Big Surprise!!! Recent research has found that therapists lie to patients

Ethics of psychotherapist deception. Drew A. Curtis & Leslie J. Kelley. Ethics & Behavior, Oct 3 2019. https://doi.org/10.1080/10508422.2019.1674654

ABSTRACT: Since Tolman’s efforts to establish a code for psychologists, the American Psychological Association’s (APA) ethics code has been maintained and revised for over six decades. One of APA’s five core principles is honesty and integrity. Recent research has found that therapists lie to patients. The current project explored therapists’ and non-therapists’ beliefs about the ethics of therapist deception. We recruited 245 students and 38 therapists who read and rated vignettes of therapists lying or being honest. Overall, participants judged therapist deception as unacceptable and unethical. The results of therapist honesty perceived as most ethical and acceptable align with APA’s value of honesty and integrity for the profession. Given findings from previous research suggesting the use of deception by psychotherapists, psychologists’ ethics code would benefit by addressing honesty and integrity in more detail within the context of psychotherapy.

KEYWORDS: deception, honesty, therapists, ethics, psychotherapy

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Discussion

The current study evaluated the ethics of psychotherapist deception from the perspectives ofpsychotherapists and non-therapists. Therapist honesty was perceived to be more ethical thantherapist deception when using an ethics scale to rate vignettes and when being asked to explicitlyrate therapist deception. Additionally, psychotherapists endorsed that they and other psychothera-pists would be most likely to act in accordance with the therapist’s actions in the honest vignettecompared to all the deceptive vignettes. Therefore, psychotherapists appear to follow the principle ofintegrity in their actions and believe that other practitioners act similarly.

Both psychotherapists and students indicated that lying to clients is unethical and unacceptable touse within therapy. Therapists’beliefs about the use of deception being unethical was not related totheir years of experience or the worldviews they held. This finding is not surprising given theprofessional values of integrity and honesty (APA,2017) and therapists’value of honesty (Curtis &Hart,2015). Honesty is often seen as virtuous in ethics (Aquinas,1947; Aristotle,1941; Kant,1997)and is viewed as part of a person’s moral identity (Strohminger & Nichols,2014). Lying on the otherhand, is generally costly (Bok,1978). Deception threatens the value of honesty within the profession.The use of deception may be viewed as unacceptable within psychotherapy because of attitudestoward people who use deception and its effects on relationships. Psychotherapists and otherprofessionals hold negative attitudes toward clients and patients who lie (Curtis,2015; Curtis &Hart,2015; Curtis, Huang, & Nicks,2018; Dickens & Curtis,2019). Additionally, the use ofdeception in relationships damages trust and is related to less satisfaction (Hart et al.,2014;Kaplar,2006; Möllering,2009).

Most psychotherapists indicated that the use of deception should never be used or used rarely(less than 10% of cases). This finding is interesting because research has revealed that mostpsychotherapists have lied to their clients or patients in therapy (Curtis & Hart,2015). However, while most therapists have been deceptive, it is unclear how often therapists use deception withintherapy. If psychotherapists employ deception as often as the general population (Serota et al.,2010)or clients (Curtis & Hart,2019), then most would not lie often. In the current study, over half ofpsychotherapists believed that the use of deception may be acceptable in less than 10 percent ofcases. Considering that previous research suggests that large percentage of psychotherapists admitthey have lied, while a large percentage of psychotherapists in the current study indicated thatdeception should rarely or never occur, perhaps there is a discrepancy between the values andactions of many psychotherapists. This discrepancy could be explained by moral disengagement(Bandura,2016) or moral hypocrisy (Batson & Thompson,2001; Batson, Thompson, Seuferling, &Strongman,1999; Hart et al.,2014). Therefore, psychotherapists may strive for and value honestyand the ethical standards of the profession while sometimes engaging in deceptions.

Over half of psychotherapists believed that deceptive instructions contradict the informed consentprocess and violates APA’s ethical principles and code of conduct. Additionally, just under half ofthe psychotherapists believed that lying to clients is not permissible even if it maximizes benefits andminimizes harm, while about 29% affirmed this position and 24% held a neutral position. Aspreviously mentioned, the APA (2017) ethical principles and code of conduct states“In situationsin which deception may be ethically justifiable to maximize benefits and minimize harm, psychol-ogists have a serious obligation to consider the need for, the possible consequences of, and theirresponsibility to correct any resulting mistrust or other harmful effects that arise from the use ofsuch techniques”(¶ 4). Given the code, many psychotherapists appear to exercise caution whenconsidering the use of deception psychotherapy, while some affirm the use of deception when itbenefits the client and many remain neutral. This wide variety of perspectives provides some initialevidence that further guidance regarding the use of deception within therapeutic interactions may behelpful to psychotherapists. Additional guidelines to Section 10 of the APA (2017) code can helpbring uniformity of practice and training, with the potential of positively influencing the reputationof psychotherapeutic practice by decreasing the frequency of trust violations. Based on the currentfindings, guidelines in Section 10 may need to provide more coverage of the use of deception basedon the principle of integrity and with regards to the informed consent process (10.01).

In order to provide additional specificity beyond deception being tacitly and explicitly rated asless ethical than honesty, we explored various types of deceptions. White lies were rated as the leastethical by the psychotherapists and blatant lies were rated as least ethical by students. Our hypothesiswas partially confirmed, in that students rated the blatant lie as the least ethical, however, therapistsrated the white lie as the least ethical. This finding is interesting because blatant lies are typicallyviewed as the least acceptable type of deception and white lies are often viewed as more acceptablethan other deceptions in similar vignette studies that have examined intimate relationships(Peterson,1996), parental relationships (Cargill & Curtis,2017), and in psychotherapy relationshipsfrom a client perspective (Curtis & Hart,2019). Curtis and Hart (2015) found that therapists weremost likely to lie to patients if they thought it protected patients. While white lies are generallyperceived to be more acceptable to tell, they are not as well received (Hart et al.,2014) and arenegatively correlated with relational satisfaction (Kaplar,2006). Further, when the norm of honestyis salient, white lies can lead to cognitive dissonance and produce negative affect (Argo & Shiv,2012). The reason for therapists rating the white lie as least ethical was not clearly identified in thecurrent study. One possibility is that the white lie vignette involved a deception to the patient abouthope of a treatment rather than a white lie based on a patient’s new haircut. Both lies carry an intentto maintain the therapeutic alliance but psychotherapists may have perceived the former as moreconsequential. Psychotherapists may have believed that a positive response to a patient asking abouttreatment, while it could foster a therapeutic alliance, may not protect the patient. Psychotherapistsalso indicated that they would be less likely than other therapists to use white lies. Interestingly, thestudents rated the white lie as more ethical than psychotherapists. Students may have focused moreon the hope that the therapist seems to instill in the patient compared to the concerns of treatment.

There was also a difference between students and psychotherapists with regard to the ethics ofthe failed deception, where students rated it higher than psychotherapists. A failed deceptioninvolves something actually occurring but the communicator still intentionally misleads another(Peterson,1996). Students may have rated this vignette as more ethical than psychotherapistsbecause of the result being congruent with what was initially stated, even with the intent tomislead. Psychotherapists may have viewed it as less ethical because it involves a psychologisttaking deceptive action against the patient. However, it is important to note that while differenceswere found between the samples, the failed deception vignette was significantly rated less ethicalthan the honest vignette. This finding, along with the white lie, suggests that psychotherapists andstudents or the general public may view the use of deceptions differently within psychotherapy.

While the current study is unique by its empirical approach to investigating ethical perceptions oftherapist deception, there are some limitations to note. The study used a response-driven samplingmethod for recruiting psychotherapists. This method can lead to a sampling bias, in that partici-pants are sharing the study with others who are like them or hold similar values. Another limitationof the study is the recruitment of undergraduate students to represent the general public. Whileundergraduate students represent the public by having attended psychotherapy or able to seektherapeutic services, they also may have different experiences and education that affect theirperceptions of psychotherapists. Another limitation is in the use of vignettes. Participants wereintentionally not given explicit instructions about whether the vignette was an honest exchange ordeceptive exchange so that they rated the deception without being primed. However, when usingvignettes, participants could be responding to a specific part or adding to the vignette. For example,the white lie vignette could have been viewed as holding more serious consequences for psy-chotherapists than students based on the white lie involving a response about treatment. Futurestudies could examine simplified vignettes or even ask therapists to indicate beliefs about theacceptability of using various types of deception with patients. The current study did not differ-entiate between everyday lies (DePaulo & Kashy,1998) and serious lies (DePaulo, Ansfield,Kirkendol, & Boden,2004). Future research may want to explore if therapist deception is vieweddifferently when the lies told are serious compared to everyday or social lies. Additionally, futurestudies could explore the nuances of telling white lies in therapy by measuring the ethics andacceptability of a white lie told for the sake of client, therapeutic relationship, or involving treatmentand outcome. Researchers may also explore the various situations and ethical decision-makingprocess of therapists when using deception within therapy. This is especially important to under-stand the attributions and biases that play into decisions to deceive (e.g., this will benefit the clientor the relationship). Bok (1978) claimed that“the most serious miscalculation people make whenweighing lies is to evaluate the costs and benefits of a particular lie in an isolated case, and then tofavor lies if the benefits seem to outweigh the costs”(p. xix). Bok (1978) suggested that these specificmiscalculations can impact a person’s integrity, self-respect, and endanger others. Lastly, it isunclear how often therapists use deception in psychotherapy. Given that therapists report deceptionshould rarely be used or never used, it would be important to discover the frequencies by whichtherapist use deception.

The use of deception in the practice of psychotherapy has been largely overlooked in literature.Medical ethics, specifically in the practice of medicine and nursing, has extensively addressed thevarious aspects of using deception in practice (Fallowfield, Jenkins, & Beveridge,2002; Fowler,2004;Hoppin,2011; Huddle,2012; Jackson,2001; Olsen,2012; Sade,2012; Tavaglione & Hurst,2012).Arguments for the use of deception have been that practitioners can game the system for the benefitof treating patients (Tavaglione & Hurst,2012) whereas it should be avoided because of the negativeeffects it has on the practitioners image and character (Sade,2012) and goes against the internalnorm of honesty (Huddle,2012). The current findings reveal that psychotherapists and the generalpublic believe that honesty in psychotherapy is the best practice. We hope that our findings stimulatecontinued  discussion  and  research  of  the  practice  and  ethics  of  using  deception  withinpsychotherapy.

Based on the current findings, there is a lack of clinical training in working with deception inpsychotherapy. The lack of training and exposure to deception in psychotherapy has been reportedin other studies (Curtis,2013; Curtis & Hart,2015; Dickens & Curtis,2019).The lack of clinicalexperience with deception is also found in other health care professions (Curtis,2015; Curtis et al.,2018). To remedy this, more clinical training in patient deception has been suggested, embedded inprogram curricula or through workshops (Curtis & Hart,2019; Dickens & Curtis,2019). Training inthe ethics of psychotherapist deception could also assume the format within continuing education(Curtis,2019). Along with consideration of additional training formats, we encourage therapists toconsider the use of deception through the application of ethical decision-making models (e.g.,Barnett & Johnson,2008; Knapp & VandeCreek,2012) within practice. Similar to developedguidelines regarding deception in research, we encourage practitioners, researchers, professors,supervisors, and ethics committee members to consider addressing the use of deception in psy-chotherapy within training, practice, continuing education, and the APA ethical principles and codeof conduct.