When a Patient Presents with a Present: Quantitative and Qualitative Assessment of Gifts Given to Psychiatrists
Patel, Richard M., Miller, Raquel, Ethical Human Psychology and Psychiatry
Objective: This article reviews the issue of patients giving gifts to psychiatrists and mental health providers. Method: Anonymous survey of 100 academic psychiatrists measured prevalence of receiving gifts, type and estimated dollar value of gifts given, and psychiatrists' reactions to gifts. Case vignettes illustrate clinical situations associated with gift giving and how failure to recognize motivation of gift giving may lead to situations requiring immediate intervention. Results: 71% of psychiatrists surveyed received (were offered & accepted) at least one gift in prior year (average 0.36 per month and 3.6 per year; $11.40 average [estimated] amount per gift). Group comparisons achieving at least a p , 0.05 significance: outpatient psychiatrists received gifts twice as often as inpatient, female and outpatient groups' gifts were estimated as more expensive, a positive correlation was found between psychiatrists receiving gifts and psychiatrists giving a positive response to gifts, there was significantly more negative responses to high cost gifts (.$100) than to low cost (,$20), and outpatient psychiatrists reported interpreting gift's meaning more often than inpatient. Conclusions: Psychiatrists are commonly offered and accept gifts from patients. Gifts communicate patient information and response to treatment. Although the act of gift giving sends important data to the receiving psychiatrist, including boundary violation issues, there are no agreed upon guidelines regarding how to respond. Future study should explore the meanings and appropriateness of a gift regarding type, cost, timing, frequency, intent, as well as how providers can respond to the gesture.
Keywords: gift giving; ethics; patient motivation; boundary violation; therapeutic frame; survey clinical psychiatrists
"Generosity is the vanity of giving."
And thou shalt take no gift:
for a gift blindeth them that hath sight,
tand perverteth the words of the righteous
EXODUS, xxiii, 8
François de La Rochefoucauld's sobering experiences with 17th century French bureaucracy, bloody rebellion, and exile led him to conclude that people are divisible to a single motive, self-interest, and that gift givers should be viewed with suspicion. "Don't look a gift horse in the mouth," comes from aging horses growing "long-in-tooth," a sign of their lessening value. Contrary to Rochefoucauld, the equestrian idiom suggests accepting gifts and being grateful.
In every culture throughout history, people have given gifts to their health care providers. Yet in the mental health field, the process of taking a gift, being grateful, and moving on, is riddled with hitches.
La Rochefoucauld and Biblical quotes recognize gifts as communicating messages to the world and to specific receivers. Messages may be brief and innocuous as a Thank You card but can profoundly affect giver and receiver, changing the relationship in meaningful ways. Mental health providers should be aware of the meanings and consequences of a patient presenting with a present. Giving is only half the exchange. Giver and receiver have conscious and unconscious expectations after such a gesture.
Analysis of gifts' undercurrents can be exhausting, leading many providers to purport refusing them as "forbidden fruit." Still, questions arise: How can gifts be refused in a constructive way? What are the ramifications of refusal or acceptance?
Patient gift giving is common (Borys & Pope, 1989; Drew, Stoeckle, & Billings, 1983; Knox, DuBois, Smith, Hess, & Hill, 2009; Lyckholm, 1998; Pope, Keith-Spiegel, & Tabachnick, 1986; this study). Unfortunately, no formal guidelines exist directing response. Accepting gifts has been touted to threaten impartiality, yet the issue receives little inquiry in the literature (Capozzi & Rhodes, 2004; Knox, Hess, William, & Hill, 2003; Nisselle, 2000). Drew et al. (1983) noted, "[While] nearly every other aspect of the doctor-patient relationship has undergone careful scrutiny, patient gifts pass virtually without mention."
This article reviews the issue of patients giving gifts to psychiatrists and, more broadly, to all mental health providers. A survey was conducted to measure prevalence of psychiatrists receiving gifts, type and estimated dollar value of gifts given, as well as psychiatrists' reactions to gifts. Case vignettes illustrate clinical situations associated with gifts, and how failure to recognize motivation may lead to situations requiring intervention. Case vignettes are reconstructed from author's case notes. Names and identifying information are altered to protect confidentiality.
VIGNETTE # 1 GOODBYE CARDS
Rose was a single woman with anorexia and borderline personality disorder seen weekly. She had given me several small gifts and, because of an experience I had during residency, I accepted them, exploring the meaning of each particular gift.
Rose's first gift during our second session-simple store bought card of Thanks!-was discussed without revelation. She was glad "someone's listening." The next came on our fourth session-subsequent to an emotional third when she recalled her abusive father's death. Rose verbalized both sadness and anger. Of the gift, she said she appreciated me "looking out for her." It was a small box of chocolates.
Next, a self-made collage of nature pictures. Again, prior session was emotional-I asked if her father was responsible for her feelings even after his death. The card was of more thanks. I reminded her I was paid for my services and paraphrased Charles Dudley Warner, "In helping others you help yourself in the act."
She sparred, "This is for respect and thanks. Money's separate." She professed "faith in doctors" and refused to further the subject, instead complaining of increasing anxiety and guilt. I asked if this was related to the gift. She blamed depression. An antidepressant was prescribed and Rose took a horrible turn. She began to fight with her mother and was "too tired to work." Despite this, she said the medicines "helped," that I was "so nice," then pulled from her purse a box of "Calming Tea" for my waiting room.
I asked if she felt indebted.
"It's not obligation. I need familiarity. Plus, I don't like your teas out there."
I asked about giving in her family. She shrugged, recalling a story about her grandfather's doctor visiting on Christmas. I asked, "He made house calls?"
She nodded, "It's nice to have that kind of doctor."
"Is giving to doctors different than to family?"
"Not for me," she replied, offhandedly revealing it was Christmas when her father sexually assaulted her. The session's remainder involved her contracting no harm, ingratiating me with assurance and thanks.
Rose missed her next session. A call from the hospital confirmed her overdose. Out of danger, Rose asked a nurse to apologize to me for being "a treatment failure". The nurse said, "It'd mean the world if you'd visit. Rose is so nice." I asked, why nice?
"She made me a darling card." The nurse read, "Give in every way you can, of whatever you possess. To give is to love. To withhold is to wither."
Rose said she had found the quote on a tea-box in my waiting room.
VIGNETTE # 2 LESSON IN RESIDENCY: WHEN A PATIENT PRESENTS WITH A PRESENT
During my first year of residency, my supervisor advocated that psychiatrists should never accept a gift from a patient. It was simple as that.
Reassured by this clear instruction I returned to the inpatient ward to round, reluctantly, because of one patient in particular, a young woman admitted with her first psychotic break. Improved, she had made me a card reading, "Thank you! For not making fun of me." Now I was convinced I had to give the card back. Something inside felt this was a bad idea. Regrettably, I had not yet the experience to heed intuition.
As it was, I explained to her, "The rules of my profession prohibit me from accepting gifts from patients." Objectifying her from person to patient-the instant was noticed and she was hurt. Yet, she said it was "no big deal" and settled back into routine.
That night she nearly completed suicide with a sheet. Later she apologized, saying my "rejection" left her "embarrassed, scared and angry [at me] for not holding up [my] end of the bargain."
VIGNETTE # 3 A CASE OF SURPRISE GROUP THERAPY
"It's the same every year. I expect endlessly. Nobody ever does anything."
"What would you like people to do?"
"You know, something, like a surprise!" Shelly squealed, harboring secret delight. By this sixth visit, I had already experienced her roller-coaster moods and need for stimulation and drama. Today, whatever she wished to reveal, she was not doing so directly. It was intriguing; normally she would simply blurt out whatever came to mind.
"It's like this," Shelly collapsed back on the couch, "No one ever throws me a party. I organize office parties, you know. But me, forget it. As a kid, sure-balloons, cake." Expressive with unfettered gestures and clichés, today Shelly was giddier than usual. Prescribing serotonin reuptake inhibitor two weeks prior, I wondered about mania. Barely containing her flirtatious smile, "Doctor, don't you ever feel like you need a party?"
There came a knock, which was odd, as my patients are versed in waiting room protocol. I opened the door to find a fidgeting Humphrey-an introverted, self-critical man I have seen for years. "Hello Humphrey, you're early. Have a seat-"
Shelly pealed, "Never mind him. Come in."
And to my disbelief Humphrey obeyed her, averting his eyes and shuffling past, quickly taking a seat on the couch next to Shelly. He stared guiltily at his shoes.
"Shelly," I said unsure, "it might be better-" when another knock came.
"Sorry for interrupting, doctor," said Mrs. Holderstein-an elderly, typically gruff patient that I had seen the hour before, "I believe I left my purse in here. Do you mind?"
I did mind and there was no purse, "Mrs. Holderstein, I don't think you left it."
"Okay," she said, causally passing to sit opposite Humphrey. She shed Shelly an awkward smile. Mrs. Holderstein wore her purse on her shoulder. I was going to mention this when the door . . .
"We late?" Harvey Johnson led his wife Lucy in by the hand. The couple was not scheduled for a week. "No, no" Shelly spouted. "More the merrier!"
Checking for no further intrusion, I closed the door and braced myself. They were all smiles, even Mrs. Holderstein. Humphrey actually giggled as Shelly produced a noisemaker and blew. They sang Happy Birthday and as the song subsided, I asked how the apparent mastermind, Shelly, brought about this surprise session of group therapy?
"That was easy," she boasted, "Humphrey has the time before me. And Betty" (Mrs. Holderstein's surname) "has the appointment after. And, you know, the Johnson's referred me to you."
"Yes, of course." I said, still mystified. "But why?"
"You mean how'd I know about your birthday?" Shelly's encroachment into my personal affairs caused me an inward shutter, "Look at your desk calendar."
And sure enough, written on today's date was MY birthday-get gift.
"Oh, I see." I said and Shelly undoubtedly misconstrued my smile as surprise. I did not reveal that "M.Y." are the initials of a colleague whose birthday was that day.
Gifts given, my patients demanded me to open them right then and there.
How different they seemed in the context of this unorthodox group! Normally timid, Humphrey was grinning broadly. It was heartwarming the way he explained how the Freud Pillow sang Memories when wound. And the Johnson's were holding hands after 3 months of couple's therapy; I rarely saw them look one another in the eye. Now, together, they alternatingly described how they choose the wrapping paper, what to paint on the coffee mug-a Frommian inscription "Giving is the highest expression of potency." Mrs. Holderstein, Betty, sat petting her small handbag in her lap like a kitten. I did not know she could crochet. She accepted compliments graciously.
The effects of giving gifts seemed mammoth. Giving offered them opportunity for self- expression, to voice approval or acknowledgment, perhaps a shared moment of joy from suffering before plunging back in again alone.
VIGNETTE # 4 LUBRICATIONS FROM A MANIC
Emergency psychiatry is a home for unexpected surprises. A colleague recently admitted a patient diagnosed of acute mania. Not wanting to be hospitalized, the patient contested, won his hearing, and was released. Within days, the patient sent a series of provocative letters to the staff detailing the injustices of his admission. After the letters, a heart printed package arrived specifically addressed to his admitting psychiatrist who was not working that day. The staff, myself included, speculated on the gifts' contents, jesting it lacked ominous ticking and the almond odor of cyanide. Aware of the patient's angry, obsessional nature, we conceded apprehension.
The psychiatrist returned to more nervous jokes. Gift opened, out poured a cascade of yellow jars and gelatinous tubes of petroleum jelly lubricant, the disquieting plastic pile clearly communicating the patient's feelings toward the admitting psychiatrist (see Figure 1).
The four-case vignettes, as well as minivignettes alluded to in Figure 2, demonstrate some messages gifts convey, as well as the consequences of gift giving, whether rejected or accepted. Illustrative case testimonies, however, do not give quantitative data regarding patient gift giving.
To better quantify prevalence of psychiatrists receiving gifts from their patients-the number, types and estimated costs of gifts, as well as a review of psychiatrists' reaction to gifts-a survey of academic psychiatrists was conducted.
SURVEY OF PSYCHIATRISTS
One hundred surveys were sent by mail to randomly selected academic psychiatrists affiliated with University of California, San Francisco. By self-addressed stamped envelope, return rate was 79%. Data collected in anonymous survey included psychiatrist self-report of gender, type of practice, type and number of gifts received (i.e., gift offered and accepted) during prior month and year, estimated dollar value of gifts, as well as a short narrative regarding "feelings and reactions to receiving gifts from patients." "Narrative response" categories were: positive (gratitude, flattered, touched, moved, appreciated, helping therapeutic process, enjoyed, pleased, fine), negative (uncomfortable, obliged, awkward, inappropriate, indebted, afraid, worried, concerned, reluctant, wary), indifferent (indifferent, unremarkable, no feelings), interpretative (analyze meaning), no response, and other. "Type of gift" categories listed in Table 2. "Received" group was defined as psychiatrists offered and accepting gifts. "Did not receive" group was psychiatrists not offered gifts, plus psychiatrists offered but refusing gifts. Comparison of two "did not receive" subgroups was not performed.
Demographics of 78 psychiatrists completing and returning survey: 42% female, 58% male, 9% resident, 91% attending, 73% outpatient, and 27% inpatient. One male survey was removed because of incomplete demographics.
Seventy-one percent of psychiatrists surveyed accepted at least one gift in the last year. An average of 3.6 gifts per year was received; an average of 0.36 gifts were received the month prior. More than 71% of psychiatrists were offered gifts (gifts accepted plus gifts rejected); exact percentage unknown because of incomplete record of psychiatrists rejecting gifts.
Significant findings (p , .05) comparing subject groups (MAI, MAO, MRI, MRO, FAI, FAO, FRI, FRO) include greater percentage of outpatient compared to inpatient psychiatrists received gifts (82% and 42%, respectively). Also, outpatient psychiatrists gave significantly more interpretive responses to gifts (16%) than inpatient psychiatrists (0%).
Psychiatrists receiving gifts responded more positively (33%) to getting gifts than psychiatrists who did not receive gifts (4%). In male and outpatient groups given gifts, 24% and 30% reported a positive response, whereas male and outpatient groups not given gifts both had no (0%) positive responses.
Average estimated expense per gift was at $11.40. Female and outpatient groups received gifts were estimated to be more expensive than male and inpatient groups. Average female estimated expense per gift was at $14.78, average male was at $8.59; average outpatient was at $12.06, average inpatient was at $7.94.
An increase in negative response is noted when comparing low-cost gifts (,$20) 21% to high cost gifts (.$100) 57% negative response. Of note, percentage of positive response did not significantly change in all three cost breakdowns (35%, 40%, and 29%) for low, medium ($20-$100), and high cost groups (see Figure 3).
To our knowledge, no other quantitative study of patient gift giving to psychiatrists has been performed (Drew et al., 1983; Nisselle, 2000). We believe that the most striking finding from the study is also the most fundamental: psychiatrists are offered and accept gifts from patients. The study was self-report, and because no measure of psychiatrists' explicit or implicit openness to accepting gifts (thus promoting or discouraging patient gift giving) was performed, the impetus for the gift cannot be determined.
In a similar survey of psychologists, 5% believed that accepting a gift worth less than $5 is clearly unethical, with only 8.6% stating they never accepted such gifts (Pope, Tabachnick, & Keith-Spiegel, 1987). In contrast, about 66% surveyed thought a gift worth more than $50 is rare if ever ethical, with nearly 75% never excepting such a gift. In this same study, inexpensive gifts were seen as appreciation, whereas more expensive gifts were interpreted as bribes and having a greater influence on professional judgment. Similarly, in the current survey, percentage of psychiatrists giving negative response increases as the gift worth increases.
Although findings in Table 4 may spur speculation on causality and lively debate, they do not answer how to best understand and respond to a patient offering a gift.
American Medical Association (AMA), American Psychological Association (apa), American Psychiatric Association (APA), and Beauchamp and Childress' (1994) Principles of Biomedical Ethics all have not published consensus statements or guidelines addressing patient gift giving. American College of Physicians does have a medical ethics position paper stating, "A small gift to a physician as a token of appreciation is not ethically problematic," noting consideration be given to the nature of the gift, potential implications to doctor-patient relationship, and patient's motivations (American College of Physicians, 2005). United Kingdom's Good Medical Practice Guidelines warns against soliciting gifts from patients, yet says nothing about what to do if one is offered (British General Medical Council, 2001).
Gifts from corporations, however, have been vigorously addressed. "$165 million to $2.5 billion is spent annually by pharmaceutical companies on promotional practices directed to medical professionals in the forms of symposia, reminder items, gifts, honoraria/ expenses, and prescription sample units" (Gift Giving Comes After Scrutiny, 1992, pp. 15-16). This practice caught the attention of the U.S. Senate Labor and Human Resources Committee and Food and Drug Administration (FDA), which has ongoing investigations of company gift giving. FDA established a hotline to express the ethics of drug company gift giving and how it affects physician-patient relationships. Establishment of a "you scratch my back and I'll scratch yours" rapport may not be "sufficiently strong enough to make doctors prescribe incorrect medications," but biases physicians toward which correct medicine is prescribed (Margolis, 1991, pp. 1233-1237). A gift "makes physicians agents of the companies that have entered into a relationship with them," violating fidelity to the patient.
Responding to concerns, AMA Council on Ethical and Judicial Affairs explicitly stated which gifts from industry are acceptable and which are not (see Table 5).
AMA opinion admits gifts from industry can serve socially beneficial functions, providing for seminars and educational conferences. Discrepancies arise in the presented guidelines, such as why are medication samples for personal or family use acceptable? Or, how does the practitioner determine if "strings are attached" when accepting a gift? Ultimately, individual physicians and other professionals are responsible for minimizing conflicts with patient care, which is difficult as situations and standards may go against published tenets. Black-and-white arguments of whether or not to accept gifts rapidly give way to gray debates of what type of gifts are acceptable (Ault, 2008; Knox et al., 2009; Spandler, Burman, Goldberg, Margison, & Amos, 2000). What can patients give to their psychiatric care provider as a gesture of genuine gratitude?
When a patient presents with a present, the event should be thoughtfully explored. Motives and meanings, when understood, can steer therapy in beneficial directions. Because motivations are multifold, nuanced, unconscious, often embarrassing to patients, sometimes frankly antisocial or illegal in nature, and when exposed may be seen as pejorative, time, patience, and a therapeutic delicacy are required to reveal them in full.
Why Patients Give Gifts to Their Psychiatrists
Table 6 lists motivations collected from study responses, clinical practice, and literature review. Motivations cluster in three categories: psychotherapeutic, intimacy seeking, and manipulation. No category is mutually exclusive; any combination or all three can occur with a single gift.
As a Normal Part of Therapy
Outside the psychotherapeutic frame, gifts are given for many reasons. A gift from a patient likewise reflects giver attitudes-the gift being a symbol of that not easily verbalized or emotions not safely shared. Gifts are a social exchange; most people give to friends or family. If a patient has similar feelings toward their therapist, they may respond accordingly. Gifts are nonverbal clues to "underlying unconscious material seek[ing] expression through the act of giving" (Laborde, 1979).
An alternate idea is that the patient perceives psychiatrist's actions as a gift. The psychotherapeutic or doctor-patient experience may be fathomed as warranting reciprocation (Gouldner, 1960, pp. 176-177). Drew et al. (1983) promotes this idea that a patient's gift is not necessarily the beginning of the exchange, but rather reciprocation for care received. The patient, in this case, is not starting the exchange but rather "perceives some aspect of the physician's performance as the initiating gift" and in turn gives back. As reported by a physician in Drew et al.'s study (in succeeding texts), "I think they give me a gift for something I've already done-something about their blood count, the way the heart sounds."
Giving's therapeutic effects can be immediate and striking. As in Vignette #3, when a patient, Humphrey, with social phobia used a gift as an opportunity to reach out to others; or as Mrs. Hoderstein, Betty, usually bitter and pessimistic, found similar pleasure in connection, radiating with pride as her crochet skill was recognized; or as the disgruntled Johnson couple, agreeing on how to make a coffee cup together.
Communication of Signs and Symptoms
A gift requests the therapist to look, or not look, at something-either way, it is an emphasizer. A suicidal person giving away belongings, a manic patient lavishing presents on everyone-a cry for help or appealing forgiveness, all are signs and symptoms. Gifts convey the present state of health and effectiveness of treatment. Receiving a book on grief from a depressed patient, or aluminum foil hat to "protect from space radiation" from a psychotic patient are palpable symptoms requiring pursuit.
Examples include patients giving gifts not because they are grateful but because they are angry; or, as in the sublimation of petroleum jelly (Vignette #4), an expression of indignation toward involuntary hospitalization. Gifts should cause pause to consider the possible underlying, alternative messages they hide or convey.
Expression of Gratitude
Levene and Sireling (1980) sent out questionnaires to 374 British doctors over a 3-month period tallying gifts. Fifty-eight gifts were received, and types of gifts and doctors (e.g., surgeon, psychiatrist, etc.) receiving gifts were detailed. "Twenty-two of the doctors felt that the patient had given the gift out of a feeling of gratitude, but two were given the gift before any investigation or treatment was started, two were given gifts by patients they had seen only very briefly in their stay, and three thought the gift had been given in an attempt to manipulate them . . . nine doctors said they felt embarrassment."
In the literature, in all Vignettes (except #4) as well as in the psychiatrists' responses to our survey, the most common reason cited for gifts is gratitude. A gift is a manifest "Thank you," presumably for work done. Andereck (2001) and Wiejer (2001) assert that gifts given for reason of beneficence and gratitude should be accepted, whereas gifts given to influence should be denied. Authors admit ascertaining motive is troublesome but conclude most patients "simply generous by nature," and that such gestures should not be "thwarted." Expressing deeply felt gratitude in words may be difficult and patients may accommodate by giving beyond prescribed fee. It is important to express genuine appreciation for this gesture even if the gift is returned, thus assuring the patient's message has been conveyed and therapeutic alliance strengthened.
Excessive appreciation may not signal gratitude, but apprehension, fear, or an otherwise distressed patient seeking support. It may also signal psychosis (e.g., de Clérambault's syndrome) or the onset of a slippery slope toward boundary violation.
Out of Guilt
Patients reported giving because they "felt so guilty" about interactions in therapy. Patients claim lack of improvement (Vignettes #1 and #2 patients apologized for "failure in treatment") as reason for guilt-inspired gifts. By giving, patients hope for redemption or at least alleviation from painful feelings without addressing them directly.
To Bond, Be Liked or Accepted
Most patients want to be liked by their psychiatrist. Some believe they will not be liked unless they give something, such as symbolic gifts (a poem, humor, information) or concrete gifts, as discussed. Patients may feel not accepted or connected unless providing beyond fiduciary agreement. These feelings of connection can serve to ease communication about sensitive material, as in Vignette #19s patient needing "familiarity." Refusal of such a gift offers the patient a deeper understanding that they are enough by themselves, worthy of attention, and accepted without blandishment.
"Bonding" has other implications, for example, agreements have been made, such as the helper will not leave, will be together if only as patient and psychiatrist. In Vignette #2, to the young psychotic patient, the return of her gift was a failure of "not holding up [my] end of the bargain" a breech contributing to attempted suicide.
Fear of Being Forgotten
Gifts are tangible embodiments representing the giver, the relationship, or an event. Gifts often last beyond the instance or relationship in which they are given. A gift may indicate the psychiatrist persists in the patient's mind as an internalized object to which action or desire is directed (Spence, 2005). As the thought of therapy is a reminder of the therapist, a patient's gift is a physical reminder of the patient given in kind.
Security: Avoid Abandonment
Fearing abandonment is common. Patients fear overwhelming caregivers or not being good enough to maintain attachment (see Vignette #2). To alleviate anxiety, patients attempt to strengthen ties. This desire is stronger during difficult times. Largesse in these instances is an appeal for the provider to "hang in there."
To Be Special or Privileged
A patient's wish to feel important can reach a level where providers feel manipulated or their boundaries encroached (as Shelly's intrusion in Vignette #3). Patients may feel "special" if they find out something about their therapist (e.g., what gift is appreciated or a birthdate). Gifts accepted may be perceived as a sign of significance, setting the giver apart from others, promoting other unspoken expectations as well.
Some gifts leave the receiver feeling uncomfortable or blatantly threatened. Presentations of this kind requires safe, immediate response, often involving third parties such as police, legal restraining orders, or involuntary admission if there is danger to the psychiatrist or others. Although in our study, no threatening or sexualized content were reported, gifts crossing boundaries (e.g., Vignette #4) denote emergent situations warranting consultation and an immediate, well-thought out reply, including potential termination of therapeutic relationship.
Gifts can cause receivers to feel indebted-a feeling lingering until reciprocation is offered, at which time debt is paid and balance is restored. Coping with the social obligation of reciprocating a gift-possibly leading to preferential treatment and violation of ethical codes-was studied by Drew et al. (1983) who reported 72 gifts given to 14 staff over 14 months (5.1 per year [our survey averaged 3.6 per year]). Drew et al. contextualized by discussing jobs where tips are expected, such as in restaurants, and motivated by desires for good service, to be remembered, or to be tolerated, just as in tipping a waiter.
Alternatively, Zinn (1990) declared that "Gift giving can be seduction by nonsexual means . . ." is manipulative and to be discouraged; he tells the case of a patient desperate for companionship, complained his doctor ignored him so he attempted a bribe (pp. 293-298). Individuals consciously and unconsciously believe that to get more time, attention, prescriptions, or quality care, they have to give something. Some patients curry special attention by pleasing the provider, engaging in a "you scratch my back, I'll scratch yours" relationship (Chiodo & Tolle, 2000, pp. 12-15). "The feeling of obligation [to accept gifts] may taint the doctor-patient relationship, leading to later regret of having accepted the gift" (Levene & Sireling, 1980, p. 1685).
Perhaps, greater concern should be given to gifts in the form of a service: babysitting, gardening, and so forth. If a patient paints a psychiatrists house, and the work is dissatisfactory, the therapeutic relationship is compromised.
Barter as payment had its place in history and was not always controversial. A farmer exchanging produce for care, or a physician-patient giving a colleague wine during holidays as thanks for free advise, are examples. Barter is a conscious act, differentiated from bribes, which is a plea "designed to keep aggression, negative feelings or unpleasant subjects out of the doctor-patient relationship" (Nadelson & Notman, 2002, pp. 191-202). Regardless, gifts motivated by hope of special favors warrant careful deliberation, with acceptance purportedly leading down a slippery slope toward boundary violation.
The Slippery Slope Toward Boundary Violation
No one wishes to criminalize a patient's expression of appreciation. However, the medical ethics literature contains ample words urging professions against accepting gifts, arguing the practice is counter therapeutic and a boundary violation.
Despite this, in our survey, 71% of psychiatrists accepted gifts during the prior year. Reluctance to talk openly about receiving gifts may be caused by fear of being viewed as committing a boundary violation or that they are exploiting their patients (Zur, 2007).
A boundary violation is when the patient or psychiatrist steps outside what is known as the therapeutic-fiduciary relationship or "therapeutic frame." Walker and Clark (1999) wrote, the prestige and "special role in society" of a mental health professional carries a "duty to safeguard the welfare of the public" (pp. 1435-1439). This fiduciary responsibility places the relationship in an ethical framework distinguishing psychotherapy from social, family, or other relationship types. Nadelson and Notman (2002) believe these boundaries
. . . help health professionals navigate the complex and sometimes difficult experience between patient and doctor where intimacy and power must be balanced in the direction of benefiting patients. . . . consensus [is] that harm to patients is a critical determinant of whether a violation of boundaries has occurred, although boundary violations may occur when harm is not demonstrated. (pp. 191-201)
Some signals of impending violation include strong feelings about a patient, extended sessions, gift giving between clinician and patient, and so forth (Walker & Clark, 1999). Examples of boundary violations are physical contact, very close physical proximity of psychiatrist and patient in session, psychiatrist self-disclosure, contact outside therapy, and, possibly, gift giving. If the therapeutic relationship is fiduciary, accepting gifts is a violation, which may lead down a slippery slope (Weijer, 2001).
This slippery slope refers to how outwardly insignificant acts may catalyze development of unethical behavior. Appreciation and gratitude can progress into more personal gifts or demands, "doctor-patient sexual relationships are preceded by nonsexual boundary violations. These minor boundary crossings initially can become more serious if they are part of a continuum" (Nadelson & Notman, 2002, pp. 191-201). Slippery slope begun, other boundary crossings may be assumed possible (Gaufberg, 2007). Erotic transferences, psychotic delusions of unique connection may be stoked by a simple gift or gesture outside the normal doctor-patient rapport. Even if later the psychiatrist decides not to accept, the earlier precedent makes it harder to reject future gifts.
Patients do have responsibility. However, judgment may be impaired or they may be unfamiliar with what's expected. Thus, the onus is on the healthcare worker.
Arguments for refusing gifts from patients are summarized in Table 7 (Andereck, 2001; Weijer, 2001; Zinn, 1990).
Capozzi and Rhodes (2004) state that an inappropriate gift should be politely declined with the reasons explained to the patient. Although reasons for refusal are outlined before hand, in discussions with medical students and residents, most do not know how to refuse a patient's gift (see Table 8).
Therapeutic relationships are strengthened by attributes paralleling that of a friendship, such as compassion and trust, an approximation that the patient may interpret as a friendship or other relationship where gift giving is acceptable (Andereck, 2001; Weijer, 2001). Refusal of a gift may be taken as refusal of intimacy or denial of a safe environment for being vulnerable. This idea of stretching the neutral, impersonal relationship was broached by Lyckholm (1998, pp. 1944-1946), "declining a gift actually may cause more damage than any harm done by accepting it [and] may be interpreted by the patient as a lack of regard for the patient's wishes, and may hurt the patient's feelings, irrevocably fracturing the patient-physician relationship."
Benefits of Accepting Gifts: Positive Patient Response
According to Spence (2005) gift giving provides insight into mental processes and is useful from a psychoanalytic perspective. As Gutheil and Brodsky (2008, p. 87) stated, ". . . a gift may constitute a boundary crossing-not harmful and perhaps helpful to therapy-rather than a boundary violation." Gabbard (1999, p. 155) goes further to state, "certain kinds of gifts may signal a turning point in the treatment and that to decline the gifts can be a devastating technical error." In certain populations, as in children or Vignette #3, gift accepting can be relationship building and important to the patient role (Chiodo & Tolle, 2000; Gutheil & Brodsky, 2008). See Table 9.
Fiduciary relationships such as psychotherapy do not require thanks. Yet social or cultural convention may dictate otherwise and should be acknowledged.
No culturally sensitive guidelines exist regarding patient gift giving, even though many cultures openly accept the practice (Abbasi & Gadit, 2008). Muslims "praying (dua)" to physicians is an acceptable expression of gratitude. Takayama (2001) explains that in Japan during winter and summer months, the traditions of Oseibo and Ochugen call for gifts to "friends, relatives, and others who have helped them during the year." This plays a role in "lubricating relationships, including those between patients and physicians." Japanese physicians' offices may teem with "colorfully wrapped boxes containing a variety of gifts," including orei, a gift extended to doctors before surgery. Orei of 10,000 yen gift ($100 US) or more is commonly tucked into an envelope and offered anonymously. Refusing in Japan may be interpreted as impolite, reminding that gifts carry a symbolic worth often more than their intrinsic worth. For this reason, it is important to consider culturally appropriate gifts and deny those that are inappropriate.
Different cultures accept different gifts and reject others. In Levene and Sireling's (1980) survey of British physicians, patient gifts accepted were commonly alcohol or cash. In contrast, American physicians are reluctant to accept money or alcohol, but receive food or chocolate (Spence, 2005).
Gifts are a normal part of human interaction. Future study should explore what are appropriate gifts regarding type, cost, timing, frequency, intent, and so forth. Limitations include that it is a small regional sample and exams only concrete and not symbolic gifts. Other future directions include other measures of interactions between giver and receiver, the patient and the psychiatrist.
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Richard M. Patel, MD
University of California, San Francisco, and San Francisco General Hospital
Richard M. Patel, MD, is a clinical professor of psychiatry at University of California, San Francisco, and an attending psychiatrist at San Francisco General Hospital.
Correspondence regarding this article should be directed to Richard M. Patel, MD, University of California, San Francisco, 3340 Folsom Street, San Francisco, CA 94110. E-mail: richardmpatel@ earthlink.net…
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Publication information: Article title: When a Patient Presents with a Present: Quantitative and Qualitative Assessment of Gifts Given to Psychiatrists. Contributors: Patel, Richard M. - Author, Miller, Raquel - Author. Journal title: Ethical Human Psychology and Psychiatry. Volume: 13. Issue: 3 Publication date: October 1, 2011. Page number: 209+. © Springer Publishing Company 2008. Provided by ProQuest LLC. All Rights Reserved.
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