When We Give More: Reflections on Intangible Gifts from Therapist to Patient
Smolar, Andrew I., American Journal of Psychotherapy
Since Freud's time, psychoanalytically oriented therapists have been wary of accepting gifts from patients, and have also been reluctant to give them to patients. This article first provides a literal definition of the word "gift," and then defines it within the context of the therapeutic relationship. It then reviews the literature on gifts and presents clinical examples describing five categories of offerings from therapist to patient, experienced by the patient as gifts, namely: 1. the gift of a transitional object; 2. the gift of self-disclosure; 3. the gift of time; 4. the gift of physical touch; and 5. the gift of developmental presence. Examples of therapists' considering but not offering gifts to patients are discussed and viewed from the perspective of whether they are requested by the patient, whether they arise from within the therapist, or whether they are offered in a context of reciprocation. Guidelines for how and when the therapist could attempt such interventions most safely are suggested, placing particular emphasis on countertransferences.
While explicitly warning that analysis be ". . . carried through, as far as is possible, under privation-in a state of abstinence" (1), Freud often traded gifts and special consideration with patients through all stages of treatment. For example, Freud's patient E "concluded his career as a patient by coming to supper at [Freud's] house" (2); Freud treated the Wolfman for some period of time gratis, and gave him money later in his life (3). He also gave books to patients (4), sent them postcards, and gave them photos of himself.
The subject of gift exchange from therapist to patient has, however, not been addressed directly and distinctly in the adult psychoanalytic literature. For one, although concrete gift exchange is common in the child psychotherapeutic setting, it is not all that common with adults. When therapists have offered gifts to patients, they have been reluctant to report it, partly out of deference to the tradition of "abstinence," and partly because its occurrence has suggested significant countertransference difficulties. Contemporary relationists have begun to think differently about such exchanges between therapist and patient, viewing them and other extra-verbal transactions as potentially useful. Moreover, they think carefully about the sources of their own motives when they give something beyond what the patient has come to expect within the therapeutic relationship. It is this kind of intervention, sometimes received by the patient as a "gift," that I will consider in this paper.
The Oxford English Dictionary defines the word "gift" as follows: "something, the possession of which is transferred to another without the expectation or receipt of an equivalent; a donation, present" (5). Stein outlines the derivation of the word in several different languages, pointing out that connotations of the words for "gift" in Spanish, German, and Greek range from generous giving, to poisoning, to a binding of the receiver. She also provides a cultural history of gifts, noting that exchanges have not been exclusively of tangible items, but also of rituals and courtesies, sometimes with reciprocation (6). This spectrum of meanings raises questions about what constitutes a gift from one person to another, and about how its rendering may influence the relationship between the two parties.
Exchanges of tangible items from therapist to adult patient are atypical, and will not be primarily addressed in this paper. For my purposes here, I wish to discuss a range of interventions that, whether or not intended by the therapist as a gift to the patient, may be experienced as such. For many patients, the therapeutic setting itself, in which the therapist listens in a nonjudgmental, empathic fashion, while placing the patient's needs as primary, represents a gift never experienced previously. I will consider specific actions taken by the therapist that potently enhance the everyday therapeutic setting. …