Fredric Neuman M.D.

Fighting Fear

Taking Advice

When patients are offered advice, why do they tend not to take it?

Posted Sep 04, 2018

Psychotherapy has different purposes. Primarily, patients come to therapy to deal with symptoms of one sort or another — anxiety, depression, or some other definable condition — but they are also troubled, as perhaps everyone is to some extent, by the ordinary problems of life. One person may be in the midst of marital problems or stresses at work. Another may come to treatment because of a phobia  or obsessive thoughts, but will also have to deal with a recalcitrant child, or a difficult dating relationship, or some other mundane problem. Sooner or later, invariably, psychotherapy will devolve into a discussion of these matters. Psychotherapy, therefore, tends to resemble less the medical model of treating disease, but rather, out of a more ancient tradition, the practice of consulting a village elder, or a priest, or some other person who is presumed by virtue of greater experience and, perhaps, training to be wise in the ways of the world. Whether, in fact, a particular therapist is wise or not, patients will expect him or her to have sensible advice to offer. Patients want help in coping. Psychotherapy is a kind of influencing machine to point patients in the right direction.

It was surprising to me, therefore, to discover that men and women who came to me as a therapist looking for better ways to manage their lives were not likely to accept my advice! That response is so much the rule that I am surprised when someone actually does follow my advice. Between one thing and another, I am continually in a state of surprise.

Some examples:

Much of the advice I give is obvious and usually echoes the oft-expressed opinions of the patient’s friends and family. Sometimes the patient will agree with what needs to be done, but not do it anyway. For instance:

If you wish to maintain a relationship with the man you love, do not pester him with demands for affection. Do not check on him repeatedly throughout the day to make sure he is not cheating on you. Do not complain endlessly of his not treating you deferentially. Do not scold him. Do not get sick drunk in his presence. Do not see other men occasionally, because you feel insecure.

If you wish to advance at your job, do not embarrass your boss by contradicting her in public. Do not come to work 10 minutes late every day. Do not pick fights with your colleagues, because you need to show them you will not be intimidated.

If your children are having temper tantrums, do not indulge their wishes just to keep them quiet. Be firm, so that you do not have to end up yelling at them. Do not scold them when they get less than perfect marks. Don't blame them for getting sick.

And, of course, don't drive after drinking. Do not use drugs. Don't get into fistfights with passing motorists. In short, do not engage in any one of the vast panoply of self-destructive behaviors.

Consider Sandra (as I shall call her). Sandra came uninvited to a party of a roommate. She then sequestered herself in the kitchen and ate her roommate’s birthday cake. She ate the whole thing. When I asked her why she defied a roommate with whom she wanted to be friends — in fact, going out of her way to annoy her — she said, “I couldn’t help myself.” What can that mean?

Similarly, a man showed up at the apartment of his former girlfriend and would not leave until the police had been called. “I had to go,” he said to me, “It hurt too much to stay away.” When I pointed out that other people can put up with the almost universal circumstance of being jilted, he said, “I’m not other people.”

Reasons why people don't take advice:

These are the same reasons people behave in ways that are disadvantageous to themselves in the first place.

One might say, in explanation of repeated self-defeating behaviors, that the affected person has some sort of impulse disorder, not being able to resist urges that other people readily resist. But this begs the question: What drives those impulses?

Sometimes it's an unwillingness to resist a pleasurable feeling. Examples include the use of alcohol and drugs, gambling, promiscuity, and harassing others sexually. But also, as in the case of Sandra, it could be the wish to be close to someone else, even if that person does not wish to be close. There are all kinds of more subtle pleasures, such as seeking revenge, venting angry feelings, and so on. It seems the momentary but immediate satisfaction of indulging a wish outweighs a readily predictable set of consequences. Now counts for more than later.

The second reason is fear. A patient may not look for work, consider a divorce, or otherwise seek to live more happily, because that person is afraid of failure or rejection or some other imagined danger, such as ending up alone or helpless.

It could also be plain habit.  Many individuals are simply stuck in a rut. They cannot reach out to improve their lives, because “that is not me.” They cannot venture onto a dating service, or look for work in a distant neighborhood, or take up the study of a new skill, because they do not see themselves in that role. It is as if they were poured out of a mold and cannot change. A contributing factor to these failures is low self-esteem. These men and women have reasons, it seems to them, to think that they cannot succeed. So they do not try. Advice to behave differently is likely to be ignored.

Having, for one of the reasons mentioned above, a disinclination to behave effectively in their own interest, they will not take advice pushing them in that direction. Given this profound resistance, how can a therapist help patients to change?

The goal of psychotherapy is to help patients get to where they want to go in life. One problem is that they do not always know where they want to go. They think they want one thing, but indicate by their actions that they really want something else. The second, more important, problem is that getting where they want to go almost inevitably involves their doing something that makes them uncomfortable, such as looking for a new job or seeking a divorce. Solving these problems can be done only over a period of time. The therapist has to expect that any advice offered up at this point will not be persuasive. Therefore, initial goals must be limited. Expecting the patient to suddenly change dramatically will only lead both of them to become discouraged. Some things can only be accomplished a little at a time. Phobias are treated in such a manner, for example. But so is a task such as looking for work or dating. Small successes counter the demoralization which often underlies the inability to change.

Certain bits of advice are always useless. I do not tell someone enamored of an unsuitable person to stop seeing that person. It is too hard. Everyone in that person’s life has already given that advice. Instead, I encourage that man or woman to start dating others. Even that advice is hard to follow; but it's possible. Somewhere down the road, the patient will meet someone else and be more amenable to turning away from the unsuitable partner.

The influence a therapist can exert on a patient depends on their relationship, and so needs time to develop. Advice is more readily accepted from someone who is understanding and optimistic and patient. The therapist, who in general is likely to have more authority than others, will be still more readily attended to after knowing the patient for a period of time. Still, in the final analysis, trying to influence a particular patient is likely to be difficult. It may take a long time. When I grow impatient, I remind myself of this old joke:

A prisoner on a chain gang was told to clear rocks from a road they were building. He came to a very large rock, which he struck at repeatedly, but feebly, with a pickax. He continued without making any noticeable progress. A guard watching him proceed ineffectually lost his temper finally. “Give me that ax,” he said, pulling it from the prisoner’s hands. He took the ax and slammed it against the rock, splintering it into dozens of pieces. “That’s the way you’re supposed to do it,” the guard said, handing the ax back to the prisoner. “Yes,” the prisoner said, “but I softened it up for you.”

I sort of identify with that prisoner.

I saw a young girl who was refusing to dress properly for a job interview. Consequently, she was turned down over and over again. Each time, I suggested to her that she speak to someone about dressing properly. She ignored me. A year later, her friend told her the same thing; and after dressing more appropriately, she did, indeed, get the job. The reason I remember her in particular was what she said to me afterwards. “Why didn’t you give me that advice?” she asked, although I had said the same thing to her a dozen times. She wasn’t ready to hear that advice until things had changed, and, finally, she was ready to listen. I think doing therapy is like being that prisoner on the chain gang. My patient, who seemed not to be changing, was getting “softened up,” speeding up the process of her changing eventually.

One of the changes that does take place routinely in psychotherapy is the patient regarding himself, or herself, with more respect. Having greater self-esteem contributes to a willingness to take advice and confront new challenges.

(c) Fredric Neuman, Author of Detroit Tom and His Gang

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