New article from the Zur Institute:

This is a special season of celebration and sharing. For many people gift exchange is an enjoyable and meaningful practice. As therapists, we can take a clinical and ethical pause for contemplation, and remember that giving or receiving a gift between psychotherapists and their clients can promote positive effects toward clinical goals. Gift-giving during the holiday season is very common and can be a clinically enhancing way to share in the celebration and natural expressions of appreciation.

(We had such a positive response to this email last year, we thought we would send it again this holiday season. Many of you have already read it. Nevertheless, it might be worth reviewing or sharing with others.)

Similar to touch, greeting cards, home visits, attending a graduation, or bartering, gift-giving and receiving in the therapeutic relationship, if done appropriately and ethically, is likely to provide a sense of bond and warmth, which are the best predictors for positive therapeutic outcomes.

In my own practice, I receive and give gifts throughout the year - on special occasions, to commemorate a successful therapeutic relationship, a graduation or many more moments worth marking. The holidays are an especially ripe time for this: last season, I received a toy car from a teenage client who was allowed to get his license due to the impressive work he did in therapy. A Jewish client gave me a loaf of challah (traditional bread), and a Christian client gave me a tree ornament she made herself. In the same season, I gave a special card to a Christian client for whom Christmas is a time of bonding, a DVD on religion to a client who had just begun seminary study and a rock from Jerusalem to a client for whom the holidays bring up difficult memories.

Here are some points to remember:

Giving a gift is an ancient and universal way to express gratitude, appreciation, altruism, and love.

Appropriate gifts in therapy are ethical and enhance authentic therapeutic relationships, which is the best predictor of therapeutic outcome.

Rejecting clients' clinically appropriate gifts is likely to be perceived as personal rejection, or even as insult. It may harm the therapeutic alliance or end therapy.

Remember that practicing rigid and cold, so-called, 'risk management' by rejecting all gifts from all clients can be harmful to clients and counter clinical.

Gifts in therapy can be symbolic (e.g., a poem, drawing, or card) or concrete (e.g., a DVD, book or rock from Jerusalem).

Therapists do not need to always explore the meaning or unconscious motivation of the gifts with clients. Sometimes just a simple "thank you so much" is sufficient.

An agency's standard of "no gifts policy" does not resolve the negative impact on a client, who is likely to experience it as rejection or insult.

The meaning of gifts can only be understood within the context of therapy.

Gifts can be appropriate or inappropriate with regard to their type, monetary value, timing, content, intent of the giver, perception of the receiver, and their effect on the giver or the receiver.

Symbolic and appropriate gifts from children to therapists or therapists to children are very common and are usually clinically appropriate.

Sometimes even very inexpensive gifts can be inappropriate, such as those with sexual or racially offensive connotations.

While some gifts in therapy are expressions of appreciation and gratitude, they can also be a way:
to level the playing field between therapists and clients
to "buy" love
to counteract negative feelings (e.g., given to the therapist after a disagreement)
to create indebtedness or manipulation

Appropriate therapists' gifts to clients may include:
a symbolic gift (e.g., a card that has meaning to the client)
a gift that serves as a transitional object (e.g., a rock from the office rock collection)
a clinical aid (e.g., a note from the therapist with a specific saying, as a way to help a client who is dealing with anxiety)
therapy-related educational materials (e.g., a CD on mood swings for a bi-polar patient)
giving an affirming or acknowledging gift (e.g., a small or symbolic graduation or wedding gift)
a supportive, reassuring gift (e.g., giving a flashlight to a child-patient who is going on his first overnight camping trip)
an affirmation of the relationship (e.g., a small/symbolic souvenir from a trip abroad)

Clinically appropriate gift-giving is ethical and clearly falls within the standard of care.

Understanding the meaning of gifts in therapy requires a look at the context of therapy and special attention to the client's culture, timing of the gifts, client's history, patterns in regard to gifts, and the nature of the therapeutic relationship.

Cultural aspects of gift-giving must always be taken into consideration.

Timing of gifts is important. While an appropriate present at termination is common, a present at the very beginning of therapy may need more careful examination.

Wealthy clients are most often aware of the significant impact of their wealth on other people and, therefore, therapists should be careful when dealing with expensive or inexpensive gifts from wealthy clients.

Excessive gifts, gifts by a client who has a history of buying love through gifts, gifts by a borderline patient who regularly oscillates between love and hate, should not be accepted uncritically.

Examples of unethical and clinically inappropriate gifts include:

stock market investment tips
large financial loans are most often unethical as they are likely to result in conflicts of interest

None of the major ethics codes declares all gift exchange as unethical.

Therapists should consult with experts when they receive gifts as a bequeath upon the death of a client.

Document gift exchanges in the clinical records. If possible, greeting cards, paintings, poems, etc. should be part of the clinical records. Articulate briefly who gave the gift, exactly what the gift was, what the response to the gift was, and any related discussions with the client. When appropriate, add a clinical note about your thoughts and interpretations of the meaning of the gift.

Consult in complex cases and document the consultation in the clinical records.