When should psychiatrists give advice to patients?

This post was inspired by Dinah, a psychiatrist over at Shrink Rap.

She recently described how a psychiatrist friend of hers has been going through some phase-of-life changes. Recently he has regretted some of the advice that he previously had given to patients who were going through the same life changes he’s now going through himself. He realizes that he was not nearly so qualified to give the advice he gave because he looks at the situation differently through the new lenses of his own experiences.

Reading the post got me thinking more about psychiatrists and advice. When should and shouldn’t psychiatrists give advice to patients? I’d love to hear your opinions about this, but first I want to lay some groundwork and give you my own opinion.

1. Psychiatrists should clearly give advice and opinions about psychiatric diagnostic impressions and treatment recommendations. It’s one of our main roles. We should collaborate with our patients and offer them appropriate options, but I believe some physicians try to avoid giving an opinion about treatment options out of fear of litigation. Instead they simply state the choices to the patient  I think that’s a cop-out. If we have an opinion, it’s our responsibility to share it.

2. Psychiatrists should not tell patients what they should do when it comes to major life decisions. For example, a psychiatrist should not tell a person that they should get divorced, quit or start a particular job, or move to a new city. In fact, psychiatrists can be sued for recommending to patients that they make life changes such as divorce. (The only exception I can think of, and it still may be challenged legally, is the ethical decision a psychiatrist might make to recommend that a patient leave an abusive domestic situation).

3. Advice about day-to-day life situations: This is really where most of the life “advice” a psychiatrist might give comes into play. It’s a very grey zone. Whether and when to do it depends a great deal on so many circumstances that I believe it’s not possible to say always or never. Let me explain.

Back when most psychiatrists primarily provided psychotherapy, a psychiatrist typically would not have considered telling a patient what they should do. It was the job of the psychotherapist to help the patient figure out for him/herself what to do.

Personally, I’m most likely to give advice in crisis situations where the stakes are high, and I may have only one shot at making a difference.

For example, if I’m seeing a new patient who is acutely suicidal or who is so depressed that she’s barely functioning, then I’m going to take a much more active role than usual. It’s very likely that I will respectfully and politely tell them some things they need to do right now in order to survive and function adequately until I can see them again. I then quickly back off on being so directive as they feel more in control of their own lives.

Another situation where I’ve given advice is to inmates who are feeling rejected by their children. The inmates often want to give up on the relationship because they believe it won’t work, they often feel worthless, and they don’t want to risk getting rejected more by trying to make it work and then failing. I realize that a child’s life is at stake, and I see this as an opportunity for a helpful intervention. I don’t tell my patients that they need to have a relationship with their children — they don’t.

Instead, I try to get them to put themselves in the shoes of their children (something that some inmates can do) and ask them how they would want their incarcerated parent to handle the situation if they were the child. I tell them that they’re at a major decision point and that what they do or don’t do now may make a difference in the lives of their children forever. I recommend that IF they want to help to improve the relationship they absolutely must not give up. They should let their children know regularly (without harassing them) that they love them unconditionally–and do so through their actions (remembering birthdays and other special occasions) and not just their words. Most of them seem to appreciate this guidance.

Psychiatrists are not wise gurus with the answers to life’s problems, but most of us are experienced in treating many patients in very difficult life circumstances. We’ve often heard variations of the same tragic stories many times. As relatively objective third parties with exposure to what has and hasn’t worked for many other patients, we may have some helpful ideas. But should we share them?

In my opinion, we should give out life advice very sparingly and typically help our patients figure out for themselves what’s best for their given situation. If we’re hesitant about saying something that sounds like advice, then we probably shouldn’t say it. Otherwise I fear that we risk convincing our patients (and ourselves) that we have the answers when we really don’t.

The bottom line: no advice is better than bad advice.

Jeffrey Knuppel is a psychiatrist who blogs at The Positive Medical Blog.  This post originally appeared on Lockup Doc.

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  • http://shrinkrapping,blogspot.com/ Gregory E. Smith MD

    Excellent post.
    Agree.
    We do not have all the answers, though I still see many patients who just want me to give them the quick fix and move on.
    The work is ALWAYS in the process that leads the patient to some resolution of their problem, whether that process is taking a course of medication or completing a course of psychotherapy or entering a grief support group. It is most always hard work, but it’s always worth it in the end.
    Thanks for the post.

    Greg

  • http://fertilityfile.com IVF-MD

    Can doctors and patients ever interact like amicable neighborly human beings or is too late? Have lawyers and politicians really really hijacked the entire doctor-patient relationship?

    For example, if a patient mentions to my nurse that she needs to get an oil change, would my mention of the half price special at the new place down the street constitute an illegal referral?

    If my patient tells me about behavior problems with her new puppy and I give her some advice on clicker training, is that illegal because I’m not a certified dog trainer? (I’m a very experienced dog trainer by the way and my dogs have a combined 20-word vocabulary of tricks that they do. One is even a certified therapy dog for sick children)

    If my patient shares that her sister is looking for a job and I suggest some good job-seeker websites, am I breaking some rule of conduct because I’m not a registered career coach?

    If my patient asks me if I know of any good Thai restaurants, should I reply “I am not a culinary expert and can not give you professional culinary advice”?

    Isn’t there some context where a physician can offer suggestions to another human being who happens to be his patient without it requiring congressional oversight or being in the context of some supreme authority lording over a subject?

    I understand that psychiatry might have its unique rules, but do I really have to go get a Marriage and Family Therapist license if I wanted to sit down with my patients as part of their fertility treatment and listen supportively to their marital conflicts and suggest some stress-reduction behavior options?

    Being a doctor is not just about memorizing antibiotics and preforming surgery. It’s about communication also. We need to treat patients like adults who can hear our words and yet make up their own minds. I can’t picture myself telling a patient “get a divorce, join a cult and move to Madagascar” and that they blindly obey, no matter how much they revere doctors.

  • Joy Fugate

    Speaking as a patient…I can sign a release of any sort and you can have a record of my informed consent. I am seeking your advice, and paying for it as such. Why would I want you to hold back? Not giving at least a range of options is in my mind, refusing to treat. Patients may ask non treatment questions (Thai for lunch…oil changes? Really?) because they value a Doctor’s opinions on life in general. We are at a specific Doc’s office because we need either answers or adjustments to our psyches to find them. So please don’t join the “they’ll sue me” bandwagon and leave us struggling. It isn’t cricket, and if the Thai isn’t served they’ll find another restaurant…if the oil isn’t changed they can get it done elsewhere…you get the idea. Best of Luck with the rationalizations!

  • Dinah

    Ah Dr. Knuppel,
    I am so glad I’ve been inspirational! Sadly, I’d fail here. I give all sorts of advice (IVF-MD, if you ever need a shrink, I’m here for you, I recommend restaurants and even movies and websites and I can tell you where to get the best crabcakes in Maryland…I’m not that big on Thai).
    Thanks for the link back…and for the thought provoking post.
    Dinah

    • http://fertilityfile.com IVF-MD

      :) You and I may love living in a friendly non-litigious world with our fellow neighbors and we’ll try to continue laughing and enjoying life while keeping a peripheral eye out for dangerous sharks who would seek to profit though harnessing the power of their lawsuits against us.

  • Jenny

    I’m a medical student with much to learn, but I do have a lot of life experience. I expect that giving advice to patients in a non-confrontational and positively enabling way is a good thing. I found a very useful way to give advice which has allowed me to help my friends and family without being overbearing or belittling. I have seen this used with patients as well, and it seems effective. This is what I mean:

    Walk the person through different options, discussing the merits and foreseeable problems. Clarify their goals and values as these merits and problems are discussed. Focus on ways each solution could meet or contradict their goals and values. If one seems particularly useful, say so, and show why. Emphasize that they likely know more about their particular situation than I do and they should do what they think is best. I am not invested in WHAT they choose. I am invested in their eventual happiness. Assuming they also want to be happy, we are on the same team. If the decision turns out to make them unhappy, I didn’t cause the unhappiness, and I am ready to help them change their course they for a better life–as defined by THEM.

    This is a different sort of advice than the kind given with a paternal tone (you WILL do what I say, because I know best), a punitive tone (do what I advise or else!) or an insulting tone (if you don’t do what I say, you are an inferior individual). No matter what the person chooses, they know that you will still accept them and they will let you help them more. This works with decisions regarding college, marriage, children, divorce, making new friends or detaching from old ones, changing jobs or locations, making a mjaor purchase, deciding to get a new pet or get rid of an old one, and a host of other issues.

  • http://behavenet.com moviedoc

    Should. The S word. Implies a moral or ethical assessment. Let’s remember psychiatrists treat mental illness. Would you ask whether an oncologist or ophthalmologist “should” give advice? How is it that this question is asked of psychiatry and not to psychotherapy or to all mental health professionals. Some psychotherapies (analysis) view advice giving as sacrilege while for others advice giving does most of the work. The real question is whether giving advice treats the illness and/or helps the patient. Dump the should. Give advice if it works.