The Ethics Corner

FOR IMMEDIATE RELEASE
The Ethics Corner
Excerpt from FREEDOM November-December 2006

Ethics Chair - Jennifer Delmhorst Berton, M.S.W., CADC II
'Tis the season of gift giving… or is it?

The question of whether or not to accept gifts from clients is another complicated dilemma that challenges the minds of many a clinician. What is your policy about gift giving? What, if any, is your agency's policy about gift giving? Here are some common answers I hear:

I accept gifts from my clients. I don't want to hurt them by saying no. I accept gifts only when they are graduating from the agency. It is their way of thanking me for helping them and I think showing gratitude is a positive behavior we should support.2. I accept a gift only if it is something that the whole agency can enjoy (e.g., food, flowers, etc.).3. I accept a gift only if it is food.4. I accept gifts only if they are handmade.How am I supposed to turn down a gift that they made? As long as they didn't spend money on it, it's ok.5. Certain cultures communicate thanks through food sharing and it would be rude of me not to accept. Since I strive to be "culturally competent" I don't want to offend anyone's culture, therefore I accept gifts when clients are from those cultures.6. I only accept gifts from clients in private, never in front of other clients or staff.7. I only accept gifts from clients of the same sex. I don't want other clients to get the wrong idea.8. I assess the individual offering the gift, some clients I accept from because it is an important part of their therapy, and some clients I decline because it would not be helpful therapeutically.9. I accept cards from clients since they are not really gifts.10. I never accept gifts from any client. I tell them "I'm not allowed to" and leave it at that.

So which is the correct plan of action? Well, the first thing as always is to go to the Ethical Code. When you do that you will notice that gift giving is not specified. Although there is an important section on Remuneration for Services (see Principle 11), personal non-financial gifts are not clearly discussed. This is because gift giving was thought to be a personal choice, dependent on your personal tier of ethics, or an agency choice, dependent on the agency's tier of ethics and rules of conduct. However, this only makes it possible to have ten different responses to the same question, and it would be helpful to the profession and all of us in it if we could clarify a plan of appropriate action.

If you are following a good ethical regime, your first two questions should be: a) what is his or her intention in giving me this gift and b) what is the effect on the client if I accept his or her gift? Both of these questions are important to consider, and usually difficult, if not impossible, to answer with certainty. The first asks you to consider his or her motivation for giving you the gift. Is your client able to separate the boundaries necessary in a clinical relationship? In other words, what is the difference for them between giving a gift to a friend, a significant other, or a clinician? Is there a difference for you? The second asks you to consider what the client's response will be if you accept the gift. Will he/she be confused about your relationship? Will he/she think that there is a special bond that was not there before? The problem with gift giving and receiving is that it is important to know a client's motivations, and to plan for his or her reactions, before accepting any single gift. And how can you know these things? A client may tell you that he/she only wants to thank you, but really there is a hidden meaning perhaps they don't even understand. I'll give you an example:

Years ago, I was working in an outpatient clinic, and a client I had been working with for 3 years was graduating. At the end of the group on her last night, she gave me a wrapped box. This client was aware of my policy of not accepting gifts, and before I could protest she explained that she had called staff and asked if this was an appropriate gift to give and had been told it was. (The agency had a policy of accepting gifts if they could be enjoyed by the whole agency.) I believed her - my first mistake, because in retrospect a good staff would have notified me of her phone call and their response to her. Since no such notification came, I should have been suspicious. I took the gift and opened it to discover a palm pilot! I immediately tried to return the gift to her, which sent her into tears and she ran from the clinic. Now I have the palm pilot burning a hole into my hands, and the client is no longer a client and is therefore not scheduled to be seen again to return the gift. After consulting with my supervisor, I was fortunate that the client agreed to come back in to meet with me. We discussed the gift and she was able to explain that the gift was a token of her personal attraction for me. Once this was out on the table we could together work on that issue, which was really the important clinical piece that the gift represented. I use this is an example of how her motivations appeared to be a simple thank you but was so much more than that unbeknownst to me. I also remember thinking that this was someone I had worked with for 3 years, and I thought her boundaries were firm and trustworthy, which was an unfair assumption on my part. I was treating her differently than I would have treated a client I had worked with for a short time, and that did not make me feel ethically good.

So going back to the ten options listed above, which is ethically correct? Have you guessed? If you guessed none of them, you would be correct! Really none of these answers takes the client needs and the professional boundaries into account effectively. Let's look at them:

• This answer is really more about the clinician not wanting to confront the client, and feeling awkward in giving the gift back. True, if you simply say no and hand the gift back to the client, you are at risk of hurting their feelings. But you can explain why you can't accept the gift in a way that minimizes that hurt.
• This is the most common response I hear, and a seemingly appropriate one. It is good for the clients to express gratitude, but there are ways they can do this that do not blur the boundaries between the client and clinician. Tell them if they want to thank you for helping them they should tell others about this agency, or let clinicians know good areas to put up clinic advertisements. Tell them a good way to express gratitude is to (safely) help someone else in recovery (Step 12). I often tell clients the best way they can express gratitude is to stay sober and keep working their recovery. It sounds hokey to some, but really it gets at what you want to express. Despite what they might think, we are not in the business of saving lives - we do not have that kind of power. Clients succeed because they fight for themselves. We help guide them and support them, but we can't do the work for them. And we don't want them thinking that they could not have done it without us; they can and need to continue the fight without us.
• This is a common agency policy. The problem, as my example shows, is that some clients can use this as a way to give you a personal gift. But more importantly, it gives the impression that giving a gift is acceptable form of saying thank you. Really you want to reserve gift giving for friends, family, and loved ones - clinicians should not fall into any of these categories. Therefore showing thanks in the examples listed above are better than baking brownies for the whole agency. This of course depends on your agency. Some clinicians have no problem setting the boundary of accepting gifts for the whole agency. This is fine, but can you be sure the clients are able to understand and maintain the same boundaries?
• Haven't you heard that the way to enter the heart is through the stomach? I know food items seem innocent enough, but food can be prepared with a lot more love than you realize. Depending on the client, cooking can be a very personal and intimate gift. Be careful about assuming it is no big deal. It is a gift like any other.
• Actually, a gift is a gift is a gift, meaning that there should not be distinctions between types of gifts. First of all, you may be able to understand the distinction but can you be sure your clients do? Second, a handmade gift often has more love poured into in, takes more time, is more personal, and can often cost money to buy the craft supplies. Also don't forget that if one client tries to give you a purchased gift and you decline, then accept a handmade gift from another client, will that first client understand the distinction? Will they feel you are playing favorites?
• This is a common response, and again at first glance it seems appropriate. But being culturally competent does not mean you have different rules for different cultures! Being culturally competent means you take into consideration the cultural influences in each of your clients, and discuss those influences with the client. It is a way of understanding, not excusing, client behaviors. If you are worried about being rude to a client given his/her cultural expectations, sit them down and explain that while you understand how his/her culture values food gifts, you need to adhere to the rules and traditions of the agency's culture, which doesn't allow for food gifts.
• Where you open the gift is not as important about whether to accept the gift or not. The gift is still a gift whether opened in private or in public. In fact, it can be safer to open gifts while other people are present, not necessarily in your conversation, but in the room. This can help prevent the boundaries from becoming blurred into a personal and not professional thank you. You may need to discuss the gift and why you cannot accept it in your private office, which is a more appropriate setting.
• Ah, this is clearly coming from a heterosexual clinician, but there are all sorts of intimacy you should be thinking about, not just one form. Obviously your clients could be homosexual or bisexual and be thinking of you in a sexual way, and the gift as a token of those feelings. But also gifts can be intimate without being about sex. Clients of any gender can become connected or attached to clinicians of any gender in more of an emotional than sexual way. These connections can be just as dangerous as sexual ones, and by accepting a gift you can be encouraging these connections.
• Usually treating clients individually is a good plan, but here is one area where it is not recommended. You should have a blanket policy about gift giving that is appropriate for most, if not all of your clients. Clients observe much of what happens in the agency and they often talk to each other. Consider the above example of declining a gift from one client and accepting one from another. You may have clinical reasons for doing this, but the declined client shouldn't know what those reasons are. What they see is you playing favorites, or that there is something wrong with them that would make you decline their gift. Be very careful here. You can actually do a lot of damage without intending to by treating clients differently. Even if you don't think two particular clients talk to each other, I would still strongly advise you not to treat clients differently in this way.
• Many clinicians accept cards feeling that it is a good way to support client expression and is not considered a gift. If clients send you cards, you can't send them back. But cards can also be dangerous. Think of what some clients write in a card. Taken out of context, those cards may suggest relationships that never existed. Sadly, I know several clients who were legally reprimanded - in some cases with serious consequences - largely due to cards found in the clinician's possession. If you receive cards from clients, share them with your supervisor immediately, then either destroy them or place them in the client chart for filing. Do not keep them in your personal or professional belongings.
• This may sound like the answer, as not accepting gifts from clients can be a good idea. But simply stating, "I'm not allowed to," is a good way of closing the issue for you, but not as good for the client. You want to explain why you can't accept this specific gift, but you want to explore what the gift means to the client, give them a chance to express in words what the gift was meant to express. This is therapeutically important for them as we have mentioned. You also want to suggest ways they can express gratitude as we have mentioned. Use the gift as a great therapeutic opening instead of immediately closing it. Then you will be both ethically and clinically astute.

In summary, think about the following things when creating your personal gift policy:

1. remember that a gift can bear a lot more meaning than is obvious to you. Accepting a gift can bear a lot more meaning than you intend;
2. have a policy that is true for all clients;
3. encourage (beg if you need to) your agency to develop a gift policy so that you have the support of the agency around you. In my experience, some clients will fight you on your personal gift policy and it can be helpful to explain that in addition to your feelings the agency has rules about gifts. This also helps if you are using your agency as a culture in the cultural example above;
4. explain your gift policy up front to clients in group or individual settings so there is no confusion. If your agency has a gift policy, make sure it is part of the intake paperwork so that clients can understand that policy from the beginning of treatment;
5. always be thinking of how to use these circumstances in a way that clinically benefits the client as discussed. There is often great clinical opportunity here; and finally
6. this article did not discuss the flip side of clinicians giving gifts to clients, particularly at graduations. The same rules of this article apply to that situation, and gift giving to clients is strongly discouraged. The exception is if your agency has a policy of giving graduating gifts to all clients that is clearly an agency and not a personal gift, e.g. a mug or pen with the agency name on it. Be very careful here, or you can be sending a message you do not intend.

Remember there are a lot of ways to give and receive the holiday spirit. Emphasize togetherness, family, support, love for others, and gratitude - all things that can be expressed without gifts. In the meantime, if you have any questions or comments about this or other articles from the past, please do not hesitate to email the ethics chair below or if you have new questions that need to be answered. We look forward to hearing from you!

Happy Holidays!

Please address any comments, concerns or questions to E-mail: Ethics Chair.

— Jennifer Delmhorst Berton, M.S.W., CADC II
Ethics Chair