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Ethics Boundaries  continuing education psychology CEUs

Section 16
Ethics: Client Gift-Giving in Counseling

Ethics CEU Question 16 | Ethics CE Test | Table of Contents | Boundaries
Counselor CEUs, Social Worker CEUs, Psychologist CEs, MFT CEUs

The Extent and Nature of Client Gift-Giving in Counseling
Webster's Third New International Dictionary (Gove, 1993) defines a gift as "something that is voluntarily transferred by one person to another without compensation" (p. 953). The inherent value of the gift might be monetary, but can also be psychological and symbolic. The recipient knowingly recognizes its gift status and accepts it as such. There is no prior claim upon the gift by the recipient. In addition, the recipient is under no obligation to pay for it in the future.

It is not unusual for mental health counselors to receive gifts from clients, although few studies have been conducted to investigate this phenomenon. In a review of the professional literature, only one empirical investigation on the gift-giving behavior of clients was found (Spandler et al., 2000). Another investigation examined the gifts received by physicians from their patients (Drew, Stoeckle, & Billings, 1983). Anecdotal evidence accrues from informal discussion with colleagues, who reveal numerous occasions of gift-giving. For example, one female client, who was typically scheduled at the dinner hour, frequently brought in food items such as strawberry pie or pizza to share with her mental health counselor. Another client, whose spouse worked for a snack distributor, would bring in bags of chips or pretzels that had reached their shelf life expiration date.

Sometimes, the practice of gift-giving does not take place in such a straightforward manner. One client gave her mental health counselor a large photo album containing a number of family pictures. Another mental health practitioner, working for a nonprofit agency, reported that a client donated a large quilt for an agency fund-raiser and had attached to it a poster-sized note thanking the mental health professional for her excellent service. In each case, the gift item was dropped off at a time when the mental health professionals were in session with other clients.
Drew et al. (1983) identified three general categories of gifts. First, gifts are often seen as a type of tip to the professional. The underlying motive of the gift-giver in this case may be likened to the restaurant diner. The client, who is pleased with the personalized service, degree of tolerance displayed, and timeliness of service seeks to compensate the mental health professional for providing service that is beyond the call of duty. Second, gifts are given to address a perceived imbalance in the professional relationship. For example, a store manager, upon an improved level of functioning, might give her counselor a gift certificate that is redeemable at her store. Such a gift may help the client regain status that was temporarily lost during her increased sense of dependency during a major portion of her counseling. Third, the gift might serve as a payment of homage or sacrifice to the mental health professional (Drew et al.). In such cases, the client sees the mental health counselor as using professional power on his or her behalf. For example, it might be through signing of appropriate forms by the mental health counselor that the client is entitled to specific benefits such as special housing, worker's compensation, or Supplemental Security Income. Gifts received in such circumstances can be viewed as the client giving thanks with a gift, similar to primitives paying homage to their god for a plentiful harvest.

Sometimes, gifts offered by clients mark specific events or transitions (Spandler et al., 2000). For example, a client may give the mental health counselor a gift at their last scheduled session. Or a gift and card might be given in relation to a holiday or birthday. Gifts of these types might be related to culture and the gender. In one study, it was reported that the majority of such gifts offered to counselors were given by female clients (Spandler et al.).

It is useful and appropriate to consider gift-giving as a form of communication. Spandler et al. (2000) speak of the meaning of gifts. For example, gifts come into being as a result of the will and intention of the gift-giver (Camenisch, 1981). And, in accepting the gift, mental health counselors implicitly acknowledge the giver's will, intention, and reasons for giving it. In addition, giving gifts is a common way of expressing and strengthening one's social attachments (Schudson, 1986). It is a socially acceptable way of communicating gratitude and eliciting positive emotions from the receiver. Gifts are used to buy love and soothe feelings of guilt. Gifts are a way of restoring a balance of power within a relationship (Camenisch). It is likely, though, that the client's meanings and intentions are implicit and may even be beyond the awareness of the gift-giver.

Gifts can also be distinguished by the depth of meaning attached to them. Thus, it is useful to view the various types of gifts as lying along a continuum. At one end of the continuum, gifts received from clients can be considered as a form of ritualistic behavior. Wolin and Bennett (1984) distinguish between family celebrations and traditions. Although a party is a celebration, traditions include holidays, weddings, funerals, and other rites of passage. Frequently, the giving of gifts by clients accompany occasions in the counselor-client relationship that can be construed as traditions. For example, Shapiro and Ginzberg (2002) describe the use of "parting gifts" as a termination ritual in group therapy. Such gifts carry with them an intended meaning that is conveyed in an overt and intentional manner. The meaning and significance of the gift is readily perceived through an accurate perception of the situation and accompanying verbal behavior of the gift-giver.

On the other end of the continuum, giving gifts serve as metaphors. In these instances of metaphorical communication, it does not suffice to literally interpret the gift or the interactive process surrounding the giving and receiving, because as Searle (1993) notes, the literal meaning calls into mind another possible meaning. Metaphors work by taking concepts that are not normally associated and juxtaposing them in a meaningful way that illuminates the similarity that exists in some way between them (MacCormac, 1985). In the example of the client who gave her counselor a family photo album at the termination of treatment, a deeper meaning might be related to unresolved issues of transference.

Ethical and Therapeutic Issues
The Code of Ethics of the American Mental Health Counselors Association (AMHCA, 2000) does not specifically address the topic of gift-giving by clients. It does, however, discuss the related issue of bartering. Bartering raises concerns about therapeutic boundaries and multiple relationships, as does the issue of clients' gift-giving (Corey, Corey, & Callanan, 2003). In contrast to gift-giving by clients, bartering is the exchange of goods or services without the exchange of money. Like gift-giving, bartering is not prohibited by codes of ethics. But mental health counselors ordinarily refrain from the practice because such arrangements create potential for conflicts, exploitation, and distortion of the professional relationship (AMHCA).

It is the potential for exploitation and distortion of the professional relationship that make the receiving of gifts from clients an ethical concern. Yet, a dilemma occurs as mental health counselors also are called upon to respect the dignity and worth of clients (AMHCA, 2000). In addition, being a gracious receiver is an accepted social protocol. To do otherwise is to negate the giver's experience of the "blessing" that supposedly comes with giving. And the refusal to accept a gift could communicate rejection of the client and that could result in a diminished view of self.
On the other hand, many examples can be noted where the act of giving gifts may not be in the best physical or psychological interest of the client. For example, gift-giving can, in fact, be a feature of the clinical picture for clients with dependent or borderline personality disorders. The mental health counselor passively accepting a gift from such a client may reinforce patterns of manipulative or self-debasing behaviors that are symptomatic of the problematic levels of functioning. In such instances, mental health counselors must discern which course of action is truly in the client's best interest.

Several principles of AMHCA's Code of Ethics (AMHCA, 2000) have implications for mental health counselors in client gift-giving situations. First, Principle 1 states that the "primary responsibility of the mental health counselor is to respect the dignity and integrity of the client. Client growth and development are encouraged in ways that foster the client's interest and promote welfare" (Principle 1.a.1). In addition, it warns that mental health counselors guard against the misuse of the influence they possess by virtue of role and position. To do so, mental health counselors must be aware of the degree of influence they have by virtue of their professional role (Principle 1.a.2). Thus, mental health counselors do well to recognize and respond to such underlying motives in ways that enhance the client's dignity and self-respect rather than reinforce his or her sense of inferiority.

The potential for exploitation exists when a real or perceived power differential exists in the therapeutic relationship. The gift becomes a cue that increases the mental health counselor's awareness of the power differential and can influence specific therapeutic decisions. For example, if I must adjust my schedule of appointments for a particular day, I might be more inclined to reschedule the client who has given me a gift. Or the decision to reschedule the client may be founded upon the socially accepted meaning of a gift (e.g., a sign of liking and appreciation; a willingness to please). Thus, my decision to reschedule the gift-giving client, rather than another client, reflects my attempt at identifying the path of least resistance. Because of having been offered a gift in the past, 1 assume that this specific client will not mind. On the other hand, mental health counselors may be more inclined to compromise agency policy related to no-shows and cancellations when the offending client happens to be one from whom the mental health counselor has received gifts in the past. The motive for such a show of grace on the part of the mental health counselor, in this latter case, might be more out of reciprocity than client need.

By being a gracious receiver of the gift, the accepting behavior of the mental health counselor can serve as a powerful reinforcer of the gift-giving behavior. Thus, when in similar conditions, the client's gift-giving behavior may tend to recur. Such was the case when a clients brought in a number of packages of snack products. The client's partner worked for a food distributor, leaving the client with an abundance of these tasty morsels whose expiration date had just passed. Staff fussed over the client's thoughtfulness, and, consistent with opérant principles, the client continued to bring cartons of snacks even when the mental health professional communicated that the behavior was not warranted or needed. By accepting gifts without question, mental health practitioners may or may not be acting in ways that are truly supportive of the client's welfare. It is clear that in many cases such determinations cannot be made without a consideration of the underlying intentions and motives of the client and counselor as well as the dynamics of the therapeutic relationship. Therefore, constructive therapeutic responses can be identified only upon first considering the therapeutic implications of the gift alongside the ethical concerns.
- Gering, Mark S.; Receiving gifts from clients: ethical and therapeutic issues; Journal of Mental Health Counseling, Jul 2004, Vol. 26, Issue 3.

Personal Reflection Exercise #6
The preceding section contained information on receiving gifts from clients. Write three case study examples regarding how you might use the content of this section of the Manual in your practice.

According to Drew et al., what are the three general categories of gifts? To select and enter your answer go to Ethics CE Test.

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