Giving a gift is an ancient and universal way to express gratitude, appreciation, altru- ism and love. Appropriate gifts in therapy are ethical and enhance authentic therapeutic relationships, which is the best predictor of therapeutic outcome.
Rejecting clients’ clinically appropriate gifts is likely to be perceived as personal rejection or even an insult, and may harm the therapeutic alliance or end therapy. A standard “no gifts policy” does not resolve the negative impact on a client.
Gifts in psychotherapy most often come in these varieties: gifts from clients to therapists, gifts from therapists to clients and gifts from clients’ families.
Gifts can be symbolic (e.g., a poem or card) or concrete (e.g., a CD or book). The meaning of gifts can be only understood with- in the context of therapy.
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. Most often clinically and ethically appropriate gifts from clients are inexpensive.
Symbolic and appropriate gifts from children to therapists or therapists to children are very common and clinically appropriate. Therapists do not need to always explore the meaning of the gifts with clients. Sometimes a simple “thank you so much” is sufficient. Sometimes very inexpensive gifts can be inappropriate, such as those with sexually or racially offensive connotations.
Gifts can express appreciation and gratitude, enhance or cement a bond, level the playing field between therapists and clients, “buy” love, counteract negative feelings (e.g., given to therapist after a disagreement) or cre- ate indebtedness or manipulation.
Appropriate therapists’ gifts to clients may include a symbolic gift (e.g., a card that has meaning to the client), a gift that serves as a transitional object (e.g., a rock from the office rock collection), a clinical aid (e.g., a note from the therapist with a specific saying, as a way to help a client who is dealing with anxiety), or therapy-related educational materials (e.g., a CD on mood swings for a bi-polar patient), following social convention by giving an affirming or acknowledging gift (e.g., a small or symbolic graduation or wedding gift), a supportive, reassuring gift (e.g., giving a flashlight to a child-patient who is going on his first overnight camping trip) or an affirmation of the relationship (e.g., a small/symbolic souvenir from a trip abroad.)
Clinically appropriate gift giving is ethical and clearly falls within the standard of care. 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 and the nature of the therapeutic relationship. Cultural aspects 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 “thank you”) against the clients’ potential feelings of rejection, shame or insult.
Timing of gifts is important. While an appropriate present at termination is common, a 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.
Wealthy clients are most often aware of the significant impact of their wealth and, therefore, therapists should be careful when dealing with expensive or inexpensive gifts from wealthy clients. 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. Examples of unethical and clinically inappropriate gifts include:
- Gifts for referrals of new clients
- Stock market investment tips
- Financial loans are most often unethical and likely to result in conflicts of interest
None of the ethics codes declares all gift exchange as unethical. Therapists should consult with experts when they receive gifts in a client’s will upon the death of the client.
Document all gift exchanges in the clinical records. If possible, greeting cards, paintings, poems, etc. should be part of the clinical records. Document all gift exchanges in therapy. Articulate, briefly, 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.
Consult in complex cases and document the consultation in the clinical notes.
Ofer Zur, Ph.D., is director of the Zur Institute in Sonoma, Calif., which offers online CE courses and other resources for psychologists and other mental health profes- sionals. His website is: www.zurinstitute.com