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The gift of culture

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Title:
The gift of culture the roles of time, diagnosis, and culture in accepting gifts in therapy
Creator:
Espil, Flint Martin
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Language:
English
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xi, 104 leaves : ; 28 cm

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Subjects / Keywords:
Psychotherapist and patient ( lcsh )
Gifts ( lcsh )
Psychotherapy -- Moral and ethical aspects ( lcsh )
Gifts ( fast )
Psychotherapist and patient ( fast )
Psychotherapy -- Moral and ethical aspects ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Bibliography:
Includes bibliographical references (leaves 100-104).
General Note:
Department of Psychology
Statement of Responsibility:
by Flint Martin Espil.

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Source Institution:
University of Colorado Denver
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Auraria Library
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All applicable rights reserved by the source institution and holding location.
Resource Identifier:
656841597 ( OCLC )
ocn656841597
Classification:
LD1193.L645 2010m E76 ( lcc )

Full Text
THE GIFT OF CULTURE: THE ROLES OF TIME, DIAGNOSIS, AND CULTURE
IN ACCEPTING GIFTS IN THERAPY
by
Flint Martin Espil
B.S., University of Idaho, 2006
A.A., College of Southern Idaho, 2004
A thesis submitted to the
University of Colorado Denver
in partial fulfillment
of the requirements for the degree of
Master of Arts
Psychology
2010


The thesis for the Master of Arts
degree by
Flint Martin Espil
has been approved
by
Allison Bashe
Date


Espil, Flint Martin (M.A. Clinical Psychology)
The Gift of Culture: The Roles of Time, Diagnosis, and Culture in Accepting Gifts in
Therapy
Thesis directed by Professor Mitchell M. Handelsman
ABSTRACT
This study looked at factors therapists consider when offered gifts in therapy.
Do therapists consider any of the factors discussed in the literature on gifts such as
time in therapy or diagnosis of the client? What if the client is from a culture with a
rich history of gifts? The study also examined what factors are considered important
by therapists who accept gifts and therapists who reject gifts. Do therapists who
accept gifts consider a different set of factors than other therapists who reject gifts?
Practicing therapists from professional organizations and clinical psychology
doctoral students read one of eight vignettes in which a therapy client offers a gift.
Participants then answered a series of questions about the vignette and past
experiences with gifts. Results indicated that therapists consider the time in therapy,
diagnosis of the client, and culture of the client in accordance with advice from the
literature on gifts. Therapists are more likely to accept gifts offered at the end of
therapy, when the client does not have Borderline Personality Disorder, and when the
client is Japanese.


There were some important differences between those who accepted the gift
in the vignette and those who declined the gift in the vignette. Acceptors not only
ranked more factors as important, but also believed the most important factor to
consider was the potential harm to the client in rejecting the gift. Rejecters focused
more on factors that would decrease the likelihood of acceptance, and believed the
most important factor was the potential for the gift, if accepted, to blur boundaries.
Acceptors were more likely to be older therapists with more years of
experience and a past history of accepting gifts. Rejecters were more likely to be
younger, student therapists without a past history of accepting gifts. Based on these
findings, there may be generational or cohort effects of ethics training, training on
gifts, or an overall effect of time and experience delivering psychotherapy. Although
therapists are generally making decisions in accordance with advice from the
literature, the contribution of various factors on decisions may not be as
straightforward as past studies predicted.
This abstract accurately represents the content of the candidates thesis. I recommend
its publication.
Signi
Mitchell M. Handelsman


DEDICATION
I dedicate this thesis to my father, who supported me throughout my education and
taught me the importance of hard work. I also dedicate this to my mother, who always
believed I would be successful no matter what I pursued.


ACKNOWLEDGMENT
Thanks to my committee members, Allison Bashe and Farah Ibrahim, for
staying with me throughout this long project. Thanks to Ryo Morimoto, for his
helpful ideas during the early phases of my thesis. I also wish to thank Mitchell M.
Handelsman, who not only taught me how to be a better writer, but devoted a great
amount of personal time and effort to this project.


TABLE OF CONTENTS
CHAPTER
Tables.............................................................x
Figures............................................................xi
1. INTRODUCTION....................................................12
Purpose of the Study........................................12
Background..................................................13
Gifts.................................................14
Ethical Codes and Gifts...............................16
Ethical Considerations and Gifts......................17
Decision-Making Models................................22
Exploring Gift Variables..............................24
Qualitative Studies on Gifts..........................26
Quantitative Studies and Cost.........................28
Independent Variables.......................................31
Moving Beyond Cost: Time in Therapy...................31
Diagnosis.............................................32
Culture...............................................35
Gift Giving in Japan...........................35
Whats Missing..............................................41
vii


Hypotheses.................................................42
2. METHOD........................................................45
Participants...............................................45
Demographics........................................45
Procedure..................................................46
Design.....................................................47
Measures...................................................47
3. RESULTS.......................................................50
Overall Percentages and Means..............................50
Acceptance.................................................51
Ethicality.................................................52
Confidence.................................................53
Complexity.................................................54
Gift Factor Importance.....................................54
Gift Factors: Acceptors vs. Rejecters......................56
Gift Factors in Past Decisions.............................58
Gift Factors and Demographics..............................60
One Piece of Information...................................62
4. DISCUSSION....................................................63
Time.......................................................63
viii


Diagnosis..........................................66
Culture............................................69
Demographics of Those who Accepted the Gift........72
Conclusions........................................75
APPENDIX
A. TABLES AND FIGURES...................................79
B. EMAIL, INFORMED CONSENT, AND DEBRIEFING..............86
C. VIGNETTE.............................................90
D. QUESTIONNAIRE........................................91
REFERENCES..................................................100
ix


LIST OF TABLES
Table
1. Important factors for gift decision-making:
prevalence in the psychotherapy literature...............................79
2. Descriptive statistics of ethicality, confidence, and complexity ratings..81
3. Rank-ordered gift factor importance by group..............................82
4. What one piece of information would need to be
different to change your decision? Organized by
gift factor category......................................................83
x


LIST OF FIGURES
Figure
1. Interaction of Time Point in Therapy and Past
Acceptance on Ratings of Ethicality..........................................84
2. Interaction of Previous Acceptance and Diagnosis
on the Importance of Evaluating Monetary Value of the Gift...................85
xi


CHAPTER 1
INTRODUCTION
Purpose of the Study
Imagine you are a therapist who has been working with a young Japanese
American client. You have been seeing the client for a few sessions now and have
been making progress in therapy. The client reports feeling better and is beginning to
gain control over some of the issues presented at the beginning of therapy. At your
next session, the client hands you a set of keys to your new BMW and thanks you for
all of your hard work so far. You think your client is joking until you glance out the
window and see the sleek, beautiful car parked outside. What do you do? Apparently
you have done your job well and perhaps you deserve a reward. It is a nice car, so
why not accept it? The car is nothing more than a tip, and people accept tips in all
sorts of professions, right? Would there be any negative consequences if you
accepted the gift? Would it harm the relationship with your client if you declined?
The number of therapists being offered brand new cars from their clients may
be extremely small, but the question of whether or not to accept a gift is confronted
by many therapists (Borys & Pope, 1989). How do they decide? Many therapists
confronted with a tough decision in therapy consult their respective professional code
of ethics. Unfortunately, most ethical codes from professional organizations such as
12


the American Psychological Association (APA, 2002) rarely, if at all, mention gifts.
Feeling completely unaided by their ethics code, their next question might be, Well,
what does the research literature say? Several authors have written about some
important factors (Spandler, Burman, Goldberg, Margison, & Amos, 2000; Gross,
2002; Knox, Hess, Williams, & Hill, 2003) and decision-making models (Brendel,
Chu, Radden, Leeper, Pope, Samson, Tsimprea, & Bodkin, 2007) therapists might
consider, but very little empirical research examining how therapists make the
decision to accept or reject a gift has been conducted.
This study empirically examined three of the factors believed to be important
to consider when offered gifts in therapy. Practicing psychologists and students in
psychology graduate programs read a vignette in which a client offers a gift.
Vignettes varied based on time in therapy, the cultural background of the client, and
the diagnosis of the client. Participants then decided whether they would accept or
decline the gift. Participants also answered a series of follow-up questions to
determine which, if any, additional variables were important to consider when offered
gifts in therapy.
The primary goal of the study was to go beyond previous research on how the
cost of gifts offered in therapy relates to whether or not therapists believe accepting
gifts to be ethical by examining other potential factors that may influence decision-
making (Borys & Pope, 1989; Baer & Murdock, 1995; DeJulio & Berkman, 2003;
Nigro, 2003; Brown & Trangsrud, 2008). In addition to cost, it has been proposed
13


that the treatment phase of therapy, diagnosis (Smolar, 2002; Knox et al., 2003), and
cultural background (Spandler et al., 2000; Smolar, 2002; Corey, Corey, & Callanan,
2007), are also factors therapists should evaluate when deciding to accept or decline a
gift. This study examined whether these three factors are actually considered by
therapists. A secondary goal of this study was to help lay some groundwork for
future studies on gifts and provide implications for continuing education on gifts in
therapy.
Gifts
Almost everyone has received a gift at some point. Holidays and special
occasions are well-known instances of gift-giving in American society. Christmas,
birthdays, weddings, or even celebrations such as a promotions at work are instances
where giving occurs. Gifts can also express gratitude, such as when a service has
been performed. One very common example of gifts of gratitude in North America is
tipping. It is common courtesy to tip servers, valets, and other servicepersons in
exchange for whatever service they have performed. Although giving a tip is usually
not mandatory it has become an expectation, a form of reciprocity, and a way to make
a living. It may be common for many clients to think of gift-giving in therapy as a
tip. In this fashion the gift might represent reciprocity for the services therapists
offer.
If gifts in therapy are merely tips, one would think it would be appropriate
always to accept them as such. Outside of restaurants, however, the decision is not
14


always so straightforward. For example, professors and medical doctors often face
the decision to accept or decline gifts in their respective professions (Lyckholm,
1998). Students might give gifts to professors after working in their research
laboratories. A medical doctor may encounter gifts from patients after successful
treatment. Whether each of the professionals accepts the gift may depend on several
factors. What if the student enrolls in one of the professors classes? Will the
professor now give the student preferential treatment compared to others? What if
the doctor naively accepts a gift that is meant as payment for care? These are
examples of factors that such professionals may need to consider. The decision to
accept a gift may become even more complex when more factors enter into the
relationships equation.
In the realm of psychotherapy, the most general factor to consider is how
accepting or declining the gift will affect the therapeutic relationship. The therapeutic
relationship between therapist and client is unique in that the therapist is an ally in
discussing the clients problems and struggles (Frank & Frank, 1993, p. 176).
Therapists build close relationships with clients but strive to maintain a professional
distance. This distance helps therapists remain objective and free from biases one
might have when discussing problems with, for example, close friends. If you, as a
therapist, were to accept the BMW mentioned earlier, would you then feel obligated
to treat the client differently? Professionals have an ethical obligation to evaluate
how accepting or declining a gift would influence the therapeutic relationship.
15


Ethical Codes and Gifts
One might expect professional ethics codes to offer some guidelines for
accepting or declining gifts. For psychologists, the closest issue to gift-giving
mentioned in the APA (2002) ethical standards is bartering for services. Standard
6.05 defines barter as the acceptance of goods, services, or other non-monetary
remuneration from clients/patients in return for psychological services (APA, 2002,
p. 1068). The code also cautions psychologists to barter only if the situation is (1)
not clinically contraindicated and (2) the resulting arrangement is not exploitive
(APA, 2002, p. 1068). The ethical code of the American Mental Health Counselor
Association (AMHCA) also discusses bartering in section L.3, stating, Mental health
counselors ordinarily refrain from accepting goods or services from clients in return
for counseling service because such arrangements create inherent potential for
conflicts, exploitation and distortion of the professional relationship (AMHCA,
2000).
Unfortunately, clients do not usually offer gifts to therapists as a form of
barter (Knox et al., 2003). When confronted with the decision to accept or decline a
gift, therapists belonging to the APA or AMHCA may have a difficult time if they
rely solely on their codes of ethics. What professional codes do offer guidelines for
evaluating gifts in therapy? Both the Association for Marriage and Family Therapy
(AAMFT) and the American Counseling Association (ACA) codes specifically
mention the subject of gifts. The AAMFT (2001) code, in Principle 3.10, advises
16


therapists to evaluate the monetary value of the gift as well as boundary issues. The
code instructs therapists to decline gifts if they are expensive or likely to impair the
therapeutic relationship. This is consistent with research showing therapists view
accepting expensive gifts as unethical (Borys & Pope, 1989). The ACA (2005) code,
in Standard A.IO.e, Receiving Gifts, also mentions the importance of the
therapeutic relationship and monetary value of the gift but also mentions culture: The
code explicitly reminds counselors to recognize that in some cultures, small gifts are
a token of respect and showing gratitude, although it gives no further guidance
(ACA, 2005).
Ethical Considerations and Gifts
Although the APA code may not specifically mention gifts, it can still be
useful in helping therapists decide whether to accept or decline gifts. The APA ethics
code comprises five principles and ten standards psychologists should follow when
working in therapy, research, assessment, and training. The five principles represent
general norms therapists should aspire to and can be helpful in situations that may not
be covered in the ten standards (e.g., gifts). The five principles are fidelity and
responsibility, integrity, beneficence and nonmaleficence, respect for peoples rights
and dignity, and justice (APA, 2002).
The relationship between the client and therapist is built on trust. The
expectation that the therapist will be loyal and trustworthy in honoring this
relationship reflects the ethical principle of fidelity (Kitchener, 2000); clients expect
17


therapists to be faithful to clients best interests in all matters discussed in therapy.
Integrity in psychotherapy means that therapists are open and avoid engaging in
cheating, misrepresentation, or other forms of subterfuge (APA, 2002). A promise or
commitment made to clients in the informed consent process or at any other point in
therapy should be honored.
Beneficence is the idea that therapists seek to benefit the clients with whom
they work. The client comes to the therapist in a state of need and it is the therapists
responsibility to provide a treatment that will be beneficial. Nonmaleficence means
that therapists should not inflict harm upon clients. Although therapists should strive
to benefit their clients, they should also be aware of the ramifications of any treatment
they may choose to use. It is important that therapists not only strive to avoid
intentionally harming a client, but also eschew activities that may put the clients well
being at risk (Kitchener, 2000).
In the example of the BMW, would it be beneficial to the client if you
accepted the car? What if the client is a multimillionaire and can easily afford such a
gift? What if the client is of a lower socioeconomic status and took out a loan to help
pay for the car? One might argue that it would be beneficial to accept the car in the
first scenario (after all, you do not want to insult the giver), but not in the second
scenario (the clients money would be better spent on more important things). How
might accepting the car affect the therapeutic relationship? Regardless of the clients
socioeconomic status, accepting the gift might create an expectation that the client
18


should receive something in return. Such an expectation would likely influence the
process of therapy and in the end could have detrimental effects on treatment. This
would be inconsistent with the principle of nonmaleficence.
The cultural background of clients may be an important consideration in
regard to another APA principle: respecting the rights and dignity of others, or
autonomy. Clients come to therapy with problems and expect therapists to be able to
provide some help. Therapists must be careful not to eclipse clients rights to (a)
make decisions, (b) follow personal values, and (c) act as an autonomous agent
(Kitchener, 2000, p. 25). Many clients have personal beliefs and goals that stem from
their cultural background. As such, some authors recommend that therapists consider
the unique culture of the client when providing psychotherapy (Sue & Zane, 1987).
In the matter of gift-giving, recognizing the client to be from a cultural background
rich in gift-giving could be very helpful in determining whether or not to accept such
a gift.
As a therapist you might think, Wow. That is a lot to consider. How do I
balance all of these issues in my decision? Taken a step further, How do I balance
all of these issues in a way where all are influential with every client? The short
answer is that although many factors have to be considered when offered gifts, not all
are necessarily influential. These questions are relevant to the final ethical principle
of justice. Therapists strive to distribute fair treatment across all clients yet remain
sensitive to the particular needs of each (Kitchener, 2000). The finding that therapists
19


generally view accepting expensive gifts as unethical (Borys & Pope, 1989) is an
example of how therapists might approach an initial decision across all clients. If
cost is not an issue, then other factors might have more or less of an impact on
therapists decisions to accept or decline gifts, depending on the situation. An
example of one of these other factors could be client culture, as discussed above.
One final ethical issue relevant in deciding whether or not to accept a gift is
boundaries. The importance of having clear boundaries between therapists and
clients has been studied extensively in psychology ethics research (Pope, 1991).
Sommers-Flanagan, Elliot, and Sommers-Flanagan (1998) define a boundary as a
distinction between the expectations of what is appropriate or inappropriate in a
relationship. The therapeutic relationship is based on the idea that clients can safely
disclose information to an unbiased third party in a safe environment.
Pope (1991, p. 23) pointed out that boundary violations distort the
professional nature of the relationship and can eventually lead to dual relationships.
A dual relationship is one in which the therapist and client are in an additional,
significant relationship outside of therapy (Kitchener, 1988). Expectations and rules
of a relationship outside of therapy can strongly interfere, usually for the worse, with
the process of therapy (Pope, 1991). Such interference is one reason why
psychologists do not treat close friends or family members. It is very easy for
conflicts of interest to occur between the roles of therapist and friend. A therapist
who is treating his or her best friend may be reluctant to bring up issues pertaining to
20


others in the friend circle or the client might not want to share certain information
about people the therapist may know.
Therapists have an ethical obligation to maintain clear boundaries with clients.
Gifts in therapy can be potentially problematic and may represent boundary
violations. If therapists were to accept gifts from clients offered as a token of
friendship, for example, clients may begin to think of therapists as close friends.
Identifying with therapists as more of a friend would impose a different set of
expectations, rules, and behaviors than those that are crucial in the traditional
therapeutic relationship (Kitchener, 1988).
Austin, Bergum, Nuttgens, and Peternelj-Taylor (2006), in their work on non-
traditional definitions of boundaries, explain that accepting a gift from clients is
usually viewed as a boundary transgression in Western mental health services (p.
80). Not accepting the gift would likely be viewed as an insult to the giver in most
other parts of the world (Austin et al., 2006). There is also a difference between a
boundary crossing and a boundary violation. Crossings are usually viewed as
relatively innocuous whereas violations bring significant harm to the client and are
exploitative in nature (Austin et al., 2006). Under these definitions, accepting a book
on traditional Japanese cooking from a Japanese client might be an example of an
acceptable boundary crossing. Accepting a brand new BMW from the same client
would be a boundary violation.
21


Decision-Making Models
To help evaluate whether accepting a gift violates ethical standards such as
boundaries, four sets of authors have created decision-making models for therapists to
use when offered gifts. Corey et al. (2007, pp. 285-286) offer a model with five
critical questions the therapist should consider when offered a gift: (a) What is the
monetary value of the gift? (b) What are the clinical implications of accepting or
rejecting the gift? (c) When in the therapy process is the offering of a gift
occurring? (d) What are your own motivations for accepting or rejecting a clients
gift? (e) What are the cultural implications of offering a gift? The authors advise
therapists to avoid gifts of high value as well as those offered at the beginning of
therapy. Accepting a gift near the beginning of therapy may lead to the formation of
weak boundaries between therapist and client (Corey et al., 2007). Therapists should
also be aware of how their own boundaries, the feelings of the client, and the
desirability of the object all may be influencing their judgment. Of the four decision-
making models in the literature, this model was the only one to mention culture.
When discussing culture the authors point out that gift-giving is a common practice in
many Asian cultures (Corey et al., 2007).
Gross (2002) offers a similar question-based model to determine whether or
not it is ethical to accept a gift. The six questions cover issues of cost, how intimate
the gift might be, reason for giving, whether therapist and client can process the
meaning of the gift, and overall impact that accepting or declining the gift will have
22


on the course of therapy (Gross, 2002). If the gift is expensive, highly intimate,
detrimental to therapy, or cannot be discussed it should not be accepted. In addition
to evaluating these questions, it is important for the therapist to envision whether or
not they could explain their decision to an ethics board (Gross, 2002). Such a
technique could be helpful in many areas of ethical decision-making. Although the
model is helpful for general situations involving gifts, it does not give examples of
how therapists can make such decisions. The model also fails to provide questions
relating to cultural issues.
Gerig (2004) advises therapists to examine the gift within two categories:
therapeutic significance and ethical concern. The model comprises two levels of
therapeutic significance of the gift (relatively high, relatively low) and two levels of
ethical concern associated with the gift (relatively high and relatively low).
Consistent with past research examining cost of the gift, Gerig (2004) considers gifts
that are relatively inexpensive as having a low ethical concern. When ethical concern
is low the therapist is free to choose to accept or decline, but in situations of relatively
high ethical concern the recommendation is typically to decline the gift. Where the
model becomes more complex is in situations where both ethical concern and
therapeutic significance are high. For these situations Gerig (2004) offers
recommendations such as exploring deeper meanings of the gift and processing the
gift directly and metaphorically. Although the model discusses the importance of
avoiding exploitation and boundary crossings it does not mention culture of the client.
23


All of these models are holistic in nature. The models involve a set of general
questions therapists should consider when offered gifts in therapy. The final model
by Brendel et al., (2007) is a sequential, decision tree model. This pragmatic model
advises therapists to ask a series of six questions to evaluate a gift. Question one
asks, Would accepting the gift be exploitative insofar as it would benefit the
clinician and possibly harm the patient financially, emotionally, or otherwise?
(Brendel et al., 2007, p. 45). If the answer is yes, the therapist immediately rejects
the gift and discusses his or her reason for doing so. If the gift is not exploitative the
therapist then moves on to questions examining cost, desirability, professional norms,
potential impact of rejection, and what the therapist deems to be in the clients best
interest (Brendel et al., 2007). These questions emphasize the importance of
evaluating factors of cost and boundaries, but none specifically mention culture.
Exploring Gift Variables
Beyond decision-making models, several authors have identified general
factors therapists should consider when offered gifts in therapy. Examining potential
variables woven into a clients gift basket is a common procedure discussed by
psychologists, physicians, and psychiatrists (Brendel et al., 2007). Reviewing
psychoanalytic literature, Smolar (2002) lists kind of patient, phase in treatment, and
dynamic meaning of the gift as being important variables analysts should consider.
For example, some patients handle rejections better than others. Psychoanalysts
usually view the beginning of treatment, holidays, and termination as being more
24


appropriate occasions to accept gifts (Smolar, 2002). Dynamic meaning of the gift
refers to whether the gift is related to any potential issues between clients and
therapists. A gift may have transferential, defensive, or object-relational meanings
and should be discussed between therapist and client (Smolar, 2002).
Smolar (2002) also attempts to give therapists a more clearly defined list of
gift variables and their influence in therapy. Consistent with psychodynamic theory,
the first variable is how the gift may be related to pathology rooted in early
development. Smolar (2002) continues in a psychodynamic framework, listing
transference interpretation, therapeutic alliance, and ego strength of the patient as
important factors. The two variables outlined by Smolar (2002) with particular
relevance to this study are cultural differences and weak boundaries. Recent
immigrants might offer gifts in the tradition of their homeland and may be offended
by even the mere discussion of whether or not it is appropriate for therapists to accept
gifts.
The other relevant variable, boundaries, will vary by individual client. Smolar
(2002) advises therapists to be aware of any boundary violations clients have had in
the past. Clients subjected to severe boundary violations in the past, such as sexual
abuse, may not have a clear understanding of how boundaries work in therapy
(Smolar, 2002). An example of a client with an unstable sense of boundaries might
be someone who presents with the symptoms of an Axis II disorder such as
Borderline Personality Disorder.
25


Qualitative Studies on Gifts
Although the factors pertaining to gifts in therapy have been discussed in the
literature since Freud (Knox et al., 2003), very little research has been conducted to
see which factors may be important in the decision-making process. Spandler et al.,
(2000) describes the discrepancy between the vast general literature (Anthropology,
Womens Studies, Economics) on gifts and the dearth of psychological research on
gifts in therapy as disturbing. In a field where therapists tout the importance of
processing the content discussed in therapy it is ironic that so little has been said
about gifts. Although the research on gifts is lacking, two major qualitative studies
have provided insight into therapists experiences with gifts in therapy.
The first study used a general, open-ended questionnaire that asked eighty
British psychotherapists, all members of the Society for Psychotherapy Research, to
report past experiences in which clients had offered gifts (Spandler et al., 2000). In
justifying the study the authors pointed out the lack of research on the subject of gifts
in psychotherapy. A primary objective of the study was to provide awareness of this
lack of research and stimulate discussion of gifts in therapy so that future studies on
gift-giving might be conducted. If more studies are conducted on evaluating gifts in
therapy, training and continuing education in the helping professions could make use
of important results. An interesting finding related to this objective was that many of
the therapists explained how their participation helped them evaluate their gift
experiences (Spandler et al., 2000, p. 78).
26


Common themes that surfaced across the eighty therapists were cost of gift,
sexual meaning, time in therapy when the gift is given, boundary violations, power,
and culture. If a gift was given at the end of therapy, of low cost, nonsexual in nature,
and did not blur boundaries it was seen as more acceptable (Spandler et al., 2000).
Culture and the impact of cultural issues were hardly mentioned in responses. The
authors speculated this might be due to (a) the general lack of literature and
understanding of cultural/racialized issues in psychotherapy (p. 88) and (b) a
tendency for most therapists to interpret gifts from their own cultural context without
considering how the client may be different. It could be that a lack of research on the
subject of gifts may be responsible for the lack of cultural understanding in therapists.
If such a therapeutic issue is rarely discussed it might be less likely to be incorporated
into training manuals, ethics codes, and other clinical guidelines. These questions
could be explored with more research on gifts given in therapy.
The second qualitative study examining gifts in psychotherapy used
interviews. Knox et al. (2003) interviewed 12 therapists from the APAs independent
practice division and obtained descriptions of their experiences with gifts from clients
in psychotherapy. Although 12 therapists were interviewed, 200 were initially sent
letters asking for participation in the study. The authors acknowledged that such a
small sample, although within the fields methodological guidelines, may not be
representative of all types of therapists and clients. All therapists interviewed had
been offered and accepted gifts at some point in their practice.
27


The authors identified common factors that increased or decreased the
likelihood of accepting a gift as well as the frequency of each factor (Knox et al.,
2003). Typical situations that decreased the likelihood of accepting were when gifts
were of high monetary value, given too early, or violated therapeutic boundaries. The
only factor found to be typical among some respondents that increased the likelihood
of accepting was in situations where refusal would be hurtful (Knox et al., 2003).
Although there are factors that typically make accepting a gift unethical, there does
not appear to be a common factor that increases the likelihood of acceptance. If the
client was from a culture where gifts are known to be important, would that increase
likelihood of acceptance? Unfortunately, culture was not assessed in the study of 12
therapists.
Quantitative Studies and Cost
The studies that have used quantitative methods to evaluate how therapists
make decisions about gifts have done so in the larger context of dual relationships.
The first of these studies was by Borys and Pope (1989). The authors sample
included 1,108 psychologists, psychiatrists, and social workers. These participants
completed the Therapeutic Practices Survey (TPS), which asked questions relating to
participants ethical beliefs and behaviors in matters of dual relationships (Borys &
Pope, 1989). Of the 18 questions on the survey, two specifically addressed gifts in
therapy. Therapists used a 5-point Likert scale to indicate how ethical Accepting a
gift worth under $10 and Accepting a gift worth over $50 would be if they were
28


offered in therapy (Borys & Pope, 1989, p. 287). The rating anchors were: 1 = never
ethical, 2 = ethical under rare conditions, 3 = ethical under some conditions, 4 =
ethical under most conditions, and 5 = always ethical (Borys & Pope, 1989, p. 287).
Participants later indicated if they had ever accepted a gift worth less than $10 or
more than $50.
For accepting gifts worth less than $10, 38% of participants viewed it as
ethical under some conditions, 40% as ethical under most conditions, and 5% as
always ethical. This means that roughly 83% of participants viewed accepting a gift
worth less than $10 as being ethical at least under some conditions. In contrast, 82%
of respondents believed accepting a gift worth more than $50 to be rarely to never
ethical. When asked about accepting gifts from actual clients, at least 70% of
participants indicated having accepted a gift under $10. Ninety-two percent of
respondents indicated they had never accepted a gift worth more than $50 (Borys &
Pope, 1989). The results demonstrate that when cost is concerned, therapists may be
practicing what they preach.
Borys and Pope (1989) also found several differences in ethical ratings of
incidental boundary crossings (i.e., the group of boundary crossings that included
accepting a gift worth less than $10) among various demographics. Psychologists,
therapists with a humanistic or eclectic approach, therapists seeing predominantly
female clients, and private practitioners all viewed incidental crossings as more
ethical. Psychologists viewed accepting a gift worth less than $10 as significantly
29


more ethical than did social workers and psychiatrists. Studies on accepting gifts
since Borys and Pope (1989) have not examined ethics ratings across disciplines.
These results were corroborated by Baer and Murdock (1995) in their study of
dual relationships. Although the authors used the Ethical Assessment Survey (EAS),
a modified version of the TPS, the questions on accepting gifts were the same. Six
hundred members of APA responded. The authors used the same Likert scale as
Borys and Pope (1989) but instead of using percentages to report results, the authors
documented ratings based on Likert scale means. Accepting a gift worth less than
$10 had a mean ethics rating of 3.38 while accepting a gift worth more than $50 had a
mean ethics rating of 1.6. Although Baer and Murdock (1995) did not use
percentages to report results, the Likert scale means are similar to the results in the
previous study. Most psychologists viewed the inexpensive gift as being ethically
acceptable some of the time and the expensive gift as being never to rarely ethical.
DeJulio and Berkman (2003) used the EAS to study perceptions of nonsexual
dual relationships in social workers. Using percentages for the gift questions, the
authors obtained results similar to Borys and Pope (1989). Accepting a gift worth
less than $10 was viewed as ethical under some conditions by at least 76% of social
workers while accepting the gift worth more than $50 was seen as being rarely to
never ethical by 85.5% of social workers. In discussing their findings, DeJulio and
Berkman (2003) noted that future studies should examine how other factors such as
cultural values inform the decision-making process.
30


In another study of dual relationships, Nigro (2003) surveyed 206 members of
the Canadian Counseling Association. Although the study used the same Likert scale
measures of ethical and unethical decisions, the gift questions were slightly altered.
Two questions regarding gifts were included in the survey but the prices were
different than those used in previous studies. Instead of using a<$10/>$50
distinction, Nigro (2003) asked how ethical it would be to accept a gift worth less
than $20 or more than $20. This difference had a slight effect on the reported means
for each question. Gifts worth less than $20 were seen as being somewhat more
unethical (M = 2.5) than the mean for gifts less than $10 (M=3.38) in Baer and
Murdock (1995). Changing the value from more than $50 to more than $20 had little
effect on the overall mean (M = 1.73) (Nigro 2003).
Independent Variables
Moving Beyond Cost: Time in Therapy
In all of the studies examining gifts so far, cost has been a decisive factor in
determining whether or not therapists accept gifts offered in therapy. In 2008, the
first study examining therapists judgments regarding gift giving in clinical vignettes
was published by Brown and Trangsrud. The authors replicated findings about the
importance of evaluating the cost of gifts, reporting monetary value of the gift to be
one of the most influential factors in the clinical vignettes presented to participants.
Given the repeated finding that high cost gifts are typically not as acceptable as low
cost gifts, the present study did not manipulate cost of gift. The gift presented within
31


all conditions cost 20 dollars, a price that falls into the more acceptable cost range
when the results from past studies (Borys & Pope, 1989) are adjusted for inflation
(Brown & Trangsrud, 2008).
In addition to cost, one variable that has been mentioned in some studies but
not systematically researched is the time in the course of therapy when the gift is
offered. Many authors have described gifts offered at the end of therapy, termination,
to be more acceptable than gifts offered at other phases of treatment (Gerig, 2004;
Knox et al., 2003; Gross, 2002; Smolar, 2002; Spandler et al., 2000). In one of their
four vignettes involving gifts in therapy, Brown and Trangsrud (2008) reported
treatment phase to be one reason for not accepting a particular gift. To expand the
research on the variable of time in therapy I included it as the first variable under
investigation.
Diagnosis
The second variable I investigated in the current study was diagnosis of the
client. The diagnoses of clients can influence how they are treated, viewed, and
responded to by therapists. Some diagnoses are viewed as being more difficult to
work with than others. Historically, clients with personality disorders have a
reputation as difficult patients (Lewis & Appleby, 1988). One personality disorder
that has gained a particularly notorious reputation as being difficult is Borderline
Personality Disorder (BPD). Some authors have gone so far as suggesting that BPD
is the blanket term for difficult patients (Gallop, Lancee, & Garfinkel, 1989). In a
32


study of 65 registered nurses working in an inpatient psychiatric unit, the majority of
the nurses had negative reactions to patients with a diagnosis of BPD (Deans &
Meocevic, 2006). In a similar study of psychiatric inpatient nurses, Gallop et al.
(1989) found that nurses treated patients with BPD more negatively than patients with
schizophrenia.
In a review of the literature between 1979 and 2004, Koekkoek, Meijel, and
Hutschemaekers (2006) identified three types of difficult patients: unwilling care
avoiders, demanding care claimers, and ambivalent care seekers. The third category,
ambivalent care seekers, is typified by a diagnosis of BPD. Psychiatrists mentioned
BPD four times more often than other diagnoses when asked to define difficult
patients (Koekkoek et al., 2006). Although most authors believe labeling clients as
difficult is pejorative, the trend of doing so has continued for over 25 years.
If clients with BPD are often seen as being difficult, would that lead to biases
in therapists decision-making? In their book, What Therapists Dont Talk About
and Why: Understanding Taboos That Hurt Us and Our Clients, Pope, Sonne, and
Greene (2006) discuss common cognitive strategies to justify unethical behavior.
They list several common fallacies therapists have been guilty of, such as blaming
poor decisions on clients or describing decisions as being in the clients best interest
(Pope et al., 2006). Would it be in the best interest of clients diagnosed with BPD
always to decline their gifts? When therapists define relationships with clients based
on diagnosis, the therapists biases related to those diagnoses may lead to faulty
33


decision-making. If therapists only view clients with BPD as being more difficult and
having no boundaries, they may be more inclined to view accepting a gift from such
clients as unethical.
Although making such a decision seems safe prima facie, such all-or-none
thinking is not always the most ethically just decision-making policy. Although
clients with a diagnosis of BPD traditionally present with problems with boundaries
in relationships (Sadock & Sadock, 2003), it does not guarantee that all gifts offered
in therapy will blur boundaries. Thus, what do therapists do if offered gifts from
clients with BPD? Should such a diagnosis always override the other factors present
when clients offer gifts? Would that be an ethically just decision-making strategy for
therapists to use when offered gifts? Smith (2003) proposes that by setting up clear
guidelines, boundaries, and expectations at the outset of therapy, therapists can avoid
later problems related to boundary violations. If therapists set up a good ethical
offense with every client, then deciding whether or not to accept gifts offered by
clients with BPD should not be more problematic than making such a decision with
other clients.
The study by Brown and Trangsrud (2008) found that client intent was an
important factor that influenced participants decisions to accept or decline gifts
across all four vignettes in the study. The authors noted this to be consistent with
previous literature recommending therapists to consider the meaning of gifts in
therapy. It is possible that therapists may use the diagnosis of the client heuristically
34


to infer the meaning of the gift offered in a vignette. I predicted that therapists in the
current study would view accepting gifts from clients with BPD as less ethical than
accepting gifts from clients with non-difficult disorders. To test this hypothesis,
diagnosis of the client was the second major variable included in the study.
Culture
The third variable I investigated in the current study was culture of the client,
which has recently been recognized in the psychotherapy literature as being important
to evaluate (DeJulio & Berkman, 2003; Spandler et al., 2000). Frequency of giving
and reason for giving gifts can vary across cultures. In her book, Gift-giving in
Japan, Rupp (2003) explained how the Japanese operate within a system relying
heavily on gift-giving. Therapists are beginning to recognize that clients from Asian
cultures such as Japan find gifts to be a very common way to show gratitude (Corey
et al., 2007). Cultural considerations such as this have led some professional ethics
codes (e.g., ACA) to acknowledge the importance of evaluating client culture when
presented with gifts in therapy. It may help therapists make decisions about gifts if
they understand some of the cultural reasons behind the gift. In the next section I
explore why culture is important in evaluating gifts in the context of the Japanese
culture.
Gift-Giving in Japan
A review of the gift-giving system in Japan is necessary to understand why
therapists are likely to encounter gifts from Japanese clients. The tradition of giving
35


gifts in Japan has been around for thousands of years and is still present in second and
third generation Japanese-Americans (Johnson, 1974; Rupp 2003). The Japanese
system of giving and receiving gifts is highly complex and depends on several
cultural factors. Given these complexities, I will review only the basic components.
Gift-giving is so important in the Japanese culture that many families will
allocate a substantial amount of income specifically for gifts. Some families have
even reported spending more money every year on gifts than food (Johnson, 1974).
The first encounter with gifts usually begins at ones high school graduation and
continues throughout their life (Johnson, 1974). Rupp (2003) detailed this complex
system based on 18 months of fieldwork in Japan in both metropolitan and rural
areas. The three factors Rupp (2003) identified as being important in determining
whether a gift is given and how much money is spent on the gift are strength of the
relationship, gratitude, and hierarchy. Each of these factors could potentially play a
role in a Japanese clients decision to offer a gift to his or her therapist.
Strength of the relationship is divided on three levels: chikai/toi (close/far),
koi/usui (strong/weak), and fukai/asai (deep/shallow). Close and far refer to spatial
distances. A chikai relationship might be with someone who lives in the same
neighborhood or city or with someone at ones work. Toi on the other hand would be
a relationship in which one rarely sees the other, such as in different cities or even
countries. The distinction between koi and usui is traditionally defined by blood
relationships with koi usually pertaining to parent/child or sibling relationships and
36


usui being much more removed. Fukai and asai are used to describe the depth of the
relationship. Close friends would likely have a deep, fukai relationship while
acquaintances or superficial friendships are usually asai. Each of these levels affects
the amount of money or cost of a gift (Rupp, 2003).
Gratitude and hierarchy are more easily defined. Gratitude is the factor that is
probably most similar in Japanese and American cultures. In discussing gratitude,
Rupp (2003) gives several accounts where gratitude was an important factor in people
giving more expensive gifts. For example, a man was given a higher amount of
money at his house-building ceremony because his wife cared for the givers younger
sister when she was ill. Regardless of the event prompting the gift, those who had
performed services or favors in the past were more likely to receive more expensive
gifts. The general rule for hierarchy, as outlined by Rupp (2003), is that people
higher up in status usually receive and give higher amounts of money or objects of
higher value. If a worker was going to give a present to his boss it would be more
expensive than if he were buying a gift for another coworker. Reciprocally, if the
boss was giving a gift to an employee it would be of higher value than gifts between
subordinates.
Strength of the relationship, gratitude, and hierarchy would all play a role if a
Japanese client were to offer a therapist a gift. The strength of the relationship would
most likely be chikai (close) and usui (weak), given that both likely live in the same
city and ethically, should be unrelated. The most important strength factor is whether
37


the relationship is fukai (deep) or asai (shallow). If the client has been seeing the
therapist for a while, rapport has been established, and progress has been made, the
relationship is likely to be fukai (deep). Because it is traditionally the rule to give
more expensive gifts in fukai (deep) relationships, it would be reasonable to expect a
Japanese client to do so in therapy.
Regardless of culture, gratitude certainly plays a role in many gifts offered to
therapists. The case with a Japanese client is unique, however, in that gift-giving is
the expected way to show gratitude (Rupp, 2003). It is not uncommon to give a
doctor a gift in return for services rendered. Patients will not only bring a doctor a
gift, but their gift will often reflect a value they believe to be proportionate to the
seriousness of their illness (Befu, 1968; Rupp, 2003). To give a gift of high value
following successful treatment of his or her issues in therapy may not seem as
unusual or out of place to a Japanese client as it may to the therapist.
Hierarchy and its role in gift-giving within therapy has an interesting
relationship with power. Clients often come to therapy feeling vulnerable and operate
under an assumption of being able to trust the therapist. Vulnerability and inherent
trust create an imbalance in power that therapists try to minimize and avoid exploiting
(Gerig, 2004). Although therapists strive to minimize the imbalance of power, a
Japanese client may view the therapist as being above them in a hierarchy. In
discussing hierarchy, Rupp (2003) points out that those in higher positions of social
status are usually seen as being higher up in the gift hierarchy. If a therapist is
38


viewed as being above the client hierarchically then he or she is likely to receive a
more expensive gift from a Japanese client than they might from other clients.
In addition to strength of the relationship, gratitude, and hierarchy there are
two general, overarching forces that act as motivators in gift-giving: giri and ninjo.
Giri is the more traditional, social dictator of when gifts are supposed to be given and
what is acceptable as a gift in each situation (Befu, 1968; Rupp, 2003). Japanese gift-
giving is a system of giving and reciprocating. A family given money in celebration
of their newborn child will give a certain portion back to the giver depending on the
original amount. A family given a koden, or funeral donation, will reciprocate the
same amount of money when a death occurs in the givers family (Befu, 1968; Rupp,
2003). The system is so intricate that companies have been established in Japan to
organize and manage a familys gifts in such events. Sue and Zane (1987) note that
the benefits of therapy are, in a way, gifts to clients. The aforementioned instance of
patients giving doctors gifts relative to the nature of their illness is an example of a
giri dictated gift. As such, giri could likely play a role in the therapist-client
relationship.
The motivational force of ninjo is more modern and in addition to giri, is
popular in urban Japan (Befu, 1968; Rupp, 2003). In contrast to giri, gifts motivated
by ninjo are less of an obligation and more of a personal present. In this situation the
giver cares more about what he or she is giving and less about appropriate amount or
quantity (Befu, 1968). These gifts surface in situations of mutual trust and close
39


relationshipssimilar to a more Western concept of gifts. A gift given in therapy
motivated by ninjo would come more from a personal appreciation and trust with the
therapist and less from social obligation. Gifts in therapy could be motivated by
either giri or ninjo. Turning down gifts of giri, which might be less emotionally
laden, may not be as devastating to the client as rejecting gifts of ninjo, which may
have more meaning to the client.
Another potential concern for therapists involves the presentation of the gift.
Traditional Japanese gifts come wrapped in order to belittle the price or content of the
gift, and are usually opened when the giver is not present (Befu, 1968; Rupp, 2003).
Making a decision to accept a gift on the spot can be difficult on its own. When the
therapist has no idea what the gift is and is encouraged to open it later the decision
becomes even more difficult.
Gifts presented have many implications for therapy, and no situation presents
a simple decision. Even though clients may be Japanese, their motivations for giving
may depend on several factors. In examining culture-specific techniques in
psychotherapy, Sue and Zane (1987) note the importance of going beyond culture-
specific strategies and examining within-group differences. Although knowing some
of the rudimentary factors involved in Japanese gift-giving is important it is still not
enough to make assumptions. The culture of the client and decision to accept or
reject a gift needs also to be evaluated on an ethical level. This is why culture of the
client was the third variable included in the present study. In this study, I predicted
40


that therapists would consider the culture of the client when deciding whether or not
to accept or decline a gift. Gifts offered by a Japanese client would be seen as more
ethical to accept than gifts from a White, European-American client.
Whats Missing?
Although several authors have outlined some important factors to consider
when offered gifts there is a serious lack of empirical studies. Studies that not only
mention each factor but also have therapists rate the subjective importance of each
would give us a better idea of what therapists consider important. These data may
inform the discussion of strategies that might work for therapists. Additionally, all
but one of the studies mentioned so far have looked at gift decisions retrospectively.
Studies that have therapists make decisions in real time may be closer to actual
decisions in therapy. Such real-time decisions may help reveal both strengths and
weaknesses in clinical judgment when presented with gifts. This information could
be helpful in identifying information that might be helpful for therapists to know.
Finally, although many studies have mentioned boundaries and cost as being
important factors to consider, more studies are needed to examine how culture of the
client weighs in on the decision-making process.
The current study aimed to expand the literature on gifts and inform the
mental health field about how colleagues are approaching the topic of gifts. Before
deciding what direction to take for research and training on gifts in therapy, we need
to know where the field currently stands. How are peers making decisions? What are
41


they considering important? How often are therapists confronted with gifts? Once
we have established a baseline for decision-making, more focused studies can be
conducted to help guide research, training, and changes in ethics codes.
The current study aimed to address these specific deficits in the literature on
gifts in therapy. Building on past research, I included the factors of time, diagnosis,
and culture in vignettes where clients offered gifts. Participants decided whether or
not to accept the gift offered in each situation. After making a decision participants
rated the importance of each of the factors in their decision. I also asked participants
to identify which factors mentioned in the literature (e.g., cost, intimacy, clients
reason for giving, impact on the relationship, meaning behind the gift, attractiveness
of the gift, type of gift, potential for gift to blur boundaries) were important for their
decision. Participants also rated how important each of these factors generally are
when evaluating gifts from clients.
Hypotheses
Time in therapy, diagnosis of the client, and the cultural background of the
client each represented a two-level factor in a 2 x 2 x 2 between subjects design. Past
research exploring whether or not there is an appropriate time in therapy has noted
that gifts are generally perceived to be more ethically acceptable when offered near
termination (Gerig, 2004; Knox et al., 2003; Gross, 2002; Smolar, 2002; Spandler et
ah, 2000). The first hypothesis in the proposed study was that there would be a main
effect for time in therapy. Gifts offered to therapists near the end of therapy would be
42


seen as more ethical to accept than gifts offered in the middle of the course of
therapy.
Research has shown that therapists often consider clients with Borderline
Personality Disorder (BPD) as difficult. Clients with BPD are noted as being more
difficult in the literature more often (32 to 46 percent of studies discussing difficult
patients) than clients diagnosed with other disorders (4 to 16 percent of studies
discussing difficult patients) (Koekkoek et al., 2006). Labeling clients in this way
may influence how the therapist makes decisions in therapy. Because therapists view
and react negatively towards clients with BPD in general it is logical to assume
therapists would do so when offered gifts from these clients. The second hypothesis
was that gifts offered by a mildly anxious/depressed client would be viewed as more
ethical to accept than those offered by a client with BPDthis would be a main effect
for diagnosis.
Anthropological literature, research on gift factors, and the recent demand for
multicultural training in the field of psychology all discuss the importance of gifts in
some cultures. In the only published study examining the impact of client culture on
therapists decisions to accept or decline gifts, Brown and Trangsrud (2008) found
that client culture influenced the decision to accept gifts. The third hypothesis was
that there would be a main effect for culture, such that gifts offered from Japanese
clients would be seen as more ethical to accept than gifts from Caucasian, European-
American clients.
43


Because this study is the first of its kind it is primarily exploratory in nature. I
predicted three main effects at the outset of the study. Although interactions among
the independent variables are also a possibility, not enough is known about the
manipulation and impact of each variable to meaningfully predict an interaction.
44


CHAPTER 2
METHOD
Participants
I recruited participants through APAs Division of Independent Practice, the
Division of Counseling Psychology, the National Association for Social Workers, and
the American Counseling Association. I also recruited graduate students enrolled in
APA-accredited clinical psychology Ph.D. programs across the nation. Each
professional organizations web liaison received an email advertising the study and
requesting that the study details be forwarded to any interested members. Department
chairs in accredited clinical psychology Ph.D. programs received a similar email to be
forwarded to graduate students. If interested, participants could then follow a link to a
webpage containing informed consent and an online survey. Recruitment materials
can be found in Appendix B.
Demographics
A total of 296 people participated in the study. There were 81 (27.4%) men
and 205 (69.3%) women in the study. Ten (3.4%) did not report gender. The sample
was primarily White/Caucasian (84.1%). Other ethnicities reported included
Black/African American (3.4%), Hispanic/Latino (2.4%), Asian/Pacific Islander
(4.1%), Native American (.7%), and Other/Multiracial (2%). Of those who reported
education, 231 (78%) of the sample consisted of graduate students, 53 (18%)
individuals reported being licensed therapists, and 15 did not indicate education level.
45


Year of licensure ranged from 1965 to 2009. One hundred and fifty participants
(50.7%) reported having accepted gifts in the past.
The primary practice settings for those in the study were outpatient clinics
(49.7%), outpatient solo therapy practice (practicing with no other therapists, 10.5%),
inpatient individual and/or group therapy (5.4%), outpatient group therapy (3%), and
other (25%). The primary treatment population for the sample was adults (58.1%),
followed by children (20.3%), and then both about equally (15.5%). Sixty-five
percent of participants reported working primarily with both sexes equally. Seventeen
percent indicated working primarily with women and 9% reported working primarily
with men. With respect to theoretical orientation: 45.3% reported cognitive
behavioral therapy, 14.5% eclectic/integrated, 9.1% psychodynamic, 4.7%
behavioral therapy, 2.7% interpersonal therapy, 2% systems therapy, and 8.4% other.
Procedure
The survey was hosted online by a website called Zoomerang, an internet
company that sets up online surveys. This survey method of data collection has been
effective in past studies (e.g., Klevansky, 2002). At the website the participants
viewed the informed consent information (see Appendix B) before they were allowed
to continue. After completing the survey (see Appendix D) they received debriefing
information. Zoomerang stored completed surveys electronically on a secure server
until the study was complete. Data collection lasted for 6 months.
46


Design
The current study was a 2 x 2 x 2 between subjects design. Each of the eight
conditions included a vignette with some combination of the three factors being
studied. The three respective variables were TIME (middle vs. end of therapy) x
DIAGNOSIS (mild anxiety and depression vs. borderline personality disorder) x
CULTURE (Japanese vs. American).
Measures
One clinical vignette with eight variations addressed every level of the
independent variables. Participants were asked to act as if they were actually seeing
the client in the vignette and then make a decision to accept or decline the gift based
on the available information. Each of the vignettes was identical with the exception of
information about the three independent variables under study (time in therapy,
diagnosis, culture). The therapy was described as being either at the middle or near
the end. The client portrayed was being seen in therapy for either (a) mild depression
and anxiety issues, or (b) Borderline Personality Disorder. The client was portrayed
either as (a) a Japanese woman (salient gift-cultured background) who had moved
from Japan to the United States in the past year or, (b) an American woman who had
moved from one state to another in the past year (not a salient gift-cultured
background). Upon agreeing to participate, each participant was randomly assigned to
one of the eight conditions.
47


Because about two-thirds of those seeking therapy are women (Vessey &
Howard, 1993), the client in the vignette was also a woman. Other important gift
factors outlined in the literature such as cost, intimacy, clients reason for giving, and
gift desirability were also included in the vignettes (Spandler et al., 2000; Gerig,
2004; Corey et al., 2007). These additional factors were held constant across each of
the eight vignettes so as not to weigh against the likelihood of accepting the gift. The
vignette can be found in Appendix C; manipulations for each of the conditions are
shown in brackets.
Participants read the vignette and completed (a) ratings of acceptance of the
gift, ethicality of accepting the gift, confidence in their decision, and the complexity
of the decision, (b) ratings of important variables to consider, (c) questions about past
experiences with accepting gifts, and (d) demographic questions. All questions can be
found in Appendix D.
After reading the vignette participants decided whether or not they would
accept the gift on a 4-point Likert scale (1 = definitely not accept, 2 = probably not
accept, 3 = probably accept, 4 = definitely accept). They then rated, on a 5-point
Likert scale (1 = not ethical, 3 = somewhat ethical, 5 = completely ethical), how
ethical they believed accepting the clients gift in this situation to be. This was the
scale Borys and Pope (1989) used in their study of ethical decision making and dual
relationships. Participants also used 5-point scales to rate how complex their decision
was (1 = not complex, 3 = somewhat complex, 5 = extremely complex) and how
48


confident they were in their decision (1 = not at all confident, 3 = somewhat
confident, 5 = extremely confident).
Participants used a 5-point Likert scale (1 = not at all important', 3 =
somewhat important, 5 = extremely important) to rate how important each of the
factors presented in the vignette (time in therapy, diagnosis, culture, cost, intimacy,
clients reason for giving, meaning behind the gift, attractiveness of the gift, type of
gift, potential for gift to blur boundaries) was in deciding to accept or decline the gift.
Participants also answered the open-ended question, What ONE piece of information
would have needed to be different (and specifically how) to change your response?
Participants reported their own past experiences with gifts including ever
being offered gifts and if so, ever accepting gifts. If offered gifts in the past,
participants reported how important each of the previously mentioned gift variables
were in making decisions about gifts in general.
49


CHAPTER 3
RESULTS
Overall Percentages and Means
In regard to accepting the gift presented in the vignette: 50 participants
(16.9%) indicated they definitely would not accept the gift, 85 (28.7) would probably
not accept, 148 (50%) would probably accept, and 13 (4.4%) indicated they would
definitely accept the gift (n=296). The mean rating for accepting the gift across all
eight conditions was 2.41 (1 = definitely not accept, 2 = probably not accept, 3 =
probably accept, 4 = definitely accept). With respect to how ethical participants
believed others in their field would view their decision; 118 (39.8%) believed
accepting the gift to be somewhat to completely unethical, 89 (30.1%) believed
accepting to be somewhat ethical, and 89 (30.1%) believed accepting to be somewhat
to completely ethical. The mean level of how ethical participants believed others
would view their decision to be was 2.83 (SD = 1.12). Reported levels of confidence
in ones decision to accept or reject the gift were as follows: 17 (5.8%) were not at all
to somewhat confident, 101 (34.1%) were somewhat confident, and 177 (59.8%)
were somewhat to extremely confident. The mean level of confidence for the sample
was 3.69 (SD = .82). One hundred forty-two (48%) individuals reported the
complexity of the scenario in the vignette and their respective decision as not at all to
50


somewhat complex, 115 (38.9%) rated the decision as being somewhat complex, and
39 (13.2%) indicated the situation to be somewhat to extremely complex. The overall
mean level of perceived complexity in the scenario and decision was 2.53 (SD = .90).
A table summarizing these results can be found in Appendix A (Table 2).
Acceptance
To evaluate whether or not the hypotheses for gift acceptance were supported,
2x2x2 factorial Analyses of Variance (ANOVA) were computed entering
diagnosis, culture, and time as the independent factors. There was a significant main
effect, F (1, 288) = 5.79, p < .05, for diagnosis in that gifts were less likely to be
accepted in the borderline scenario (M = 2.34, SD= .06) than in the anxiety scenario
(M = 2.57, SD = .07). This finding supports the hypothesis that participants will be
more likely to accept gifts in the scenarios involving anxious clients. There was a
significant main effect, F (1, 288) = 4.77, p < .01, for culture in that gifts were more
likely to be accepted when the client was Japanese (M = 2.59, SD = .07) compared to
when the client was American (M = 2.33, SD = .06). This finding supports the
hypothesis that participants will be more likely to accept gifts in the scenarios where
the client is Japanese. For the third main hypothesis, there was a significant main
effect for time, F (1, 288) = 5.84, p < .01. Participants were more likely to accept gifts
offered at the end of therapy (M = 2.61, SE = .06) compared to gifts offered in the
middle of therapy (M = 2.31, SE = .06). This third finding supports the third
hypothesis that gifts offered at the end of therapy are more likely to be accepted.
51


Given the almost even split between those who reported having accepted gifts
from clients in the past (50.7%) and those who had not (49.3%), previous acceptance
was added as a fourth (quasi) independent variable and included ina2x2x2x2
factorial ANOVA. Results showed a significant main effect for previous acceptance,
F (1, 280) = 6.65, p < .01. Those who had previously accepted a gift were more
likely (M = 3.00, SD = 1.13) to accept the gift in the vignette than those who had not
previously accepted gifts (M = 2.67, SD = 1.08). There were no significant
interactions on the acceptance questions.
Ethicality
There were no main effects of diagnosis and culture on ratings of ethicality.
There was a significant main effect, F (1, 288) = 15.88, p < .001, of time in that gifts
were seen as being more ethical to accept at the end of therapy (M = 3.11, SE = .09)
compared to the middle of therapy (M = 2.59, SE = .09). The 2 x 2 x 2 x 2 factorial
ANOVA showed a significant interaction, F (1, 288) = 7.93, p < .01, between
diagnosis and culture. Ratings of how ethical it would be to accept the gift across
diagnosis depended on the level of culture. Ratings of ethicality were higher for
accepting the gift when the client was American and anxious (M = 2.98, SD = 1.12)
than Japanese and anxious (M = 2.73, SD = 1.07). Ratings were lower when the client
was American and had BPD (M = 2.68, SD = 1.13) compared to Japanese with BPD
(M = 2.95, SD = 1.10). However, results from the post hoc Tukeys Honest
Significant Difference (HSD) tests indicated no significant difference across the
52


means. Tukeys HSD test is primarily used for post hoc analyses to examine
individual mean differences among groups. Although many post hoc tests exist,
Tukeys HSD applies a correction that accounts for the possibility of family-wise
error rate (Gravetter & Wallnaue, 2009). This type of error is the increased
likelihood of committing a type I error (finding a significant difference when none
actually exists) when multiple analyses of the same data are conducted (Gravetter &
Wallnaue, 2009).
There was also a significant interaction, F (1, 280) = 6.84, p < .01, between
previous acceptance and time point in therapy on ratings of ethicality. Post hoc
Tukeys tests showed that for the end of therapy scenario, ratings of ethicality were
not significantly different between past acceptors (M = 3.12, SD = 1.14) and non-past
acceptors (M = 3.05, SD = .1.09). However, for the middle of therapy scenario,
ethicality was significantly higher for past acceptors (M = 2.89, SD = 1.12) than non
past acceptors (M = 2.27, SD = .91). These results are displayed in Figure 1
(Appendix A).
Confidence
There were no main effects of diagnosis, culture, time, or previous acceptance
on ratings of confidence. Although a significant interaction, F (1, 279) = 4.27, p <
.05, was found between previous acceptance and diagnosis in the aforementioned 2 X
2X2X2 factorial ANOVA, post hoc Tukeys tests showed no significant
differences among means. Means are displayed in Table 2 (Appendix A).
53


Complexity
There were no main effects of diagnosis and time on ratings of complexity.
There was a significant main effect, F (1, 288) = 4.58, p < .05, for culture.
Participants who received the Japanese client viewed the decision to be more complex
(M =2.66, SD = .08) than the participants who received the American client scenario
(M 2.43, SD = .07). There were no main effects for previous acceptance on ratings of
complexity.
Gift Factor Importance
A mean rank analysis of the 15 gift factors revealed the most important gift
factor across the sample to be the potential harm to the client in rejecting the gift.
The least important gift factor across the sample was the attractiveness of the gift
(Table 3, Appendix A). A Multivariate Analysis of Variance (MANOVA) was
conducted to examine differences in ratings of gift factor importance across the
independent variables of diagnosis, culture, and time, and the quasi independent
variable of previous acceptance. Using Wilks criterion (Wilks ), the combination
of importance ratings was significantly affected by diagnosis, F (15, 255) = 2.03, p <
.05, culture, F (15, 255) = 7.54, p < .01, time, F (15, 255) = 2.09, p < .05, and
previous acceptance, F (15, 255) = 2.00, p < .05. The MANOVA did not yield any
interactions among any combinations of the IVs.
In the MANOVA univariate analyses for diagnosis, Diagnosis of the client
was rated as being significantly more important, F (1,269) = 16.20, p < .01, in the
54


decision for those with the BPD client (M = 3.59, SE = .10) than those receiving the
anxious client (M = 2.96, SE = .12). This difference remained significant in a follow-
up univariate ANOVA using the Bonferroni correction to account for family-wise
error rate.
In the MANOVA for culture, four of the 15 questions regarding gift factors
showed statistically significant differences between the two levels of culture.
Cultural background of the client was rated as being significantly more important,
F(l, 269) = 73.87, p < .001, in the decision for those receiving the Japanese client (M
= 3.86, SE = .12) than those receiving the American client (M = 2.52, SE = .09).
Potential for hidden meaning behind the gift, F(1,269) = 4.88, p < .05, was rated as
less important in the decision for those receiving the American client (M = 3.20, SE =
.09) than those receiving the Japanese client (M = 3.37, SE = .12). Potential harm to
the client in rejecting the gift was rated as being significantly more important, F(l,
269) = 7.81, p < .01, in the decision for those receiving the Japanese client (M = 4.55,
SE = .08) than those receiving the American client (M = 4.26, SE = .06). Potential
for the gift, if accepted, to blur boundaries was rated as being significantly more
important, F(l, 269) = 15.00, p < .001, in the decision for those receiving the
American client (M = 4.39, SE = .08) than those receiving the Japanese client (M =
3.88, SE = .10). All of these differences except for potential for hidden meaning
remained significant in follow-up univariate ANOVAs using the Bonferroni
correction.
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The MANOVA for time showed a significant main effect for only one of the
15 gift factors across the two levels of time (End/Middle of therapy). Time point in
therapy was rated as significantly more important, F(l, 269) = 11.04, p < .01, in the
end of therapy condition (M = 3.53, SE = .10) than in the middle of therapy condition
(M = 3.04, SE = .10). This difference remained significant in a follow up univariate
ANOVA using the Bonferroni correction.
No main effects were found in the MANOVA evaluating the effect of
previous acceptance. A significant interaction was found, F (1, 261) = 8.47, p < .01,
between previous acceptance and diagnosis for the importance of the monetary value
of the gift in the vignette. Post hoc Tukeys tests showed that for past acceptors, the
importance of evaluating the monetary value of the gift was not significantly different
between BPD clients (M = 3.43, SD = 1.41) and anxious/depressed clients (M = 3.63,
SD = 1.11). However, those with no history of accepting gifts rated the importance of
evaluating the monetary value of the gift significantly higher for clients with BPD (M
= 3.67, SD = 1.23) than anxious/depressed clients (M = 3.12, SD = 1.26). These
results are displayed in Figure 2 (Appendix A).
Gift Factors: Acceptors vs. Rejecters
To obtain a clearer picture of the factors considered to be important by those
who accepted the gift in the vignette, the sample was divided into those who accepted
the gift (54.4%) and those who did not accept (45.6%). Rank order analyses showed
that both groups rated the attractiveness of the gift as being the least important
56


factor in the decision to accept or reject. The most important gift factor in the decision
was different between the two groups. Acceptors rated potential harm to the client in
rejecting the gift as the most important while rejecters rated potential for the gift, if
accepted, to blur boundaries as most important. Wilks criterion (Wilks ) showed
a significant main effect, F (15, 247) = 6.36, p < .01, in a MANOVA with acceptance
as the quasi independent variable and the 15 gift factors as the dependent variables.
Six of the 15 gift factors were rated significantly different between those who
accepted and those who did not: Time point in therapy, monetary value of the gift,
level of intimacy, clients reason for giving the gift, potential harm to the client in
rejecting the gift, and the potential for the gift (if accepted) to blur boundaries. These
differences remained significant in a set of follow-up analyses using the Bonferroni
correction to account for family-wise error rate.
Time point in therapy was rated as significantly more important, F (1, 294) =
19.18, p < .003, for those who accepted the gift (M = 3.59, SD = .09) than for those
who did not accept the gift (M = 2.93, SD = .12). Monetary value of the gift was also
rated as significantly more important, F (1, 294) = 24.99, p < .003, to those who
accepted (M = 3.87, SD = .10) than to those who did not accept (M = 3.05, SD = .12).
Level of intimacy was rated as significantly more important, F (1, 294) =38.44, p <
.003, to those who accepted (M = 4.16, SD = .09) than to those who did not accept (M
= 3.23, SD = .11). Clients reason for giving the gift was rated as significantly more
important, F (1, 294) = 18.27, p < .003, to those who accepted (M = 4.09, SD = .09)
57


compared to those who declined (M = 3.44, SD = 11). Potential harm in rejecting the
gift was rated as significantly more important, F (1,294) = 15.82, p < .003, for the
acceptors (M = 4.60, SD = .06) compared to the rejecters (M = 4.16, SD = .08).
Potential for the gift to blur boundaries if accepted was the only gift factor variable
that was less important for the acceptors (M = 3.91, SD = .08) when compared to the
rejecters (M = 4.40, SD = .10). This difference was also significant in post hoc
follow-up, F (1, 294) = 13.38, p < .003.
Gift Factors in Past Decisions
I conducted analyses to determine which factors participants consider to have
been important when confronted with gifts by clients in the past. Of the 294 people
who completed the study, 165 (55.7%) reported having been offered gifts in the past.
Of those who had been offered gifts, approximately 146 (88.4%) had accepted a gift
at one time or another. For the following analyses, only those who reported accepting
a gift from a client were included.
Similar to the rating scale used to evaluate the importance of gift factors for
the decision in the vignette, participants used the same 5-point Likert scale (1 = not at
all important; 3 = somewhat important, 5 = extremely important) to report the
importance of each gift factor in past decision-making. A one sample t-test revealed
all gift factors to be significantly greater than 1 (not at all important). Using 3 (the
middle of the scale, somewhat important) as a test value, another one sample t-test
was conducted to determine if any of the gift factors differed significantly from the
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middle rating. All variables remained significantly greater than 3 except for culture of
the client, which was nonsignificant, t (146) = 1.84, p = .067.
Similar to the series of analyses for demographics and the importance of
factors in the decision to accept the gift in the vignette, MANOVAs were conducted
to explore differences among demographic groups and gift factor importance in past
decisions. A MANOVA was conducted for each of the following demographic
groups: age, gender, ethnicity, years of practice, primary practice setting, primary
population seen in treatment, sex of primary population seen in treatment, and
theoretical orientation. No significant differences for age, ethnicity, years of practice,
primary practice setting, sex of primary population seen in treatment, and theoretical
orientation were found. For gender, significant differences were found for time point
in therapy, F (1, 144) = 7.91, p < .01, and for client reason for giving the gift, F (1,
144) = 7.55, p < .01. Females gave higher ratings (M = 3.98, SD = 1.10) for the
importance of evaluating the time point in treatment during which the gift is offered
than males (M = 3.34, SD = 1.38). Females also gave higher ratings (M = 4.38, SD =
.86) for the importance of evaluating the clients reason for giving a gift than males
(M = 3.89, SD= 1.05).
The other demographic variable in which a significant difference was found
among groups was the primary population participants reported seeing in therapy.
The three groups (those who see adults, those who see children, those who see both
populations about equally) were entered as the IV in a one-way ANOVA. There was
59


a significant difference, F (2, 143) = 3.76, p < .05, among the three groups on
reported ratings of importance for level of intimacy in a gift. Results from Tukeys
HSD test revealed that those who primarily see adults gave significantly higher
ratings of importance for evaluating intimacy (M = 4.20, SD = .89) than those who
primarily see children (M = 3.55, SD = 1.10).
Gift Factors and Demographics
A series of MANOVAs were conducted to examine whether or not differences
in ratings existed across gender, age, year of licensure, professional status, and history
of accepting gifts. For gender, male and female were entered as the two groups in a
MANOVA and decision and gift factors were entered as the DVs. There was a
significant difference between means on importance of evaluating the potential harm
to the client in rejecting the gift, F (1,267) = 8.02, p < .01. Females rated this gift
factor as being more important (M = 4.45) than males (M = 4.08). This difference
remained significant in a follow-up univariate ANOVA.
A median split was conducted to determine differences in ratings between
younger and older participants. With the median age being 28, the sample was
divided into two groups (28 and older or under 28), which were then entered as the IV
in a MANOVA. Decision and gift factors were entered as the DVs. There was a
significant difference between means on importance of evaluating the potential for a
gift, if accepted, to blur boundaries F (1, 265) = 4.266, p < .05. A follow-up
60


univariate ANOVA revealed those in the lower age group rated this factor as being
significantly more important (M = 4.32) than those in the older age group (M = 4.02).
A median split was also conducted for years of licensure. With the median
number of years of licensure being 18, the sample was divided into two groups (under
18 years and 18 or more years), which were then entered as an IV into a MANOVA.
Decision and gift factors were entered as the DVs. There was a significant difference
between means on ethicality, F (1, 47) = 4.485, p < .05, and confidence in decision, F
(1, 47) = 4.862, p < .05. The follow-up univariate ANOVA for ethicality was not
significant. The ANOVA for confidence remained significant. Those in the higher
number of years group were more confident (M = 4.11) in their decision than those in
the lower number of years group (M = 3.59). Overall, year of licensure was not
significantly correlated with likelihood of accepting a gift.
To determine whether or not differences in ratings existed between students
and professionals, the two groups were entered as the IV in a MANOVA with
decision and gift ratings as the DVs. There were significant difference between the
two groups on overall decision to accept the gift in the vignette, F (1, 265) = 9.25, p <
.01, the importance of evaluating the time point in therapy, F (1, 265) = 4.801, p <
.05, and the importance of evaluating the potential for the gift, if accepted, to blur
boundaries, F (1, 265) = 9.71, p < .01. All three of these differences remained
significant in follow-up univariate ANOVAs. Professionals were more likely to
accept the gift (M = 2.75) than students (M = 2.34). Time point in therapy was
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viewed as more important to evaluate by professionals (M = 3.66) than students (M =
3.22). Professionals viewed the potential for accepting gifts to blur boundaries as less
important (M = 3.78) than students (M = 4.26).
One Piece of Information
The final primary area of concern for the current study was to evaluate the one
piece of information from the vignettes participants would change in order to change
their decision (and how). Although participants gave a variety of responses, most
chose areas related to one or more of the gift factors discussed in the literature and
included in the present study. The frequency of each type of response was tallied and
used to compute an overall proportion (see Table 4, Appendix A). The percentage of
participants mentioning each gift factor were as follows: 23.7% mentioned cost,
12.8% mentioned time point in therapy, 9% mentioned diagnosis, 7.9% mentioned
culture, 6.8% mentioned the intimacy of the gift, 5.6% mentioned the potential for
hidden meaning behind the gift, 4.9% mentioned the type of gift, 4.5% mentioned the
reason for giving the gift, 4.1 % mentioned the boundary issues pertaining to the gift,
1.5% mentioned harm in rejecting, .8% mentioned harm in accepting, and .8%
mentioned gender. An additional 12.8% mentioned a reason not specific to one of the
gift factors (e.g., previous history of this type of behavior, or check consensus
with other therapists), and 4.9% indicated they would not change their decision.
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CHAPTER 4
DISCUSSION
The current results supported all three of the studys hypotheses. In addition,
I suggest some speculations based on the effects of each independent variable on
scenario ratings, gift importance ratings, and interactions with previous acceptance.
Time
Participants were more likely to accept gifts offered at the end of therapy than
in the middle of therapy. Participants viewed gifts offered at the end of therapy as
more ethical to accept than gifts offered during the middle of therapy. These findings
are consistent with the literature stressing the greater acceptability of gifts offered
later rather than sooner (Smolar, 2002). Smolar (2002) stressed the importance of
rejecting gifts offered in the middle of therapy to avoid changing the nature of the
therapeutic relationship. Therapists in qualitative studies by Spandler et al. (2000) and
Brown and Transgrud (2008) viewed gifts offered at the end of therapy as more
acceptable.
Participants in this study with no history of accepting gifts viewed accepting
gifts in the middle of therapy as less ethical than did participants with a history of
accepting gifts. The literature does not discuss how accepting gifts in the past affects
therapists decisions to accept gifts in the future. It could be that accepting gifts in the
past increases the overall likelihood of therapists accepting gifts in the future.
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Accepting gifts in the past might lead therapists to believe it is okay to accept
simply because they have accepted in the past. Therapists may use past acceptance to
justify accepting the gift in the vignette (e.g., Ive accepted before and obviously that
was the right decision). When these therapists are offered gifts, they may rationalize
accepting gifts by thinking, Accepting gifts in the past did not lead to any problems
with the therapeutic relationship, so I guess I will accept this one too. This could be
an example of cognitive dissonance, especially if therapists feel the need to resolve
anxiety-producing decisions. For example, if therapists feel they may have erred by
accepting a gift, they may look for reasons why accepting was okay. One of the
reasons to justify the decision to accept, and reduce dissonance, could be that
accepting past gifts did not cause any harm. If past gifts have not caused any
problems, or even helped build better rapport with clients, then therapists might be
more likely to accept gifts in the future.
Therapists might operate on all-or-none principles such as I always accept
gifts or I never accept gifts. This could be due to training, past experiences with
gifts, or maybe even a belief that no harm can come to pass if gifts are never
accepted. Another reason could be how rigid therapists are when evaluating gifts.
Therapists with a history of accepting gifts might evaluate gifts on a case-by-case
basis while therapists with no history of accepting gifts use more rigid rules. Finally,
it might also be that those therapists who accepted gifts in the past are part of a subset
of therapists who accept gifts more often than not.
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Participants did not rate scenarios with gifts offered in the middle of therapy
as more complex than scenarios with gifts offered at the end of therapy. They were
also no more confident regarding their decisions in one scenario versus the other. It
could be that therapists are typically confident in their decisions or the vignettes were
too straightforward. Participants rated time in therapy as being more important to
consider in the end of therapy vignette. Therapists may be following
recommendations from the psychotherapy literature and recognize the end of therapy
to be more ethically appropriate to accept gifts.
It might be that therapists use certain factors to reject a gift (e.g., boundaries)
but others to accept gifts (e.g., time). Factors that increase the likelihood of rejecting
would be red flags, or warning signs that accepting is not a good idea. Factors that
increase the likelihood of accepting gifts might be green lights, or indications that
accepting would be beneficial to the clientor in line with the ethical principle of
beneficence. Time point in therapy was seen as more important to consider by
participants who accepted the gift. Therefore, time may be one of the green light
factors. The presence of red flag and green light factors increases the decision to
accept or reject, but the absence does not sway therapists decisions in either
direction.
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Diagnosis
Participants were less likely to accept gifts when the client was being treated
for BPD. This finding is consistent with the literature on difficult patients (Deans &
Meocevic, 2006; Koekkoek et al., 2006; Gallop et al., 1989) and weak therapeutic
boundaries (Sadock & Sadock, 2003). Participants did not rate the BPD scenario as
more complex than the mild anxiety and depression scenario. Therapists might
automatically rule out accepting gifts when clients are diagnosed with BPD.
Situations involving clients with BPD would be seen as more straightforward if this is
the case. If a diagnosis of BPD does not automatically rule out acceptance, the results
of this study indicate that this diagnosis, when present, certainly decreases the
likelihood of accepting gifts.
Although participants accepted gifts less often from clients with BPD,
participants did not view accepting gifts from these clients as less ethical than
accepting gifts from anxious clients. A diagnosis of BPD may be a red flag warning
therapists not to accept gifts, but the decision might be based on clinical judgment
instead of ethical judgment. Therapists may be aware of the boundary concerns
clients with BPD often present and take those under consideration when offered gifts.
Instead of thinking my ethical code warns me about keeping a professional
relationship, therapists might view the situation this way: Given this diagnosis it is
probably not a good idea to accept the gift. Therapists may not necessarily view
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accepting gifts from BPD clients as unethical, but the diagnosis decreases therapists
likelihood of accepting gifts.
A closer look at the what one piece of information would need to be changed
to alter your decision question provided more insight on this topic. Participants with
the BPD client provided comments such as, The diagnosis of the client. Borderline
Personality Disorder makes the blurring of the lines too risky, and, .. .because
boundaries are so difficult with borderline clients, I would not find it appropriate.
Participants rejected gifts from BPD clients regardless of other factors such as
time in therapy and culture of the client. Are there other factors or specific situations
that make accepting more likely with BPD clients (or other traditionally difficult
clients)? A past history of accepting gifts may be one of these factors. Participants
with no history of accepting gifts considered the monetary value of the gift as less
important for anxious/depressed clients compared to BPD clients. Participants with a
history of accepting gifts did not view the importance of monetary value of the gift
differently between the two scenarios. Therapists with no history of acceptance may
be less likely to look beyond the BPD red flag. For these therapists, other factors
related to boundaries (i.e., cost) are more salient when clients have BPD. Therapists
with no history of accepting gifts may look for any reason possible to reject gifts from
clients with BPD. Making decisions based on a diagnosis, and not the person, may
not be seen as professional. Using cost to justify the decision to reject gifts from BPD
clients may be seen as more professional.
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Therapists with no history of accepting gifts may not be able to look beyond
the diagnosis and instead choose to equate BPD with other problems (e.g., difficult
patients). This explanation would be consistent with the studies on how those with
BPD are perceived negatively (Koekkoek et al., 2006). If clients with BPD are treated
differently than other clients in general (Deans & Meocevic, 2006), it follows that
therapists might treat them differently than other clients when offered gifts in therapy.
Many therapists do not want to work with clients with BPD (Gallop et al., 1989), so
why would they want to accept gifts from these clients?
Participants with no past history of accepting gifts evaluated other factors in
gift decisions differently for clients with anxiety and depression issues than they did
for clients with BPD. In situations with mildly anxious or depressed clients, these
participants viewed the cost of the gift as being less important in such scenarios. If
therapists with no past history of accepting gifts are indeed automatically equating a
BPD diagnosis with potential boundary problems, this heuristic may serve any
number of functions. Automatically suspecting the potential for boundary problems
with BPD clients may serve as a protective factor, or a rule to avoid any potential for
boundary violations. Always suspecting boundary issues in gifts from BPD clients,
however, could also become an inability to look beyond a diagnosis. The inability to
look beyond a diagnosis of BPD and evaluate gifts in light of other factors would be
akin to pigeonholing clients by their diagnoses, and would be inconsistent with the
ethical principle of justice.
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In the real world, however, it might be easier to resolve the problem of
pigeonholing clients by their diagnoses. If the client in the vignette was a real client,
therapists would be able to evaluate if the diagnostic label truly fit the client or not.
This knowledge could then be used to accept or reject gifts. If the client had a history
of boundary concerns it might be justified to reject gifts from that client. Participants
may respond more conservatively without this information. This could be the case in
the present study.
Even though they were no more likely to accept gifts from clients with BPD,
participants with a history of accepting gifts may not immediately rule out accepting
gifts from clients with BPD. They continue to consider cost of the gift along with
other factors regardless of clients diagnoses. These participants may have
encountered similar experiences in the past. They might also be more likely to accept
gifts simply because they have accepted in the past and be more open to gift
encounters in general. Regardless of the specific reasons, the finding that participants
with no history of accepting gifts viewed cost as less important when the client did
not have BPD shows that even factors traditionally seen as being relatively
straightforward to evaluate, such as cost (Nigro, 2003; Borys & Pope, 1989), can
change in the presence of other factors (e.g., previous acceptance).
Culture
Participants were more likely to accept gifts from a Japanese client than an
American client and to consider gifts from Japanese clients to be more important to
69


evaluate than gifts from American clients. Smolar (2002) and Corey et al., (2007)
mentioned the importance of gifts in some cultures and how gift-decisions with those
clients have large impacts on the therapeutic relationship. Therapists appear to
recognize the implications of accepting gifts from such cultures. Participants rated
potential harm in rejecting the gift significantly more important when the client was
Japanese. It appears that participants recognized the potential harm to the client in
rejecting gifts from Japanese clients. Rejecting gifts may shame or disrespect clients
from cultures rich in gift giving. Accepting the gift in order to avoid shaming the
client, and potentially compromising the therapeutic relationship, is consistent with
the ethical principle of nonmaleficence.
Participants regarded gifts from Japanese clients as having less potential to
blur boundaries than gifts offered by American clients. If clients are from cultures
where gifts are known to be important, therapists may worry less about boundary
violations. Acknowledging the cultural importance of gifts may be appropriate in
general, but it may be dangerous to assume gifts from cultures rich in gift-giving are
necessarily safer. The literature on gifts does not mention that gifts from gift-salient
cultures are necessarily safer. In fact, Rupp (2003) notes that gifts in Japan can
sometimes imply subtle manipulation or expectation of reciprocation. Participants in
the present study may in fact be aware of the complex relationship between the
culture of clients and the culture of psychotherapy. Participants rated the Japanese
scenario as more complex than did participants with the American scenario.
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Therapists may recognize that manipulation can still exist with Japanese clients. It
could also be that therapists see the addition of a foreign cultural background as
another variable that needs consideration, therefore making the situation more
complex.
Therapists may need to weigh the cultural importance of a gift against the
potential for the gift to create problems. This process involves the reconciliation of
two cultures, or finding a balance between Japanese clients culture and the culture of
psychotherapy (i.e., ethical principles and standards). The literature explains how
important gifts can be in the Japanese culture, but the culture of therapy (ethical
principles and guidelines) dictates the importance of maintaining the therapeutic
relationship. Based on the results of this study, it is encouraging to find that therapists
notice cultural variables and consider them in the decision to accept or reject gifts.
Additionally, culture of the client did not outweigh the importance of diagnosis.
Participants did not accept gifts from clients with BPD more often if the clients were
Japanese compared to when the clients were American. The impact of culture does
not appear to extend beyond diagnosis. The failure of cultural impact to extend
beyond diagnosis, however, could be due to how I worded the vignettes and follow-
up questions.
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Demographics of Those Who Accepted the Gift
This study provides a glimpse of what therapists may consider important
when accepting gifts. Participants who accepted the gift rated five of the gift
factorstime point in therapy, monetary value of the gift, level of intimacy, clients
reason for giving, and potential harm in rejectingas more important to consider
than those who did not accept the gift. On average, participants who accepted the gift
were older and more likely to be professional therapists. The longer you practice
therapy, the more likely you are to come into contact with gifts. The results of this
study showed that acceptors not only encountered gifts in the past, but also were
more likely to have accepted gifts in the past.
Acceptors and rejecters may approach gifts differently for several reasons.
The passing of time may provide therapists with more opportunities to encounter
situations where accepting gifts was beneficial. If accepting gifts was beneficial in the
past it might be beneficial in future decisions. There might also be a generational
effect, with differences in training models and guidelines concerning gifts in therapy.
Older therapists may use models of decision-making that are different from younger
therapists training. Older training models might stress the importance of evaluating
more factors while more recent models may place more emphasis on boundary
concerns. Older models of training might be different with respect to multicultural
issues. Unfortunately, I did not ask participants to report their past educational
experiences with multicultural training.
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Another possibility is that therapists may get more lax in their standards
regarding gifts as the years pass. These therapists may perceive gifts as innocuous in
relation to other complexities inherent in therapeutic decisions, such as those
regarding confidentiality, transference, and termination, especially if they have
accepted gifts in the past. Or perhaps these therapists overestimate their ability to
perceive the potential harm in accepting gifts. Older therapists might believe they are
experts at knowing when a gift is potentially harmful. It could also be that older
therapists are genuinely better at analyzing gift situations. These therapists may take
more factors into consideration in addition to boundary concerns.
Acceptors rated more factors as being important compared to rejecters.
Therapists who accepted gave more importance to five of the 15 gift factors
mentioned in the study: time point in therapy, monetary value of the gift, level of
intimacy, clients reason for giving, and potential harm in rejecting. Acceptors gave
greater importance to the time point in therapy, monetary value of the gift, the level
of intimacy in the gift, the clients reason for giving the gift, and the potential harm in
rejecting the gift. The decision-making models in the literature mention many of
these factors (Brendel et al., 2007; Gross, 2002). It could be that in general, therapists
operate from the viewpoint that gifts should not be accepted unless certain factors are
present. Older therapists seem more likely to look beyond some of the red flag
factors mentioned earlier (diagnosis of BPD, potential for the gift to blur boundaries)
and consider factors that may facilitate acceptance. These therapists might think, for
73


example, Sure, the client has a diagnosis of BPD, but it is the end of therapy, the
cost of the gift is low, the gift is not highly intimate, and there is a high potential to
hurt the client if I reject the gift.
Rejecters were less likely to have accepted gifts in the past, more likely to be a
student, and were younger. Younger participants also viewed the potential for the
gift, if accepted, to blur boundaries as more important to consider than the older
participants. Younger participants view potential boundary violations as most
important, while older participants rated the harm in rejecting the gift as most
important. Potential for boundary violations was the only factor rated as more
important to consider by the rejecters. Younger therapists may seek out reasons to
decline the gift and older therapists may focus on reasons to accept the gift. If
younger therapists detect the slightest possibility of boundary violations they might
immediately reject without considering any attenuating variables. This is a highly
cautious approach, which may be justified given fewer years of experience. It could
also be that younger therapists simply give more weight to boundary violations, or are
not aware of all of the factors important to consider. As mentioned earlier, this
difference could also be a product of different training. If younger therapists are being
trained to reject gifts or accept very rarely, any potential for harm should warrant
rejection. This decision may be consistent with the ethical principle of
nonmaleficence. Unfortunately, I did not ask any questions related to training on
gifts.
74


I also failed to ask participants to provide a list of all of the gift factors they
believed important to consider. Instead I provided a list with several gift factors,
which may have primed participants to think differently about the relative importance
of each factor. For example, rejecters may have rated the culture of the client as
extremely important, but then changed the rating to somewhat important after
reading the question about the potential for boundary violations.
Participants who rejected the gift may use a more strict definition of boundary
violations. Whereas acceptors may view accepting the gift as being more of a
boundary crossing, rejecters may see acceptance as a boundary violation, or
something that would distort the professional nature of the relationship (Pope,
1991, p. 23). Different attitudes regarding violations versus crossings could be due to
such factors as changes in ethics training over the years, level of experience, or
adherence to specific guidelines concerning gifts. Some schools of thought, for
example, believe all gifts are unacceptable within the context of therapy (Brendel et
al 2007).
Conclusions
This study had several limitations. The sample size was much lower than I
expected. A priori power analyses indicated a sample of 552 would be necessary to
detect a small effect. Only 296 people enrolled in the study. This limited the potential
to identify small effects such as interactions among variables. For example,
participants did not accept gifts from Japanese clients with BPD more often than
75


American clients with BPD. I cannot conclude, however, that culture does not
influence decisions with BPD clients. The interaction between culture and diagnosis
could be more subtle.
Another limitation is the low number of professionals who participated in the
study. Despite having thousands of members, only 65 members across the APA
Division of Independent Practice, the Division of Counseling Psychology, the
National Association for Social Workers, and the American Counseling Association
elected to participate. Although consistent with past attempts to recruit professional
therapists in studies (Knox et al., 2003), this small number of therapists may not be
representative of all professionals. These therapists may be more likely to participate
in studies, regularly access organization message boards, and/or check their email.
This self-selecting sample may not be representative and therefore restricts the ability
to generalize the results to all therapists.
Another limitation to the study is the unknown response rate. I do not know the
ratio between those who were contacted and those who participated. I cannot
determine whether or not the low sample size was due to something about the format
of the study (e.g., reluctance to disclose personal information over the internet), the
subject matter (gifts in therapy), or something about the professional organizations
(e.g., poor communication). Knowing the number of people notified about the study
could help develop strategies to increase enrollment in the future.
76


The way I manipulated the independent variables (time, culture, diagnosis) and
presented the other gift factors is also an inherent limitation in the study. Some levels
of independent variables may be more salient to participants than others. Borderline
Personality Disorder may trump any issues related to time or culture. Time in therapy
may interact in more subtle ways with diagnosis when the diagnosis is not a
personality disorder with well-known stigma. In addition to the independent
variables, I selected the other gift factors (i.e., cost of the gift, type of the gift,
personal use for the gift) in the vignette based on recommendations from past work
on gifts (e.g., Smolar, 2002, Spandler et ah, 2000). I tried not to present the other gift
factors in a way that would dissuade acceptance. For example, a twenty dollar gift
was selected based on the findings of Borys and Popes (1989) $10 versus $50
distinction when adjusted for inflation. However, $20 for a gift may still be too
expensive to accept, especially because I did not include the clients socioeconomic
status.
These data are useful in providing an early snapshot of what will hopefully
become a more detailed picture. Future studies on gifts in therapy could explore how
often Japanese and other gift-salient cultures offer gifts in therapy. These studies
could assess the frequency of gifts, how often gifts are accepted, and common reasons
for accepting gifts from gift-salient cultures. Do therapists identify culture as the
reason for accepting gifts and how do they weigh other factors? What are therapists
motivations for accepting or rejecting gifts from these cultures? Other studies could
77


go beyond the American/Japanese distinction presented in this study. Other cultures
with a rich history of gift giving (e.g., Latino) could be included to determine if
acceptance rates vary across cultures. These studies could also explore whether the
likelihood of accepting gifts increases when the therapist and client are from the same
culture or if the gift is culture-specific (e.g., calligraphy from a Japanese client).
Future studies could also examine the age and experience distinction found in this
study. How do experience, age, and professional status affect decisions involving
gifts? Are there potential cohort or generational effects on decisions to accept or
decline gifts? These studies could explore how therapists training types and past
experiences with gifts influence decisions, especially those involving clients from
gift-salient cultures.
Let us go back to the question presented at the beginning of this paper. Your
client is still standing in front of you with that set of keys to a gorgeous new car. Do
you accept the gift? Based on studies concerning cost of the gift, definitely not. But
what if the gift is something less costly, maybe around 20 dollars or so? If it is the
end of therapy, the client has not been diagnosed with Borderline Personality
Disorder, and identifies with her Japanese background, you just might consider it.
You are even more likely to accept if the gift is not intimate in nature, the client is
merely giving it out of gratitude, there is a high risk in harming the therapeutic
relationship if you reject the gift, and you have accepted gifts in the past. But wait!
Suddenly you realize there is a high potential to blur the crucial boundaries in the
78


therapeutic relationship. Maybe it would be better if you declined the gift? There are
also so many factors you might need to address first. Perhaps you decide to consult
with your supervisor, an older therapist with 20 years of experience. Your supervisor
may tell you to evaluate other factors such as the harm in rejecting the gift and the
time point in therapy. If your supervisor has accepted gifts in the past the advice you
receive might be different. Although this study does not inform therapists on how
they should be making decisions, the current data are a useful starting point in helping
us to examine how decisions are being made.
79


APPENDIX A
Table 1
Important factors for gift decision making: prevalence in the psychotherapy
literature
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79


Table 1 (Cont.)
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80


Table 2
Descriptive statistics of ethicality, confidence, and complexity ratings
Not at all to Somewhat Somewhat Somewhat to Extremely Mean (SD)
According to generally accepted standards of practice, how ethical do you think others in your field would judge accepting the gift to be? 118 (39.8%) 89 (30.1%) 89 (30.1%) 2.83 (1.12)
How confident are you that you made the right decision? 17 (5.8%) 101 (34.1%) 177 (59.8%) 3.69 (.82)
How complex was the scenario (and thus the decision) in the vignette? 142 (48%) 115 (38.9%) 39(13.2%) 2.53 (.90)
81


Table 3
Rank-ordered gift factor importance by group
Entire Sample Acceptors Rejecters Past Acceptors
Potential harm to the client in rejecting the gift 1 1 3 1
Potential for the gift, if accepted, to blur boundaries 2 6 1 2
Potential harm to the client in accepting the gift 3 5 2 3
Potential benefit to the client in accepting the gift 4 4 6 4
Clients reason for giving the gift 5 3 8 5
Level of intimacy in the gift 6 2 9 6
Potential benefit to the client in rejecting the gift 7 9 4 7
Potential for hidden meaning behind the gift 8 10 5 8
Monetary value of the gift 9 7 10 9
Time point in therapy 10 8 11 10
Diagnosis of the client 11 11 7 11
Cultural background of the client 12 12 12 12
Type of gift 13 13 13 13
Gender of the client 14 14 14 14
Attractiveness of the gift 15 15 15 15
82


Table 4
What one piece of information would need to be different to change your decision?
Organized by gift factor category
Gift Factor Mentioned N (266) Percent
Cost of the Gift 63 23.7
Time Point in Therapy 34 12.8
Diagnosis of the Client 24 9
Culture of the Client 21 7.9
Intimacy of the Gift 18 6.8
Potential for Hidden Meaning in the Gift 15 5.6
The Type of Gift 13 4.9
Clients Reason for Giving the Gift 12 4.5
Boundary Issues 11 4.1
Harm to the Client in Rejecting 4 1.5
Harm to the Client in Accepting 2 .8
Gender of the Client 2 .8
Other Factors 34 12.8
83


Middle End
Time Point in Therapy
Figure 1
Interaction of Time Point in Therapy and Past Acceptance on Ratings of Ethicality.
84


BPD Anx./Dep.
Diagnosis of Client
Figure 2
Interaction of Previous Acceptance and Diagnosis on the Importance of Evaluating
Monetary Value of the Gift.
85


APPENDIX B
EMAIL, INFORMED CONSENT, AND DEBRIEFING
Dear Doctor,
I am a graduate student at the University of Colorado Denver, and for my masters
thesis I am conducting a survey on clinical decisions. As a member of the American
Psychological Associations Division of Independent Practice, you are one of a small
sample I have selected to participate. Below you will find a link to the website where
you may, if you consent, take a survey comprising a scenario and some questions
relative to that scenario. The survey also asks you some general questions related to
factors that influence your decisions in general. The entire survey should take no
more than 15 minutes. Data collected from the survey will be used for the purposes
of my thesis and to contribute to the psychology research literature. As such, your
participation would represent an important contribution to the field and would be very
much appreciated!
If you have any questions, please let me know. You can also contact my thesis
advisor, Dr. Mitchell Handelsman.
Thank you,
Flint Espil
M.A. candidate
flint.espil@email.ucdenver.edu
Mitchell M. Handelsman, Ph.D.
Professor of Psychology
mitchell.handelsman@ucdenver.edu
(303) 556-2672
Before taking the survey, please read the following consent form:
Consent to Participate in a Research Study
University of Colorado Denver
Who is doing the study, what is the purpose, and why am I being asked to
participate?
86


Flint Espil, a masters candidate at the University of Colorado Denver, is the principal
investigator for the study. Data from the study will be used to satisfy a masters
thesis requirement and may eventually be published. You are being asked to
participate because, as someone who has conducted therapy, you have engaged in
clinical decision-making similar to what is being assessed in this study.
What will I do and how long will it take?
You will read a clinical vignette and then answer some questions about it. You will
also answer some questions about your decision-making in general. The survey
should not take you more than 10-15 minutes to complete.
Are there any possible risks to participating?
The questions in this survey are not intimate in nature. They do not ask you to reveal
any sensitive information about yourself or your clients. It is unlikely that this survey
will cause you any significant distress.
Security of information sent over the internet is always an issue. We have taken
every effort to make sure the information you submit is secure and available only to
those directly involved with the study. As is the nature with information sent over the
internet, however, there is still a slight risk of your responses being intercepted
electronically. Because you are not asked any information that would jeopardize your
career, clients, or reputation, this should not be a threatening issue.
Will I benefit from participation?
There is no direct benefit to participating other than the contribution you will be
making to the research on clinical decision-making. If the study is published you
may benefit from reading the results.
Is participation mandatory?
Your participation in this research is voluntary. If you begin the survey and decide
you want to quit you may do so at any time. Because we do not collect any
identifying information, however, we will not be able to delete your survey once it
has been submitted.
Who will have access to the information I give?
With the exception of the limitation of online information mentioned above, only
those directly involved in the research will see your answers. The information will
also be kept in a secure location. Your responses will not be connected to your name
or other identifying information.
87


What if I have questions?
If you have any questions either before or after you take the survey you may contact
the principal investigator, Flint Espil, with the contact information presented below.
If you have any questions concerning your rights as a volunteer research participant
you may consult the University of Colorado Denvers Human Subjects Research
Committee Administrator at 1380 Lawrence Street, Suite 1400, Denver, CO 80204 or
(303) 556-4060.
Principal Investigator:
Flint Espil
M.A. candidate, Clinical Psychology
University of Colorado Denver
Department of Psychology
Campus Box 173, P.O. Box 173364
Denver, CO 80217-3364
flint.espil@email.cudenver.edu
Advisor:
Mitchell M. Handelsman, Ph.D.
Professor of Psychology
University of Colorado Denver
Department of Psychology
Campus Box 173, P.O. Box 173364
Denver, CO 80217-3364
mitchell.handelsman@ucdenver.edu
(303)556-2672
To take the SURVEY please click on the link below or copy and paste it into your
web browser:
surveyzoomer ang .com
88


University of Colorado at Denver
Research Debriefing
Thank you again for participating in this study. The purpose of this study was
to evaluate how practicing therapists make decisions when confronted with gifts in
therapy. We specifically wanted to see how time in therapy (presented as midway
through treatment or near the end of treatment), diagnosis of the client (presented as
either borderline or depressed/anxious), and culture of the client (presented as either
Japanese or American) all play a role in the decision to accept or decline the gift. We
also wanted to evaluate how therapists view some of the other decision-making
factors mentioned in the literature. In addition to decision-making, we also wanted to
get an idea of how often therapists encounter gifts in therapy and whether or not gifts
are accepted. The information you have provided will be used to help shape future
studies on gifts in therapy.
89


APPENDIX C
VIGNETTE
You have been seeing [Susan/Harumi], a 3 5-year-old [American
woman/Japanese woman], for quite some time now and therapy has been going well.
[Susan/Harumi] has made some positive gains in therapy since she originally came to
you. She had moved from [another state/Japan] a year before starting therapy and
had been experiencing a number of clinical symptoms. After a careful assessment
you diagnosed her with having [Borderline Personality Disorder/some mild anxiety
and depression]. [You feel satisfied with the progress made so far and believe your
client to be about midway through therapy/Now that she is doing much better you
decide to begin your next session discussing a timeline for termination]. At the
beginning of your session [Susan/Harumi] hands you a gift-wrapped box and instructs
you to open it. Upon opening the box you find it contains a polished stone
paperweight from a local gift shop, clearly worth around 20 dollars. You have
needed a paperweight and could certainly use the gift. Beaming with excitement,
[Susan/Harumi] tells you how grateful she is for all the work the two of you have
done and wanted to show you her appreciation.
90


APPENDIX D
QUESTIONNAIRE
Please answer the following questions based on the information given in the vignette.
Q1. Would you accept the gift?
1 = definitely not accept
2 = probably not accept
3 = probably accept
4 = definitely accept
Q2. According to generally accepted standards of practice, how ethical do you think
others in your field would judge accepting the gift to be?
1 = not ethical
2 =
3 = somewhat ethical
4 =
5 = completely ethical
Q3. How confident are you that you made the right decision?
1= Not at all confident
2
3= Somewhat confident
4
5= Extremely confident
Q4. How complex was the scenario (and thus the decision) in the vignette?
1= Not at all complex
2
3= Somewhat complex
4
5= Extremely complex
How important was each of the following factors in making your decision?
Q5. Time point in therapy
1= Not at all important
2
91


3= Somewhat important
4
5= Extremely important
Q6. Diagnosis of the client
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
Q7. Cultural background of the client
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
Q8. Gender of the client
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
Q9. Monetary value of the gift
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
Q10. Level of intimacy in the gift
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
92


Q11. Clients reason for giving the gift
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
Q12. Potential for hidden meaning behind the gift
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
Q13. Potential harm to the client in accepting the gift
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
Q14. Potential harm to the client in rejecting the gift
1= Not at all important
2
3- Somewhat important
4
5= Extremely important
Q15. Potential benefit to the client in accepting the gift
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
Q16. Potential benefit to the client in rejecting the gift
1= Not at all important
2
3= Somewhat important
93


4
5= Extremely important
Q17. Attractiveness of the gift
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
Q18. Type of gift
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
Q19. Potential for the gift, if accepted, to blur boundaries
1 = Not at all important
2
3= Somewhat important
4
5= Extremely important
Q20. What ONE piece of information would have needed to be different (and
specifically how) to change your decision (from accept to reject, or reject to accept
the gift)?
Q21. Have clients ever offered you gifts in your own practice?
1= Yes
2= No
94


Q22. Have you ever accepted a gift from a client?
1= Yes
2= No
3= na
IF you have been offered gifts from clients in the past, please rate how important each
of these factors typically has been when trying to decide whether or not to accept the
gift. If you have not accepted gifts from clients please answer na.
Q23. Time point in therapy
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
6=na
Q24. Diagnosis of the client
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
6=na
Q25. Cultural background of the client
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
6=na
Q26. Gender of the client
1= Not at all important
2
3= Somewhat important
4
95


5= Extremely important
Q27. Monetary value of the gift
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
6=na
Q28. Level of intimacy in the gift
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
6=na
Q29. Client's reason for giving the gift
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
6=na
Q30. Impact the gift will have on the therapeutic relationship
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
6=na
Q31. Potential for hidden meaning behind the gift
1= Not at all important
2
3= Somewhat important
4
96


5= Extremely important
6=na
Q32. Potential harm to the client in accepting the gift.
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
Q33. Potential harm to the client in rejecting the gift.
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
Q34. Potential benefit to the client in accepting the gift.
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
Q35. Potential benefit to the client in rejecting the gift.
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
Q36. Whether or not the gift was attractive to you.
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
6=na
97


Q37. Type of gift
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
6=na
Q38. Potential for the gift, if accepted, to blur boundaries
1= Not at all important
2
3= Somewhat important
4
5= Extremely important
6=na
For the final part of the survey please provide the following demographic
information:
Q39. Year of Birth (four digits)____________________________________________
Q40. Gender
1 =Male
2=Female
Q41. Race/Ethnicity (please select one)
1= White/Caucasian
2= Hispanic/Latino
3= Black/African American
4= Asian/Pacific Islander
5= Native American
_______6= Other/Multiracial, Please Specify
Q42. In what year did you receive your psychology license?
98


Q43. Primary practice setting
1= Outpatient Solo (practice with no other therapists)
2= Outpatient Clinic
3= Outpatient Group Therapy
4= Inpatient Individual and/or Group Therapy
________5=Other, Please Specify__________________________________
Q44. Population primarily seen in treatment
1 = Children
2= Adults
3= Both about equally
Q45. Sex of primary population seen in treatment
l=Male
2=Female
3= Both about equally
Q46. Theoretical Orientation____________________
99