What Do We Believe and Whom Do We Trust?

Earn CE Credit

• Clients Who Lie and Deceive
• Some Reasons Why Clients Lie
• Fear of Shame and Humiliation
• Disappointing the Therapist
• Ignorance
• Living Alternative Realities

Caitlin had been referred by her physician because he could find no organic cause for her symptoms. She had complained of a variety of medical problems that led to being run through a gauntlet of tests, scans, and diagnostic procedures, all negative. Yet her problems, regardless of their origin, seemed to worsen over time. Caitlin was hardly the most expressive or verbal client I'd seen.

Although in her mid-twenties, she reminded me of some adolescents who would rarely speak; in her case she was virtually mute.

"What can I help you with?" I asked to begin our first session. Shrug.

"You're not sure?" Another shrug.

Was she playing a game with me? Was I being tested? Did she have laryngitis or a mental handicap? I could not be sure.

After five long minutes of silence in which she stared at the floor, seemingly fascinated by the weave of the carpet, I had finally had enough. "Look Caitlin, I'm not sure what you expect of me or why you're here. The only thing that I know is that your doctor sent you to me because he couldn't help you. I understand you are having a lot of problems, and, apparently, he thinks it might be helpful for you to talk about them. But I can't help you unless you tell me what's going on."

Incredibly, Caitlin shrugged again but this time offered a wry smile.

Now I was determined to wait her out. There was something going on here that I did not understand, but I sensed that pushing her further was not going to work. I just wanted to get through the hour and send her on her way. Obviously, she was not ready for therapy.

We sat silently for the rest of the session, Caitlin alternately staring at the floor and some undetermined spot over my left shoulder. I checked a few times, just to see what was so interesting, but it was one of the few blank spots on the wall. Maybe she was projecting her own images. At this point I did not know or care; I was already thinking about my next client and what I could do to make up for this disaster.

Imagine my surprise when the session finally ended and Caitlin said to me, "Same time next week?"

I was taken by such surprise that all I could do was nod my head. Now I was the one who was rendered mute.

The second session repeated the pattern of the first: Caitlin took her seat but would not speak. She just sat there, apparently comfortable and unconcerned with the silence. Even though I was prepared for this eventuality, and had rehearsed several things I might do to draw her out, each overture was met with a shrug or ignored altogether. By the time the second session ended, I was resolved that I'd had enough: no more "same time next week."

I was just about to call for an end to this charade, pretending to be therapy, when Caitlin abruptly stood up, handed me an envelope, and exited, stage left. I was dumbfounded, frozen in place, holding this offering in my hand, unsure what to do next. I told myself that I should just put it aside for now—it could not be good news—but my curiosity got the better of me. I ripped open the envelope to find a five-page single-spaced letter in which Caitlin had outlined the sorry state of her life. It included all the things that a client would normally reveal in the first few sessions, talking about her early history, her family situation, her living arrangements, employment, and cogently reviewing all her various physical symptoms. She ended the self-report by stating that she hoped I understood how difficult it was for her to talk about these things and asked if I could be patient with her. She said she would return the following week if I'd still be willing to see her.

What could I say to that? I just shook my head, eager to resume this "conversation" during our next meeting. Oh, did I mention that I assumed that the structure of our communication might change? No such luck. It was more of the same: continual and unremitting silence. In response to everything I brought up from her letter, Caitlin would smile or shrug or sometimes frown and shake her head. I was so desperate, that seemed like progress: at least now I could get a tentative yes or no in response to a question.

"Caitlin," I tried again, "you wrote in your letter that you live with your brother. How's that working out?" Shrug.

"Just okay? You mentioned in your letter that you were close." She nodded her head.

And so it went, another frustrating, laborious, tedious (did I mention frustrating?) hour.

Fast forward five months. I have now seen Caitlin every week at our appointed weekly time. We are talking now. Or at least I am mostly talking and she occasionally rewards me with an actual verbal yes or no response, and sometimes she even utters a whole sentence. But basically she does not say much—until she hands me a letter at the end of the session that basically answers every question I asked the previous session and even a few things I wondered about but had not yet broached. I have certainly never done therapy quite like this, and it sure is hard work, but I tell myself that she is coming back, so she must be getting something out of the experience.

Another few months go by and I eventually learn a lot about Caitlin's life and her predicament. Her physician has been increasingly concerned because of abrasions in her vagina and burns on her breasts, wounds that appeared to be self-inflicted. When I asked her about this, Caitlin immediately clammed up and would not talk about them at all, even in a follow-up letter. The doctor called a week later to tell me that he "fired" Caitlin as a patient, refusing to see her any longer. I assumed this was because she was playing the same kind of silent treatment games with him that she was acting out with me, but I was wrong. Apparently, Caitlin had been left alone in an examining room when a nurse unexpectedly entered and found her holding the thermometer that had been placed in her mouth underneath the flame of a lighter to artificially raise the temperature and fake a fever. All of a sudden things started to fall in place, and the doctor realized that he was dealing with a case of Munchausen syndrome in which Caitlin had been manufacturing various disorders and diseases all along as an excuse for attention. This was clearly a case for psychological treatment, way out of his domain—and firmly back into mine.

But this called into question everything that she had thus far told me in her letters. How much of this was really true? How much could I trust anything that she had related to me? If she had been willing to fake her various ailments, and lie about her symptoms, what was to say that anything about her history was true? How could I work with a client who was now identified as a chronic liar?

I'm hardly the first therapist to work with someone with Munchausen syndrome, or a factitious disorder, or a sociopath, or any other client who knowingly lies, but once these fabrications and deceit are uncovered, what are we to do with them?

After so many months invested in our relationship, I initially felt betrayed, just as I had with Jacob. But in Caitlin's case, I quickly realized this was one very vulnerable, terrified, disturbed young woman who was doing the best she could to hold things together. If she was willing to go to such extremes for attention and self-protection, what did that say about anything she would tell me in therapy? And how and when is it appropriate and safe enough to confront this issue directly?

I decided that I really did need to confront the issue of truth with Caitlin, not for my own satisfaction, but to make it possible for us to have a truly trusting relationship, maybe the first one in her life. I had by this point learned that there were all sorts of weird things going on in her family, lots of secrets and lies that had been kept hidden.

It was during the middle of one of our silent conversations that I took a deep breath and told Caitlin that I had a few things that I wanted to bring to her attention. One of the advantages of having a client who does not talk is that it is very easy to carve out time to say whatever I want and expect a fairly compliant audience. She cocked her head and actually made eye contact, signaling that she realized that something important was coming.

I told her everything that I had recently learned, that she had been making up her various ailments and faking the symptoms in order to visit the doctor, perhaps for attention and sympathy, or perhaps for other reasons that she might reveal. I presented specific, irrefutable behavioral evidence, complete with witnesses, so there would be no sense denying the "charges." Furthermore, I shared with her my concerns that all along she had been playing games with me, just as she had with the doctors giving me the silent treatment and refusing to talk (except in carefully constructed letters). She seemed to be taking this with relative calmness, so I went further and talked about how this made it difficult for me to trust her. I told her how much I cared about her, how much I wanted to know her better, how important it was for me to help her if she would let me, and how I was bringing all this up because it felt like we could never go much further unless we were more honest with one another. Maybe this is coming across as harsh, but I tried to be as gentle and loving as I could while bringing the deceit into the open. And I insisted on thinking about this as an issue of honesty in our relationship rather than as a pathological condition named after an obscure German baron.

Caitlin looked at me thoughtfully after I finished what I had to say. I fully expected complete silence and so was surprised—and delighted—that after close to nine months we had our first real face-to-face conversation. It was as if a door had been opened and she had decided to walk through and meet me, if not halfway, then a few tentative footsteps in my vicinity. For the rest of that session, and the few that followed, she told me about the sexual abuse she had experienced since she had been a child by her brother, the same brother who was still living with her, and still sneaking into her room at night. She admitted that she had been hurting herself, sticking objects in her vagina and burning her breasts with lit cigarettes, in order to discourage her brother from continuing to have sex with her. She talked about all the guilt she had been feeling and how she understood the meaning of the self-punishment. She even understood that her silence in her relationship with me was a way for her to maintain control, to take care of herself while in the room with a strange man who might hurt her the way she had been betrayed before.

Yes, I know what you are thinking: Was this true?

This time I can say, unequivocally and without reservation, yes, I am convinced that Caitlin did eventually trust me to risk revealing herself in a more honest and authentic way. How do I know that? Well, for one thing her symptoms disappeared. She moved out of the apartment where she had been living with her brother. She became functional in a whole host of other ways related to her work and other relationships. She confronted her brother, finally, and told him to never, ever come near her again or she would call the police. (I was able to get corroboration that this, in fact, did take place, and I was prepared to testify on her behalf.)

Yet would I be surprised if I ever learned that I had been scammed, that she made the whole story up, that she was still playing me—but simply changed tactics once I caught on to the previous game? Yes I would. I will never know of course. Most of the time we can never really know what is true and what is not. We have to live with this uncertainty and give people the benefit of the doubt. To do otherwise, we could never do this work or function at all.

Maybe you are not very surprised that there would not be much neat closure to our topic. You already knew there is no certainty in what we do, given the complexities and ambiguities or the territory in which we operate.

Clients Who Lie and Deceive

It is the client's job description in therapy to tell us what is going on as fully, completely, and honestly as possible, providing the most detailed and robust descriptions of complaints, life history, contextual features, and innermost thoughts and feelings. The reality of what we actually get from clients is less than ideal for a number of reasons. There are unconscious distortions and imperfect memories. Defense mechanisms operate to protect the client against pain, discomfort, and perceived attacks. Character traits may compromise trust and intimacy.

In a blog (psychcentral.com), psychologist John Grohol (2008a) asked people why they would ever lie to therapists. This was a question that he could never really understand. "If you lie to your therapist," he pointed out, "especially about something important in your life or directly related to your problems, then you're wasting your time and your therapist's time." He cites lies of omission as an example, such as a client saying he is depressed and uncertain why, yet failing to mention that his mother recently died. Or another example in which someone complains about low self-esteem but neglects to say that she binges and purges after every meal.

When Grohol first wrote his essay, musing about the ridiculousness of lying to the person who is paid to help you, he was completely unprepared for the barrage of clients who would respond on his blog. Here are a few representative reasons posted why people lie to their therapists:

I don't yet trust my therapist, partly because I'm not confident that this therapist has the skills or experience to handle my problems in the first place. (Adrivahni, January 9, 2008)

i lie to my therapist about what i'm feeling towards her. i'm embarrassed about these feelings, and when i do try to share them, they come out wrong. those are that i feel too dependent, that I want more than what she can give me, and that i find these feelings to be a sort of weakness in me. (Cameron, January 9, 2008)

We all lie to our shrinks, just like we lie to our dentists (Sure, I'll floss twice a day) and our mechanics (It's not so much a click as a drum roll). But the point of repeat visits to our shrinks is to allow for the time necessary to figure out what's a lie, what's a misconception, and what the truth (for that day) is. (Gabriel, January 10, 2008)

Dozens of other confessions led Grohol (2008b) to write a follow-up essay about common reasons to lie to your therapist. Contributions from him and from other sources (DeAngeles, 2008; Gediman & Leiberman, 1996; Kelly, 1998) identified several of the most common reasons for deception in therapy sessions.

Some Reasons Why Clients Lie

We have seen how lying is a natural and normal part of daily life, a practice that first begins about age 3 or 4 when we first learn we have choices about what we tell others, each presenting different consequences. Biologist Lewis Thomas once observed that if people stopped lying, the world would end, politicians would be arrested, media would be cancelled, and people would stop talking to one another. Lies, or at least half-truths and other fractions of complete honesty, allow trust to build. In therapy, deception is just another in a series of defenses that clients use to remain in control and to protect themselves.

Many, if not most, clients keep certain things from their therapists in order to present themselves in the best possible light. Whereas previously it was believed that lying or deceiving a therapist would only sabotage the treatment, it would appear as if clients may actually benefit by keeping some things private (Kelly, 1998). People lie to their spouses and partners, their family and friends, especially to coworkers and others in which favorable impressions are critical to continued success. It should come as no surprise that clients also lie to their therapists, a lot.

Fear of Shame and Humiliation

Let's face it: it is hard to talk about secrets, about sex, about mistakes and failures, about shortcomings, about feeling helpless to take care of one's own problems, about almost anything that people bring to sessions. It hurts.

Many clients lie to their therapists to avoid feelings of shame, embarrassment, and what they believe will be critical judgment by their therapists (DeAngelis, 2008). We may think of ourselves as neutral, accepting, and nonjudgmental, and advertise ourselves as such, but that does not mean that people actually believe us. And they aren't far wrong. The reality is that we are sometimes critical and judgmental (at least inside our heads) when clients do or say things that seem stupid, even as we keep the poker face in place, nod our heads, and pretend we do not care one way or the other.

Much of the content of therapy involves talking about things about which people feel most ashamed and embarrassed, and most reluctant to admit. It takes awhile for clients to warm up, to feel safe enough, in order to broach the subjects that are most sensitive. It is during this period in which the therapist is on probation that clients will take any steps necessary to risk greater vulnerability. When we think about it, it is absolutely ridiculous for us to anticipate anything different—that is, to actually expect a new client during the first few weeks to spill his or her guts and come clean with anything and everything that has been previously disguised or hidden. Lying during the initial (and subsequent) stages of therapy is not only normal but highly adaptive and healthy.

Disappointing the Therapist

Whether clients are afraid of disappointing their therapists, or whomever he or she represents as an authority or parental figure, there is often concern (or perception) that the naked truth will result in a loss of respect. One client explains why she lied: "For myself, one of my biggest problems has been worrying that I was letting my therapist or psychiatrist down in some way. I try to hide when I feel depressed, fearing that my mood is somehow going to wreak havoc on others. My therapist is a cognitive behaviorist and I used to fret that she'd think I hadn't been doing my homework. Also, she was so clearly concerned for my well-being that it upset me to come in when I was feeling lousy!" (MacNamarrah, 2008).

It is ironic, but all too often the case, that clients do not talk about what is really bothering them, or even cancel sessions when they need help the most. They believe that others—even someone who is paid to be helpful—cannot really handle their deepest secrets and innermost selves. In addition, therapists are required by law to report suspected (or confessed) cases of physical, emotional, or sexual abuse. We are also forced to act when there is a risk of harm to self or others. Then there are other illegal or moral transgressions that may have been committed in the past, or are still currently going on. It behooves such an individual to be less than completely forthcoming with anyone, much less a professional who is mandated to contact authorities.

Ignorance

Some clients, who are relatively unsophisticated about therapy, or about how change takes place, leave out all kinds of important stuff because they did not know it was particularly important. It wasn't exactly that they were lying as much as choosing to ignore, deny, or otherwise gloss over things that did not seem all that important—and besides, they are uncomfortable to mention.

Physicians are able to run all kinds of diagnostic tests—blood work, magnetic resonance imaging (MRI), electrocardiograms (EKGs), ultrasound, urine analysis, biopsies, X-rays—because they do not fully trust self-reports as accurate data. We are left with what clients choose to tell us based on their beliefs about what is relevant, awareness of what they know and understand, and willingness to share information selectively. It is no wonder that we are operating with imperfect, flawed, and incomplete data. Even in cases of clear success, how confident do you feel that you really understood what was going on? How certain are you that the results reported were truly accurate? If you answer, unequivocally, that you are very confident, perhaps you should consider your own degree of honesty.

Living Alternative Realities

For those with personality or factitious disorders, lying is a way of life. It has become so habituated that the person actually comes to believe the fantasies that are spun; they become an alternate reality.

When Meghan first contacted me, it was in a letter she had written after discovering one of my books at a garage sale (the first book I ever wrote that she purchased for a dollar). At the time she was a teenager and we struck up a correspondence that lasted for 20 years. Meghan struggled with depression throughout most of her life, had contemplated and attempted suicide many times, never deciding on the best method to end her life.

I'm still not sure what role I played in her life, but I always responded to her letters with support and caring, encouraging her to stay in therapy and continue to work on herself. She ended up reading many of my books over the years and, each time, would send her comments and reactions. Over the years she also told me a lot of things about herself, sent photos, brought me up to date on her family and relationships, and occasionally asked for advice. Even though she was not a client, and I never actually met her, I felt a certain responsibility to be as kind as I could; there was obviously some kind of transference going on and I wanted to be careful.

Eventually I learned that much of what Meghan had told me over the years were lies. I believe the part about her depression and suicidal thoughts, but I discovered that the photos she sent me were of someone else, the stories she told me were fictions, and that she had even sent me e-mails masquerading as other people. It was a bizarre case that I did my best to extricate myself from, although every few years Meghan will contact me again in some other disguised form.

There are other people like Meghan in the world and you have met them, perhaps worked with them. Sometimes you recognize them before you are sucked into their fantasy worlds; other times (most of the time in my experience) you do not realize the level of deception until it is far too late. One of the reasons it is so difficult to detect such mendacity is because the individuals have managed to confuse lies from truth; they cannot seem to tell the difference.

Unlike Jacob, I did have the chance to confront Meghan directly (and repeatedly) about the games she had played over the years. After each instance of discovering a lie, she would first deny it, then apologize profusely and beg for another chance. I gave up trying to negotiate a more honest form of communication with her soon after she sent me a draft of her autobiography, which she claimed would soon be released by a major New York publisher (another lie). It was titled: "I Will Tell You No Secrets and Tell You All Lies."

As with Meghan, some clients are not really lying to "us" but to individuals we represent, whether transference objects or surrogate authority figures. When all is said and done, therapists are never going to be very good at detecting client lies. It is just not part of our constitution, or our training, in which so much of what we learn to do is build trust.

Given the uncertainty and doubt we must accept and live with related to our work, the question remains: How do we work with issues of deception and lies in therapy?

This excerpt from The Assassin and the Therapist: An Exploration of Truth in Psychotherapy and in Life was reprinted with permission from the publisher. For more information and to purchase the book, visit Amazon.com.

Copyright © 2010 Routledge. Reprinted with permission. Published June, 2010.