An Ethical Dilemma: When Therapy Clients Give Gifts

Reconciling Boundaries with the Therapeutic Alliance

Jenny Newsome

When I was young and only three years out of graduate school, one of my first private clients came into a session carrying a small package simply wrapped in brown paper and string. The memory of that package and how I reacted to it haunts me still.

The client---Katy---was a businesswoman who had come to me six months earlier, dumbfounded by a depression so deep that she was fighting the impulse to drive her car off a bridge. In cognitive-behavioral therapy, she'd improved steadily, returning to activities she had previously enjoyed and finding the strength to let go of unfixable situations she'd badly wanted to fix.

She was dressing more casually, laughing easily and entertaining ways to broaden her already full life. She'd decided to leave her present employer, expand her private consulting business and enroll in a Ph.D. program. Even though her depression was resolved, she had continued in therapy in order to solidify her changes and stay in touch with her long-term goals. All in all, I couldn't have been more pleased about the progress of her therapy.

Then came the fall day when, much to my surprise and horror, Katy came into her session and gave me the little brown-paper package. I unwrapped it and found a small, black velvet box. Inside, was a necklace, and not just any necklace: a gold chain with a diamond pendant that she had designed herself, worth about $500.

Katy knew that giving a gift to one's psychologist could be tricky, so she was also armed with a persuasive list of reasons why I should not refuse her gift. She told me earnestly that it gave her great joy to thank me in a special way. She wanted to celebrate her therapy success, and this was a way of making it tangible. The choice of a diamond held great significance: it was analogous to her experience of the transformative power of therapy. The earth, she explained, takes a dark substance (carbon) and subjects it to great pressures that make it clearer and better than it was before.

Being young and new and the good ethical psychologist that I was trained to be, I did just what she feared: I refused her gift. I thanked her for the thought and said it was against my professional code of ethics to accept.

Katy looked pale and shaken and said she felt dizzy. I had to suggest she take some deep breaths. I tried other cognitive-behavioral strategies, but this was not a simple panic attack.

I asked her if this was a transference issue in which she was confusing aspects of our relationship with other significant people and events from her past? No. Was she trying to bribe me into having a non-therapy relationship? No again. Did she have trouble receiving help without reciprocating? She said that although she liked to reciprocate kindnesses, she did not feel "driven" to do so.

Then she told me she felt insulted that ethical rules designed to protect vulnerable patients were being applied to her, even though her depression was in remission. Would she now always be classified in such a way that her own judgment could be questioned? Didn't I trust her to make good decisions? And isn't a cigar sometimes just a cigar?

Finally, terrified and exhausted, I told her flatly that accepting something so expensive was against the ethical rules of my profession and I did not want to place myself at legal risk. Katy got so upset that, again, I thought she might faint. I agreed to hold onto the necklace for 10 days and talk about it again at our next session.

Meanwhile, I talked to close colleagues, called the American Psychological Association ethics board, my state ethics board and a lawyer-psychologist who specialized in ethics law. I took the train to Philadelphia and New York to consult with two of my mentors, one of whom had supervised me in graduate school.

My mentors told me I was running the risk of dehumanizing Katy and jeopardizing our therapy relationship by being so scared and rigid. The ethics boards and lawyer both told me that it was in Katy's interest that I accept her gift.

With much anguish, after 10 days, I accepted the necklace, thanked Katy and brought the black velvet box home. Katy and I continued therapy for several more months before terminating, but something had changed. The sense of a "dirty little secret" had leaked into our sessions.

I had consulted with everybody I could think of and tried to please them all. Losing touch with my own best instincts, I'd gotten enmeshed in our profession's confusion over how to respond to a client's gratitude while safeguarding her from exploitation. In the process, the beautiful necklace Katy had given me had become tainted---not the celebration of growth and gratitude she had meant it to be. I'd allowed other voices into the sanctuary of our therapy and once they were there, I couldn't get them out.

This blog is excerpted from “The Necklace: When Does a Rule Become a Straightjaclet?" (March/April 2002)Read the full article here. >>

Topic: Ethics

Tags: ethical issues | behavioral therapy | code of ethics | depression | ED | fighting | panic attack | psychologist | psychotherapy | SPECT | success | TED | therapy | Transference | Psychotherapy Networker | clients | strategies

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Wednesday, February 14, 2018 8:08:32 PM | posted by Diana Blackwell
"If they make it, bake it or shake it you can take it." Advice from my licensure supervisor, a professor at Washington University in St. Louis.

Friday, January 5, 2018 3:10:49 PM | posted by RcW
Psychology is one of the only professions that cannot accept any gifts without it being overly analyzed. Medical professionals, lawyers, bakers, pastors and priests, all received gifts humbly and appreciate it, as long as it is not trying to be manipulative or buy some outcome. That is the key. Refusing gifts, especially home made gifts is very injuring to clients but has passed for humility, however false that humility is, which is really arrogance, as in I am so important, so different that the regular customs of society and culture and appreciation dont apply to me, I am outside culture and merely work with it. Freud actually thought gifts of appreciation were common and meaningful near the ends of analysis and therapy so the client could show some tangible personal thankfulness beyond money to show appreciation. Therapy is not just some business transaction, actually, most business transactions are personal too, so that person shows of care and appreciation given meaning to this connection. They are not required by any stretch, but to willy nilly refuse them plays God, and as I recall even God accepts gifts from the three kings. Every situation is different, so I am not saying always accept a gift or reject it, use good sense, in context of the relationship, the gift, the cultural and personal meaning, that is a good start.

Saturday, August 12, 2017 2:30:11 PM | posted by Connie
In response to Robert - I say give them the gift, and know that if it is turned down, it isn't a rejection of you and your connection to that person, but a reflection of their wrestling with a professional/ethical dilemma. My guess is that a macrame planter will be appreciated, and far less likely to cause worry than a diamond necklace would. It sounds like a thoughtful, genuine token of thanks,

Friday, July 7, 2017 7:14:29 AM | posted by Robert H Reynolds Jr
Well, this sort of sux. Here I am contemplating an appreciation gift to my PhD when we complete the CBT program which has only 3 sessions left. This program and the way she approached every session has all the makings of a wonderful person who genuinely cares. It was a great match from day 1. Of course I was only going to give her a macrame' plant hanger that I was going to make. The significance of this is appropriate and was at the time a part of some discussion. Any thoughts?

Thursday, September 29, 2016 10:13:08 PM | posted by Zar
An interesting blog and very thoughtful comments. I agree that the nature of professional boundaries in modern day therapy can be quite confusing and something I have given a lot of thought to. It is indeed "a personal relationship (albeit within the boundaries of a therapeutic relationship which are absolutely essential for both parties)" as pippag said and yet that is not always so easy to navigate. I have turned down various Facebook friendship requests, invites to important events, invitations for just a cup of tea, etc. over the years and always with a heavy heart. Please know that sometimes a therapist's clients are some of her most favorite people in the world. However, there is a reason why a therapist is your therapist and not your friend. Both friends and therapists may support you, advise you, and sit with you through difficult times. But friends and family also have opinions and agendas based on what they know about you, want for you, how they feel about you - and themselves - and the experiences they've share with you. Friends and family are not typically trained in how to ask facilitating questions nor should they be expected to remain neutral. Therefore it's important for therapists to maintain professional boundaries in order to be most beneficial. That being said, I have accepted small gifts once in a while as "a human being from another human" as Monica described. I usually take into consideration the cultural background of the client and how the gift might affect our future work together. The best timing is really when the therapy is ending. For example, someone gave me a nice little tin with a flavored soap inside when she transferred to a new therapist that offered more long-term services. However, if you would like to express your gratitude to your therapist, the best thing is to send a card or leave a positive comment for his/her supervisor - or yelp if the person is in private practice.

Wednesday, September 14, 2016 8:43:28 AM | posted by Monica
I feel that some "ethical" guidelines are ridiculous. Why is it not appropriate to give at least a small gift to your therapist? I understand the deliberation of the author. That gift was expensive. However, I feel that "ethics" restrains the therapist from accepting even a small gift. I remember seeing flowers (that are usually not there) in my therapist's office and wondering if they were a gift from a client. I hope that if they were a gift, she accepted them as a human being from another human being whom she helped. I understand that it is necessary to watch out for transference and unhealthy attachment to a therapist, but I don't want my therapist to be a robot whom I (or others) can't thank with this common social gesture.

Sunday, April 26, 2015 7:11:51 AM | posted by pippag
As a person in the "gift giving" role, I found this article to be very confirming of my recent experience when I tried to give a gift to my therapist, as a token of appreciation, but also in recognition of all the times she has allowed the session to run over (slightly). We have got tangled up in the web of ethical issues associated with gift giving - which for my part threatens to sever the therapeutic alliance that we have built up over a number of years. I have needed to be in therapy for this long in order to have someone to touch base with and as a sounding board to deal with life...I am not dependent - I hope - I am not in love with my therapist (but I can hear some people saying "but you would say that wouldn't you") !) - it is hard to discuss these kind of issues without an avalanche of questions being raised about unconscious motives (the first and last retreat for therapists since who can prove/disprove that one?). Sometimes a gift is just a gift - though it is certainly helpful to analyse what might be going on in the gift giving and receiving. I have felt offended and shamed - and angered to be honest - by my therapist's refusal to accept my (small) gift (in fact she decided not to even open the envelope I sent her following our discussions) - it feels that she has set herself "above" such things, as if it is beneath her to accept it - or that by accepting it she would be allowing us to stand more as equals than in one up , one down positions - like parent/child. We have discussed all this of course and will do so again I guess. I suppose what I am saying is that it is not just about me - it is about her too - and I have come to think that the separation of "therapist" and "self" is a very artificial one - either it is a business transaction and you stick to the rules and contract - or it is a personal relationship (albeit within the boundaries of a therapeutic relationship which are absolutely essential for both parties) - I don't think it can be therapeutic and business - and to pretend otherwise is a kind of deception on the part of the therapist - or a pretence that they can somehow keep themselves out of and above the messiness/ordinariness of interpersonal relationships - which sometimes involve one person wanting to give another a gift as an expression of gratitude - no more or less. The assumption of concealed motives on the part of the gift giver is helpful to explore - and needs to be - but with an open mind that allows for there to be no such motives - just a simple - yes maybe child like - wish to say thanks - and I think it should be accepted in that spirit - with the therapist being able to take pleasure for having been thus appreciated and thanked - not feel somehow indebted, beholden, compromised or whatever.....