Attorney Articles | Understanding the Legal & Ethical Considerations of Gifts in the Therapeutic Relationship
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Articles by Legal Department Staff

The Legal Department articles are not intended to serve as legal advice and are offered for educational purposes only. The information provided should not be used as a substitute for independent legal advice and it is not intended to address every situation that could potentially arise. Please be aware that laws, regulations and technical standards change over time. As a result, it is important to verify and update any reference or information that is provided in the article.

Understanding the Legal & Ethical Considerations of Gifts in the Therapeutic Relationship

CAMFT Attorney Alain Montgomery, JD, takes a deep look into the various—and highly nuanced—elements that therapists must evaluate when receiving gifts from clients and when thinking of giving a gift to a client.

Understanding the Legal & Ethical Considerations of Gifts in the Therapeutic Relationship

Alain Montgomery, JD
Staff Attorney
July/August 2022


Introduction
Gift giving is one of many ways to demonstrate our sense of appreciation and gratitude, to celebrate someone or to mark in time a milestone or watershed accomplishment. This article will discuss the legal and ethical considerations that relate to gift exchanges within the context of the therapeutic relationship, predominantly from the perspective of when a client presents their therapist with a gift. However, it is important to note that the same legal and ethical considerations equally apply when a therapist gives a gift to their client.

Ethical Considerations
There is no outright ethical prohibition against the giving and/or receiving of gifts within the therapeutic relationship. However, in certain circumstances a therapist may be subject to an ethics complaint or formal discipline for the giving and/or receiving of gifts. Therefore, it is imperative to understand the applicable ethical standards that pertain to gift giving and receiving. Under the CAMFT Code of Ethics, marriage and family therapists have an ethical obligation to maintain high standards of professional competence and integrity.1 The Code of Ethics specifically addresses some of the factors therapists must consider when deciding whether to give or receive a gift within the therapeutic relationship. The CAMFT Code of Ethics states the following:

5.8 GIFTS: Marriage and family therapists carefully consider the clinical and cultural implications of giving and receiving gifts or tokens of appreciation. Marriage and family therapists take into account the value of the gift, the effect on the therapeutic relationship, and the client/patient and the psychotherapist’s motivation for giving, receiving, or declining, the gift.

As indicated by the applicable ethical standard, therapists are encouraged to be aware of and evaluate a host of interrelated and equally important elements to assess when presented with a gift from a client or when deciding whether to give a gift to a client. While the CAMFT Code of Ethics lists a number of factors, the guidance is not exhaustive. Therapists may need to consider other variables depending on the particular client, the therapist’s theoretical orientation and their practice setting. Let’s take a closer look at the considerations presented in the CAMFT Code of Ethics:

Clinical Implications
Whether or not a therapist chooses to accept a client’s gift, reject a client’s gift or offer a gift of their own, the therapist’s intent should be to ensure their response—and the manner in which it is communicated and handled— strengthens the therapeutic alliance, reinforces the effectiveness of therapy and enhances clinical outcomes.2 Here, additional relevant factors may need to be considered, such as, the client’s reasons for participating in therapy, the goals of treatment, the applicable diagnoses, the stage of treatment in which the gift is exchanged and the length and duration of the therapeutic relationship. Hence, a therapist must decide whether the overall clinical benefit of accepting an appropriate gift outweighs the risks to the therapeutic process if the gift is refused. It is recommended that therapists seek clinical consultation as a way to obtain objective feedback from colleagues about potential clinical implications.

While there are a myriad of clinical perspectives regarding appropriate gift related behavior, when a client presents a gift to a therapist, therapists are encouraged to understand the client’s reasons for giving the gift. It is acknowledged repeatedly in the empirical research and literature that:

“Gift acceptance without some attempt to understand its meaning from the patient’s perspective may bypass an opportunity to illuminate the patient’s subjective experience.” 3

It is important to accept that a client’s gift giving may not be well intentioned. A client’s motivation for giving a gift could be a way to express negative feelings or could be a manifestation of acting out. Where a client’s motivations are unclear, therapists are encouraged to process the various potential meanings and intentions that underlie the gift. When appropriate, it may be necessary or beneficial to explain to the client that their gift will be kept and that nothing will be done with it until there has been an opportunity to discuss what the gift represents.4 Such an approach may mitigate potential feelings of rejection the client may experience if their gift is declined. Also, this approach creates the opportunity and conditions to explore the underlying clinical aspects of the client’s gift giving inclinations or patterns.

Cultural Implications
Sensitivity to a client’s culture of origin is imperative because the cultural meanings of gift giving and receiving outside of the therapeutic context can provide deep insight and understanding about the meaning of a gift exchange within the therapeutic relationship. The CAMFT Code of Ethics encourages therapists to obtain knowledge and develop a personal awareness of their client’s cultural attitudes towards gift giving.5 For example, in some cultures exchanging gifts is a highly valued custom while in other cultures gift giving is unimportant. Having a cultural understanding of gift giving etiquette can help avoid misunderstandings which could result in a client taking offense when a gift is not acknowledged or accepted. In the article, “Reflections on Gifts in the Therapeutic Setting: The Gift from Patient to Therapist,” Andrew Smolar, M.D., writes:

“The therapist must weigh the degree to which the patient’s cultural traditions are influencing [their] inclinations regarding a gift at the time [they]...give something to the therapist...therapists should also gauge how open the patient will be, according to [their] culture of origin, to discussing the idea of gift exchange. Some cultures would consider such a discussion, even if the gift were not outright rejected by the therapist, insulting to the gift giver.”

Thus, it is important to understand how cultural nuances enter the therapeutic relationship through gift giving. Since gifts have different meanings in different cultures, therapists must strive to understand and respect the client’s cultural norms with respect to gift exchanges.

Value of the Gift
While there are no prescribed limits on the monetary value of a gift that make it appropriate to accept, the value of the gift is an important factor. With respect to considering the perceived monetary value or cost of a gift, it is generally accepted that small, inexpensive and appropriate gifts are neither clinically detrimental nor unethical.6 On the other hand, concerns may arise when a client presents a gift that is objectively high in value, expensive or costly because such gifts could be inappropriate to accept even if the client has the wealth or financial means to afford such a gift. Therapists must bear in mind that the value or cost of a gift is not determinative as to its appropriateness because even very inexpensive gifts or those without any monetary value can be highly inappropriate depending on their suggestive content or connotations.

Effect on Therapeutic Relationship:
Therapists have an ethical obligation to set and maintain clear and appropriate boundaries that prioritize therapeutic benefits, safeguard the best interests of clients and refrain from behaviors and actions that exploit the trust and dependency of clients or cause harm to clients.7 Understanding the importance of boundaries in therapy as they relate to gift giving is primarily the responsibility of the provider. As Smolar explains:

“Patients often begin treatment with only a limited understanding of their motives, and with a limited understanding of the ground rules of therapy...the beginning phase of treatment is typically marked by patients’ uncertainty about the treatment relationship.”8

Empirical literature suggests that a therapist’s approach and attitude towards gifts should focus on the welfare of the client. Therapists must evaluate and understand whether accepting or declining a gift would strengthen the therapeutic alliance, distort the nature of the professional relationship for either the client or the therapist or violate professional boundaries.

Even when considering whether or not to adopt a strict “no gifts” policy—which is not inherently unethical—therapists should examine how such a policy could potentially cause a client to feel rejected or humiliated. For example, when a client who has difficulty in outwardly expressing feelings of gratitude—or who has difficulty giving anything to anyone— presents a gift to their therapist because they feel the therapeutic environment is a safe space in which to do so, a therapist’s decision to not accept the gift could be damaging. Hence, the outright refusal to work with or to accept a client’s gift could undermine opportunities to have clinically valuable discussions, fracture the therapeutic rapport or stand in the way of therapeutic outcomes. However, therapists who work in group settings or clinics with strict “no gift” policies can rely on the company policy as a reason to decline a gift so as not to offend the client.

Psychotherapist’s Motivation for Giving, Receiving or Declining the Gift
A therapist’s exploration of their own motivation for giving, receiving or declining a gift must be investigated through interpreting the meaning of the gift. It has long been recognized that gifts within the psychotherapeutic relationship can at times have a deep symbolic meaning beyond what words can express:

“Gifts likely hold conscious meaning, as well. In this way, gift giving serves as a symbolic communication between giver and recipient...this communication via behavior rather than words heightens the chances of misunderstanding... gifts are viewed as unconsciously motivated representations of symbolic desires.”9

Thus, when a therapist is presented with a gift from a client it may be necessary for the therapist to explore and assess the gift’s meaning. Attempting to understand the meaning of the gift is a way to understand what the gift may symbolize. For instance, it is important to understand whether the gift is a mechanism or tool through which the client is trying to please, manipulate, triangulate, humiliate or even seduce the therapist. While it is certainly a delicate matter that needs to be handled with sensitivity and care, therapists can encourage and invite the client to share their experience of giving and receiving gifts and to talk about the meaning of the gift they present to their therapist. Understanding the client’s desire to give the gift—and the therapist’s own motivation for accepting or declining a gift—is a very important component of therapy. When a Therapist Gives a Gift to a Client As previously mentioned, it is important to note that when a therapist gives a gift to a client, all of the same ethical and therapeutic considerations that have been discussed equally apply. With respect to exchanges from a therapist to a client, Smolar writes:

“Think carefully about the sources of [your] own motives when you give something beyond what the patient has come to expect within the therapeutic relationship... therapists should be especially clear on the source of their motives...we should not forget that patients sit in a vulnerable position, and we must always try to remain aware of the manifold ways our actions may impact them.”10

Therefore, therapists need to be very clear with themselves about their own intentions when offering a gift to a client and to share that meaning with the client to make sure the client does not misunderstand the intent and meaning of the gift.

Legal Issues
There is no legal prohibition against the giving and/or receiving of gifts between a therapist and a client. However, this does not insulate a therapist from formal disciplinary action for either giving or receiving gifts. Let’s look at some examples of how gift giving and/or receiving within the therapeutic context gave rise to disciplinary actions against therapists and discuss their outcomes in the context of the relevant ethical considerations.

Case 1:
Summary of Relevant Facts: In this case, a licensee provided treatment to a client who was previously diagnosed with Borderline Personality Disorder (BPD). The licensee gave the client mixed messages throughout the years of treatment regarding the boundary of their professional therapeutic relationship. Specifically, the licensee gave gifts to the client and communicated with the client frequently through overly familiar and lengthy emails and text messages that would span hours outside of the face-to-face therapy sessions.

BBS Decision: The Board of Behavioral Sciences (BBS) determined that this licensee was grossly negligent, incompetent and demonstrated a lack of skill and knowledge regarding the importance of maintaining clear and consistent boundaries in the treatment of their client. The BBS held that the licensee engaged in a dual relationship with their client when they gave the client mixed messages throughout her years of treatment regarding the boundary of their professional therapeutic relationship and specifically when the licensee gave gifts to their client.11

Case 2:
Summary of Relevant Facts: In this case, a licensee rendered psychotherapy to an adult woman who was diagnosed with bipolar disorder, post-traumatic stress disorder, and polysubstance abuse and had a history of sexual abuse. The licensee gave multiple handwritten notes and cards to their client using emotionally charged words and also exchanged many gifts with their client. BBS Decision:The Board of Behavioral Sciences (BBS) determined that this licensee committed acts of gross negligence and incompetence and recklessly caused physical and emotional harm to their client. The licensee used unprofessional language and contact to foster a dependency through giving gifts to their client that ultimately harmed their client.12

Case 3:
Summary of Relevant Facts: In this case, Client X and her husband, Client Y, (Clients) began therapy with licensee. Over several years, Clients attended very intensive and costly therapy. Clients attended some social events with the licensee who asked Clients if they could store items at their home. In February of 2010, the licensee accepted a $20,000.00 check from Clients for prepayment of further therapy sessions. In June of 2010, Respondent accepted a $1,000.00 check as a gift from Clients. In July 2010, the licensee accepted a $30,000.00 check from Clients as prepayment of further therapy sessions. In September 2010, the licensee accepted a $3,000.00 check from Clients as a gift. In October 2010, the licensee accepted a $20,000.00 check from Clients as prepayment of further therapy sessions. In December 2010, the licensee accepted a $10,000.00 check from Clients as a gift. In 2011 the licensee was having financial trouble and was having his home foreclosed upon and Clients wished to help avoid that result. In June 2011, Respondent accepted a $200,000.00 check from Clients. Although there was a dispute about the nature of the $200,000.00 check, the licensee claimed it was a gift.

BBS Decision: The Board of Behavioral Sciences (BBS) determined that this licensee was grossly negligent and incompetent in the practice of marriage and family therapy when the licensee accepted significant sums of money as personal gifts from Clients. The Board concluded the licensee intentionally and recklessly caused harm to their client when they used the professional relationship to further their own interests, financially exploited their client and/or failed to maintain appropriate professional boundaries with their client and had unethical dual relationship(s) with their clients simultaneously with the therapeutic relationship, without taking sufficient precaution to ensure that exploitation did not occur.13

Discussion: The facts of these cases allude to the importance of maintaining appropriate boundaries to safeguard the interests of clients and refrain from behaviors that harm or exploit the trust and dependency of clients when gifts are exchanged. These cases illustrate how gift giving and/or receiving within the therapeutic context, if not handled appropriately, can give rise to a host of ethical dilemmas and legal ramifications. Using the ethical guidance to assess and evaluate the meaning, the symbolism and the appropriateness of a gift in the context of the client’s unique diagnosis is necessary to mitigate the negative impacts that both gift giving and receiving can have on a client. One of the above cases in particular emphasizes how the value of gift relative to the client’s ability to afford it is not determinative of whether or not those factors can still negatively impact the therapeutic relationship and lead to the exploitation of the client. Thus, it is imperative to understand the ethics around gift giving in the context of the therapeutic relationship to avoid causing undue harm to clients.

Conclusion
So, when you receive a gift from a client—or feel compelled to give a gift—as a token of either appreciation or celebration, may it be accepted and/or given with grace and gratitude in a way that is thoughtful, clinically appropriate and aligns with the ethical guidelines and legal standards of your profession. Take advantage of the opportunity to consult with colleagues when needed and err on the side of caution when appropriate.


Alain Montgomery, JD, is a staff attorney at CAMFT. Alain is available to answer member calls regarding legal, ethical, and licensure issues.


Endnotes

1 CAMFT Code of Ethics, Section 5. PROFESSIONAL COMPETENCE AND INTEGRITY, Preamble: Marriage and family therapists maintain high standards of professional competence and integrity.
2 Brendel, D.H., et. al., (2007) Harvard Review of Psychiatry, as cited in Zur, O., “Gifts In Psychotherapy & Counseling Ethics, Cultural and Standard of Care Considerations”
3 Hahn, W. K. (1998). “Gifts in psychotherapy: An intersubjective approach to patient gifts.” Psychotherapy, 35, 78–86 as cited in Zur, O., “Gifts In Psychotherapy & Counseling Ethics, Cultural and Standard of Care Considerations (Gifts in Psychotherapy and Counseling, by Ofer Zur, Ph.D. (drzur.com))
4 Id.
5 CAMFT Code of Ethics, Section 5.7 SENSITIVITY TO DIVERSITY: Marriage and family therapists actively strive to identify and understand the diverse backgrounds of their clients/ patients by obtaining knowledge, gaining personal awareness, and developing sensitivity and skills pertinent to working with a diverse client/patient population.
6 Zur, O., “Gifts In Psychotherapy & Counseling Ethics, Cultural and Standard of Care Considerations.” Retrieved from Gifts in Psychotherapy and Counseling, by Ofer Zur, Ph.D. (drzur.com)
7 CAMFT Code of Ethics, Preamble, Section 4: Dual/Multiple Relationships; CAMFT Code of Ethics, Sections 4.1: Dual/Multiple Relationships and 4.2: Assessment Regarding Dual/Multiple Relationships.
8 Smolar, A., “Reflections on Gifts in the Therapeutic Setting: The Gift from Patients to Therapist,” (2002) American Journal of Psychiatry, Volume 56, No. 1, pg. 12.
9 Knox, S., “Gifts in Psychotherapy: Practice Review and Recommendations,” (2008) Marquette University Publications.
10 Smolar, A., “When We Give More: Reflections on Intangible Gifts from Therapist to Patient,” (2003) American Journal of Psychotherapy, Vol. 57, Issue 3.
11 BBS Disciplinary Action. Case No. 2002016000247
12 BBS Disciplinary Action. Case No. 2002015001970
13 BBS Disciplinary Action. Case No. 2002016001955


This article is not intended to serve as legal advice and is offered for educational purposes only. The information provided should not be used as a substitute for independent legal advice and it is not intended to address every situation that could potentially arise. Please be aware that laws, regulations and technical standards change over time. As a result, it is important to verify and update any reference or information that is provided in this article.