Why Patient Gift Giving Can Be An Ethical Dilemma

Holidays are the giving season. Beyond family and friends, many people choose to “give a little something” to those who have provided some service or support throughout the year. 

But what about a patient gifting to her therapist? Is it ever appropriate?

A summary on the topic published in the Journal of Psychotherapy noted that Sigmund Freud himself accepted gifts from patients. While explicitly warning against gift exchanges between patient and therapist in either direction, the founder of modern psychotherapy often accepted gifts and other special considerations from patients through all stages of treatment. For example, one patient presented him with an express letter from the Minister of Education, announcing Freud’s appointment as professor.

Here’s what the professional codes of ethics offer has to say on the topic.

The American Association for Marriage and Family (AAMF)

Section 3.9 of the AAMF’s ethics code states, “Therapy Marriage and family therapists attend to cultural norms when considering whether to accept gifts from or give gifts to clients. Marriage and family therapists consider the potential effects that receiving or giving gifts may have on clients and on the integrity and efficacy of the therapeutic relationship.”

The American Counseling Association (ACA)

ACA’s code of ethics notes that small gifts from a patient are an expression of  respect and gratitude. “When determining whether to accept a gift from clients, counselors take into account the therapeutic relationship, the monetary value of the gift, the client’s motivation for giving the gift, and the counselor’s motivation for wanting to accept or decline the gift,” its guidelines state. 

The American Mental Health Counselors Association (AMHCA) 

The organization’s code of ethics advises counselors to make sure they are aware of, and understand, the cultural norms of each patient in relation to their fee arrangements, bartering, and gifts. Therapists should clearly explain all financial arrangements related to counseling, including gift giving, early on in the therapeutic relationship.

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National Association for Addiction Professionals (NAADAC)

To summarize the NAADAC’s point of view on this topic, mental health providers should make every effort to avoid creating multiple relationships with a client, but when a “dual relationship is unavoidable, the professional shall take extra care so that professional judgment is not impaired and there is no risk of client exploitation.” When a counselor does accept a gift, they should document the transaction in the patient’s records along with any resulting outcomes, the association suggests.

The National Board of Certified Counselors (NBCC)

This is the only other major mental health professional organization that appears to have explicit guidelines on receiving patient gifts.  It warns that in general, the practice is a no-no. However, the board does concede that small tokens of appreciation are acceptable if the exchange fits within a patient’s cultural norms or has therapeutic relevance. “Consider the value of the gift and the effect on the therapeutic relationship when contemplating acceptance,” the organization’s guidelines advise. “This consideration shall be documented in the client’s record.”

American Psychological Association (APA)

Though the APA doesn’t offer specific advice on whether or not gift giving by clients is kosher, it asks the therapist to consider if accepting a present could potentially harm the patient. In other words, evaluate on a case-by-case basis. 

What the studies say

There is virtually no literature that examines how gift giving may affect the patient or the therapeutic process. One Marquette University paper sought to at least understand what therapists do when faced with the gift-giving dilemma. 

In a survey of the limited literature available, the researchers found that most therapists accepted gifts worth less than five dollars, whereas most never accepted a gift worth more than $50. Nearly 80 percent of the respondents considered accepting client gifts worth under $10 to be ethical under some or most conditions. In contrast, the majority of respondents considered it unethical to keep a gift worth more than $50.

The paper also found that gift giving by patients was rare, but when it did occur, female patients were the most likely to show up to an appointment with something in hand. Most gift givers also included a note of gratitude. In 90 percent of the cases, the therapist accepted the gift. Only exceedingly expensive items were nearly universally rejected. 

Is it appropriate to give your #psychiatrist a holiday gift? (If you answer yes, tell us what gifts are acceptable or that you would love to get from a patient.)

— Psychiatrist.com (@PsychiatristCNS) December 14, 2022

The bottom line? Should you be presented with carefully wrapped boxed-and-bowed token, most professional organizations agree you may accept it so long as it isn’t over the top and doing so won’t cause any harm to the patient. Consider the value, intent, and nature of any gift, and document all such transactions in the patient’s notes, including any effect it has on the therapeutic relationship. To avoid misunderstandings, think carefully about your gift policies and make sure your patients are clear about your stance right from the get go.