Practicing psychologists typically believe that their offices are safe spaces, places where patients can feel comfortable sharing their deepest, most intimate thoughts and feelings without judgment, and work toward resolution and healing. Yet a surprisingly high percentage of patients—if not nearly all—admit that they have either lied to or not been completely truthful with their therapists.
"It’s not just common, it’s ubiquitous," notes Barry Farber, PhD, a professor in the clinical psychology program at Columbia University’s Teachers College and the editor of the Journal of Clinical Psychology: In Session. "Lying is inevitable in psychotherapy," he says.
Everyone shades the truth sometimes, whether it’s telling a friend that color really does look good on her or making up an excuse as to why you were late for dinner at your in-laws. "We are always deciding what we are going to say and what we may conceal from others," says Farber. And it seems time spent in a therapist’s office isn’t an exception.
Farber isn’t just speculating—he’s studied this topic for decades. In a survey of 547 psychotherapy clients, 93 percent said they consciously lied at least once to their therapist (Counselling Psychology Quarterly, Vol. 29, No. 1, 2016). In a second survey, 84 percent said this dishonesty continued on a regular basis.
And while therapists might suspect that they can tell when patients are being less than truthful, research shows this is not the case. In Farber’s study, 73 percent of respondents reported that "the truth about their lies had never been acknowledged in therapy." Only 3.5 percent of patients owned up to the lies voluntarily, and in another 9 percent of cases the therapists uncovered the untruth, notes Farber, who reports on this and related research in a new book, "Secrets and Lies in Psychotherapy," with co-authors Matt Blanchard, PhD, and Melanie Love, MS. "It seems therapists aren’t particularly good at detecting lies," Farber says.
What's not being said
Patients tend to lie or not be entirely truthful to their therapists on a wide range of topics, but the researchers were surprised at some of the most common areas of misinformation. "The most commonly lied-about topics were often very subtle," observes co-author Blanchard, a clinical psychologist at New York University. More than half of the respondents (54 percent) in the first study reported minimizing their psychological distress when in therapy, pretending to feel happier and healthier than they really were. This minimizing was nearly twice as common as all other forms of dishonesty, the authors report. The second most commonly reported lie—similar to the first, though somewhat more focused—was minimizing the severity of their symptoms, reported by 39 percent of the sample.
The third most commonly reported lie was concealing or hiding thoughts about suicide, reported by 31 percent of the respondents, and the fourth was minimizing or hiding insecurities and self-doubts. (See a list of more common lies on the next page.) In all, six of the 20 most common lies were about the clients’ experience of therapy itself, such as pretending to find therapy effective.
Why lie?
Clients devote a good deal of their resources (both time and money) to therapy, so what’s the impetus for hiding the truth? Researchers say it all depends on the lie itself. For the high percentage of clients who are either minimizing their distress or saying that therapy is going better than they really think it is, it’s likely a combination of things. "This ‘distress minimization,’ or acting happier or healthier than they may really feel, may come from not wanting to upset the therapist or be seen as a complainer," says Blanchard. "But it may also be a way to protect themselves from a painful realization of how bad things may actually be. There’s this idea that ‘talking about how I’m doing makes me feel more depressed,’ or that they can’t admit a painful situation to themselves, let alone say it out loud."
For patients who are hiding thoughts of suicide or drug use, the primary reason is likely a fear of the consequences if the truth does come out. "About 70 percent of people who had concealed thoughts of suicide worried about being carted off to the hospital—yet most of them didn’t appear to be suicidal to the point where most clinicians would be forced to take that action," says Blanchard. "Many clients simply didn’t understand the triggers for hospitalization."
The same may be true for drug use, with patients concerned about being coerced into rehab. "Telling you I smoke weed isn’t that big of a deal, but I’m not sure I might want to tell you about the cocaine or OxyContin habit I’ve developed," says Farber.
Then, too, there is the idea of shame—especially as it relates to sex. "Many clients are motivated by shame and embarrassment to lie or hide the truth about this topic," says co-author Melanie Love. "There was also concern that the therapist might judge them or simply not understand where they were coming from."
Some patients were also concerned that if they admitted certain thoughts or feelings to their therapists, it would have an outsize effect on the rest of their therapy. "Some clients think that if I let my therapist know I have an occasional thought of suicide, it will be all he wants to talk about and we will never get to anything else," says Farber.
It’s also important for therapists to recognize the difference between a secret and a lie. The two are related but distinct, says Ellen Marks, PhD, an associate psychologist with University Health Services at the University of Wisconsin–Madison, who has conducted research in this area. "While they both may include a level of deception, a secret is an act of omission, while a lie is an act of deception," she notes.
This can be an important distinction, she adds, especially when it comes to clients revealing secrets during therapy or choosing to keep them to themselves. In Marks’s research, 41 percent of clients concealed at least one secret, while 85 percent disclosed at least one secret (Journal of Counseling Psychology, Vol. 66, No. 1, 2019).
"We have to recognize that keeping secrets may not be a bad thing all of the time," she says. "We need to let go of our expectations that clients share everything with us." Instead, she says, by focusing on what patients do choose to share and establishing the therapist as a trustworthy confidante, "if and when the time is right, the space will be there for the client to share the secret."
Moving forward
So, what can psychologists do about lies in therapy? "In some cases, the best action is to do nothing," says Farber. For example, he says, a therapist might want to keep silent "if the client has explicitly told you that he or she needs to go at his or her own pace on this particular topic and doesn’t want to be rushed into discussing something difficult before he or she is ready, or if you have the sense that pursuing the truth—even gently—means the client may leave therapy altogether." The therapist may also find that a minor lie, such as why the client was late for a session, is better dealt with only if it occurs again or is part of a pattern that needs to be addressed.
But there are steps therapists can take to keep their sessions on track and their clients as honest as possible.
Be up front about the disclosure process. "Clients mentioned that they want therapists to be more active in explaining the process of disclosure," says Love, a predoctoral psychology intern at Temple University. "They would like a therapist to outline what might happen if they were to talk about this topic." Helping to explain why disclosure is valuable for treatment and what the client may gain from it—as well as exploring the idea that clients may experience certain emotions that motivate avoidance—can all be key.
This communication can and should begin early, even in the intake process, says Love. "Taking the temperature of what clients may be ready for and planting the seeds of what types of topics you may be covering is important," she notes.
For patients who may worry about discussing any thoughts of suicide, explaining the limits of confidentiality as clearly and openly as possible can be especially helpful. Knowing what triggers the process of hospitalization may help those who worry about this step if they have suicidal thoughts. Help keep patients safe and comfortable by educating them on what may or may not require a higher level of care.
Ask direct questions. Clients are often willing to discuss almost anything but may be hesitant to take the first step, especially around a topic they find shameful. Therapists who don’t introduce challenging topics can (inadvertently) communicate to the client that these areas are off-limits, according to Farber and his co-authors. Instead, they write, therapists should "model for clients that all topics are discussable in therapy."
The research bears this out. "In our second survey, 46 percent of clients reported they would have been more honest if the therapist had asked direct questions," says Blanchard. "As therapists, we don’t want to be seen as pushy because it’s not our job to be interrogator[s], but there are times when the therapist may need to lead a client toward disclosure with direct questions."
In some cases, questions that elicit a simple "yes" or "no" response may be the easiest way to move things forward. "We may be trained to ask open-ended questions, but this isn’t always the best approach," adds Blanchard.
Providing positive feedback when clients are more open is also important, especially when it comes to reducing some of the shame that may be associated with disclosures on topics that may be perceived as taboo. Ultimately, the authors say, this will strengthen the relationship between patient and therapist.
Be mindful about how you come off. Authenticity is important, especially in therapy, so it’s vital to come across to patients as both understanding and genuine. "For the most part, therapists need to balance curiosity with acceptance and understanding of clients’ limits for disclosure at any one time," the authors note. Using language that feels comfortable and authentic can help, as can being conscious of your own tone. A therapist who comes across as too eager or who overreacts emotionally or, conversely, who acts completely unaffected, like a topic is ho-hum—can lead a patient to shut down.
Some of the female respondents to the survey reported they were worried their female therapists would be especially judgmental of what they might reveal. "One of the most desired interventions was to normalize that it’s OK to talk about certain subjects in therapy and provide a rationale of why it may be helpful," explains Love.
Circle back to certain topics. Patients tend to drop what Farber calls "a doorknob comment," an off-handed comment at the end of a session that indicates there’s a deeper topic involved. "A good therapist is sensitive to this type of comment and will make a note that it may be worth revisiting at a future time," says Farber.
The need to revisit tough topics can also change over time, since some patients will want to wait until they are further into therapy before they feel comfortable discussing such topics; others will give some small indication that they might be hiding something and wait to see how the therapist reacts. It can help to start with a broader topic and narrow it down based on patient cues—such as asking more about relationships in general before getting into details about sexual issues, or broaching symptoms of depression before talking specifically about suicidal thoughts, says Farber.
A therapist may also need to be attuned to body language or other cues that the patient may not be being entirely truthful on a topic. "Take note if you notice that a client feels uncomfortable on a certain topic, and then wait for the right time to talk about it," advises Blanchard. "A lot happens around a person’s eyes, so I will often watch someone’s eyes for a reaction and notice if something is registering that he or she may not be willing to share."
Acknowledge difficulties. Therapy isn’t easy, and therapists sometimes need to take a moment and address that fact, both to themselves and to their patients. "It is sometimes difficult to get to the difficult part," says Farber. Often, it’s important to deal with the resistance to the topic before the topic itself. "It can be helpful to say, ‘We should talk about this more, it feels important,’ or even, ‘I understand it can be difficult to talk about this—let’s not talk about this issue, but why it’s hard to talk about it.’"
For patients who may be worried that their responses may elicit unwanted action by the therapist (such as hospitalization for suicidal thoughts or recommendations for rehab for an alcohol or drug issue), it’s especially important to address these concerns up front. "We need to be sensitive about how to address these issues," says Farber.
The bottom line
It seems inevitable that patients will lie to their therapists, but there is a bright side, says Blanchard. "With time and patience, we can create conditions where clients can be comfortable disclosing their feelings."
And sometimes, perhaps, not being truthful may play its own part in the therapy process.
"Although we most often consider concealment and lies as inevitably problematic, in minimal doses these behaviors are not only inevitable, but can help individuals create more effective narratives about their lives," says Farber. "That, in turn improves their sense of self and their ability to engage with others."
In fact, most therapists should be prepared to acknowledge that they may never really know what’s happening inside a patient’s mind. Even when it may be obvious that a client is hiding something, ultimately it is his or her own prerogative whether or not to share. "It’s not in our interest to be punitive—clients have the right to lie all they want to their therapists," says Blanchard. "Honest disclosure is at the heart of all psychotherapy, but if someone feels like they need to lie, that may also be important."
