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.