I was a big fan of the television drama House, which first aired in the early 2000s. The show’s main character, Dr. Gregory House, was portrayed as an irascible, sarcastic, genius diagnostician with the worst bedside manner imaginable. Yet as coarse as he was, House routinely managed to find a cure for his patients via his second to none medical intelligence. Dr. House’s often repeated admonition to his residents regarding patients was “everybody lies,” which brings me to the topic of honesty in the therapeutic relationship.
Clinical relationships, regardless of context, rely on honesty between clients and clinicians. We therapists and counselors depend on accurate information from clients to develop a diagnosis, and clients require accurate information from us to make decisions regarding the course and direction of their care. The thing is though… falsehoods, misrepresentations, and yes even some lies will occupy the therapeutic relationship.
Clients Withhold Information
This is of course, no surprise to any of us working in healthcare. “Are you taking your medication as directed?” “Sure Joe.” “We spoke of your exercising regularly to help manage your anxiety, have you been doing so?” “Of course, at least four days per week, sometimes even five or six days.”
With the exception of certain psychotic conditions and circumstances in which clients intentionally malinger, the majority of our therapeutic encounters are not marked by blatant dishonesty. Instead, clients are typically seeking to avoid clinician judgment and feel embarrassed for not having followed through, so they tell us these little “untruths” hoping we’ll buy in and just move on. Unfortunately, this means clinicians are left to decipher which portion of the client’s self-report is accurate, which is just plain false, and what’s been omitted, turning the process into a guessing game.
Clinicians Are Culpable Too
Let’s flip the script for a second or two here. Clinicians are at times patients too. Last week I told my dentist I floss every single day; two weeks ago I told my primary care physician I typically consume a very healthy diet. Both statements are partially true, but not completely so, because sometimes we respond to questions based on our intentions, not our actual actions.
Sometimes when faced with discussing a difficult diagnosis with a client, we oversimply our explanation, leaving the client in a quandary as to what they’re really facing. And sometimes we’re not fully transparent about certain alternative treatment options, favoring instead our own preferences.
The Buck Stops With Clinicians
Clinicians bear the responsibility for guiding truthful, meaningful interactions with our clients, here’s how:
- No mincing words. Take a compassionately direct approach: “I believe you have bipolar disorder, and here’s why I think so.” Follow that with a positive, hopeful statement: “Your condition is certainly treatable, and if you choose to work with me, I believe that together we can achieve a favorable outcome. Does this sound okay to you?” Straightforward, direct, honesty helps enhance patient compliance and fosters a sense of urgency to act upon treatment recommendations.
- Own what you don’t know. In mental health, there are often far too many questions than answers, and that’s okay. If you’re unaware of the long-term safety profile of a particular medication your client has been prescribed, just simply say so, while adding what is known about other possible alternatives for the same condition or diagnosis. And when asked about something which you know is beyond your expertise, you can respond that you’ll consult with a colleague or help arrange a referral where warranted and appropriate.
- Rehearse. Difficult-to-convey, sensitive information is challenging to communicate with complete honesty even in the most caring of ways. Enlist a colleague or even a particular family member to participate in a role-play practice session. Ask the participant for honest feedback, and then as you become more proficient, solicit feedback from your clients.
Half-truths, deceit, and outright dishonesty corrode clinical relationships and compromise care. And although both clients and clinicians bear responsibility for communicating with openness and clarity with one another, clinicians cannot control what clients say or do, and therefore must take the lead.
Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.
To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.