I received a question about whether clinicians should give advice to patients receiving mental health treatment. This is a frequent concern, especially among those of us who went through some form of psychodynamic psychotherapy training where such concerns are given voice, and with good reason: advice giving is a complex issue and some forms can be counterproductive.

The quick answer to whether a psychiatric clinician should give patients advice is: yes, of course, but not always, and some ways of giving advice are better in a situation than others. Since entire books have been written on advice -giving (see Duan et al, 2018 below), what I present today is a start, just some thoughts to start you on your own path of considerations.

First, let’s define advice. Here’s a good definition, “Guidance or recommendations concerning prudent future action, typically given by someone regarded as knowledgeable or authoritative.” (Oxford Living Dictionaries)

Next, let’s differentiate advice along these two parameters that can guide our considerations: Levels of Advice Directiveness and Type of Advice.

Levels of Advice Directiveness

Advice can be nuanced regarding the force of its directiveness. Notice how the following terms convey different levels of the force of directiveness, roughly from strongest to weakest: a directive, a recommendation, advice, guidance, a suggestion. Directiveness lies on a spectrum and no level of forcefulness is essentially better than other levels. Some situations call for higher degrees while others for lesser ones. For example, if a patient with a sore throat tests positive for group A beta-hemolytic strep (GABHS) their doctor is likely to say, “Take this antibiotic for 5 days as directed. Your throat infection can lead to long-term problems with your heart and joints and other organs. By taking this medication it will not lessen or shorten your sore throat, but it will nearly eliminate those possible serious long-term problems. Any questions?” This is an example of high directiveness, spoken as a directive. Since in general people don’t like being directed, except in emergencies and by a person they regard as an authority, the doctor’s high directiveness is justified to the patient by pointing out that 1) serious yet entirely avoidable long-term sequelae exist and 2) that a highly effective treatment exists. By presenting a single treatment—“Take this antibiotic.”—the implication is that this effective treatment stands alone. If there were a range of effective approaches, one would expect less univocality about the treatment and more discussion about various treatment options. (Actually, with GABHS it is not true that there is a single accepted approach, but most clinicians have their own standard way of treating GABHS, one they learned and stick to.)

In psychiatry, it is unlikely that any clinician would say, “Take this medication as prescribed and see me back in two weeks.” One reason is simply that we aren’t trained to assume such an authoritative stance. This is good, of course, especially given that there are rarely single best treatments for psychiatric conditions. Things are more often a complicated mess, and trial and error treatments are the norm. This is not to say that we don’t categorize treatment interventions as more or less appropriate because we do, but we usually present a range of options. I will pick up on this point later. First, though, I discuss the second parameter of advice.

Type of Advice

Advice can be process advice or choice advice. I define process advice as advising a person on how to make a choice and choice advice as advising a person on what choice to make. Of course, these two types of advice are both often conveyed to various degrees to a patient. Nevertheless, the distinction is valuable because process advice is almost always welcome while choice advice often should be minimized. (Also, both types of advice can be conveyed at different levels of directiveness.)

Process advice is designed to help a person make better decisions for themselves, to increase their independence by increasing their choice-making skills. Choice-making is a component of problem-solving. Problem-solving involves conceptualizing the nature of the problem one faces, the possible choices available to solve the problem, a method for judging the choices, making a choice, tracking the outcomes of the choice made, and adjusting based on the outcome, thus forming an ongoing monitoring/adjusting loop.

Oftentimes people have intuitive choice-making strategies, ones that are effective under the circumstances of routine decisions faced in day-to-day life. These gut strategies fall apart when the person enters a choice landscape that is unfamiliar to them, such as when a depressed person is faced with choosing the best treatment approach. To guide a patient such as this, the clinician can structure a discussion in a way like this. Notice, when done this way, the need to give advice to the patient is minimized. In effect, the structure of the discussion, one provided by the clinician, plays the role of advice-giving, minimizing the need for explicit forms of giving advice.

  1. Educate the patient on their illness: depression, its causes/contributors, protective factors, its future risks, and prognosis with and without treatment.
  2. Educate the patient on the range of treatment options. This can start by initially dividing up treatment categories into three easy-to-understand ones: medications, psychosocial therapies, and no treatment. Next, the clinician can add details but only as appropriate to the patient’s current situation. For example, if the patient has had treatment failures and neuromodulatory treatments are under consideration, then the category can be expanded from medications to somatic treatments, thus encompassing both medications and neuromodulatory therapies such as TMS, VNS, and others. If instead the patient is treatment-naïve, then discussion should be limited to first line treatments only, which often at this point need not include discussion of neuromodulatory treatments.
  3. Educate the patient on the benefits and risks of “adequate” first-line treatments and include discussion of the risks and benefits of no treatment. Usually, the option of no treatment is not discussed, but I think it should be; many patients do not show up for a second appoint and most do not complete a treatment course. Thus, it is realisitic to present the possible consequences of no treatment, such as heightened risk of suicide, continued symptoms, increasing dysfunction with real life consequences, such as loss of job, etc. Thus, even if the patient fails to continue treatment, they are left with a better understanding of their range of options and, I like to believe, more likely to come back. By not stigmatizing no treatment and presenting it as one option out of several, it makes it easier for the patient to decide to return to treatment.
  4. Encourage discussion and answer questions and concerns.
  5. Based on the questions and concerns that arise, you can add clarifications and guide the discussion. There is rarely a need, outside of emergencies, to tell the patient what to do. Rather than phrasing your advice as, “You should …” you can phrase it as “If …, then …” For example, you can say, “Given the level of your depression, the highest chances of treatment success are associated with getting both medication and psychotherapy. If this approach seems like too much of a commitment all at once, then a choice of either medication or psychotherapy is also acceptable. If you choose a single approach, we’ll monitor your response, and make adjustments as needed…”
  6. If the patient continues to have difficulty choosing, you can say this, “The most important factor for treatment success is sticking to the treatment, regardless of which one it is. So, out of the treatment options that I’ve presented which are you most likely to stick to? Be honest with yourself and know that whichever one you choose, we will continue to work together and make changes as needed.”
  7. If the patient requests treatment you believe does not meet standard of care, you should refuse to provide it. There are caveats and I cover this point below.

Standard of Care

Being mindful of standard of care often clarifies which treatment options are presented and agreed to. Based on the patient’s mental disorder(s) and circumstances, there are a range of treatments considered adequate and others considered inadequate. This is the major demarcation. As the clinician you should not provide treatments you judge as inadequate and instead offer for consideration only treatments you judge as adequate.

There is a gray zone, however, and it is this: there are inadequate treatments you may agree to provide temporarily while making clear to the patient and in the chart that the treatment is likely inadequate and temporary. The justification for being a party to inadequate treatment—and there must always be a clear justification in these circumstances—is that the patient is unwilling at this time to accept an adequate form of treatment and the provision of inadequate treatment is only to have the opportunity to continue to engage the patient. The point is that this inadequate treatment is better than the alternative, which is no treatment. Keeping the patient in treatment affords further discussions and trust-building which, one hopes, leads to adequate treatment. For example, a patient with severe psychotic depression agrees to psychotherapy only. By standard of care guidelines, this is clearly inadequate treatment. Of course, even inadequate treatment—by virtue of time passing and natural disease resolution as well as by placebo and active effects of the inadequate treatment—can result in recovery. So, the possible outcomes in a case such as this, 1) the patient will recover with the inadequate treatment, 2) the patient will eventually agree to adequate treatment, or 3) the patient will continue to neither recover not agree to adequate treatment. The latter eventuality is the toughest of the three situations you can face and should lead to reconsideration of continuing the inadequate treatment for a while longer or instead forcing a choice of either adequate treatment or discontinuation of the treatment relationship (of course, keeping in mind and minimizing risk of patient abandonment). In all cases in which you agree to provide inadequate treatment, this approach to treatment must be justified in the chart. The risk of bad outcomes is high.

Why Increase Patient’s Contribution to Affirmatively Choosing Treatment

It is good to advise patients on their treatment options and provide an “if/then” structure, but it can be counterproductive to advise them to choose one option vs. other available, adequate options. A direct type of advice-giving can result in blaming the clinician for poor outcomes. This places risk on the clinician AND removes responsibility for the decision from the patient. By increasing the gravity and care with which a patient engages in the decision-making process, they increase their ownership of the choice made. By taking responsibility, the patient may be more likely to adhere to the treatment. Why? Because the patient chose it for themselves. They are not complying with YOUR treatment but with their own treatment. You are seen as the facilitator and provider of the treatment rather than as the owner of that treatment. The way this plays out between clinician and patient is subtle but ubiquitous. In hindsight, I believe this dynamic of moving responsibility for treatment onto me and away from themselves occurred in most of my patients. Of course, nudging the patient to choose is not fool-proof—a patient can still claim that you misled or underinformed them—but it does help.

Non-Treatment Advice

So far I’ve focused on treatment related advice, but patients often push for getting advice on important life decisions: moving to another city, out of their parents’ house, changing jobs, breaking up, or getting married. In these circumstances I always refuse to give choice advice. I say, “I appreciate the trust you place in me by asking for my advice on this important topic, but no matter how well I get to know you, you will always know yourself better. Also, you are the one who will live with the choice. So, it’s only fair that you get to make the decision.” I do guide the patient, however, with process advice and, more so, guide them directly through the choice-making process. Last, I point out that everyone has their own way to make decisions and that they need to trust their way. I give the example that making a list of pros and cons seems completely ridiculous to me, while it works well for others.

Let me know what you think and which direction I can take this discussion.

Thanks,

Dr. Jack

Language Brief

“Waiting hurts. Forgetting hurts. But not knowing which decision to take can sometimes be the most painful…” ― José N. Harris

“The straight line, a respectable optical illusion which ruins many a man.” ― Victor Hugo

“The elegance under pressure is the result of fearlessness.” ― Ashish Patel

“Accepting trial and error means accepting error.” ― Tim Harford

“It is often said that a wrong decision taken at the right time is better than a right decision taken at the wrong time.” ― Pearl Zhu

Resources

Duan, Changming, Sarah Knox, and Clara E. Hill. “Advice Giving in Psychotherapy” The Oxford Handbook of Advice (2018): 175.

Prass, Megan, et al. “Solicited and Unsolicited Therapist Advice in Psychodynamic Psychotherapy: Is it Advised?” Counselling Psychology Quarterly 34.2 (2021): 253-274.