An Analyst’s Advice

Most of my patients come to me seeking advice. Since I was taught that advice inhibited the analytic process and was not helpful to the patient, it has only been after two decades of work as an analyst that I have found this strict orthodoxy did not always reflect what is best for the patients in my care.

According to Webster’s, advice is “an opinion or recommendation offered as a guide to action, conduct, etc.” To advise is defined as “to give counsel to; offer an opinion or suggestion as worth following.” While it’s unlikely that I would ever proffer an opinion to a patient, I might, on the other hand, find myself giving counsel or recommendation. Clearly there is a distinction between giving counsel or recommendation and advancing an opinion.

While some might say I’m unorthodox, at times I find that giving advice is the exactly appropriate course of action. Working in the trenches has taught me the need for flexibility when applying the precepts of psychotherapy to the needs of a patient.

Several years ago, I treated a man who had difficulty maintaining an erection when having sex with his girlfriend. While Viagra was helpful with sustaining an erection, the medication inhibited an orgasm. This problem had been ongoing since the beginning of their relationship. At one point I asked him if and how his partner’s orgasms might play a role in their sexual dysfunction. Nonplussed, he said he had no idea and had never thought to ask. My thinking was that if the focus of their sexual difficulties was only on him, satisfying her may open up their sex life in new ways. I recommended that he approach the topic with her and do his best to break the sexual stalemate. By advising him, I allowed him to talk about the difficulties he had expressing sexual thoughts.

Another patient who was in a long-term relationship became infatuated with a co-worker and was having an affair. She felt very guilty about the affair and put an end to it while she contemplated what to do next. But because she saw her co-worker every day at work, she found herself being pulled into continuing spending time with her. This was confusing and only exacerbated her guilt. I thought it would be helpful to establish boundaries with her co-worker. I helped her set ground rules governing how much time she spent with the other woman. By working with her and advising her around boundries, I helped her clarify her needs and feelings.

As therapists, we must remain open to what may be best for those patients in our care. While there are many theories and modalities on how to best treat patients, it’s essential to remain flexible. I find that being open and eclectic, even at times giving advice, serves the people I treat and best yields improvements to their mental health.

Teaching Couples to Empathize

Empathy forms the cornerstone for a successful therapeutic relationship.  While we may find empathy difficult to establish or even define, it is vital for building trust and engendering communication.

When working with couples, empathy is complicated because the therapist must, in addition to conveying empathy to each individual, teach each member in the couple to empathize with each other.  Within this triad, the danger of rupture is real, and the work, perilous.

In couples’ therapy I begin by framing the issues as they’ve been presented.  I make it clear that such problems will be considered on a 50/50 basis.  That this is imperative is obvious – I’m not going to take sides or make one person the sole cause of a problem. When a member of the couple feels that responsibility for a particular action (or non-action) resides with the other, I remain rigorous in holding to the premise that responsibility is shared equally.  I never treat an issue as though it were one person’s fault even when pressured by a member of the couple to do so.  I have found that this egalitarian approach is eventually accepted by the couple and contributes greatly to the balance of the work.

Virtually all problems with couples result from misunderstanding and a lack of communication.  Once I’ve taught the couple to behave in an empathic way, issues long cemented shut through repetition are revealed such that the couple can view the problem from a different perspective.

Sex and money are the most problematic and intractable issues in most relationships because those issues are really about much more than just sex and money.  Couples generally have assumptions that issues like sex and money will be complimentary and problems suggest dysfunction in the relationship.  But in fact conflicts in relationships are natural when two people merge their lives, each of the couple bringing into the relationship the entirety of his or her histories.

I often work with couples who have a substantial sexual problem, mostly when sex has ceased to be an expression of intimacy.  This is probably the most difficult area to facilitate change and growth.  

I worked once with a couple who had a total breakdown of physical intimacy, each blaming the other for   the dysfunction.  The man in the relationship had closed down and was not capable of physically or emotionally initiating or following through with physical intimacy.  His early sexual trauma was reactivated when he shared it with his girlfriend.  The woman blamed her boyfriend for not being attracted to her anymore (their early sexual relationship was very good) and angrily accused him of distorting his history.  This created a serious rupture of trust that caused the man to shut down.  I helped each of the couple talk about their pain – she of being rejected, he of not being trusted and cared for.  This reframing helped them feel empathy for the other.  The couple did not stay together but they were able to part with understanding and compassion.

Such understanding, compassion, and honesty are necessary for establishing empathy and replace defensiveness with loving communication.  The role of the therapist is to model empathic behavior and help each in the couple accept and appreciate their differences as well as similarities, furthering an emotional maturity in which a healthy relationship thrives.