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?