When a Patient Presents with a Present: Quantitative and Qualitative Assessment of Gifts Given to Psychiatrists

Article excerpt

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."

La Rochefoucauld

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). …