On Advice-Giving in Psychotherapy

"After all, analysis does not set out to make pathological reactions impossible, but to give the patient's ego freedom to decide one way or the other." – Freud, The Ego and The Id (1923)

A young woman presented to me for psychotherapy with the chief complaint of problems with her on-again, off-again boyfriend of three years. Our initial exchange went something like this:

Patient: My last therapist told me that he was no good for me and that I could do so much better. I agreed with her sometimes, but not at other times. She wanted me to leave him. It was a power struggle. That's when I knew I had to find a new therapist.

Me: It seems like your opinion of your boyfriend vacillates between two extremes: at times you really love him, and, at other times, you hate him.

Patient: Yes, exactly. And it's not the first time this has happened with a boyfriend. I've felt like this in pretty much all of my relationships.

Me: Has anyone ever tried to help you explore what might be going on with this type of relational pattern? To try to help you understand what might be happening "beneath the surface"?

Patient: No, but that's what I thought therapy was about. Most therapists I've had have just wanted to give me pep talks and tell me what I should do.

Unfortunately, this wasn't the first time I've had this type of interaction. In fact, it's a pretty frequent occurrence.

What is the appropriate role of the therapist in the psychotherapy arrangement? Does the therapist serve as a guide to self-understanding and introspection, an interpreter of communication, or, alternatively, a type of professional advice-giver, a "coach" or teacher who directly instructs the patient to change their behavior? The answer ultimately hinges on the question of freedom in psychotherapy.

Discussions of personal freedom and autonomy are generally limited to writings in the areas of philosophy, political science, and economics. With some notable exceptions (see, for example, Langs, 1973; Szasz, 1965), few psychotherapists have directly addressed these issues as they relate to the psychotherapy frame. Yet, Freud and many of the pioneering psychotherapists considered personal freedom to be a guiding principle—in fact, the ultimate goal—of psychotherapy.

With the advent and widespread popularity of the alphabet soup therapies (CBT, DBT, ACT, MBCT, etc.), many therapists now knowingly employ strategies that limit the patient's autonomy in the service of treatment. It is standard practice in cognitive behavioral therapy, for instance, to directly instruct the patient to think or behave in different ways. The therapist in a cognitive therapy arrangement serves as a teacher, pointing out "errors" in patients' thinking and encouraging them, in a more-or-less straightforward way, to adopt different perspectives or modes of behaving.

It is this type of direction in the treatment that I have argued most clearly delineates, on a philosophical level, the superficial, symptom-focused therapies from meaningful, insight-oriented psychotherapy (see Ruffalo, 2019).

The psychotherapy couch.

Source: Public domain

Some therapists now unashamedly admit that they routinely give advice to their patients on all sorts of matters—family relationships, career decisions, whether to divorce or stay married, etc. Many advertise themselves as professional "coaches," seeing their role as similar to that of a pitching coach teaching a baseball player how to throw a curveball. This type of advice-giving has historically been eschewed by those of us practicing traditional psychotherapy; to me, it seems to be anything but psychotherapy.

Why did Freud and the later psychoanalysts place such an emphasis on the freedom of the patient? I find it to be no surprise that the mid-century American analysts, many of whom fled the threat of Nazism and authoritarianism in Europe, found themselves oriented towards a therapeutic approach emphasizing freedom, self-determination, and personal autonomy. Freud, who himself later escaped the Nazis for England, wrote that the therapist must "leave untouched … the patient's personal freedom" and should not "hinder the patient from carrying out unimportant intentions, even if they are foolish" (Freud, 1914).

Robert Langs, a psychiatrist-psychoanalyst who wrote extensively on the concept of the psychotherapeutic frame, echoed a similar sentiment in his classic book The Technique of Psychoanalytic Psychotherapy:

I wish here to underscore a fundamental therapeutic principle: many incorrect "supportive" interventions (and many other technical errors) arise out of a particularly unfortunate therapeutic stance that is characterized by a need to infantilize the patient and, especially, by a failure to believe in his own integrative capacities. (Langs, 1973, p. 555)

Of course, many patients come to therapy with specific life concerns and may ask for direct guidance or advice. When a patient asks for advice, a therapeutic response is to explore why the patient feels inadequate in making the decision themselves, and then to explore the goals of the patient and the options they have to extricate themselves from their predicament, within the context of the patient's broader psychology. It is not to give direct advice, which is antithetical to psychotherapy.

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A therapist who routinely provides advice to patients may do so for their own personal reasons, which could include a need to feel powerful or in control, or to mitigate their own anxieties. The result of advice-giving is the infantilization of the patient, reflective of the belief that the patient is defective, inadequate, and incapable of acting as their own person. It deprives the patient of the exact thing psychotherapy should aim to provide: autonomy.

The psychotherapy patient can often find advice anywhere he turns: family, friends, the Internet, self-help books, gurus, coaches, ministers, etc. Though he may ask for advice, he does not come to psychotherapy for it. He comes for understanding, exploration, and knowledge of himself. These are the aims of any ethical, meaningful psychotherapy.