Beyond Boundaries and Slippery Slopes: A Case for the Therapeutic Benefits of Gift-Giving in Psychotherapy

Clients with chronic and severe psychiatric illnesses, such as schizophrenia, often present with significant challenges in psychotherapy, particularly in establishing a stable therapeutic alliance. This paper details a novice therapist's experience and initial challenges in establishing a bond with a client diagnosed with chronic schizophrenia. After initial efforts and 12 months of fluctuating client engagement, the treatment team recognized the need for a stronger alliance. Unconventional methods, including the strategic use of ethical gift-giving, were explored to foster the alliance with the client, which eventually led to improved client engagement and therapeutic results. The paper critically reviews the existing literature on the ethics of gifting in psychotherapy, highlighting the scarcity of research on the therapeutic use of gifts and the predominant cautionary stance in ethical codes with respect to gifting. We argue for the potential benefits of, and a proposed framework for, ethical gifting when properly executed, particularly for clients in the concrete operational stages of cognition and impaired social and interpersonal functioning. The framework underscores factors such as formulation, cultural context, and therapeutic motive, emphasizing the importance of supervision and consultation. Insights from the trainee therapist's reflections shed light on the process, revealing initial reservations followed by gradual acceptance and professional development as a reflective therapist. These reflections underscore the significance of incorporating reflective practice in psychotherapy, especially when navigating challenges and dilemmas. We advocate further empirical research on the role and implications of gifting in psychotherapy.