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.
