By: Ofer Zur, Ph.D.
Introduction
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 & Cosmides, 1992).
Even though most therapists have regularly received gifts from clients (Borys & Pope, 1989; Pope, Keith-Spiegel & Tabachnick, 1986), the phenomenon of gifts in therapy has received minimal attention in the theoretical literature (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). For the same reason many therapists are even less willing to discuss the gifts they give to clients. 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, emphasize the cultural and other context-related factors affecting gift-giving, and finally, provide psychotherapists with basic guidelines for dealing with gifts in psychotherapy.
Gifts in Therapy
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 gift and the potential benefit of interpretation or exploration of the meaning (Hahn, 1998; Knox et al., 2003; Kritzberg, 1980; Spandler et al., 2000). 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; Zur, 2007). 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). It is hoped that 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 not likely to shame or cause the client to feel rejected. On the most basic level gift-giving and the reciprocal appreciation of the gift 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.
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Types Of Gifts In Therapy
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 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 Medications 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, 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 influence physicians’ professional integrity (Polster, 2001).
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, they have 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, 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 disclosure. A further discussion of these two types of gifts is beyond the scope of this chapter.
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Gifts From Clients
Accepting, Rejecting And Hesitating
Even though there is some hesitation to discuss gifts openly, most psychotherapists neither view it 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; Pope, Keith-Spiegel & Tabachnick, 1986; Pope, Tabachnick& Keith-Spiegel, 1987; Tabachnick, Keith-Spiegel & Pope, 1991). Small and symbolic gifts from clients during the holiday season, at termination, or 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 (MD, 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 (Corey, Corey & Callahan, 2003; Hahn, 1998; Spandler et al., 2000; Zur, 2004, 2007).
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, or cause clients to feel rejected and thus is detrimental to the therapeutic alliance and the therapeutic process (Knox et al., 2003; Spandle, 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 financial loans 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 in which 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 theme, 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; Spandler et al., 2000). Rather than going along and uncritically accepting these gifts in such situations, therapists should use them 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). At times, therapists may choose to accept small gifts that seem to try to buy their love in order not to shame or insult the client 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 behavior 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). Spandler 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, and the client’s culture, history, and presenting problem are some of the factors that determine the appropriateness of the gift (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, carved gourd, lampshade, or poem. Many rural or ethnic settings often readily embrace gift-giving as a common expression of connection and gratitude (Zur, 2006, 2007). As long as the gifts are neither overly expensive nor excessive nor 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 An 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 the client feels slighted by the therapist. Such negative feelings 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 is. 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 theater or baseball season tickets or a weekend at a patient’s vacation home, without discussing the meaning of the gift with their client and seeking consultation in regard to its 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.
Gifts in Therapy
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 for ordinary people because people often have certain expectations, hopes, or fantasies of what rich people can do for them. Gabbard and 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 are of extreme importance and may be the only way to untangle these complicated webs. Additionally, owing 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 are often an important clinical issue that can be brought to the surface where it may generate discussion of the meaning of money in general, the client’s wealth in particular and, when appropriate, his or her 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.
Investment Tips
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 because 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 in which 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 toward 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
The timing of 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).
Cultural Considerations
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 be understood only within this cultural context (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 that 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.
Cultural Gifts in psychotherapy
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 prescribed 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 cook 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.
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Therapists’ Gifts to Clients
Therapists’ gifts to clients have 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 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 affirming the relationship (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 & Keith-Speigle, 1998) or sharing a lunch with a client or a ride to a nearby bus stop on a rainy day (Lazarus, 1994).
Gifts in psychotherapy
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 with the pharmaceutical company and the clients is an ethically and even clinically problematic area (Polster, 2001; Reist & VandeCreek, 2004). The second concern is that, besides gratitude, clients may feel indebtedness toward 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. it is hoped that such concerns will be addressed in therapy to reduce interference in the therapeutic process.
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Codes Of Ethics
Despite the prevalent belief to the contrary, there are no ethics codes or guidelines that specifically deal with boundary crossings (Zur, 2002). And except for the AAMFT and ACA Codes of Ethics, none of the major professional organizations’ (i.e., APA, ApA, CAMFT, NBCC, NASW) 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 do not give to or receive from clients (a) gifts of substantial value or (b) gifts that impair the integrity or efficacy of the therapeutic relationship.” (2012, Section 3.10).
The new APA Code of Ethics of 2016 has taken a positive step in regard to boundaries in its revised Introduction and Applicability sections, in which 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.
The American Counseling Association (ACA) revised code of 2014 takes a flexible stance on gifts and states in section A.10.f.: Receiving Gifts: “Counselors understand the challenges of 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.”
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The Standard Of Care
The standard of care is defined as the 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). 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 are 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.
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Summary
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, client’s culture, therapist’s culture, type and length of treatment, and quality of the relationship. Additionally, the client’s 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 client’s gifts, such as those that are very expensive, are ill-timed or have sexual or offensive themes, should not be accepted uncritically. Instead, therapists should discuss the meaning and intent of the gift 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.
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