On Giving Advice

One of my favorite moments in a therapy session is when a patient asks me, “What should I do about this situation?” It almost always makes me smile. If I’ve worked with the patient for a long time, I might ask, “What in the history of our relationship makes you think that I’m going to give you the answer you want?” If they are a new patient I might simply say, “Well I don’t really like to give advice like that.”

 

It’s a natural request on the patient’s part. The cultural impression of psychotherapists is often one that depicts us as guides or coaches, and that is very often reinforced by therapists who find it easier to work in this way. And patients often look up to their therapists- it’s only natural to ask those we look up to for advice. It’s important to acknowledge the significance of the request in the first place- someone is making themselves vulnerable to their therapist.

 

 
And on the other hand, if the advice is authentic and organic, it may come out. If a patient who I know well tells me he is thinking about getting a face tattoo the night before a job interview, I might say “Don’t get a face tattoo!” I guess that could very well be construed as advice.

 

 
But really what this all comes down to is the question of what purpose is the therapist there to serve. If our therapists won’t tell us how to run our lives then why the hell are we paying them?

 

 
Well there are certainly therapists out there you can pay to tell you how to do all sorts of things, and many of them are caring and compassionate as they help guide you. I tend to live in the territory of non-authoritarianism.  What does this mean? It means I’m not an authority on your life. I can really only speak authoritatively on my own experience, and sometimes that includes my experience of you, but it’s still my experience. The minute we begin to speak authoritatively about someone else’s experience, we cease to live authentically.

 

And yet, you naturally want to work with a therapist who practices their job with authority- who is knowledgeable, trained well, competent. And so the phrase we use to describe when a therapist authoritatively practices therapy in a competent way without exercising authority over their patient is “symmetrical asymmetry.” The relationship is symmetrical in that there are two subjective personalities who are autonomous and self-advocates. And the relationship is asymmetrical in that these two subjective personalities have different skills, experiences and realms of authoritative knowledge. The therapist may be able to steer the therapy process, but cannot steer you.

 

So, no advice, no guidance, no life coaching? We still haven’t answered the question- Then why go to therapy? There are thousands of valid answers to and opinions on this question but one might be this- to form a healing relationship with someone who won’t tell you how to run your life. We get advice and guidance and suggestions from people all day, every day. In our culture, every one has an opinion about what we should be doing. Try getting sick- every person in your life will have an answer for what treatment you should take part in. Maybe it’s important to have a relationship with someone who is trained in identifying their own agenda for you and putting it aside. Someone who can be supportive of you and what you want for your life, without needing you to do what they want you to do.

 

These are ideals, of course, and at the end of the day, both of us are human. Having an agenda for those we care about is human. Tell me you are getting a face tattoo the night before a job interview and you’ll see what I mean.
 
 

 

On familiarity

A client recently told me "I'm in danger of having two good weeks in a row." I quote this (with his permission) because it says so much to me about the weirdness of therapy and our ambivalence about making things better. If you are my client, you've heard me say that even good changes can feel odd. In past work with client's who feel terminally unlucky in relationships, I've often seen this as depression sets in as soon as they find a partner. Addicts speak about the "comfort of discomfort." All of this is because doing something new is scary for us. We have a hard time reconciling the fact that we would prefer to keep doing the same stuff and thinking the same ways even when we feel unsatisfied. And accepting goodness feels too different, or dangerous. It requires openness- our own openness to the possibility of life being different than it has been in the past. Therapy can help with this, in the same way that physical therapy can help open up our muscles. But it's not always easy to take that step and I'm always impressed when someone reaches out for help in order to find something new that is good but dangerous.

On Evidenced Based Therapy

Ever since I have been doing this work, there has been a preference in the mental health field, as well as in our culture, for therapy practices that are based in what can broadly be called “evidence based techniques.”

What does this mean? It sounds like an obvious choice. If you were to choose a doctor who admittedly practiced medical techniques that were not based in evidence, your loved ones might certainly hold an intervention. You probably definitely want a therapist who is practicing a kind of therapy that has been proven to work.

And that is the real purpose for this term- to indicate a focus on results. Evidence based techniques have been empirically proven in countless peer-reviewed studies to deliver results, and in a timely manner. An example of these techniques might be Cognitive Behavioral Therapy (CBT), which is sort of the gold standard of evidence based therapeutic techniques. Another one, particularly popular in Seattle due to its origins here, is Dialectical Behavioral Therapy (DBT), which has been proven to be one of the most effective therapies for those struggling with Borderline Personality Disorder among other mental health issues.

Insurance companies and mental health clincis love evidence based techniques because they provide measurable results. It only makes sense right? When you are paying for someone to go to therapy, you’d like to know they are making progress and eventually going to finish treatment. And since there are only two people allowed in the treatment room, it would be nice for them to have some sort of indication that actual therapy is happening and progress is being made. Evidence based techniques supposedly provide that reassurance.

But there is still a problem with designating these techniques as evidence based and leaving other techniques out, and that is the relational factors in any treatment duo. In fact, Relational, or Interpersonal Therapy might be the epitome of what kind of therapy we are not talking about when we talk about evidence based techniques.

What is Relational or Interpersonal therapy? The late interpersonal therapist, Stephen A. Mitchell said that it was therapy with the central principle that “the relationship is curative.” There are a thousand explanations for what this therapy includes but simply put, it is therapy practiced from the perspective that the relationship itself is healing, not the technique.  

But this might include all kinds of different techniques. This is often why relational therapists call themselves “psychodynamic.” It isn’t that they don’t understand CBT or DBT or so-called evidence based techniques, it’s that they understand that the relationship is more important than the technique.

But what about research? Is there no scientific accountability for those practicing relational therapy? Well this is yet another problem with labeling certain techniques as evidence based. There is research about Relational Therapy. In fact, Relational Therapy along with Cognitive Behavioral Therapy have similar test results when used to treat depression. So it has been scientifically indicated to be successful.

But it’s hard to study relational therapy because it’s hard to measure a relationship. Conversely, the “evidence” that supports those other techniques is difficult to measure apart from the relationship. For example, your therapist may be a cognitive behavioral therapist, but you still have a relationship with them, and that relationship is incredibly significant in your treatment.  If it wasn’t, cognitive therapy would just consist of handing a workbook to a client and telling them to work through the chapters on their own.  So when our data indicates that Cognitive Behavioral Therapy works, it’s not so easy to say that the technique worked apart from the relationship. And until we have robots that practice therapy, it will be difficult to say.

So what does that mean for how we should choose our therapists? Well, it means that we should probably pick someone who fits, based on their personality and how we connect with them, not based on what proven techniques they use. And for some people, they will fit better with a Cognitive Behavioral therapist. The therapy will focus more on goals and modifying behaviors, but the relationship will still be important. Some people will fit better with a Relational/Interpersonal therapist. The therapy will focus more on relational patterns and understanding the Self, but there will still be important goals.

In the end, the hope is transformation. And whether or not that transformation is through hard goal-oriented step work, or whether or not it is through abstract relational analysis and dialogue, transformation, and the contexts that it takes place in, are beyond immeasurable.