(I have followed my usual practice in this post of disguising the patient.)

Someone responded to a previous blog post by asking why her therapist suspected the things she told him about family experiences were not true. She did not understand why he thought that she would spend all that money on therapy sessions just to make up stories. Of course, he insulted her. Patients deserve the benefit of the doubt, whatever the therapist may suspect. Besides, as that previous post suggested, strange stories can be true.

Still, she asks a good question. I have heard similar sentiments many times from patients who were talking about other patients at the time. Certainly, patients come to therapy looking for help. They spend money, sometimes a lot of money, pursuing that help. And, certainly, as everyone knows, a basic rule of psychotherapy is that patients should be open about their thoughts and experiences, and truthful.  It is common sense. And most patients do tell the truth most of the time. Few patients out and out lie, I think; although they are more likely to mislead a therapist by omitting things that they know are relevant to treatment

And some patients do make up stories, perhaps not the outlandish anecdotes I was complaining about in that post; but stories nevertheless. The short answer to my correspondent’s question is that some of these patients do not feel the stories they tell will prevent them from profiting from psychotherapy. The stories seem not so important, or not really relevant to that patient’s concerns. In short, they do not really believe that an innocent lie will sabotage their treatment. Lies do interfere, but some people are inclined generally to embellish their life stories, and the habit continues into psychotherapy.

I indicated why some people tell the particular stories they do: to make themselves more interesting in general and, in particular, to have interesting symptoms; to make themselves seem better: more intelligent and more capable; to explain away and justify failures, to put one over the psychiatrist, who may present himself as preternaturally wise; to gossip about others; and to distract from the ordinary business of life which is usually the source of most patients’ distress, but which is painful to contemplate because it is so intractable. In sum, people lie to cover up an unpleasant picture that they have of themselves. Patients want their therapists to think well of them.

But I left out the most important reason that patients lie.

There was a time when I was running a stop-smoking clinic. One of the patients, a very successful senior bank executive, did, in fact, stop smoking during the course of the clinic, and immediately---in the usual perverse way of things—dropped dead from a heart attack. Inevitably, I came to know his 53 year old widow, and at some point began formally to treat her. During the next number of months following her husband’s death, she became withdrawn. She stopped driving and stopped seeing her friends. Only her two children, fraternal twins, were allowed to visit her. She was, in short, depressed. She might have been clinically described as having a prolonged and exaggerated grief reaction.

I put her on anti-depressant medications without much expectation she would respond, and she did not. But there was nothing remarkable about her condition during those months. She was suffering because her life had revolved completely about her husband, and he was no longer there. She was alone much of the time and pessimistic about her future.

This situation is familiar to most people. Someone bereft from the death of a loved one—or from being divorced or jilted—must fill up the empty places left behind In order to live on successfully. That person must find something like work, must become active with friends, and, if possible, find someone new to love. In the way of struggling to accomplish those goals, it is good to be physically and intellectually active. It is a matter of coming back to life.

There is a time for mourning, but, soon enough, friends and family will encourage these activities. And so will a therapist.

By the way, I would like to be explicit about what I think the role of the psychotherapist is. He, or she, is in the influencing business. We try to encourage the patient to behave in ways that will widen the scope of life. In order to live happily, there has to be involvement with friends, family, work, and with someone to love. The fewer of these things there are, the less likely it is that that person’s life will be happy. What sets apart a therapist’s approach from that of an unskilled person—presumably—is the ability to encourage someone without hectoring or scolding. It is a matter of judgment and depends not only on the particular inclinations and personality of the patient, but also on the style of the therapist.

In this case, the patient’s twin children became more and more aggressive about encouraging their mother to go places and do things. They had an agenda for her which included not only regular church attendance, but also taking adult education classes, going to a gym and also—especially—getting on dating sites and seeking out male acquaintances. As her therapist, I more or less agreed. The strategy is to return to an active life. As usual, it is the tactics that make this process difficult. How far and how fast can a particular patient go? This particular woman seemed unsure of herself and discouraged.

Nevertheless, there came a time a few months later when she told me and her family that she had met a man. He was a successful builder, although he was having some financial problems at the time. He seemed pleasant enough, although she reported he could be stubborn about small matters. He was close to a grown daughter, whom my patient had met and liked. The new couple went places in New York City, including the ballet. He had a gruff manner quite unlike that of her husband, but she grew to like him more and more.

There came a time when they entered into a sexual relationship. This did not always go well. Her companion had diabetes and was sometimes impotent—but not invariably. This was one of those situations where drugs for erectile dysfunction made a big difference. My patient seemed happier. Her children were happier. Even I felt good about her return to what promised to be an exciting and fulfilling life.

Then, about six months after this affair started, she told me she made the whole thing up! There never was such a man. She had not gone to any of these places. She reported this lie to me with some embarrassment. She seemed more discouraged than ever. She stopped seeing me a few weeks later and I know nothing more of her story.

But I know why she made up this romantic story: she was tired of being told to do things for her benefit that she felt she could not—or did not want—to do. She wanted us all to stop bothering her. It was easier to lie than to argue with us.

Her story is unparalleled in my experience, but it is quite common for patients to tell their therapists that they have started to do things that they have agreed are in their best interests, but have not yet done. They lie because it is easier to do that than to confront new situations that are frightening to them. It is often the job of a therapist to convince them that there is no rational reason to be afraid. Small changes have big effects in life. But sometimes that is recognized only in retrospect. (c) Fredric Neuman 2013. Follow Dr. Neuman's blog at fredricneumanmd.com/blog.

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