ANNALS Nov/Dec 2002

THE PRICE OF A GIFT

Bruce Gross, Ph.D., J.D., M.B.A., DAPA

The giving and receiving of gifts as a simple expression of gratitude and affection isn’t so simple when it occurs in the context of a thezrapeutic relationship. Unlike other areas of possible violation of professional ethics violations, there are no laws specifically regulating the exchange of gifts between therapist and client. Even in the most extreme cases, the giving of gifts between therapist and client is generally an ethical issue or conflict rather than a legal one.

An incredible example of mental health professionals helping themselves to gifts occurred in the mid-1990s when a psychiatrist treated a very successful Hollywood producer for depression and drug-related problems. As part of her client’s treatment and in the midst of other serious ethical violations (including prescribing drugs to a diagnosed drug-addict), the psychiatrist recommended a trip to Hawaii for stress-reduction. With travel expenses paid by the client, the psychiatrist accompanied the client to Hawaii, charging $500 per hour, 24 hours per day (citing “on call” status) for the five-day stay. She charged to the client an additional $500 for two salon visits (including a massage and facial), $1,000 for new clothes, and $23,500 for jewelry purchased while in Hawaii. Five months later, the client committed suicide by a drug overdose. It was not until a surprising five years later that the psychiatrist lost her license during an administrative hearing of the Medical Board of California.

While such extremes should not need to be addressed, ethical guidelines related to a therapist giving and/or receiving gifts in general are provided by many, but certainly not all, licensing and professional organizations. In Section 1.18 of the Ethical Principles of Psychologists and Code of Conduct (1992), for example, the American Psychological Association advises, “Psychologists ordinarily refrain from accepting goods, services, or other non-monetary remuneration from patients or clients in return for psychological services because such arrangements create inherent potential for conflicts, exploitation, and distortion of the professional relationship. A psychologist may participate in bartering only if (1) it is not clinically contraindicated, and (2) the relationship is not exploitative.”

Similarly, in Section 3.10 of the July 2001 Code of Ethics, the American Association of Marriage and Family Therapists advises, “Marriage and family therapists do not give to or receive from clients (a) gifts of substantial value or (b) gifts that impair the integrity or efficacy of the therapeutic relationship.” While the guidelines of other associations and licensing agencies may not include specific directives regarding the exchange of gifts, that omission does not imply gift giving between therapist and client is ethical, or for that matter, unethical. In the event a therapist’s licensing agency is one that does not provide such guidelines, that therapist should consult with a qualified professional to determine how to respond, should the issue of gift giving arise with a client.

To avoid ethical violations and potential disciplinary action, therapists should consider the following questions when confronted with the issue:

1. What is the cost of the gift – is it expensive or beyond the means of the client?

2. Is the gift personal or impersonal in nature?

3. For what reason is it given (in conjunction with a holiday, birthday, termination of treatment, etc.)?

4. Can the gift, and the meaning behind it, be easily talked about?

5. Does the giving and/or acceptance of the gift further or hinder therapeutic progress?

6. If given by the therapist, is the gift such that there is an underlying message the client might misperceive?

In general, the giving and receiving of small, inexpensive, impersonal gifts are unlikely to lead to an ethics investigation of the therapist. As “small,” “inexpensive,” and “impersonal” don’t have universally accepted definitions, by maintaining a standard of practice that excludes gift giving and receiving, therapists can avoid potential ethical conflicts and disciplinary consequences. It’s far easier to deal with a client therapeutically regarding the rejection of an offered gift than with a licensing board.

In the event therapists choose to accept or give a gift, before doing so, they should consider if they would be able to explain their choice to an ethics board. If facing an ethics board or licensing board, the therapist must be able to clearly and reasonably describe and defend the therapeutic value of giving and/or receiving a gift with a specific client. If the therapist is unable to identify therapeutic value, or how the exchange would further therapeutic progress, s/he should not accept or receive the gift.

Regardless of the therapist’s choice, the event should be carefully documented in the client’s file. If a gift offered by or to a client is rejected, the express reason for doing so should be clarified. If a therapist accepts a gift, the client’s record should document the specifics of the gift, the significance of the gift to the patient and the effect on treatment. Whenever a client gives or sends a card, the card and the envelope should be maintained in the client’s file, as should any pictures given to the therapist by a client. These precautions need to be taken because, while a picture or card or gift may seem “inexpensive” and acceptable, the actual cost to the therapist can be quite high, including restricted use or loss of his or her license.