accepted uncritically. While the client’s wealth may be a consideration, it is not a justification for accepting very expensive gifts.
- Therapists must take into consideration that wealthy clients are most often aware, consciously or unconsciously of the significant impact of their wealth on other people (Knox, et. al., 2009; Zur, 2007) and therefore should be careful when dealing with expensive gifts from wealthy clients.
- Sometimes even very inexpensive gifts can be inappropriate, especially if they have sexual, racist, sexist or other offensive connotations.
- Excessive gifts, gifts by a client who has a history of buying love through gifts, gifts by a borderline patient who regularly oscillates between love and hate should not be accepted uncritically.
- Therapists should explore their own relationships to gift-giving, their motivations for accepting or rejecting a client’s gift and, if necessary, get consultation to help them explore acceptance or rejection of a gift.
- Appropriate gift-giving is boundary crossing, which can enhance the therapeutic work. Offensive or inappropriate gifts can be boundary violations.
- While analytically oriented therapists may choose to neither accept nor give gifts for clinical reasons, theoretical orientations, such as humanistic psychology and feminist therapy, have emphasized the importance of congruent relationships between therapists and clients, which are often enhanced by giving and receiving gifts. Behavioral, cognitive, cognitive behavioral, family and group therapies are likely to support any boundary crossing, including appropriate gift-giving, if they are likely to enhance therapeutic effectiveness.
- Appropriate therapists’ gifts may include:
- A symbolic gift (i.e., a certain card with an image that has meaning to the client).
- A gift that serves as a transitional object (i.e., a rock from the office rock-collection that the client can carry in his pocket or her purse affirming the connection with the therapist between sessions).
- A clinical aid (i.e., a note from the therapist with a specific saying, as a way to help a client dealing with anxiety).
- Therapy-related educational materials (i.e., a book, audiotape or CD on mood swings for a bi-polar patient).
- Following social convention by giving an affirming or acknowledging gift (i.e., as a small graduation or wedding gift).
- Supportive reassuring gift (i.e., giving a flashlight to a child-patient who is going on his first overnight camping trip).
- An affirmation of the relationship (i.e., a souvenir from a trip abroad).
- Gifts in the form of medication samples, while common, can be complex, as they may create indebtedness on the part of the clients. It also may create a conflict of interest for the therapists who may be influenced in favor of the pharmacological company that gave the gifts.
- Gifts that are given in response to a referral of new clients, gifts of stock market tips or gifts of financial loans may be unethical and may create a complex dual relationship and/or conflict of interest.
- Risk management practices discourage the exchange of gifts in therapy because of how it may be viewed by ethics committees, boards or courts.
- Appropriate gift-giving is clearly within the standard of care.
- None of the ethics codes declares gift exchange as unethical. In fact, most professional organizations’ codes of ethics do not even mention gifts.
Guidelines for Gift-Giving in Psychotherapy & Counseling
Generally, there is not one right way to deal with gift-giving in therapy. How therapists, ethically and clinically, appropriately handle gift-giving is determined by their culture, theoretical orientation, training, history, clientele (i.e., clients’ factors, such as culture, history, Dx) and setting and context of therapy. Keeping this in mind, following are some general guidelines for gift-giving in psychotherapy and counseling:
- Explore your own attitudes, thoughts and feelings towards gift-giving in general and, more specifically, gift-giving in psychotherapy by clients and by therapists.
- Be aware that appropriate gift-giving is neither boundary violation nor unethical nor below the standard of care.
- Do not uncritically reject clients’ appropriate gifts out of fear of ethics committees, licensing boards or courts. You are being paid to help your clients, not to practice risk management. The good new is that thoughtful and competent therapists can simultaneously serve their clients well and protect themselves.
- Do not indiscriminately reject all clients’ gifts. This is likely to lead to clients feeling rejected and insulted and, in turn, harm the therapeutic alliance and clinical progress.
- Having pre-existing “No-Gifts” policies does not prevent a client’s sense of rejection or insult when their gift is rejected. Such policies can also eliminate the benefits of the potential therapeutic benefits of gift-giving and receiving.
- Remember that while traditional analytically oriented therapies frown on gift-giving, most other therapeutic orientations, such as humanistic, behavioral, feminist, family, child and adolescent or group therapies, view appropriate gift-giving as a potentially valuable way to enhance therapeutic alliance and therapeutic outcome. Get clarity on what your relationships are to gift-giving in the context of your primary theoretical orientation.
- It is very important that, whenever it is appropriate, you express gratitude and thank the client for the present.
- When given a present by a client, if you are inclined to, try first to assess its meaning, symbolism and appropriateness. Besides the actual present, take into consideration the timing of the gift-giving, client’s culture, history, presenting problem and Dx, the therapeutic relationships, the setting and the context of therapy.
- Evaluate and appraise the meaning, symbolism and appropriateness of the gift in regard to its content. Evaluate the content also by considering the client’s individual and unique experience relative to the symbolic meaning of the gift.
- While it is important to note whether the content of the gift is sexual, offensive or illegal, even in situations where you may not accept the gift, it is still as important to understand the meaning and intent of the gift from the client’s perspective.
- It is very important not to initiate a discussion prematurely or compulsively of the meaning or symbolism on the gifts. Such discussion should be carried out with thoughtfulness and clinical sensitivity. Some situations may call on the therapists to simply express gratitude and nothing more. For some clients in certain situations a basic “Thank you, how thoughtful of you!” may be all that is clinically necessary.
- If you feel strongly that a non-critical acceptance of the gift is counter-clinical or unethical, it is less offensive to most clients if you discuss the process of gift-giving and their experience of it rather than the meaning of the present itself.
- If necessary, you can tell clients that you would “hold” the present in your office. This would be an option with a gift that is given at the end of a session or one that presents a clinically or ethically complex or uncertain situation. This is a way to neither accept nor reject the gift, which can be discussed and dealt with at a later time, if necessary.
- Determine if the gift may affect other people related to the client, especially when it comes to gifts that are bequests.
- If you choose to give a present to a client, treat it as any other clinical intervention or boundary crossing (i.e., self disclosure, touch) and make sure it is always done with the client’s welfare in mind.
- Document all gift exchanges in therapy. Articulate who gave the gift, exactly what the gift was, what the response to the gift was and any related discussions with the client. When appropriate, add a clinical note in regard to your thoughts and interpretation of the meaning of the gift.
- Whenever possible add the gift itself into the record. This is mostly done with greeting cards or small paintings.
- Consult, in complex cases, and document the consultation in the clinical notes.
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