By Theodore A. Stern, M.D. and Shawn Hirsch, PhD.

Honesty is at the heart of the relationship between patients and healthcare providers. It is challenging to decide on the proper workup, make the correct diagnosis, and create and implement a sound treatment plan without accurate information. Unfortunately, omissions, inaccuracies, and falsehoods are inevitable in therapeutic relationships.

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Each of us has occasionally stretched the truth or withheld information from our doctor.

  • How many drinks do you have in a month? Oh, just a couple, but only on special occasions.
  • Have you been exercising? Of course, 5-6 days a week!
  • Have you been using those grounding techniques we practiced the last session? For sure! Super helpful!
  • Have you been taking your medications as prescribed. Always!
  • Have you had thoughts of hurting yourself or killing yourself lately. Nope, not at all!

Fortunately, most therapeutic relationships are not marked by extreme dishonesty, but at times, unconscious or uncontrollable motivations underlie symptom fabrication or embellishment. Rarer still is intentional malingering (or faking illnesses or symptoms) to gain something (e.g., disability income or a pain-relieving medication) or to avoid something (i.e., legal consequences). Far more common are “little white lies” like those discussed above.

We tell “white lies” (and notably don’t say other things), knowing full well that it’s not the truth, the whole truth, and nothing but the truth. We may simply want to avoid being judged by our healthcare providers, as well as by their scolding and their nagging us to do this and not that. We want to maintain our autonomy (I’ll decide whether I keep that sleep diary or make space to feel my feelings, thank you very much). We want to avoid being embarrassed. After all, how bad can it be to go on lying to ourselves? We tell our little white lies and grin until our clinician moves on to another domain–duped–at which point we breathe a sigh of relief and congratulate ourselves on our “master-mindedness.” Little do we realize…

Clinicians are aware that patients sometimes withhold information, exaggerate symptoms, or even lie through their teeth. They know this empirically; research has demonstrated that patients aren’t always truthful with their healthcare providers. But they also know it from a much more personal, practical source. When clinicians are not working, they are also patients themselves.

Although it can be easy to understand why patients mislead their clinicians, the unspoken game of two truths and a lie, unfortunately, muddies the doctor-patient relationship, treatment plan, and patient outcomes. Rather than having all the information they need, clinicians are left to discern which portions of the his-story are accurate, omitted, and straight-up fabricated. That makes for an uncomfortable and precarious guessing game wherein the clinician is forced to err on the side of skepticism.

Clinicians are neither clairvoyant nor psychic and are no more adept at reading patients’ “tells” than are law enforcement officers at detecting deceit in a suspect (which is no better than the flip of a coin). As a result, they are left in the dicey position of judging patients’ honesty to guide treatment recommendations.

We, as patients, should obviously be (fully) truthful with our clinician, and that is clear. The onus, however, does not fall solely on the shoulders of patients, nor does the tendency toward deceit in the therapeutic relationship. This dates back to way back when the Hippocratic Decorum set a precedent for withholding information from the patient by encouraging clinicians to downplay negative diagnoses and prognoses instead of focusing on the positive to instill hope in patients. A good intention, to be sure, but patients deserve to know the truth about their conditions, prognoses, and treatment options.

Although today’s clinicians are not trained to withhold patient information, they don’t always tell the whole truth. Sometimes they give an overly simplistic explanation that prevents the patients from fully understanding what they’re facing. Sometimes they gloss over certain treatment options in preference of the one that they most highly recommend. Sometimes they make an error in clinical judgment or technical skill, and (perhaps to avoid litigation or guilty conscience) they paint a picture that minimizes their culpability. Sometimes, they don’t know the answer to your question, but instead of saying so directly, they respond in vague terms or state their best guess as to if it’s a clinical certainty.

Regardless of who’s deceiving or when it occurs, untruths erode the therapeutic relationship and complicate care. Ultimately, both parties are accountable for transparency and honesty with one another. Honesty in the therapeutic relationship can be facilitated by either or both parties by explicitly highlighting the importance of mutual openness, acknowledging when you’re reluctant to share information that may feel painful or embarrassing, asking one another if there is anything else you should know, and practicing truth-telling as an ongoing action rather than as a time-limited outcome.

Direct, thoughtful, and open communication is likely essential to facilitating honesty within the therapeutic relationship; it can promote positive outcomes and patient satisfaction.

Theodore A. Stern, M.D. is the Ned H. Cassem Professor of Psychiatry in the field of Psychosomatic Medicine/Consultation at Harvard Medical School, Chief Emeritus of the Avery D. Weisman Psychiatry Consultation Service, and Director of the Thomas P. Hackett Center for Scholarship in Psychosomatic Medicine at the Massachusetts General Hospital in Boston, Massachusetts. Dr. Stern has written more than 475 scientific articles and book chapters and edited more than 50 books.

Shawn Hirsch, Ph.D. is a staff psychologist with Outpatient Assessments for The Menninger Clinic and an assistant professor at Baylor College of Medicine.

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