Just a Little Something I Made for You: Gifts in Psychotherapy

Thanks to my supervision group for exploring this issue so openly and frankly in discussing their responses and thoughts on gifts as part of our supervision session. This has led me to summarise some of these thoughts and add a few of my own that I thought might be useful for other students and supervisors to think about.

Gifts in psychological treatment are complicated. They inevitably arouse conflicts and emotions within the therapist including:

• Pleasure, feeding of self-esteem, specialness, feelings of approval

• Conflict and anxiety to accept or not to accept

• Guilt about accepting gift:  I want to but I am not allowed but maybe just this once

• Guilt about rejecting the gift: I will hurt the client, they will disapprove, become angry, punish me, I may not be able to cope with their rejection

• Anger how dare they intrude on my boundaries, how dare they put me in this conflict.

Why do clients give gifts?

Clients may have a genuine appreciation of the therapist. At times of significant change clients may what to genuinely acknowledge the contribution the therapist has made to their lives.

Clients may want to test the boundaries of the relationship with the therapist.Clients may attempt to bind the therapist to them. I have given you a gift now you owe me. Clients may want to see how far they can personalise the relationship with the therapist. Gifts may be given at times in attempt to make the therapist  “be nice” to avoid confronting certain issues or themes i.e. to buy the therapist off. They can be a defence or an attempt to ward off perceived therapist anger or criticism A need to feel special may underly some gift giving.A gift may be an attempt to become more special in the eyes of the therapist. Gifts made by the client may reflect “look at what a clever boy/girl I am”. Gifts may be an attempt to personalise the relationship with the therapist and balance the power in the relationship.

Gift giving may have a masochistic or serve the purpose of confirming an underlying negative schema. Clients may give gifts knowing they will be rejected.

Gifts can be an expression of unexpressed feelings about therapy.A client of mine gave me a book of crossword puzzles to do over my holidays.  Cross words = angry words.  How dare I go and leave him for 4 weeks.

Some ideas on handling gifts

Gifts must be acknowledged.

You have brought me a gift/present

Gifts in general should not be accepted although see the debate below

I know it is important to you that I accept your gift.  We have a policy at the clinic of not accepting gifts

The positive intent behind the gift should be acknowledged first.

You feel coming to see me as really important  in your life and you felt a need to acknowledge this with a gift.

The trick is to acknowledge and accept the meanings behind the gift but not the gift itself.

I wonder if the your gift doesn’t also have some other meanings?

Some general musings on gifts

If you do decide that accepting a gift is ok what types of gifts will you accept and not accept

• Are gifts under 10.00 OK under 20 under 50 under 100?
• What kinds of gifts are OK? Are flowers, wine and food acceptable?
• Is a carving acceptable?  What if the carving is erotic or violent?
• Is it OK to accept gifts at the start of treatment, part way through or at the end?
• Are cards OK even at the end of therapy.  Even these can be problematic.  One client gave me a card of a half dressed woman standing over a man in stylised modern art. Did I think that termination was successful; no I did not.
   

My own thoughts:  Gifts even at the end of therapy usually indicate some lack of resolution on the part of client with termination.  A message to the therapist to "never forget them" to make them still special in the therapist’s eyes.  On another level they may reflect also genuine appreciation for what has happened in the therapeutic process.  Their complexity is that they are multidetermined. Gifts part way through therapy are always likely to be problematic either accepting or refusing will raise issues that need to discussed and processed.

Clearly the nature of many gifts is symbolic: Carved totems, pictures clearly representing the therapy journey or intrapsychic conflicts or resolutions.  Food and drink. (nurturance) Growing plants (growth) and surprisingly often blankets with personal embroidery are not uncommon gits.

Interestingly some state level code of ethics in the USA ban the acceptance of gifts.  However both the American Psychological Association (APA) and the Australian Psychological Society (APS) appear to have no comment on how to manage this issue.

Comments

[Yvette Vardy]

Why are we, as therapists, afraid of being "misunderstood", by accepting a gift when we are unsure what the client means by giving the gift? Should we not be equally afraid of how the client might interpret the refusal to accept a gift?

Rejecting a gift out of fear seems quite a defensive reaction. Gift giving can be an appropriate and effective way of showing appreciation, so why put up a wall around that method of expression rather than any other method of expression? Why is the verbal expression of gratitude so much "safer" than a gift?

[a client]

So interesting!

I'm new to this therapy thing, and it seems to be a very unique relationship. I take a pottery class in between sessions, that has helped reduce my anxiety quite a bit.

I was thinking that a mug made in class would make the perfect christmas gift -- since it's not expensive and it represents the work I'm doing, which I'm grateful for.

I never even considered that this would create some kind of moral dilemma for my therapist. But this makes me stop and think.

I guess I'll ask first!!

[Marcia Naomi Berger, LCSW]

As a psychotherapist, I have occasionally been in the position of being offered a gift by a patient My training stressed the importance of not accepting gifts during the course of treatment because of the likelihood that doing so will, in the long run, interfere with the effectiveness of the therapy.

While it is tempting to provide immediate gratification to the giver by accepting the gift, it does push the boundaries and distort the frame of what therapy is and should be about. Accepting a gift during a course of treatment subtlely implies a different kind of relationship. Therapy is not a friendship where gifts are often accompanied by expectaions of some sort of reciprocation. Such expectations may be counterproductive to the patient. The patient may feel off the hook about bringing up difficult subjects or feelings in session, thinking unconsciously that the therapist owes him or her that "out" as a quid pro quid. And the therapist may either unwittingly succumb to that expectation or exert too much energy to counteract a natural desire to reciprocate in a way that is not in the best interest of the patient in the long run.

When a gift is offered during the course of psychotherapy, I acknowledge appreciatively the feelings of gratitude to me that it expresses, but explain that it is not my policy to accept gifts because I believe that the patient will get more out of therapy when I do not accep them. The discussion that follows between my patient and myself, particularly when the patient feels rejected, can have profound implications for the patient's healing and growth that will translate into more fulfilling relationships with others outside of the therapy office.

[Ofer Zur, Ph.D.]

Giving gifts is an ancient and common and human way to express gratitude, appreciation, and care. Gifts in psychotherapy and counseling are very common and often take place around the holidays, with children-clients, in termination, at an important junction of therapy. Therapists not only receive gifts they also may give gifts. Usually therapists' gifts have clinical significance and involve appropriate symbolic gifts, greeting cards, transitional objects, or psycho-educational material, such as books, audiotapes or CDs. Appropriate gifts by therapists to clients and by clients to therapists are ethical and can benefit the therapeutic process.

As my paper at http://www.zurinstitute.com/giftsintherapy.html discusses, rigidly rejecting clients' gifts can be insulting and harmful to therapy, especially to children and certain cultures.

[gift to the Philippines]

I recently came across your blog and have been reading along. I thought I would leave my first comment. I don't know what to say except that I have enjoyed reading. Nice blog. Anyway, I'm been looking for topics as interesting as this. Looking forward to your next post.

-pia-

[a member of the public]

Overall you make some interesting points, but I have the feeling this shouldn't have been posted on a 'public' forum... It seems a little insensitive (for example the comment you made about 'a client' who gave you the 'cross words' gift - If I were that person and read it here I would feel like my trust and right to privacy have been completely betrayed!)
I understand that this blog is more for professionals than 'clients', but it is a 'public' space after all...

[Angelina]

I thought of giving a handmade card to my therapist and doctor? Both of them have been really kind and i wanted to give them something like a handmade card to show my appreciation. Now that i know i'll be leaving for good and not see my therapist again makes me sad. He's a grandpa figure to me :(

do you think if i ask to take a picture of them will be offensive / unprofessional / conflicting etc. ? I wanted to make a scrap book of people who had helped me through tough times. I thought it will be good for me. It will be a reminder for me that life is worth living.

[Send Flowers to France]

Lovely flowers! Wish I can also arrange beautiful flowers like that. I want to learn how to arrange flowers cause it so interesting. Anyway, I enjoyed reading this post. Thanks for sharing!

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You have good insight on the topic, i have bookmarked your site. I have to show my mate this.

[oil mill]

The patient may feel off the hook about bringing up difficult subjects or feelings in session, thinking unconsciously that the therapist owes him or her that "out" as a quid pro quid. And the therapist may either unwittingly succumb to that expectation or exert too much energy to counteract a natural desire to reciprocate in a way that is not in the best interest of the patient in the long run

[Femmes russes]

A good blog! I was thinking that a mug made in class would make the perfect christmas gift -- since it's not expensive and it represents the work I'm doing, which I'm grateful for.

[coach outlet]

well done!thank you for your comments!

[newport]

Fabulous article!

http://www.newportpsychotherapy.com/index/list_index.html
Kaynaz Nasseri’s psycho-therapy practice is built on a broad range of training and knowledge that allows her to address a wide variety of issues, some of which include relationships, mood, school concerns, life transitions, and other psychology issues. Her approach to psychotherapy and psychological assessment is warmly interactive, providing support, insight and useful feedback to help one resolve difficulties and achieve one's goals.

[Coach Factory]

well done! we hope you can give us more useful opinion!

[newport]

Nice post....

My psycho-therapy practice is built on a broad range of training and knowledge that allows me to address a wide variety of issues, some of which include relationships, mood, school concerns, life transitions, and other psychology issues. My approach to psychotherapy and psychological assessment is warmly interactive, providing support, insight and useful feedback to help one resolve difficulties and achieve one's goals. http://www.newportpsychotherapy.com/index/list_index.html

[Calvin Klein]

thank you1

[Camarad]

I think, this theme is quite actual now. The patient may feel off the hook about bringing up difficult subjects or feelings in session, thinking unconsciously that the therapist owes him or her that "out" as a quid pro quid. And the therapist may either unwittingly succumb to that expectation or exert too much energy to counteract a natural desire to reciprocate in a way that is not in the best interest of the patient in the long run.

[Sara]

I'm in my last few months of school for social work and this topic has come up a few times.
It is so important to reflect on cultural differences before rejecting a gift.
Also, it can be really shaming to deny a gift. Clearly, there are some gifts that are inappropriate, ie-sexual gifts, but often times clients just want to show appreciation with a small gift during holiday season or at termination. I wouldn't jump to the conclusion that the client had issues with termination because they gave a gift. I would definitely want to explore it with my client but at the end of the day, I would probably accept it because I would never want to shame a patient.

[Jason Segel]

Thanks for this post! Thanks to my supervision group for exploring this issue so openly and frankly in discussing their responses and thoughts on gifts as part of our supervision session. This has led me to summarise some of these thoughts and add a few of my own that I thought might be useful for other students and supervisors to think about.

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