Healthcare Training Institute - Quality Education since 1979
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Ethical and Therapeutic Issues
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.
Assessing and Responding in Gift-Giving Situations
In light of the discussion above, a model for assessing gift-giving situations can be put forth. Clients' gift-giving behavior can be viewed as lying along two dimensions. The first dimension relates to the ethical implications of receiving the gift. On this dimension, gifts can range from having little or no ethical implications to being unethical. Receiving gifts from clients can also be viewed as lying on a second dimension related to the therapeutic meaning of the gift. Gifts, on this second dimension, can range from possessing relatively low to high levels of therapeutic meaning. When viewed in this manner, gifts can be seen as falling into one of four categories.
Many gifts presented in the context of counseling fall in the category of carrying a low level of ethical concern and therapeutic meaning. Receiving cards (e.g., Christmas, Passover) and inexpensive gifts often fall into this category. For example, one client gave the mental health counselor a paperback book with a card at their final session. On such occasions, the gift can be received with a brief collaborative exploration of the client intention and meaning followed by a genuine "thank you." Little therapeutic gain is achieved by attempting to excavate a deeper meaning for the gift, and such explorations can, in fact, be seen as communicating disrespect to the client.
In contrast, a second category might be gifts characterized as relatively low in therapeutic significance, but the acceptance of them may border on unethical behavior. For example, as a genuine show of appreciation for services rendered, a client might attempt to give to the therapist a very expensive set of books at the final session. At some point, accepting such gifts can be construed as a tip, and so become exploitive. Although not desiring to be inappropriately confrontive, mental health counselors do well to take some time and process the behavior, feelings, and underlying meaning associated with the giving of such an expensive gift in order to avoid the potential for unprofessional or unethical behavior or for unintentional harm to be inflicted upon the client.
In the third category, gifts presented by clients may, on the surface, appear to raise few ethical issues. But, upon exploration of the client's underlying intentions or motives, a deeper meaning is revealed. For example, a child may draw a picture and bring it in as a gift to the therapist. It is a mistake to simply accept the drawing without considering underlying motives, thoughts, and feelings of the child. Such events can be the occasions where the child is actually conveying important and powerful feelings that can be identified and related to other themes emerging in the treatment process. As Beier and Young (1998) note, powerful social conventions associated with gift-giving and receiving can lead mental health professionals to choose paths that limit therapeutic effectiveness in such situations (e.g., routinely responding as a gracious receiver and, in doing so, relinquish the role of mental health counselor).
Finally, it may be unethical to accept a gift that also carries a high level of therapeutic meaning. Take, as an example, a female client and male therapist. The client stalked the mental health counselor to discover where he lived. She, later, stopped by the house and attempted to initiate a personal relationship, stating that the therapist would be given "a night he would remember." To accept this gift, of course, would be highly unethical. Yet, it was vital that the counselor explore the deep meanings and motives beneath the client's behavior in order to discern the significant therapeutic implications. Seeking supervision or consultation with an experienced colleague is an important way of maintaining objectivity and developing therapeutic responses in such situations.