new boundaries need to be put in place to protect the client and the therapy relationship, including potential referral to another provider. The overlapping relationship should be discussed with the client and documented in the chart. These situations highlight that not all encounters outside of the therapy office constitute an ongoing, involved relationship. The
central question in any dual or multiple relationship situation to consider is whose needs are being met, the client’s or the therapist’s. Brownlee and colleagues (2019) note that any time a dual relationship has occurred, the therapist should self- reflect and consider the specific circumstances surrounding the boundary crossing, including frequency and intent.
BOUNDARY CROSSING: GIFTING
A boundary crossing situation that is seemingly benign and that is frequently faced by the clinician is the giving and/or accepting of gifts to or from a current client. Appropriate gift-giving is a boundary crossing that may potentially enhance the therapeutic relationship. Inappropriate gift giving moves into the realm of a boundary violation. Gift-giving is a nearly universal way of showing gratitude, appreciation, respect, and caring toward others. It is not uncommon for clients to offer gifts to providers, especially around traditional holiday times or at the conclusion of treatment. Many providers also choose to give a small gift or token to their client at various times. Any exchange of a gift must be considered in terms of appropriateness due to type of gift, value of the gift, timing in treatment, intent of the gift-giver, and perception by the recipient of the gift’s purpose. How gifts are given or received in the context of a therapeutic relationship requires careful consideration as this seemingly benign act of a boundary crossing may have a significant impact on the provider, client, or both. Gifting is typically viewed as a boundary crossing and, as such, is addressed directly or indirectly by the ethics codes of many professions. For those fields where the code of ethics does not specifically address the issue of gifts, ethical considerations can be inferred. For example, the APA Ethical Principles (2017) and the NASW Code of Ethics (2021) do not directly discuss gifts but are clear about prohibiting exploitation of the client, they have several sections addressing the issue of multiple relationships, and they also state that the provider must, above all, strive to do no harm. The ACA Code of Ethics (2014) is more specific and states counselors must take into account the monetary value of the gift, the client’s motivation for giving it, and the counselor’s motivation for wanting to accept it. The AAMFT Code of Ethics (2015) states that therapists must consider the potential effects that receiving or giving gifts may have on clients and the efficacy of the therapeutic relationship. The NBCC Code of Ethics (2023) is even more specific by stating “Counselors shall not accept gifts from clients except in cases when it is culturally appropriate or therapeutically relevant. Counselors shall consider the value of the gift and the effect on the therapeutic relationship, and acceptance of a gift shall be documented in the client’s records” (Standard 21). Other professions take an even stricter stance on gifting. Witts and colleagues (2020) note that the ethical code for applied behavior analysists forbids giving or accepting gifts from clients as this act moves into the realm of friendship and therefore is an example of a multiple relationship. However, even with this clear directive in place, if a complaint is lodged against the therapist, the intention of the gift-giving (e.g., culture), the judgement of the clinician, and the possibility of causing harm to the therapeutic relationship if the gift is declined are taken into consideration. Appel (2023) states that any interaction that moves beyond the traditional therapy boundary, including a gift exchange, must be examined in terms of intentionality and risk–benefit, and the therapist and client should have the same understanding of the motive and purpose of the situation. He notes that the justifications for accepting a gift from a client must be to help the client feel empowered through expressing gratitude and to avoid offending the client by rejecting the gift. The justification for accepting must not be mainly for the therapists’ benefit. It is critical for the therapist, when accepting a gift, to not allow the act to compromise care or create a bias in that clients’ favor over other clients that cannot or do not offer gifts.
There are different types of gifts that can occur. Gifts can be symbolic of a particular thought, feeling, or situation. These are quite often of minimal monetary value but of greater emotional value. Gifts can be appropriate or inappropriate based on emotional or monetary factors as well as due to the timing in the therapeutic relationship, the frequency of giving, and/or the intent of the giver or intent of the recipient. Even small gifts with little monetary value may be inappropriate, for example, if they have a romantic or sexual theme. Small gifts from clients which are symbolic, have minimal monetary value, and are given at appropriate times like at a holiday or termination of therapy are among the most common and mostly uncontroversial types of gifts. The therapist must consider all of the factors, including the culture of the client, when deciding to accept a gift, as turning down such gifts may mean rejection or disrespect to the client in some situations (Zur, n.d.). The main consideration when accepting or giving a gift is the welfare and emotional safety of the client. Accepting a minor gift, such as homemade brownies or an appropriate inexpensive token item, while technically a boundary crossing, typically does not cause an ethical dilemma. The therapist should consider the context, perception, and motivation of the client: ● 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 therapeutically 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.
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Book Code: PYFL4024
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