Blanchard, M. & Farber, B.A. (2016). Lying in psychotherapy: Why and what clients don’t tell their therapist about therapy and their relationship, Counselling Psychology Quarterly, 29, 90-112.
Clients’ disclosure of their thoughts and feelings are key aspects of psychotherapy, and trust is at the heart of the therapeutic relationship. However clients are not always honest with their therapist. Clients may keep secrets, hide negative reactions to interventions, minimize, spin, or tell outright lies. In this study, Blanchard and Farber asked: “what do clients lie about in therapy and why”. The authors used a broad definition of dishonesty that included: consciously twisting the facts, minimizing, exaggerating, omitting, and pretending to agree with the therapist. The authors excluded delusions, repression, denial, and other forms of unconscious deception. Blanchard and Farber were particularly interested in client dishonesty about therapy itself and about the therapist. The authors conducted an online survey of psychotherapy clients recruited from a community sample in a U.S. city, and 547 adult clients responded. The sample was surprisingly similar to a therapy-using population reported in the National Survey on Drug Use and Health. Most clients were women (78%), White (80%), saw a female therapist (71%), received CBT (35.4%) or psychodynamic therapy (18%), and were treated for depression (64%) and/or anxiety (49%) disorders. The survey asked about a wide range of possible topics for dishonesty such as use of drugs or alcohol, desire for revenge, pretending to agree with the therapist, etc. With this broad definition of conscious dishonesty, 93% of clients reported lying to their therapist, in which the average number of topics lied about per client was 8.4 (SD = 6.6). Those who lied more often also reported a general tendency in their lives to conceal negative personal information (r = .45). Only 6.8% of clients reported having told zero lies in therapy. Some topics were highly endorsed by clients – for example, 54% endorsed lying about “how badly I really feel – I minimized”, 25% did not disclose “my thoughts about suicide” and “my use of drugs or alcohol”. Other topics (endorsed by 5% to 25% of clients) included lies about eating habits, self-harm, infidelity, violent fantasies, experiences of physical or sexual abuse, and religious beliefs. About 72.6% of clients lied about at least one therapy-related topic, including: “pretending to like my therapist’s comments or suggestions” (29%), “reason for missing an appointment” (29%), “pretending to find therapy more effective than I do” (28%), “pretending to do the homework” (26%), “my real opinion of the therapist (19%), “not saying I want to end therapy (16%), and “my therapist makes me feel uncomfortable” (13%). Other items were relatively rare in the sample including “my romantic or sexual feeling about my therapist” (5%). Survey respondents were then asked why they were dishonest. Reasons why clients were dishonest included: “wanting to be polite”, “I didn’t want my therapist to feel he was bad at his job”, “I didn’t want to look bad or feel embarrassed”, “I would feel bad if I told her it really didn’t help me”, “wanting to avoid my therapist’s disapproval”, and “wanting to avoid upsetting my therapist”.
Using a broad definition of dishonesty, this study found that 93% of clients did not tell the truth in one way or another to their therapist. Concern about self-judgments (i.e., embarrassment) or external judgments (i.e., avoiding therapist’s disapproval) may lead most clients to be less than honest at some times. Over 70% of clients reported lying about an aspect of therapy itself or of the therapeutic relationship. Clients appear to be particularly sensitive to upsetting or disappointing their therapist. This suggests the importance of therapists monitoring the level of emotional safety, trust, and alliance in the therapeutic relationship. Therapists may have to accept a certain level of dissimulation by clients in the therapy. Engaging in empathy, positive regard, and a focused attention on the therapeutic relationship may be important for therapists in order to overcome a level of fear or distrust among some clients about their self-judgement or the therapist`s judgment. These findings suggest that clients may benefit from therapists who receive training in identifying and resolving therapeutic alliance ruptures.