● 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
Giving or receiving gifts for referrals should be avoided. It is considered a kickback and is viewed as unethical by professional ethics codes and may even be illegal in some jurisdictions. The APA Ethical Principles (2017) states that when psychologists 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.
BOUNDARY CROSSING: BARTERING
Bartering is another area that poses a potential multiple relationship and boundary crossing. Bartering is considered the exchange of goods, services, or other nonmonetary renumeration from clients in return for therapy services. It is also part of the societal norm in many cultures and communities. Bartering is a boundary issue as it is outside of the normal therapy parameters for payment (self-pay, insurance). The exchange of specific goods is a boundary crossing. The bartering for the exchange of services, however, also creates a secondary relationship outside of the therapeutic one and therefore also constitutes a dual relationship that must be navigated. Bartering is not specifically prohibited by professional codes or regulations in limited circumstances, provided that it is not clinically contraindicated and that it does not result in an exploitative arrangement. However, it is strongly discouraged by all professional ethics codes. ● APA (2017) states that psychologists may barter only if it is not clinically contraindicated and the resulting arrangement is not exploitative (Standard 6.05). ● NASW (2021) states that social workers should avoid accepting goods or services as payment for professional services because bartering arrangements create the potential for conflicts of interest, exploitation, and inappropriate boundaries. This code specifically states that bartering should take place in very limited circumstances and only when it is an accepted practice among professionals in the local community and is negotiated without coercion (Standard 1.13). ● ACA (2014) limits counselors to barter arrangements only if they do not result in exploitation and are an accepted practice in the community. The cultural implications must be discussed, and there must be a clear written contract documented. This code also adds that the barter arrangement must be requested by the client, inferring that it is not acceptable for it to be suggested by the counselor (Standard A.10.e). ● AAMFT (2015) states that the client must request the arrangement. The bartering arrangement must not be exploitative, the professional relationship must not be distorted, and there must be a clear written contract. ● NBCC (2023) states that counselors generally do not accept goods or services in return for providing counseling services. They enter into a bartering arrangement only when no other referrals are possible or appropriate, the arrangement is
discussed with the client in advance, the barter exchange is of equivalent value, the exchange does not place the counselor at an unfair advantage, the arrangement is not harmful to the client, and it is documented in the counseling services agreement (Standard 20). The ethics codes of these professions specifically address the issue of bartering since bartering constitutes a boundary crossing and it could therefore be exploitative due to the power disparity between therapist and client. The primary question is whether accepting goods or services in exchange for therapy services increases the potential for conflict of interest or exploitation or harm to the client. On the surface, entering into a bartering agreement may seem beneficial at times, for example, when the client is experiencing hard economic times. Entering into a bartering agreement, however, can potentially lead to problems in the therapeutic relationship. What happens if the client does not fulfill their part of the barter? What if services by either party do not meet the other parties’ expectations for quality or timeliness? A better option when the affordability of therapy services is an issue may be referral to a lower fee option or use of a sliding scale fee schedule. The issue of exploitation becomes apparent when values for the barter are assigned. Is the value for the therapist’s time and expertise placed at a higher level than the client’s part of the barter? Who sets those values? The risk of exploitation is quite high and suggests that the barter arrangement could easily move into the realm of a boundary violation rather than a nonharmful arrangement. When considering expanding a boundary to include bartering, the trading of goods or services which have known cost estimates has been suggested. Therapists have standard fees that they charge—a known cost. Providing therapy services at that fee rate in exchange for a service that also has a known cost may appear to be an equitable arrangement. For example, the therapist could provide therapy at the normal fee rate for as many sessions as necessary to equal the known cost of a house painting job. While on the surface this seems to be a fair agreement, this arrangement commits the therapist and client to a future number of therapy sessions that may not be needed. It may cross into the realm of exploitation if the therapist works on a sliding scale and would have charged the client a lower fee rather than full fee.
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