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. 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. ● 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.
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