Should a Therapist Give Advice?

Most therapists avoid giving advice — most of the time. Even so, it is hard not to. Perhaps impossible, unless you are a 100% non-directive or psychoanalytic counselor.

Here is an example of the difficulty. When a profoundly depressed patient comes to you, you would be remiss not to suggest antidepressant medication. Not demand, but suggest.

Or, let’s say he consulted you for your expertise in cognitive-behavioral therapy (CBT). You’d then evaluate him and work out a CBT treatment plan. A workbook of your choice might supplement your sessions together. This and the other details of the program are directive. They are advisory, even if not so stated.

The very “brand” of therapy you choose preempts the patient’s choice of treatment possibilities. Most people come to the first session without a flavor in mind. No practitioner could review all the strawberry, vanilla, and mango varieties for the new arrival. How do you describe a taste to someone who has never tasted? Such an education, taking as long as a semester of university classroom study, would still be inadequate. In actual practice, the shrink might instead discuss a few possible prescriptive approaches, but since the client is probably a therapy novice, he’d rely on the professional to suggest — advice again — which is best.

True, therapists usually don’t go so far as to say, “You must” or “You mustn’t” do that, unless facing a life or death issue. Even then, the phrasing would differ.

Once the goals and treatment approach are determined, therapy proceeds in something like the following way. The Therapist and Patient here are engaging in a Socratic dialogue within a session of cognitive-behavioral therapy:

P: I’m too scared to go to the party.

T: What will be the cost to you if you don’t?

P: I’ll be lonely, but at least I won’t get ignored or rejected.

T: Why do you think you won’t fit in?

P: Because that’s what always happens.

T: On every occasion? Can you remember any time it didn’t happen?

P: Yeah. One birthday celebration, someone came up to me and said he liked my hat. He asked me questions and we discovered we enjoyed the same music.

T: So, is it possible you wouldn’t be rejected or ignored?

P: Yes, but a long shot, for sure.

T: What do you think you’ll need to learn in order to make success more likely?

The conversation (much simplified above) would go on for a while, but a couple things have already been accomplished:

• The patient has moved from his avoidance of social contact to the more hopeful project of learning something new.
• Catastrophization has stopped (at least temporarily). P is thinking in a more nuanced fashion, admitting a small possibility of a good result.

What if, however, P gets stuck? Assume everything has been tried to reduce anxiety, yet the next step remains daunting. Say, he wishes to go on a date or a trip alone, but can’t budge. It now becomes hard for the therapist to refrain from encouraging the person to take a big risk.

Yet some guidance shouldn’t be offered by the therapist. Moreover, if offered, the patient should hesitate. Sometimes the advice of financial, legal, and career consultants, as well as therapists and friends, is suspect. All have less at stake than their advisee. For example, an investment professional might profit more from the portfolio of stocks or bonds he is endorsing than those he doesn’t tout. Brokers offering retirement suggestions, in particular, are not usually required to disclose conflicts of interest.

Human communities require trust to function. We approach all sorts of service providers with assumptions, from auto mechanics to massage therapists. A minimal level of unspoken confidence in others must exist for everyday social intercourse and commerce. The default standard for dealing with these unfamiliar people causes us to accept, without thinking, that the relationship has been arranged for our satisfaction. As George Eliot wrote in Middlemarch, “we carry (our) fool’s cap (unaware)” of the danger of a naïve attitude. Yet, to be ever-vigilant and suspicious leads of a life of perpetual anxiety and misery, questioning everything.

The counselor or friend laying out a pattern of advice is also in a dangerous spot. In a certain sense, if you push an unhappy buddy or your patient to dump his significant other, you own the suggestion you passed along. Should he come to regret propelling his girlfriend out the door, you are to blame. Worse yet, were the man in distress to ignore this direction and then report his idea back to the lover, the confidant might find himself out the door.

From a therapist’s perspective, P best “own” his therapy, his decisions, and his life. T makes this harder when he becomes like a parent and infantilizes the patient. One mothering mother in any life is usually enough.

Where disclosures of conflicting interests are not required, P is on his own in the jungle. We assume our lawyers, insurance salesmen, and doctors are always putting our well-being first. One counterexample occurs if a physician prescribes medication for which he is being paid by the manufacturer (drug company) to lecture other medical professionals about its advantages. Yikes!

An old Depression-era vaudeville routine demonstrates the downside when an adviser (in this example, a lawyer) acts on your alleged behalf. The sketch appears in the 1945 movie, Ziegfeld Follies. The two-man show is darkly humorous and all too representative of the risk when those at a safe distance push us into a safari to parts unknown.

As this skit amusingly demonstrates, we must always be careful with whom we deposit one of our most precious possessions: our trust.

Take my advice (oops) and watch, Pay the Two Dollars:

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Pay the Two Dollars stars Victor Moore as the “little guy” and Edward Arnold as his lawyer.