In Secrets and Lies in Psychotherapy (2019) authors Barry A. Farber, PhD, Matt Blanchard, PhD,
and Melanie Love, MA, report on two different studies on this subject. A main finding is that the most common and frequent omissions in therapy by clients involve minimizing “how bad they really feel” and the “severity of their symptoms” (per Bella DePaulo, PhD, Psychology Today).

Another frequent category of omissions in therapy is suicidal thoughts. A significant percentage of clients have been “engaged in ongoing deception” about these.

From WTOP.com, an essential quote from co-author of Secrets and Lies in Psychotherapy Blanchard:

‘Dishonesty in psychotherapy is more the rule than the exception,’ Blanchard says. This lack of candor in therapy isn’t necessarily injurious to the therapeutic process, which is complex and often occurs over the course of months or years. ‘Not only do the vast majority of clients readily admit being dishonest with their therapist, a clear-eyed look at therapeutic communication suggests that truth is almost always partial, the result of a negotiation between a client and his or her therapist that is always ongoing,’ he says. ‘Dishonesty may be ubiquitous, but that doesn’t put the truth out of reach.’

In other words, if what’s actually said by a client doesn’t give the therapist enough info verbally, there are often other signs to follow. What about body language, for example? Or noting the possible importance of what’s been omitted?

Also, how about generally proceeding with the assumption that any admitted thoughts and feelings may just be the tip of the iceberg?

Speaking for myself, when I meet a new client I don’t explicitly ask for the truth and nothing but the truth. I start a conversation and expect to hear his or her or their version of the truth at that moment in time. I work on building rapport and trust so that truth-sharing becomes more possible than not.

Clients who have serious secrets, including suicidal or homicidal thoughts, may need time with that trust before they reveal them. Many clients, by the way, believe that therapists have to do something drastic, such as committing them to a hospital against their will or notifying either the police or an intended victim, if they admit to such thoughts. It’s actually, however, only in cases of active suicidal or homicidal planning that this may have to occur. (Ideation in this regard, it should be noted, is way more common than follow-through via actions, especially regarding homicide.)

It’s our duty, in fact, to tell clients right off the bat about this exception to the rule of confidentiality. If clients don’t want to experience the above stated consequences, it’s understandable that they’d hold back information. Whether or not that’s helpful to them is another question altogether, as is whether there’s a better way to go about this.

In conclusion, any number of reasons might prevent clients from expressing sensitive info of any kind. Shame, guilt, and fear are just a few notable examples. Although we as therapists work to encourage open and honest communication, clients also have a right to withhold. Many have been able to make significant therapeutic accomplishments regardless.