Eye on Ethics

’Tis the Season: Managing Client Gifts
By Frederic G. Reamer, PhD
December 2013

Raise your hand if a client has offered you a gift. That social work club has lots of members, especially this time of year. Did you accept the gift or politely refuse it because you thought accepting the gift might complicate the boundaries in your professional-client relationship?

The Gift That Keeps on Giving
Throughout social work’s history, practitioners have wrestled with the perennial challenge of gifts offered by clients. Clearly, some clients offer social workers gifts—often modest in value—as genuine expressions of appreciation with no ulterior motive or hidden agenda. A client may give the practitioner a home-baked bread or Christmas tree ornament at holiday time, an infant’s outfit when the counselor has delivered a baby, a framed poem that has special meaning to the client, or a piece of handmade pottery at the conclusion of treatment. Typically, these gifts represent tokens of appreciation—nothing more and nothing less. The client likely would feel wounded or insulted if the professional rejected such a gift on ethical grounds.

Then there are more complicated situations involving clients who offer social workers gifts of considerable value or gifts that represent a more complex practitioner-client relationship (sometimes from the client’s view, sometimes from the practitioner’s, and sometimes from both). Relatively affluent clients—and even clients of more modest means—sometimes will feel moved to give a practitioner a gift as a gesture of pure, unadulterated generosity.

In my experience, most clinical social workers agree that in many instances, especially when there is no evidence of ulterior motives that may lead to egregious boundary violations, practitioners may keep gifts of minimal value and emotional significance. As a matter of policy, some social service agencies permit staffers to do so, particularly when the gift is one that can be shared among staffers, although they may stipulate that staff members must thank the clients on behalf of the agency. This protocol can defuse the interpersonal dynamic and potential boundary confusion between the client and practitioner; depersonalizing the transaction may help staff members avoid complicated boundary issues.

Social workers face unique challenges when they receive gifts that appear to have no ulterior motive but could introduce complex boundary issues. Sometimes clients may not be consciously aware of the emotional meaning and significance—and the mixed messages and complications—that may be attached to a gift. Social workers sometimes face a difficult choice in these situations; the decision to reject a gift can have significant clinical repercussions because the client may feel hurt, wounded, humiliated, or guilty and the decision to accept a gift may trigger boundary issues that complicate and reverberate throughout the clinical relationship.

Ethical Judgments
In such circumstances, social workers are wise to obtain sound consultation and supervision to think through how best to handle the client’s gesture, including assessing the meaning behind the gift, ethical and clinical implications, potential responses and related consequences, and any risk management issues (e.g., related to potential ethics complaints and lawsuits). It is critically important to document the client’s gift and any related consultation and supervision to protect both the client and clinician.

In their book Preventing Boundary Violations in Clinical Practice, Thomas Gutheil and Archie Brodsky encourage practitioners to carefully consider several key criteria when deciding whether to accept a gift from a client:

• Monetary value of the gift: Inexpensive gifts are more likely than expensive gifts to be mere expressions of appreciation or personal consideration, although their potential symbolic meanings still must be considered.

• Handmade vs. purchased gifts: If a client makes the social worker a ceramic bowl as an expression of appreciation, it may be best to accept the gift while exploring its meaning. A client may be especially upset by the rejection of his or her own handiwork. At the same time, the clinical significance of such a gift is that it was made with the social worker in mind and therefore could be saturated with personal meaning and active fantasies, including perhaps the assumption that the gift would be accepted coupled with fear that it would not be. Thus, a handmade gift is all the more to be appreciated and all the more to be understood.

• Characteristics of the client: The clinical and ethical calculus with respect to giving or receiving gifts is different when the client is a child. Likewise, since gifts have different meanings in different cultures, the client’s cultural background is another contextual factor to be evaluated. The nature of the client’s unique clinical profile and challenges also is a factor. Managing gifts offered by clients who struggle with boundary issues in their personal lives can be especially complex.

• Type of therapy or relationship: Where the contract between a clinical social worker and client does not limit their interaction to words, a gift is not necessarily a breach of contract. In contrast, when a social worker is in a position of authority (e.g., a social worker who serves as a client’s probation or parole officer), it would not be appropriate to accept a gift, which could take on the appearance of a bribe even if it is offered innocently.

• Appropriateness of the type of gift: A homemade Christmas fruitcake generally is regarded as innocuous. Likewise, books or articles relevant to the clinical relationship may be appropriate when offered in a spirit of mutual interest or simple goodwill. At the other extreme, sexually suggestive gifts are clearly inappropriate.

• Stage of relationship: Early in the professional relationship, considerations of trust and therapeutic alliance building may argue for accepting a gift, at least provisionally, in marginal cases. On the other hand, early in the relationship it is also critical to establish and maintain a therapeutic frame strong enough to withstand the client’s wishes, fantasies, or bribes. Gifts at termination also raise special issues.

• Red-flag contexts: Anything out of the ordinary about the situation in which a client offers a gift should be documented and explored, and usually will rule out accepting the gift. Any circumstances indicating an expectation of a quid pro quo (a return of a gift or favor) also change the nature of the gift.

In Conclusion
Whenever a social worker seriously considers accepting a gift or favor from a client, of whatever value or tangibility, the practitioner should consult with thoughtful colleagues and supervisors, when feasible, and critically examine the clinical and ethical implications, including current ethical standards and agency policy, the client’s and practitioner’s motives, and any alternatives. The social worker should carefully document in the case record the client’s offers, the process the practitioner used to make the decision (e.g., relevant consultation and review of the NASW Code of Ethics), the nature of the decision, and the rationale. This documentation can prove to be enormously helpful if the client or some other party raises questions about the appropriateness of the practitioner’s judgment.

— Frederic G. Reamer, PhD, is a professor in the graduate program of the School of Social Work at Rhode Island College. He is the author of many books and articles, and his research has addressed mental health, health care, criminal justice, and professional ethics.