Guilty Until Proven Innocent
Dishonesty is the best policy: The reverse jurisprudence in psychotherapy
Foreword: The essay argues a position that is more in negation of the title.
“Except you give me a reason to doubt you, I start with the assumption that you're telling the truth.” Scott Alexander Siskind (Psychiatrist).
Like Dr Gregory House, in the now retired medical series House (2004 - 2012), would always assert: "Everybody lies". He unshakably believes in the sanctity of this rule of human nature in the manner of a religious zealot. In S4E10, he preached: "Lie is a tool" used to smoothen human affairs and ensures everyone is happy. In other words, he was saying it's a necessity for collective sanity. Once in every 15 or so cases he is proven wrong. But he is mostly proven right. He unashamedly and unapologetically starts with the assumption that his patients lie because everyone has got something to hide. In fact, he has a policy of not interrogating his patients unless he's unable to proceed otherwise.
"Everybody lies" sure seems like a more reliable and far less risky guiding axiom than "Everybody tells the truth", no matter how cynical it sounds. As a matter of fact, cynicism may be the most incisive instrument for unearthing the most dangerous kind of lie - that which sounds (or looks) so much like truth. Only the cynic is immune to the convincing antic of the most skillful liars. And so naturally, cynicism comes with a heavy judicial price - a high rate of false positives in which someone telling the truth is wrongly accused or perceived as lying.
However, which axiom a person comes to adopt, believe and operate by is barely a product of a detached logical assessment of the merits and demerits of the claim the axiom foregrounds, but more a function of the person's personality-guided predisposition. In other words, a character like House did not come to the conviction that lying is a default human behavior through careful empirical observation and logical analysis (even though those were definitely involved at some latter stage of his moral evolution and merely as secondary processes), he did so primarily because he is by nature a cynical mistrustful SOB who is chronically averse to vulnerability. And this claim would still be true even if people who have gone through the trauma of betrayal, because not everyone who has experienced the sting of betrayed trust ended up in the camp of “everybody lies”. And someone like House didn't come to embrace this belief because he is intelligent and perceptive either as there are equally intelligent and perceptive people who believe in the opposite claim that espouses the supremacy of “the better angels of our nature”.
But the fact that Dr Gregory House is an SOB does not mean he is wrong. It means cynical mistrustful misanthropes are far more likely than most to not only axiomize the fact that humans are fundamental liars but also more likely to incorporate it into their operational worldview. In other words, such people are far more likely to come into every interpersonal engagement cognitively armed with the assumption that the person or people they're dealing with is either motivated or predisposed to dispense information in ways that serves their own end game. And for the extremely cynical mistrustful SOBs like House, they'd rather describe the rare human in whom they're yet to catch a lie as "not lying...yet" rather than as "truthful". Of course, in spite of their status as cynical and mistrustful SOB, they are more often eventually justified than proved wrong. That's because one cannot even remotely become socially accomplished and/or relationally valued without the capacity for measured and timely systematic lying (whether consciously or unconsciously).
The only period in our entire developmental career that truth-telling is the prevailing instinct is in toddlerhood. As the old English adage says: ‘Children and fools tell the truth’. Children as young as age 2 years are already capable of lying. That's how incredibly loooong our truth-telling-innocence phase lasts. We then spend the rest of our growing and living career honing our lying instinct. Knowing how to lie, when to lie, where to lie, and to whom not to lie is actually a sophisticated behavior that perhaps best define the most emotionally intelligent and socially skillful amongst us. These people are sometimes known in scientific literature as “effective liars” and Sarzyńska-Wawer, et al. (2023) in their study found that the ability to successfully tell lies correlates with fluid intelligence. And it goes without saying that the best kind of lies are those that sound like truth and sometimes it doesn't matter even if the other party suspects it might be a lie; as long as the two sides implicitly agree that the lie is more palatable than the truth, they would both leave the situation feeling satisfied.
However, there is another category of people that's worse than the cynical mistrustful SOB type, they are the ones that would boldly claim: "I never lie". Yes, such type also exists and I've met a few share in my lifetime. They are as a rule insufferable to live with. Mark Twain was really on to something when he wrote:
“None of us could live with an habitual truth-teller; but thank goodness none of us has to. An habitual truth-teller is simply an impossible creature; He does not exist; he never has existed. Of course, there are people who think they never lie, but this is not so - and this ignorance is one of the things that shame our socalled civilization.”
I know this first hand. I used to work with a female non-clinical colleague who once proclaimed with a firm tone and a dead serious face that she never lies. When she first spewed this mother of all lies I was taken aback and immediately tried to push back but she never backed down. Then I relented and withdrew to ponder this latest encounter with this type of human being. I did a quick memory search of similar persons I know who has either made or is capable of making such moral perfectionist claim and this is what I deduced: as a rule, such people tend to be extremely religious, morally rigid, sexually frigid, interpersonally and socially superficial, interpersonally and socially unaccomplished (and if they appear to be, only superficially), and are often afflicted with a complex of their own moral superiority. They are unrelentingly and unapologetically judgemental, preachy, and extravagantly certain of their beliefs. Fun fact: if such people take the MMPI personality test, their Lie scale would shoot out like the middle finger. But in truth, nobody wants to have to live with someone who is either incapable of lying (actually this is not always an indication of moral virtue, it could also signal a neurodevelopmental, genetic, neurological, or medical problem) or incapable of telling the truth (this is mostly a psychopathic behavior but could also be neurological or psychopathological).
But what about mental health practitioners? What should be their starting attitude when professionally transacting with their clients/patients? Over the course of my short professional career as a clinical psychologist working with other allied MHPs, I have come to notice that two distinct attitudes are projected when it comes to how mental health professionals view a patient's disclosures.
Aside: I’m excluding patients who're obviously psychotic, delusional, manic, suicidal, addicted, or with criminal record. Any other attitude other than a curious scepticism towards these type of patients would surely be misguided.
The types of patients I have in mind here are those broadly referred to as neurotics, that is, patients whose mental tether to the fabric and workings of reality has not been warped to such a degree as to render honesty and forthright communication with regular people impossible. This would include such patients as those suffering from depression (non-psychotic), phobias, anxiety, grief, personality disorder, substance use, eating disorders, etc.
When dealing with the latter category of patients, some MHPs start with the implicit assumption that the patient is "probably lying" while some start with the assumption that the patient is "probably telling the truth". These attitudes are mostly not arrived at by conscious deliberate process of rational choice. Many MHPs are often not even aware of either of these attitudes in themselves until pointed out to them. And to further prove that it's not a product of conscious rational choice, when pointed out to most people and they desire to switch or temper the specific mental attitude they project, they found out they're mostly unable to do so to any significant degree (still pointing to its root in personality). And by the way, neither attitude is decidedly superior to the other as they're both differently engineered to optimize engagement with different kinds of persons and encounters. For me, I have long found that my natural tendency is more towards the assumption that a patient is "probably telling the truth" in spite of the fact that I'm also somewhat generally cynical. This often makes me come across as too trusting and naive, and I found this out in a very embarrassing way during a ward round meeting. One of my already introverted patients (let's call him O) who was overusing cannabis had told me that his reason for not going out as often as he would sometimes like is largely because of his financial limitation. And in the course of reporting my engagement with O to the team, I had added that I told O that "I understand you". And the whole team, starting with the presiding psychiatrist, almost unanimously agreed that I shouldn't have told the patient "I understand you" based on the premise that he was probably lying. In fact, they argued that his real reason for not going out more often probably has little or nothing to do with his financial condition. I remember I was immediately compelled to push back against this orientation but I did such a poor job that I was increasingly made to sound ridiculous and I quickly had the sense to back down when I sensed I was sounding too defensive. But in retrospect, I still couldn't agree with the team's position nor was it subsequently justified by my later dealings with O. It turned out that the team underestimated the introverted nature of O and his aversion to overly new and unstructured social situations. And of course, because O was in for drug rehabilitation, they also assumed he was "probably lying". Their preferred hypothesis was that he was probably staying more indoors because he was becoming more addicted to smoking weed. But the record indicated that he wasn't much outgoing even before he became more dependent on cannabis. I had, as usual, assumed O was "probably telling the truth" because (1) it was shameful for him to admit that not having enough money was making him less confident to venture out, and (2) the general pattern in his self-disclosure had been mostly towards revealing embarrassing personal info. In O's case, I was eventually vindicated as he reasoned that it's far cheaper and psychologically safer for him to stay indoors and smoke than to go for social outings. And in a place like Lagos, where cost of living is high, combined with a personality that's chronically introverted and a condition of financial constraint, this is doubly true.
However, there have been other cases in which I had been wrong in my assumptions and indeed successfully deceived and manipulated in a way that someone who starts with the assumption that a patient is probably lying is not likely to fall prey to. Nevertheless, I still assert that in the specific arena of psychotherapeutic relationship, it is always better and safer to start with the assumption that a patient is "probably telling the truth" even when adopting the opposite claim might have spared us being fooled. And this is always going to be okay as long as we know and accept that one's starting attitudinal position does not have to be one's eventual position. In fact, the internal shift and movement in these attitudes as observed by the therapist in her own self can be diagnostic of the progress or otherwise being achieved with the patient. Growing trust and confidence in the therapist always lead in the direction of being more truthful, while frustration and resentment always lead the patient to detach by concealment and hesitancy with the truth.
So why is it a better policy to always start with the assumption that any patient who is neither psychotic nor manic is "probably telling the truth", even when it perfectly plays into the hands of a manipulative or psychopathic clinical characters?
It is ethically the correct attitude to take just as in medicine Doctors are admonished first and foremost to "do no harm". It is potentially psychologically harmful to distrust a client before she even opens her mouth. And a hundred untruthful clients still do not justify permanently adopting a cynical front if only for the sake of that one client who might one day come in to agonizingly bare her soul. It is always easier to correct for the error of trusting too readily too much than to atone for the insult/injury of not trusting enough.
It minimizes cynicism and reduces the risk of epistemic injustice1. Cynicism is, more often than people would like, effective and justified, but it is never adequate. It faces its limit when confronted with any character that is open and guileless. In the presence of such people, chronic cynics like House are often left confused and confounded. In other words, clients who are childlike, dependent, trusting, and psychologically unsophisticated blunt the perceptive edges of a cynical therapist by making everything rather too plain and simple. Another category of clients who renders cynicism superfluous are those who come into the therapy relationship expecting to talk honestly as one adult to another. For either of these categories of client to find out that their therapist holds them in a skeptic’s bad faith will be very hurtful and potentially damaging to any evolving therapeutic alliance.
It reduces the risk of iatrogenic harm. There are many ways, often subtle and unspoken, that clinicians can hurt/harm/insult/upset their patients. One of such ways is when a therapist dismisses or minimizes an important piece of disclosure by a client simply because of the therapist’s belief that “clients always lie”. The problem with this starting attitude is two-fold: first, it is obviously unhelpful to clients who are actually more inclined to be honest in self-disclosure. However, it is also quite harmful even in the case of a client more inclined toward dishonesty. How? Because there is no client who is 100% dishonest, not even the most callous psychopath. With such pathologically dishonest subject, it is already difficult separating what is true from what is not, but it’ll be doubly more difficult for the clinician who is operating with a skeptical lens, and the thicker the lens the more difficult this truth-sieving exercise. Too many things that are true are dismissed as lies or dubious, and too many lies than is the case are attributed to the unfortunate client. In the end, more truths are missed than lies are caught.
It is more conducive to building therapeutic alliance. What kind of therapist would you rather want to be listening to your tales of struggle: one who thinks “He’s probably lying” or one who thinks “He’s probably being honest”? Even a lying or manipulative patient would still prefer a therapist who thinks or at least appears to think that they believe them. Yes, a trusting therapist may come across as naïve and psychologically unsophisticated, but we can’t keep up acts of dissimulation in the presence of a child indefinitely. Sooner or later a lying or truth-hesitant client is bound to let down their guards if only out of the false sense that the therapist is too naïve to pick up on it. The question then is: Do therapists’ ego ever allow them the patience and ease to assume the role of a child being taking for a fool?
It is by itself therapeutic. Beware! you may be the first person that has ever taken a patient seriously. Anything conducive to therapeutic alliance must also by itself be therapeutic. It is true that a dishonest and manipulative client impedes therapeutic connection and slows progress. But this is worsened if it is in conjunction with a cynical therapist who suffers from a need to be right all the time and to out clients in their lies.
It is the more logical position to start from; just as "innocent until proven guilty" is the more logical counterpart in judicial matters. Just as it is the more ethically correct starting point (point 1 above), it is also the more logically correct starting point. Absolutely no one is hurt by a therapist’s attitude that says, “I’ll at first act towards all my clients as though they’re telling me the truth to the best of their knowledge and awareness.” At worst, this therapist finds out he/she is dealing with a verbal dribbler and then quickly adjust accordingly. However, imagine another therapist whose starting attitude is, “In psychotherapy, customers are always wrong (lying)”.2 And then you treat a painfully honest client as though they’re lying about their experience or motive. Someone is being needlessly hurt and it’s certainly not the therapist.
It is an assumptive error very easy to correct for with very minimal damage to the therapeutic process. Its counterpart is definitely more costly in its ramifications. This has already been covered from different angles. It is relatively easier to backtrack from a trusting position to a skeptical one than to redeem oneself from a position of a betrayal of lack of trust with the additional risk of overcompensation. The therapeutic cost of wrongly mistrusting a client can be great indeed, sometimes to the point of being irredeemable.
It's clinically more defensible: even a patient's lie is a form of truth about them. I’ve written something about this before. I have a guiding axiom to capture this truth: A client never lies. Why? Because a lying client is also telling you a truth about them. If he is lying to you his therapist, he is probably also lying to others in his life. This is fodder for psychotherapeutic exploration rather than for punishment or criticism. Besides, there’s nothing in the psychotherapy process that gives therapists any reason to expect their clients to start with ‘truth and nothing but the whole truth’. When they are neither before a judge or in a court of law. A therapist is neither a priest nor a judge, but his role is more akin to the former than the latter. In fact, in therapy, what a person is trying to hide is more often than not more informative than what they’re trying to reveal. And a therapist who feels betrayed after discovering a client in lie is probably a very limited one.
Therapists are justified if they, by degrees, have to adopt a more skeptical attitude. This may especially be inevitable when dealing with certain population of patients where the information they share are crucial for making practical treatment plans, e.g., SUD, suicidal, and Forensic patients. But at least she’d have secured herself against any accusation of “you don't trust me?”. And the therapist can now justifiably reply: “I guess you'd have to earn it the same way I have to earn yours.”
It is diagnostic of an omniscient complex in a psychotherapist. Better to undermine the integrity of the patient than be undermined. Better to doubt everything than to be led on a fool’s trip. A therapist who is afraid of being knowingly led astray by the client is perhaps one who is wont to take things more personally than they should. Except in cases where clients came into therapy by way of some mandate, a voluntary client is less likely to knowingly mislead their therapist in such a manner and to such a degree that their goal for seeking therapy is defeated.
It models what healthy mature interpersonal relationship should feel like: a healthy trust is sincere but also casually vigilant; it is readily given and adjusted upwards or downwards according to the client’s behavior. Most mental health patients are steeped in the morass of deception (of self and others) and mistrust. It is a pattern that psychotherapy should aim to discontinue with rather than reinforcing through modelling of mistrust and doubt. The only exception may be a client who trusts too readily, too completely, and too uncritically. For such clients, it may be necessary to remind and demonstrate throughout the therapeutic encounter that not even the therapist’s utterances and opinions should be absorbed without critical examination.
Finally…
Therapists also lie. They lie about their feelings, motives, and ignorance. Most therapists would rather lie than admit their ignorance about a matter. Most would rather deny than admit their countertransferential feelings. And most will never admit to their real motive if it ever deviates from what is professionally and ethically acceptable. It is easy to be wrong about people but, ironically, very difficult to allow ourselves the opportunity and permission to be wrong.
“Patients suffering from fibromyalgia frequently report that healthcare professionals are suspicious of their knowledge claims. Practitioners might doubt, ignore, or consider patients’ arguments irrelevant in treatment and care.“ (Heggen and Berg, 2021)
It is a comedic twist of the popular HR line “Customers are always right”. I first heard it in the well-written psychotherapy TV series In Treatment.