Thursday, November 19, 2009

What Should I Do?


A reader asks if we give advice. I hope it's okay if I copy and paste the question from the comment section of another post, I'll leave the commenter's handle out:

I went to a psychologist 7 or 8 years ago and all she did was tell me what I should do. “Go there, do this, etc.” She didn’t listen to me at all. If she had, she would have known that the things she was telling me to do were things that I would never ever do. I quit after 2 or 3 sessions. I decided to try therapy again about a year and a half ago and my psychiatrist is the complete opposite. She has never given me a single word of advice and even when I directly ask her opinion, she will only occasionally give me a straight answer. I appreciate the fact that she isn’t trying to force off-the-wall ideas on me, but sometimes I wish she’d put in her 2 cents. Where do you guys stand on this? I’m just curious as to what’s the “norm” since my 2 experiences have been so drastically different. Thanks.

Traditionally psychotherapists don't give advice--- perhaps this differentiates "therapy" from "counseling" which does imply that one person knows what's best. Psychodynamic psychotherapy is about delving and understanding unconscious conflicts, and it's done by looking at the process of the material a patient brings to the session. Rather than go for the superficial and concrete, perhaps there is something to be gained in understanding why a patient wants the therapist to give them advice. It's about understanding the mechanisms that guide the patient, not the specifics.

So I'm not an analyst, I'm particularly quiet, I tend to say what I think, and I'm a physician who treats conditions that I believe have some biological input. To some extent, I have to give advice: Take this medicine at this time. Don't take that medicine with this one, it'll kill you. Don't drink alcohol when you're taking Xanax, that'll kill you, too. I believe that when someone is suffering from a problem in a way that up-ends them, they should make it their job to do what they have to get well. What helps depression: medicine, exercise, sleeping enough, not sleeping too much, structure, being empowered. There was a study recently that suggested a link between Mediterranean diets and lower rates of depression--- so I tell people to eat hummus (if they like it!). I even suggest a brand because I've personally taste tested them all and have a strong preference. (Is it awful to admit this?)
Do I give advice otherwise? Yeah, sure. Sometimes I tell people who need more structure that they should get a dog. Dogs are good--- ya gotta get up and walk them, they're interactive, they're entertaining, you have to feed them, they pull people outside of themselves just a little, and they are object of passion-- passion, I think, is good.

What have I discovered? People come to their appointments, mostly. They take their medicines, mostly. No one really does much more of what I suggest. No one has bought a dog because I've told them to. And people who don't want to exercise rarely do so because a psychiatrist tells them the research says this will help. I'll let you know how it goes with the hummus. I don't think Freud would have liked me.

So I tell my patients what to do sometimes. The more salient question would be: Do you tell Roy what to do?

25 comments:

Aqua said...

I completely agree with the "get a dog" advice. Getting a dog has literally saved my life. There have been times where I wanted to commit suicide and was ready to do it...and then I look at my beautiful boxer, and I think...he depends on me to take care olf him, what will happen to him if I die? What if no one finds me and he starves to death because I killed myself.
On top of saving my life he forces me out of the house for a walk, rain or shine, 3-4 times a day, cuddles me anytime I want, and is a general source of love and amusement every (well maybe...most) moment I am with him.

Dogs are a huge responsibility though and before adopting one people need to understand that it can be hard to find housing with a dog...many place do not allow dogs as tenants, It takes TONS of patience, time, and effort to train a new puppy...and sometimes it is hard to plan your other activities around taking care of your dog. Also, if you have a big dog food costs are pretty high.

I do not want to discourage anyone from getting a dog, because they truly are a joy to be with, but I think people need to very carefully considered their lifestyle and there ability to care for another being like a dog...That goes for anyone considering a dog, whether they have a mental illness or not.

Personally...it is worth it to me. I love my dog so much and his impact on my metal health has been 99.9% positive.
...aqua

The Girl said...

Telling people who have never tried hummus before which brand they should first try is really sensible - if they tried a brand that was awful and hated it, they would not try it again. Wise. ;)

I think I would be like you when I practice. Neither one extreme or the other, but the best of both worlds.

onelongjourney said...

So what brand of hummus do you recommend? I've tried a lot also :)

Interesting post - I sometimes counter with my T "I know you want to know WHY I am asking this question, but what I really want is an answer." :) Sometimes she gives one, sometimes not.

OLJ

Dinah said...

Aqua: No one has ever gotten a dog because I've suggested it (it's been a couple of times...) Maybe if you were the therapist, they would. Thanks for the confirmation. Passion remains a good thing.

OLJ: Why do you want to know? What is your favorite brand? Can your share your childhood hummus memories?

I will eventually endorse a brand--I'm waiting for everyone else to chime in. I'd also like the company to sponsor us. We often eat it at Podcasts. (yes, they are coming back, think spring or summer when the book manuscript is done.

jessa said...

As a patient, I really wasn't very good at therapy. That might sound kind of silly -- how can someone be bad at therapy? -- but therapy does require that you talk, and I didn't. (Incidentally, I can't have been the only person who has ever been in therapy who had really bad social anxiety, who was afraid to talk about the things therapy requires me to talk about.) I don't know if the therapists I had would have given so much advice if I had talked more, but I do know that they talked more than usual with me because I talked so little. (Seriously, when I started therapy at 17, for months I would go through entire hour-long sessions saying maybe a half-dozen words. My first therapist tried sometimes to force me to talk by staying silent himself, but even his greeting was more words than I would say in the whole hour, and this never got me to talk.) I got a lot of really bad advice. This was probably partially because I got so much advice, some of it was bound to be bad, and partially because I spoke so little, they didn't have enough information to give me good advice. (Also, about half of the words that came out of my mouth at this time were lies. Not that I intended to lie, but I was scared and would answer the question before I had enough time to think about it properly. And I didn't correct the lies, because that would have required speaking far too much, and explaining what had happened, which was just more than I could have managed.) Even when I did talk more in therapy, I was still often told that most patients talk more.

tracy said...

"Sabra"!!! Not only does it have a wonderful name, but it is the most deliciouis hummus out there, especially the pinenut and sweet red pepper varities. Yum! It is a bit more expensive than the others (and we are on a budget!) , but very, very worth it!

hee verification: banter

Lu said...

I recommend Cedar's hummus. I eat it all the time. It's the least grainy and the least garlicky of the ones I've tried.

Anonymous said...

There is advice and there is advice. Had a therapist for awhile who was telling me how to live my life. I didn't ask for or want the advice but I got her opinion on what to do about every major decision in my life. It had no relationship to my own ideas and it was more a statement of her need to control me. I stopped seeing her, against her advice.
My current doctor also gives advice but usually only when I ask and it is clear that she has considered who I am, meaning what she thinks might work for me is not always what she would choose to do. There is a big emphasis on the fact that this is her suggestion but that I should consider if it seems right for me. I like that kind of advice. Some I take and some I don't but even if I take it is always my decision, and I never get the sense she is offended or disappointed if I don't.

Anonymous said...

I agree about the dog too. I can't imagine that I'd have survived this long without her. She's been the most consistent thing in my life over the past six years.
I spoke to somebody whose psychiatrist had recommended that they leave home and get a cat. It wasn't feasible because they probably wouldn't be able to afford their own place at all, let alone one that would allow a cat. I suggested a ferret, which can act a bit like a cross between a cat and a dog, but might be considered by most landlords to be closer to a "small caged animal" even though a cage for a ferret is generally optional. I'll let ya know if I hear any more on that..

I LOVE hummus, and though I think I've bought it a few times, no specific brands stick out in my mind; I usually make it myself. It doesn't even require cooking, why spend so much on a container of "gourmet" hummus when you can make your own exactly as you like it?

Anonymous said...

therapists who give no advice can make the patient think that no one has any advice for their psychiatric problems

Rach said...

Sabra is the best Hummus (it may be canadian though... not sure). Tastes the closest to what you'd get in Israel.

When I ask "what should I do", my shrink usually helps me look at the other side(s) of the problem. Reframing, if you will. Drives me crazy. But usually helpful.

Battle Weary said...

Hey...I started exercising when my pdoc advised it! Okay, okay, I'm not YOUR patient! And my pdoc advised exercise after my GP and psychologist both already had...and after my cousin challenged me to train for a marathon with her. The hummus though...not sure I could follow that advise! Any idea what the carb content is in hummus? That's a serious question...I'm diabetic. :P

onelongjourney said...

HA! No childhood hummus memories. I like Tribe (I think that is it) the extra lemon variety. Also like Sabra and homemade.

Do share.....

Dinah said...

Battle Weary:
Hi protein, high fat, low carbs (?4g/serving?)...eat it with strips of green pepper for the lowest carb content. Otherwise carrots or wheat pita. It's garbanzo beans (chick peas), and tahini (sesame paste) with garlic and olive oil. This stuff just can't be bad for your mood.

A friend in high school used to call me "ferret face," never my favorite animal, and a neighbor's kid used to stick one on a skateboard and send it on journeys...

Anonymous said...

Homemade humus is the only way to go.

That being said, I understand my pdoc's reluctance to give advice, and I appreciate it. She's not taking away my power to live my life as I see fit. I've had pdocs/t's in the past who have, and it always ended badly.

I also think that too much advice-giving leads to dependence on the therapist. I need to feel capable of making decisions. I need to be empowered.

Anony-me

Anonymous said...

i still want a dog.

Sunny CA said...

My psychiatrist rarely gives lifestyle advice and I rarely ask for it. Sometimes he builds a set of questions that when taken as a whole look like a case of him "leading the witness". He lets his opinions leak in the way he phrases questions.

He has recommended specific books, movies, music, and theater events because he thinks they will elevate my mood, and other times because they shed light on something we've discussed and other times just because he likes them. I follow up on 100% of his recommendations on books, theater, etc. (Just today he recommended 1 DVD and 1 book, though I recommended a movie to him today as well). I exercise more and eat better than most of his patients so don't know if he'd have advised those things for a typical patient. My nearly-ex-husband was advised to run by his psychiatrist and he ran for the next 10 years as a result and he still hikes daily 30 years later, so I don't think that non-compliance is always the rule.

Dinah said...

Sunny CA: Wait, giving movie/book recommendations is kind of akin to telling someone what to do.

Hummus: I like Sabra best. I stopped making homemade when I discovered it because it's great. And yesterday it was on sale, 2 for the price of 1. I do have some tahini in the refrigerator now, so I'm going to make a comparison batch soon...it's been a while.
Think I like classic best, but for a while there, I was going with roasted red pepper. Really good stuff.

Rach said...

I find tahini goes rancid very quickly. I always open a can of it and ALWAYS throw it out :(

Battle Weary said...

Okay...sounds like hummus is worth a try. Might even be easy to carry with me to school. Food options on campus really suck...I can have salad for lunch...or I could have salad...or maybe salad. Gets rather boring. A am often questioned on why I "always eat rabbit food". Better than ferret face I suppose, but ferrets are actually pretty cute!

Anonymous said...

I did follow my therapists's advice about a accepting a job, but now I think it was the wrong advice. And I want to ball her out for it but I'm too scared to. What happened was that I was unemployed for 1 long year and then I was offered a 25-hour-per-week position which I took. 8 days later, I was offered a full-time position across the street (I interviewed for the two positions 2days apart, but the second employer was slow to get back to me). I told the folks offering me the full-time work "Thanks but no thanks--I'm working."

That evening, I had an appt. with the therapist. She tells me that I must call the full-time job offer people back at once and accept. That is so not like me, though. I don't renege on promises or leave employers in the lurch. But then my spouse and a trusted colleague all mirror the therapist's advice, so I quit, give notice, and swap one job for another. It was extremely stressful stepping on peoples' toes and looking indecisive--calling up an employer and saying, "I know I just turned you down, but can you offer it to me again today?" It was foolish.

After a couple of months, it became clear to me that the part-time position would've grown into more hours and the type of work was going to be a perfect match for me. The job I did accept is very stiflng without room for growth, whereas the first gig would've had great growth potential.

I feel like telling this therapist she was dead wrong and she ruined my life--but I can't because two other people who had no qualms about running my life for me gave the exact same advice as she. Only they were all mistaken and my gut instinct on how to handle things was RIGHT.

I wish she had just told me to do what I thought was right for me.

Roy said...

I agree. Sabra. A fellow psychiatrist during residency, David Rosenberg, used to make his own hummus when we went over his apt to play poker. I don't know the recipe but that was the best hummus I've ever had.

And I'm in the middle with the advice-giving. I don't know that I "give advice" so much as I help explore the options and guide away from the danger areas. Kind of a sherpa.

Dinah said...

Roy: here was your opportunity to complain about how I tell you what to do! You missed it!

And no matter how much you confine yourself to the Sherpa role, it's really hard to keep quiet when someone tells you they are going to do something really self-destructive.

To Battle Weary: let us know how it goes on the hummus front. My kid says the school cafeteria sells snack sized sabra hummus with pretzel chips.

Anon: The specific "do this" choice on options is hard...since no one actually does what I say (...something about me must be particularly non-threatening, no one does what I say and no one seems at all concerned about telling me how they haven't done what I've suggested)....I don't worry so much about giving bad advice, but I don't want to be responsible for peoples' regrets. I think it's beyond the usual therapy bounds to tell a person to quit a specific job and take another. Hindsight is worth a lot. Too bad we don't have more of it before we make decisions...

Overall, it's hard to have an exact answer for this that is right for every person in every situation. Like most of our Shrink Rap discussions...It depends on the patient, the therapist, and the specifics of the situation.

Ferrets are cute? I guess in a rodent-y sort of way.

lea said...

I've recently switched from sabra to sonny and joe's hummus. it was a total accident - my store put the sonny and joe's where the sabra had always been, and the containers are similarly shaped and colored. I have to tell you, the sonny and joe's brand is even better then sabra's! (coming from one who's lived in israel for many years). i especially recommend (in both brands) the "galillee humus" (aka humus with olives).

Battle Weary said...

Ferrets aren't rodents...they diverge at the order level. Order: carnivora, family: mustelidae. They are related to mink, otters, badgers, wolverines, and skunk. But if you don't like them, you don't...where they fall in classification doesn't change that! lol