Disclosure and Concealment in Psychotherapy

Sarah Knox, Clara Hill, Sarah Knox, Clara Hill

• Publisher: Taylor & Francis
• Year: 2018
• Print ISBN: 9780415366564
• eBook ISBN: 9781351857871
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Although clients disclose many of their concerns to therapists, they often choose to conceal some of their concerns as well. Equally, therapists occasionally reveal something of themselves to clients via therapist self-disclosure, but typically keep the focus on clients. Such disclosure, whether by clients or therapists, is seldom easy, and is instead often fraught with questions as to what, how much, and why to disclose, as well as concerns regarding the consequences of disclosure. Clearly, disclosure (or the lack thereof) is an important phenomenon of the therapy endeavour.

The chapters included in this book examine various aspects of the disclosure and concealment phenomena, whether from client or therapist perspective. Contributions examine the relationship of therapist self-disclosure to alliance and outcome; the phenomenon of therapist self-disclosure in psychodynamic therapy; client concealment and disclosure of secrets in therapy; young adults' disclosures in psychotherapy and on Facebook; and lying in psychotherapy. Each offers intriguing insights into the disclosure, or lack of disclosure, in psychotherapy, from the therapist or client perspective. This book was originally published as a special issue of Counselling Psychology Quarterly.

Lying in psychotherapy: Why and what clients don’t tell their therapist about therapy and their relationship

Matt Blanchard and Barry A. Farber

Teachers College, Columbia University, New York, NY, USA

Objectives: The primary aim of this study was to investigate one facet of a survey of client lying in psychotherapy, that which focused on the nature, motivation, and extent of client dishonesty related to psychotherapy and the therapeutic relationship. Method: A total of 547 adult psychotherapy patients reported via an online survey, incorporating both quantitative and qualitative methodologies, what topics they were dishonest about in therapy, and the extent of and reasons for their dishonesty. Results: Ninety-three percent of respondents reported having lied to their therapist, and 72.6% reported lying about at least one therapy-related topic. Common therapy-related lies included clients’ pretending to like their therapist’s comments, dissembling about why they were late or missed sessions, and pretending to find therapy effective. Most extreme in their extent of dishonesty were lies regarding romantic or sexual feelings about one’s therapist, and not admitting to wanting to end therapy. Typical motives for therapy-related lies included, “I wanted to be polite,” “I wanted to avoid upsetting my therapist,” and “this topic was uncomfortable for me.” Conclusions: Clients reported concealing and lying about therapy-relevant material at higher rates than previous research has indicated. These results suggest the need for greater therapist attention to issues of client trust and safety.

Seldom, very seldom, does complete truth belong to any human disclosure; seldom can it happen that something is not a little disguised or a little mistaken. (Emma, Jane Austen)

Client honesty has been central to psychotherapy since Freud set out his “fundamental rule” – that the client should reveal everything that came to mind, as it came to mind, as honestly as possible. More generally, clients’ disclosure of thoughts and feelings constitute the primary source material with which therapists work (Stiles, 1995). Nevertheless, as Freud and many other subsequent theorists and researchers found, clients are not always honest. They keep secrets (Kelly, 1998), hide their negative reactions to clinical interventions (Hill, Thompson, Cogar, & Denman, 1993), minimize discussion of personally salient topics (Farber & Sohn, 2007), and sometimes spin elaborate outright lies (Gediman & Lieberman, 1996). Researchers have tried to quantify the prevalence of dishonesty in psychotherapy, arriving at estimates between 20 and 46% of clients admitting to “secret-keeping” in therapy (Hill et al., 1993; Kelly, 1998; Pope & Tabachnick, 1994). A broader definition of dishonesty that includes twisting the facts, minimizing or exaggerating, omitting, or pretending to agree with the therapist would probably find that client dishonesty is almost universal. Defined in this manner, dishonesty is likely to be present to some extent in virtually all human interaction (DePaulo & Kashy, 1998; DePaulo, Kashy, Kirkendol, Wyer, & Epstein, 1996; Jellison, 1977). For purpose of this study, and reflective of the ways in which clients themselves view their lying in therapy (Blanchard & Farber, 2015), our focus is not just on overt distortions of facts but includes as well instances of concealment.

The question for clinicians, then, may not be “who lies in therapy?,” but rather “what do clients lie about, and why?” The study of client dishonesty can highlight problem areas in psychotherapeutic treatment, alerting therapists to topics about which they may not have sufficient accurate information to know how to proceed clinically. Although clients lie about a great many matters, including the extent to which they experience distressing and even suicidal thoughts (Blanchard & Farber, 2015), in this paper, we focus on one specific category of client lie, one with significant implications for the therapeutic process: client dishonesty about therapy itself or their feelings about their therapist.

Most every contemporary psychotherapy, even those seen as primarily manual-driven and symptom oriented, endorses the central importance of the therapeutic relationship. It is widely considered a common element across therapeutic approaches (e.g. Norcross, 2011). Some orientations (e.g. Person Centered) hold the relationship as primary, as the essential healing force underlying therapeutic progress; others (e.g. CBT) view it as the foundation for effective interventions, and still others (e.g. relationally oriented psychodynamic psychotherapy) see the therapeutic relationship as both healing in its own right as well as the basis for understanding other prior and current interpersonal relationships. Extensive research on the significant positive relationship between treatment outcome and an effective therapeutic alliance (e.g. Horvath, Del Re, Fluckiger, & Symonds, 2011) as well as effective resolution of alliance ruptures (e.g. Safran, Muran, & Eubanks-Carter, 2011) provide further evidence of the importance of a good – and presumably trusting and honest – therapist–client relationship. Some theorists (e.g. Cabaniss, 2011) have even suggested that trust is at the heart of the therapeutic relationship. Thus, client concealment of salient information and/or outright lies may be seen as threats to the integrity and mutative potential of the client–therapist relationship. This is especially the case, given the evidence that therapists are typically unable to detect hidden client reactions and things left unsaid during sessions (Hill et al., 1993).

As noted above, we define client lying and dishonesty broadly – as any decision by the client to not be honest with their therapist about relevant information. This definition assumes both the intent to conceal or deceive, and a conscious awareness of the falsity. In keeping with previous work in this area, the definition excludes delusions, rationalization, repression, denial, or other forms of unconscious self-deception. While some authors have focused on specific types of dishonesty (e.g. secrets, etc.), we believe client dishonesty is best assessed as an all-encompassing phenomenon. Investigating any one portion of the dishonesty spectrum, such as secret keeping or extent of self-disclosure, is likely to offer only a partial view of the underlying clinical situation, and may fail at Plato’s classic injunction to “carve nature at its joints.” When clients decide not to be honest with their therapist, they can choose from a range of strategies, from subtle avoidance and evasion to wild fabrications. The choice of strategy, while clinically interesting and perhaps diagnostic, is arguably less important than the underlying decision to be dishonest, which typically has significant implications for the therapeutic process.

The clinical and research scholarship on client dishonesty, though modest, addresses three major areas: (a) the types of and motives for dishonesty, (b) topics about which clients are dishonest, and (c) the consequences of dishonesty for therapy. We review these studies with a particular focus on the extent to which they have shed light on client dishonesty about therapy per se or the therapeutic relationship.

Types and motives

Several authors have sought to delineate types of dishonesty encountered in therapy, and in most cases, the notion of “type” encompasses both the strategy used and the client’s motive for lying or concealing information. This approach has produced several taxonomies of clinical lying, with Gediman and Lieberman (1996), Ford (1996), and Grohol (2008), each proposing lists with more than a dozen separate types of client dishonesty. Gediman and Leiberman’s taxonomy is the most comprehensive, consisting of 13 categories, including white lies (told for reasons of politeness), gratuitous lies (told to establish psychological distance), omissions, secrets (a subtype of omissions that is conscious), outright lies (told deliberately to mislead), and pseudologia fantastica (pathological lying) and delusions. Their list is meant to capture “all varieties of deception in the analytic dyad” (p. 15), with each associated with a motive. Thus, the white lie is thought to be motivated by politeness, whereas true delusions are considered the product of psychotic retreat from reality. By contrast, Newman and Strauss (2003) argue that non-delusional clinical lies fall into just two important categories: lies wherein the motive is fear and shame (i.e. the client is ashamed or afraid of the truth), and calculated lies where the motive is to achieve some conscious purpose (e.g. the client wants to escape responsibilities, get a prescription, or win a legal case).

Hill et al. (1993) distinguished between three types of “covert processes” engaged in by clients: hidden “reactions” to therapist interventions; “things left unsaid” in regard to their thoughts and feelings; and “secrets” about major facts or feelings outside therapy. Several studies by Hill and colleagues (Hill, Thompson, & Corbett, 1992; Hill et al., 1993; Thompson & Hill, 1991) found that clients hide negative rea...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Citation Information
• Notes on Contributors
• Introduction: Disclosure and concealment in psychotherapy
• How therapist self-disclosure relates to alliance and outcomes: A naturalistic study
• Therapist self-disclosure in psychodynamic psychotherapy: A mixed methods investigation
• Client concealment and disclosure of secrets in outpatient psychotherapy
• Young adult self-disclosures in psychotherapy and on Facebook
• Lying in psychotherapy: Why and what clients don’t tell their therapist about therapy and their relationship
• Index