Nondirective Counseling or Advice

Psychotherapy as Value Laden Traditionally, psychoanalytic psychotherapists eschewed giving their patients advice--at least so they claimed and so they believed. Advice suggested that the patient required rational guidance in the real world. Psychoanalysts believe that the basic pathology of a patient resides in internal conflicts. Another reason given for avoiding advice was that it might open the door for the therapist's judgments and values to intrude into the therapeutic hour. The therapist has advertised himself as a value-free agent. But this is an exercise in self-deception. The unavoidable truth is that--whatever else he is doing--the therapist is always directing, advising, and introducing The desire to be nondirective and value free stemmed from a yearning to be admitted as a bona fide member of the scientific community. In the early days of psychoanalysis, the activities and assumptions of medicine were presumed to be part of a value-free enterprise--a concept that, ironically, the successes of medicine, the capacity to do new and unprecedented things, has forced us to re-examine (giving birth to the field of bioethics). What holds true in surgery, gynecology, obstetrics, dermatology, is singularly valid in psychiatry. In psychotherapy we deal with complex human functioning involving emotions and aspirations for which we have few universally accepted norms. We do not have the fixed point of departure that exists in physical medicine. We know what normal breast tissue should look like, and we can see how cancer distorts both the structure and the function of cells. Psychotherapists do not have tissue to examine, and the borders between unhealthy conduct and idiosyncratic behavior are not always so apparent. But a definition of mental health is essential, and without anatomic or physiological guidelines, that definition will inevitably be subjective and value laden. The propriety of infusing values will be determined in part by how narrowly or widely we define the term values. As a therapist--indeed, as a human being--one must recognize that people of good will may fall on opposite sides of critical moral issues. Attitudes about abortion, capital punishment, the atom bomb, nuclear energy, pacifism, truth-telling to the dying, autonomy versus beneficence are hardly trivial issues, but they are rarely relevant or even appropriate in therapy. It would be presumptuous and wrong-headed for the analyst to correct the values of his patient, which may be as defensible and reasonable as the therapist's. These types of values are clearly beyond the authentic expertise inherent in being a psychotherapist. And these issues are unlikely to be of therapeutic interest Moreover, a therapist with integrity must be ever vigilant to avoid exploiting the power of the transference. It is hard to imagine a therapist cheeky or stupid enough to misuse precious therapeutic time on stuff that is not central to the adjustment of the patient, or not in the service of alleviating the distress that drove the patient to treatment. Having said this, I am sure that in some shabby venues every aspect of the power of the therapist over the patient has been abused and passed off as therapeutic. Some judgment calls are difficult: what does a therapist do about his patient's racial or religious bias when it is not obsessive or a paranoid fixation but, rather, a casual part of the cultural bias of the community from which the patient comes? In this case, it is unlikely even to come up except in a semantic way (I wouldn't let him Jew me down). The therapist might, or might not, comment on the language, but he is unlikely to divert the course of the therapy to analyze the roots of anti-Semitism. I would draw a distinction between two patients who might have a social bias against minorities. If it were a Connecticut business man from a conservative background who came to treatment with a marital problem, his bias (which he probably shares with his wife) would have no bearing on the central aspects of his unhappiness or functioning. …