Risk management makes therapy less attractive to consumers, because, as Williams asserts, it tends to replace what the therapist can offer of warmth, soul, spontaneity, and human connection with a prissy, unattractive defensiveness. One of my clients was a gentle, pleasant young man suffering from chronic paranoid schizophrenia, with whom I worked for many years. As part of therapy, I was continually in touch with his parents, stepparents, sisters, landlord, employer, psychiatrist, and everyone else involved in his life. He happened to be a Starsky and Hutch junky and it seemed that, with my curly, dark hair, I reminded him of Starsky—in fact, at times, he confused me with the character. He drove a 1974 Grand Torino, the signature car of the show, with the same racing stripes and other accessories as the original.
This car was the "office" where we'd meet. He'd never liked my office—being there made him feel nervous, frightened and withdrawn—but he felt relaxed and engaged, open and receptive, while tooling around town in his car. During our weekly appointments, we cruised around, checking out the hot spots, all the while talking about his employment, medications, fears, girlfriends, or anything else on his mind. Several ethicists, graduate school instructors, and attorneys raised legitimate questions. What would happen if we got into a car accident? How did I bill for it—was there a CPT code for "car therapy"? Some wondered how I managed the transference, while others strongly recommend that I look at my own countertransference issues. After consulting with several experts, I decided my countertransference issues could wait, and that I'd continue this form of therapy because it appealed to him and, most important, it seemed to work well. Besides, the way I looked at it, I was paid to help him, not practice defensive medicine.
As for the issue of gifts, I long ago decided that the meaning and significance of the gift to the client, as well as whether giving or receiving a gift is in the service of the work, should determine whether it's "appropriate" or not. When I come back from a visit to Israel, I regularly bring gifts—rocks from Jerusalem or water from the Jordan River—to certain clients who find them meaningful. One workshop attendee, who's Jewish, once told me that a non-Jewish client, a craftsperson, had made a stained-glass menorah for her. The work itself was nourishing to the woman's spirit and the feeling of gratitude expressed by the gift was an important part of the therapeutic encounter. Not only would it be hurtful and churlish to high-mindedly refuse such gifts, it would be utterly untherapeutic—in its own way a betrayal of good clinical practice.