Wednesday, January 28, 2015

Do Therapists Give Advice?

A couple of years ago, I and some other therapists were debating whether or not we should give advice to patients. Traditionally, advice-giving has been frowned upon in the field of psychotherapy. Psychotherapy is supposed to be a treatment process to help people to grow emotionally--to understand themselves, to become aware of unconscious thoughts or suppressed emotions, to build a sense of self and to increase mastery over both feelings and behaviors. The giving of advice was seen as potentially undermining the patient's autonomy and sense of self. The reason I and the other therapists were pondering this tradition was because many of us were working with young adult patients who did not seem to have anyone in their lives from whom to ask for advice. Ultimately we reached a consensus that we often had to give advice, because no one else was advising our patients, who often were in the position of having to make important life decisions. 

There are many pitfalls in giving advice, the most obvious one being that you could be wrong. When I give advice to patients I usually start by saying "in my experience." I also advise people to seek out advice from other professionals, such as attorneys or accountants, if they need legal or financial counseling that I'm not qualified to give.

Sometimes patients ask me bluntly what they should "do." In most circumstances, I don't tell people what to do. It's important to learn how to make decisions. Usually, I just help people evaluate their choices and offer what information and insight into their situations that I might have.

It's easier to be a therapist who never gives an opinion, because this means fewer opportunities for disagreement with a patient. Sometimes patients will drop out of therapy if the therapist doesn't nod in agreement with all of their decisions. In my opinion, it is better to risk losing some patients than to allow someone to leave my office on the verge of making a bad, perhaps life-altering decision, without hearing some information that might suggest they give the decision more thought. Here is an example of such a situation:

A young woman who was seeing me for problems with anxiety mentioned to me that she was planning on entering the same type of graduate program I had completed 20 years earlier. She told me she planned to take out $40,000 in loans for this program. I informed her that her starting salary would probably be $40,000 and since she already was paying loans for her undergraduate degree, the total would be quite a lot of money for someone making a fairly low salary. The patient looked at me quizzically and told me that the financial aid office had told her it was ok to take out loans up to one's expected annual salary. It hadn't occurred to the patient that the financial aid office had a vested interest in getting people to enroll in the university and pay however they could. (I find many patients, and people in general, do not evaluate the sources of the information they receive and their possible bias). The cost of the type of graduate program I attended is approximately four times what it was when I was a student, and entry level salaries haven't even doubled. I suggested to the patient she think about a different degree that would allow her to make more money in the short term but also allow her to pursue a career in the mental health field. The patient never came back for another session. Did she drop out of therapy because I suggested her plan wasn't the best idea? It really doesn't matter, because I could not in good conscience allow a young person to leave my office thinking a lifetime of debt for a degree that isn't worth what it used to be was a good idea.

When I work with patients who are a little bit older--in their 30s and 40s--I not uncommonly find that their lives have been severely disrupted by bad choices. I often wonder if they discussed their choices at the time with anyone and what that person or people said. Sometimes I ask this question. Here are a few of the disastrous situations I have encountered. I found myself thinking, in each of these cases, that I wished I had seen the person earlier in life and given them some advice:

1. A middle-aged woman came to me with  complaints of dissatisfaction and irritability. She had a job she didn't like and some family and marital conflict. When I explored her history, I discovered she had made a couple of fatal career decisions some years previously--decisions to turn down great job offers. She turned down the job offers for the sake of a relationship with a man. Then she discovered marriage isn't a  solution to life's problems. If I had been the woman's therapist earlier in her life, I would have advised her to think of the long-term consequences of giving up what might be one-time career opportunities.  I might have also asked her to ponder why her boyfriend would want his future wife to derail her career in order to be in closer proximity to him and what this might indicate for their future relationship.

2. A man who was seeing me lost his $300,000 a year job and was forced to live off of unemployment compensation and savings. He had acquired student loans in the sum of six figures. I discovered that he didn't really like his career and only entered it for the money. Unfortunately, most people who enter careers only for the money aren't very successful in those careers. If I had been his therapist years earlier, I would have encouraged him to do something he liked and to choose a university and/or graduate program he could afford.

3. A woman who worked in a prestigious field complained of constant anxiety. She was wracked with anxiety because her job involved making life-or-death decisions and she did not have a decisive personality. I found out she had accrued more than $100,000 in student loans and it wasn't feasible for her to switch careers because her job was one of the few that would allow her to pay off these loans. In addition, she was no longer young. If I had been her therapist years earlier, I would have helped her explore whether her personality and talents fit the career she thought she wanted. I strongly believed she chose her career  because it seemed prestigious, not because she really wanted to do it. Her family may have played a role in her decision to choose this ill-fitting career.

My experience with patients has taught me that helping patients explore life choices can be an important part of therapy. Sometimes it may be necessary to give advice, in one form or another.