Clinical and Empirical Perspectives On Secrets and Lies in Psychotherapy

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Clinical and empirical perspectives on secrets and lies in

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DOI: 10.1037/0000128-004
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6
THE COLUMBIA PROJECT
ON LYING IN PSYCHOTHERAPY:
Copyright American Psychological Association. Not for further distribution.
WHAT DID 1,345 PSYCHOTHERAPY

CLIENTS TELL US?
Lying is man’s only privilege over all other organisms. . . . Not one truth
has ever been reached without first lying fourteen times or so; maybe a
hundred and fourteen, and that’s honorable in its own way.
—Fyodor Dostoevsky, Crime and Punishment
Whenever we present our research on client dishonesty, no matter

how large or small the audience, there is always someone who challenges
the direction of our questioning. Why would we survey and interview clients
about lying? Are we out to catch them? Surely clients have a right to share
what they want to share in therapy and to conceal what they do not feel ready
to discuss. Is there not something accusatory, something at the very least
shame inducing, about the entire thrust of our research?
These questions are good ones. The answers—the real reasons we study
client dishonesty—can be found in poignant stories shared by clients like
Sarah, a woman in her mid-20s who sought psychotherapy to deal with post-
traumatic stress disorder–like symptoms after a traumatic assault. Throughout
her 2-year individual treatment, she found herself concealing the fact that
the trauma had ever happened. Sarah had plenty of good reasons for con-
cealment: She feared becoming too upset to keep her composure, too upset
http://dx.doi.org/10.1037/0000128-007
Secrets and Lies in Psychotherapy, by B. A. Farber, M. Blanchard, and M. Love
Copyright © 2019 by the American Psychological Association. All rights reserved.
113
to advocate for herself if she wanted to stop the discussion, too upset and
ashamed to even remember what she wanted to tell her therapist, and too
upset to allow herself to believe that her therapist could understand or
help. Yet she also left therapy frustrated and feeling more alone. “I couldn’t
be honest about the main reason why I was seeking therapy, so I feel that it
prevented me from making any real progress at all.” The other side of this
story, though not as poignant or consequential as Sarah’s side, would reveal
the frustration and pained helplessness of her therapist, someone who truly
wanted to help but did not have the means to do so.
Few of the 1,345 clients we surveyed liked being or feeling dishonest.

Like Sarah, they were often conflicted, frustrated, or confused and decided
concealment or outright dishonesty was their best option. Yet also like Sarah,
they frequently wished their therapist could have helped them be more honest,
helped them make a tough disclosure or reveal a secret, or somehow freed
them to stop perpetuating a lie. The real reasons we study client dishonesty
have nothing to do with “catching” clients or making moral judgments. We
study dishonesty not to end dishonesty, which we see as the right of all
clients, but to learn how to better foster honesty when our clients need it.
Our research suggests that most clients want to discuss the important secrets
of their lives, but that they often need our help.
In this chapter, we discuss in greater detail than in previous chapters
what we have learned about client dishonesty from two national surveys con-
ducted by the Psychotherapy, Technology, and Disclosure Lab at Teachers
College, Columbia University (overseen by the senior author [BAF]). Our
first major survey asked 547 clients what they had lied about in therapy, with
our choice of the word lying being a deliberate one. Our goal was to capture
the client’s felt experience of being dishonest, and pilot testing showed that
lying was the clearest way for respondents to get this and understand that we
were not simply asking about topics that had not come up in their therapy.
Study 1 collected hundreds of examples of both active dishonesty (telling a
lie) and passive concealment or avoidance (lying by omission). As it hap-
pened, and as we noted previously, 93% of all respondents could recall at
least one time they had lied during psychotherapy, and most could recall
lying about two, three, four, or even eight, 12, or 20 different topics. Study 1’s
online delivery platform allowed hundreds of clients to type in personal
stories about a time when they had lied, what their motive was, and how it had
affected them.
Although the Study 1 findings were intriguing, we knew we had cap-
tured only one angle of a wide phenomenon. Study 2 would help us see
client dishonesty in several additional dimensions. For starters, there was the
dimension of time. We knew that the vast majority of clients could recall
moments when they lied about at least one topic with their therapist. But
114 secrets and lies in psychotherapy

beyond single-incident lies, how many clients would report a more ongoing
or routine pattern of dishonesty? How many would say that they are generally
not honest about certain topics? As expected, when we asked about the sense
of being dishonest on a continuing basis, the prevalence of dishonesty fell
somewhat to 84% of the 798 clients queried in Study 2 but clearly remained
quite high. Study 2 also allowed us to experiment with semantics. What
would happen if we dropped the word lying and instead asked people to rate
how honest they were with their therapist? As it happened, this positive spin
appeared to have little effect on the type of material offered by respondents.
And finally, Study 2 broached what might be the most important question of
the project: “How could your therapist make you feel more comfortable being
honest about this?” Thanks again to the online platform we used for Study 2,
hundreds of clients could offer their perspective on changes to clinical prac-
tice that might foster honesty on a wide range of topics.
We set out to remedy some of the limitations of previous research. First,
much of the best-known work on client dishonesty had been conducted with
small samples. For example, Hill, Thompson, Cogar, and Denman’s 1993
qualitative study of “covert processes” was designed to capture subtle “hidden
reactions” and “things left unsaid” between client and therapist and so under
standably involved only 26 clients. Larger sample quantitative studies also
had limitations. Pope and Tabachnick (1994) queried 476 people in therapy,
but all were psychotherapists themselves, suggesting a level of education,
income, and psychological sophistication well above the general therapy-using
population. Similarly, a study by Martin (2006) drew a sample of 109 clients,
all of whom were graduate students studying to become psychologists.
Our instinct was to cast the widest possible net, distributing our first
online survey via Craigslist volunteer opportunities sites to 13 large metro-
politan areas in the United States: New York, Los Angeles, Chicago, Boston,
San Francisco, Houston, Philadelphia, Atlanta, Miami, Seattle, Phoenix,
Denver, and Washington, DC. We added 28 smaller cities and rural areas for
our second survey. This enabled us to reach 547 clients with our first survey
and 798 with the second; less than 20% of respondents had a job or train-
ing in the mental health field. Our respondents ranged in age from 18 to 80
(mean age was 35), and they tended to be quite well-educated, with 57%
having a college degree. In terms of gender and race, our sample was 22%
male and 24% nonwhite, which although not representative of the general
population, resembles the subset of the population that uses mental health
services in the United States, as captured in annual surveys by the federal
government’s Substance Abuse and Mental Health Services Administration
(2011, 2014).
A subtler limitation of previous studies we sought to address had to do
with survey design. Previous studies tended to start out by asking respondents
the columbia project on lying in psychotherapy 115

a single question to separate those who had been dishonest in therapy from
those who had not. Such filter questions can take on outsized importance in a
survey, at a single stroke ruling some people in and other people out, so they
must be used with caution. For example, the filter question in Martin (2006)
asked, “Since your 18th birthday, other than in an intake session, have you
ever lied to a therapist during a therapy session?” (p. 44). To answer such a
question accurately would require quite a lot from the survey taker. It could
mean mentally reviewing years of therapy, a task that is likely beyond the
cognitive capacity or commitment level of most respondents. Not surpris-
ingly, only 37% of Martin’s sample reported having ever lied to their thera-
pist, a far lower number than that suggested by the body of research on lying
in everyday life (e.g., DePaulo, Kashy, Kirkendol, Wyer, & Epstein, 1996;
Serota, Levine, & Boster, 2010), where we see at least 40% of people having
told one or more lies in just the past 24 hours. The approach in our first survey
was to skip the filter question altogether to avoid overtaxing our respondents’
memory. Instead, we presented a diverse list of 58 topics that respondents
might have lied about—from “times I cheated on a partner” to “why I was late
or missed a session” or “my use of drugs or alcohol.” Respondents had only to
click the box next to any lie that jogged their memory. Alternatively, they
could respond, “No, I have never lied to my therapist,” which only 7% did.
Our memory-jogging approach gave us access to small but fascinating lies that
could have otherwise been forgotten.
That goal, to capture big and small acts of dishonesty alike, also pro-
pelled us to break down a long-standing semantic barrier in the field between
“secrets” and other types of dishonesty such as “lies.” Up to now, secrets have
been the main preoccupation in studies of client dishonesty. Beginning with
Norton, Feldman, and Tafoya in 1974, psychotherapy researchers have used
filter questions asking whether there was “something important they had
kept secret” (Pope & Tabachnick, 1994) or whether there were “any secrets
that you have not disclosed to your therapist that seem relevant to your
treatment” (Baumann & Hill, 2016). The focus on secrets is understand-
able. Secrets are by definition at least moderately important. It is not
quite a secret if you do not mention getting intoxicated on a Friday night,
for example, but it becomes a secret if, while intoxicated, you totaled
the family car or relapsed from a long period of sobriety. Secrets also
get “kept” for periods of time and are thus at least moderately persistent
features of a client’s experience. The danger of focusing on secrets, then,
is precisely that you get the seemingly important and persistent topics of
dishonesty at the expense of the seemingly minor and ephemeral. And as
we see in the next section, this can be a major limitation indeed. To our
great astonishment, the number one most commonly reported topic of
dishonesty found in our first study was not something most people would

consider a secret at all, but yet its importance goes right to the heart of
the therapeutic experience.
WHAT PEOPLE LIE ABOUT IN THERAPY
Predictions based on the mostly secrets-focused past research led us to

include the classic topics such as sex, substance abuse, and suicidal thoughts—
each of which ended up being important findings for us and are prominently
discussed in this book. But we also included some innovative items, one of
which was by far the most common lie being reported. It was “I minimized
how bad I really feel,” and it was endorsed by 54% of all respondents (see
Table 6.1). That so many therapy clients selected this topic out of dozens of
possible topics was striking. This “minimizing” was nearly twice as common
as other types of dishonesty we imagined would be almost universal, such as
“Why I missed appointments or was late.” In addition, the second most com-
mon item was similar: “I minimized the severity of my symptoms,” which was
reported by 39% of the sample. Both items had originally appeared mixed
among all the other 57 options, each paired with its opposite (e.g., “I exagger-
ated how bad I really feel”). These opposites, which asked about exaggeration
rather than minimizing, were endorsed by only 6%. Clearly, the idea of mini-
mizing one’s suffering had struck a chord with our sample.
We came to call this type of client dishonesty distress minimization, and
it appeared that taken together, 62% had endorsed one or both of these lies
about their level of suffering in therapy. What is more, this distress minimi-
zation was not an area of subtle downplaying or slight shading of the truth.
When asked to what extent they felt they had minimized their suffering,
three fourths of these individuals reported “moderate” or higher levels of dis-
honesty. Further, the types of distress they minimized were highly relevant to
their progress in therapy. When asked how important their minimization had
been to their therapy, slightly more than 80% said it was either “important”
or “very important.”
Overall, the survey collected a total of 4,616 lies from all respondents.
As noted in Chapter 1, the average number of topics lied about was 8.4
(range 0–39, SD = 6.6), with no difference observed between men and women
or between income or education levels or based on the gender of the thera-
pist. A small but significant correlation with age (r = −.16, p < .001) suggests
that younger clients are more likely to report a greater number of topics
about which they had lied. The majority of topics were selected by between
5% and 25% of respondents, including lies about eating habits, self-harm,
infidelity, violent fantasies, experiences of physical or sexual abuse, religious
beliefs, lies to get a certain prescription, and many more.

TABLE 6.1
Lies Reported by Therapy Clients in Study 1 (N = 547)
Percent
Topic n reporting lie
1. How bad I really feel—I minimized 295 54

2. The severity of my symptoms—I minimized 212 39
3. My thoughts about suicide 172 31
4. My insecurities and doubts about myself 167 31
5. Pretending to like my therapist’s comments or 161 29
suggestions
6. My use of drugs or alcohol 159 29

7. Why I missed appointments or was late 157 29
8. Pretending to find therapy more effective than I do 156 29
9. Pretending to be more hopeful than I really am 145 27
10. Things I have done that I regret 141 26
11. P retending I did homework or took other actions 140 26
suggested by my therapist
12. My sexual history 119 22
13. My eating habits 113 21
14. My real opinion of my therapist 100 18
15. My feelings about my body 99 18
16. My sexual fantasies or desires 93 17
17. Not saying that I want to end therapy 86 16
18. Self-harm I have done (cutting, etc.) 85 16
19. What I really want for myself 83 15
20. Things I have done that were illegal 81 15
21. Things my parents did that affected me 81 15
22. Secrets in my family 75 14
23. How I really act outside of therapy 73 13
24. The state of my sex life these days 72 13
25. Basic facts about my life 71 13
26. My real feelings about my parents 71 13
27. My masturbation habits 69 13
28. That my therapist makes me feel weird 67 12
or uncomfortable
29. How I really act in relationships 62 11
30. The way I give in to others’ demands 61 11
31. Experiences of sexual abuse or trauma 56 10
32. My attempts to commit suicide 55 10
33. My real feelings about my friends 55 10
34. My desire for revenge 54 10
35. How I am mistreated by others 54 10
36. A sexual problem I have had 53 10
37. My real feelings about my spouse or partner 53 10
38. Times I cheated on my spouse or partner 52 10
39. Violent fantasies I have had 51 9
40. My use of pornography 50 9
41. How I really act with my friends 45 8
42. What I can afford to pay for therapy 45 8
43. P lacing blame on others when much of it lies 44 8
with me
44. My accomplishments (academic, professional, etc.) 39 7

TABLE 6.1
Lies Reported by Therapy Clients in Study 1 (N = 547) (Continued)
Percent
Topic n reporting lie
45. U
nusual experiences (e.g., seeing things, hearing 39 7
voices)
46. Experiences of physical abuse or trauma 35 6
47. How bad I really feel—I exaggerated 34 6
48. Religious or mystical beliefs that I hold 33 6
49. The severity of my symptoms—I exaggerated 33 6

50. My romantic or sexual feelings about my therapist 27 5
51. Lies to get a certain prescription 26 5
52. Cruel things I have done to people or animals 25 5
53. Racist feelings I have had 25 5
54. Not saying that I am seeing another therapist 16 3
55. Political beliefs that I hold 15 3
56. Lies to get a certain diagnosis 15 3
57. The way I treat my children sometimes 12 2
58. My real feelings about my children 9 2
In addition to the high prevalence of distress minimization, the results

contained genuine surprises. For example, we found that 31% of the sample
had lied about having suicidal thoughts, a sobering number given the poten-
tial consequences. We also found that six of the 20 most common lies were
about the patient’s experience of therapy itself, including pretending to like a
therapist’s comments or suggestions, which was endorsed by 29% of the sample.
In subsequent chapters, we discuss in depth several of the most common lies,
including those related to suicide and distress minimization (Chapter 7) and
those related to therapy and the therapist (Chapter 11). Other surprises
included the relatively small proportion of the sample that endorsed certain
topics, including one’s behavior in relationships (11%), feelings about one’s
spouse or romantic partner (10%), and romantic or sexual feelings about
one’s therapist (5%). We had imagined that these relational issues would
have been endorsed by greater numbers of our sample.
Back to the issue of distress minimization—therapy is supposed to be
the one place where it is safe to explore the depths of one’s psychological
pain. Indeed, the special confidentiality of therapy is designed to foster this
honesty. Could it be that clients routinely downplay the extent of their suf-
fering? Could the majority of clients be acting happier and healthier during
therapy sessions than they really feel? If so, why? Is it to please their therapist?
To avoid seeming too needy or hopeless? To avoid seeming too disturbed
or pathological? To avoid therapist overreaction? Could such minimizing be
a personal trait? Or perhaps the result of something about the therapeutic
relationship?

The mystery of distress minimization provides a chance to describe the
design of our first round of research further. Endorsing any one topic of dis-
honesty led to opportunities for clients to tell us to what extent they were
dishonest about this topic and how important this topic was to their therapy.
Data were also collected about clients’ level of trust in their therapist and
their tendency toward self-concealment generally (Self-Concealment Scale;
Larson & Chastain, 1990). Finally, participants could choose one of the topics
they found it hardest to be honest about to answer a set of detailed follow-up
questions, including open-ended essay-box questions where they could write
about their experiences in their own words. Their narratives provide a quite
vivid picture of the circumstances and consequences of their dishonesty,
though it is also important to keep in mind that these are descriptions offered
by those who struggled most to be honest about a given topic, and their
responses may not be typical of all clients who have lied about this topic.
Our distress minimizers tended to be younger and less satisfied with
therapy. They were less likely than other respondents to endorse the state-
ment “I trust my therapist” and had a higher tendency to self-conceal in gen-
eral. They tended to feel regretful, guilty, and frustrated about downplaying
their distress, and they reported negative effects on therapy of doing so, with
most saying that this particular form of dishonesty had hurt their progress
(68%) and prevented them from addressing real issues that brought them
in. Distress minimizing looked like a major problem. So why did they do it?
Essay responses written by clients could be analyzed qualitatively. A
substantial subset (n = 52) elected to write about their motives for mini-
mizing emotional distress, and two basic motives emerged. The first was a
desire to manage the therapist’s emotions, primarily to protect the client from
some truth he or she imagined the therapist would find disappointing or
overwhelming. Several respondents said they were anxious not to worry their
therapist or be seen as a complainer. As one client wrote,
She has worked very hard on me and is proud of my good progress. It’s
important—to me—to not be such a downer in our sessions after such a
positive breakthrough. . . . She has become that missing maternal figure
to me and sometimes I try to spare her the distress/disappointment of my
life. I don’t want her to feel like she’d failed or I’m hopeless.
A second basic motive behind distress minimization was to protect the
self, often from the painful realization of precisely how bad things are. Clients
shared reasoning such as “Talking about how I am really doing makes me feel
more depressed,” and “I can’t admit it to myself, let alone say it out loud.
I want to tell her everything, but I can’t bring myself to do so.” As with so
many types of client dishonesty, respondents’ ambivalence about the choice

to hide their distress was laced through their descriptions. Respondents often
seemed to weigh the pros and cons of dishonesty as they wrote, “I waste my
own therapy by not getting to the core as I know I should, but I maintain a
comfort zone because 50 minutes would never cover the depth. So keeping
it mostly buried works.”
As evidenced by clients’ narratives, our studies generally indicated that
clients use dishonesty to actively tailor the therapist’s experience of their
problems. When it comes to being deceptive about the extent of felt distress,
this tailoring is motivated by the avoidance of painful feelings and fear of
interpersonal consequences should the depth of their suffering be known. As

we see later on in this chapter, the motives driving concealment and lies tend
to vary somewhat according to what is being lied about or concealed.
ONGOING DISHONESTY IN THERAPY
As noted earlier, our second survey provided a somewhat different per-

spective on client dishonesty. Rather than asking about lies, we wondered
what would happen if we asked clients how honest they typically were while
discussing important topics in therapy. Further, if they did not discuss certain
material, was it because it just did not apply to them? Or were they deliberately
avoiding it? Respondents were presented with a reduced list of 33 topics and
asked whether they discussed or did not discuss each topic in therapy. They
were then asked to rate their typical level of honesty when talking about topics
they discussed. Respondents were also asked whether they were deliberately
avoiding any topics they did not discuss. This approach was designed to help
us move beyond single-incident lies told in therapy and capture some sense
of the magnitude of routine or ongoing dishonesty and concealment in
therapy. By asking about ongoing dishonesty, this approach also brought us
closer to the secrets-based research tradition. We also got an opportunity
(see Table 6.2) to compare the prevalence of active lying (i.e., speaking dis
honestly) with passive avoidance (i.e., never bringing this topic up).
Just as in Study 1, respondents in Study 2 were given the opportunity
to select one topic that was “hardest to be honest about” and about which
they were willing to answer a series of follow-up questions. These follow-up
questions covered their motives for dishonesty, their feelings about lying,
and whether and under what circumstances they could imagine being more
honest about the topic. We also asked about their perceptions about how
dishonesty had impacted their progress in therapy and what their therapist
could do differently to help them disclose. The sheer volume of data gener-
ated by Studies 1 and 2 is too much to cover even in a book-length format, so

TABLE 6.2
Most Commonly Reported Topics of Ongoing Dishonesty
in Psychotherapy, With Breakdown of Active Lying
and Passive Avoidance: Study 2 (N = 798)
Total percent Percent Percent who
reporting who speak deliberately
Topic dishonesty dishonestly avoid
1. My sexual desires or fantasies 34 4 30

2. Details of my sex life 33 7 26
3. Suicidal thoughts 21 10 11
4. My real reactions to my therapist’s 20 6 14
comments
5. My sexual orientation 17 7 10
6. Times I treated others poorly 16 7 9
7. Secrets in my family 16 5 11
8. Whether therapy is helping me 16 7 9
9. Trauma or abuse experiences 15 7 8
10. Self-harm (cutting, etc.) 13 5 8
11. Feelings of despair or hopelessness 13 8 5
12. My eating habits or eating disorder 13 5 8
13. Times I was mistreated by others 13 8 5
14. Habits I know I should break 13 6 7
15. Things my family did that hurt me 13 7 6
16. My feelings about the cost of 12 4 8
therapy
17. Past suicide attempts 12 6 6
18. Why I missed a session or was late 12 7 5
19. My religious or spiritual beliefs 12 6 6
20. My financial situation 12 5 7
in the chapters that follow we have focused our discussion on certain key data
points. A chart of the major domains of inquiry and how we studied them is
provided in Table 6.3.
As predicted, our study of ongoing dishonesty returned lower preva-
lence rates than those seen in Study 1’s assessment of lifetime prevalence.
It should also be noted that, for various reasons, Survey 2 included no items
that captured pure distress minimization. We introduced the topic “Feelings
of despair or hopelessness” to see whether it might account for the bulk of
distress minimization, but with 13% of respondents endorsing it, it appears
that distress minimizing applies to a broader set of experiences.
In keeping with previous studies (e.g., Baumann & Hill, 2016), the
results reported in Table 6.2 suggest that sexual matters, both the details of
one’s sex life and one’s sexual fantasies or desires, are the most commonly
endorsed topics of ongoing dishonesty. Just as in Study 1, suicidal thoughts
were disturbingly prevalent, with 21% endorsing ongoing dishonesty. Also

TABLE 6.3
Overview of Variables Investigated in Studies 1 and 2
Domain Study 1 (N = 547) Study 2 (N = 798)
Prevalence of Assessed lifetime prevalence Assessed current levels of honesty,

dishonesty of dishonesty on 58 topics: dishonesty, and avoidance on
“Have you ever lied to your reduced list of 33 topics:
therapist about any of “Have you discussed this topic with
these topics?” your current or most recent thera-
pist?” (yes/no)
If yes, “How honest are you when
discussing these topics?”
(1 = not at all, 2 = a little, 3 = moder-
ately, 4 = a lot, 5 = completely or
totally)
If no, “What is the main reason you
have not discussed this?”
(Options: “It does not apply”;
“I would discuss this if it came
up”; “I try to avoid this topic”)
Techniques of Active dishonesty attributed to those
dishonesty: who discussed a topic but reported
Active versus being “not at all honest” or “a little
passive honest.”
Passive dishonesty attributed to
those who reported they do not
discuss it in therapy because
“I try to avoid this topic.”
Extent of Assessed extent of dis-
dishonesty honesty on all topics lied
about:
“To what extent did you mis-
represent the truth about
this topic?”
(1 = a tiny bit, 2 = a little,
3 = a moderate amount,
4 = a lot, 5 = totally or
extremely)
Motives for Respondents from both surveys provided short essay answers to the
dishonesty question “Please tell us more: What makes it hard to be honest
about this?”
Content analysis conducted to identify major themes.
Assessed motive with mul- Assessed motive with multiple
tiple choice question with choice item:
28 options (e.g., “I was “Which of these describes your rea-
being polite”; “to avoid son for not being more honest?”
hospitalization”; “to direct (Options: “Practical consequences”;
the conversation”). “My therapist would be upset,
hurt, or disappointed”; “I didn’t
want this to distract from other
topics”; “I doubt my therapist can
help or understand”; “Embarrass-
ment or shame”; “It would bring
up other overwhelming emotions
for me”; “Other reason”)
(continues)

TABLE 6. 3
Overview of Variables Investigated in Studies 1 and 2 (Continued)
Importance of Assessed with 7-point Likert

the topic scale item:
“How important was this
topic to you?”
(1 = not important, 7 = very
important)
Assessed with 7-point Likert

scale item:
“How important was this
topic to your therapy?”
(1 = not important, 7 = very
important)
Timing of Assessed with multiple-
dishonesty choice item:
“How much consideration
did you give this lie before
you told it?”
(Options: “None, it was
spontaneous”; “I planned
to lie beforehand”;
“I often lie about this
to others”; “I can’t
remember”)
Assessed with multiple-
choice item:
“About when in your therapy
did you first tell this lie?”
(Options: “During the first
session”; “During the
early sessions”; “After
I knew my therapist well”;
“Towards the end of
therapy”)
Attitude toward Assessed perceived likelihood of
future honest future honesty with multiple
disclosure choice item:
“Is this a topic you would ever be
more honest about?”
(Options: “Yes with my current
therapist”; “Yes but with different
therapist”; “Yes, but only with
family or friends”; “No, not with
anyone”)

TABLE 6. 3
Perceived Assessed clients’ ideas about how

facilitators of therapists could foster honesty
honesty with short essay response:
“How could your therapist make
you feel more comfortable being
honest about this?”
Content analysis conducted to
identify major themes.

Assessed clients’ ideas about what
could help them be more honest
with multiple choice item:
“Under what circumstances would
you be more honest about this
topic?”
(Options: “If I trusted my therapist
more”; “If my therapist was
warmer”; “If my therapist was
more skillful”; “If my therapist
asked me about it directly”; “If I
knew my therapist had a similar
problem”; “If my therapist under-
stood my culture or class”; “If
I knew my therapist would not
over-react”; “If I knew it wouldn’t
ruin my relationship with my
therapist”; “If I felt like this was
blocking my progress in therapy”;
“Under no circumstances would
I be more honest”)
Feelings Assessed with a multiple-choice
after being item:
dishonest “How did you feel after being dis
honest about this?”
(Options: “frustrated,” “guilty,”
“worried,” “regretful,” “satisfied,”
“safe,” “in control,” “true to
myself,” “neutral,” “confused,”
“conflicted,” “unconcerned”)
Perceived impact Assessed with a multiple-choice item:
of dishonesty “Has not being honest affected your
on therapy therapy?”
(Options: “It hurt my progress”; “It
helped my progress”; “No effect”)
Assessed with short essay question:
“Can you tell us how not being fully
honest affected your therapy?”
Content analysis conducted to iden-
tify major themes.
(continues)

TABLE 6. 3
Disclosure and Assessed with multiple

detection of choice item:
lies “Does your therapist know
that you were untruthful?”
(Options: “I don’t know,”
“definitely not,” “probably
not,” “maybe,” “probably
yes,” “definitely yes”)

Assessed with multiple
choice item:
“How has the lie been
acknowledged in therapy?”
(Options: “It has not been
acknowledged”; “I told
my therapist I lied”; “My
therapist said he/she
knew”; “I was called out
about it”; “The lie eventu-
ally unraveled on its own”;
“The lie itself wasn’t dis-
cussed, but some of the
details were”)
Assessed with multiple
choice item:
“When was the lie acknowl-
edged in therapy?”
(Options: “never,” “within
the same session,” “after
a few sessions,” “months
later,” “years later”)
Self-concealment Self-Concealment Scale Self-Concealment in Therapy Scale
(Larson & Chastain, 1990); (adapted from Larson & Chastain,
10-item measure 1990); 10-item measure
Therapeutic Assessed with five 7-point Short Revised Working Alliance
relationship Likert scale items: Inventory (Hatcher & Gillaspy,
• I like my therapist. 2006); 16-item Likert scale
• I respect my therapist. measure
• I feel that my therapist is
honest with me.
• I feel that my disclosures
are confidential.
• I trust my therapist.
• (1 = not at all, 7 = to a very
great extent)

common was the routine concealment of real reactions to comments made by
the therapist, endorsed by 20%. As expected, asking about routine dishonesty
returned lower levels of prevalence than did asking about lying. For example,
whereas 29% could recall being dishonest about why they missed a therapy
session in Study 1, only 12% reported regular or ongoing dishonesty about
this topic in Study 2.
TECHNIQUES (ACTIVE VS. PASSIVE) OF CLIENT DISHONESTY

We have argued in earlier chapters that deception can be seen on a

spectrum from active to passive. When clients decide not to be honest with
their therapist, they can choose from a range of strategies, from actively
exaggerating or making up wild fabrications to passively avoiding, omitting,
or concealing information. Our research suggests that passive strategies are
clearly dominant in psychotherapy, as they are believed to be in everyday life.
A glance at Table 6.2 shows that for almost every topic presented in
Study 2, passive techniques of avoidance and concealment were more preva-
lent than active lying. For example, although 33% of the sample reported dis-
honesty about their sexual fantasies or desires, a mere 4% reported actually
speaking falsely (telling a lie) on this topic. This confirmed something we had
previously observed in Study 1. Even though that survey asked about lying, the
nature of the dishonesty shared by clients was still heavily weighted toward
passive dishonesty (e.g., concealment) and away from active dishonesty (e.g.,
fabrication). Specifically, whereas 50% of respondent lies involved minimiz-
ing, only 8% involved exaggeration. And although 42% involved omitting
important information, only 12% involved making up facts.
Interestingly, the most common topic of active lying was suicidal
thoughts, with 10% of our respondents reporting this. It is ironic, con-
sidering that lies to conceal suicidality are probably those most feared by
therapists, and surprising because only about 4% of the general nonclinical
U.S. population has reported experiencing “serious” suicidal thoughts in
a given 12-month period (Substance Abuse and Mental Health Services
Administration, 2014). Ours being a clinical sample, the proportion of
suicidal respondents would certainly be higher. But we were curious: Why
would suicide be associated with more active lie telling than other topics?
One explanation has to do with the routine suicide assessments conducted
in most hospitals and clinics. While being assessed, patients who wish to
conceal suicidal ideation are confronted with direct questions to which they
must actively verbalize a response. If they choose to conceal, they must at
least say “no.” Passive avoidance is less of an option when being assessed.
Therefore, suicide tops the list of topics about which clients tell active lies.

Evidence supporting this explanation comes from Study 1, in which suicide
concealers were three and half times more likely than all other respondents
to describe the nature of their dishonesty with the following statement: “I
denied something that was true.”
MOTIVES BEHIND CLIENT DISHONESTY
Our assumption, which our studies confirmed, is that when patients

decide not to be honest, their reason for doing so depends to a certain extent
on the topic. For Sarah, the client concealing a past trauma whom we intro-
duced at the opening of this chapter, several emotional and relational motiva-
tions were in play: a fear of being emotionally overwhelmed, a sense of shame,
and uncertainty about whether her therapist would understand. By contrast,
another female client, whom we will call Dana, lied to her therapist based on
a motive that was entirely practical. Although Sarah hid her experience of
being a victim, Dana hid the fact that she had committed a crime and lied to
keep her therapist in the dark: “I was afraid she might tell the police.” Different
secrets, different motives. Dishonesty in each of several clinically important
areas—suicidal thoughts, sexual issues, substance abuse, trauma, and lies about
therapy and feelings about one’s therapist—appears to be associated with dis-
tinct patterns of motivation and is addressed separately in subsequent chapters.
We must also acknowledge the complexity of motivations that can be
present in any one example of client dishonesty. When a painful truth threat-
ens to emerge, there are fears about what might happen inside the therapy
room, such as upsetting the therapist. These fears can sometimes interlock
with fears about possible consequences outside the therapy room, such as the
police being notified. And both types of fear are often accompanied by fears
of what might happen inside the client him- or herself, such as intense or
overwhelming feelings of guilt or shame. Such feelings can be the product, at
the same time, of feeling judged by a therapist and judged by oneself. Many
clients in our research reported this complex and overlapping array of moti-
vations. One young woman, a victim of childhood sexual assault, was begin-
ning to feel sexual urges toward young children and also animals, but she did
not breathe a word of it to her therapist:
I lied because I felt that the truth would land me in heavier-duty therapy,
which I didn’t have the emotional fortitude or the time for. I also felt
shame and wondered what my therapist would think of me. I also felt that
maybe the whole mandated reporting thing might cause me some trouble.
I was basically a teenager and thought that just having pedophile-type
urges, even if I never acted on them, was enough to put me on a watch
list to ensure I never made it to offender status.

This client struggled with her feelings of shame and was concerned too
with what her therapist would think and how this would impact her therapy.
In fact, emotional, practical, and legal motivations for concealment are all
present in her narrative, each playing a role in the difficult choices she made
about what to share and what to conceal in therapy.
With this complexity in mind, however, there is still something appeal-
ing about having an overall answer to the question “Why do clients lie?”
And so, in addition to collecting written narratives, we asked respondents to
select from among six possible motives, generated in great measure from pre-
vious research in this area (Farber, 2006; Hill et al., 1993; Hook & Andrews,
2005; Kelly, 1998). Table 6.4 provides responses from Study 2, drawn from
the 84% of respondents who reported dishonesty on at least one topic.
Consistent with prior research in this area, shame and embarrassment
were the most frequent motivators for dishonesty in therapy, cited in 61% of
the situations shared by our respondents. Also of interest is that the desire
to not “distract” the therapist and thus control the direction of therapy was
the second most common motive, cited in 27% of cases. This makes sense,
given the complaint frequently lodged by clients in our data set that thera-
pists “overreact” to certain material (e.g., disclosures about substance use).
Lying and concealment is an effective way to keep such hot-button issues off
the table.
We also learned that Dana was not alone: Nineteen percent of reported
motives had to do with practical consequences, such as legal problems or
unwanted hospitalization. That suggests that, rightly or wrongly, nearly a fifth
of clients in this sample feared therapists would feel professionally obligated
to break confidentiality and begin to take actions that could impact their
lives outside the therapy room. A closer look at these 127 clients reveals the
reason why: Fifty were concealing suicidal thoughts or behaviors, 16 lied
about drugs or alcohol, 10 were concealing eating disorders, and nine con-
cealed homicidal thoughts, with smaller numbers reporting dishonesty about
TABLE 6.4
Most Commonly Reported Motives for Ongoing Dishonesty on All Topics:
Study 2 (N = 672)
Reported motivation for dishonesty n Percent
Embarrassment or shame 410 61

I didn’t want this to distract from other topics 179 27
I doubt my therapist can help or understand 161 24
Practical consequences (e.g., legal problems, hospitalization) 127 19
It would bring up overwhelming emotions for me 120 18
My therapist would be upset, hurt, or disappointed 109 16

issues such as self-harm or being the victim of sexual abuse. Clients conceal-
ing these aspects of their lives appear to be making hard calculations about
the impact of their disclosures: If I tell my therapist I have a drug problem or
have had homicidal or suicidal thoughts, what might he or she do and who
else will be told? It is a reminder that clients may be quite aware that the
confidentiality of therapy has limits, a point which becomes paramount for
clients concealing suicide and self-harm, as we discuss in Chapter 7.
THE “BIGGEST” AND “SMALLEST” LIES
The most common lies are not necessarily the biggest or most dramatic.
Our research suggests there are a number of topics about which clients are
inclined to be totally dishonest. Most of these “big lies” were relevant to
only a small subset of respondents. Indeed, the topic that was associated with
the most extensive dishonesty—romantic feelings about the therapist—was
something that, as noted earlier, only applied to 5% of respondents. Our
method for identifying these “biggest” (i.e., most extensive) lies was to ask in
our first study about the extent to which clients felt they were dishonest on
a 5-point scale, ranging from 1 = a tiny bit dishonest to 5 = totally or extremely
dishonest. Table 6.5 shows the top 10 topics on which respondents reported
a 5 on this scale.
Four of these topics involved therapy itself, with respondents reporting
extreme dishonesty about romantic attraction to their therapist, their desire
TABLE 6.5
Topics on Which Dishonesty Was Most Likely to Be Extensive:
Study 1 (N = 547)
Percent of Percent of those who
sample endorsed “total or
Topic reporting extreme” dishonesty
1. M y romantic or sexual feelings about my 5 46

therapist
2. Not saying that I want to end therapy 16 37
3. Experiences of sexual abuse or trauma 10 33
4. My masturbation habits 13 32
5. My use of pornography 9 31
6. That my therapist makes me feel weird or 12 30
uncomfortable
7. Times I cheated on my spouse or partner 10 29
8. My real opinion of my therapist 18 27
9. Racist feelings I have had 5 26
10. My past attempts to commit suicide 10 26
Note. “Total or extreme” dishonesty was defined as a score of five on a five-point dishonesty scale.

to end therapy, their real opinion of their therapist, and their sense that their
therapist makes them feel uncomfortable. Experiences of sexual abuse are also
on the list, as are pornography and masturbation. Racism and infidelity were
also subjects of extensive dishonesty for the small subset of respondents who
reported lying about them. One young woman who acknowledged extreme
dishonesty (i.e., reported a score of 5) regarding her habit of watching violent
pornography reported, “I’ll never explicitly tell her any of this, even though
I think it is probably deeply relevant to have a serious violent pornography
addiction.”
On the opposite end of the spectrum, we can identify the “smallest” lies,
topics that are subject to only slight levels of dishonesty. The data reported
here are for those who reported concealing or distorting the truth on these
topics (in Study 1) but reported only doing so “a tiny bit,” with scores of
1 on a 5-point scale: “The way I treat my children sometimes,” “Lies to get a
certain prescription,” and “What I can afford to pay for therapy.” Each is an
easy subject for fudging and minor distortion: putting a positive spin on the
sometimes-chaotic process of child-rearing, shading the truth about symp-
toms to ensure a certain prescription, and downplaying one’s ability to afford
the therapist’s fee.
WHO LIES?
To reiterate, 93% of clients surveyed were able to recall being dishonest

with their therapist on some topic in the past, and in a second survey, 84%
reported being dishonest or deliberately avoiding at least one topic on an
ongoing or routine basis. These prevalence estimates are the highest yet in
the literature on client dishonesty in psychotherapy; previous studies have
arrived at estimates between 20% and 46% of clients admitting to the specific
act of “secret keeping” in therapy (e.g., Hill et al., 1993; Pope & Tabachnick,
1994). The difference is likely due to our broader definition of dishonesty that
includes twisting the facts, minimizing, omitting, or pretending to agree with
the therapist, all smaller acts that do not rise to the level of secrets but are
nonetheless relevant to the psychotherapy process. Because subtle dishonesty
such as the “white lie” is woven into the fabric of social communication
starting in middle childhood (Talwar, Murphy, & Lee, 2007), we might ask
why fully 100% of our participants did not endorse lying to their therapist.
The answer? Research into everyday lying outside of therapy appears to sup-
port the near but not total ubiquity of dishonesty, with polls of the general
public suggesting that 90% to 96% of adults can recall specific instances of
lying in the past (Kalish, 2004; J. Patterson & Kim, 1991). We also imagine,
though we do not know for sure, that at least some of our respondents were

less than totally honest with us about the extent of their dishonesty with
their therapists.
This question aside, we were interested in knowing how much lying
people would report and how it was distributed. Recall from Chapter 2 that
a fascinating body of recent research (Levine et al., 2011; Serota et al., 2010;
Serota, Levine, & Burns, 2012) has demonstrated that dishonesty does not
follow the bell curve. That is to say, the distribution of dishonest communi-
cation appears to be deeply skewed toward a small number of “prolific liars,”
perhaps 5% of the population, whereas as much as 60% of the adult popula-
tion will go through the average day without telling any lies at all. The skew
was so dramatic in these studies that, within a given 24-hour period, the
prolific 5% were responsible for 50% of all lies recorded.
Did we find the same prolific liars in psychotherapy that Serota et al.
(2010) found in everyday life? Although our surveys were not designed to
replicate that other work, the results are intriguing. Turning to our findings
from Study 1, we see that about 60% of respondents reported dishonesty on
between zero and eight topics over the course of their psychotherapy treat-
ments (see Figure 6.1). In contrast, it was possible to identify a small group of
about 6% who reported 20 or more topics of dishonesty.
Who were these prolific therapy liars? We found no racial or gender dif-
ferences, but they were, on average, about 5 years younger (M = 30, SD = 12.5)
than the mean age of the rest of the sample (M = 35, SD = 13). They not only
lied about more things but also were more likely to tell bigger lies—that is, to
distort the truth more extremely—and they reported a greater general ten-
dency toward self-concealment. Most interestingly, this group was more than
twice as likely to cite “traumatic experiences” as a reason they had entered
therapy (55% of them did, compared with 22% of the rest of the sample).
Other reasons for entering therapy that prolific liars were significantly more
likely to give included suicidality, self-harm, social anxiety, mood problems,
depression, and anxiety or panic attacks. To our surprise, the prolific liars had
not been in therapy for a longer time. Nor had they had more sessions; there-
fore, it was not simply a matter of having had more time to exhibit dishonesty
on more topics. Rather, prolific liars in our sample appeared to be more symp-
tomatic, with at least some characteristics and problems often associated with
borderline level pathology.
TIMING AND PLANNING
Everyday experience gives us two possible models for imagining when

in the therapeutic relationship a client is likely to be dishonest about a given
topic. The first we might call the “stranger on a train” hypothesis, which

45
40
35
30
Number of Clients Reporting
25
20
15
10
0
0 5 10 15 20 25 30 35 40
Total Number of Topics Lied About
Figure 6.1. Distribution of topics lied about (Study 1). Mean = 8.4, Std. Dev. = 6.6,
N = 547.
suggests that clients are likely to be more honest early in therapy because,
just as when unburdening ourselves to a stranger on a train, the client barely
knows the therapist at the start of therapy and therefore should have reduced
sensitivity to shocking or upsetting them. A new therapy is, by this theory, a
clean slate on which patients can honestly and freely write without the kind
of embarrassment that can creep in later when their therapist has become
someone they actually know, someone with assumptions and expectations
about them, someone whose image of them patients might want to protect.
The alternate model we might call the “first date” hypothesis, which sug-
gests that dishonesty and concealment would actually be at their highest
during the initial meetings, when the client, like someone on a first date,
would be most preoccupied with making a good impression and thus most

likely to use strategies such as concealment. The first date model suggests
that honesty is more likely in later sessions, when presumably a level of
mutual trust has been established, and secrets can safely be disclosed.
Our first study included an item that allowed us to gauge which model
is correct. At first glance, the findings appear to favor the first date hypoth-
esis over the stranger on a train by a substantial margin. Among all Study 1
respondents, 71% of client dishonesty incidents occurred in the early sessions,
with about a quarter of that coming in the first meeting with the therapist. The
remaining 29% of client dishonesty incidents we captured happened in later
sessions, “after I knew my therapist well.” We could conclude that the first
date hypothesis prevails. This picture changes, however, when we account
for the fact that many of our respondents may only have had 10 to 20 ses-
sions of therapy, necessarily limiting their lies to the early sessions. When
we narrow the focus to just those clients with 20 or more sessions of psycho-
therapy with their current therapist, we see the proportion of lies first told
during the early sessions drop to 57%, with an increase to 43% of those hap-
pening after client and therapist knew each other well. First date or stranger
on a train? Our research suggests something close to an even split.
Most client lies were not specifically planned. They were either spon-
taneous (45% of the time) or part of a general habit, something the person
generally conceals from others in most settings (28%). In only about 16% of
cases did respondents describe a premeditated effort to deceive their thera-
pists. What kind of lies do clients plan beforehand? Three topics were clear
winners: concealing suicidal thoughts, hiding alcohol and drug use, and lying
about the reasons why they were late or missed an appointment.
For the most part, then, clients appear to lie without great forethought
and, to a great degree, early on in the therapeutic relationship. For clinicians
interested in fostering disclosure, these findings could indicate a need to
“circle back around” to topics about which honesty is important, providing
opportunities for clients to reconsider disclosure at various points in the course
of therapy.
FEELINGS ABOUT HAVING BEEN DISHONEST
Although it has been argued that some types of client dishonesty can
help clients to manage their self-presentation and construct desirable identi-
ties by avoiding shameful disclosures (Kelly, 2000), respondents in our first
study reported overwhelmingly negative feelings after telling a lie. In that
study, they were allowed to select as many emotions as they liked from a list
of 13; on average, they selected three emotions that characterized their feel-
ings after being dishonest. Of the emotions reported, 58% were explicitly

negative, including guilt, regret, frustration, and shame. Only 7% of all
descriptors were positive emotions such as pride, relief, powerfulness, or
satisfaction.
In our second study, we asked respondents to choose just one dominant
feeling they had after being dishonest, providing an equal number of posi-
tive and negative options from which to choose. Again, negative emotions
(e.g., frustrated, guilty, worried, regretful) were the most commonly cited,
by 31% of this sample; another 22% of the sample reported feeling primar-
ily confused or conflicted. Only 20% reported positive emotions (e.g., satis-
fied, safe, in control, true to myself). Those who felt neutral or unconcerned
made up 27% of the sample. Among those reporting positive emotions, few
endorsed feelings of “satisfaction” about dishonesty; instead, positive feelings
were more in the realm of feeling “in control” (assumedly of the therapeutic
process) and “safe” (assumedly from various perceived dangers, such as feeling
an emotion they wanted to avoid or being hospitalized involuntarily). These
findings are in keeping with those of Baumann and Hill (2016), who noted
higher levels of negative emotions about concealment among 61 clients who
had kept a secret from their therapist.
Again, we were curious: Would some topics buck the negative feelings
trend—that is, topics for which lying more often led to positive feelings? As
can be seen in Table 6.6, there were indeed a handful of subjects for which
positive emotions were more commonly reported than negative. These topics
TABLE 6.6
Topics That Elicited the Highest Percentage of Positive
and Negative Emotions Following Client Dishonesty
Respondents’ reported emotions
Topic Percent positive Percent negative
Topics that elicited the highest percentage

of positive emotions
Suicidal thoughts (n = 64) 37 27
Times I treated others poorly (n = 28) 28 6
Trauma or abuse experiences (n = 66) 27 24
Topics that elicited the highest percentage
of negative emotions
Habits I know I should break (n = 25) 20 60
My insecurities or doubts about myself 14 59
(n = 32)
My real reactions to my therapist’s 13 53
comments (n = 30)
Note. Rows do not equal 100%; remaining respondents reported either neutral or conflicted emotions.
The n’s noted in this table reflect the number of respondents who chose that topic as the “hardest to be
honest about.”

included suicidal thoughts, times the respondent treated others poorly, and
trauma and abuse experiences. As we see in later chapters, each of these
topics comes with different reasons why concealment or dishonesty may be
experienced more positively—or at least with greater satisfaction and less
regret—by clients. Topics for which dishonesty triggered mostly negative
emotions were far more common, and each of these were subjects that clients
wanted to discuss honestly but for various reasons could not.
DETECTION OF DISHONESTY
Does the truth ever come out? Apparently not, or at least rarely. In our
first study, we asked a series of multiple-choice questions about the eventual
disclosure and detection of various lies reported by respondents. Across all
topics, 73% of respondents said the truth about their lies had never been
acknowledged in therapy. Only 3.5% came clean and told their therapist
about the lie. Another 9% were essentially discovered, either because the
therapist called them out or because the lie unraveled on its own. Accord-
ing to our clients, then, less than a tenth of client lies were detected in
any way by therapists. This is somewhat of a worse track record than might
be predicted by previous literature. In their detailed study of the “hidden
reactions” of clients to events in session, Hill et al. (1993) found that expe-
rienced therapists had a hit rate of about 45% in detecting these reactions.
There is a chance, of course, that our study might have shown a higher rate
of detection for dishonesty had we been able to query therapists as well
as clients.
What sort of deceptions do therapists detect? According to clients,
by far the most common type of deception detected involved the minimiz-
ing of symptoms and distress, which accounted for about four out of every
10 detected lies. This suggests that therapists have some ability to notice
when clients are faking good during a session, and their actual hit rate (per
client report) was not too bad. As we can see in Table 6.7, for clients who
minimized the severity of their symptoms, the truth came out in about 41%
of the cases recorded in our research. By comparison, deception regarding
alcohol or drug problems was reversed only 11% of the time and among
those concealing suicidal thoughts only 6% of the time. One explanation
for the higher levels of eventual truth about distress minimization is that it
involves events occurring in the therapy session itself. In that sense, mini-
mizing distress is akin to the hidden reactions studied by Hill et al. (1993).
This would be unlike, for example, the client who conceals something that
by its nature happens outside therapy, such as self-harm, for which the rate
of reported detection was 0%. The overall picture, however, is that clients

TABLE 6.7
Rate at Which Therapists Eventually Detect Dishonesty
on Selected Topics, per Clients’ Perception: Study 1 (N = 547)
Topic Rate of detection
I minimized the severity of my symptoms 41%

I minimized how bad I really feel 20%
Pretending to find therapy more effective than I do 16%
Not saying that I want to end therapy 14%
My use of drugs or alcohol 11%
My sexual history 8%
My thoughts about suicide 6%
My insecurities and doubts about myself 0%
Self-harm I have done (cutting, etc.) 0%
All topics combined 9%
who desire to hide facts and feelings from their therapist generally believe
they have been quite successful in doing so.
THE IMPACT OF DISHONESTY ON THERAPEUTIC PROGRESS
It may be impossible to know what impact dishonesty has on the effec-

tiveness of psychotherapy, especially given the variety of possible topics and
situations involved. As we noted in the case of Sarah at the start of this chap-
ter, concealment can be an important way for emotionally fragile clients to
protect themselves. We were nonetheless curious to see what clients would
say when we asked them how being dishonest impacted their progress in
therapy. Respondents in both surveys were asked to assess the likely impact
of their dishonesty as helpful, harmful, or as having no effect on their therapy.
Because we asked the same question in both studies, we are able to report the
answers of well over 1,000 clients.
As Table 6.8 indicates, across both surveys, 42% of respondents felt their
dishonesty was harmful, having a negative impact on their therapy, and they
often expressed this with palpable regret. Dishonesty made their therapy “use-
less” and “moot” because they never got to the “real issue” and ended up “not
really doing therapy.” Many looked back ruefully at the progress they could
have made if they had only been honest. As one client wrote: “I wasted years
in therapy when I could’ve been 100% upfront and truthful about my situation.
I could have spent that time working on myself and learning what a healthy
relationship is.” Clients were more likely to see dishonesty as harmful if they
were lying about certain topics. For example, a large majority of distress mini-
mizers (68%) felt their dishonesty was harmful to their progress in therapy.

TABLE 6.8
Perceived Impact of Dishonesty About Selected Topics
Hurt my Helped my No
Topic progress progress impact
Minimizing level of distress (n = 52) 68% 5% 27%

Traumatic experiences (n = 80) 48% 5% 47%
Use of drugs or alcohol (n = 80) 41% 3% 57%
Why I missed a session or was late (n = 21) 33% 0% 67%
Sexual topics (n = 158) 28% 5% 67%
All topics combined (n = 1,130) 42% 5% 54%

Note. Samples noted are drawn from both studies, with the exception of the item “Minimizing level of
distress,” which was only investigated in Study 1.
By contrast, only 5% of respondents felt their dishonesty had been

helpful for therapy. For these clients, dishonesty often helped them avoid
unwanted interventions by their therapist, who they felt would overreact to
the truth. As one male patient with posttraumatic stress disorder and bipolar
disorder wrote,
My personal experiences with the mental health field has taught me
that it is BEST that I don’t always disclose how I am really doing. . . .
[Dishonesty] has kept me from being thrown into a state institution,
I am sure of that.
Many of these clients appear to be experiencing more severe symptoms,
including suicidality. There was, however, no single topic for which lying
was more commonly seen as helpful. For example, clients concealing suicidal
thoughts to avoid hospitalization were four times more likely to describe their
dishonesty as harmful rather than helpful.
Victims of physical or sexual abuse may have particular sensitivities
about how and when they reveal their traumas in psychotherapy (Farber,
Feldman, & Wright, 2014). We might imagine that controlling the timing
of trauma disclosures could be seen as helpful by patients in this category.
Nonetheless, among those who concealed physical or sexual trauma in ther-
apy, only 5% found concealment to be helpful, whereas 48% found it harm-
ful, and the remaining 47% felt it had had no effect. As one client wrote,
“I have made little progress. The pain and fear is so overwhelming that I can’t
bring myself to talk about the abuse.”
Finally, 54% of clients across all topics found their dishonesty or con-
cealment had no serious impact on their therapy, either negative or positive.
Substantial numbers of clients on a wide range of topics reported no impact
on their therapy of lying about matters such as family secrets, use of drugs and
alcohol, or self-harm. According to our research, the area in which lying was

most likely to be seen as irrelevant to psychotherapeutic outcome was sex,
including topics such as sexual fantasies, one’s sexual history, masturbation,
or the use of pornography, with 67% reporting that dishonesty had no effect.
For some, sex just seemed out-of-bounds for their particular psychotherapeu-
tic relationship or irrelevant to their primary problems, so a smattering of pas-
sive dishonesty is used to prevent awkward conversations or fend off therapist
curiosity about topics clients believe are tangential to their core concerns.
Even when clients allow that there could be serious issues in their sex lives,
they are often happy to dodge questions about sex. As one client put it, “I just
move around this topic and we work on other areas.”
HOW CAN THERAPISTS HELP CLIENTS BE MORE HONEST?
As we noted, a major goal of studying client dishonesty is to find ways to

help clients become more honest about topics that matter to their progress.
Perhaps it was the arrogance of assumed expertise, but we had been studying
this problem for several years before it occurred to us to simply ask clients
directly “Under what circumstances would you be more honest about this?”
The results shown in Table 6.9 come from our second study. They should not
be taken as gospel for clinical practice because respondents had to choose
from among 10 answer choices chosen a priori by our team. But we also
asked respondents to write short narratives in response to the related ques-
tion “How can your therapist help you be more honest?” A good number of
respondents offered unrealistic ideas, and another subset frankly said they
did not know how their therapist could help—as one client put it, “Don’t ask
me. I’m not the doctor!” Yet the majority of respondents did have workable
TABLE 6.9
Circumstances Under Which Clients Would Be More Honest About a Topic
About Which They Had Been Dishonest (N = 672)
Circumstance n Percent
If my therapist asked me about it directly 311 46

If I felt like this was blocking my progress in therapy 218 32
If I knew my therapist would not overreact 169 25
If I trusted my therapist more 168 25
If I knew my therapist had a similar problem 157 23
If I knew it wouldn’t ruin my relationship with my therapist 124 18
If my therapist was warmer 99 15
If my therapist was more skillful 96 14
Under NO circumstances would I be more honest 79 12
If my therapist understood my culture or class 76 11

ideas, which provided a useful illustration of their multiple-choice responses.
Where possible in the chapters that follow, we apply content analytic tech-
niques to these open-text responses to derive the major themes. These analy-
ses were performed per Neuendorf’s (2002) protocol, with a research team of
psychology graduate students overseen by the senior author.
One major takeaway from this could be summed up in two words: “Just
ask.” Nearly half (46%) of clients reported that they would be more honest if
their therapist asked direct questions about the topic at hand. Across a wide
range of secrets, from self-harm to feelings about therapy, clients expressed
a desire for therapists to bring up things they do not feel ready to bring up
themselves. In some cases, this sounded like an unrealistic wish that the
therapist could read their minds; as one client wrote, “He’d need to bring
up the subject without me mentioning it.” But more often, the desire for
therapists to ask direct questions seemed to reflect a need for the clinician to
take leadership of the discussion, to walk the client down the very path he or
she is most afraid to tread. Sarah, the young female client concealing a trau-
matic past that we have returned to several times in this chapter, was among
those who felt this way. She wrote about powerful, fearful words and about
wanting her therapist to take the lead by “saying the words” and about allow-
ing her to respond with only “yes” or “no,” if that was all she could manage.
I think it would be helpful if my therapist asked me direct questions
about it, especially yes/no questions. This would make it less embarrass-
ing for me. I think that if I’m asked open-ended questions about this
topic, I’m so focused on avoiding things that would be uncomfortable for
me to say, that anything I do say probably isn’t honest or fully honest.
Words have a lot of power, so if the therapist is the one saying the words
that are difficult to say, and my job is only to say yes or no, then it lifts
away a lot of the burden for me. I really wish that therapists did this more
often, or at least asked whether I prefer open-ended questions or yes/no
questions. I feel that I would have made a lot more progress in therapy.
A variant of “just ask” was the hope that therapists would “just ask
again,” circling back to ask about things that may have made the client balk
the first time they came up. One client, who said she concealed her struggle to
find a “healthy sexuality” in relationships due to shame, wished her therapist
had gone back to reopen that door. She wrote,
It did somehow come up one time near the end of a session, but we never
came back to it. . . . If she would have brought it up again after the first
time it came up I think I could have talked some more about it.
For others, the “just ask” wish took the form of wanting the therapist to ask
on a regular and routine basis. One client who engaged in occasional acts of
nonlethal self-harm decided to completely conceal this from her therapist,

rather than bring it up and trigger a big response. She felt that honesty could
have been possible if her therapist had made asking about self-harm a routine
part of their weekly sessions. As she explained, “It would be easier if she asked
every week. Then she could see that it doesn’t happen all that often and it’s
not necessarily a sign of me completely falling apart. It’s just a thing that
happens sometimes.” Routine asking like this is built into several manualized
therapies, for example, dialectical behavior therapy, in which a weekly diary
card is used to capture incidents of suicidality, self-harm, or substance use
that may occur, without relying on the client to bring them up. Our research
suggests that when topics are brought to the table and kept on the table in
this way, clients find it easier to be honest.
Asking direct questions was not the preferred tactic in all situations or
for all clients. A majority of clients who were concealing sexual infidelity,
for example, reported feeling in control of their decision not to disclose. Few
reported a desire to be asked about it. Similarly, clients who were conceal-
ing alcohol or drug abuse, suicidal thoughts, or homicidal urges were more
inclined to be honest if they could be guaranteed that disclosure would not
lead their therapist to “overreact.” At times, a strong therapist reaction can
be clinically or legally necessary. Nonetheless, clients concealing these seri-
ous issues saw no reason to be honest if honesty would land them in hot water.
Often, they wanted to know where the boundary line was between things
one could safely say in therapy and things that would have to be reported. A
client concealing violent urges wrote that he would be honest if his therapist
could “assure me that I will be completely in control of my freedom as long as
I only talk about, and don’t act upon, homicidal ideation.” A different client
saw some chance for honesty through “discussing what is and isn’t grounds
for immediate hospitalization.” We discuss this link between certainty and
disclosure in our chapter on suicide and self-harm (Chapter 7), where our
respondents speak of wanting to know precisely how therapists will react to
certain disclosures before they risk being honest.
One surprise in Table 6.9 is that trust appears to be only a second-
tier factor in fostering honesty. When asked under what circumstances
they might be more honest, only 25% of our sample selected the option
“if I trusted my therapist more.” This number is partially composed of cli-
ents concealing certain topics for which trust was valued by a mere 10%
of respondents (e.g., anxiety symptoms, labile moods). However, trust
appeared to play a much larger role for clients concealing depression symp-
toms; 42% of respondents saw it as a way to foster honesty. Increasing trust
was also important to clients concealing mistreatment in relationships and
even for those lying about self-harm. The reasons for the uneven impor-
tance of trust are not immediately obvious. It may well be that many clients
already believe they have a good level of trust with their therapist and

therefore do not see increasing trust as a way to foster honesty. As one client
with a binge eating disorder remarked,
She really already does everything that she could possibly do to make the
subject more comfortable. Sometimes certain things are simply difficult
to talk about, because they are repressed or show a darker side of yourself,
and all a therapist can do is listen and clarify your own thoughts, ask
questions, be understanding and not judgmental.
The importance of trust can also be examined through the therapeutic
alliance, a popular and highly influential concept in psychotherapy research

that captures the client’s felt sense of being in alignment with his or her clini-
cian on the tasks and goals of therapy, as well as a sense of having a solid bond
with that clinician. The alliance is often measured with a standardized scale
called the Working Alliance Inventory; we used its short form in our second
study (WAI-SR; Hatcher & Gillaspy, 2006). We were interested in seeing
how the strength of the alliance would affect the amount of honesty reported
by clients, so we also developed and validated our own measure, the 15-item
Honesty in Therapy Scale (HITS), also used in our second study. Results
showed a significant correlation between the WAI and the HITS (r = .54,
p < .01), suggesting that greater trust between therapist and client does indeed
co-occur with greater honesty by clients. In a similar vein, those with higher
alliance scores were significantly more likely to predict that they could one
day “come clean” and be honest with their current therapist. This effect was
found irrespective of the topic being lied about.
There were also circumstances in which clients felt they could be honest
if their therapist had a similar problem or had some clearer understanding of
their culture or class. These “I’ve been there, too” factors were notably impor-
tant to clients concealing a handful of specific subjects, such as eating disor-
ders, and also for those who felt unable to be honest about their religious or
spiritual lives in therapy and those whose experience of being a racial minority
was largely avoided or concealed in their therapy. Showing a client that you
have “been there” was seen as effective for between 44% and 83% of clients in
these categories. But it can also involve significant self-disclosure by the thera-
pist, which some clients say is exactly what they want. Respondents frequently
mentioned a desire to “know my therapist better.” One respondent reported
concealing a particular erotic interest out of shame but said she was willing to
disclose provided her therapist could meet her halfway. Her particular fascina-
tion was with vampires, and she hoped for some hint that her therapist might
understand. “The thought of talking about what I like makes me feel like I’m
going to explode from total embarrassment,” she wrote. “He’d have to share
something personal about himself that involved his fantasies, sexual thrills,

etc.” Unfortunately, this might be a place where the client’s wishes and clinical
prudence diverge.
Finally, there were two topics for which the prevailing feeling was that
under no circumstances would the client be more honest, no matter what
the clinician might do. Fittingly, these were “my romantic or sexual feelings
about my therapist” and “how much I can afford to pay for therapy,” two
topics for which clients were most likely to see no benefit to honesty and
believe the truth was better left unexplored.
In this chapter, we have been able to highlight only some of the fas-
cinating nuances of when, why, and how clients in psychotherapy decide

to conceal their true feelings and the true facts of their lives. It has been a
whirlwind tour of our research that might seem a bit overwhelming unless
one was taking copious notes. In the following chapters, we slow things down
a bit and provide more focused discussions of client dishonesty and conceal-
ment on several of the most critical topics that clients bring to treatment:
suicide and self-harm, the broad field of sex and sexuality, substance abuse
and trauma, and finally, the client’s feelings about therapy and about their
therapist, too.
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Clinical and empirical perspectives on secrets and lies in

Chapter · January 2019

Barry Farber Matt Blanchard

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WHAT DID 1,345 PSYCHOTHERAPY

Whenever we present our research on client dishonesty, no matter

Few of the 1,345 clients we surveyed liked being or feeling dishonest.

114 secrets and lies in psychotherapy

the columbia project on lying in psychotherapy 115

116 secrets and lies in psychotherapy

WHAT PEOPLE LIE ABOUT IN THERAPY

Predictions based on the mostly secrets-focused past research led us to

the columbia project on lying in psychotherapy 117

1. How bad I really feel—I minimized 295 54

6. My use of drugs or alcohol 159 29

118 secrets and lies in psychotherapy

49. The severity of my symptoms—I exaggerated 33 6

In addition to the high prevalence of distress minimization, the results

the columbia project on lying in psychotherapy 119

120 secrets and lies in psychotherapy

interpersonal consequences should the depth of their suffering be known. As

ONGOING DISHONESTY IN THERAPY

As noted earlier, our second survey provided a somewhat different per-

the columbia project on lying in psychotherapy 121

1. My sexual desires or fantasies 34 4 30

122 secrets and lies in psychotherapy

Prevalence of Assessed lifetime prevalence Assessed current levels of honesty,

the columbia project on lying in psychotherapy 123

Importance of Assessed with 7-point Likert

Assessed with 7-point Likert

124 secrets and lies in psychotherapy

Perceived Assessed clients’ ideas about how

identify major themes.

the columbia project on lying in psychotherapy 125

Disclosure and Assessed with multiple

yes,” “definitely yes”)

126 secrets and lies in psychotherapy

TECHNIQUES (ACTIVE VS. PASSIVE) OF CLIENT DISHONESTY

We have argued in earlier chapters that deception can be seen on a

the columbia project on lying in psychotherapy 127

MOTIVES BEHIND CLIENT DISHONESTY

Our assumption, which our studies confirmed, is that when patients

128 secrets and lies in psychotherapy

Embarrassment or shame 410 61

the columbia project on lying in psychotherapy 129

THE “BIGGEST” AND “SMALLEST” LIES

1. M y romantic or sexual feelings about my 5 46

130 secrets and lies in psychotherapy

To reiterate, 93% of clients surveyed were able to recall being dishonest

the columbia project on lying in psychotherapy 131

TIMING AND PLANNING

Everyday experience gives us two possible models for imagining when

132 secrets and lies in psychotherapy

the columbia project on lying in psychotherapy 133

FEELINGS ABOUT HAVING BEEN DISHONEST

1. M y romantic or sexual feelings about my 5 46