Managing Professional Boundaries _ ____________________________________________________________
• Turning down a small gift may mean disrespect to a client whose culture stresses the importance of the gift-giving ritual, and this could lead to unintended therapeutic roadblocks. • Gift-giving in therapy can be an expression of appreciation and gratitude, but it can also have more negative motivations. For example, a gift by a client may be an attempt on their part to level the power differential in the relationship, or it may be a way of counteracting negative feelings after a disagreement with the therapist. • The timing of the gift has implications. Receiving a gift from a client at the termination of therapy likely has a different meaning than a gift presented at the start of therapy. • The frequency of gift-giving should be considered. The underlying motives for excessive gifts from a client should be explored in therapy. Situations where the clinician gives a gift to the client have received minimal attention in the literature and are not addressed in the ethics codes. A small clinically relevant gift is not unethical in and of itself. Appropriate clinician gifts to a client may include a symbolic gift like a card, a small gift that serves as a transitional object at the termination of therapy, or a therapy-related educational item like a workbook. However, the therapist must stay aware of their motives when providing the gift and also consider the client’s perception of its meaning. Is this boundary crossing clinically or therapeuti- cally relevant? Also, consider whether the gift-giving gesture places pressure on the client to reciprocate in some way. The therapist should be mindful that if the giving or receiving of a gift is accepted, the gift exchange should be documented in the client’s clinical record. Briefly document who gave the gift, what the gift was, what the response to the gift was, and any related discussion with the client about the meaning of the gift. This documentation provides clinical relevance for the boundary crossing. Remember that while it may be important to discuss the meaning and purpose of a gift, this should be done in the context of all considerations. Sometimes a simple “thank you” is more appropriate than an extensive discussion which could trigger feelings of guilt, shame, or insult on the part of the client. Giving or receiving gifts for referrals should be avoided. It is considered a kickback and is viewed as unethical by profes- sional ethics codes and may even be illegal in some jurisdic- tions.
The APA Ethical Principles (2017) states that when psycholo- gists pay, receive payment from, or divide fees with another professional other than an employer, payment is based on the services provided and not based on the referral itself (Standard 6.07). The NASW Code of Ethics (2021) states that social workers are prohibited from giving or receiving payment for a referral (Standard 1.16). The ACA Code of Ethics (2014) states that it is an “Unacceptable business practice” for counselors to participate in fee splitting, or to give or receive commissions, rebates, or any other form of renumeration when referring clients for the professional’s services (Standard A.10.b). Noted psychology educator Ofer Zur (n.d.) offers numerous helpful guidelines for gift giving in counseling and therapy. These include the following: • The therapist should examine their own attitudes, thoughts, and feelings about gifting within the therapy relationship. • Appropriate gift-giving is a boundary crossing but is not inherently unethical or a boundary violation. • Do not indiscriminately reject all clients’ gifts as the gift may be culturally and otherwise appropriate. • When given a gift by a client, assess its meaning, symbolism, and appropriateness while considering timing, client culture, client diagnosis, and the context of therapy. • Even in situations where the therapist chooses to not accept the gift, its meaning and intent must be explored with the client. Focus the discussion on the meaning and process of gift-giving rather than the specific gift itself. • If the therapist chooses to give a gift to a client, treat it as any other boundary crossing and make sure that it is done with the client’s welfare in mind. • Document all gift exchanges in the client’s chart, including what the gift was, what the response was, and any related discussions about the gift. • Do not hesitate to use consultation in complex cases or in situations where the therapist is uncomfortable with the situation. Self-Assessment Quiz Question 3. When considering accepting a client’s gift, the therapist should: A) Consider the timing of the gift B) Consider the monetary value of the gift C) Consider the client’s intent for giving the gift D) All of the above
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