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Ex} nI-L. a Ill“ 1 willMillil llllllll * ;, 3 1293 10789 092 LIBRARY Michigan State 5 University This is to certify that the dissertation entitled A Descriptive Study on the Phenomenon of Client-to-Therapist Gift Giving from the Perspective of the Psychotherapist presented by Martha Jeanne Barry has been accepted towards fulfillment of the requirements for Ph. D. degree in CounselingPsychology 4M” I Major professor Date ’0” 8? MSU is an Affirmative Action/Equal Opportunity Institution 0-12771 ‘bvisSI—J RETURNING MATERIALS: Place in book drop to LlBRARlES remove thls checkout from —:-—. your record. F__I____NES will be charged if book is returned after the date I stamped below. ‘ A. rd. n.- NVMM.» .M— .1 s. . muw.J-.—m-_—--..a w-.. A DESCRIPTIVE STUDY ON THE PHENOMENON OF CLIENT-TO-THERAFIST GIFT GIVING FROM THE PERSPECTIVE OF THE PSYCHOTHERAPIST By Martha Jeanne Barry A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Health Education, Counseling Psychology, and Human Performance 1987 DEDICATION This dissertation is dedicated to my mother, Luz Angelina Castellanos de Barry, who taught me the importance of giving from the heart. ii ACKNOWLEDGMENTS The motivation behind most gift giving becomes especially apparent to me when words do not seem sufficient to express gratitude. Nevertheless, I would like to thank Dr. Rochelle Habeck, my committee chairperson, for her constant guidance and encouragement throughout this research project. I would also like to express my appreciation to Drs. Donald Freeman, Richard Johnson, and John Powell for offering their expertise and assistance. Just as gifts are given more frequently on certain occasions, Lucero Barry, Ginny Duerst, and Fran Davis gave me love and support on the occasions when I needed it most. iii ABSTRACT A DESCRIPTIVE STUDY ON THE PHENOMENON OF CLIENT-TO-THERAPIST GIFT GIVING FROM THE PERSPECTIVE OF THE PSYCHOTHERAPIST By Martha Jeanne Barry In addition to gathering descriptive information from psychotherapists about the phenomenon of client-to-therapist gift giving, the purpose of this mail survey study was to explore responses to client gifts and the factors that influence decisions on whether or not to accept gifts. The interrelationships among response variables and psychotherapist professional and demographic characteristics were also investigated. A sample size of five percent (39243) was randomly drawn by computer from the American Psychological Association's Division of Psychotherapy (Division 29) membership list. The initial mailing was followed by three follow-up mailings for a return rate of 62%. Client-to-therapist gift giving tended to be described as a personal event where a client offered a token gift (usually hand-made) on a holiday or other special occasion. Psychoanalytic theorists have suggested that the "ideal" response to client gift giving was to recognize and interpret unconscious motivations behind a client's gift Martha Jeanne Barry and not accept the gift because this would interfere with the psycho- therapeutic process. However, the psychotherapists in this study were just as likely to recognize and affirm the conscious motivations of a client's gift (e.g., appreciation) and accept the gift which, from their perspective, usually enhanced the psychotherapeutic relationship. It was hypothesized that specific psychotherapist professional and demographic characteristics would be related to variables associated with therapist response to client gifts: anxiety, worry, and gift acceptance. A negative relationship was found between anxiety and years of experience. No other statistically significant relationships were found among these variables. No significant differences were found between specific subgroups of psychotherapists (e.g., gender, degree specialty) and the same response variables. Although the negative findings may have been due to measurement limitations, they may also have been due to the possibility that demographic and professional characteristics (with the exception of years of experience) may have little to do with how client gifts are responded to and managed. By far, the factors that were rated as most important in influencing decisions on acceptance or non-acceptance of gifts were related to the therapeutic process or relationship. TABLE OF CONTENTS List of Tables CHAPTER I: STATEMENT OF THE PROBLEM Need Purpose Definition of Terms Overview of Remaining Chapters CHAPTER II: LITERATURE REVIEW Gift Giving from an Interdisciplinary Perspective Client-to-Therapist Gift Giving Research and Theory on Psychotherapist Response to Client Gifts CHAPTER III: METHOD Subjects Design Instrumentation Procedure Data Analyses CHAPTER IV: RESULTS Sample Representativeness Summary of Descriptive Information Section One: Clients and Their Gifts Section Two: Psychotherapist Responses to Client Gifts Section Four: Critical Incidents Tests of Hypotheses Hypothesis One: Anxiety and Years of Experience Hypothesis Two: Worry and Years of Experience Hypothesis Three: Anxiety and Gift Training iv ix H \lO‘tI-‘N 25 46 46 52 54 63 65 68 68 68 69 72 80 108 108 108 110 Hypothesis Four: Worry and Gift Training Hypothesis Five: Gift Acceptance and Primary Theoretical Orientation Post Hoc Analyses of Other Variables Gender with Anxiety, Worry, and Gift Acceptance Academic Degree with Anxiety, Worry, and Gift Acceptance Specialty of Academic Degree with Anxiety, Worry, and Gift Acceptance Primary Job Affiliation with Anxiety, Worry, and Gift Acceptance Primary Theoretical Orientation with Anxiety, Worry, and Gift Acceptance Anecdotal Data Discussion Current Characteristics of the Phenomenon Relationship among Variables CHAPTER V: SUMMARY AND CONCLUSIONS Review of the Problem Statement Synopsis of the Literature Review Review of the Methodology Summary of the Results Summary of Discussion Limitations of the Study Implications and Conclusions Practical Implications for Psychotherapists and Supervisors Suggestions for Future Research APPENDICES REFERENCES 110 110 112 112 112 114 114 117 117 123 123 130 134 134 136 138 140 146 149 150 155 160 164 183 4-1 4-2 4-3 4-4 4-5 4-10 4-11 LIST OF TABLES Distribution of Sample by Gender Years of Post-Degree Experience Primary Job Affiliation' Primary Theoretical Orientation Distribution of First, Second, and Third Choices of Eclectic Theoretical Orientation Percentage of Time Conducting Individual Psychotherapy Mean Percentage of Clients Seen in Individual Psychotherapy by Client Gender, Client Age, and Length of Therapy Types of Gifts Offered to Psychotherapist- Respondents (N-l41) Psychotherapist-Respondent's Definition of an ”Expensive" Gift (N-l38) Factors Influencing Acceptance or Non-acceptance of Client Gifts (N-138) Other Important Factors Influencing How Psychotherapists Responded to Client Gifts as Described by Respondents (n-17) Distributions for the Response Variables: Anxiety, Worry, and Gift Acceptance Distribution for the Variable of Formal Graduate Training in Client-to-Therapist Gift Giving (N-141) Gift Policies in Therapeutic Work Settings (N-lS) Most Recent Gift: Type of Gifts Offered and Gift Acceptance as Reported by Respondents in Item 27 (a and d) Most Recent Gift: Perceptions of Client Motiva- tions for Offering the Gift as Reported by Respondents in Item 27 (b and c) Most Recent Gift: Perceptions of How Accepting the Gift Affected the Client as Reported by Respondents in Item 27 (f) Most Recent Gift: Perceptions of How Acceptance or Non-Acceptance Affected the Therapeutic Relationship as Reported by Respondents in Item 27 (g) 48 48 SO 50 51 53 53 7O 7O 73 74 76 78 79 82 83 86 88 4-12 4-13 4-14 4-15 4-16 4-17 4-18 4-19 4-20 4-21 4-22 4-23 4-24 4-25 4-26 4-27 Most Most Most Most Most Most Most Most Gift Gifts Not Accepted: Gift Gift Troublesome Gift: Type of Gift and Gift Acceptance Reported in Item 28 (a and e) Troublesome Gift: Variables that Made a Gift Troublesome as Reported by Respondents in Item 28 (d) Troublesome Gift: Rationale for Accepting a Troublesome Gift as Reported by Respondents in Item 28 (f) Troublesome Gift: Rationale for Not Accepting a Troublesome Gift as Reported by Respondents in Item 28 (f) Troublesome Gift: Perceptions of How Accepting the Gift Affected the Client as Reported by Respondents in Item 28 (g) Troublesome Gift: Perceptions of How Not Accepting the Gift Affected the Client as Reported by Respondents in Item 28 (g) Troublesome Gift: Perceptions of How Acceptance of Gift Affected the Therapeutic Relationship as Reported by Respondents in Item 28 (h) Troublesome Gift: Perceptions of How Not Accepting the Gift Affected the Therapeutic Relationship as Reported by Respondents in Item 28 (h) Not Accepted: Types of Gifts Not Accepted as Reported by Respondents in Item 29 (a) Perceptions of Motivations for Offering a Gift as Reported by Respondents in Item 29 (b and c) Not Accepted: Rationale for Not Accepting the Client Gift as Reported by Respondents in Item 29 (d) Not Accepted: Perceptions of How Non- Acceptance Affected the Therapeutic Relation- ship as Reported by Respondents in Item 29 (f) Correlations Among the Variables Anxiety, Worry, Post Post Post Gift Acceptance, Gift Training, and Years of Experience Hoc t-tests for Male and Female Psycho- therapists on the Measures of Anxiety, Worry, and Gift Acceptance Hoc t-tests for Ph.D. Versus Non-Ph.D. Psychotherapists on the Measures of Anxiety, Worry, and Gift Acceptance Hoc t-tests for Clinical Psychology Versus Other Degree Specialty Psychotherapists on the Measures of Anxiety, Worry, and Gift Acceptance vii 91 93 95 96 98 99 100 102 104 105 106 109 111 113 115 116 4-28 Post Hoc t-tests for Private Practice Versus Psychotherapists in Other Primary Job Affiliations on the Measures of Anxiety, Worry, and Gift Acceptance 116 4-29 Post Hoc t-tests of Eclectic Versus Non-Eclectic Psychotherapists on the Measures of Anxiety, Worry, and Gift Acceptance 118 viii One CHAPTER I STATEMENT OF THE PROBLEM of the oldest of human rituals is that of giving gifts (Mauss, 1954; Munzert, 1983; Stein, 1965). Gifts have been used to bring about and maintain human relationships for centuries, and, as a universal form of human interchange, it should not be surprising that gift giving can, and often does, occur in the context of psychotherapy. Freud was the first to mention receiving gifts from patients during the course of psychoanalysis. For instance, Freud (1917) described a patient who possessed a rich English library and [he] used to bring me books from it. I owe to him an acquaintance with such authors as Bennett and Galsworthy, of whom till then I had read little . only a few days before the occurrence I am speaking of, he had brought me a fresh volume from this series. (p. 49) Likewise, while describing one of his dreams, he said More The seat . . . was an exact copy of a piece of furniture which had been given to me as a present by a grateful woman patient. It thus reminded me of how much my patients honored me. (Cited in Silber, 1969, p. 338) recently, Stein (1965) stated that We have a communion with the past in the universality, symbolism, and archaism of gifts. The patient too is a living link to a past. He [sic] has his history and his symbolism and his development. And he [sic] may be the bearer of gifts. (p. 483) An examination of the relevant psychological literature reveals an obvious gap; to date there has been no research identified that has empirically investigated the phenomenon of client-to-therapist gift giving despite evidence that psychotherapists are offered gifts and have difficulty knowing how to respond to them (Glover, 1955; Lorand, 1946). Client-to-therapist gift giving is a complex phenomenon that often requires therapeutic and/or ethical decision-making on the part of the psychotherapist, yet such decisions are difficult to make without the benefit of research or empirically-based guidelines. Need To date the only information available on the significance of client-to-therapist gift giving and recommendations for how psychotherapists should respond to the gift comes from a psychoanalytic perspective. Stein's (1965) summary offers a good example of how client gift giving (or ”patient" gift giving) is conceptualized in the psychoanalytic literature. Gifts presented during therapy are a special form of communication, having roots in unconscious fantasy. The patient symbolically gives the therapist a gift on an oral, anal, phallic, or genital level and wishes to bind the therapist to a gift in return. Gifts serve as a defense against both hostile and erotic impulses. They are a form of "magic action," intermediate between dreaming and acting out. They may also conceal a repressed traumatic memory. (p. 486) Additionally, from a psychoanalytic perspective, the therapeutic response to client gifts is to refuse them (there are a few exceptions outlined in the literature, however). The ”ground rule" is that analysts should not accept gifts from patients because it interferes with the therapeutic process. According to Langs (1973), . the accepted gift is a shared corruption (patient and therapist deny the appropriate enforcement of superego sanctions). It is also a shared defense which usually includes a denial of rage, a denial of an appropriate degree of separateness and a denial of the appropriate therapeutic relationship, including the agreed- upon fee. (p. 159) Langs further states that refusing a patient's gift can provide crucial models of self-control, appropriate distance, self-worth, and frustration tolerance. The problem with the above perspective is that interpreting and responding to client gifts is based solely on the principles of psychoanalysis while professional psychotherapy currently encompasses a broader range of professional groups, training centers, work settings, value systems, and orientations in addition to psychoanalysis (Garfield, 1977). In fact, a decline in the number of psychotherapists choosing psychoanalytic and neo-Freudian orientations has been reported, with an increase in those favoring an eclectic point of view (Garfield & Kurtz, 1976). Given that such professional variability exists in the field of psychotherapy, it can be expected that a psychoanalytic theoretical interpretation of client-to- therapist gift giving is necessarily of limited applicability. To date, no empirical investigation has been found regarding how present-day psychotherapists (analytic and non-analytic) actually respond to client gifts in their day-to-day clinical practice, nor has there been empirical research examining current factors that may influence psychotherapists' responses to client gifts. Given the above described limitations of the research and literature on client-to-therapist gift giving, there is a need for research designed to understand (a) client-to-therapist gift giving beyond the psychoanalytic perspective and (b) the factors that may influence psychotherapists' responses to client gifts. The proposed study is designed to meet that need. Bernese The purpose of the present study is twofold. The first is to establish the status of the phenomenon of client-to-therapist gift giving in present-day psychotherapy and describe its characteristics from the perspective of the psychotherapist. The literature suggests that gift characteristics such as type, timing, and value of the gift are important variables in the gift giving situation between client and psychotherapist and these variables will be explored in this study. Other variables of interest include psychotherapists' responses to client gifts and important factors that may influence their response. The second purpose of this study is to explore interrelationships that may exist among psychotherapist demographic and professional characteristics and reported response to client gifts. There is some evidence that psychotherapists vary widely in their behavioral and emotional response to client gifts. Behaviorally, they may differ in terms of accepting or not accepting gifts when offered to them by clients. Emotionally, they may differ in the amount of anxiety they experience when offered a client gift or on how much they worry about the appropriateness of their behavioral response to the gift. One approach to understanding these differences is to analyze how psychotherapist demographic and professional characteristics may influence acceptance of gifts, psychotherapist anxiety, and worry regarding acceptance or nonacceptance. The literature further suggests that the following variables may be important in helping to explain the differences in behavioral and emotional responses as outlined above: reported years of post- graduate experience, reported amount of graduate training on responding to client gifts, and reported primary theoretical orientation. Specific hypotheses will be tested using these variables in addition to analyzing other demographic and professional variables of interest. A Survey research was chosen as the appropriate methodology for this study because it has been recommended as the method of choice when it is important to establish the status of a given phenomenon and the possible relationships among variables (Mouley, 1970). This is usually done by asking a specific population of individuals what they know, believe, or value about a given phenomenon. This information is collected through one of three methods of survey administration face- to-face interview, telephone interview, and mail questionnaire (Babbie, 1973). The latter method, mail questionnaire, will be employed in this study to investigate the phenomenon of client-to- therapist gift giving from the perspective of the psychotherapist. It has also been pointed out that survey research, at its best, offers both immediate and long-range clarification of a problem (Mouley, 1970). Thus, it is believed that a descriptive study of this nature will address a current gap in the literature as well as help to establish client-to-therapist gift giving as an important clinical phenomenon worthy of further investigation. An assumption of this study is that psychotherapists need better training on how to respond to client gifts; however, before better training can be provided, individuals who are responsible for training psychotherapists need to understand the phenomenon of client-to-therapist gift giving as it currently exists. For the purposes of this study, a sample of psychotherapists will be mailed a survey and asked general questions about client-to- therapist gift giving and how they respond to client gifts. Since no study to date has addressed this topic empirically, it is hoped that this study will provide answers to the following broad research questions: 1. What are the current characteristics describing the phenomenon of the client-to- therapist gift giving from the perspective of the psychotherapist? 2. What relationships exist between (a) psychotherapist professional and demographic characteristics and (b) psychotherapist response to client gifts, as reported by psychotherapists? Definition of Terms To provide a basis for common understanding, the following key terms are defined for the purposes of this study. Client_gifit: a tangible or concrete object given as a present from the client to the psychotherapist during the course of psychotherapy (up to and including termination). Psychotherapy: in its broadest terms, psychotherapy encompasses a person (the client) who recognizes that he or she needs help and an expert (the psychotherapist) who agrees to provide that help and a series of human interactions designed to bring about beneficial changes in the client's feelings and behavior that the participants and society at large will view as therapeutic (Strupp, 1977). Psyghgthgrapistj a professional psychotherapist is someone who (a) has completed a formal training program that leads to a relevant and accepted graduate degree (e.g., MD, PhD, EdD, MSW, MA); (b) has had both didactic and supervised clinical experiences requiring a substantial degree of comprehension in the basics of personality theory, human development, psychopathology, and individual, group, and systems behavior change principles and strategies; and (c) specializes in the practice of psychotherapy (Garfield, 1977). w emai ter The relevant literature is reviewed in Chapter II. The focus is on the following: Gift giving in general from a social science, interdisciplinary perspective (which includes anthropology, sociology and psychology); a presentation of the available literature on the theoretical significance of client-to- therapist gift giving; and a review of the research and theory on psychotherapist response to client gifts. The methodology of the study is presented in Chapter III. Specifically, this includes a description of the sample, instrumentation, procedures, research questions, and the statistical procedures used in answering the research questions. A detailed analysis and discussion of the results is given in Chapter IV. In Chapter V, a summary of the study, the major findings and their interpretation, and the conclusions and implications of the study are presented. CHAPTER II LITERATURE REVIEW Social science data on gift giving behavior is scant; perhaps because the complexity of the behavior does not lend itself well to study by experimental techniques. Consequently, the bulk of the literature available for this review is descriptive in nature. For the purposes of the present study, an interdisciplinary approach to the literature will be taken, and the chapter is divided into three sections, with a summary following each section. In the first section, the anthropological, sociological, and psychological [literature on gift giving are reviewed in order to provide a framework for understanding the socio-cultural and individual context from which client gift giving emerges. In the second section, the available literature on client-to-therapist gift giving are reviewed, and the major focus is necessarily on the meaning and significance of client gifts from the psychoanalytic perspective. This is followed by a review, in the third section, of the research and theory on psychotherapist response to client gifts. Gift Giving from an Interdisciplinary Perspective In his seminal essay on gift giving in archaic societies, Mauss (1924) described the gift as a "total social phenomenon." By studying the function of gift giving rituals such as the potlatch system of the 10 American Pacific Northwest Indians or the kula ring structures of the Pacific Trobriand Islanders, Mauss observed that gift giving was a phenomenon that included aesthetic, economic, legal, moral, religious, and mythological components. He further concluded that there were three types of obligations in the gift exchange process: the obligation to give, the obligation to receive, and the obligation to repay (or reciprocate). According to Belk (1976), The obligation to give may be based on moral or religious imperatives, the need to recognize and maintain a status hierarchy, the need to establish or maintain peaceful relations, or simply the expectation of reciprocal giving. These motives, which do not admit purely selfless giving, become institutionalized in a society so that under appropriate conditions an individual is socially obligated to give. Receiving is seen as similarly obligatory, and avoiding or refusing gifts is construed as an unfriendly or even hostile act. Mauss noted, however, that there is a certain tension created in receiving a gift since acceptance is an implicit recognition of dependence on the giver. This tension may then be reduced by fulfilling the third obligation, the obligation to repay. (p. 155) The potlatch system of the Kwakiutl is a good example of the social obligations and motivations of influence, power, and prestige involved in gift exchange. Under their system, tribal chiefs would gather and store goods until they had amassed an impressive amount. They would then invite neighboring chiefs to a potlatch feast in which the host would distribute his wealth to the guests. The more he gave away, the greater was his glory and strength. Taking their gifts, the guests would then return home planning to outdo their host at a potlatch of their own (Poe, 1977). Similar to the potlatch, the kula ring (a kind of shell armband or necklace) of the Trobriand Islanders 11 allowed the donor to hold temporary social advantage over the recipient. When the gift was repaid, the tables turned and the donor was in the debt of the recipient. Although the system was generally a dyadic encounter, the kula ring included many villages and thereby established important tribal links and trade contacts (Mauss, 1924; Poe, 1977). More recently it has been noted that Mauss' early observations of archaic gift giving rituals apply to modern day gift giving as well (Dillon, 1968; Hyde, 1983; Poe, 1977; Shurmer, 1971). Whether on an international or interpersonal level, gift exchange obligations and motivations remain very similar. On an international and political level, Dillon (1968) investigated the effects of foreign aid given to other nations by the United States and found that the three basic obligations of gift exchange (as described by Mauss) held true in modern industrial societies. On a corporate level, Deal and Kennedy (1982) indicated that gifts are used for purposes of conflict resolution, alliance formation, and socialization. On a community level, public status is often maintained and augmented by the conspicuous presentation of gifts. Schwartz (1967) pointed out that generous contributions to charity have always been a source of prestige in the United States. It has also been observed that gift exchange between associations is an important community event. Warner (cited in Caplow, 1982) noted that gifts between two associations are visible emblems in social solidarity and that the act rt a) (7'1 '91 m r' m) '1 12 of giving evokes latent feelings of solidarity, unity, and interdependence. Elements of control and status also exist on a family level, especially in middle- and upper-class families. For instance, gifts are often given to individuals perceived as status subordinates such as news carriers, waitresses, postal carriers, delivery people, and other persons who perform routine services for the givers throughout the year (Caplow, 1982; Sherry, 1983). A husband can also maintain his social status by being publicly seen as the "bestower of gifts” and the source of gratification to his family (Schwartz, 1967). Schwartz further noted that the wife is a “ceremonial consumer of goods” in that she is "required by decency to consume goods conspicuously for the reputability of the household and its head" (p. 3). Whether it is because of her role as ”conspicuous consumer" or for other reasons not presently found in the literature, several authors have noted that women give the majority of gifts in society (Caplow, 1982; Evans, 1978; Schudson, 1986; Shurmer, 1971). In a sociological study on American Christmas gift giving (Caplow, 1981), it was found that women were the ”chief performers" in the Christmas gift giving ritual in that they did most of the decorating, most of the shopping, and most of the gift wrapping. In a sample of 110 respondents and their family networks, Alone or jointly, they [women] gave 87% of all the gifts recorded and received only 61%. Male givers without female collaborators accounted for only 16% of the total and most of their gifts were given to females. Gifts from males to males were few (four percent of the total) compared to gifts from 13 females to females (17%). Females divided their gifts evenly between male and female receivers while male givers concentrated their gifts on female receivers. (p. 387) Along these lines, Hyde (1983) observed that the “rules of etiquette" that accompany modern-day wedding rituals reinforce giving as a “female commerce" and gifts as “female property.” He went on to say that “only the bride is able to affirm her gender, her social sexuality, by concerning herself with gift exchange" (p. 103). Furthermore, by ”attending to relationship and muting her individualism, she is supposed to become the active link that will unify the two families” (p. 103). Control and status through gift giving can also be seen on a parent-child level. Schwartz (1968) indicated that control is . perhaps nowhere better seen than through the character of Santa Claus, the greatest of all givers, whose powers of surveillance and ability to grant and withhold benefits are annually exploited by parents as instruments of control over their children. (p. 4) According to Schwartz, children pay the "cost of inferiority" when they accept gifts from their parents and fail to reciprocate. Consequently, the only way for a child to pay his or her debt is to accept the orders of the giver. Hyde (1983) also pointed out that the bonds established by a gift can maintain an old identity and limit freedom of motion in children. As an example of this, he suggested that as soon as an adolescent truly wants to leave his or her parents, he or she should stop accepting gifts from them since such gifts only serve to maintain the parent-child bond. SOC Be: de ‘0 14 The role of gift giving in the formation of identity or self-concept is addressed in the sociological and social psychology literature. Several authors agree that by presenting a gift to children or adults, the giver is imposing an identity on the receiver (Banks, 1979; Sherry, 1983; Schwartz, 1967). With regard to child socialization, Banks (1979) indicated that parents, other family members and friends influence the socialization of children with gifts. He further noted that “these gifts affect the child's developmental processes, interests, knowledge acquisition, view of the world and basic values” (p. 320). Schwartz (1967) made the point that if gift giving socializes and serves as a generator of identity, it is important to acknowledge the existence of gifts which facilitate or impede maturation. For example parents may cause anxiety in their children by offering gifts for which they are not yet ready or gifts they have already outgrown. Identity conflict may also arise when gifts are expressing dissatisfaction with the way the receiver is perceived. The following example of identity conflict was offered by Bursten (1959). To the young scholar we give a book, while we choose a baseball glove for the young athlete. These gifts will be received with delight showing that the donor has been aware of the role of the recipient and that receiver accepts this role. However, if we give a book to the athlete he [sic] is likely to be disappointed or even angry at being forced into a role he [sic] does not wish to assume. (p. 444) Gifts also transmit a set of social values and, not surprisingly, some gender role stereotyping is bound to occur simply because the "correct" gender role gift is given (Banks, 1979; 15 Schwartz, 1967). Belk (cited in Banks, 1979) examined the possession and perception of various gender role related toys by a small sample of 22 preschool children and their parents. He arrived at the following conclusions with regard to the significance of gifts in the socialization of children: (a) children own more same-gender toys than cross-gender toys (however, this pattern is weaker for toys given by the child's parents); and (b) toy ownership plays a significant role in the development of gender role preference. A glance through popular adult magazines reveals that gifts for men and women are also gender role specific. Suggestions for "masculine” gifts for men have to do with computers, sports, recreational hobbies such as hunting or fishing, and tools for repairing or building. Suggestions for ”feminine” gifts for women are luxury gifts such as perfume, negligees, silk, furs, and jewelry, as well as domestic gifts such as food processors or vacuum cleaners. It is obvious, therefore, that gender role stereotyping through gifts is not limited to children. With regard to the timing of gifts, society dictates the occasions for which gift giving is expected. On many occasions we are expected to signify our good wishes to others by giving them presents. Thus, gifts are exchanged as Christmastime; birthdays are not complete without presents; even Easter baskets and Valentine candy have become popular. Likewise, on Mothers' Day and Fathers' Day, it is not sufficient to remember and honor our parents; custom requires that we show our feelings in a material, tangible form. The list for socially encouraged occasions for giving is indeed a large one; and, when the list of socially encouraged occasions for gift giving is exhausted, there still remain certain occasions where, although custom does not demand a gift, many people 16 bring or send a present as a means of expressing their sentiments. (Bursten, 1959, p. 437) According to Sherry (1983), gift giving occasions can be formal, structural events such as rites of passage, marked by ceremony and ritual, or gift giving occasions may be emergent, transient events. Gennep (1960) divided rites of passage into three groups: rites of separation, rites of transition, and rites of incorporation. Hyde (1983) observed that ”threshold“ gifts, or gifts that accompany rites of transition, are the most common form of gift. 1 They attend times of passage or moments of great change. They are with us at every station of life, from the shower for the coming baby to the birthday parties of youth, from graduation gifts (and the social puberty rites of earlier times) to marriage gifts, from the food offered newcomers and the sick to the flowers placed on the coffin. (p. 41) The tokens received at times of change, then, are not mere compensation for what is lost, but the promise of what lies ahead. ”They guide us toward new life, assuring our passage away from what is dying" (p. 45). Indeed, threshold gifts mark the time of individual transformation (Hyde, 1983). In addition to their socio-cultural significance, gifts are an important form of communication. In an attempt to better understand the communicative properties of the gift, Bursten (1959) cited Sterba's conceptualization of speech and language and applied them to gift giving. According to Sterba, there is a three-fold aspect of language: (a) it expresses the conscious contents which the ego wants to communicate (i.e., what the person wants to say); (b) it expresses unconscious contents through the conscious expression as a mediator; and (c) peculiarities in the pronunciation of language and mannerisms 17 of speech serve as manifestations of unconscious contents apart from the verbal expressions in their obvious and in their hidden meanings. Conscious reasons for gift giving are usually a positive expression between giver and recipient. However, Schwartz (1967) pointed out that sincere affection is not a necessary correlate of gift presentation. There can be an unfriendly or hostile component to gift giving as seen in some of the anthropological literature. According to Sherry (1983), the conscious or unconscious motivation behind a gift may range from altruistic (wherein the donor attempts to maximize pleasure of the recipient) to "agonistic" (attempts to maximize personal satisfaction). He stated that gift giving typically falls between the two poles. In one consumer research study (cited in Banks, 1979), participants were asked their primary reasons for giving gifts. Twenty-seven percent indicated "to obtain pleasure,” 16% to "show friendship/love,” 16% to do the ”expected thing," 5% to "show appreciation," 5% to express "sentimentality," 6% "other," and 4% "don't know." Other gift giving motivations mentioned briefly in the literature are gratitude (Schwartz, 1967), support (Levi-Strauss, 1965), insecurity (Caplow, 1982), feelings of inequality (Belk, 1976; Poe, 1977; Sherry, 1983), anxiety (Schwartz, 1967), obligation (Schwartz, 1967), confirmation of giver's and/or receiver's identity (Banks, 1979). In addition to the giver's motivation, properties of the gift itself can also communicate conscious or unconscious messages. Conventional gifts (such as money) are often given out of anxiety and 18 a desire not to expose feelings (Burstein, 1959). Schurmer (1971) also indicated that the value of the gift partially reflects the weight of the relationship. According to Sherry (1983), expressive gifts are invested with greater symbolic value than utilitarian ones. In other words, it might be expected that utilitarian gift exchange occurs where role distance between partners is relatively great. Thus, as further noted by Sherry, “gift dimensions such as price or quality are used to create, maintain, modulate, or sever relationships with individuals" (p. 158). As a form of communication, gifts are messages that must also be interpreted by the receiver. Since there are always a number of places in the communication process that misunderstandings can occur, the message of the gift may be taken to mean something other than what was intended (Bailey, 1971). This, of course, has implications for how the receiver responds to a gift based on his or her evaluation of what the gift means. Based on equity theory, Poe (1977) indicated that it is satisfying for the receiver to know that the level of interaction with the giver is understood by that person to be correct. When a gift indicates that the estimation of this level is incorrect or not understood by the giver, it will undoubtedly be evaluated negatively. Such a state of affairs may exist whenever the gift is found by the recipient to be outside of the limits of his [or her] expectations at either end of the scale applied (e.g., whether too cheap or too expensive, whether too servile or too disdainful, whether too intimate or too distant). (Poe, 1977, p. 53) SOC *4 \L} ¢7\ 19 Unfortunately, as Sherry (1983) pointed out, violations of gift giving etiquette are currently imperfectly described. Although a gift may be rejected forthrightly, or more subtly in its subsequent disposition, discussions of ”aborted" gift exchange are currently unavailable. Spmmppy. In summary, Befu (1980) has observed that social scientists use contrasting methods in explaining gift giving behavior. As can be seen in the above review, anthropologists and sociologists favor functional explanations of gift giving through observation and description. In other words, they explain events or behavior by stating the function or functions that an object, action, person, or institution performs in order to maintain the social system to which the object, action, person, or institution belongs (Senn, 1971). Thus, from a functional standpoint, the principles of give and take and reciprocity are seen in the anthropological and sociological literature as universal, cultural norms that provide a means for social control and protection of social status, as well as a means for socializing individual members, stabilizing social relationships, and holding important social structures together (Davis, 1973; Goulder, 1960; Levi-Strauss, 1965; Mauss, 1924). In contrast to functional explanations, psychologists are described as favoring motivational explanations of gift giving behavior wherein individual (intrapsychic) motivations take precedence over cultural rules (Befu, 1980). From this perspective, gifts are vehicles for conscious and unconscious communication (Bursten, 1959; Sherry, 1983; Schwartz, 1967). Wolff (1971) advocated understanding the client as a "whole person," which he felt included the person's den If“ 7‘ 20 development, previous learning experiences, and the social context in which s/he lives. Thus, an introdisciplinary perspective on gift giving may provide a broader framework from which to understand client-to-therapist giving in particular. -t - e t G v In the field of psychology, theoretical perspectives on client- to-therapist gift giving originate from psychoanalytic theorists. While psychoanalysis is primarily a verbal process, Szasz (1965) indicated that the "language" of gifts offers the patient a ready medium of communication with the psychoanalyst. The psychoanalytic literature on client-to-therapist gift giving is explored in the following section in order to understand the significance of this event in the psychotherapeutic relationship. The significance of patient gift giving is described in the psychoanalytic literature in many ways. First of all, patient gifts are seen as symbolic of psychosexual development. According to Anna Freud (1963), there is a clear symbolic link between body parts and material possessions. Thus, patient gifts are often described as oral, anal, phallic, or genital (Silber, 1969; Stein, 1965). It was also believed that patient gifts serve a defensive function (Kritzberg, 1980; Silber, 1969; Stein, 1956). Lorand (1946) pointed out that patients harbor feelings of hostility and aggression towards the analyst even though they may not be aware of these feelings at the moment of offering the gift. The gift, then, "expresses, substitutes and wards off these feelings" by becoming a reparation for destructive fantasies (Stein, 1965). IEZIC 21 Patient gift giving has also been described as a form of "acting out." Greenson (1967) defined acting out as a well-organized, cohesive set of actions which appear to be purposeful, consciously willed and ego syntonic, which turn out to be a reenactment of a past memory. Consequently, patients will act out their transference reactions instead of reporting them in words and feelings. Stein (1965) reported an example where a gift of yellow roses aided a patient in the recollection of having worn a yellow dress as a child and being slapped the only time in her life by her father when she told him that she looked pregnant in the yellow dress. Additionally, patient gifts have been described as a wish for symbiosis with the therapist (Silber, 1969; Stein, 1965), as a wish to identify with the omnipotent therapist (Kritzberg, 1980), as well as being similar to dreams (Stein, 1965) and slips of the tongue (Bursten, 1959). Kritzberg describes a specific case where a formerly alcoholic patient offered him a bottle of gin at Christmas time. He stated the following. The patient's gift to me in this instance served many functions. It expressed his strong oral needs and dependent longings. It served as a defense by displacing their expression onto me. It also enabled him to communicate the conflict to me so that with assistance he was better able to manage the problem. (p. 105) Kritzberg (1980) concluded that gift giving in the therapeutic situation is generally an "unconsciously motivated symbolic transaction" (p. 100). As a means of expression, not only does a patient's gift stand for unconscious motives, impulses, feelings and thoughts, but the 22 symbolic potential of the gift may reside in one or more of its properties or functions (Kritzberg, 1980). A gift of food or beverage has been described as expressing the patient's oral needs to be fed, nurtured, and/or indulged in his or her dependent strivings (Kritzberg, 1980; Stein, 1965). Animate gifts such as plants or flowers have been said to represent a patient's desire for continued care and nurturance (Kritzberg, 1980). The patient who gives a plant may wish to remain ”rooted in the office" and helped to grow (Stein, 1965). Both Kritzberg and Stein mentioned that the sexual or ceremonial significance of flowers must be kept in mind since they are commonly used in courtship, weddings, births, and funerals. Kritzberg indicated that personal artistic and literary creations as gifts from the patient are inevitably revealing. According to Langs (1973), patients unconsciously generate artistic creations when specific unconscious fantasies and conflicts are especially active. He noted that some will write poems or stories in an attempt to communicate these fantasies and adaptively resolve within themselves the related instrapsychic conflicts. Kritzberg (1980) offered an interesting example of the symbolic aspects inherent in the type of gift a patient presents. In their seventh session, a female patient presented him with a "peculiar gadget" that she impulsively bought just before her appointment with him. The gift was a combination compass/levelling device/bottle opener, and he asked her how she had come to purchase the gift and what her thoughts were about it. The patient said that it reminded her of her previous therapist who she felt had steered her wrong so 23 that she almost "lost her bearings." In the end, Kritzberg concluded that the gift represented a complex expression of wishes for him to guide her honestly, keep "on the level,“ and help to ”open her up.” In addition to the type of gift given, the timing of a patient's gift is also mentioned in the psychoanalytic literature. Stone (Langs & Stone, 1980) mentioned that gifts given "out of the clear blue sky" (not because they fit the person's habits and customs) are the most puzzling in the treatment process. Kritzberg stated that on some occasions early in therapy (i.e., the first half-dozen or dozen sessions), gifts are brought to the therapist. He believes that these ”early phase gifts" (as exemplified in the previous example) communicate the patient's concerns, thoughts, or feelings about the therapist or the therapeutic relationship. In his words, "they may be attempts at ingratiation or appeasement, unconscious efforts at concealment and/or bribery of the threateningly perceived omnipotent therapist" (p. 112). Edelson (1963) indicated that a gift given early in treatment is a way of buying the therapist off from some issue that is being worked on. Seasonal holidays and returning from their own vacations offer patients a pretext for giving behavior (Kritzberg, 1980; Langs & Stone, 1980; Szasz, 1965). The patient usually perceives the act of giving as an expression of benevolent feelings, appreciation, and gratitude; and it is this conscious perception that may lead patients to present gifts at what appear to be socially acceptable occasions such as a return from a vacation, seasonal holidays, or termination (Kritzberg, 1980). Kritzberg pointed out that patients will also give Kr; .. u. 50.. v te 24 gifts before a therapist's vacation or at other times of separation. He offered the following example of such a gift. An interesting and touching painting was given to me by one young schizophrenic woman patient. It [was given in the last hour prior to my summer vacation, which was the first significant separation between us since treatment had started one year before . . . This unhappy, bitter and chronically pessimistic young woman was distinctly not prone to such generosity. I expressed my genuine appreciation for her painting and asked her to tell me a little about it . . . I assured her that it would have a secure place in my home, just as she would have a secure place in my thoughts though we would not see each other for a month. (p. 107) Kritzberg believes that this type of ”goodbye" gift, which is sometimes received prior to separations such as vacations or termination, is a fairly direct symbolic attempt to give him/herself or part of him/herself to the departing therapist. Edelson (1963) noted that a gift at the end of treatment usually carries a burden of ambivalent feelings; each gift expresses affection and can summarize symbolically some aspect of or feelings about termination itself. Summary. In the psychoanalytic literature, gifts are portrayed as a vehicle of symbolic communication. Specifically, gifts symbolizethe unconscious expression of developmental or psychosexual conflicts (Freud, 1963; Silbur, 1969; Stein, 1965), defensiveness against hostility and aggression (Langs, 1973; Lorand, 1946), a form of acting out past memories (Greenson, 1967; Stein, 1965), and a wish for symbiosis with the therapist (Silber, 1969; Stein, 1965). Additionally, it was noted that the symbolic potential of the gift may reside of the ltsell Challt piece inter‘ (Stei \v_ ' 7G1, CESC 25 reside in one or more of its properties or functions, or in the timing of the gift (Kritzberg, 1980; Langs & Stone, 1980; Stein, 1965). It has been pointed out that gift giving to the therapist lends itself to scrutiny and analyzing and, therefore, constitutes a challenging opportunity for a constructive and possibly even critical piece of therapeutic work (Kritzberg, 1980); likewise, the proper interpretation of a gift may mark a crucial turning point in therapy (Stein, 1965). Although the manner in which gifts are responded to by psychotherapists is believed to have important meaning for treatment, varied, and sometimes contradictory recommendations regarding psychotherapist response to client gifts are found in the psychoanalytic literature. In addition to the two surveys which are summarized below, the available literature on psychotherapist response to client gifts is descriptive in nature and based on clinical interpretation. Psychoanalytic and developmental theories of psychotherapist response to client gifts will be reviewed in this section. To date the only empirical research found on therapist response to client gifts involved two surveys. These surveys, however, did not address this topic exclusively. In both surveys, psychotherapists responded to questions on a variety of common ”technical problems" or issues arising in the conduct of psychotherapy of which client-to- therapist gift giving was but one. issx the p51“ pa: you re; me by tra COT pa: 0'? :7" L4. 26 In one survey, Fey (1958) designed a simple questionnaire of issues "commonly arising in the conduct of therapy" as a way to study the influence of theoretical orientation and experience on psychotherapist behavior. Two of the 30 items were on client-to- therapist gift giving: (a) Would you accept a small gift from a patient in psychotherapy? and (b) Would the size of the gift influence your decision? Although actual responses to these questions were not reported, the inclusion of questions on therapist response to client gift giving suggests that this is a common therapeutic issue. In 1938, Glover (1955) conducted a confidential survey of 29 practicing analysts (of which 24 returned the questionnaire) who were members of the British Psycho-Analytic Society. He based the questionnaire on problems that he found were most frequently discussed by individual analysts and students in the process of clinical training. In the questionnaire, under Section E (fees and extra-mural contact), the third question was, "Do you accept presents from patients? If so, on what system?" Glover summarized the results to this question as follows. No one accepts large presents or money offerings. In some cases acceptance was said to be conditioned by the patient's means, but these conditions vary. It has been noted that some patients who cannot afford full fees are more inclined to offer small gifts. Acceptance is more often determined by reference to the analytic situations, e.g., where giving is a sign of progress, where snubbing is undesirable, etc. The majority evidently do not receive gifts gladly; there is a marked tendency to analyze [sic] the motives of giving with a view to curbing gifts. There emerged an interesting difference of opinion re the significance of gifts. One analyst thinks gifts a sign of counter- transference. Another thinks "few gifts" is a sign of a defect in the analyst. Apart from some 27 reports of ”few gifts" there is no other information about the ”giving" reactions of special types of case. (p. 319) Glover noted that analysts who were against verbal reassurance were not against accepting small gifts. He stated that they were prepared to make concessions regarding reassurance when the issue became more direct and personal as in the case of gifts. Glover points out, however, that if one accepts small gifts in order not to appear inhuman, it is not simply due to the avoidance of snubbing, but it is reassuring to the patient. He then asks, "If reassurance is justified at one point, what are the proper or expedient limits of the process?" In other words, assuming that accepting the patient's gift is gratifying, when is it appropriate to reassure or gratify the patient? This question of gratification remains a relevant one, albeit controversial, in today's literature on psychoanalytic technique. The controversy on frustration-gratification stems from Freud's (1915, 1919) ”fundamental principle" that analytic treatment should be carried out, as far as possible, under conditions of privation or in a state of "abstinence." He defined the principle of abstinence in 1915 when he proposed that: The treatment must be carried out in abstinence. By that I do not mean physical abstinence alone, nor yet the deprivation of everything that the patient desires, for perhaps no sick person could tolerate this. Instead, I shall state it as a fundamental principle that the patient's need and longing should be allowed to persist in her [or him] . . . impelling her [or him] to do work or make changes and that we must be aware of appeasing those forces by means of surrogates . . . (pp. 164-165) 28 Several authors later noted that the idea became popular that the proper psychological condition for patients undergoing analysis was a state of frustration and that, over time, the "principle” of abstinence became the "rule" of abstinence (Fox, 1984; Lorand, 1946; Szasz, 1965). According to Fox (1984), Freud's initial statement of this principle emphasized the withholding of gratifications on a selective (but not defined) basis and, while no one has challenged 'this as a technique, ”the issues become redefined as appropriate or inappropriate gratifications and necessary or unnecessary deprivations" (p. 227). He further stated that the literature is characterized by a "for" or "against” quality (such that there are "deprivers" and 'gratifiers") and that what is missing is a sense of option or conflict within the analyst about the management of clinical situations. The controversy of "for" or "against” frustration-gratification is based on deeper, underlying assumptions about the technical and non-technical functions of the psychotherapist in general. In examining such underlying assumptions, Wile (1985) distinguished pre-l920 psychoanalysis or id analysis from post-1920 psychoanalysis or ego analysis. He described these as separate models with different assumptions and goals. Ego analysis approaches the main goal of psychoanalysis--raising warded-off contents to consciousness--in a manner that is incompatible with the way that id analysis does so. The id analyst typically pursues this goal by assuring an adequate (i.e., optimal) level of anxiety and by frustrating clients. The ego analyst seeks this goal by decreasing anxiety (and self-hate) and by promoting safety. (p. 794) 29 Wile stated that the major impediment to conscious awareness, according to the id analyst, is resistance-~clients' efforts to keep their impulses and fantasies unconscious and to thwart the purposes of analysis. Thus, the therapeutic task is to intensify the expression of infantile wishes, directing the client's attention to these wishes and keeping them in the client's awareness through frustration. He notes that gratifying the wish is thought to be incompatible with analyzing it. On the other hand, according to Wile, the ego analyst attributes clients' defenses against awareness of their impulses to their distress about these impulses (in other words, ego analysts believe that clients worry about what it means to have such impulses). Consequently, the way to raise the impulse or feeling to consciousness is not to frustrate it but to decrease their alarm about these impulses through safety. Wile maintained that the methods that many therapists employ are derived from the frustration-oriented id-analytic model. Citing Langs as saying that the analyst must stick to certain ground rules in order to avoid gratifying the client's regressive wishes and fantasies, Wile contended that, Langs' concept of the frame is a formalization of id-analytic technique. Analysts have classically refrained from answering clients' questions, giving advice, and so on for fear that such actions would violate the rule of abstinence, interfere with the development of the transference, constitute an acting-out with the client's infantile fantasy wishes, gratify or traumatize the client. (P. 797) Although Wile conceded that Langs attempted to integrate the two conflicting purposes of classical id-analytic technique (i.e., frustration and safety) by stressing the importance of maintaining 3O predictable therapeutic boundaries, he stated that predictability differs from safety. Indeed, Wile questioned the type of safety clients obtain in knowing that they will always get negative and unresponsive reactions. In contrast, Wile observed that the ego-analytic position is not based on whether therapists should or should not gratify patients, but rather that it is not very important, and making it important may have negative therapeutic consequences. In other words, from Wile's conceptualization of the ego-analytic perspective, the significant interference in therapy is not in collusion with clients' defenses and gratifying their transference fantasy wishes, but rather in becoming side-tracked over inconsequential issues that could negatively affect the treatment outcome. The same underlying assumptions discussed by Wile (1985) above may also account for the “for" or "against" quality that exists in the clinical literature on psychotherapist response to client gifts. This is particularly evident in a dialogue between Langs and Stone (1980). On the one hand, from a strictly technical point of view, acceptance of a gift is seen as a gratification; and because gratification interferes with treatment, the "ground rule is that gifts should not be accepted from client/patients, but rather should be analyzed and interpreted (Langs, 1973; Lorand, 1946; Szasz, 1965). Langs, a major proponent of a rigorous technical approach to client gifts, indicated in a dialogue with Stone (Lambs & Stone, 1980) that he . would simply not accept the gift, and indicate to the patient in an open-ended way that we will explore this as we explore anything else. Now that is a certain level of rejection, in that 31 it isn't the direct acceptance of the gift. But it is also turning to the analytic situation and to basic analytic work, in essence implying to the patient that we will analyze her [or his] offer and from her [or his] associations, we will make a decision, and also understand how the gift offer came to be actualized on the basis of unconscious needs and behaviors in both herself [or himself] and the analyst . . . (p. 305) Stone (in Langs & Stone, 1980), on the other hand, coming from a more lenient approach, cautioned that emphasizing the elements of abstinence and deprivation may override realistic common sense toward issues like patient gift giving. He stated that he ”doesn‘t fuss too much and too actively" about commonplace material or events that may emerge in the natural course of things. For example, he said the following. A package of homemade cookies is still a package of homemade cookies; it is a feeding gift to you. But it is not, economically, so important that it can't be lifted from the position of an important contamination . . . . I don't think it need be very important; it can be blown up and exaggerated, on a doctrinaire basis. (PP. 312-313) Thus, using Wile's conceptualizations, Langs seems to represent a more id-analytic approach to patient gifts while Stone seems to take a more ego-analytic approach to patient gifts. Though not referring specifically to the gift situation, Greben (1983) has pointed out that Freud's admonition for psychoanalysts to be objective in their work has been excessively adhered to in such a way that many psychotherapists have become unduly "unresponsive" (p. 76). He indicated that psychotherapists have become preoccupied with a "host of petty practices" (such as payment of fees, vacations, protecting patients from meeting each other, and missed appointment 32 hours) to the extent that they did not respond to clients in a natural and human way despite the importance of psychotherapy as a human relationship. When psychotherapists have been studied, their personal contributions have been found to over-shadow their technical skills in psychotherapy (Strupp, 1960). Characteristics such as warmth, attentiveness, interest, understanding, and respect have been found to be the core facilitative characteristics of the “good" psychotherapist (Strupp, Fox, & Lessler, 1969). According to Greben (1981a), these qualities are sought by all human beings and represent a prerequisite for any good human attachment. He stated the following. 1 In therapy, we cannot do without them, for the therapist who lacks these qualities will not win our trust and, hence, will not get us to abandon our unsuccessful defensive postures. We will not show ourselves to an untrustworthy, uncaring stranger . . . (p. 452) Other writers have also commented that the underlying assumption of abstinence has created too much reliance on transference interpretation which can interfere with the psychotherapeutic relationship and result in negative therapeutic consequences (Chrzanowski, 1980; Greben, 1981a, 1981b; Wolff, 1971). An example of this was offered by Fox (1984) in his review of the literature on abstinence. During the early phases of her analysis, a patient asked her analyst if she might use his bathroom. She travelled some distance to her analysis and did not feel that she should have to stop at a gas station at the end of each hour. The analyst refused, saying that his home office was not equipped with a bathroom; and he attempted to explore the meanings of the patient's reaction to this 33 deprivation. This struggle continued for weeks until the patient stopped asking. The analysis continued another few months until the patient decided to quit because she felt that nothing was happening. Fox concludes that the too-distant, purely interpretive stance of the analyst was experienced as narcissistic injury by the patient and that her response was withdrawal and a failure in the development of the transference. Along these lines, Anna Freud (1954) observed that, in addition to the strictest handling of the interpretation of the transference, there should be room for the realization that the analyst and patient are also two real people, of adult status, in a real personal relationship to each other. She questioned whether neglecting this side of the matter was not responsible for some of the hostile reactions which analysts get from their patients and which are often attributed to the transference only. Several contemporary psychoanalytic writers have emphasized the existence and importance of the non-transference, real relationship between client and psychotherapist (Chrzanowski, 1980; Fox, 1984; Greenson, 1965; Greenson & Wexler, 1969). In their review of the literature on the non-transference relationship, Greenson and Wexler (1969) pointed out the following. We do not deny the central importance of the transference interpretation in psychoanalysis proper, but it has been a repeated experience that for our patients to develop healthy ego functioning, object constancy, and the capacity for full object relationship, the analytic situation must offer them an opportunity for experiencing in depth both the realistic and unrealistic aspects of his [sic] dealing with objects. Interpretation removes old unconscious and irrational anxieties, 34 guilts, and depressions. Beyond that, many of our patients need the experience of feeling in ways that "they are right.” (p. 37) It was also pointed out that rigid insistence on maintaining a psychotherapeutic frame with such things as punctuality or ending the session exactly after 50 minutes may set the psychotherapist up as an authority figure (Wolff, 1971). Greenson and Wexler (1969) suggested that dealing with non-transference aspects of the patient's productions reduces the danger of omniscience in the analyst. With regard to client-to-therapist gift giving, Langs' concern with the therapeutic frame led him to focus on the more technical aspects of psychotherapy while Stone tends to address the non-technical or non-transference aspects of the real relationship between psychotherapist and client. This is illustrated in Stone's comment that individuals who are not familiar with the "ground rules" of analysis or who come from places outside of New York may offer token gifts (e.g., cookies at Christmas) out of respect, gratitude, or affection, and that this is nothing more than their "breeding and background." He further stated the following. If this token gift is not accepted from a shy person, who doesn't automatically know the ground rules . . . there may be a "hurt" which is also integrated into the analysis . . . [and the patient would say] "What is this? You didn't take my gift--just a little package of cookies that showed my respect and affection for you-osomething that I do with anybody of importance in my life . . . (p. 307) Langs, on the other hand, responded to the above comment by stating that a certain level of hurt may be necessary as a "therapeutic frustration" so that the analyst is seen as being different from other 35 figures in the patient's life. Thus, in addition to differences in underlying assumptions between id- and ego-analytic psychoanalysis, assumptions about the role of the psychoanalysist in the therapeutic relationship also have important implications for how gifts will be conceptualized and responded to. Thus far the discussion has focused on the psychoanalytic perspective of how psychotherapists respond to gifts. Although they do not specifically address the issue of how to respond to client gifts, developmental theorists have addressed relevant assumptions underlying a client's need for gratification and security (Bowlby, 1977; Chrzanowski, 1980; Hackie, 1981; Nacht, 1962; Winnicott, 1953; Wolff, 1971). For example, Winnicott proposed that therapists should attempt to imitate the natural processes that characterize the behavior of the mother with her child. He further distinguished between the ”doing to" function and the ”being with" function of mothers in order to make this point clearer. According to Winnicott (1971), the ”doing to” function, or “male element knowing," is a standing back and observing function. ”Being with," or "female element knowing," on the other hand, is based on the mother's feeling at one with her baby through identification and intuition which allows her to be a "good enough mother." As such, Winnicott concluded that the therapist's technical skill, or ”doing to” function, must be an adjunct, and not a substitute for, his/her personal knowing or "being with" the patient (which would also allow the psychotherapist to be a "good enough therapist"). 36 Part of the mother-child relationship necessarily includes gift giving behavior. Freud (1917) maintained that an infant's first gift is its feces and that the infant will spontaneously give up part of his or her body to someone he or she loves as a token of affection. Later, after the child's excrement has lost its value, material objects are then presented as gifts to loved ones. In fact, children come to believe the gift itself 'is' love (Isaacs, 1933). Just as a “good enough mother" would never reject her child's gift, accepting gifts from child patients can reinforce the child's undeveloped or newly developed ability to give and, thus, have important consequences for libidinal and ego growth (Kay, 1967). It is important to note that, while the clinical literature on child analysis suggests that the analyst should accept the child's gift in order to help the child work through developmental stages, this is not advocated in the clinical literature with adult psychoanalytic patients. This is especially interesting given the popular hypothesis that adults who require psychotherapy usually show an impairment in their capacity to love or form affectionate bonds--generally because of a disturbance of bonding in childhood (Bowlby, 1977; Nacht, 1962; Winnicott, 1963). Bowlby has argued that the requirement of an attachment figure persists throughout adult life. However, because this is overtly less obvious than in childhood (in adulthood being most evident during situations of uncertainty) and because of the value placed in Western culture on "independence," the requirement of adults for such a secure base tends to be overlooked or regarded negatively. Furthermore, 37 Bowlby's notion of an attachment figure seems to apply to how a client may perceive his/her therapist, and this also has implications for gift giving. Kaufman (1980) stated that a client who has received something useful from the psychotherapist will grow to have special feelings which are sometimes expressed in the direct offer of a gift. He indicated that these gifts may come in the form of a treasure made or found such as a piece of finely cut glass, a poem, or a photograph (not unlike gifts from children to adults), and that the manner in which the offer is received by the psychotherapist carries a great deal of impact at a moment when the self of the client has become vulnerable. Presumably, then, it would be important to accept a gift offered under these circumstances. Because of their developmental experiences, some clients may never share or give; consequently, a gift in therapy would be significant in terms of their object relatedness (Kritzberg, 1980). Accordingly, when a client who has had great difficulty in giving anything is able to give the therapist a small present, it would be a serious mistake not to accept the gift (van der Waals, cited in Menninger, 1958). Indeed, as Nacht (1961) has pointed out, If the need for the parent's love, frustrated in childhood, is again fostered indefinitely by an equally frustrating attitude unvaryingly imposed by the analyst, how should the patient give up the need to suffer or to cause suffering in which his [sic] neurosis is so deeply rooted? It seems obvious to me that only a timely and technically appropriate attitude of gratification can allow the patient to accept his [sic] need to love and be loved, and to express it without fear. (p. 209) 38 Gifts, then, may be a good example of how adult clients express their need for security, attachment, and affirmation (needs that are discussed by other authors as well: Greenson & Wexler, 1969; Mackie, 1981). Despite some of the differences noted thus far, one area of agreement in the clinical literature in which it is believed that responding to patient gifts must be done sensitively is in terms of the patient's psychological illness and/or level of ego strength. Anna Freud (1963) stated that most analysts would agree that in the analysis of a neurotic patient, it is preferable to analyze the wish of a patient to give a gift than to accept the gift itself; however, this general rule may need to be modified with other types of patients. She goes on to say that with some patients it might be essential both to accept the gift and to analyze the motives for giving it and with other patients it might be essential to accept the gift and analyze the motives at another time. Several authors have indicated that gifts should always be accepted from borderline or psychotic patients (Edelson, 1963; Langs, 1973; Tarachow, 1963). The reasons given for this policy is that such patients interpret the refusal of a gift as a concrete, personal rejection and narcissistic hurt. It is also important for the patient's self esteem that the therapist accept the patient's gift so that the patient can feel "now I'm not so desperately hungry that I can't give something . . . now I can give you something" (Edelson, 1963, p. 72). Edelson saw this as being especially important for the patient who felt too empty to give, who had always found it too 39 painful to part from anything of him/herself, either overvaluing it as precious and irreplaceable or fearful it would be rejected or depreciated as worthless. Another area of agreement in the clinical literature is that expensive gifts should not be accepted. Most authors agree that it is inappropriate to accept expensive gifts under any circumstances (Langs, 1973; Lorand, 1946; Szasz, 1965). It is also understood, however, that therapists may be vulnerable when offered expensive gifts. Three safeguards to this dilemma are discussed in the literature: (a) a fee-for-service contract, (b) self-monitoring countertransference, and (c) ethical principles and standards. Each will be described in some detail. First of all, a firm understanding of the fee for service contract may help avoid problems with expensive gifts. Goldberg (1977) contended that exchanging a fee-for-service reinforces the essential notion that psychotherapy is an exchange that benefits both agents; and that without a reciprocal consequence for the practitioners' involvement, there is often confusion about why the agents are involved in an encounter. Szasz (1965) suggested that if the analyst is paid for his/her services, his/her wish to collect from patients in extramonetary ways is reduced. Lorand (1946) offered two examples where expensive gifts were accepted because of problems with the negotiation of fees. One colleague who was being supervised by me justified his acceptance of a gift saying that the patient did not pay him enough anyway and he therefore felt entitled to it. (He had, however, never discussed with the patient the fact that he felt he was being underpaid.) In another instance, 40 the same type of explanation was given with the added comment that ”the patient is nasty and abusive and has enough money besides.“ In this case also the analyst failed to discuss with the patient the matter of raising his fee. (p. 222) Szasz concluded that if the patient offers gifts and the therapist accepts them, the contract becomes overfulfilled. He stated that the patient may respond with efforts to compensate for this imbalance by wanting to reduce the fee or by trying to get more from the therapist. At the same time, the therapist may respond with some inappropriate (nonanalytic) gesture to mitigate his/her guilt for taking too much from the patient (e.g., prolonging the patient's sessions). The second safeguard is that of self-monitoring counter- transference issues (i.e., personal motives and conflicts) regarding client gifts. Kritzberg (1980) pointed out that countertransference feelings aroused in the therapist by his/her own nonreceptive conflicts may impede objective scrutiny or appropriate handling of the gift. He went on to state that the narcissistic significance to the therapist of the patient's gift giving behavior may also disturb the therapist's effective analysis and management of the gift. Langs (1973) went so far as to say that the unconscious fantasy related to the accepted gift is often that of a violation of the incest barrier and a gratification of incestuous wishes. In terms of the therapist's ego, he further believes that it is a failure to renounce or find suitable conflict-free avenues of gratification, therefore promoting immediate discharge of narcissistic needs without regard for the object (i.e., the patient). Regardless of what the actual counter- 41 transference issues are, analysts are expected to monitor their own countertransference reactions in order that these reactions will not interfere with professional judgment. Langs (Langs & Stone, 1980) questioned whether or not analysts actually monitor countertransference reactions. He stated the belief that analysts fail to study their subjective responses and, therefore, should follow the "ground rule" of not accepting patient gifts. Indeed, according to Weiner (1983), neutrality is the safest stance because it protects the patient from potentially harmful aspects of the therapist's personality while protecting the therapist from manipulation of the patient. Lastly, recognizing that accepting gifts can lead to ethical dilemmas, other professions have imposed strict guidelines regarding the giving and receiving of gifts. For instance, many national businesses and corporations either forbid gift exchange or place a limit on the value of the gift itself. The United States government also prohibits all government employees from accepting gifts, entertainment and favors within the business relationship. Interestingly, as the largest employer of psychologists in the United States government, the Veterans' Administration explicitly prohibits all employees (including psychologists) from accepting gifts. Specifically, from the Code of Federal Regulations (1985), An employee is prohibited from accepting gifts or gratuities such as goods, money, services, purchases at discount, entertainment, or similar favors from claimants, patients, ex-patients, or other beneficiaries of the Veterans' Administration, or their relatives, friends, or agents, since it could be interpreted that the 42 favors are in return for official services rendered. (Section 0.735-11, p. 7) In any setting, psychotherapists are expected to conduct themselves in an ethical manner at all times. Psychotherapists hold an advantage of power over those with whom they work; they occupy a position of trust and are expected to advocate the welfare of those who depend on them (Keith-Spiegel & Koocher, 1985). The Ethical 211ngiplg§_gf_£§yghglgg1§;g (American Psychological Association, 1981) recognizes the potential harm of relating to clients on other than a professional level (dual relationships) and holds the psychotherapist responsible for being continually aware of his/her own needs and potentially influential position. Specifically, Principle 6a states the following. Psychologists are continually cognizant of their own needs and their potentially influential position vis-a-vis persons such as clients, students, and subordinates. They avoid exploiting the trust and dependency of such persons. Psychologists make every effort to avoid dual relationships that could impair professional judgment or increase the risk of exploitation . (p. 636) The Ethical Standards (American Association for Counseling and Development, 1981) for the helping professions also indicates that the member's primary obligation is to respect the integrity and promote the welfare of the client. Additionally, Section A(8) states the following. In the counseling relationship the counselor is aware of the intimacy of the relationship and maintains respect for the client and avoids engaging in activities that seek to meet the counselor's personal needs at the expense of that client. (p. l) ar 0': ps ju CO GE t! ('1 43 As a conflict of interest situation, ethical dilemmas may occur around the issue of client-to—therapist gift giving in subtle or obvious ways. For instance, acceptance of a gift may meet the psychotherapist's personal needs or compromise his/her professional judgment because of its timing, value, or symbolic properties. While codes for psychotherapists do not specifically define when it is unethical to accept a client's gift, psychotherapists must always keep the client's best interests in mind. Unfortunately, this is not an easy task. When psychologists place their own needs and goals above those of clients or when they lose sight of the fiduciary nature of their professional relationships, exploitation, faulty professional judgment, and harm to the client (as well as to themselves) can result (Keith-Speigel & Koocher, 1985). According to Keith-Speigel and Koocher, accepting small or material tokens (e.g., homemade cookies or an inexpensive gift) usually poses no ethical problems; however, when the gift is valuable, the issue becomes more complicated from an ethical perspective. They offer the following case as an example of how accepting an expensive gift can lead to negative consequences for the psychotherapist. Rich Porsche gave his recently licensed therapist, Grad Freshly, Ph.D., a new car for Christmas accompanied by a card stating: “To the only man who ever helped me." Dr. Freshly was flattered and excited. He convinced himself that his services were worth the bonus since Rich had churned through many previous therapists with disappointing results. As a more seasoned therapist might have predicted, Rich soon began to find fault with Dr. Freshly and brought both ethics charges and a legal suit against him for "manipulating him into giving expensive gifts." (p. 281) Ke fa 44 Keith-Speigel and Koocher believe that such an example illustrates the naivete and inexperience among psychotherapists who accept gifts and favors beyond “one-time" or ”special occasion" tokens. A similar distinction is made in the psychoanalytic literature between small or ”trifling” gifts and valuable or expensive gifts (Lorand, 1946). Lorand specifically noted that expensive gifts were often mishandled by beginning analysts, but that . analysts who became thus involved usually stated, and with some justification, that they did not have the opportunity of learning to handle such matters because it was not a problem in their own analysis and they did not hear it discussed at seminars. (p. 221) This lack of discussion or research remains true today; and, according to Welfel and Lipsitz (1984), issues that receive little public attention result in greater confusion for psychotherapists about what behaviors would be ethically appropriate. Given the paucity of literature on the phenomenon of client-to-therapist gift giving and methods of responding, the potential for unethical and/or nontherapeutic behavior is high. Summary. According to psychoanalytic "ground rules," gifts should not be accepted by the psychotherapist because this would be gratifying the client based on his/her unconscious sexual and aggressive fantasies (Langs, 1973; Lorand, 1946; Szasz, 1965). Therefore, gifts should be analyzed and interpreted only. (Some psychoanalytic writers concede that exceptions may be made when the gifts are "trifling" or inexpensive.) In contrast, developmental writers indicate that clients often have a history of a disturbance of bo 8f] 45 bonding in their childhood [Bolby, 1977; Nacht, 1962; Winnicott, 1963] and gifts may represent an important attachment to a psychotherapist (Kaufman, 1980). Consequently, it is considered to be important to accept gifts from clients as a way of affirming their worth; much as a mother affirms her child. There is general agreement in the literature that gifts should always be accepted from clients with ego deficits and personality or character disorders because they would conceptualize the rejection of their gift as a personal rejection. In addition to the above, it is agreed that expensive gifts should never be accepted from clients for both therapeutic and ethical reasons. CHAPTER III METHOD Meets Papalatiga. The population surveyed in this study was psychologist-psychotherapists who were members of the American Psychological Association (APA) Division of Psychotherapy (Division 29). Division 29 was chosen because two recent surveys (Norcross & Wogan, 1983; Prochaska & Norcross, 1983) suggested that members of this division would be the best source for sampling a population of psychotherapists. Prochaska and Norcross, in particular, described their sample as a group clearly committed to the practice of psychotherapy and that 98.5% of their sample spent 53.3% of their professional time engaged in psychotherapy. Sampla. It has been noted that the most desirable sample for survey research is a random sample in that it is most representative of the entire population and is least likely to result in bias (Alreck & Settle, 1985). The sample in this study consisted of 243 randomly selected members of APA Division 29, or five percent of the total population (fi-4,863). Random selection was done through an APA computerized mailing list service in which a simple random sample of current Division 29 members was selected. 46 47 Of this sample, eight members refused to participate, one was unreachable at the current address, one was on sabbatical, and one did not complete the demographic section of the survey. A total of 150 psychotherapists completed the survey, resulting in a return rate of 62%. (It should be noted that surveys were used when they were only partially completed as long as the demographic section of the survey was completed. This necessitated the use of varying sample sizes in data analyses.) The mean age of the sample was 49.4 years (S2r11.3, ranging from 28 to 85; 39150). The percentages of women and men in the sample are presented in Table 3.1, along with the actual gender distribution within Division 29. Of the respondents, 40% (a—60) were women, and 60% (nr89) were men. Respondents indicated a mean of 17.4 years of experience in practicing psychotherapy (SQ-9.38, ranging from 2 to 45; E9150). More detailed data on years of experience are given in Table 3.2. Of the total sample, 83% had Ph.D. degrees, 5% had an Ed.D., 9% had an M.A. or M.S., 2% a Psy.D., and 1% fell in the "other” category. The largest percentage of respondents had their academic degrees in clinical psychology (67%), followed by 20% in counseling psychology, and 3% in educational psychology. Additionally, 10% fell into the "other" category, which included counselor education (a—l), developmental psychology (9-2), experimental psychology (3-2), general psychology (as3), training at a psychoanalytic institute (3-2), pastoral counseling (a=l), school psychology (3-2), and social psychology (a=2). 48 Table 3-1 Distribution of Sample by Gender W Acme}: Gender N % % Female 60 40 31 Male 89 60 69 * Actual figures were from the 1987 APA.Hembership Register, based on a total of 4,559 in Division 29. Table 3-2 Years of Post-Degree Experience Years of Experience N % O - 9 years 31 21 10 - 19 years 60 40 20 - 29 years 38 25 30 - 39 years 17 11 40 - 49 years 4 13 Totals: 150 100 49 Data on the primary job affiliation of respondents are presented in Table 3.3. As depicted in this table, the majority of the respondents were in private practice (68%, nylol). No other place of employment accounted for even 10% of the sample. The next largest percentage of respondents were in university academic positions, followed by those in clinical positions in university counseling centers. The survey asked respondents to identify their primary theoretical orientation (of 14 choices), and these results are presented in Table 3.4. First of all, the eclectic orientation was the most frequent choice with 49% endorsement. The second through fourth most common theoretical orientations for psychotherapist- respondents were a psychodynamic orientation, followed by a psychoanalytic orientation and a cognitive-behavioral orientation. Those respondents who selected the "other" category specified the following orientations: feminist, Jungian, rational-emotive, reality therapy, self psychology, and transactional analysis. Respondents who endorsed "eclectic" as their primary theoretical orientation were asked to rank-order the theoretical orientations that contribute to their eclecticism. Their top three choices are presented in Table 3.5. Respondents were also asked to endorse the theoretical basis of their most common psychotherapeutic interventions into one of four categories. The results were the following: 42% eclectic, 39% psychodynamic, 13% "other," and 6% behavioral. 50 Table 3-3 Primary Job Affiliation Primary Affiliation N % Private Practice 101 68 University: Academic 14 9 University: Counseling Center 8 5 Other 8 5 Community Mental Health Center 7 5 Veterans Administration Hospital 3 2 State Psychiatric Ward or Hospital 3 2 Medical School 3 2 Private Psychiatric Ward or Hospital 2 1 Outpatient Clinic 1 1 Totals 150 100 Table 3-4 Primary Theoretical Orientation Theoretical Orientation N % Eclectic 74 49 Psychodynamic 22 15 Psychoanalytic 15 10 Cognitive-Behavioral 11 7 Other 8 5 Systems 4 3 Behavioral or Learning Theory 3 2 Humanistic 3 2 Client-Centered 3 2 Sullivanian 3 2 Gestalt 2 1 Adlerian 1 1 Relationship 1 1 Existential 0 0 Totals: 150 100 51 Table 3-5 Distribution of First, Second and Third Choices of Eclectic Theoretical Orientation First Second Third Choice Choice Choice Orientation n % n % n % Adlerian O 0 1 l O 0 Behavioral/Learning 6 9 4 6 9 l4 Client—Centered 7 10 7 10 7 10 Cognitive-Behavioral 8 12 8 12 10 15 Existential 3 4 3 4 6 9 Humanistic 6 9 6 9 10 15 Gestalt 3 4 l 1 2 3 Psychoanalytic 2 3 5 7 4 6 Psychodynamic 27 40 15 22 3 5 Relationship 1 l 8 12 ll 16 Sullivanian 1 l l l 0 0 Systems 4 6 8 12 4 6 Other 1 l 2 3 1 1 Totals 69 100 69 100 67 100 52 With regard to client caseload, the information on Tables 3.6 and 3.7 indicates that this group of psychotherapists work primarily in individual psychotherapy with adults. Seventy-six of the total respondents (52%) reported spending an average of 75-100% of their time conducting individual psychotherapy. Other break-downs for time spent conducting psychotherapy are provided in Table 3.6. They also reported seeing an average of 61% female clients and 39% male clients. Approximately 82% of their clients were reported to be adults, 12% adolescents, and 6% children. Almost half (45%) of their cases were reported to last more than 12 months, 32% between 3 and 12 months, and 22% under three months. Design A descriptive research design was used in this study to explore the phenomenon of client-to-therapist gift giving and how psychotherapists respond to client gifts during the course of psychotherapy. A survey research design was chosen as most relevant for this study since it has been recommended as the method of choice when it is important to establish the status of a given phenomenon (Mouley, 1970). Likewise, using this design, survey data are collected from all or part of a population to assess the relative incidence, distribution, and intercorrelations of specific variables of interest (Rigsby, 1981). There are three general survey research designs: the one-shot or cross-sectional study, the successive independent samples study, and the panel or longitudinal study (Shaughnessy & Zechmeister, 1985). The survey research design chosen for this study was the one-shot or 53 Table 3-6 Percentage of Time Conducting Individual Psychotherapy Percentage of Time N % 75 to 100% 76 52 50 to 75% 35 24 25 to 50% 21 15 Less than 25% 13 9 Totals 145 100 Table 3-7 Mean Percentage of Clients Seen in Individual Psychotherapy by Client Gender, Client Age, and Length of Therapy Variable % Mean Gender of Client Female 61 18.3 Male 39 18.6 Age of Client Adults (18 and older) 82 20.7 Adolescents (12 to 17) 12 13.4 Children (under 12) 6 10.7 Length of Therapy Under 3 Months 22 24.3 Between 3 and 12 Months 32 23.6 Over 12 Months 46 34.0 54 cross-sectional study. In this design, a sample of the population is selected, and standardized data are then collected from the sample at one point in time. The focus in a one-shot survey is on description (i.e., describing characteristics of a population) and assessing interrelationships among variables within a population at the time of study (Babbie, 1973; Borg & Call, 1971; Shaughnessy & Zechmeister, 1985). While descriptive research does not address causality, it has heuristic value in that it helps to establish facts and relationships which may later lead to the development of causal laws. It was expected that the results of this study in particular would determine the present status of client-to-therapist gift giving from the psychotherapist's perspective as well as generate hypotheses for future research. St tat Given the exploratory nature of this topic and the fact that no relevant instruments were available for use in this study, a self-administered survey was designed to gather descriptive data about client-to-therapist gift giving from the psychotherapist's perspective as well as to test the effects of specific variables which were expected to influence the way psychotherapists respond to client gifts. Next to the choice of a suitable topic and population, no other aspect of a survey study is more crucial to its success than adequate construction of the survey itself (Mouley, 1970). The first step in the construction of an adequate survey is conceptualization, that is, 55 a thorough grasp of the available literature, the objectives of the study, and the nature of the data needed (Babbie, 1973; Mouley, 1970). It has previously been suggested that while a thorough review and understanding of the literature can point out general areas of significance, survey researchers may gain a more realistic perspective of the important variables in their study by having ”exploratory conversations“ with representatives of the population for whom the survey is intended (Mouley, 1970; Sheatsley, 1983). Because of the paucity of literature on the topic of client-to-therapist gift giving and the exploratory nature of this study, it was believed that important information for survey construction could be obtained by conducting exploratory interviews with psychotherapists in the field. During the month of July 1986, 10 consultant-psychotherapists were chosen for one-hour interviews based on a purposive sampling procedure. In purposive or judgmental sampling, the researcher uses his/her judgment to choose respondents who fit the purposes of the study, rather than just choosing the nearest available individuals as in convenience sampling (Bailey, 1978). Because the purpose of this phase was exploratory in nature, it was felt that the sample of consultant-psychotherapists should be a diverse group of male and female practicing psychotherapists who differ with regard to degree, training, level of experience, theoretical orientation, and therapeutic work setting. The sample of consultant-psychotherapists included five female and five male psychotherapists. In terms of highest degree earned and major field of study, five held Ph.D. degrees (three in counseling 56 psychology, one in clinical psychology, and one in a combination of_ counseling and clinical psychology), two held Master's degrees in social work, one held an M.D. with a specialty in psychiatry, and one held a Master's degree in rehabilitation psychology. They had an average of 10.9 years of post-graduate experience, ranging from 2 to 23 years. Four consultant psychotherapists were employed in community mental health clinics, two in private practice, two in a university counseling center, one in a university-based outpatient clinic, and one in a community-based outpatient clinic. Four psychotherapists indicated that their primary theoretical orientation was psychodynamic, while the other six indicated one of the following: Adlerian, cognitive-behavioral, client-centered, ego analytic, reality therapy, and self-theory. Interviews with consultant-psychotherapists revealed that they had all been recipients of client gifts and that the majority of them accepted gifts that were offered to them by their clients. Most gifts were viewed as token gifts, usually given at termination, showing appreciation or care. Those who had found it necessary to reject a client's gift in the past had done so for a variety of reasons. For example, one psychotherapist (after the birth of her child) was ' offered an antique child's dress which was a family heirloom. She emphasized her appreciation of the thought behind the gift, but told the client that she could not accept the gift because of its special meaning and value to the client and her family. At a time when the therapeutic relationship was not going well, another psychotherapist was offered a hand-crafted figure in a jar with the caption "World's 57 Greatest Therapist." She chose to discuss and analyze the gift with the client rather than accept it. Another psychotherapist who worked in a setting which prohibited acceptance of gifts, felt it was more important for the therapeutic relationship to accept a sea shell offered by a client when she returned from vacation than to refuse it on principle. This same psychotherapist was offered an expensive book from a client and, rather than hurt the client by completely refusing the gift, chose to accept the book conditionally, as a donation to the agency library. Only one psychotherapist indicated that she never accepted gifts from clients because of the transference issues involved. Thus, gifts were generally accepted, and most exceptions to this were based on the type of gift offered, the timing of the gift, the monetary value of the gift, the existence of a work policy prohibiting the acceptance of gifts from clients, or theoretical reasons. It was also found that views on client-to-therapist gift giving seemed to differ according to psychotherapist characteristics such as years of experience or theoretical orientation. For example, those with less years of post-graduate experience had not yet formulated a personal gift policy and stated that they felt more discomfort with client gifts than those with more experience. Furthermore, one psychotherapist with a psychodynamic orientation stated that she experienced conflict between what she saw as an "expected” response based on her theoretical training and her own inclination to respond differently than the theoretical expectation. Those with a psychodynamic orientation were also more likely to mention the 58 transferential aspects of a client's gift. Only one consultant-psychotherapist reported that client-to-therapist gift giving was addressed in his formal clinical training. Based on the literature and exploratory conversations with psychotherapists, it was decided that the major areas to be covered in the survey would include items on gift characteristics (e.g., type or timing), factors that may influence psychotherapist responses, psychotherapist demographic and professional characteristics, and clinical vignettes. The second step in the construction of an adequate survey is item construction. Items for this survey were constructed by making use of the numerous guidelines available (Babbie, 1973; Berdie & Anderson, 1984; Selltiz, Wrightsman, & Cook, 1981). The following composite list of suggestions from the survey literature were used in item construction: (a) questions should be relevant to most respondents; (b) respondents should be asked about information that they are competent to answer or can give reliably; (c) sentence structure should be short and simple; (d) items should be clear and specific, and they should only ask for one bit of information at a time; (e) items written in the negative should be avoided; (f) response alternatives in closed-ended questions should be mutually exclusive and cover all significant alternatives; (g) items which are biased or contain biased terms should be avoided; (h) items should be in correct psychological order and should not influence answers which proceed or follow them; and (i) items should be both open- and closed-ended questions and statements. 59 Backstrom and Hersh-Cezar (1985) describe four types of survey questions: questions of fact, information, opinion or attitudes, and behavior. They classify the form of questions as either free- response (open-ended) or fixed-response (closed-ended). A free- response question invites respondents to compose their own answers while a fixed-response question gives a respondent a choice of specific answer categories. Although most questionnaires contain a mixture of both response formats, the choice is determined largely by the nature of the problem. In general, it is desirable to use free-response questions in the early stages of investigating a topic and fixed-response questions to ask simple, informative questions and to reduce questionnaire length (Mouley, 1970). Among 29 items in the final draft of the survey used in this study, 19 items were fixed-response or closed-ended, 7 were "semi- open-ended" items requiring a "fill in the blank" type of answer, and the remaining 3 items were a series of free-response or open-ended items based on a critical incident approach. Following the OBEEQPEQHélization of theoretical concepts and item W-»_._._ « a»..,—.a-.__z__k, construction, the final step in survey construction is refining the __.— instrument through pretesting and piloting. The purpose of conducting pretests and pilot studies is to assess item clarity and to locate errors in formatting or directions. Pretests refer to initial testing of one or more aspects of the study's design, while pilot studies refer to a "miniaturized walk-through" of the entire study's design (Babbie, 1973). 60 In this study, a draft of the survey was pretested twice, then piloted. In retrospect, however, the pilot study was also a pretest since revisions of the survey were made after the survey was piloted and one step of the research design was not included in the pilot study (surveys were not coded for follow-up mailings). Detailed descriptions of each of the three pretestings will be given separately and in the order in which they were conducted. 2££££§£;22§- A convenience sample of 10 practicing psycho- therapists was selected for pretest one. The sample of actual respondents (N-9) consisted of three females and six males. The age range was from 26 to 58, with a mean age of 43. All respondents were psychotherapists at a university counseling center. Five of the respondents had received a Ph.D., one had received an Ed.D., and three had received Master's degrees in counseling. Respondents reported an average of 12.5 years of post-graduate experience, ranging from 1 to 24 years. With regard to theoretical orientation, one reported humanistic, three reported psychodynamic, and five reported eclectic. On November 18, 1986, the sample of psychotherapists was given a cover letter and a first draft of the survey. In addition to completing the survey, respondents were encouraged to comment on item construction and clarity and were asked for their ideas on items or sections that would make the survey more complete (a form was provided for their comments). Nine of 10 respondents completed and returned the first draft of the survey, providing useful comments on survey construction. Based on the information gathered in pretest one, revisions were made. 61 Specifically, ambiguous wording was clarified throughout the survey, specific response categories were added or deleted as suggested, several response categories were defined more clearly, and the order of items in the survey was re-arranged. Egagaa§_§gg. The same convenience sample of 10 counseling center psychotherapists selected in pretest one was again selected for pretest two; however, one of the male respondents in pretest one was replaced by a younger female respondent with a Ph.D. in counseling psychology and five years' less experience. On January 26, 1987, the sample of psychotherapists was given a cover letter and a second draft of the survey. Nine of 10 respondents completed and returned the survey and provided useful comments on its construction. Once again, revisions were made. Ambiguous wording was clarified in the directions and in several response categories of the survey. {retest three. A random sample of practicing psychotherapists was selected for pretest three. Psychotherapists were selected from the 1987 Maine telephone directories of the three most populated areas in the state of Maine (Portland, Lewiston-Auburn, and Bangor). Of a total of 120 psychotherapists listed, every fourth psychotherapist (a randomly selected number) was selected for the sample. On March 16, 1987, a total of 30 psychotherapists were mailed cover letters (see Appendix A), a third draft of the survey, and stamped return envelopes. One packet was returned by the post office with no forwarding address available, and another was returned with a note 62 from the psychotherapist indicating that he did not wish to participate in the study. On March 25, 1987, a first follow-up post card (see Appendix B) was mailed to all potential respondents. On April 6, 1987, a second follow-up post card (see Appendix C) was again mailed to all potential respondents (the surveys were not coded to distinguish respondents from non-respondents in follow-up mailings). Of a sample of 30, two were accounted for as ineligible. Sixteen respondents completed and returned the survey, resulting in a return rate of 53% (NyBO). As indicated earlier, the purpose of this third mailing was to pilot the final version of the survey and test the research design procedures. However, because one item was revised after the pilot and the research procedures were not followed exactly, this third mailing was considered to be a third pretest rather than a true pilot test. Regardless, the overall results of this pretest indicated that the directions of the survey were clear, items were unambiguous, and items were in appropriate order. These conclusions are'based on the fact that respondents followed the directions given (e.g., leaving items blank when not applicable to them), they did not write down any questions about the items themselves which would have indicated problem areas, all items were filled in with the expected information (with the exception of one item that was later revised), and items that appeared in the beginning of the survey did not appear to contaminate items that followed. Final survey. The final survey (see Appendix D) which resulted from three pretests had a front and back cover in addition to the six 63 pages of items. The survey was photographically reduced to 90% of its original size and was stapled together in the form of a booklet. Preparation of the survey was based on a variation of the "Total Design Method" (Dillman, 1978). The survey included four major areas: a section that covered general questions about clients and the gifts they offer (six items), a section on how psychotherapists respond to client gifts in their day-to-day clinical work (six items), a section on professional and demographic characteristics of the psychotherapists in the study (14 items), and a critical incident section in which the psychotherapists in the study were asked to describe client gift situations from their personal clinical experience (three items). mm In addition to survey preparation, data collection was also based on a variation of Dillman's (1978) "Total Design Method." Descriptions of the mailing procedure used in this study follow. Initial mailing. On May 1, 1987, each potential respondent in the sample was mailed a copy of the first cover letter (see Appendix E), a coded copy of the final survey, and a stamped return envelope by first class mail. The initial cover letter had the date mailed and the potential respondent's name and address typed at the top of it. The cover letter detailed the purpose of the study, its usefulness, why the recipient was important to the research, who should complete the survey, a promise of confidentiality with an explanation of the identification number located on the survey booklet, and an offer of 64 the results as a reward for participation. Each cover letter was individually signed. Sixty percent of the completed surveys were returned within two weeks of the initial mailing. £1;a§_£gllgg;ap. The first follow-up post card (see Appendix F) was mailed to the entire sample exactly one week after the initial mailing (May 8, 1987). This post card served as a thank you to respondents for sending in their completed surveys and a reminder to potential respondents regarding the importance of their participation. In the event that the survey had never arrived or had been misplaced, the opportunity to contact the researcher for a replacement survey was given. Secgag fallow-up. The second follow-up post card (see Appendix G) was mailed to non-respondents only, exactly three weeks after the initial mailing (May 22, 1987). This post card again served to remind potential respondents that their participation was important and included an offer by the researcher to replace the survey if needed. Iaird follow-up. Five weeks after the initial mailing on June 6, 1987, a second cover letter (see Appendix H), a replacement coded survey booklet and a stamped return envelope were mailed to each respondent by first class mail. The second cover letter included the same details described in the first cover letter, with a special appeal for participation. Summary of the resulta. A total of 65 respondents requested a summary of the study's results. A cover letter thanking respondents 65 for their participation and a summary of the results of this study were mailed to them in November, 1987. W Each of the item responses from the self-administered survey was edited and then coded appropriately for computer analysis using the Statistical Package for the Social Sciences (SPSS). The items in the survey were analyzed using qualitative and quantitative approaches to explore client-to-therapist gift giving from the perspective of the psychotherapist. Information was gathered in four sections of the survey. In Section I, descriptive information was collected about the types of gifts clients offer, the gender of clients who offer gifts, the timing of client gifts, and the psychotherapist-respondent's definition of an expensive client gift. In Section II, descriptive information was collected on the factors that may influence the psychotherapist-respondent's response to client gifts, reported level of anxiety when offered client gifts, frequency of accepting client gifts, reported level of worry regarding the appropriateness of the response to client gifts, the extent to which client-to-therapist gift giving was addressed in formalgraduate training, and whether or not psychotherpist-respondents are bound by a formal work policy limiting or prohibiting the acceptance of client gifts. In Section III, the following data on professional and demographic characteristics of psychotherapist-respondents were gathered: age, gender, highest academic degree earned, academic 66 specialty of highest degree earned, years of post-degree experience as a psychotherapist, the state in which the psychotherapist is currently practicing psychotherapy, primary job affiliation, percentages of client case load in terms of age of clients seen (adults, adolescents, and children), gender of clients seen, approximate length of psychotherapy (less than 3 months, 3 to 12 months, or more than 12 months), approximate percentage of work time spent conducting psychotherapy, primary theoretical orientation, and most common psychotherapeutic intervention. In Section IV, psychotherapists were asked to describe personal clinical experiences with client gifts using a critical incident approach. Three incidents, in particular, were studied qualitatively! (a) the most recent gift offered, (b) a client gift that was perceived as the most troublesome or difficult to respond to, and (c) a client gift that was not accepted by the psychotherapist. Qaalitagive aaalyses. The above descriptive data were summarized in the form of frequency distributions. Additionally, measures of central tendency and dispersion were calculated for interval data. Qaantitative analyses. In addition to reporting the above descriptive information, specific hypotheses were addressed. It was hypothesized that: H1: There is a negative relationship between psychotherapist's years of experience and reported level of anxiety. H2: There is a negative relationship between psychotherapist's years of experience and reported level of worry. V.l|l|1||l 1| '1' 67 H3: There is a negative relationship between psychotherapist's level of training regarding gifts and reported level of anxiety. H4: There is a negative relationship between psychotherapist level of training regarding gifts and reported level of worry. H5: Psychotherapists with a psychoanalytic theoretical orientation will accept gifts from clients less often than psychotherapists with other theoretical orientations. In Hypotheses 1 through 4, both the dependent variables (anxiety and worry) and the independent variables (years of experience and training regarding client gifts) were treated as interval scale data. Relationships between dependent and independent variables were analyzed using the Pearson Product Moment Correlation. In Hypothesis 5, the dependent variable (acceptance) was treated as interval scale data and the independent variable (theoretical orientation) was measured on a nominal scale. Differences between the psychoanalytic and the non-psychoanalytic groups were analyzed using the Mann-Whitney U-test and a a-test. CHAPTER IV RESULTS 8 a ve s of the sample was assessed by comparing the gender distribution of the sample to the known gender distribution of the population of Division 29 members using a Goodness-of-fit test. The sample consisted of 40% women and 60% men, and the Division 29 population consisted of 31% women and 69% men as depicted in Table 3.1. The results of the Goodness-of-fit test indicated that there was a significant statistical difference between the sample and population on percentage of males and females (a - 7.14, p<.01). Summary of Descripgive Information As described in Chapter III, the survey designed for this study had four major sections: (a) general questions about clients and the gifts they offer; (b) psychotherapist responses to client gifts; (c) demographic and professional characteristics of the sample of psychotherapist-respondents; and (d) three critical incidents based on personal experience (most recent gift, most troublesome gift, and a gift that was not accepted from the client). The following summary will include sections one, two, and four (section three, demographic and professional variables, were covered in the previous description of sample characteristics). 68 69 S c 0 ° 1 ts a d r f 3 Section one was divided into the following categories in order to summarize the data on clients and their gifts: incidence, type, value, timing, and client gender. Inaiganaa. To begin with, respondents were asked if they had ever been offered gifts from clients. The answer to this question was overwhelmingly “yes.” Of a total of 150 respondents, 141 or 94% had been offered a gift or gifts from a client(s). The six percent who had never been offered a gift were only asked to complete section three of the survey, the demographic and professional characteristics. pra. In order to gather information on what types of gifts clients may offer to psychotherapists, there was a checklist in the survey of possible types of gifts. Results of this checklist are provided in Table 4.1. Arts and crafts made by the client was the most frequently reported type of gift, followed by food, literature purchased by the client, plants or flowers, decorative items for home or office, literature written by the client, arts and crafts purchased by the client, novelty items such as posters or stuffed animals, beverages, music, "other," clothes, jewelry, and money. Gifts that fell into the "other" category were objects for use in the office (aé9); tickets for or invitations to social functions (a—S); objects from nature such as shells, stones, or pine cones (a—4); offer of services or favors (3-3); personal care items such as perfume or soap (a=3); appliances (a=2); and photographs (a=2). Some miscellaneous 70 Table 4-1 Types of Gifts Offered to Psychotherapist-Respondents (N-141) Type of Gift n % Arts and Crafts (Made by Client) 101 72 Food 86 61 Literature (Purchased by Client) 81 57 Plants or Flowers 74 53 Decorative Items 69 49 Literature (Written by Client) 60 43 Arts and Crafts (Purchased by Client) 59 42 Novelty Items 44 31 Beverages 43 31 Music 34 24 Other 34 24 Clothes 22 16 Jewelry - 22 16 Money 7 5 Table 4-2 Psychotherapist-Respondent's Definition of an "Expensive" Gift (N-l38) Value Category N % $ 10.00 or more 64 - 47 $ 25.00 or more 55 40 $ 50.00 or more 13 9 $ 100.00 or more 4 3 $ 250.00 or more 2 1 71 items mentioned once included leather checkbook cover, walking stick, family recipe, audiotape of a goodbye, and a magic kit. Valaa. Respondents were asked to choose a category that best described what they considered to be an ”expensive" gift. As indicated in Table 4.2, the majority of respondents believed that a gift of $10 or more (47%) or a gift of $25 or more (40%) was expensive. A small number of respondents believed that $50 or more, $100 or more, or $250 or more defined an expensive gift. Timing. Respondents were also asked to provide information on when clients have offered them gifts. Again, there was a checklist in the survey of possible times that clients may offer gifts (N-139). The time that was checked most frequently by respondents was on or near a holiday (76%), followed by gifts offered at termination or the last session (58%), during the middle phases of treatment (57%), for special occasions in the psychotherapists' life (31%), after client vacations (21%), during the early phases of treatment (14%), and before the psychotherapists' vacation or other temporary break in treatment (3%). Client gender. Respondents were asked if male clients were more, equally, or less likely to offer gifts in psychotherapy. Fifty-eight percent indicated that males were less likely to offer gifts, 15% indicated that males were about equally likely to offer gifts, and 3% indicated that males were more likely to do so. Twenty-four percent of the respondents indicated that they had not received enough gifts to make this judgment. 72 ec on Tw0° Ps chot er t onse to C e G fts In order to explore how psychotherapists respond to client gifts, respondents were asked to rate a list of factors that may have influenced their decision of how to respond to client gifts according to the degree of their importance. The four-point scale ranged from one to four, where one was "not important,“ two was “minimally important," three was ”somewhat important," and four was “very important." Means and standard deviations for each factor are supplied in Table 4.3. Important factors that were reported by psychotherapists in the "other" category appear in Table 4.4 In order to better summarize the data, the factors are clustered into three areas: therapy-related factors, gift-related factors, and client-related factors. Therapy-related factors had the highest rating of the three. The gift-giving factors had a lower rating, and the client-related factors had the lowest rating. Iberapy-ralated factors. In rank order of importance, the therapy-related factors were (a) therapist perception of the dynamics of the therapeutic relationship, (b) therapist perception of how the response to the gift would affect the therapeutic relationship, (c) therapist perception of how the response to the gift would affect the client, and (d) therapist perception of the client's personality dynamics. Gift-related‘factora. In rank order of importance, the gift-related factors were (a) the monetary value of the gift, (b) the type of gift, and (c) the timing of the gift. 73 Table 4-3 Factors Influencing Acceptance or Non-acceptance of Client Gifts (N-138) Factors M SD Gift-related Factors 1. Type of gift 3.18 1.00 2. Timing of gift 3.11 1.02 3. Monetary value of gift 3.26 1.00 Client-related Factors 4. Age of the client (i.e., child or adult) 2.47 1.11 5. Gender of the client 1.77 .86 6. Financial status of the client 2.42 1.03 Therapy-related Factors 7. Therapist's perception of the client's personality dynamics 3.68 .73 8. Therapist's perception of the dynamics of the therapeutic relationship 3.78 .55 9. Therapist's perception of how response to the gift would affect the client 3.73 .67 10. Therapist's perception of how response to the gift would affect the therapeutic rela- tionship 3.77 .58 Note: The reported means and standard deviations are based on a scale ranging from 1 to 4, where l-not important and 4-very important. 74 Table 4-4 Other Important Factors Influencing How Psychotherapists Responded to Client Gifts as Described by Respondents (n-17) Factors Gift-Related Factors 1. 2. 3. What the gift symbolizes (np3) Individual or family gift (n-l) Is gift likely to have been stolen from someone else (nvl) Client-Related Factors 1. 2. 3. oowasmb Ego strength (n-l) Client's cultural understanding regarding gift (n-l) Does it represent a transition, e.g., resolution of crisis, comfort, etc. (n-l) Developmental level of patient (n-l) Client motives, e.g., sincerity vs. manipulation (n-2) Level of insight (n-l) Extent to which client is willing to discuss meaning (n-l) Degree of client's ”innocence" in gift giving (n-l) Therapeutic- or Ethical-Related Factors 1. 2. 3. Try not to "abet the patient's acting out" but also try not to offend (n-l) Perception of how refusal would affect client, relationship, etc. (n-l) Institution or state laws (n-l) 75 Sliaar-relared factora. The age of the client and the client's financial status were rated as somewhat important factors, and, overall, the factor rated as least important of the client-related factors was the client's gender. The following possible responses to client gifts were also explored in this study: anxiety, worry, and acceptance of client gifts. For these items, a four-point scale was employed where one was "never," two was "occasionally," three was "usually," and four was "always.” The distributions for these three response variables are shown in Table 4.5. Agaiary. With regard to the response variable of anxiety, respondents were asked how often they experienced anxiety or other forms of distress when offered client gifts. On the average, they reported that they experienced anxiety "occasionally" (M—1.96, SQ-.86). Egrry. Respondents were asked how often they worried about whether their responses to client gifts were appropriate; on the average, it was found that they tended to worry "occasionally" about the appropriateness of their responses to client gifts (M92.13, SQ-.86). Gift acceptance. Respondents were also asked how often they accepted client gifts; using the above scale, they reported an average of accepting gifts somewhere between "occasionally" and "usually" (a=2.7a, SQ=.67). 76 Table 4-5 Distributions for the Response Variables: Anxiety, Worry and Gift Acceptance N % Anxiety Never 33 24 Occasionally 81 59 Usually 19 14 Always 4 3 137 100 Worry Never 29 21 Occasionally 79 56 Usually l7 l2 Always 15 11 140 100 Gift Acceptance Never 1 l Occasionally 50 36 Usually 71 51 Always 17 12 139 100 77 The extent to which the topic of client gift giving was addressed in respondents' formal graduate training was assessed using a four-point scale where one was ”never," two was ”minimally,” three was "adequately," and four was ”thoroughly." Of 141 respondents, client gift giving was reported to have been addressed on an average of "never” to ”minimally" in respondents' formal graduate training (Mr1.84, SQ-.82). Only 23% said it had been "adequately" addressed. The distribution of this variable is presented in Table 4.6. Respondents were asked to indicate whether or not there was a formal policy in their primary therapeutic work setting limiting or prohibiting acceptance of client gifts. Just over 10% (3915) reported that there was a formal policy in their primary therapeutic work setting limiting or prohibiting acceptance of client gifts. Eleven respondents worked in private practice, two in Veterans' Administration hospitals, and two in state psychiatric hospitals. Table 4.7 includes a description of the policies according to work setting. Respondents were also asked to rate the importance of their work policy in influencing how they responded to client gifts. They used a four-point scale where one was "not important," and four was "very important." For this subgroup of 15 respondents, the policy was "very important" in influencing how they respond to client gifts (M—3.80, SQ-.56). 78 Table 4-6 Distribution for the Variable of Formal Graduate Training in Clientoto-Therapist Gift Giving (N-l4l) Amount of Formal Training Reported N % Never 57 40 Minimally 52 37 Adequately 29 21 Thoroughly 3 2 79 Table 4-7 Gift Policies in Therapeutic Work Settings (N-15) Policy Private Practice 1. "In private practice, I made the decisions" 2. “Never accept a gift unless it would be very harmful to (always very disturbed clients) patient to reject it" 3. "Generally not done” 4. "I have my own policy--depending on the factors involved in Section II 5. "Primarily with respect to the dynamics of the therapeutic relationship" 6. "1950's no gift giving, after 60's became eclectic depends on dynamics of patient where they are in treatment" 7. "No one who works in our institute is allowed to accept anything outside formal remuneration" 8. "The policy is: to always assess the personality and therapeutic dynamics, never receive gifts except at Christmas time, always analyze the gift” 9. "I am in private practice--I 'never' accept gifts, except occasionally as the patient's needs dictate" 10. "An 'inexpensive' gift will be accepted first time offered (generally)--gift giving is discussed with client and informed not accepted in the future unless 'homemade' and inexpensive" 11. No description of policy given Veterans Administration Hospital 1. "Do not accept gifts" 2. "No gifts of monetary value that could affect client-therapist relationship" State Psychiatric Ward or Hospital 1. "Accepting gifts is discouraged and prohibited in the case of money or objects of some values” 2. "Gift receiving is prohibited (recent rule)" 80 WW There were three critical incidents requested at the end of the survey where psychotherapist-respondents were asked to describe client gift situations from their personal clinical experience. The first incident asked each respondent about the most recent gifts s/he was offered, the second about the gift s/he found most troublesome to respond to, and the third asked about a gift s/he did not accept. Each incident was divided into several open-ended ”parts.” In all three incidents, the results of parts ”b" and ”c" (gift symbolism and client motivation, respectively) were combined since respondents did not seem to differentiate between the two. The results for each incident will be presented separately. t a de # ° ost ece t. Of 141 possible respondents who had been offered at least one client gift (see ”incidence” from Section I for reference), 136 respondents (97%) completed Critical Incident #1. This critical incident was divided into seven open-ended questions: (a) the type of gift most recently offered, (b) what the psychotherapist perceived the gift symbolized, (c) what the psychotherapist perceived motivated the client to offer the gift, (d) whether or not the gift was accepted, and (e) the psychotherapist's rationale for accepting or not accepting the gift and the psychotherapist's perceptions of how accepting or not accepting the gift affected (f) the client and (g) the therapeutic relationship. Responses to each part were grouped into categories based on content analysis, and then frequencies of responses were calculated. 81 Llal__Iyna_gf_gi£r. Table 4.8 presents the types of gifts that respondents reported were offered to them most recently. As a gift, 20% of the respondents reported that they were offered food, which was the most frequently reported type of gift offered. This was followed in frequency by plants or flowers (13%). Arts and crafts made by the client were also reported to have been offered to 13% of the respondents. Examples of this were Christmas ornaments, an afghan, a pottery bowl, a model ship, framed pictures or paintings, and needlework crafts. WM- The Perceived motivations for offering the most recent gift as subscribed to clients by the respondents are presented in Table 4.9. The perceived motivation most frequently reported was that of communicating feelings of appreciation, care, gratitude, and warmth toward the psychotherapist. This was reported by 37% of the respondents. Communicating needs to the psychotherapist was the second most frequently reported motivation (18%). Examples of this were need for acceptance and approval; need to please; need to nurture; dependency needs; need for security; and a need to confirm the relationship, bond, or connection. The socially acceptable time for giving was reported as the third most frequent motivation (10%) and gift giving times included holidays, birthdays, retirement, and termination. Communicating therapeutic issues through the object itself was reported as another perceived motivation (8%). Examples of this included an adolescent, male client who presented a nutcracker to his psychotherapist who viewed this as being indicative of castration 82 Table 4-8 Most Recent Gift: Type of Gifts Offered and Gift Acceptance as Reported by Respondents in Item 27 (a and d) N % Type of Gift Food 27 20 Plants/Flowers 18 13 Arts & Crafts (made by client) 18 13 Books, literature, poetry (purchased by client) 15 ll Novelty Items 9 7 Clothing 9 7 Arts & Crafts (purchased by client) 9 7 Office Supplies for Personal Use 7 5 Other 6 5 Books, literature, poetry (written by client) 6 5 Beverages 3 2 Decorative 3 2 Jewelry 2 1 Music 2 1 Tickets or Invitations to Social Events 2 1 Money 0 -- Total 136 100 Acceptance of Gift Yes 130 96 No 6 4 Total 136 100 83 Table 4-9 Most Recent Gift: Perceptions of Client Motivations for Offering the Gift as Reported by Respondents in Item 27 (b and c) Number of % of Total Perceived Motivation Responses Responses Communicating feelings about the psycho- therapist (e.g., gratitude, warmth, etc.) 88 37 Communicating needs to the psycho- therapist (e.g., need for acceptance) 44 18 Socially acceptable time to give gift or appropriate timing of gift 23 10 Communicating therapeutic issues through object itself 20 8 Communicating personal change as a result of the therapeutic process 15 6 Commmunicating self-identity to the psychotherapist (e.g., talent, values, etc.) 14 6 Communicating feelings of imbalance in the relationship (reciprocity issue) 14 6 Other motivations l3 5 Anticipation of the psychotherapists' actual needs or interests 8 3 A sign of therapeutic change (e.g., ability to desire to give) 3 1 Total 242 100 84 anxiety; or an adult, female client who presented a book about gender issues to her psychotherapist during a time when she was learning to express anger at men. Another motivation that was reported by respondents was communicating personal change as a result of the therapeutic process (6%). For example, one client offered her psychotherapist a kaleidoscope because of her ability to view herself in a new way. Another client made a pottery bowl that symbolized her feelings of increased freedom and her ability to be less controlled. 0 e t. As shown in Table 4.8, 96% of the respondents (£7136) to Critical Incident #1 accepted the client gifts offered to them, while 4% did not accept the gifts. (1a) Earignale fgr acceptiag. Of a total of 162 responses, the rationale most frequently reported by respondents was a desire not to hurt, insult, or reject the client (21%), followed by a desire to affirm and/or respect clients' feelings as expressed through the gift or the act of giving (20%). Another rationale for accepting the gift was because it was perceived as appropriate and/or it would not interfere with the therapeutic process (14%). In addition to other reasons given, respondents reported accepting gifts because of a desire to affirm and/or respect client needs as expressed through the gift or the act of giving (9%). Some respondents reported that they accepted gifts because they were personally gratified or pleased by the client gift (7%) or because of the amount of effort that the clients put into making the gifts for them (5%). Diagnostic qualities of the client (4%) were also reported as a rationale for accepting 85 gifts (e.g., borderline or schizoid personality disorder). A few respondents also reported that accepting gifts was a way of acknowledging client needs for reciprocity (3%) or was a socially desirable thing to do on their part (2%). Seventeen respondents (10%) reported ”other“ reasons which were broken down as follows: that the gift was inexpensive; that it would be therapeutic to accept the gift because the client was young, because of the gift's perceived symbolic meaning, because it was mailed after treatment, because the client was wealthy, because the client had good intentions, and because of the timing of the gift (a special occasion or near termination). TM- The gifts not accepted were a book, fur coat, homemade baklava, invitation to dinner, a painting, and a rare book. Of a total of seven responses, the rationale most frequently reported for not accepting the gift was a preference for analyzing the gift, rather than accepting it (pr3). Client dynamics (pe2), a gift policy at the work place prohibiting acceptance of gifts (p—l), and an effort to maintain boundaries of the therapeutic relationship (p-l) were also reported as rationale for not accepting gifts. (1f) Effect of acceptance on client. Perceptions of how acceptance of the gifts affected clients are provided in Table 4.10. The majority of the responses to this item indicated the perception that accepting a gift from a client led to positive feelings (74%) such as feeling understood, pleased, happy, gratified, comfortable, 86 Table 4-10 Most Recent Gift: Perceptions of How Accepting the Gift Affected the Client as Reported by Respondents in Item 27 (f) Perceived Effect of Acceptance Number of % of Total On Client Responses Responses Resulted in positive feelings 95 74 No effect or change 8 6 Felt more equal in relationship 7 5 Confirmed therapeutic connection 6 5 More open and able to take risks 4 3 Effect unknown 4 3 Assisted in "rite of passage" 3 2 Therapeutic learning experience 3 2 Total 130 100 87 safe, valued, and relaxed. While no other perceived effect accounted for even 10% of the responses, other perceived effects were reported as follows: the client felt more equal, the client was able to confirm the therapeutic connection, the client was more open and able to take risks, it assisted in a "rite of passage" for the client, or it was a therapeutic learning experience for the client. Additionally, some respondents perceived no effect on the client or did not know what effect, if any, acceptance had on the client. - e ce e t. Of a total of six responses, five shared the perception that the initial effect of not accepting the gift was the expression of negative feelings; however, these feelings were reported to have been resolved as the client came to understand the reasons for non-acceptance of the gift. One . respondent also reported that it helped the client. (lg) Effect on the rherapeutic relationship. Perceptions of how acceptance or non-acceptance of the gift affected the therapeutic relationship are provided in Table 4.11. Of a total of 133 responses, the most frequently perceived effect on the therapeutic relationship that was reported was that both acceptance or non-acceptance enhanced the therapeutic relationship (56%). Examples of this included the perception that the therapeutic relationship was strengthened or deepened as a result of the gift situation. Other perceived effects reported were that it aided in the termination process, that it equalized the relationship or was a stimulus for bringing out underlying dynamics. The perception that there was no significant 88 Table 4-11 Most Recent Gift: Perceptions of How Acceptance or Non-Acceptance Affected the Therapeutic Relationship as Reported by Respondents in Item 27 (g) Perceived Effect on Therapeutic Number of % of Total Relationship Responses Responses Enhanced the therapeutic relationship 74 56 No significant effect . 27 20 Aided in termination process 11 8 Equalized the relationship 9 7 Stimulus for bringing out underlying dynamics and increasing client awareness 7 5 Unsure 3 2 Other 2 2 Total 133 100 89 effect on the therapeutic relationship was reported by 20% of the respondents. SEW. Of 150 possible responses, 61 respondents (41%) completed Critical Incident #2 (the gift perceived as being most troublesome to respond to). Six incidents were accounted for as ineligible: three were gifts from non-patients and three were unclear examples and difficult to understand. Therefore, the total number of eligible incidents was 55 (37%). Respondents were asked to leave the critical incident blank if they had never been offered a gift which they perceived as troublesome which probably accounts for the lower response rate of this critical incident (as compared to Critical Incident #1). (Some respondents also indicated on the survey that they did not complete the critical incident because of the time involved which may also account for a lower response rate on this item.) While this may also reduce generalizability of the responses, it should be kept in mind that this also reflects agreement with earlier responses and descriptive statistics, indicating that most gifts are accepted by psychotherapists. This critical incident was divided into eight open-ended questions: (a) the type of gift offered, (b) what the psychotherapist perceived the gift symbolized, (c) what the psychotherapist perceived motivated the client to offer the gift, (d) what made the gift so troublesome to the psychotherapist, (e) whether or not the troublesome gift was accepted, (f) the psychotherapist's rationale for accepting or not accepting the troublesome gift and the psychotherapist's 90 perceptions of how accepting or not accepting the troublesome gift affected (g) the client and (h) the therapeutic relationship. Responses to each part were grouped into categories based on content analysis, and then frequencies of response were calculated. (2a) Iype pf gift. Table 4.12 presents the types of gifts perceived as troublesome to respondents. The category with the most frequently reported troublesome gifts was the ”other” category. Gifts in the "other” category that were accepted included a coffeemaker, radar detector, "bootleg" software, and a valentine's day card. Gifts in the ”other” category which were not accepted were a mechanical swing for the psychotherapist's newborn infant, a VCR, an expensive cassette recorder, an offer of assistance, and a large wrapped box that was left at the psychotherapist's door and was returned unopened. (2b and 2c) Sllent notivatlon. Of a total of 95 responses, the perceived motivation most frequently reported was the client's desire to alter the boundaries of the therapeutic relationship (23%). Examples of this included the desire to alter the boundaries socially, sexually, or with regard to power, status, and control. Communicating feelings (19%) and needs (11%) to the psychotherapist were also perceived motivations. Transference issues were reported in 10% of the responses as well as the perception that the client's relationship dynamics were seen through the gift giving behavior (9%). An example of the latter was a client who often gave expensive gifts to people in her life. She presented a large framed print of a famous artist which the psychotherapist perceived as being indicative of her need to 91 Table 4-12 Most Troublesome Gift: Type of Gifts and Gift Acceptance Reported in Item 28 (a and e) Number Number Not Accepted Accepted Total % Type of Gift Other 4 5 9 16 Beverages 3 5 8 15 Arts and Crafts (purchased by 3 2 5 9 client) Food 3 2 5 9 Office Supplies (for personal use) 5 0 5 9 Plants/Flowers 3 2 5 9 Clothing 2 2 4 7 Arts and Crafts (made by client) 2 0 2 4 Books, literature, poetry 1 1 2 4 purchased by client) Money 1 l 2 4 Music 2 0 2 4 Novelty Items 2 O 2 4 Tickets or Invitations to O 2 2 4 Social Events Decorative Items 1 0 1 1 Jewelry 0 l l 1 Books, literature, poetry written by client) 0 0 0 -- Totals 32 23 55 100 Acceptance of Gift Yes 32 59 No 23 41 Totals 55 100 92 compensate for low self-esteem in relationships by showing love in a "flashy way." Another example was a client who offered to obtain tickets for the psychotherapist who perceived that the client only felt love and acceptance if he took care of others (something he learned in relating to his mother). In this situation, the psychotherapist did not accept his offer to obtain tickets in order to help him understand that he could be accepted for himself without necessarily being the caretaker. Other perceived motivations included low self-esteem or worth, projecting a self-image, defensiveness, as part of a holiday or special occasion, or to equalize the relationship. d t e w s t oub esome. As seen in Table 4.13, the variables that made a gift seem troublesome to a psychotherapist were divided into five general areas. Perceived characteristics of the client was the category with the highest number of responses. These included the client's financial status, level of insight, level of self-esteem, and suicidal ideation or risk. Perceived characteristics of the gift itself were reported as the second most troublesome category which included monetary value of the gift (too costly) and type of gift (e.g., alcohol). The third most troublesome category was perceived characteristics of the therapeutic relationship or the therapeutic process. This included issues of maintaining the boundaries of a therapeutic relationship, analyzing the transference, and trying to balance rejection of the gift with acceptance of the client and his/her intent for giving the gift. Personal reactions to the gifts that were troublesome were also reported. Examples of 93 Table 4-13 Most Troublesome Gift: Variables that Made a Gift Troublesome as Reported by Respondents in Item 28 (d) Number of % of Total Troublesome Variables Responses Responses Perceived characteristics of the client himself or herself (e.g., financial status or motivation) 22 31 Perceived characteristics of the gift itself (e.g., monetary value or type of gift) 19 26 Perceived characteristics of the therapeutic relationship or process 13 18 Psychotherapist's personal reaction to the gift (e.g., guilt or obliga- tion) 10 14 Perceived timing of the gift 8 11 Totals 72 100 94 personal reactions included guilt, obligation, not wanting the gift, knowing that the gift would not be used, and difficulty knowing how to relate the inappropriateness of the gift to the client. Lastly, the timing of the gift was reported as troublesome. (2a1__fiaappnaa_rp_glfr. As shown in Table 4.12, 59% of the respondents to Critical Incident #2 (NrSS) accepted client gifts offered to them, while 41% did not accept the gifts. (2f) Raripnale for accepting. Rationale for accepting troublesome gifts are presented in Table 4.14. Of a total of 41 responses, the rationale most frequently reported by respondents was a desire to not hurt, insult, or reject the client, followed by a desire to encourage a therapeutic learning experience. Some respondents reported that they explored the meaning of the gift with the client before accepting the gift. Other reported rationale were appropriate timing of the gift, desire to affirm and/or respect the client's feelings as expressed through the gift or act of giving, the result of consulting with a colleague or supervisor, feeling obligated to accept the gift, and as a compensation for low fees. (2f) Rationale for not accepting. Rationale for not accepting troublesome gifts are shown in Table 4.15. Of a total of 23 responses, rationales most frequently reported were a desire to maintain the professional boundaries of the therapeutic relationship and to clarify transference and other relationship problems. Other reasons given by respondents for not accepting gifts from clients were 95 Table 4-14 Most Troublesome Gift: Rationale for Accepting a Troublesome Gift as Reported by Respondents in Item 28 (f) Number of % of Total Rationale for Accepting Gift Responses Responses Desire to not hurt, insult or reject the client 14 34 Desire to encourage a therapeutic learning experience 6 15 Explored the meaning of the gift with the client 6 15 Timing of the gift 5 12 Desire to affirm and/or respect the client's feelings as expressed through the gift or act of giving 4 10 Consulted with colleague/supervisor 3 7 Felt obligated to accept the gift 2 5 As compensation for low fee 1 2 Totals 41 100 96 Table 4-15 Most Troublesome Gift: Rationale for Not Accepting a Troublesome Gift as Reported by Respondents in Item 28 (f) Number of % of Total Rationale for Not Accepting Gift Responses Responses Desire to maintain professional boundaries of therapeutic relationship 6 26 Clarify transference and other relationship problems 6 26 Avoid collusion with client 5 22 Desire to maintain therapeutic focus 5 22 Insecurity (early in training) 1 4 Totals 23 100 97 to avoid unhealthy collusion with a client, a desire to maintain the therapeutic focus, and personal feelings of insecurity. Wigs;- Pereeptions of how acceptance of a gift affected a client are provided in Table 4.16. Almost half the total responses to this item indicated the perception that accepting a gift from a client led to positive feelings. Other perceived effects reported were as follows: a therapeutic learning experience, a confirmation of some aspect of a client's identity, a desire to avoid rejection of a client, an increase in a client's awareness of underlying dynamics, and a reinforcement of giving behavior. The perception that there was no effect or change was also mentioned. (2g) Effaar pf npn-aaceptanca on pliant. Perceptions of how non-acceptance of a gift affected a client are provided in Table 4.17. Of a total of 23 responses, 13 responses indicated the perception that the initial effect was the expression of negative feelings which were later resolved. Other responses were that non- acceptance resulted in unresolved negative feelings, feelings of acceptance, clarification of relationship boundaries, and facilitation of client self-expression and increased awareness. (2h) Effect of acceptance on the therapeutic relationship. Perceptions of how acceptance of a gift affected the therapeutic relationship are provided in Table 4.18. Of a total of 32 responses, the most frequently reported perceived effect was that it enhanced the therapeutic relationship. Other perceived effects reported included 98 Table 4-16 Most Troublesome Gift: Perceptions of how Accepting the Gift Affected the Client as Reported by Respondents in Item 28 (g) Perceived Effect of Acceptance Number of % of Total on Client Responses Responses Resulted in positive feelings 14 47 No effect or change 5 l7 Therapeutic learning experience 4 13 Confirmed aspect of client's identity 3 10 Increased client's awareness of underlying dynamics 2 7 Desire to avoid rejection of client 1 3 Reinforced giving inappropriate giving behavior 1 3 Totals 30 100 99 Table 4-17 Most Troublesome Gift: Perceptions of how Not Accepting the Gift Affected the Client as Reported by Respondents in Item 28 (g) Perceived Effect of Non-Acceptance Number of % of Total on Client Responses Responses Initially resulted in negative feelings which were later resolved 13 57 Resulted in negative, unresolved feelings 6 26 Accepted explanation for refusal 2 9 Clarified boundaries of relationship 1 4 Facilitated self-expression and increased awareness l 4 Totals 23 100 100 Table 4-18 Most Troublesome Gift: Perceptions of how Acceptance of Gift Affected the Therapeutic Relationship as Reported by Respondents in Item 28 (h) Perceived Effect on Therapeutic Number of % of Total Relationship Responses Responses Enhanced the relationship 10 31 Stimulus for bringing out underlying dynamics and increasing client awareness 7 22 Other 7 22 No significant effect 5 16 Adverse effect 3 9 Totals 32 100 101 that it was a stimulus for bringing out underlying dynamics and increasing client awareness, that it had no significant effect on the relationship, or that it had an adverse effect. QMWWE {glaripnah1p. Perceptions of how non-acceptance of a gift affected the therapeutic relationship are provided in Table 4.19. Of a total of 22 responses, half of them indicated the perception that it enhanced the therapeutic relationship. Other perceived effects included that it clarified boundaries of the therapeutic relationship, resulted in a positive learning experience for the client, did not interfere with the relationship, or had an adverse effect. 2W. Of 150 Possible respondents, 31 (21%) completed Critical Incident #3. Respondents were asked to leave this critical incident blank if they had never declined to accept a client gift. This, in addition to the time factor, may account for the low response rate to this item. Again, this may also reduce generalizability of the responses. This critical incident was divided into six open-ended questions: (a) the type of gift offered, (b) what the psychotherapist perceived the gift symbolized, (c) what the psychotherapist perceived motivated the client to offer the gift, (d) the primary reason for not accepting the gift and the psychotherapist's perceptions of how not accepting the gift affected (e) the client and (f) the therapeutic relationship. Responses to each part were grouped into categories 102 Table 4-19 Most Troublesome Gift: Perceptions of how Not Accepting the Gift Affected the Therapeutic Relationship as Reported by Respondents in Item 28 (h) Perceived Effect on Therapeutic Number of % of Total Relationship Responses Responses Enhanced the relationship 11 50 Clarified boundaries of the therapeutic relationship 4 19 Positive therapeutic learning experience for client 3 14 Did not interfere 2 9 Adverse effect 1 4 Other 1 4 Totals 22 100 103 based on content analysis, and then frequencies of responses were calculated. (3a)__1¥pa_pfi_g1fr. Table 4.20 presents the types of gifts offered (but not accepted) by respondents. The most frequently reported category of gifts that were not accepted was the ”other" category of gifts which included hallucinogens, cigarettes, rolls of tape, pine cones, a condom, a shaving kit, and an offer to use a vacation home. The categories of money and food were also reported frequently. (3b ana Sp) Sllant nprlvatipn. The motivations for offering a gift as subscribed to clients by respondents are presented in Table 4.21. Of a total of 40 responses, the motivation most frequently reported related to client dynamics (58%). Examples of this included a client's need for approval through gift giving, seductiveness, desire to control, and defensiveness. The following motivations were also reported: a client's desire to mix professional with social roles, to communicate positive feelings toward the psychotherapist, bribery, to communicate negative feelings toward the psychotherapist, and social habit. (3d) Rationale for not accepting. Rationale for not accepting the gift are presented in Table 4.22. Of a total of 33 responses, the rationale most frequently reported by respondents was to clarify the nature of the therapeutic relationship and to maintain appropriate boundaries. Other rationales included the desire to use the gift incident as a therapeutic learning experience (e.g., value of 104 Table 4-20 Gift Not Accepted: Types of Gifts Not Accepted as Reported by Respondents in Item 29 (a) Type of Gift N % Other: 7 23 hallucinogens cigarettes rolls of tape pine cones condom shaving kit offer to use vacation home Food 5 17 Money 5 17 Tickets or invitations to social events 4 13 Arts and crafts (made by client) 2 7 Beverages (alcoholic) 2 7 Jewelry 2 7 Arts and crafts (purchased by client) 1 3 Clothing 1 3 Plants and flowers 1 3 Totals 30 100 105 Table 4-21 Gifts Not Accepted: Perceptions of Motivations for Offering a Gift as Reported by Respondents in Item 29 (b and c) Number of % of Total Perceived Motivations Responses Responses Client dynamics (e.g., need for approval through gifts, seductiveness, desire to control, defensiveness) 23 58 Desire to mix professional and social 6 15 Communicate positive feelings toward psychotherapist 4 10 Bribe 3 7 Communicate negative feelings toward psychotherapist 2 5 Social habit 2 5 Totals 40 100 106 Table 4-22 Gift Not Accepted: Rationale for Not Accepting the Client Gift as Reported by Respondents in Item 29 (d) Rationale for Not Accepting Number of % of Total Client Gift Responses Responses Clarify nature of the relationship and maintain appropriate boundaries 10 31 Desire to use incident as a therapeutic learning experience (e.g., value of self without gifts) 6 18 Illegal/unethical/against personal values and principles 4 12 Inappropriate to accept (reason for inappropriateness was not specified by respondents) 3 9 Did not like or want gift 3 9 Other 3 9 Did not want to participate in negative self-expression which would be destructive to client 2 6 Better to analyze than to gratify l 3 Too valuable l 3 Totals 33 100 107 self without gifts), because accepting would have been illegal/ unethical/against personal values and principles, because accepting would have been inappropriate in some way, because the psychotherapist did not personally like or want the gift, because the psychotherapist did not want to participate in what s/he perceived as a negative self-expression on the client's part, because it was better to analyze the gift rather than gratify the client, because the gift was too valuable, because the psychotherapist perceived that the client needed the gift more than s/he did, because the psychotherapist perceived that the client would regret it later (in the case of a valuable gift), and because it was perceived that the gift showed resistance to engaging in the therapeutic relationship. (3;) Effear of nan-acceprance on client. The majority of the 31 responses to this item indicated the perception that not accepting a gift from a client led to initial negative feelings such as anger, confusion, hurt, and rejection, which were reported to have been resolved later in a positive manner (n-l9). Other perceived effects included a positive therapeutic learning experience for the client (n-4), increased awareness of boundaries of the therapeutic relationship (n-2), slowed client growth (n-l), and, in two cases, client withdrawal from treatment after the gift was refused. Three responses also indicated the perception that not accepting the gift had little or no effect on the client. (3f) Effect of non1acceptance on therapeutic relationship. Perceptions of how non-acceptance of gifts affected the therapeutic 108 relationship are provided in Table 4.23. There were a total of 37 responses, and they were as follows: it enhanced the therapeutic relationship, it clarified the therapeutic focus and relationship, it had little or no effect, it modeled more appropriate ways to interact with others, it increased client insight and provided access to new therapeutic material, it had a negative effect, it increased respect for the psychotherapist, and it ended the therapeutic relationship in two cases . Iaata of Hypotheses t S e ' e W A Pearson Product Moment Correlation Coefficient was used to test the first hypothesis, that there would be a negative relationship between psychotherapist's years of experience and reported level of anxiety. The relationship between the variables anxiety and years of experience was statistically significant in the expected negative direction (re-.23, p<.01, nrl37), and this provided some support for the hypothesis. The null hypothesis that there would be no relationship was rejected, although the amount of variance in anxiety accounted for by years of experience was only about five percent. Hypothesis Two: Worry and Years of Experience A Pearson Product Moment Correlation Coefficient was used to test the second hypothesis, that there would be a negative relationship between psychotherapists years of experience and reported level of worry. The relationship between the variables worry and years of 109 Table 4-23 Gift Not Accepted: Perceptions of how Non-Acceptance Affected the Therapeutic Relationship as Reported by Respondents in Item 29 (f) Perceived Effect of Non-Acceptance Number of % of Total on Client Responses Responses Enhanced the therapeutic relationship 9 25 Clarified the therapeutic focus and relationship 7 19 Little or not effect 6 l6 Modeled more appropriate way to interact with others 5 14 Increased client insight and provided access to new therapeutic material 3 8 Negative effect (e.g., strained relationship, client distanced self, client became more cautious) 3 8 Increased respect for psychotherapist 2 5 Ended the therapeutic relationship 2 5 Totals 37 100 110 experience was in the expected direction, but not statistically significant (re-.09, p9.13, npl40). Therefore, the null hypothesis that there was no relationship was not rejected. W Was A Pearson Product Moment Correlation Coefficient was used to test the third hypothesis, that there would be a negative relationship between reported level of anxiety and amount of formal graduate training on client gift giving. The relationship between anxiety and gift training was not statistically significant (re-.01, pe.44, 39137); therefore, the null hypothesis was not rejected. flyppthesis Epnr; Worry mm A Pearson Product Moment Correlation Coefficient was used to test the fourth hypothesis, that there would be a negative relationship between reported level of worry and amount of formal graduate training on client gift giving. The relationship between worry and gift training was not statistically significant and was not in the expected direction (r--.08, p-.18, n-140); therefore, the null hypothesis was not rejected. The correlations for Hl-H4 appear in Table 4.24. Hypothesis Five: Gift Acceptance and Primary Theoretical Orientation The fifth hypothesis, that psychotherapists who reported psychoanalytic as their primary theoretical orientation would accept gifts from clients less often than psychotherapists with other primary theoretical orientations, was examined using a Mann-Whitney U-test Table 4-24 Correlations Among the Variables Anxiety, Worry, Gift Acceptance, Gift Training, and Years of Experience 111 Variable l 2 3 4 5 1. Anxiety 2. Worry -.53* (137) 3. Gift Acceptance -.03 -.12 (135) (138) 4. Gift Training -.01 .08 -.09 (137) (140) (139) 5. Years of Experience -.23* -.09 -.11 .05 (137) (140) (139) (141) * p < .01 NOTE: The numbers in parentheses are the number of subjects on which each of the correlations was based. 112 Post Hoc Analyaea pf ther Variablas In an effort to further explore the relationship between response variables and psychotherapist demographic and professional characteristics, the following post hoc analyses were done in addition to the above-noted hypotheses tests. The research question that guided this exploration was whether or not a psychotherapist's response to gifts (amount of reported anxiety, worry, gift acceptance) differed among subgroupings of psychotherapists according to demographic and professional characteristics. The following section examines the differences between group means on anxiety, worry, and gift acceptance in subgroups of psychotherapists based on their gender, degree type, degree specialty, primary job affiliation, and primary theoretical orientation. In all cases, two-tailed t-tests were used to test the difference between group means with the probability of a Type I error fixed at .01. Sender with Anxiety, WorryI ang Gift Acceptance Two groups were formed based on the gender of psychotherapist- respondents. The group means for female versus male respondents were not found to be significantly different on the measures of anxiety, worry, and gift acceptance (see Table 4.25). grademic Degree with Anxiety; Worry. and Gift Accepgance The variable of academic degree was divided into Ph.D. versus all other types of degrees (Ed.D., Psy.D., M.A. or M.S., and "other") to form two groups. This was done because of the small number of 113 Table 4-25 Post Hoc t-tests for Male and Female Psychotherapists on the Measures of Anxiety, WOrry and Gift Acceptance Female Male p Response Variable N M N M t df value Anxiety 57 1.90 79 2.00 -.85 134 .39 Worry 57 2.04 82 2.20 -l.07 137 .29 Gift Acceptance 56 2.80 82' 2.71 .82 136.41 114 respondents in the non-Ph.D. categories. Table 4.26 shows that the group means for respondents in the Ph.D. group versus the group with other types of degrees were not found to be significantly different on the measures of anxiety, worry, or gift acceptance. Spagialty of Acadamia Degree wlph Wo d C t c The variable of academic degree specialty was divided into clinical psychology versus all other academic degree specialties (counseling psychology, educational psychology, and "other”) to form two groups. Again, this was done because of the smaller number of respondents in the non-clinical psychology categories. The results displayed in Table 4.27 indicate that the group means for respondents in the clinical psychology specialty group versus the combined academic degree specialty group were not found to be significantly different on the measures of anxiety, worry, and gift acceptance. Erlmary Job Affiliation with Anaiety, Worry, and Gift Acceptance The variable of primary job affiliation was divided into private practice versus all other primary job affiliations (state psychiatric ward, private psychiatric ward, veteran's hospital, outpatient clinic, community mental health center, medical school, university--academic and university--counseling center, and "other") to form two groups. Table 4.28 shows that the group means for the private practice group were not found to be significantly different on the measures of anxiety, worry, and gift acceptance. 115 'Table 4-26 Post Hoc t-Tests for Ph.D. Versus Non-Ph.D. Psychotherapists on the Measures of Anxiety, Worry and Gift Acceptance Ph.D. Non-Ph.D. p Response Variable N M. N M t df value Anxiety 116 1.94 21 2.05 -.64 135 .52 Worry 118 2.08 22 2.41 -l.67 138 .10 Gift Acceptance 117 2.74 22 2.82 -.53 137 .60 Table 4-27 116 Post Hoc t-Tests for Clinical Psychology versus Other Degree Specialty Psychotherapists on the Measures of Anxiety, Worry and Gift Acceptance Clinical Psychology Other Response Variable N M ' N M t df value Anxiety 92 1.87 45 2.13 —2.08 135 .39 Worry 94 2.13 46 2.13 -.02 138 .99 Gift Acceptance 94 2.71 45 2.82 -.90 137 .37 Table 4.28 Post Hoc T-Tests for Private Practice Versus Psychotherapists in Other Primary Job Affiliations on the Measures of Anxiety, Worry, and Gift Acceptance Private Practice Other p Response Variable N M N M t df value Anxiety 95 1.92 42 2.05 -l.01 135 .32 Worry 97 2.16 43 2.05 .75 138 .46 Gift Acceptance 96 2.75 43 2.74 .05 137 .96 117 ma eoretica O entat o wit et Wor and Gift cce tance The variable of primary theoretical orientation was divided into eclectic orientation versus all other theoretical orientations combined (Adlerian, behavioral, client-centered, cognitive-behavioral, existential, humanistic, gestalt, psychoanalytic, psychodynamic, relationship, Sullivanian, systems, and "other"). This was done because of the smaller number of respondents in the non-eclectic categories. The results of the t-tests displayed in Table 4.29 show that the group means for the eclectic orientation group versus the combined theoretical orientation group were not found to be significantly different on the measures of anxiety, worry, and gift acceptance. Summary of post hoc analyses. No formal hypotheses were offered with regard to how subgroups of psychotherapists might differ on the response variables of anxiety, worry, and gift acceptance. The results of the two-tailed t-tests of differences in subgroup means for psychotherapists (according to gender, academic degree, specialty of academic degree, primary job affiliation, and primary theoretical orientation) were not statistically significant for any of the response variables. Anecdotal Data On the last page of the survey, respondents were invited to offer any further comments they might have concerning client-to-therapist gift giving. A total of 24 respondents (16%, N=150) provided comments, and a summary of these follow. 118 Table 4-29 Post Hoc t-Tests of Eclectic Versus Non-Eclectic Psychotherapists on the Measures of Anxiety, Worry and Gift Acceptance Non- Eclectic Eclectic p Response Variable N M N M t df value Anxiety 66 1.92 71 1.99 -.51 135 .61 Worry 68 2.15 72 2.11 .25 138 .81 Gift Acceptance 68 . 2.69 71 2.80 -.98 137 .33 119 Some respondents wanted to make it clear that they felt client gift giving rarely occurred in their experience and was rarely troublesome. Ex. Ex. Ex. 1 Gift-giving seems to be relatively rare, in my experience. In 10 years of private practice, I've gotten possibly 8-10 gifts, almost all past-therapy and all $10 or less, it seems. I do relatively short term therapy, most having to do with the client's relationships with spouse or family, and it is very seldom that a true ”transference" develops. That, for me, is when gifts are truly Trojan horses. I also think I would have a lot more difficulty handling expensive gifts, something I haven't had to face. In general, I have had few problems with gift giving from clients. It is not common in my practice, but is usually appropriate when it occurs, i.e., small tokens of affection. I have had gifts about five times in 20 years, so I guess this is a rather specific event in a few relationships with patients. They were all of small value, thoughtful (e.g., handmade) gifts from patients I have known for a long time. Rather special circumstances. Whether client-to-therapist gift giving happens rarely or not, some respondents felt that it was not an important topic to research, and others felt that it was inappropriate for client-to-therapist gift giving to occur in psychotherapy at all. Ex. Ex. 1 It is difficult for me to see great importance in this research effort. Well- trained, well-adjusted therapists should be comfortable about the importance of appropriate responses in all such relationships. It is not a terribly important therapeutic issue. Gift giving is one means of pleasing the therapist--whi1e hiding more Ex. 120 threatened parts of the self. As any part of the patient's self--I will accept, and push for forbidden parts. I am less interested in the social facade designed to please, then I am in that part which the patient believes will displease. In general, gift giving and gift receiving are inappropriate in psychotherapy. Only with seriously disturbed, psychotic, or schizoid patients . . . are such gifts acceptable. Exceptions for small children, also. The gift of understanding and caring for the patient should suffice in usual psychotherapy. Regardless of whether client-to—therapist gift giving is unimportant or inappropriate, one comment implied that it occurs because of a problem in the psychotherapist while another implied that it was a problem in the client. Ex. Ex. 1 The attitude of the therapist creates the climate for gift-giving becoming an issue . If the therapist knows that the client is there for his/her own needs and life, the client gives to him/herself, and does not feel pulled to give to the therapist in this material way. Such gift- giving is too often an indication of the therapist's soliciting undue dependency and results in lack of autonomy in the client. I believe the proper technique for handling a gift involves interpreting the meaning of the gift-—explaining the underlying acting out--trying to help the patient withdraw the gift in the interest of keeping treatment on a verbal-affective level. That failing--I accept graciously and keep working on the need to give beyond the gift of therapeutic participation and fee. In direct contrast to some of the above comments, many of the respondents commented that client-to-therapist gift giving was an important part of the psychotherapeutic process. Ex. 1 The unconscious implications, etc., of the preferred gift along with how consonant it Ex. Ex. 121 is, etc., in context of the therapeutic work never cease to amaze me! I use client gift-giving as part of the ongoing therapeutic process rather than shutting down this avenue of client communication. Receiving gifts must be seen in a context and there are times to accept and times to decline. All of this is in the service of Rx and there is no rigid response. Others agreed that it was important to explore the meaning of the gift with the client. Ex. Ex. Ex. 1 I will never accept a gift without first exploring with the client what it means to her/him and motivations for gift giving. I feel gifts should not be used instead of words. . I believe gifts should not be a aubstitute for expressing feelings but can be a nice way to lead to more discussion. One can sense when one may be being compromised or bought. One should explore the transference, regardless, in context. But, one should not allow the gift to loom larger than it is and become an issue of counter-transference focusing a sidetrack from therapy . Some respondents even indicated that, during the initial session, they discouraged clients from offering gifts. Ex. Ex. 1 In the initial interview, when I explain the nature of a psychotherapeutic relationship, I also say that "we," i.e., psychotherapists, do not accept gifts. Of course, young children bring me a cookie sometimes. I then share it with a child. . I make it clear either at the beginning of treatment or at an appropriate time that gifts must be discussed and that only a tiny, symbolic or token gift will be accepted, e.g., a bar of candy. 122 Some comments were also made on how their response to a client's gift is influenced by the difference between an "expensive" versus a "token" gift. Ex. Ex. 1 I have never been offered a gift that was too expensive or otherwise inappropriate-- my clients tend to offer 'tokens“--small vases, boxes, cookies, a photo--which are personal and feel okay to accept. I would certainly not accept a more expensive ‘ gift . I have never considered refusing a gift, and I have always considered it a sign of affection. Maybe that is because I have never received an extravagant gift, and even then I would have a hard time refusing. Others offered examples of their personal policy in responding to client gifts. Ex. Ex. 1 The issue with gift-giving is its appropriateness. I would never accept an expensive gift or a gift that was intended as a "bribe.” My experience with gifts has been that clients have a need to say "thanks" and that they appreciate your caring. I think it is therapeutic to allow that expression of thanks. When a client offers me a gift I accept it matter of factly. If it is or becomes or threatens to become a pattern or fits into a specific dynamic of the client (e.g., one who "buys" friendship, etc.), I will use this and have the client look at process. I don't make a fuss one way or another but look (and have the client look) at their gift giving as another example of their behavior pattern and the meanings (if any). To refuse would be to say they are "unworthy," to accept without awareness could be overlooking important dynamics. Whatever happens in the therapeutic relationship/interaction is "grist for the mill." 123 Dlapuaaion The purpose of this study was twofold: first, to describe the current characteristics of the phenomenon of client-to-therapist gift giving, including how present-day psychotherapists respond to client gifts; and second, to investigate the relationships that may exist between psychotherapist characteristics (demographic and professional) and specific behavioral and emotional responses to client gifts. A discussion of the results presented in this chapter will be guided by these two major objectives. nt C a acte cs pf rhe Phenomenon First of all, the results of this study indicate that client-to- therapist gift giving is a common phenomenon. Ninety-four percent of the respondents reported that they had been offered at least one gift; and, based on the number of types of gifts reported to have been offered by clients, it is highly likely that the number is usually much higher than just one gift for each respondent. In addition to being a common event between client and psychotherapist, the results of this study suggest that client-to- therapist gift giving can be characterized as a personal event between client and therapist. For instance, the types of gifts most frequently reported by respondents tended to be handmade gifts and food which, according to the literature, are invested with greater symbolic value and are indicative of closeness between partners (Sherry, 1983; Shurmer, 1971). Additionally, the most frequently reported time for clients to offer gifts was on or near a holiday, a ti CC it 124 time when people are socially encouraged to express their sentiments toward those who are important in their lives (Bursten, 1959). Thus, in accordance with the interdisciplinary literature, client gifts tended to be given around what Sherry (1983) described as "structural events" such as holidays or other occasions. The majority of gifts also tended to be described as "token" gifts which were personal and appropriate, while "expensive” gifts were often seen as impersonal and inappropriate in some way. (In fact, gifts over $10 or $25 were considered to be "expensive" by 86% of the psychotherapists in this sample.) One psychotherapist offered an interesting example of this notion when she described a client who offered an expensive gift (over $150). She indicated that the "issue of ostentatious gifts occurred many times with her [in all her relationships]," and went on to say that "as her [the client's] self worth improved, her gift offers changed to small tokens, and more personal." Indeed the literature bears out the notion that expensive utilitarian or impersonal gifts are common when there is a certain amount of distance between partners (Sherry, 1983; Shurmer, 1971). Thus, the personal nature of this phenomenon is evident from the types of gifts clients offer, to their timing and value. As described in the literature, the gift givers in modern society tend to be women, and some support was found for that observation in this study. Female clients were estimated by psychotherapists to be more likely to offer gifts to psychotherapists than male clients. In terms of the important factors that influence how respondents decide whether or not to accept a client’s gift, it should be pointed 125 out that the rating scale used in Section II of the survey appears to have been too simplistic. It was later revealed in the critical incidents that the factors that go into the decision of whether or not to accept a client's gift are much more complicated than was reflected in the rating scale. In other words, psychotherapists usually have to take several factors into consideration at the same time when making such a decision. For example, one psychotherapist was offered an expensive coffee-maker that she knew she would not use, yet it was offered during the last session from a client who was moving away, who did not speak English very well, and whom she felt may not have understood a refusal. In this example, then, the psychotherapist considered several variables at once: type of gift, value, timing, the client's ability to understand, and not wanting to hurt the client by refusing. Despite the limitations of the rating scale as discussed above, it was found that, by far, the factors that respondents considered most important in influencing their decision had to do with the therapeutic relationship and process (as opposed to gift- or client- related factors). This evidence was found to be quite striking in both the results of the rating scales and the critical incidents. As far as their emotional responses to a client's gift, this sample of psychotherapists reported, on the average, "occasional" anxiety when offered gifts and "occasional" worry regarding the appropriateness of their behavioral response to the gift (i.e., acceptance or non-acceptance of the gift). These findings could be explained in several ways. First, in contrast to observations made in 1! b1 126 the literature, it may be that psychotherapists do not actually experience much anxiety or worry when it comes to client gift giving. A second explanation may stem from the fact that anxiety and insecurity regarding interventions is more often associated with the beginning psychotherapist than with the experienced psychotherapist (Auerbach & Johnson, 1977), and the psychotherapists in this sample were a very experienced group (with an average of 17.4 years of experience). Lastly, the scale used to measure anxiety or worry may not have been sufficiently sensitive to yield accurate results. In terms of their actual behavioral response to gifts, respondents reported that they "usually" accept client gifts. While the measurement scale for gift acceptance may have been somewhat simplistic, the finding from the scale was further supported by the information supplied in the critical incidents. That is, most gifts were indeed reported to have been accepted by the respondents. In fact, in responding to the first critical incident describing their most recent offers of gifts, 96% of the psychotherapists reported that they accepted the client gifts. In addition to the above descriptions of the phenomenon of client-to-therapist gift giving that were based on results from Sections 1 and II of the survey, the critical incidents in Section IV revealed further information about the phenomenon of client-to- therapist gift giving (including why respondents accept or do not accept client gifts) which will be discussed below. Given the results of this study, an interdisciplinary approach to understanding client-to-therapist gift giving appears to be useful 127 since the psychotherapists in this study used both motivational and functional explanations for client gift giving. While motivational explanations were the primary method of explanation for client gifts, functional explanations were acknowledged as well. In the critical incidents, they reported the perception that both conscious and unconscious client motivations for gift giving may arise out of social and cultural norms (e.g., holiday gift giving) which have important social functions. The majority of psychotherapists in this study reported the perception that client motivations for gift giving can often be conscious, positive, and appropriate expressions of gratitude and appreciation. They also referred to the underlying motivations or thoughts, feelings, and needs that the client communicated through the gift, which they interpreted as appropriate or inappropriate to the therapeutic process. None of the respondents mentioned Freud's psychosexual stages in reference to client gifts and only occasionally were id-oriented conceptualizations of unconscious hostility or acting-out mentioned by respondents as underlying motives for gift giving. The language most often used by respondents to describe client-to-therapist gift giving tended to be more along the theoretical lines of ego-analytic and developmental psychology as described in the literature review. Given that respondents perceived client gifts as being motivated by conscious, positive, and appropriate intentions, they often indicated that it was more important to acknowledge such expressions on the client's part by accepting his/her gift than to risk hurting or 128 losing the client. In fact, using some of the language from the literature review, the psychotherapists in this study tended to be 'gratifiers" rather than ”deprivers‘ (Fox, 1984). They placed a great deal of emphasis on accepting the gift and affirming the act of giving as a way of enhancing the therapeutic encounter. Thus, in contrast to the psychoanalytic literature, accepting gifts is rarely perceived as interfering with the therapeutic process. The ”obligation to receive” has been written about and observed in both archaic and modern cultures and refusing a gift is seen as an unfriendly or hostile act (Belk, 1976; Mauss, 1924). In this study, whenever psychotherapists refused a client's gift, they reported that it had a negative initial effect on the client. In the majority of these cases, the psychotherapist had to work hard to help the client understand the reasoning behind the refusal; and, according to them, most of their clients eventually understood. In two cases, however, the psychotherapists reported that they lost their clients as a result of the refusal. Thus, the concern that refusing a gift may result in hurting or losing the client appears to be a realistic one. As mentioned briefly in the literature review, several contemporary psychoanalytic and developmental authors have written about two modes of responding to clients on the psychotherapist's part. These have been called the "technical" versus the "non- technical" (Chrzanowski, 1980) or the "doing-to" versus the "being-with" function of the psychotherapist (Mackie, 1981; Wolff, 1981). The technique of interpretation has been described as a "doing to" function, a form of behavior which often implies separateness 129 between the therapist and the client, while the "being with" function is when the psychotherapist shows empathy and sensitivity to both verbal and non-verbal communications and is able to be there as a real person for the client (Mackie, 1981). As a technique, interpretation has been described as "the major instrumentality of therapeutic movement in the psychoanalytic system" (POpe, 1977, p. 367). Yet, even Freud (1913) indicated that a well-developed rapport must be established with the patient before interpreting his/her hidden thoughts and associations. Mackie (1981) provided a summary of the above comments. Not only is the patient likely to feel alone on entering therapy, a feeling which is linked with the notion of being somehow different, of being the only person who could possibly feel and think as he [or she] does . . . The giving of interpretations involves the use of furthering this sense of isolation. The giving of interpretations involves the use of words and at times such words can be freeing and enhancing, but at other times they can be felt by the patient as unnecessary, impinging or meaningless. The therapist has to tread a very delicate path between his [or her] "being with" and "doing to" functions. (p. 208) Based on the critical incidents offered by psychotherapists in this study, it was found that they do indeed struggle to balance the technical and non-technical therapeutic functions when it comes to client-to-therapist gift giving. This was especially evident in the critical incident on the most troublesome gift where half of the gifts perceived as troublesome were not accepted by the psychotherapist involved. According to Greben (1981a): People need limits, for part of loving or caring for someone is to set him [or her] realistic goals and limits. Therefore, the therapist must not just be caring in a positive way, he [or she] must be 130 caring by saying "no," in one way or another. (p. 454) Thus, for psychotherapists in this sample, "being with" the client did not necessarily leave out the necessity to function in a technical or "doing to" manner. In fact, they were able to, and often did, set limits around the gift offer in order to maintain important therapeutic boundaries or to teach the client something by interpreting the gift or act of giving rather than accepting the gift. e ti 8 n V able The literature on client gift giving (including the manner in which psychotherapists respond to client gifts), treated the phenomenon of client-to-therapist gift giving from a technical point of view. That is, gifts were generally perceived as unconscious communications to be interpreted by the psychotherapist and not accepted (though it was believed that acceptance may be necessary with some severely disturbed or young clients). Consequently, it was hypothesized that there would be statistically significant relationships among several professional characteristics and how psychotherapists responded to client gifts. However, except for the first hypothesis that there would be a negative relationship between anxiety and years of experience, no statistically significant relationships were found using Pearson Product Moment Correlation Coefficients to test for significance. Furthermore, post hoc analyses were done using t-tests to explore whether other subgroupings of psychotherapists (based on demographic and professional characteristics which were collected in the survey) would result in 131 subgroup differences on the three response variables considered in the hypotheses tests. No statistically significant differences were found between group means in the post hoc analyses. Given the lack of statistically significant results, it is possible that the measures themselves were not accurate, detailed, or sensitive enough to yield significant statistical results. However, incorporating some of the descriptive data summarized in the first part of this discussion, it appears that the negative findings may also be due to the fact that professional and demographic characteristics (with the exception of years of experience) have little to do with how psychotherapists actually respond to client gifts. In his review of the literature on training, Garfield (1977) highlighted the evidence that psychotherapists of the same training and theoretical orientation do not necessarily function similarly with clients. Even samples selected for their adherence to specific orientation "schools" showed both similarities and differences in their theoretical belief systems and self-reported behavior (Sundland, 1977). A review of the theoretical orientation literature also revealed that as psychotherapists gain experience, they become more eclectic and tend to "rely less on rules laid down for them by others and more on a differentiated assessment of what particular situations require" (Sundland, 1977, p. 214). In their review of the literature on level of experience, Auerbach and Johnson (1977) reported that experienced therapists were found to communicate better, offer higher levels of positive regard, 132 empathy, and congruence, and were not as likely as inexperienced therapists to defensively distance themselves from the client. They contended that . increasing experience brings role mastery, in which we can discern several elements. With a reduction in his [sic] self-preoccupations, the therapist can turn his attention to the client. His self-protective mechanisms work more efficiently, so that he is less vulnerable to the client's barbs and dissatisfactions. Feeling more secure, the therapist can be warmer with the client when warmth is called for. He now feels freer to say more, commit himself, try new things. (p. 99) On the other hand, they described the beginning psychotherapist as attempting to manage his/her anxiety by "clinging to therapy systems that seem to offer certainty" (Auerbach 6 Johnson, 1977, p. 99). The psychotherapists in this study were experienced psychotherapists and over half endorsed an eclectic theoretical orientation. Their responses on the critical incidents revealed thoughtful, therapeutic considerations regarding how they interpreted, evaluated, and responded to individual client gifts. The factors that they took into consideration when deciding how to respond to the gift included virtually all of the factors that were raised by the analytic and developmental theorists in the literature review, including those raised by anthropological and sociological theorists. In the majority of the cases, acceptance of a client's gift was considered to be the most appropriate response and required little thought; however, they were also able to identify therapeutic, client and gift factors that called for more thoughtful, and sometimes difficult, responses. As experienced psychotherapists, they were clearly aware of the importance of client-to-therapist gift giving as a potentially 133 critical therapeutic event and showed a great deal of sensitivity to the existence of both technical and non-technical aspects of the gift giving situation and a clear understanding of the importance of balancing these functions with the client's best interests in mind. CHAPTER V SUMMARY AND CONCLUSIONS ev ew t In some of the earlier psychoanalytic literature, there was anecdotal evidence to suggest that a problem existed in the area of client-to-therapist gift giving. Not only were gifts offered to analysts, but both experienced and inexperienced analysts were said to have trouble knowing how to manage "patient" gifts (Glover, 1955). Additionally, it was pointed out that inexperienced analysts, in particular, often "mishandled" gifts from patients because they lacked training on the subject (Lorand, 1946). Despite the fact that this problem was observed in earlier literature, it was not given much attention in the psychoanalytic literature that followed. In fact, later writings on gift giving focused primarily on interpreting the meaning of patient gifts using psychoanalytic conceptualizations (Kritzberg, 1980; Silber, 1969; Stein, 1965) with little, if any, attention to the psychotherapist's personal experience and/or difficulties with the gift-giving event. Such psychoanalytic interpretations provided the basis for establishing a strictly technical approach to patient gifts. Langs (1973) considered the acceptance of a patient's gift to be a serious violation of important therapeutic boundaries between the 135 patient and the psychotherapist which would ultimately interfere with the therapeutic process. The task was not to collude with the patient by accepting his/her gift, but to make the proper interpretation. Thus, the focus on patient gift giving went from observations that psychotherapists experienced difficulties in managing patient gifts to a prescriptive and technical approach to patient gifts. Because the profession of psychotherapy currently encompasses a broad range of professional groups, training centers, work settings, value systems and orientations; and, because the psychological literature on gift giving is almost exclusively based on psychoanalytic theory, the theoretical interpretations and the "ground rule" for managing client gifts may not be relevant for psychotherapists today. Furthermore, psychotherapists may still experience conflict in the management of client gifts given the limitations of the psychological literature in this area. No empirical investigation was found regarding how present-day psychotherapists (analytic and non-analytic) actually conceptualize and respond to client gifts in their day-to-day clinical practice nor regarding the empirical results of these responses on therapy process and outcome. Therefore, the purpose of the present study was twofold. The first objective was to establish the status of the phenomenon of client-to-therapist gift giving in present-day psychotherapy and describe its characteristics from the perspective of the psychotherapist (including how they manage client gifts). The second objective of the study was to explore the possible 136 relationships that may exist between psychotherapist characteristics and their response to client gifts. 0 s o e tu ev ew In order to provide a framework for understanding the socio- cultural and individual context from which client-to-therapist gift giving emerges, an interdisciplinary approach to the social science literature on gift giving was taken, and this made up the first section of the literature review. As noted by Befu (1980), social scientists use contrasting methods in explaining behavior. On the one hand, Befu noted that anthropologists and sociologists favor "functional" explanations. That is, they state the function or functions that an object, action, person, or institution performs in order to maintain the social system to which the object, action, person, or institution belongs (Senn, 1971). Psychologists, on the other hand, favor "motivational" explanations of behavior wherein individual, intrapsychic motivations take precedence over cultural norms. The above observed differences between social science disciplines applied to the gift giving literature as well. From a functional point of view, the principles of give and take and reciprocity were seen in the anthropological and sociological literature as universal, cultural norms that provide a means for social control and protection of social status, as well as a means for socializing individual members, stabilizing social relationships, and holding important social structures together--such as families giving gifts at Christmas time (Davis, 1973; Gouldner, 1960; Levi-Strauss, 1965; Mauss, 1924). 137 In contrast to functional explanations, psychologists viewed gifts as vehicles for conscious and unconscious communication (Bursten, 1959; Sherry, 1983; Schwartz, 1967). Accordingly, motivations were said to range from altruistic to selfish, and included gratitude, appreciation, support, hostility, insecurity, feelings of inequality, anxiety, obligation, and confirmation of either the giver or receiver's identity. The second section of the literature review covered the psychological literature on client-to-therapist gift giving. This section was limited to psychoanalytic theory wherein gifts were portrayed as vehicles of symbolic communication between the patient and analyst. Specifically, gifts were reported to symbolize the unconscious expression of developmental or psychosexual conflicts (Freud, 1963; Silbur, 1969; Stein, 1965), defensiveness against hostility and aggression (Langs, 1973; Lorand, 1946), a form of acting out past memories (Greenson, 1967; Stein, 1965), and a wish of symbiosis with the therapist (Silber, 1969; Stein, 1965). Additionally, it was noted that the symbolic potential of the gift itself may reside in one or more of its properties of functions, or in the timing of the gift (Kritzberg, 1980; Langs 6 Stone, 1980; Stein, 1965). The third and final section of the literature review included both research and theory on the psychotherapist's response to client gifts. Although the research was limited to two survey studies that only mentioned client-to-therapist gift giving briefly among many other topics, they provided the first reports that analysts viewed 138 client gifts as "technical problems" (Glover, 1955; Fey, 1958). Later psychoanalytic writers focused on the "ground rule" as described in the above review of the problem statement. Accordingly, gifts should not be accepted by the psychotherapist because it would be gratifying to the client because of his/her unconscious sexual and aggressive fantasies (Langs, 1973; Lorand, 1946; Szasz, 1965). (Of course, some exceptions to this rule were allowed when the gifts were considered to be "trifling" or "inexpensive.") In contrast, developmental writers indicated that clients often have a history of a disturbance in bonding in their childhood (Bowlby, 1977; Nacht, 1961; Winnicott, 1963), and gifts may represent an important attachment to the psychotherapist (Kaufman, 1980). Consequently, it is presumed that accepting client gifts is an important way of affirming their worth, much as a mother affirms her child. While the psychoanalytic and developmental theorists may have disagreed on the necessity of the above described ground rule, there was general agreement in the literature that gifts should always be accepted from clients with ego deficits and personality or character disorders because they would interpret the rejection of their gift as a concrete, personal rejection. Additionally, there was agreement that expensive gifts should never be accepted from clients for both therapeutic and ethical reasons. Review of the Methodology The subjects used in this study were psychologist- psychotherapists who were members of the American Psychological Association (APA) Division of Psychotherapy (Division 29). Five 139 percent of the population (or a total of 243 members) was selected at random by computer from the division membership list. A one-shot survey research design was chosen for the study since the major purpose of survey research is to establish the status of a given phenomenon (Mouley, 1970). Given the exploratory nature of this topic and the fact that no relevant instruments were available for use in this study, a self-administered survey was designed to gather descriptive data about client-to-therapist gift giving from the psychotherapist's perspective as well as to test the effects of specific variables which were expected to influence the way psychotherapists respond to client gifts. The final survey used in the study included four major sections and was the result of a thorough review of the literature, exploratory conversations with ten practicing psychotherapists and three pretests. Survey preparation and data collection were based on a variation of Dillman's (1978) "Total Design Method." Each psychotherapist in the sample was mailed by first class mail a personalized cover letter, coded survey booklet, and a stamped return envelope. One week later, a follow-up post card was mailed to the entire sample. Three weeks after the initial mailing, a second, follow-up post card was mailed to nonrespondents only. Five weeks after the initial mailing, a second cover letter, coded survey booklet, and a stamped return envelope were mailed to each nonrespondent. Each of the item responses from the self-administered survey was edited and then coded appropriately for computer analyses using the 140 revised Statistical Package for the Social Sciences (SPSS-X). The items in the survey were analyzed using qualitative and quantitative approaches. In addition to reporting descriptive data in the form of frequency distributions, the following hypotheses were addressed and analyzed. H1: There is a negative relationship between psychotherapists' years of experience and reported level of anxiety. H2: There is a negative relationship between psychotherapists' years of experience and reported level of worry. H3: There is a negative relationship between psychotherapists' levels of training regarding gifts and reported level of anxiety. H4: There is a negative relationship between psychotherapists' levels of training regarding gifts and reported level of worry. H5: Psychotherapists with psychoanalytic theoretical orientations will accept gifts from clients less often than psychotherapists with other theoretical orientations. Summary of the Results Out of 243 sample members, a total of 150 psychotherapists completed and returned the survey, resulting in a return rate of 62%. The mean age was 49.4 years. Forty percent were women, and 60% were men. Over 80% of the respondents had Ph.D. degrees, 67% of which were in clinical psychology. The majority of the respondents worked in private practice, averaging 75-100% of their time conducting individual psychotherapy with adults. About 50% of the respondents endorsed "eclectic" as their primary theoretical orientation, and 141 about 80% reported eclectic or psychodynamic as the theoretical basis for their most primary psychotherapeutic interventions. Ninety-four percent of the respondents reported that they had been offered a gift (or gifts) from clients. The most frequently offered gifts were reported to be arts and crafts made by the client, food, literature purchased by the client, plants or flowers, or decorative items for home or office. With regard to value, 86% of the respondents reported that they considered gifts over $10 or $25 to be "expensive" gifts. The most frequently reported time for clients to offer gifts was on or near a holiday, and it was estimated that female clients were more likely than male clients to offer gifts. In terms of the factors that influence their decisions on how to respond to client gifts, this group of psychotherapists reported therapy-related factors as the most important. The therapy-related factors included the therapist's perception of (a) the dynamics of the therapeutic relationship, (b) how the response to the gift would affect the therapeutic relationship and the client, and (c) the client's personality dynamics. Rated as less important were gift- related and client-related factors. On the average, this sample of psychotherapists reported that they only experienced anxiety "occasionally" when offered a gift and that they only worried "occasionally" about the appropriateness of their responses to client gifts. They also accepted gifts, on the average, between "occasionally" and "usually." Gift giving was reportedly addressed in their formal graduate training programs, on the average, "never" to "minimally." Ten percent of the sample 142 indicated that their primary therapeutic work setting limited or prohibited acceptance of client gifts, and they rated this policy as "very important" in influencing how they responded to client gifts. Critical Incident #1, the most recent gift, was completed by 97% of the respondents, and, of these, 96% accepted the client gifts most recently offered to them. The majority of these gifts were food, flowers, or arts and crafts made by the clients, and these gifts were perceived to be a means of communicating feelings and needs through the gift, in addition to their being offered at socially acceptable times for gift giving (e.g., holidays, birthdays, retirement, termination). The major reasons described for accepting the gifts were either a desire not to hurt, insult, or reject the client or a desire to affirm and/or respect the client's feelings as expressed through the gift or the act of giving. While it was reported by some that accepting the gift had little or no effect on the client or the therapeutic relationship, the majority of responses indicated that acceptance had a positive or enhancing effect on the clients and their relationships. On the other hand, the four percent who did not accept the gifts preferred to analyze the gifts rather than accept them or thought it was in the best interests of the clients or therapeutic relationships to do so, and one respondent felt bound by a work policy on gifts. In these few cases, the clients were reported to have been affected negatively at first, but later came to understand the refusal. Critical Incident #2, the most troublesome gift, was completed by 41% of the respondents, and, of these, 59% accepted the gifts and 41% 143 did not. The majority of the reported gifts were placed in the "other" category and were perceived as being motivated by a desire to alter the boundaries of the therapeutic relationship socially, sexually, or with regard to power, status, or control. Less provocative motivations were also reported such as appreciation, needs for approval, low self-esteem, defensiveness, or because of a holiday or special occasion,. The major reason for describing the gifts as "troublesome" had to do with perceived characteristics of the client such as his/her financial status, level of insight, level of self- esteem, or suicidal risk. Perceived characteristics of the gifts themselves or their cost was another major reason for describing the gift as "troublesome," as well as perceived characteristics of the therapeutic relationship or process such as maintaining therapeutic boundaries, analyzing transference reactions, trying to balance rejection of the gift with the client's perceived innocence regarding his/her intent. Again, the major reason reported for accepting troublesome gifts was a desire not to hurt, insult, or reject the client as well as the desire to provide a therapeutic learning experience for the client. It was reported by some that accepting gifts had little or no effect on clients and their relationships. On the other hand, the major reasons reported for not accepting troublesome gifts were desires to maintain professional boundaries or to clarify transference or other' relationship problems by not accepting the gifts. Not accepting gifts was reported to have an initial negative impact on clients; some of the negative feelings were reported to have been resolved with time, 144 and some were not. Perceptions were mixed regarding how not accepting gifts affected the therapeutic relationship. Some reported that it enhanced the therapeutic relationship or provided clients with important learning experiences, while others reported that it had adverse effects. Critical Incident #3, a gift that was not accepted, was completed by 20% of the respondents. As in the critical incident on the most troublesome gift, the majority of the reported gifts were placed in the "other" category which included hallucinogens, a condom, a shaving kit, and an offer to use a vacation home. Money was also reported more frequently in this critical incident. The psychotherapists perceived the gift motives to involve the communication of underlying dynamics including the need for approval, seductiveness, a desire to control, defensiveness, a desire to mix professional with social roles, bribery, hostility, as well as to communicate positive feelings toward the psychotherapist. Overall, respondents indicated that gifts were not accepted in order to clarify the nature of the therapeutic relationship or to provide learning experiences for clients. The majority of the responses indicated that the decision to not accept the gift was based on clients' needs, although two psychotherapists did not accept gifts because they personally did not like or want them. In addition to having little or no effect, the perceived effect of non-acceptance on clients that was reported most frequently was that of negative feelings. This was often reported to have been resolved later. It was also reported to have slowed client growth and, in two cases, to result in withdrawal from treatment. Overall, 145 non-acceptance was most frequently reported to have had a positive effect on the therapeutic relationship. However, there were some reports that it had a negative effect and that, in two cases, it ended the therapeutic relationship. The five hypotheses listed above were based on suggestions in the literature that higher levels of anxiety and worry and how often gifts are accepted may depend on psychotherapists' years of experience, among of gift training, and primary theoretical orientation. Some support was found for Hypothesis One where the relationship between anxiety and years of experience was found to be statistically significant in the expected negative direction using a Pearson correlation coefficient. No statistical support was found for the remaining hypotheses. No formal hypotheses were offered with regard to how subgroups of psychotherapists might differ on the response variables of anxiety, worry, and gift acceptance. Based on the results of the two-tailed t-tests, statistically significant differences between groups means were not found. In other words, subgroups of psychotherapists according to their genders, academic degrees, degree specialities, primary job affiliations, and primary theoretical orientations did not differ statistically on the measures of anxiety, worry, and gift acceptance. Lastly, 24 respondents (16%) provided general comments on the last page of the survey. Their comments were found to be especially relevant given the fact that they illustrated many of the aspects of gift giving as brought out in the literature review. Some felt that 146 client-to-therapist gift giving was a rare event in their experience and that it was rarely troublesome (conceding that the gifts they have been offered have been appropriate and inexpensive "tokens" of affection). Others felt that gift giving was not an important therapeutic issue or that it should not occur in psychotherapy at all. When it did occur, however, one respondent indicated that it was a problem that resided within the psychotherapist, and another respondent indicated that it was a problem that resided within the client. Some respondents discouraged clients from offering gifts during the initial session, others explored the meaning of the gift when it was offered, and still others had developed their own personal policies for responding to gifts. a o o The results of this study indicate that client-to-therapist gift giving is a common phenomenon. It can also be characterized as a personal event given the types of gifts that clients were reported to have offered, and the reported timing and value of their gifts. That is, the majority of the gifts most frequently reported are hand-made, token gifts given on holidays or other special occasions. In terms of the important factors that influence how respondents decide whether or not to accept a client's gift, it was found that, by far, the factors that respondents rated as most important were those that related to the therapeutic relationship and/or process. From the descriptions given in the critical incidents, the decision of whether or not to accept a client's gift was found to be a complicated one in 147 that many factors were considered at one time in the decision-making process. The psychotherapists in this study reported minimal anxiety when offered gifts and minimal worry regarding the appropriateness of their responses to gifts. They also reported accepting most client gifts. In fact, there were few differences found on measures of anxiety, worry, and gift acceptance in the sample as a whole or in subgroups. This lack of significant findings may have been due to deficiencies in measurement; however, it is also likely that the high level of psychotherapeutic experience of the sample members contributed to these findings. The psychotherapists in this study were experienced psychotherapists (an average of 17.4 years of experience), and almost half had endorsed an eclectic theoretical orientation with an emphasis on eclectic interventions. Anxiety and uncertainty are more often associated with inexperienced psychotherapists (Auerbach 6 Johnson, 1977), as well as a stricter observance of theoretical treatment models (Sundland, 1977). Experienced psychotherapists, on the other hand, tend to feel more secure (Auerbach 6 Johnson, 1977) and use a more eclectic, case-by-case approach to situations (Sundland, 1977). From a motivational point of view, the majority of psychotherapists in this study reported the perception that client motivations for gift giving can often be conscious, positive, and appropriate expressions of gratitude at the same time that there may be unconscious, underlying motivations such as feelings of insecurity or needs for acceptance. Secondary in importance to perceived client motivations, some psychotherapists also acknowledged the existence of 148 some functional aspects of gift giving with regard to the timing of a client's gift. Using language from the psychoanalytic literature, the psychotherapists in this study can be generally described as "gratifiers" rather than "deprivers" in that they usually accept client gifts. One of their major reasons for accepting client gifts was to avoid hurting, insulting or rejecting the client, a risk that seems to be a realistic one. The "obligation to receive" has been written about and observed in both archaic and modern cultures and refusing a gift is seen as an unfriendly or hostile act (Belk, 1976; Mauss, 1924). In this study, whenever a psychotherapist refused a client's gift, s/he reported that it had an initially negative effect on the client. In the majority of these cases, the psychotherapist had to work hard to help the client understand the reasoning behind the refusal, and, in two cases, the client withdrew from treatment. The results of this study strongly suggest that client-to- therapist gift giving can be an important therapeutic event which requires skillful handling on the part of the psychotherapist. Psychotherapists in this study struggled to balance both technical and non-technical therapeutic functions. On the one hand, they placed a great deal of emphasis on accepting gifts as a way of enhancing the therapeutic encounter, yet they also knew when it was important to set limits by refusing gifts in order to clarify important boundaries of the therapeutic relationship and to maintain the treatment focus. Based on their responses to critical incidents in particular, it was clear that this group of experienced psychotherapists readily made 149 decisions on what they perceived as the most therapeutic way to manage client gifts. MW Mail questionnaires, as compared to other methods of survey administration, have limitations in and of themselves. One limitation relevant to this study is that questions must be somewhat shallow in nature. Thus, some important variables may not have been measured in all their complexity (e.g., anxiety). Another limitation of mail questionnaires is the difficulty in checking for reliability and validity. This limitation was primarily addressed by verifying content validity through consultation interviews with 10 practicing psychotherapists and three pretests of the instrument with practicing psychotherapists. Furthermore, the relatively large number of completed questionnaires returned by a national random sample of psychotherapists and both their thoughtful solicited and unsolicited comments suggest that the subjects were honest in their responses and that the data collected are valid. Another possible limitation of this study is the problem of generalization. The population sampled was limited to members of the American Psychological Association (APA) Division of Psychotherapy (Division 29). It is possible that Division 29 members are not representative of psychotherapists in general. Psychotherapists who join APA and other professional organizations may be more interested in or experienced with professional issues such as client-to- therapist gift giving. It was also found that the sample had a disproportionate number of women as compared to the actual population 150 and that this difference was statistically significant based on a Goodness-of-fit test. However, because no gender differences were found to exist on the response variables, it is less likely that the disproportionate number of women had an impact on the findings in this study. As a group, the members of this sample were also highly experienced psychotherapists, and it is possible that this sample is not entirely representative of less experienced psychotherapists and their experience with client-to-therapist gift giving. ca ions a d C s o 5 Although Freud accepted gifts from his patients, his "principle of abstinence" received more attention in this regard. This also seems to have been the case for many other issues. For instance, in a letter to Ferenczi, Freud wrote, I considered the most important thing was to say what should not be done, so as to avoid anything that may be contrary to the spirit of psychoanalysis. The result is that the analysts have not understood the elasticity of the rules I laid down and they have turned them into taboos. (Cited in Nacht, 1962, p. 208) As defined in the dictionary, a "taboo" is a prohibition resulting from convention or tradition which then becomes unmentionable (Webster's New World Dlptlonary, 1977, p. 761); and, as Nacht (1962) pointed out, rules are often transformed into taboos when they are taken too literally. Given the psychoanalytic tradition of not accepting patient gifts, along with the paucity of literature, research, or training on this topic, it would appear that the subject of client-to-therapist gift giving is taboo. This, however, is not unique to the phenomenon of client-to-therapist gift giving. Many 151 contemporary psychoanalytic writers have recently observed that the "principle" of abstinence has helped to perpetuate the notion that good psychotherapists do not gratify or respond in a caring manner toward their clients, despite evidence indicating that 1n_raal1ry psychotherapists are increasingly responsive and caring (Chrzanowski, 1980; Greben 6 Lesser, 1981; Orlinsky 6 Howard, 1977; Stiver, 1985). Thus, the real taboo seems to be one of responding in a human and caring manner toward the client. Stiver (1985) distinguished between "caretaking" and "caring about" with regard to clients. She indicated that "caretaking" implies a more parental or unequal relationship, while "caring about" suggests more of an "investment of feeling in the other person with no implication about status and equality" (p. 1). In addressing herself to the discomfort experienced by many therapists about having and expressing caring feelings toward their patients, she contended that the traditional psychoanalytic model is a masculine model that reflects a style which is much more comfortable for men (i.e., objective, nonemotional, and impersonal attitudes)--a style that, in her opinion, does not appear to work well with women. Stiver reported her belief that what women patients want (and perhaps some men as well) is to be cared about in a particular way: "to be listened to and understood in a way which precludes the kind of distancing which exists in the more traditional models of therapy" (p. 13). While she conceded that many psychotherapists are capable of "caring about" their clients, she also indicated that women therapists have learned to overconform with the distancing, masculine model as a result of 152 trying to survive and be successful in the field; while men are apt to apologize for or hide this caring style "lest they be criticized and devalued by their male colleagues" (p. 14). The following quote from a male psychiatrist offers a good example of the existing barriers to "caring about" clients.. When I first began my practice, I was much more silent and unresponsive than I am at the present. I first learned, with a very ill young woman who had been psychotic, that it was impossible to stay so much out of the process and be of significant help to her. I began to make myself more and more available to her. I know from my own experience that what I have been doing with her and with others must be right, because I see it work--my results are much better. Since I am not a senior person in our field, I keep many such thoughts to myself. I sometimes wonder whether my being more open with and responsive to my patients is unique with me, but I have come to believe that this is most likely not the case: what I have discovered must also be known to some of my colleagues, though most of us are afraid to express these conclusions, lest we be accused of being radical or irresponsible. I comfort myself with the knowledge that I am, in fact, a caring and conservative therapist. (Cited in Greben, 1981b, p. 248) It has been pointed out that experienced psychotherapists are better able to establish relationships with clients that are warm, supportive, and caring (Auerbach 6 Johnson, 1977; Strupp, 1977; Sudland, 1977); however, as illustrated in the above example, they also feel less pressured to follow traditional models. Thus, while an experienced psychotherapist might feel freer to come to the above conclusions, trainees and beginning psychotherapists are more vulnerable to the pressures and constraints of trying to follow traditional treatment models that may not be relevant or appropriate to their needs or style. 153 Several writers have indicated that trainees are not given permission from supervision or teachers to be warm, supportive, and caring to their clients, nor are they able to see that these qualities might be practiced by their supervisors (Chrzanowski, 1980; Dana, 1974; Greben, 1981a, 1981b; Greben 6 Lesser, 1981; Stiver, 1985). Stiver offered an interesting example of this. She described the termination of a psychotherapeutic relationship between a woman who was leaving the clinic setting after her last year of psychiatric training and a client whom the trainee felt connected to and sad about terminating with. When the client asked if she could contact her, the psychiatric trainee said she would be glad to hear from her. When she reported this interaction to her supervisor, a male psychoanalyst, Stiver reported that "he told her she had been very seductive and inappropriate and was too involved with her patient" (p. 14). Stiver indicated that the trainee felt bad and accepted her supervisor's criticism. At the same time, she was also terminating her own therapy with a senior male analyst; and, when asked if she could see him again when she was in town, he said he would love to hear from her. Stiver reported that the trainee felt "vindicated" and said, "What goes on behind closed doors! There are all these analysts secretly acting like human beings, but nobody is supposed to know it!" (p. 14). Stiver concluded by indicating that good caring treatment does go on behind closed doors, but that it is time to take it "out of the closet." Along the same lines, Greben and Lesser (1981) observed that there is a continuing gap between what psychotherapists do in their 154 work and what they are willing to report. They go on to say that the gap between what psychotherapists feel they should be doing (in accordance with the therapeutic ideal expressed in the literature) and what they are, in fact, doing engenders a sense of guilt and shame in the therapist. As a result, they conclude that the literature tends to be "sterilized" with regard to what really transpires between the client and the psychotherapist. These comments are particularly relevant to the topic of client-to-therapist gift giving. There is a gap in the literature that does not fully reflect what actually transpires between the client and psychotherapist with regard to gift giving, as well as a lack of clinical guidelines that include both technical and non-technical considerations on managing client gifts. The historic literature on client gift giving would suggest that the "ideal" response is to recognize and interpret unconscious motivations behind a client's gift and not accepted the gift because this would interfere with the psychotherapeutic process. However, based on the reports of psychotherapists surveyed in this study, they were just as likely to recognize and affirm the conscious motivations of a client's gift (e.g., appreciation) and accept the gift as a way of enhancing the therapeutic relationship. The critical incidents, in particular, illustrated that the respondents in this study were experienced psychotherapists who were able to show warmth, support, and care in their management of clients' gifts, while, at the same time, attending to therapeutic issues and responsibilities. In summary, the results of this study illustrate that psychotherapists can and do gratify their clients appropriately and 155 that this is done more than the literature conveys. At the same time, however, it is implied in therapist training materials, clinical supervision, and codes of ethics that client-to-therapist gift giving is an inappropriate event in the psychotherapeutic relationship and that accepting client gifts is taboo. This makes trainees and beginning psychotherapists particularly vulnerable to confusion and anxiety when offered gifts from clients, elements which have also been found to lead to ethical violations (Welfel 6 Lipsitz, 1984). Thus, it is important that clinical education, training, and research begin to reflect and shape what actually transpires between psychotherapists and their clients when gift giving is involved as well as to validate the acceptance of gifts as a potentially appropriate response to client gift giving. r ctica m c tions 0 c ot e s d u e o s Psychotherapists need to be aware that, in a society which encourages generosity and gift giving on special occasions, they will undoubtedly be the recipients of client gifts sometime during their professional careers. Additionally, it is also important for psychotherapists to realize that the phenomenon of client-to-therapist gift giving often requires skillful management on their part. There are two major ways in which client gifts were viewed by the psychotherapists in this study. They were either viewed as appropriate or inappropriate forms of communication. When viewed as appropriate, the gift was almost always accepted by the psychotherapist; when viewed as inappropriate, the gift was almost 156 always not accepted by the psychotherapist. The psychotherapists reported that acceptance had a neutral or positive impact on clients and their relationships which corresponded well with the literature indicating the importance of "sufficient" gratification in the therapeutic relationship (Waterhouse 6 Strupp, 1984). However, as further indicated by Waterhouse and Strupp, the aim of the psychotherapist is to build on the real rapport of the therapeutic alliance while also addressing the inappropriateness of the client's maladaptive interpersonal perceptions. This is where non-acceptance of a gift became important to the psychotherapists in this study. That is, they found it important to refuse a gift and discuss the reason for refusal with the client if the gift was inappropriate in some way in order to teach the client something about him/herself or about the parameters of the therapeutic relationship. From another point of view, the above comments can also be discussed from non-technical and technical perspectives. From a non- technical point of view, a client's gift is often seen as an appropriate expression in the real relationship between the client and psychotherapist, and it is assumed that acceptance of the gift will not interfere with the therapeutic relationship or process. This is generally an uncomplicated interpersonal interaction as the following critical incident illustrated: a client offered the psychotherapist a jar of plum jelly as a way of showing appreciation and gratitude. The psychotherapist indicated that she accepted the gift because it "seemed a caring response to a gracious offer." She reported that the 157 client felt accepted and that this strengthened the therapeutic relationship. On the other hand, a more technical point of view is often required, especially when a client's gift is perceived as being inappropriate in some way and the psychotherapist must then assess the extent to which acceptance of the gift might interfere with the therapeutic relationship or process. As shown in the literature review, the obligation to receive gifts is an important aspect of human connection and refusing to do so is often perceived by the giver as hostile and/or hurtful. With clients, the risk of hurt or rejection must be taken into account since this may interfere with the therapeutic relationship or process.‘ Thus, when a gift is perceived by the psychotherapist to be inappropriate, s/he must carefully weigh the benefits and/or risks involved in both the acceptance or refusal of the gift. There seems to be a continuum of inappropriateness where a gift is relatively benign (little interference with the therapeutic process) to extremely provocative (significant interference). The inappropriateness of a client's gift is usually determined by such things as the type, timing, value, or perceived meaning of the client's gift. Furthermore, the benefits and risks of acceptance or refusal seem to include such important client and therapeutic issues as trust, self-esteem, insight, ego strength, therapeutic boundaries, and object relations. In the case of a relatively benign of "token" gift, it is usually not worth the possible risks to the client or the therapeutic 158 relationship to refuse the gift. In one critical incident, for example, a client offered a loaf of bread during the initial session. The psychotherapist perceived this gift as the client's wish to be accepted, loved, and forgiven, and, while the timing of the gift was viewed as somewhat inappropriate, "to interpret or refuse would have hurt the patient." Thus, as shown in this case, the benefits of accepting a somewhat inappropriate token gift may outweigh the possible risks of refusal. 1 Of course, with gifts that are perceived as inappropriate or provocative in some way (e.g., a condom, illegal drugs, a fur coat, money, or audio equipment), the benefit of setting limits and clarifying boundaries is generally worth the risk of hurt or rejection --which can ultimately be worked through as part of the therapeutic process. For instance, in another critical incident, a client offered a framed picture from a magazine which, according to the psychotherapist, "captured the essence of a fantasy relationship or eroticized nurturance." This gift was not accepted in order to "clarify the boundary about sexual involvement." The client was described as "rejected and pouting initially, secure and contained ultimately." The psychotherapist further stated that, although refusal of the gift created a crisis, it served to clarify the relationship in an important way. As shown in this case, then, the benefits of refusing a provocative gift may outweigh the risks involved. It is clear that psychotherapists need to understand the complexities of this phenomenon and to develop a personal policy 159 toward client gift giving, especially since the management of client gifts may have a positive or negative effect on psychotherapy outcome. However, as has already been pointed out, the lack of attention to client-to-therapist gift giving can leave beginning psychotherapists, in particular, vulnerable to conflict and anxiety when they are offered gifts. While both Silber (1969) and Stein (1965) agreed that an important and critical piece bf therapeutic work emerged from the gift giving situation, the knowledge and skills must first be learned. Therefore, clinical supervisors are in a good position to assist trainees in their management of client gifts. Supervisors can help trainees develop knowledgeable skills and clinical "rules of thumb" for responding to gifts. First of all, this can be done effectively through the supervisor's modeling and sharing of personal cases. According to Greben (1981b), Warmth, caring, hopefulness, and intelligent understanding and interest are at the heart of all effective psychotherapy. The demon artefact of unresponsiveness, a product of misguided adherence to what was originally good advice, must be exorcised . . . . For the teaching of psychotherapy, we require experienced and responsive therapists, who react naturally to their students and who reveal, in their open discussion of their own therapeutic work, that they respond naturally to patients. Identification is at the heart of all teaching, including the supervision of psychotherapy so that change in this attitude in new therapists will have to come about through a change in the attitudes of their teachers. (p. 249) Secondly, in addition to supervisor modeling and self- disclosure, training programs can include the topic of client-to- therapist gift giving in classes that address clinical skills. Most 160 training programs also include classes and/or discussions on ethical issues in psychology and client-to-therapist gift giving would be an important topic to address in this context. As is sometimes done in classes on ethical issues, trainees can be given a list of clinical vignettes that involve on gift giving situations as a way to help them think through potentially conflictual gift giving situations before they actually occur. The following list provides some suggestions for discussion. 1. What might the gift symbolize? 2. What might be the client's motivation for offering the gift? 3. What are the possible benefits and risks of accepting the gift? 4. What are the possible benefits and risks of not accepting the gift? 5. How might the impact of acceptance or refusal be managed with the client? Suggestions for Enture Research One of the major contributions of this survey study is a better understanding of the phenomenon of client-to-therapist gift giving as it currently exists in the field of psychotherapy. The prevalence of client-to—therapist gift giving was documented in this study as well as (a) the types of gift giving situations that tended to occur, (b) the factors or variables that psychotherapists seemed to consider when deciding how to respond to a client's view, (c) the notion that gifts were either accepted or refused because of therapeutic considerations, and (d) that none of the psychotherapist demographic and professional characteristics, other than level of experience, were statistically 161 related to variables associated with psychotherapist response to client gifts. Because an exploratory study of this type does not permit inferences concerning causality, the next research step is to investigate the findings empirically. Some research questions might include the following: Do psychotherapists really accept gifts more than they refuse them? Does accepting or refusing the gift influence the therapeutic process and, if so, what are the important variables to consider? Do psychotherapist demographic and professional characteristics (in addition to characteristics not considered in this study) predict outcomes such as anxiety level or acceptance/refusal of gifts when other measures of the dependent variables are used? A whole range of variables of interest could be manipulated or controlled using experimental designs to empirically test some of the conclusions posited in this study. For instance, determining the variables that influence the decision to accept or not accept a client's gift and determining the outcomes of such decisions upon the therapeutic process could be examined by creating client-to- therapist gift giving vignettes and manipulating the variables and outcomes of the decision a priori. Possible differences between groups could be assessed, such as experienced or inexperienced psychotherapists or supervisors who continue to see clients while they train beginning psychotherapists and those who do not. Paper and pencil analogue studies could also test psychotherapist ability to discriminate between sensitive gift giving situations and those that are not. 162 Psychotherapist confidence in their decision to accept or not accept client gifts could also be assessed in a similar manner. Because the therapeutic implications of client-to-therapist gift giving may be complex, it is important to view this event in process terms as well as an event that has a positive or negative outcome. As Welfel and Lipsitz (1984) cautioned in the literature on ethical behavior. Just as morality is more than a behavior that ends up helping or hurting someone else, ethics is more than the outcome of behavior that conforms or violates a code. The internal processes (intentions, motivations, way of cognitively structuring the ethical sensitive situation) are equally important. (p. 38) This is also true of client-to-therapist gift giving. There is a potential danger of focusing on outcomes alone (i.e., accepting or not accepting a gift or the positive or negative impact this may have on the client or therapeutic process) without placing equal importance on coming to understand the internal processes of the psychotherapist (and perhaps the client as well) when managing client-to-therapist gift giving. Study of the process could lead to the gathering of information that may assist in preventing non-therapeutic and unethical behavior. Indeed, as Welfel and Lipsitz (1984) pointed out, there are increasing advances in experimental research designs that study complex variables such as ethical decision making or therapy process and outcome. Research designs such as small sample and intensive case study designs would also appear to work well for studying client-to-therapist gift giving from an empirical perspective 163 (see Goldman, 1976; Kiesler, 1971; and Thoresen, 1978, for more detail related to these designs). In summary, a taboo regarding client-to-therapist gift giving seems to exist in the profession of psychotherapy as a whole, and this leaves both beginning and experienced psychotherapists ill-prepared for the complex issues that may arise when a client offers a gift. Although this study begins to describe the phenomenon of client-to- therapist gift giving as it currently exists, along with the variables that seem to be considered by psychotherapists in the clinical management of client gifts, a great deal of research is yet needed on this topic in order to firmly guide clinical practice. APPENDICES APPENDIX A COVER LETTER USED IN PILOT UNIVERSITY OF MAINE at Drona manta “ppm“ A "1le Om efSMmaAflsin 0“.“qu cone is?!" can IN PILOT ”mm-1m March 16. 1987 Dear There is evidence to suggest that psychotherapists are occasionally the recipients of client gifts (i.e., tangible or concrete obJects) during the course of psychotherapy. While the decision of how to respond to client gifts may be a complicated one, no evidence has been found of studies where psychotherapists have been formally asked about this phenomenon. The purpose of this research project is to investigate client-to-therapist gift giving from the perspective of the psychotherapist in order to provide a research base for guiding psychotherapist responses to client gifts. You are one of a small number of psychotherapists being asked to share their experiences regarding client-to-therapist gift giving. Your name was selected from a list of Maine psychotherapists and it is important that you complete and return the enclosed survey whether or not you have been offered a gift before. You may be assured that the information you provide is strictly confidential. Individual psychotherapists will never be identified during analyses or in reports of the research findings. An identification number appears on the survey for follow-up mailing purposes only. I would be happy to answer any questions you might have. Please write or cell collect. My telephone number is (207) 581-1392 during the day; (207) 868-3841 during the evening. Please complete and return the questionnaire as soon as possible. Thank you for your interest and assistance. Sincerely. Martha J. Barry. M.A. Project Coordinator ( 0L\SELIV(‘. PSYCHOTHERAPY TESTING RESEARCH TRAINING tut gswo Giant UvaflStYY and SH Claw! (OHIO! O! IAIN! aw (GUM WWIWIWIIMM «non WI 164 APPENDIX B PILOT: FIRST FOLLOW-UP POSTCARD APPENDIX B PILOT: FIRST FOLLOW-UP POSTCARD (ONE WEEK AFTER INITIAL MAILING) March 25, 1987 Last week a survey on client-to-therapist gift giving was mailed to you. If you have already returned your completed survey, I would like to thank you for your participation. If not, please do so today--your responses are important to the results of the study. If you did not receive the survey or if it was misplaced, please call collect right now at (207) 581-1392 during the day or (207) 866-3841 during the evening and I will mail you another copy. Sincerely, Martha J. Barry Project Coordinator 165 APPENDIX C PILOT: SECOND FOLLOW-UP POSTCARD APFBHHX C PILOT: SECOND FOLLOW-UP POSTCARD (THREE WEEKS AFTER INITIAL MAILING) April 7, 1987 About three weeks ago a survey on client-to-therapist gift giving was mailed to you. I am writing to you again because of the significance each survey has to the usefulness of this study. If you have not already done so, I would greatly appreciate it if you would complete and return the survey as soon as possible. If you did not receive the survey or if it was misplaced, please call collect right now at (207) 581-1392 during the day or (207) 866-3841 during the evening and I will mail you another copy. Thank you for your interest and assistance. Sincerely, Martha J. Barry Project Coordinator 166 APPENDIX D FINAL SURVEY APPENDIX D FINAL SURVEY A NATIONWIDE SURVEY OF CLIENT-TG-THEEIPIST GIET GIVING NEON THE PERSPECTIVE OF THE PSTCHOTHEEAPIST 168 macs : (1) Cimleflnnmberoonemflingtommsemlessoflewiseindicated. (2) Ifforenyraasmymfeelunmiortablepmvidingtlninfomtimreqmsted inanitem,pleasesld.ptrutquestimeniomtimietlnnnvey. SectionI. Mitminthissectimaregneralqmstimabmtclimtsmdthe giftstheyoffer. Q-l Hasaclimteverofferedyouagiftduringtheomn‘seofhisorher treaumtwithyou? lYI-B 2m (Skiptoomstionn) 0-2 Usingthefollowing list of possible gifts, please indicatethetypesof giftsyouhnvebeenofferedbyclimts. (Geckalltlnt apply.) (a) mammMmmsmschmér) (b) AXIS AN) CRAFTS (m BY CLIENT) _ (c) m T (6) ms, W, m (m BY am) (e) Boats, W, mm! mm BY (1.1mm (f) crowns ’ (9) mm runs an: me, man, am.) (h) m (i) W (j) ENE! 00 MJSIC (ms (11 M) (1) MT! I'm-26 (e.g., swam ms, Poems) (m) HANDS/m (n) 011m, PLEASE SPECIFY: 169 Q—3 Relative to famle clients, hale climts are hNNH NLIKELYEIOGTERGIPIS WWYLMY‘IOG‘FERGIPI‘S IESSLMY'IOG‘EERGIPTS mvsmrmxvmmcmsmmmsm Q-4 Please clack if at least cne climt has offered you a gift (eicluding greeting cards) at each of the following tines: Q-S mornearal'nliday For a special occasion in your life (e.g., your herring, birth of a child, etc.) Beforeyourvacatimorothertaworarybmak intreamant After the client's vacatim During the early phases of treatnent Dmingthemiddleplusesoftreahmt (but before tennination) \ Termination (last sessim) Atwhichofthetines listedinQ—llabovehaveyaimoeivedthelargest umber of gifts frat: clients? . Itan #: Which of the following categories best describes what you would causider to be an "expensive" client gift? 1 2 3 4 S $ 10.00 ('1! m $ 25.00 (R $ 50.00 (R $100.00 (I! $250.0 (R SEES O 170 SectionII. finitansinthiseectimhavetodowitthyoutMnkabmtand reapmdtoclimtgifts inyun‘day-to-day clinical work. Q-7 Pleaseindicatetnvinportmtenchoffliefolladngfactorsislikelytobe Myouaredecidingmetherormttoaooqataclimt'sgift. vm W WY 101‘ m m m m 1 2 3 4 1 mafgfitOOOOOOOOOO0.0.0.0... 1 2 3 ‘ 2 TMOftl‘gifteeeeeeeeeeeeeeeee 1 2 3 4 3Mmetaryvalueofthegift.............1 2 3 4 4Ageoftheclimt(i.e.,childoradult)...... 1 2 3 4 SGenderoftheclia-It................1 2 3 4 6Financialstatusoftleclimt........... 1 2 3 4 7 Yairperoqatimoftheclimt's' ' pereanlitydyrmiicsmm... ....... 1 2 3 4 BYamperceptimofthedynmnicsinthe therapeuticrelatimsl'u'p........ ...... 1 2 3 4 9 Yourperoeptimoflnwyourrespmsem tiegiftwillaffecttheclimt 1 2 3 4 10 Yourperoqtimoflnwyournespmse tothegiftwillaffectthe therapeuticrelatimsl'iipWW.l 2 3 4 11 Other very inportant factors, please specify: Q-8 Abmttavoftmdoymeaqaerimoearmietyorotherfomsofdistreesmm youare offeredagiftbyacliait? AINAYS WY WIQQUA’ m l 2 3 4 171 Q—9 About how often do you accept client gifts? ms USUALLY oocnsmmm NEVER 1 2 3 4 Q-lo About how often do you worry about whether your response to client gifts (as indicated in Q-9 above) is appropriate? AIMS USUALLY MSIG‘IALLY NEVER 1 2 3 4 Q-ll 'Do what extent was the topic of client gift giving addressed in your formal graduate training? WY MWY MINIMAILY NEVER 1 2 3 4 Q—12 Is there a formal policy in your primary therapeutic work setting limiting or prohibiting acceptance of gifts fran clients? 1 YES 2 no (Skip to Question 13) . 3 mm (Skip to Question 13) (a) If YES, briefly describe the policy: (b) If YES, how inportant is this policy in influencing how you respond to client gifts? VERY WT MINDiAILY WT IMPOM‘ANI' IMPORTANT IMPORTANT DIPORI‘ANT 1 2 3 4 172 Section III. This section covers professional and dmographic characteristics. Q-13 Chronological age: (Write in years) Q-14Gerrier:lm 2mm 0-15 Highest acadanic degree earned: PILD. PSY.D. ED.D. M.A./H.S. CIDER, m2: UthNt-fi 0-16 Academic specialty of highest degree earned: CLINIQL PSWY W W mam. W CHER, m: IIUNH \ Q—1‘7 Ebcludingyour formal training, Iowmnyyears of experiencedoyouhave as apracticing psyclotherapist? (Write in nutter of years) Q-18 In what state are you may practicing psycl'otherapy? (Write in nae of state) Q-19 mm job affiliatim: (Circle only one) mmcmmmm PRIVA‘I‘EPSYOIIAI‘RICMQTDSPI‘I‘AL mmmxm QHPATIDPTQINIC mmmmmmm MEDICALm PRIVAIEPRPCI'ICE UNIVERSITY: WC UNIVERSITY: WWMWWIT UIiiER,SPEIZIFY: O‘DQOUIbh-DNH H 0-20 0'21 Q-22 Q-23 0-24 173 If private practice is NOijour primary’jobIaffiliaticn,, dejyou engage in.part~time:private practice? lYES 2m Of the clients that you see for individual.psychotherapy, approximately what proportion are adults, adolescents and % ADUDTS (18 and.older) imam (12t017) % CHILDREN'(under 12) mmmmmnmm m (SldptOQtBstimZS) WIIOOO 10f the clients that.you.eee for individual.psychotherapy, approximately what proportion are male and female? ”we 3m morn-100$ - \ Of the clients that you see for individual psychotherapy, approximately what proportion.do you see for the following lengths of time? , 0138m3ms tB-lZMNB‘IS SWWIZW TOTAL 8 1008 Approximately what.proporticn of work time do you spend.conducting psychotherapy? 75% - 100% 50% - 75% 25% - 50% Less than 25% bUNt—t 174 Q-ZS michofthefollowingbestdescribesymirmtheoretical orientatimtopsychotheramfl _ l Mlerian __ 8 Gestalt 2 Behavioral/learning Theory __ 9 Psychoanalytic 3 Client-Centered 10 Psyciodynmnic 4 Cognitive Behavioral __ ll lblatimship __ S Metential _ 12 Sullivanian 6 W 13 System ‘7 Eclectic (Ifyoucheckeclectic, pleaserankorderthose orientations which cmtribute to your eclecticien in their order of inportance.) 14 Other, specify: Q—26 matistl'etheoreticalbasisofyommmpsyclotherapeutic interventions? Psychodynamic Behavioral Eclectic Other, specify: \ bUNH (comma: m NEDfl‘ PIKE) 175 SectionIV. Using a critical incident approach, this section explores your actual experiences with client gifts. (leave this section blankifywhaveneverbeenofferedagiftfranaclient) 0-27 For this iten, pleasetlfinkofthebDSTRmENrgiftofferedtoyou by a client during treatnmt. Using this client gift as an exanple, fill in the box below. (a) that was the gift? (b) Describe what you think the gift itself synbolized: (c) Describe what you think notivated the client to offer this gift: (d) What actim did you take regarding the gift itself? 1 Acceptedthegift 2 Didnotacceptthegift (e) Describe your PRDIIARY reason for accepting or not accepting the gift: (f) Describe how you perceive this action affected the client: (9) Describe how you perceive this action affected the therapeutic relationship: 176 Q-28 For this item, please think of a gift offered to you by a client during treatment that posed the mar W or DIFFICULT decision regarding how you should reSpond. Using this client gift as an ample, fill. in the‘ boxbelow.(1eavethisquestimblamcifywtaveneverbeaioffereda gift you perceived as troublescne or difficult.) (a) What was the gift? (b) Dexribe what you think the gift itself synbolized: (c) Describe what you think notivated the client to offer this gift: ((1) Describe what made this gift so troublesare to you: (e) What action did you take regarding the gift itself? 1 Acceptedthegift 2 Didnotacceptthegift (f) Describe your PRIMARY reason for accepting or not acwpting the gift: (9) Describe how you perceive this action affected the client: (h) Describe how you perceive this action affected the therapeutic relationship: Q-29 177 -10- For this item, please think of a gift that was offered to you by a client that you DID NOT ACEEPT. Using this client gift as an ample, fill in theboocbelow. (Ieavethisquestimblamcifyouhaveneverdeclined accept a client's gift.) ' (a) (b) (C) (d) (e) (f) What was the gift? Watdoymthimtthegiftitselfsynbolized? Describe what you think notivated the client to offer this gift: Describe your PRIMARY reason for nor mm; the gift: Describe how you perceive this action affected the client: Describe how you perceive this action affected the therapeutic relationship: 178 Isthereanythingelseywwuldlihetotellm emcerning climt-to-therapist gift giving? If so, pleaseusethisspaceforthatptupoee. Also,ifywmfldbewilnngtoparticipatef\n'tlnr inatelqfiuneinterviavfocmingmthistmic,please provikyournme,address,mnberandtelqiure 'ihis infometim willbeimdiately smaratedfranthe restoftheqmstiomairewlmitisreoeiwd. Your contribution to this iaportant research effort is greatly appreciated. If you would like a swnnary of the results, please print your name and address on the back of the return envelope (NOT on this question- naire). we will see that you receive a copy. APPENDIX E COVER LETTER USED IN NATIONAL SURVEY UNIVERSITY OF MAINE Candiquaut manor 3 no: Far-saldl'isll “Minamolfl COVER LETTER USED IN NATIONAL SURVEY ”7’33“”: May 1. 1987 Dear There is evidence to suggest that psychotherapists are occasionally the recipients of client gifts (i.e., tangible or concrete objects) during the course of psychotherapy. flhile the decision of how to respond to client gifts may be a complicated one. no evidence has been found of studies where psychotherapists have been fornally asked about this phenomenon. The purpose of this research project is to investigate client-to-therapist gift giving free the perspective of the psychotherapist in order to provide a research base for guiding psychotherapist responses to client gifts. You are one of a small number of psychotherapists being asked to share their experiences regarding client-to-therapist gift giving and your naae was selected from a list of APA Division 29 meabers. It would be greatly appreciated if you would take fifteen minutes to complete and return the enclosed survey whether or not you have been offered a gift before. You may be assured that the information you provide is strictly confidential. Individual psychotherapists will never be identified during analyses or in reports of the research findings. An identification number appears on the survey for follow-up mailing purposes only. I am happy to make the findings of the study available to you and procedures for requesting a summary of the results are included in the survey. I would be eager to answer any questions you might have. Please write or call collect. My telephone number is (207) 581-1392 during the day; (207) 866-3841 during the evening. Please complete and return the survey as soon as possible. Thank you for your participation and personal interest in the investigation of this clinical issue. Sincerely. Martha J. Barry. M.A. PrOJect Coordinator COL NsLusc mcnmmn TESTING lame}: mmlsc M Leno Gum wvusmv one its Gum come: 0! seam Anna-emu... 17? APPENDIX F NATIONAL SURVEY: FIRST FOLLOW-UP POST CARD APRmflHX F NATIONAL SURVEY: FIRST FOLLOW-UR POST CARD (ONE WEEK AFTER INITIAL MAILING) May 8, 1987 Last week a survey on client-to-therapist gift giving was mailed to you. If you have already returned your completed survey, 1 would like to thank you for your participation. If not, please do so today--your responses are important to the results of the study. If you did not receive the survey or if it was misplaced, please call collect as soon as possible at (207) 581—1392 during the day or (207) 866-3841 during the evening. I will be happy to mail you another copy. Again, thank you for your interest. Sincerely, Martha J. Barry Project Coordinator 180 APPENDIX C NATIONAL SURVEY: SECOND FOLLOW-UP POST CARD APFEHHX G NATIONAL SURVEY: SECOND FOLLOW-UP POST CARD (THREE WEEKS AFTER INITIAL MAILING) May 22, 1987 About three weeks ago a survey on client-to-therapist gift giving was mailed to you. As of today, I have not yet received your completed survey. I am writing to you again because of the significance each response has to the value of this study. It would be greatly appreciated if you would complete and return the survey as soon as possible. If you did not receive the survey or if it was misplaced, please call collect as soon as possible at (207) 581—1392 during the day or (207) 866—3841 during the evening. I will be happy to mail you another copy. Sincerely, Martha J. Barry Project Coordinator 181 APPENDIX H NATIONAL SURVEY: THIRD FOLLOW-UP COVER LETTER UNIVERSITY OF MAINE Counseling Center APPENDIX B 1m Fernald Hall Omno. Maine (H4094) l 24 NATIONAL SURVEY : THIRD FOLLOW-UP COVER LETTER 207/58I-l392 June 5, 1987 Dear I am writing to you about our survey study on client-to- therapist gift giving. As of this date, we have not yet received your completed survey. This is the first nationwide study asking psychotherapists about their experiences with client-to-therapist gift giving. The results are of particular importance to practicing clinicians and those who train clinicians by providing a research base for guiding psychotherapist responses to client gifts. The usefulness of our results depends on how accurately we are able to describe what experiences psycho- therapists have had with client-to-therapist gift giving, and your completed survey is important whether or not you have been offered a gift before. The large number of surveys returned to date has been very encouraging. However. whether we will be able to describe accurately how psychotherapists view this clinical issue depends upon you and others who have not yet responded. Past experiences suggest that those of you who have not yet returned your survey may have had quite different experiences with client-to-therapist gift giving than those who have. It is for the above reasons that I am sending you a second replacement survey. May I urge you to complete and return it as quickly as possible in the enclosed, return envelope. I am happy to make the findings of the study available to you and procedures for requesting a sunmary of the results are included in the survey. Your contribution to the success of this study is greatly appreciated. Host Sincerely, Martha J. Barrv Prayer? Coordinator 182 REFERENCES LIST OF REFERENCES Alreck, P. L. & Settle, R. B. (1985). Ihe_§gryey_1g§gaggh,hgndhggk. Illinois: Richard D. Irwin, Inc. American Association for Counseling and Development (1981).__E§h1§al standards. 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