Not Giving Advice

I was teaching a set of my students last week and we spoke about suicide. One of my students said that it was the task of a nurse to persuade someone not to kill themselves. I said, forcibly, that I did not think this was part of a nurses’ role. Nor the role of anyone involved in therapeutic work. I believe we have a responsibility to listen to our patients. To help them think about their choices. To allow them room to breathe. Ultimately, however, if a person is going to kill themselves, they will do so. No matter how painful this might be for all involved. Professionally, I have only had one of “my” patients kill themselves. And one “shared” patient who left our Therapeutic Community to kill himself. The young man who was “my” patient was both too well and too ill for psychiatric services. He was too ill in that his psychotic material was deeply embedded and intractable and not susceptible to any talking therapy. (He would not take medication.) He was too well because he appeared to function very well despite his psychotic thinking. I was his Community Psychiatric Nurse and took the decision after quite a time that I would discharge him from my caseload. Some months after this he killed himself. Whilst I do not hold myself directly to blame, I often wonder what would have happened if I had not discharged him. His mother very generously thanked me for being one of the good things in his life. I was. But not good enough to balance the bad objects inside him.

I was talking to another counsellor the other day about being given advice. I had said that there are some people whom I find impossible to listen to. They have a way of talking to me that touches something deeply primeval in me. I cease being an intelligent, thinking adult and revert to a primitive inarticulate Neanderthal who is gripping his club with all his might just waiting for the opportunity to swing it. Hard. On their head. At which point I shall beat my chest and do a victory dance! (I have to point out that so far I have never acted out this fantasy! I go away and plot, connive, dream etc. But all in my head!)

Suicide contains this rage. There was a Twitter storm recently following the death of a man who had jumped from a motorway bridge and been hit by a vehicle. The Twitter storm was because some comments had been made about how bloody selfish this man had been. Many, many people were unable to get home. Get to appointments. Leave the motorway and the like as a consequence elf the huge delay caused by this incident. They tweeted their frustration. This lead to a counter blast from many more people castigating the former group for being so heartless. How dare they not be sympathetic that this poor man had been so needy that he killed himself. Various Mental health professionals posted their sympathies. Added links to Depression Self Help groups and the like. And were very, very angry at those who only had thoughts for their own inconvenience.

I try very hard as a counsellor not to give advice. Experience has taught me that unsolicited advice is usually ignored. I will sit with my patient and listen. And reflect. And comment on what is happening in the session. I will not give advice. Occasionally I am asked to give advice by my patients “What do you think I should do?” I try to respond by wondering what they would like me to say-not always a popular response! But a true one. I am interested in why my patients think I have answers that are better than their own. It sets the counsellor up to be a “better” human being than their pateint. My task is to allow my patient to find their answers. They, after all, have to live with their choices. Not me.

There are times when I wish I could allow myself to advise. The appeal of Cognitive Behavioural Therapy is that it is very directive. One can do CBT at home on the computer with a pre-packaged programme. Follow these steps and there will, in all probability, be this outcome. My professional life would be simpler. I could have confidence in the manual that lay behind my interventions. No more uncertain sessions sitting with my patient wondering “What is happening here today? Why am I feeling as I do in this session? What is my patient putting into me that they don’t want?” With a manualised therapy I could put my affective focus to one side and not constantly attend to our shared inner world. But I can’t do this! Or won’t. I believe deeply in the value of self determination. Freud said that the purpose of psychoanalysis was to make the unconscious conscious.Thus I learn about why I do the things that I do. Why I feel a sense of primeval rage at some people.(Yes. I do understand its origins. That way I can prevent myself acting out that rage!) When the unconscious comes into our consciousness, We can make choices. We cease to be driven my forces we do not comprehend or know.

Perhaps if the man who jumped from the motorway bridge had been able to understand his murderous rage, his life might have been different. Sadly this was not the case.

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