Exposure therapy here.

At least, I will be exposing myself to all my readers. But hey, it's the least I can do when all the other times I am exposing other therapists, therapy itself, and other stuff to my loyal (and not-so-loyal) public.

What's this about, you want to know? Gift-giving. And gift-getting.

Now that the end of the year is upon us, and clients all over the world are pondering whether or not they should be giving their therapists end-of-the-year gifts, I am totally ashamed to say that my very strong reaction to any gift has always been NO.

This issue actually originally came up this past Purim.

As a therapist, I never thought that my reaction was odd, until I received an email from a friend who is involved with girls who have lost a parent. And she informed me that on their group chat there was a heated discussion going on about whether or not to give their therapists mishloach manos. When I unequivocally stated my stance of NO, she passed on my reaction to the chat, and the girls insisted she ask me why, I figured I would do a little research to back up my point of view and deliver my answer from a position of strength that I am right.

Well, I was wrong.

After my research, both through scholarly articles and through pop culture opinions and blogs, I found out that nobody agreed with me. And that my stance was outdated, therapeutically invalidating, and—believe it or not—unethical in its rigidity.

So I swallowed my pride, and told those girls so.

And now I am telling you.

There is absolutely no code of ethics around gift-giving. As a matter of fact, the written code of ethics for most mental health disciplines don't even talk about giving gifts. If there is any mention it is simply to bring awareness that like anything else in therapy, we have an accepted mandate as therapists to do no harm, and to avoid exploiting clients in any way in order maintain the integrity of the therapeutic alliance.

The American Counseling Association (ACA), which does mention gifts in its code, does not forbid it but rather while cautioning the therapist to be cognizant of the issues surrounding gift-giving, states in section A.10.f.: Receiving Gifts: "Counselors understand the challenges of accepting gifts from clients and recognize that in some cultures, small gifts are a token 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."

If there is any concern about gift-giving, it is more about therapists who generally have inappropriate boundaries in which accepting gifts may lead to more serious breaches; or for therapists who are being attacked in lawsuits for inappropriate boundary crossing, and accepting gifts seems to be another indication of that; but otherwise accepting gifts if not considered an issue in the ordinary course of events in a therapist's practice.

So why do many therapists, me included, have this negative, visceral response to receiving gifts? Why, before I did my due diligence in research, did I want to hang up a big sign in my office asking clients to refrain from any gift-giving including mishloach manos?

I cannot speak for all therapists, but I can speak for myself. And I will. And then, armed with the information from this column, you can fight this issue out with your own therapist. Or, appreciate your therapist for not having the hang-ups I do (did!) about receiving your gifts; or, reconsider the gift-giving that has been happening between your and your therapist as potentially unhealthy. And even wonder about yourself that you have never even considered—or wanted—to give your therapist a gift. All, or none, are grist for the therapy mill that you may consider. But don't mention my name, darling. I have enough therapists annoyed at me because of my articles.

So let's first talk about which types of gifts are acceptable and appropriate and which are not (and why not).

Gifts that show appreciation, gratitude, caring, and affection (okay, okay, LOVE) are perfectly acceptable. That would include stuff like cards or poems (which are symbolic gifts; they are not gifts per se), or small tokens of appreciation. Stuff like homemade food or craft/art, a CD, a book, a trinket, or shmuntskeh. And these would apply to any gift given for a holiday or occasion, like mishloach manos, a birthday, or the like.

Believe it or not, research shows that such gifts actually enhance the therapeutic work and are positively connected to therapy outcome. Research also shows that rejecting a gift can negatively affect therapy and be really, really offensive to a client (duh!). There are some cultures in the greater world—and within the religious community—in which gift-giving is more prevalent and there is heightened sensitivity around the whole issue. I definitely notice some religious sub-cultures which routinely give gifts in my practice that manifests from a cultural norm of demonstrating gratitude and appreciation in that manner.

When talking about which types of gifts are not appropriate, a few things are involved. First, expensive or extravagant gifts are not acceptable, even if the client is so wealthy that a thousand dollar pocketbook is pocket change to her (pun intended! I'm awful, I know). Simply because wealth has an impact, and the therapy may be subtly changed by such an exchange. This is not rocket science, my dear readers, as we are all aware of these subtleties whether we pretend to or not.

Wealthy clients, however, may not know how to give little gifts, or feel it's degrading to give a dollar gift to their therapist (personally, I don't have these problems), so sometimes, when it is therapeutically appropriate, a compromise can be reached in which a wealthy client can donate a sum they want to the tzeddakah (anonymously, of course).

But it is not only the gift itself that may be a problem, but the timing, motivation, or content.

It's like this.

A gift given when a client and therapist are working together for a while and have a strong therapeutic alliance would make sense; it would make less sense if a client has seen the therapist only a few times. The timing can appear suspect and give clues to the inappropriateness of a gift; for example if a client gives a gift after a difficult session, after storming out in anger. The gift is then probably motivated by fear of the therapist's anger or upset, as a means to smooth things out, avoid the work of therapy, or following a pattern of appeasement the client has suffered all her life. Not gratitude, affection, or caring at all.

Even when a client gives a gift at the appropriate time, as in mishloach manos, the motivation of the gift-giving may not be clear. Is the client buying her therapist's love? Trying to create an indebtedness in her therapist or control in some way? Equalizing the relationship? Or trying to counteract negative feelings she may have towards, or experiencing from the therapist? Hmm. Not as simple as you thought, huh?

Lastly, a gift, no matter how insignificant, is improper if the content is vulgar, racist, bigoted, or has inappropriate innuendos.

It's definitely a challenge to any therapist when being presented with a gift that falls under the above categories, because the gift may need to be rejected; but if there is a rupture in the relationship as a result, it needs to be addressed as any other therapeutic rupture that has the capacity for increased therapeutic work.

A good rule of thumb for a therapist when accepting gifts that fall under the okay category is to express sincere appreciation for the gift, but eventually to explore the meaning behind it. It's a part of therapy as much as anything else is.

So for any clients—(or readers, siblings, parents, friends, and neighbors)--that did not get a chance to give me mishloach manos, just know that I accept small gifts like fancy cars, trips to Hawaii, diamonds, and Pesach in Italy. I do not need any pocketbooks. Except for the kinds that have cash in it. It will be very good for the therapeutic relationship. (Just kidding! I'm still in Purim mode!)

originally published in Binah Magazine


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