Receiving gifts from clients: ethical and therapeutic issues.
It is not unusual for clients to bestow gifts upon their mental health counselors who, as a consequence, experience positive, negative, and mixed emotions (Spandler, Burman, Goldberg, Margison, & Amos, 2000). In such situations, mental health professionals must manage personal emotions and behavior adequately in order to respond therapeutically. However, little attention is given to such therapeutic events in graduate training. In addition, few guidelines on appropriate therapeutic responses to client gift-giving have been developed. Such client behavior can have important ethical and therapeutic implications (Beier & Young, 1998; Cappa, 2001; Dodds, 1985; Gartrell, 1992; Kritzberg, 1980; Spandler et al.). Yet, there is frequently professional ambivalence toward this topic that is, perhaps, reflected in the dearth of existent professional literature on gift-giving. As Spangler et al. note, although "there is a vast general literature on 'gifts,' this is not the case in psychotherapy where an intriguing silence predominates" (p. 80).
The purpose of this article is to explore ethical and therapeutic issues that are relevant in client gift-giving situations. First, the extent and nature of client gift-giving are discussed. Second, relevant ethical and therapeutic issues are identified. A scheme for categorizing and assessing gift-giving behavior is developed. Finally, several general suggestions are given for handling these incidents.
THE EXTENT AND NATURE OF CLIENT GIFT-GIVING IN COUNSELING
Webster's Third New International Dictionary (Gove, 1993) defines a gift as "something that is voluntarily transferred by one person to another without compensation" (p. 953). The inherent value of the gift might be monetary, but can also be psychological and symbolic. The recipient knowingly recognizes its gift status and accepts it as such. There is no prior claim upon the gift by the recipient. In addition, the recipient is under no obligation to pay for it in the future.
It is not unusual for mental health counselors to receive gifts from clients, although few studies have been conducted to investigate this phenomenon. In a review of the professional literature, only one empirical investigation on the gift-giving behavior of clients was found (Spandler et al., 2000). Another investigation examined the gifts received by physicians from their patients (Drew, Stoeckle, & Billings, 1983). Anecdotal evidence accrues from informal discussion with colleagues, who reveal numerous occasions of gift-giving. For example, one female client, who was typically scheduled at the dinner hour, frequently brought in food items such as strawberry pie or pizza to share with her mental health counselor. Another client, whose spouse worked for a snack distributor, would bring in bags of chips or pretzels that had reached their shelf life expiration date.
Sometimes, the practice of gift-giving does not take place in such a straightforward manner. One client gave her mental health counselor a large photo album containing a number of family pictures. Another mental health practitioner, working for a nonprofit agency, reported that a client donated a large quilt for an agency fund-raiser and had attached to it a poster-sized note thanking the mental health professional for her excellent service. In each case, the gift item was dropped off at a time when the mental health professionals were in session with other clients.
Drew et al. (1983) identified three general categories of gifts. First, gifts are often seen as a type of tip to the professional. The underlying motive of the gift-giver in this case may be likened to the restaurant diner. The client, who is pleased with the personalized service, degree of tolerance displayed, and timeliness of service seeks to compensate the mental health professional for providing service that is beyond the call of duty. Second, gifts are given to address a perceived imbalance in the professional relationship. For example, a store manager, upon an improved level of functioning, might give her counselor a gift certificate that is redeemable at her store. Such a gift may help the client regain status that was temporarily lost during her increased sense of dependency during a major portion of her counseling. Third, the gift might serve as a payment of homage or sacrifice to the mental health professional (Drew et al.). In such cases, the client sees the mental health counselor as using professional power on his or her behalf. For example, it might be through signing of appropriate forms by the mental health counselor that the client is entitled to specific benefits such as special housing, worker's compensation, or Supplemental Security Income. Gifts received in such circumstances can be viewed as the client giving thanks with a gift, similar to primitives paying homage to their god for a plentiful harvest.
Sometimes, gifts offered by clients mark specific events or transitions (Spandler et al., 2000). For example, a client may give the mental health counselor a gift at their last scheduled session. Or a gift and card might be given in relation to a holiday or birthday. Gifts of these types might be related to culture and the gender. In one study, it was reported that the majority of such gifts offered to counselors were given by female clients (Spandler et al.).
It is useful and appropriate to consider gift-giving as a form of communication. Spandler et al. (2000) speak of the meaning of gifts. For example, gifts come into being as a result of the will and intention of the gift-giver (Camenisch, 1981). And, in accepting the gift, mental health counselors implicitly acknowledge the giver's will, intention, and reasons for giving it. In addition, giving gifts is a common way of expressing and strengthening one's social attachments (Schudson, 1986). It is a socially acceptable way of communicating gratitude and eliciting positive emotions from the receiver. Gifts are used to buy love and soothe feelings of guilt. Gifts are a way of restoring a balance of power within a relationship (Camenisch). It is likely, though, that the client's meanings and intentions are implicit and may even be beyond the awareness of the gift-giver.
Gifts can also be distinguished by the depth of meaning attached to them. Thus, it is useful to view the various types of gifts as lying along a continuum. At one end of the continuum, gifts received from clients can be considered as a form of ritualistic behavior. Wolin and Bennett (1984) distinguish between family celebrations and traditions. Although a party is a celebration, traditions include holidays, weddings, funerals, and other rites of passage. Frequently, the giving of gifts by clients accompany occasions in the counselor-client relationship that can be construed as traditions. For example, Shapiro and Ginzberg (2002) describe the use of "parting gifts" as a termination ritual in group therapy. Such gifts carry with them an intended meaning that is conveyed in an overt and intentional manner. The meaning and significance of the gift is readily perceived through an accurate perception of the situation and accompanying verbal behavior of the gift-giver.
On the other end of the continuum, giving gifts serve as metaphors. In these instances of metaphorical communication, it does not suffice to literally interpret the gift or the interactive process surrounding the giving and receiving, because as Searle (1993) notes, the literal meaning calls into mind another possible meaning. Metaphors work by taking concepts that are not normally associated and juxtaposing them in a meaningful way that illuminates the similarity that exists in some way between them (MacCormac, 1985). In the example of the client who gave her counselor a family photo album at the termination of treatment, a deeper meaning might be related to unresolved issues of transference.
ETHICAL AND THERAPEUTIC ISSUES
The Code of Ethics of the American Mental Health Counselors Association (AMHCA, 2000) does not specifically address the topic of gift-giving by clients. It does, however, discuss the related issue of bartering. Bartering raises concerns about therapeutic boundaries and multiple relationships, as does the issue of clients' gift-giving (Corey, Corey, & Callanan, 2003). In contrast to gift-giving by clients, bartering is the exchange of goods or services without the exchange of money. Like gift-giving, bartering is not prohibited by codes of ethics. But mental health counselors ordinarily refrain from the practice because such arrangements create potential for conflicts, exploitation, and distortion of the professional relationship (AMHCA).
It is the potential for exploitation and distortion of the professional relationship that make the receiving of gifts from clients an ethical concern. Yet, a dilemma occurs as mental health counselors also are called upon to respect the dignity and worth of clients (AMHCA, 2000). In addition, being a gracious receiver is an accepted social protocol. To do otherwise is to negate the giver's experience of the "blessing" that supposedly comes with giving. And the refusal to accept a gift could communicate rejection of the client and that could result in a diminished view of self.
On the other hand, many examples can be noted where the act of giving gifts may not be in the best physical or psychological interest of the client. For example, gift-giving can, in fact, be a feature of the clinical picture for clients with dependent or borderline personality disorders. The mental health counselor passively accepting a gift from such a client may reinforce patterns of manipulative or self-debasing behaviors that are symptomatic of the problematic levels of functioning. In such instances, mental health counselors must discern which course of action is truly in the client's best interest.
Several principles of AMHCA's Code of Ethics (AMHCA, 2000) have implications for mental health counselors in client gift-giving situations. First, Principle 1 states that the "primary responsibility of the mental health counselor is to respect the dignity and integrity of the client. Client growth and development are encouraged in ways that foster the client's interest and promote welfare" (Principle 1.a.1). In addition, it warns that mental health counselors guard against the misuse of the influence they possess by virtue of role and position. To do so, mental health counselors must be aware of the degree of influence they have by virtue of their professional role (Principle 1.a.2). Thus, mental health counselors do well to recognize and respond to such underlying motives in ways that enhance the client's dignity and self-respect rather than reinforce his or her sense of inferiority.
The potential for exploitation exists when a real or perceived power differential exists in the therapeutic relationship. The gift becomes a cue that increases the mental health counselor's awareness of the power differential and can influence specific therapeutic decisions. For example, if I must adjust my schedule of appointments for a particular day, I might be more inclined to reschedule the client who has given me a gift. Or the decision to reschedule the client may be founded upon the socially accepted meaning of a gift (e.g., a sign of liking and appreciation; a willingness to please). Thus, my decision to reschedule the gift-giving client, rather than another client, reflects my attempt at identifying the path of least resistance. Because of having been offered a gift in the past, I assume that this specific client will not mind. On the other hand, mental health counselors may be more inclined to compromise agency policy related to no-shows and cancellations when the offending client happens to be one from whom the mental health counselor has received gifts in the past. The motive for such a show of grace on the part of the mental health counselor, in this latter case, might be more out of reciprocity than client need.
By being a gracious receiver of the gift, the accepting behavior of the mental health counselor can serve as a powerful reinforcer of the gift-giving behavior. Thus, when in similar conditions, the client's gift-giving behavior may tend to recur. Such was the case when a clients brought in a number of packages of snack products. The client's partner worked for a food distributor, leaving the client with an abundance of these tasty morsels whose expiration date had just passed. Staff fussed over the client's thoughtfulness, and, consistent with operant principles, the client continued to bring cartons of snacks even when the mental health professional communicated that the behavior was not warranted or needed. By accepting gifts without question, mental health practitioners may or may not be acting in ways that are truly supportive of the client's welfare. It is clear that in many cases such determinations cannot be made without a consideration of the underlying intentions and motives of the client and counselor as well as the dynamics of the therapeutic relationship. Therefore, constructive therapeutic responses can be identified only upon first considering the therapeutic implications of the gift alongside the ethical concerns.
ASSESSING AND RESPONDING IN GIFF-GIVING SITUATIONS
Because gifts can mean so many things and fulfill social functions, the mental health counselor's task is to identify the contextual meaning what the gift is and is not. Stated another way, the mental health counselor determines when the gift is not merely a gift. To do so, the mental health counselor must "look the gift horse in the mouth" and draw out from the client information to discern the possibility of a metaphorical meaning for the gift-giving. Clues come from client statements, the context, and the specific characteristics of the gift. The degree of client awareness into the metaphorical nature of the gift-giving influences the extent to which the mental health counselor relies on client, contextual, or gift characteristics in formulating the therapeutic response.
In light of the discussion above, a model for assessing gift-giving situations can be put forth. Clients' gift-giving behavior can be viewed as lying along two dimensions. The first dimension relates to the ethical implications of receiving the gift. On this dimension, gifts can range from having little or no ethical implications to being unethical. Receiving gifts from clients can also be viewed as lying on a second dimension related to the therapeutic meaning of the gift. Gifts, on this second dimension, can range from possessing relatively low to high levels of therapeutic meaning. When viewed in this manner, gifts can be seen as falling into one of four categories (see Table 1).
Many gifts presented in the context of counseling fall in the category of carrying a low level of ethical concern and therapeutic meaning. Receiving cards (e.g., Christmas, Passover) and inexpensive gifts often fall into this category. For example, one client gave the mental health counselor a paperback book with a card at their final session. On such occasions, the gift can be received with a brief collaborative exploration of the client intention and meaning followed by a genuine "thank you." Little therapeutic gain is achieved by attempting to excavate a deeper meaning for the gift, and such explorations can, in fact, be seen as communicating disrespect to the client.
In contrast, a second category might be gifts characterized as relatively low in therapeutic significance, but the acceptance of them may border on unethical behavior. For example, as a genuine show of appreciation for services rendered, a client might attempt to give to the therapist a very expensive set of books at the final session. At some point, accepting such gifts can be construed as a tip, and so become exploitive. Although not desiring to be inappropriately confrontive, mental health counselors do well to take some time and process the behavior, feelings, and underlying meaning associated with the giving of such an expensive gift in order to avoid the potential for unprofessional or unethical behavior or for unintentional harm to be inflicted upon the client.
In the third category, gifts presented by clients may, on the surface, appear to raise few ethical issues. But, upon exploration of the client's underlying intentions or motives, a deeper meaning is revealed. For example, a child may draw a picture and bring it in as a gift to the therapist. It is a mistake to simply accept the drawing without considering underlying motives, thoughts, and feelings of the child. Such events can be the occasions where the child is actually conveying important and powerful feelings that can be identified and related to other themes emerging in the treatment process. As Beier and Young (1998) note, powerful social conventions associated with gift-giving and receiving can lead mental health professionals to choose paths that limit therapeutic effectiveness in such situations (e.g., routinely responding as a gracious receiver and, in doing so, relinquish the role of mental health counselor).
Finally, it may be unethical to accept a gift that also carries a high level of therapeutic meaning. Take, as an example, a female client and male therapist. The client stalked the mental health counselor to discover where he lived. She, later, stopped by the house and attempted to initiate a personal relationship, stating that the therapist would be given "a night he would remember." To accept this gift, of course, would be highly unethical. Yet, it was vital that the counselor explore the deep meanings and motives beneath the client's behavior in order to discern the significant therapeutic implications. Seeking supervision or consultation with an experienced colleague is an important way of maintaining objectivity and developing therapeutic responses in such situations.
MANAGING APPROPRIATE RESPONSES
Mental health practitioners are divided on how to respond to clients' gift-giving behavior. For example, Dodds (1985) suggested the following guidelines regarding gift-giving in child therapy:
* If parents ask, you suggest to them that they not bother to have the child give you a gift unless the child really pushes for it.
* If the child insists and you have an opportunity for some input on gift selection, then urge something simple like a box of candy or something the child has made.
* When the child gives you a gift, accept it graciously and gratefully, since he or she would be hurt by a refusal if the child made the present. If you can possibly display the gift over the next few weeks, the child will know that you really do appreciate and value the gift and the thought behind it. (p. 133)
In contrast, Beier and Young (1998) express a different perspective. According to these authors, mental health professionals must necessarily move ahead with caution and good clinical judgment because very strong social conventions are called into play when a gift is received. Mental health counselors can use gift-giving situations as opportunities to explore deeper feelings and motives that may lie beneath the safe structure of giving a gift. The following example clarifies their view:
When a 7-year-old girl brings the therapist a bouquet of flowers she picked in the garden, the first impulse of any receiver is to say "thank you" and feel very pleased about this expression of gratitude and friendliness. Yet within the therapeutic situation, nothing could be more wasteful. It is just because the gift is such a safe way of expressing feelings and setting up structures that some of the most therapeutically important feelings are likely to be hidden behind these expressions (Beier & Young, 1998, p. 118).
It is suggested here that the clearest path for the mental health counselor to take is found at the intersection of the ethical implications and therapeutic meaning. Once these dimensions are clearly defined by the therapist, an appropriate course of action becomes more apparent. Thus, mental health counselors should, first, assess the nature of the specific gift-giving situation using, for instance, the questions below can clarify the situation and help point the mental health counselor toward constructive responses to the gift being offered. Decisions made on how to respond to gift-giving depend to a large extent on the specific classification of the gift offered.
* To what extent would acceptance of the gift be ethical? Will accepting this gift negatively affect the well-being of this client? Is there any potential for client exploitation due to counselor/client role or power differential? By accepting this gift, is there a potential for crossing boundaries (e.g., moving from the professional to a more personal role)?
* What is the relationship of the gift-giving behavior to presenting clinical issues? Is the behavior a reflection of what occurs in the client's other social relationships? Can the gift-giving be considered as part of this client's self-defeating pattern of behavior that maintains his or her status quo?
* What am I (the mental health counselor) experiencing in this specific situation? Do I detect any personal feelings of ambivalence or dissonance? To what extent am I experiencing an approach-avoidance conflict? What would be my motives for accepting this gift? It is imperative for the mental health counselor to go beyond the superficial level of awareness in answering these questions.
* Does the gift carry both overt and covert meanings? What possible meanings may be assigned to the giving of the gift? Based on collaborative exploration, what meaning(s) can be attached to the giving of the gift? To what extent is the client aware of his or her motives for giving the gift and willing to take ownership for the behavior as well as the underlying motives? Seek clarification as necessary.
* How is the gift-giving situation best categorized (see Table 1)?
Once the category of gift-giving has been assessed, appropriate responses can be determined. As can be noted (see Table 2), mental health counselors have the option to either accept or not accept gifts when assessed as ethical. However, in such situations, the determining factor on deciding to accept the gift depends on the nature of therapeutic meaning assigned to the gift-giving situation. In addition, it is never appropriate to accept a gift when to do so would be unethical. The meaning of such a gift, though, should be processed in order to integrate its significance into the ongoing themes of counseling.
Mental health counselors should keep in mind the possible symbols and metaphors associated with the literal gift. Frequently, the best and most overlooked metaphors are those created by clients in the context of therapy. When properly constructed and invoked, metaphors enhance learning by creating a model or framework for supporting future learning of new concepts and skills. That is, the metaphor serves as a bridge from the "known to the radically unknown" (Petrie, 1993, p. 584). Being sensitive to the conditions surrounding the gift as well as background assumptions of the client, the literal meaning of the gift will tend to call a metaphorical meaning into the mind of the mental health counselor.
A provocative approach is to acknowledge or accept the gift and, then, utilize it as a metaphorical object. Occasionally, the gift or process in giving the gift symbolically represents another object, event, or process related to therapeutic issues. By playfully and respectfully focusing on, discussing aspects of, or manipulating the object in session, the mental health counselor is able to address significant therapeutic concerns through indirect communication. To effectively use gifts as metaphorical objects, mental health counselors need to be simultaneously supportive and provocative (Andolfi, Angelo, & de Nichilo, 1989). When used effectively, a therapeutic crisis, which can activate in the client's search for alternative meanings, is created by questioning the client's actions and motivations that have been typically taken for granted. The gift can become a relational link between the known (i.e., the gift) and the unknown (i.e., deeper meanings associated with presenting problems, therapeutic process, and goals). Examining gifts in this manner becomes a tool that opens up conflicts, rejections, or resolutions that may otherwise remain unexplored or hidden. Andolfi and his colleagues have found that "the images created in session and represented by metaphorical objects have a remarkable capacity to persist and reverberate that is clearly superior to those produced by verbal exchanges and interpretations" (p. 74).
Receiving gifts from clients is a frequently occurring therapeutic event. However, little has been written on its nature, significance, and therapeutic implications. Although several authors have commented on the significance of receiving gifts from clients, mental health counselors are offered few guidelines for such events. In this article, I have attempted to identify relevant ethical and therapeutic issues related to client gift-giving, put forth a model for assessing gifts, and recommended several responsible and therapeutic courses of action. However, a number of issues remain for further research. First, there are no studies that systematically investigate the actual dimensions of gifts received. Thus, the model presented in this article, which uses ethicality and level of therapeutic meaning as dimensions, requires empirical investigation. Second, future research is needed to systematically explore the experiences and practices of mental health counselors when interacting with clients who offer gifts to them. For example, it would be worthwhile to investigate the extent to which gift-giving occurs and how it varies according to gender, age, and culture or ethnicity of the client or mental health counselor. Finally, future research should explore the extent to which therapeutic responses to gift-giving vary depending on the (a) practice setting (e.g., pastoral, agency, private), (b) phase of treatment in which the gift is given, and (c) personal characteristics of the counselor. For instance, anecdotal evidence suggests that some therapists have numerous experiences with gift-giving clients whereas other counselors report few or no such experiences. Given that situations and attached meanings can be quite personal and idiosyncratic, case study or qualitative models might be well-suited to explore many of these identified research questions. Clients' welfare would be promoted as increased attention is given to these commonly occurring therapeutic events.
Table 1 Categories of Gifts LEVEL OF ETHICAL CONCERN Relatively Low Level of Ethical Concern Relatively Low Level * Minimal Ethical Risk of Therapeutic * Low Level of LEVEL OF Significance Therapeutic Meaning THERAPEUTIC and Significance MEANING & SIGNIFICANCE Relatively High Level * Minimal Level of of Therapeutic Ethical Concern Significance * High Level of Therapeutic Meaning and Significance LEVEL OF ETHICAL CONCERN Relatively High Level of Ethical Concern * High Level of Ethical Concern; Risk of LEVEL OF Ethical Violation THERAPEUTIC * Low Level of MEANING & Therapeutic Meaning SIGNIFICANCE and Significance * High Level of Ethical Concern; Risk of Ethical Violation * High Level of Therapeutic Meaning and Significance Table 2 Ethical and Therapeutic Responses Based on Categorization of Gift LEVEL OF ETHICAL CONCERN Relatively Low Level of Ethical Concern 1. Reflect client affect, behavior, and situational content Relatively Low Level 2. Self-disclose of Therapeutic personal thoughts Significance and affect 3. Choose to accept or not accept LEVEL OF THERAPEUTIC MEANING & SIGNIFICANCE 1. Seek clarification through questioning 2. Reflect client affect and behaviors 3. Self-disclose thoughts and affect Relatively High Level 4. Interpret meaning of Therapeutic and connect to thera- Significance peutic issues 5. Integrate gift-giving into treatment process by using gift as symbol, metaphor, or metaphorical object 6. Choose to accept or not accept LEVEL OF ETHICAL CONCERN Relatively High Level of Ethical Concern 1. Seek clarification 2. Reflect client behavior, affect, and situational content 3. Self-disclose personal thoughts and affect 4. Provide information regarding ethics of accepting specific gift 5. Decline gift, while LEVEL OF exhibiting positive THERAPEUTIC regard and warmth MEANING & SIGNIFICANCE 1. Seek clarification through questioning 2. Reflect clients affect and thoughts 3. Self-disclose thoughts, affect and rationale for not accepting gift 4. Reframe as and connect with therapeutic issues 5. Explore deeper meaning of gift using Socratic questioning 6. Process directly and metaphorically
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Mark S. Gerig is an associate professor of Counseling and Psychology, Bethel College, Mishawaka, IN. E-mail: firstname.lastname@example.org
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|Author:||Gerig, Mark S.|
|Publication:||Journal of Mental Health Counseling|
|Date:||Jul 1, 2004|
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