Psychiatry and the Gift Conundrum
He is a good man who can receive a gift well.
--Ralph Waldo Emerson
It's December, and the "season of giving" has rolled around again. For the past 2 months, you have been seeing a 35-year-old, recently divorced, Russian-born woman with chronic dysthymia and low self-esteem in supportive psychotherapy. One afternoon, she ends her session by saying, "Doctor, I have something for you. I hope you'll like it. It's just a little token of how much I appreciate your help." She hands you a small package and then says, "Oh, please -- do open it now! It would mean so much to me." Somewhat ambivalently, you open the package and find a small tin of home-baked cookies. Do you accept this gift? If so, do you explore the "meaning" of the gift, from the patient's perspective? And if you don't accept it, what do you say to the patient?
Before discussing this vignette, let's consider another scenario. For the past 2 years, you have been conducting psychodynamically oriented (insight-oriented) psychotherapy with a 40-year-old US-born man, in whom you have diagnosed narcissistic personality disorder (NPD). During your last session, the patient became extremely angry when you suggested that he often seems envious of others. At the end of the current session, he says, "I just want you to know, I have no hard feelings about that ridiculous comment you made about me last week -- about how "envious" I can be! And I'm sorry for blowing my stack at you. I hope you'll accept this little peace offering." He then places a very expensive Rolex watch on your desk, unwrapped, and still in its display case. Do you accept it or reject it? Either way, do you examine what the gift means to the patient, in light of the last session?
Note that several factors of potential importance distinguish these vignettes: diagnosis; type of psychotherapy; timing of the gift in relation to external events; timing in relation to the therapy; probable motivation of the patient's action; the patient's ethnicity and culture; and, of course, the expensiveness of the gift. As I'll suggest, deciding what to do about a gift from a patient requires careful attention to these and other relevant factors.
Medscape Psychiatry © 2012 WebMD, LLC
Cite this: The Patient Gift Conundrum - Medscape - Dec 10, 2012.