When Side Effects Help: Getting Creative“Tis the season – of patient gift giving and therapist angst. It comes up in my supervision sessions every year: Therapists want to know what to do when patients come to a session bearing gifts. Do we accept them? Reject them? Talk about it? Leave town until January?

Like much about our profession, the answers aren’t clear-cut or simple. As one of my colleagues pointed out, being a therapist means learning to tolerate shades of gray in just about everything. The gift-receiving issue is no different.

The ethics document of your profession only provides general guidance. The current version of the American Psychological Association Ethical Code (APA 2010) states only that psychologists should never exploit their patients and should avoid personal and financial situations that could create a conflict of interest.

Similarly, the NASW code of ethics only stresses the importance of avoiding conflicts of interest that “interfere with the exercise of professional discretion and impartial judgment.” The American Counseling Association code of Ethics (2014) advises that counselors consider the therapeutic relationship, the monetary value of the gift and the motivation for accepting or declining gifts from their clients.

Research doesn’t offer much help either. To my knowledge, there are no studies that empirically examine the effect of various therapist responses to client gift-giving.

If you work for an agency, you may be able to rely on an agency policy that therapists must not accept gifts of any kind. If you are in private practice and have a similar written policy that you give out during a first session, it may help you avoid having to deal with client gift-giving. But regardless of policies and guidelines, regardless of conversations at intakes, there are always clients who choose to ignore them.

So – What’s the right thing to do when a patient comes to a December session with a brightly wrapped box tagged for you? The answer is “It depends.” Generally, most therapists don’t accept client gifts but there are always exceptions. The meaning of giving and receiving gifts is an individual as the people we see. The meaning of a gift can only be understood in consideration of the person and in the context of the therapy.

Since there really are no easy answers, it falls on each of us give to give the issue considerable thought so we are prepared when a client shows up with a holiday gift.

Issues to Consider

Therapist motivation: As with all things, our own intellectual honesty and integrity should be our guide. Accepting or rejecting a gift should be about the patient’s needs, not ours. It can be tempting to accept something we like. It can be tempting to accept a gift to smooth over or try to improve the relationship with the client. Conversely, rejecting a gift can be an attempt to keep a difficult person at a distance. In all cases, we need to be reflective about our own motivation and to act in the best interests of the client.

Client motivation: Sometimes a gift is simply an expression of appreciation for the good work that the two of you are doing together. But sometimes a gift is used by the client to communicate or solve a problem. For example, it is possible that the client is uncomfortable on some level with the direction the therapy is taking. Giving a gift may derail or impact the conversation. Alternatively, the type of gift or the manner or presentation may be a way to approach a difficult topic. Then there are some clients who give a gift in the hopes that it will make up for their habitual cancellations or excessive phone calls.

Size or value of the gift:  Accepting small gifts (like a plant for the office or a box of cookies) is often fine. For some patientss, giving a small gift to people who have provided a valued service is simply a part of the holiday season. All that is required is a simple “thank you” to keep it simple. Gifts that are not acceptable are a large sum of money, expensive jewelry, tickets to prime seats at the World Series or a vacation to Europe – even if the client is a billionaire. Such gifts usually have meaning that should be explored.

The patient’s financial means: Giving the therapist an expensive gift may mean little to a billionaire. A box of teabags from a patient who is struggling financially may mean a great deal to them. In either case, it is a judgment call whether to respond by talking about what the gift means.

The cultural meaning of gift-giving: In some cultures, there is more emotional meaning attached to a handmade gift than something purchased. Declining that handmade scarf or ornament or bread would be seen as a rejection of the person who made it. In other cultures, giving gifts at holidays to those who provide services is customary and expected. Rejecting the gift diminishes the service provided. In still other cultures, those who receive a gift are also expected to give one. To not offer a small reciprocal gift is a violation of basic cultural etiquette. When unsure about the cultural significance of gifts that may come from clients, it’s helpful to research it.

If gift giving and the process of giving/receiving reflects a therapeutic issue: For example: Does the patient have a problem accepting help without doing something more in return? Or does the patient have a history of trying to buy love by being overly generous? Or is giving a gift a way to set up a double-bind that is typical of his or her relationships? If you reject the gift, you have rejected the person. If you accept it, the client may accuse you of taking too much from her – just as she believes everyone else does. In such cases, the issues attached to gift giving are important therapeutic material.

Gift giving and receiving is a usual part of relationships in most cultures. This is especially true during the winter holiday time of year. Depending on the client and the issues being addressed in therapy, accepting a gift is not necessarily a crossing of boundaries or unethical.

Sometimes client gift giving is an uncomplicated gesture of appreciation that can be graciously accepted. However, a gift or the process around gift-sometimes surfaces important issues for therapy. We can be more effective in our work with current clients if we take some time early in the season to think about how best to respond should any of them arrive with a present.