Tuesday, July 16, 2013

To Tell The Truth

An acquaintance asked me the other day how I knew if patients were telling me the truth. I gave her the response I usually do: It doesn’t really matter. I can only know the world through my patient’s eyes, so whatever he or she presents is what matters. Besides, I added, none of us ever know if we’re telling “the truth,” we’re only telling our version of what we assume the truth to be.

After I left, however, I began to think more about my answer. Did I really believe it didn’t matter if a patient deliberately lied to me? Since I believe in the crucial importance of the therapist/patient interaction, certainly a patient’s deliberate lie has meaning. It’s not that the patient is “bad” for lying or that the content of the lie is important in and of itself, but rather that the patient’s need to lie says something about what is happening in the relationship.

I thought of a patient I saw many years ago who had been raped. After I returned from a vacation, she told me that she had been raped again by the same man. A look of doubt must have passed across my face, because she angrily proclaimed, “You don’t believe me!”

Oops. I remember hesitating, feeling uncomfortable. “Well,” I said, “I certainly wouldn’t say it’s not possible, but I wonder about the timing. Is it true that you were raped again, or are you saying that you’re angry with me for leaving you and that you felt much more unsafe while I was gone?”

She burst into tears, told me I was correct, and then started yelling at me for abandoning her. 

Despite our difficulties, that patient and I had a solid relationship and her lie made sense in the context of that relationship.

And that led me to think of Jessica, the adolescent I saw who just lied – all the time, for no apparent reason, regardless if her lie would be discovered. 

Her parents, who seemed concerned and caring, had no idea what to with their daughter.  My initial assumption was that Jessica lied like all adolescents lied. I’d been an adolescent. I remembered. Lies about where you were, who you were with, what time you got home. 

Jessica did tell those “normal” lies, lies about going to school, about showing up for soccer practice, about spending the night at the home of one of her girlfriends. And she was good at it. She’d look you straight in the face and you’d believe her. Except now her parents checked on her. They called the school, the coach, the friend’s mother. She was always found out. She’d shrug and move on.

She also told stories. Some of them might even have been true. “On my way to school today I saw a man on a motorcycle hit a deer. He was hurt. I ran to the house near-by and they called an ambulance.”

Realizing that questioning everything Jessica said was getting us nowhere, I tried to understand the meaning behind the story.

“How did you feel being able to help that man, Jessica?” 

“I don’t know. Good, I guess.”

“Was the man grateful to you?”

“I couldn’t wait around. I had to get to school.”   

Or, “I was home alone and some guy knocked on the door asking directions. When I opened the door he looked kind of dirty. I got scared. I started to shut the door. He tried to push it open, but I managed to close it. I called the police. They came and talked to me. I gave them a description of the guy. They said they’d look for him.”

“That must have been scary,” I say, again deciding not to question the validity of the story.


“And how do you feel being home alone, Jessica?”

“I don’t know. No problem, I guess.”

“Will this incident make you more afraid?”

“Maybe. Maybe not. I just won’t open the door.”

Trying to talk with Jessica more generally about her stories also got us nowhere.

“Jessica, do you know why you make up stories? Does it make you feel smart, creative, like you can out smart other people?”

“I don’t know. I’m not so smart.”

“Is it that you don’t feel smart? That you feel bad about not feeling smart?”

“I don’t know. I guess I’m smart enough.”

This isn’t a story that has a miraculously happy ending. Jessica and I never formed a relationship. I was never able to help her. In fact, I wasn’t even able to understand her. Sometimes I wonder what became of her. Did she become a thief? A politician? Or is she just someone who always lies? 


Unknown said...

So lying in Jessica's case could be a means to avoid real contact with others?


Antonio R. Virsida said...

It seems to me that the meanings and seriousness of lying, whether to a therapist or others must consider current and historical contexts, as well as personality structures. Lying by hystrionic patients is certainly different than lying by paranoid patients. While both patients are attempting to control their affect states by lying, the hystrionic patient is often lying in order to gain some therapist approval or affinity, while the paranoid patient is attempting to separate himself from the vulnerabilities of attachment-of being known by the therapist. One is moving toward the therapist with the lie while the other is moving away, often to gain some imagined power and superiority.
Your patient who lied about being raped again was attempting to draw you closer with sympathy rather than acknowledge her feelings of attachment and dependency. Jessica, on the other hand lied in order to maintain some imagined sense of control and ward off feelings of vulnerability. Her equivocation, "maybe" and "I don't know," leaves me with the impression that she studiously avoids knowing or being known. Jessica has likely never been trusted or able to trust/depend on others, so how can she do so now or in the future.
And, BTW, do we consider resistances to be lies, attempts to avoid painful affect states by lying or minimizing to be lies, omission of details to be lies. I think so. They are self deceptions and deceptions to others, but the question, can the patient consider and reflect on their emotions seems to me to be the key to whether the patient can move toward the therapist, or must move away, for survival's sake.
Thanks for the interesting vignettes and question.
Antonio R. Virsida

Linda Sherby PH.D., ABPP said...

Thanks so much for your comment. I absolutely agree with you that my patient who lied about being raped was doing so to draw me closer to her, as well as to punish me for what she experienced as my abandonment of her. I also agree that Jessica was determined to allow no one -including herself - to "know" her in any way, and that her stories were all smokescreens to avoid contact with herself or any other person.
Resistances, however, seem different to me than lies, if only in the degree of their conscious awareness. I'm sure both of my patients knew that they were lying, while resistance seems to be further out of consciousness.
Again, thanks for your comment and for your interest.

Linda Sherby PH.D., ABPP said...

I totally and completely agree. Lying for Jessica was a way to avoid real contact with anyone - including herself. As in Antonio Virsida's comment and my response, I do think that Jessica was determined to not be known by anyone, including herself.