Psychotherapeutic Advice? Think Twice

Guest Post by Stephanie Foster

Stephanie Foster is a Registered Psychologist in Calgary, Alberta. She is in private practice and has provided short and long-term psychotherapy in a variety of treatment settings.

---

Source

A man went to see a sculptor’s work. He liked an intricate piece and asked how much it was. “1000 dollars,” said the sculptor. The man looked around and eyed a large cube of marble, untouched. “How much is that one?” 
The sculptor replied, “10,000 dollars.”
The man was stunned. “Why is that one so much more?”
The sculptor answered, “You’re paying for my restraint.”¹

The free exchange of advice characterizes our social interactions. In friendly and familial conversations, we pass around advice like trading cards – what plumber to call, what outfit to wear, whether to give that relationship another shot. Parents tend to give unsolicited advice and in-laws probably require a cease and desist notice. The provision of advice is a staple of social conversation and therein lies the rub: Psychotherapy is not a social conversation. The application of a social frame to therapeutic interactions runs counter to the design of psychotherapy. As a rule of thumb, most things done readily in social settings should be questioned in therapeutic ones. Akin to the sculptor in the parable, the psychotherapist is characterized as much by what she does not do as by what she does (Gabbard, 1996). Psychotherapy must be distinguished from all other relationships; this is where psychotherapy begins.

The mental health disciplines are careful to draw a sharp distinction between professional and personal relationships; this is codified in our ethics (American Psychological Association, 2017) as well as in our theories. Psychotherapy literature has a long tradition of advocating for neutrality, which is defined as not taking sides in the patient’s conflicts (Schafer, 1983). This is not to be confused with aloofness or emotional coldness (Eagle, 2018); rather, neutrality “… originates in genuine respect for the patient’s individuality… Neutrality is the technical manifestation of respect for the essential otherness of the patient” (Poland, 1984).  For good reason, the extent to which a therapist can maintain neutrality remains the source of endless debate. It is impossible for the therapist to be emotionally unengaged, free of bias, and non-expressive (Poland, 1984; Jones, 2000).  Nevertheless, respect for the patient’s autonomy has long been considered a therapeutic ideal (Rogers, 1961).

The anecdotal evidence suggests that some are straying far from the ideal. In the recent book Bad Therapy (2024), journalist Abigail Shrier details several instances of departure from neutrality, ranging from therapists discouraging patients from marrying to promoting familial estrangement. I have heard countless stories of therapists filling therapy hours talking about their own lives, along with serving up personal opinions on topics such as a patient’s appearance and family planning. Whether or not advice-giving constitutes “bad therapy” is one question; I would take it a step further to ask if such behavior constitutes therapy at all. The goal of psychotherapy is to help patients to understand their own psychology and difficulties, in the service of changing something that has been hard to change. Therefore, it is difficult to see how the provision of wild advice and excessive personal disclosure by the therapist meets this goal; in fact, a century of therapeutic wisdom suggests that it does not. There is a great deal of discussion in the culture nowadays about therapy, and so-called “bad therapy” spills a lot of ink. It is past time to spill some ink on the alternative, as I am frustrated by the whole profession being judged by its worst members. Horror stories do not tell the whole story.

While patients may become dissatisfied with psychotherapy experiences for any number of reasons, some of the more common complaints include feelings of being steamrolled by reckless advice or frustrated by clinicians who make themselves the focus of the hour. Therapists may become overactive to quell their own anxiety about being helpful (Gnaulati, 2021), and in doing so, miss important signals coming from the patient. An overactive therapist cannot slow down enough to notice what is happening in the room, and this slowing is one of the most valuable experiences that psychotherapy can offer (Peebles, 2022). This article is intended to be a primer, for patients and therapists alike, about the perils of advice giving in psychotherapy.

Advice? Think Twice

The limits of advice may be evidenced by the fact that the patient is attending psychotherapy in the first place: “By the time a patient makes her way to your office, she has undoubtedly received loads of suggestions. She’s in your office because they didn’t work” (Bender & Messner, 2003, p. 26). For most patients, a mental health professional is their last stop. They have consulted general practitioners, friends, family, self-help books, podcasts, and Google. Yes, they tried a bubble bath. The patient has tried all manner of suggestions and for reasons they may not fully understand, the advice will not stick: “If change were easy, psychotherapists would be out of a job” (McWilliams, 2004, p. 152). It is critical to understand that most patients do not suffer from a lack of advice but from difficulty applying it. To offer advice swiftly is to risk giving the patient more of what has already failed them. The therapist’s first task is to understand the problem, discover what has kept it going, and why attempts to solve it have failed. Ideally, this understanding will interrupt the perpetuation of an ineffective cycle: “We are all constantly awash in advice. Patients rarely have insufficient advice, but they have defensive systems that prevent them from benefiting from the advice that is out there. The therapists’ advice is likely to fare no better” (Kuhn, 2014, p.5).

In social settings, the person who gives advice easily may appear wise and confident. In clinical settings, however, the casual provision of advice tends to point to inexperience or inadequate training (Bernard & Goodyear, 2009). The clinician who identifies the problem quickly, provides excessive emotional support, and gives advice based on one’s own experience is often categorized as a lay helper, the equivalent of a relatively unskilled person. By contrast, experienced professionals have come to understand that easy answers are rarely available and tend to be more modest in their approach (Bernard & Goodyear). The provision of wild advice, particularly in the early phases of treatment, is not the mark of expertise. The skilled psychotherapist looks to understand a problem in some depth before considering solutions (McWilliams, 2021). A psychotherapy relationship is not based solely upon advice but on a working alliance (Bordin, 1994), which is a mutual agreement about the purpose, tasks and methods of psychotherapy. Psychotherapy is designed to be a collaboration, not one person telling another how to live.

Although it is common for patients to ask therapists for advice, offering it may foreclose on the deeper meanings of why the patient needs psychotherapy to begin with. In fact, the purpose of psychotherapy might be to find out why advice has such a high failure rate. Psychotherapy is an opportunity to discuss what may be difficult to share in social settings and put voice to what has gone unnoticed: “Observing and sensitively bringing up client behaviors, emotions, traits, and conflicts is part of the therapeutic task and typically not a focus of other social relationships” (Karson & Fox, 2010, p. 273). The pleading for guidance itself may be an opportunity for insight, as many patients seek advice as a way of avoiding painful topics. Ideally, psychological treatment looks for deeper meanings underneath the surface of such requests. To waste this opportunity is to waste the best thing psychotherapy has to offer, which is the chance to understand what motivates us. As previously stated, many patients have travelled the road of advice and still find themselves lost. The patient needs a compass, not another map to nowhere. Psychotherapy is a process of figuring out what is in the way of finding one’s own way.

Advice Has a Short Shelf Life

The effective psychotherapist is trying to work themselves out of a job. If a therapist is making decisions for the patient, it means that the patient is not making their own: “Following someone else’s direction, even when that person’s advice is good, does not increase patients’ confidence about their own problem-solving capacities” (McWilliams, 2021, p. 52-53). If therapist offers personal opinions in place of actual psychotherapy, the patient will fail to develop the internal compass needed to guide themselves: “Psychotherapy is meant to expand the patient’s sense of personal agency, not the therapist’s” (Shedler, 2024). A patient cannot learn how to make decisions if the process is short-circuited by an overzealous clinician. The job of the therapist is to “…make room for exploration, to open the door to possibilities, but to do so without pushing one’s own hobbyhorse” (Wachtel, 2011, p. 223).

Moreover, although patients commonly ask for advice, it is equally common for them to be ambivalent about taking it (Wachtel, 2011). They may plead for guidance only to arrive at the next session announcing that the advice was a flop. It is worth noting that many patients are frustrated by therapists who offer suggestions and personal anecdotes. Often, this frustration is silent. A patient may feel unable to decline a therapist’s counsel, so they listen politely, resist internally, and cancel their next appointment. We need to take the patient at face value but not only at face value (Schlesinger, 2014); the request for and rejection of advice often holds multiple meanings. A therapist needs to understand the risks that accompany advice (Gabbard, 2014), including the fact that it may deprive the patient of autonomy.

The provision of advice also collides with a truth that we all must reckon with: Decisions come with costs. For every pro, there is a con. For every gain, there is a loss. At the end of the day, we must balance our own emotional books. There is no one who can direct us on what to desire, change, and grieve. The psychotherapist can help to fathom the mind but cannot substitute their own for that of the patient. The cursory provision of advice can give the impression that things come easy, a promise that the world will never keep. I believe that the first principle of psychotherapy is the reality principle. Therefore, therapists should not sell the fantasy of quick fixes to their patients.

The professional role imbues the therapist with an authority that must be used judiciously. While advice might at times be required, many psychotherapies suffer from an overemphasis on “tips” at the expense of genuine therapeutic collaboration. A psychotherapist needs to ask themselves whether the advice offered is truly in the patient’s best interest, or whether they are succumbing to a “quick fix” urge, overstepping the therapeutic role, or skirting uncomfortable topics. In situations involving safety and crisis, advice may be necessary and appropriate. There are different types and doses of advice, and clinical experience tells us that patient responses to advice can vary widely (Hill, Knox, & Duan, 2023). As with most things in psychotherapy, we look to guidelines over hard and fast rules. Before giving advice, a therapist should ask themselves whether it would better for the patient to generate their own solution (Hill et al. 2023). When advice is proffered, it is best to keep as much responsibility with the patient as possible (Kuhn, 2014).

We should begin psychotherapy with the end in mind: “In a major sense, any treatment is about ending it; it is about how to obviate the need for the therapist” (Schlesinger, 2014, p. 5). The therapist should be a guiding hand, not a heavy one. The aim of effective psychotherapy is to help the patient understand their personal barriers to change, clearing the road for the future. This is best accomplished by the therapist who directs the process of the work, as opposed to offering their personal views about the content (McWilliams, 2021). I have heard it said that in the story of a patient’s life, the therapist should be a footnote, not a main character. In the evergreen words of Donald Winnicott: “We all hope that our patients will finish with us and forget us, and that they will find living itself to be the therapy that makes sense.”

---

Also by Stephanie Foster:

The Remaking of a Therapist

The Age of Acronyms

---

References

• American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (2002, amended effective June 1, 2010, and January 1, 2017). https://www.apa.org/ethics/code/

• Bender, S., & Messner, E. (2003). Becoming a therapist: What do I say, and why? Guilford Press.

• Bernard, J. & Goodyear, R. (2004). Fundamentals of Clinical Supervision (4^th ed.). Pearson.

• Bordin, E. S. (1994). Theory and research on the therapeutic working alliance: New directions. In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, research, and practice (pp. 13–37). John Wiley & Sons.

• Eagle, M. N. (2018). Core concepts in contemporary psychoanalysis: Clinical, research evidence and conceptual critiques. Routledge/Taylor & Francis Group.

• Gabbard, G. O. (1996). Love and hate in the analytic setting. Jason Aronson.

• Gabbard, G. O. (2014). Psychodynamic psychiatry in clinical practice (5th ed.). American Psychiatric Publishing, Inc.

• Gnaulati, E. (2021).  Relational Healing in Psychotherapy: Reaching Beyond the Research, Psychoanalytic Inquiry, 41:8, 593-602, DOI: 10.1080/07351690.2021.1983403

• Hill, C. E., Knox, S., & Duan, C. (2023). Psychotherapist Advice, Suggestions, Recommendations: A Research Review. Psychotherapy (Chicago, Ill.), 60(3), 295–305. https://doi.org/10.1037/pst0000476

• Jones, E.E. (2000). Therapeutic Action – A guide to psychoanalytic psychotherapy. Jason Aronson Inc.

• Karson, M., & Fox, J. (2010). Common skills that underlie the common factors of successful psychotherapy. American Journal of Psychotherapy, 64(3), 269–281.

• Kuhn, N. (2014). Intensive Short-Term Dynamic Psychotherapy. CreateSpace.

• McWilliams, N. (2004). Psychoanalytic psychotherapy: A practitioner's guide. Guilford Press.

• McWilliams, N. (2021). Psychoanalytic supervision. The Guilford Press.

• Peebles, M. J. (2022). When psychotherapy feels stuck. Routledge/Taylor & Francis Group.

• Poland, W. S. (1984). On the analyst's neutrality. Journal of the American Psychoanalytic Association, 32(2), 283–299.

• Prass, M., Ewell, A., Hill, C. E., & Kivlighan, D. M., Jr. (2021). Solicited and unsolicited therapist advice in psychodynamic psychotherapy: Is it advised? Counselling Psychology Quarterly, 34(2), 253–274.

• Rogers, C. R. 1. (1961). On becoming a person: a therapist's view of psychotherapy. Boston, Houghton Mifflin.

• Schlesinger, H. J. (2014). Endings and beginnings: On terminating psychotherapy and psychoanalysis (2nd ed.). Routledge/Taylor & Francis Group.

• Shedler, J. [@jonathanshedler]. (2024, September 3). In order words: Psychotherapy is meant to expand the patient’s sense of personal agency, not the therapist’s [Tweet]. Twitter/X. https://x.com/JonathanShedler/status/1831003863522156644

• Shrier, A. (2024). Bad Therapy: Why the kids are not growing up. Sentinel.

• Wachtel, P. L. (2011). Inside the session: What really happens in psychotherapy. American Psychological Association.

• Wachtel, P. L. (2011). Therapeutic communication, knowing what to say when (2nd ed.). The Guilford Press.

• Winnicott, D. W. (1971). Playing and reality. Penguin.

---

1. My thanks to Candice Vinson, PhD for this parable.