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Should therapists accept holiday gifts?

Gift-giving in the therapeutic relationship.

December brings the annual pleasures and challenges of holiday gifts and how to deal with them in dynamic psychotherapy. Although it is relatively easy to follow a simple rule about this, ideally a good deal of thought goes into a therapist's decision about whether to accept a patient's holiday gift. Below I will give a couple of examples of this from my own practice, and how psychodynamic theory guided my response.

All beginning dynamic therapists are taught not to accept gifts from patients. This rule follows from the principle that the therapist should decline all gratifications from the patient aside from the fee paid. A therapist who is swayed by the patient's generosity, physical attractiveness, political connections, or other factors invites a conflict of interest in himself, and thus risks distorting the therapy in pursuit of his own needs and desires. Accepting a gift would be an example of this. Afterwards, the therapist may feel disinclined to challenge the patient, to induce anxiety or point out a contradiction. Conversely, the patient may feel the therapist should reciprocate the generosity, leading to disappointment and possibly anger when the therapist fails to do so.

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Naturally, patients often do not know this rule, thus some arrive to a year-end session with a gift in hand. These gifts vary. Some are expensive, some less so. Some are "for the office," others intended more personally for the therapist. Some are homemade, or reflect something personal that had been discussed earlier in the treatment, while others are more generic. Likewise, the nature of the treatment varies from patient to patient, from relatively supportive and concrete, to very "uncovering" transference-based therapy. Given these variables, there is room for some discretion in the no-gifts rule.

A number of years ago I treated a woman who painfully described feeling unvalued by others. Men only appreciated her because she gave them sex; her employer did not value her as a person, but only for her productivity. Our therapy was fairly psychoanalytic in nature. Arriving to a session around the holidays, she handed me a large, beautifully wrapped gift box. It looked store-bought and expensive. I imagined she had taken significant time and trouble to purchase and bring it to me. With some apprehension I told her that we needed to discuss the gift before I could accept it. She was initially hurt by this. However, it soon became clear to both of us that her gift reflected her belief that I, like others in her life, did not value or appreciate her as a person - she hoped I would value the gift and therefore her. On that basis I thanked her but did not accept her gift, a decision she ultimately understood and agreed with.

It turned out very differently with another patient, an older Russian woman who saw me for supportive therapy. Around the holidays she presented me with a bottle of Kahlua, unwrapped if I recall. We had not been working with transference; I did not see how such a gift could damage our work. Also, it is customary in Russia to offer such gifts to one's doctors. I accepted the bottle with thanks, and pleased my patient. No harm done, and perhaps a bit of good in strengthening our working relationship.

Most dynamic therapies lie between these two extremes, somewhere in the midrange of the analytic-supportive continuum (more about that here). I have accepted inexpensive gifts in such cases, except when I sense that the offer is an unhealthy enactment, or that the patient is sidestepping a useful exploration. As is often the case in conducting dynamic psychotherapy, there is a balance between fostering a warm working relationship, versus encouraging reflection and insight. In my view, a blanket rule of refusing all gifts is unnecessarily cold and inhuman for many patients, while accepting all gifts may appear "normal" but does not encourage reflection, and may introduce conflicts of interest. The matter takes case-by-case consideration, neither unthinking acceptance nor unyielding refusal. It should go without saying that I never expect to receive a gift; it's also helpful to note that most patients do not offer them.

Occasionally the opposite issue proves useful to explore: Whether the patient expects (or wants) me to give him or her a holiday gift. As we all know at this time of year, both gift-giving and gift-receiving tap deep emotional aspects of our personalities, and sometimes highlight conflicts around themes of self-interest, self-sacrifice, guilt, generosity, reciprocity, and one's value in the eyes of others. I do not offer my patients holiday gifts, but I do wish them, and you, Happy Holidays.

© 2010 Steven P Reidbord MD  All rights reserved.

Steven Reidbord, M.D., is a psychiatrist and psychiatric educator, and chairs the Continuing Medical Education Committee at California Pacific Medical Center.

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