Journal of Clinical Research & Bioethics

Descriptive Phenomenology of Examples of Dishonesty in Psychotherapy from the Client's Point of View

Hossein Alipour^1* and Mahdi Akbari^{2 1}Department of Clinical Psychology, Mahmoudabad Education and Training Consulting Unit, Mazandaran, Iran
²Department of Educational Psychology, Farhangian University of Tehran, Tehran, Iran
^*Correspondence: Hossein Alipour, Department of Clinical Psychology, Mahmoudabad Education and Training Consulting Unit, Mazandaran, Iran, Email:

Received: 17-Nov-2024, Manuscript No. JCRB-24-27538; Editor assigned: 19-Nov-2024, Pre QC No. JCRB-24-27538 (PQ); Reviewed: 03-Dec-2024, QC No. JCRB-24-27538; Revised: 10-Dec-2024, Manuscript No. JCRB-24-27538 (R); Published: 17-Dec-2024, DOI: 10.35248/2155-9627.24.15.505

Introduction

Honesty in speech and behaviour, intention and action, friendship and communication with oneself and others are important in all dimensions of life. Honesty is one of the effective pillars in any relationship that provides the basis for trust and establishing a strong relationship. Honesty and lying is a key issue in understanding and criticizing all social relationships. Today, in some underdeveloped societies, lack of honesty has become a social problem that has affected professional activities and social interactions. There is evidence that people deal with lies in any field of their lives, either they lie or hide the truth. They do this from childhood onwards, starting with interactions with parents and teachers. They do this throughout their lives, with friends, love partners, spouses, children, employers, colleagues, supervisors and of course various government agencies, subsidy or taxes. However, it is somewhat surprising and even alarming to admit that this happens in psychotherapy, where even in that sacred space of near absolute secrecy, clients lie and keep secrets. Intuitively, or perhaps out of naive hope or expectation, we want this space to be different [1].

This lack of honesty in the process of psychotherapy is significant both from the client's side and from the therapist's side. Dishonesty in psychotherapy is related to cases of lying or omitting salient information in therapy; topics, thoughts and feelings specific that are lied about or kept secret in therapy and overall tendencies that people have to disclosure or hide them. In other words, uncomfortable or negative personal information that is difficult to disclose to others. Dishonesty and secrecy can be considered as an activity or behaviour, while the conscious concealment of topics in therapy is understood as a characteristic associated with individual differences which usually people tend to keep it constant over time and situations. On the other hand, the conscious and indirect use of concealment strategies in treatment (such as suppression, avoidance) can undergo changes over time and situations. Among the many variables that are significantly related to specific aspects of disclosure and secrecy in psychotherapy or the general tendency to concealment in psychotherapy, the therapeutic alliance has been the most important variable affecting therapeutic insincerity [2].

It has been reported in various studies that people often lie less often to a stranger, a social acquaintance, a primary care physician and a teacher or professor than to a therapist. This indicates a tendency to lie to others based on relational roles and emotional closeness. For example, the possibility of people lying in a job interview who generally lack emotional closeness to the interviewer, is more than lying to close friends [3]. In treatment, this relationship is considered an important factor in the effectiveness of psychotherapy. People may be less inclined to lie in therapeutic relationships than in other relationships because of the critical importance of intimacy to the relationship and to the effectiveness of therapy. Establishing emotional closeness reduces the likelihood of lying, as people tell fewer lies to those they are emotionally close to [4-6].

Farber et al., in a study with 21 clients in individual psychotherapy in a semi-structured interview that explored issues related to the internal decision-making process and emotional experiences related to disclosing intimate concerns and secrets in therapy, showed that distressing feelings (such as shame) often precede and are accompanied by self-disclosure, positive emotions (such as relief and pride) predominate during and after disclosure [7]. Farber et al., came to this conclusion that the pattern of further disclosure to the therapist, was about issues of frustration (such as feelings of depression) and his wife about fertility and physical concerns (such as birth control) and values, (such as feelings about religion, race, or politics) [8]. Also, issues related to sex were rarely discussed in both contexts and discrepancy scores (difference between the amount of disclosure and perceived importance) were higher in the spouse condition. DeLong et al., in a study assessed clients' willingness to disclose a secret to a counselor and their expected support from the counselor (i.e., outcome expectancy), that findings showed participants' experience of shame predicted their secret's less support from the advisor [9]. Blanchard et al., investigated an aspect of a survey of lying clients in psychotherapy, which focused on the nature, motivation and level of dishonesty of clients related to psychotherapy and the therapeutic relationship [1]. 547 adult psychotherapy clients participated in this research through an online survey that quantitative and qualitative methods and included the topics that were not honest about them in treatment and the extent and reasons for their dishonesty. The findings showed that 93% of respondents reported lying to their therapist and 72.6% reported lying about at least one treatment-related issue and common lies about treatment include; clients pretend that they like their therapist's comments, pretend that they are late or absent from sessions and pretend that their treatment has been effective. Also at the most extreme level of dishonesty were lies about romantic or sexual feelings about the therapist and not accepting or wanting to end the treatment. The results showed that therapists should pay more attention to issues related to clients' trust and safety. Blanchard in a study, asked a sample of 107 individuals who had concealed their suicidal thoughts to explain why they concealed their suicidal thoughts from their therapist that the findings showed that nearly three-quarters of suicide concealers cited the fear of practical consequences as the reason for not disclosing, that the most important of these fears was involuntary hospitalization, which the respondents considered to be a possible result of telling the therapist about suicidal thoughts [10]. Less obvious motivations for secrecy, such as shame or embarrassment, were important but secondary concerns. The results showed that people who concealed their suicidal thoughts were more likely to feel conflicted about their decision to conceal, with a significant number feeling hopeless or guilty, as well as feeling safe or in control. Love M, in a study on a sample of 798 outpatient clients, investigated the understanding of why clients are not being honest or avoidant about sexual matters that the findings showed that two types of sexual content (Details of my sex life and sexual desires and fantasies) were the most common themes of dishonesty in the entire sample and dishonesty about sexual relations appears in complete avoidance of the topic in therapy [11]. Approximately 80% of clients whose motivation for dishonesty was to avoid shame or embarrassment and clients who hid their sexual orientation, they wanted the therapist to demonstrate cultural competence to ensure the safety of the relationship and clients who were hiding infidelity weren't sure if the therapist could do anything or not. Blanchard et al., reported that 70% of individuals who concealed suicidal thoughts cited fear of practical unwanted effects outside of treatment as a reason for not disclosing them [12]. The most important of these unwanted complications was involuntary hospitalization, which was a perceived consequence of disclosing mild suicidal ideation. Also, less obvious motivations for concealment, such as shame or embarrassment, were important but secondary concerns and nearly half of suicidal clients said they would be more honest only if the risk of hospitalization could be reduced or controlled in some way. The results showed, promoting the disclosure of suicidal thoughts in treatment may require renewed attention to providing clear, comprehensive and understandable psychological education about the triggers of hospitalization and other interventions. Also, clients calculate the benefits and harms of disclosing suicidal thoughts, but may act with exaggerated or incorrect ideas about the consequences of disclosure. Love et al., showed that 84% of clients were not honest in expressing the details of their sex life and suicidal thoughts and people who hide themselves less, often most report being honest or avoidant, because they don't want to divert their focus from what they feel [2]. Low and high self-concealment showed different patterns of motivations, perceived consequences and attitudes about facilitating information disclosure in treatment. Other results also indicated that concealment may be an important variable in tailoring treatment to promote greater and more honest disclosure. Farber, showed that almost all clients admit that they have withheld or lied about significant information from their therapist [13]. Some of the topics that the clients hide their information about the most about include sex, their actual reactions to the therapist's comments, family secrets and suicidal thoughts. Also, the topics that clients lie about mostincluding their level of distress (especially regarding suicidal feelings); insecurities and doubts about themselves, drug use, feelings about their treatment or therapist, sex (e.g., sexual fantasies, sexual orientation, their relationships), experiences of trauma or abuse, eating disorders, etc. Curtis et al., found that most participants were deceptive in treatment and most were willing to be deceptive in future therapeutic fields [14]. Also, participants used white lies more often than other forms of deception in therapy. The results showed that the participants lied less to the therapists compared to strangers and acquaintances. Cersosimo et al., indicated that greater attention to disclosure issues may be necessary in clinical work with individuals with certain forms of self-destructive behaviours [15]. Jackson et al., showed that almost all respondents had been dishonest with their clients at least once and most of them felt that their dishonesty serves the therapy or welfare of the clients [16].

Newman showed that often, dishonesty occurs about patients' personal disclosures and typically, therapists believe that their honest disclosures have increased rather than decreased over the course of their careers [17]. Patmore et al., in a study titled "The Nature and Effects of Nondisclosure of Eating and Body Image Concerns in Psychotherapy Clients" dishonesty in the treatment of eating issues and body image concerns and the perceived consequences of dishonesty about these issues examined [18]. The findings showed that shame was the most common reason given for non-disclosure, especially body-shame, shame of pathological behaviour and shame of the therapist's anticipated judgment.

The literature suggests that a tendency to concealment is associated with poorer outcomes in psychotherapy as well as with adverse effects on physical and mental health, including anxiety, depression, or increased suicidal behaviour [19,20]. Also, self-concealment is inversely related to social support and the tendency to seek psychological services [21-23]. Fedde, in her dissertation on how client concealment affects confidentiality in therapy found that individuals with high concealment were more likely to keep treatment-related secrets from their therapists [24]. Blanchard et al., also confirmed the same issue [1]. The study of lying in psychotherapy suggests that as self-concealment scores increase, so does the number of subject’s clients have lied about. Collectively, these studies support that client-rated self-concealment is associated with less willingness to disclose in treatment, but there is much uncertainty about how and to what extent this is effective [1].

For this reason and considering that no research has been done on this subject in the country and the research evidences in this regard were not enough, this research has identified and investigated the instances of dishonesty of psychotherapy clients from the perspective of descriptive phenomenology. The main issue of this research was, what are the examples of dishonesty in psychotherapy from the client's point of view?

Materials and Methods

The method in this research is qualitative, a descriptive phenomenology type. Phenomenology study, philosophical study of the structures that make up experience and awareness around the studied phenomenon from the point of view of first-hand and knowledgeable people. This research with descriptive phenomenology, in order to deeply investigate the phenomenon of insincerity of psychotherapy from the client's point of view, has done a detailed study of this issue in the context of psychotherapy. The population of this research is made up of all the clients of counseling centers in Amol city, which according to the report of the relevant organizations, the number of clients in the first 9 months of 2011 is approximately 1000 people. In this research, the voluntary non-probability sampling method was used to select clients, after the theoretical saturation point, the interview with the twenty-third client was stopped. So the sample includes twenty-three clients. Informed consent was obtained from all individual participants included in the study. Table 1 shows the demographic characteristics of the clients participating in the research.

Table 1: Information of clients participating in the research.

Data collection

The data collection tool in this study was semi-structured interview protocol. From the point of view that the axes and questions were clear and it was possible to explore probe the interview. Interview questions of clients were set, with 3 general open answer questions. The reliability of the codings has been confirmed by four graduates of clinical psychology. In this research, a semi-structured interview method was used to collect information. At first, to master the questions related to measuring the dishonesty of psychotherapy, the researcher has studied numerous articles and sources and questionnaires and after specifying the important keywords for developing the interview protocol he has started to design the questions to conduct a semi-structured interview. By attending counseling centers and attracting the participation of clients who had experience of psychotherapy in these centers, the researcher has conducted a semi-structured interview based on the protocol designed (with 3 open questions or 3 axes):

The first axis: Dishonesty position; what topics did dishonesty include and what were your reasons?

The second axis: The record of dishonesty; has it ever happened that you were not honest in a psychotherapy session? (Did you lie?).

The third axis: Difficulty in retelling the truth; what are the topics that are difficult to talk about in a psychotherapy session?

The interview time was between 45 and 70 min and all the interviews were fully recorded with the interviewee's consent and all the recorded files were converted into Word and text files after the interview on the same day. To transfer the audio file to the text file, the opinions of four clinical psychology graduates have been used for reliability analysis. All the steps, including listening several times, typing, adapting the audio file to written, etc., have been done by the researcher so that the viewpoint of the interviewees is fully understood. Due to the emphasis on the descriptive analysis of phenomenology, in this study, the seven-step descriptive method of Colaizzi was used. By attending counseling centers, the researcher explains about the topic and purpose of the research, as well as providing reassurance about the observance of ethical principles in the research including; Observance of the principle of confidentiality, confidentiality and trustworthiness regarding the personal information of the participants and the details of their answers it has tried to attract voluntary participation from clients. Also, the code of ethics for this research has been obtained from the Research Ethics Committee of Islamic Azad University, Ayatollah Amoli branch, ID IR.IAU.AMOL.REC.1402.021 on 13/02/1402.

Results

By coding and interviewing 23 clients in the first axis, the following concepts have been obtained; all of them are shown in Table 2.

Table 2: Concepts extracted from the first axis regarding the position of dishonesty.

As shown in Table 2, the clients mentioned many concepts about the position of dishonesty, which are the following: Some of them include; Dishonesty about matters of feeling relationships, excessive alcohol consumption, obsessive thoughts, harm to others, sexual issues, etc.

The results of the analysis show that clients prefer dishonesty in situations where they experience fear of evaluation (judgment), feeling shame and guilt and they believe that a good therapeutic relationship, ensuring the therapist's professional ability, ensuring the therapist's Secrecy and not having previously Unfamiliarity with a therapist outside the treatment room help to disclosure more issues.

From the concepts extracted from the interviews with 23 clients in the first axis, the following categorization can be provided, all of which are shown in Table 3.

Table 3: Categorization extracted from the position of dishonesty (clients).

In this axis, we categorized two categories of concepts that the reasons for clients' dishonesty include individual and out individual that the individual category includes feeling and affection experiences and the out individual category includes the therapist's reaction and lived experiences in society (Figure 1). In the individual category, feeling and affection experiences refer to events which is feeling and affection relationships, dishonesty due to shame, dishonesty due to avoiding negative emotions, dishonesty due to avoiding guilt and dishonesty in negative and wrong function that the client is consciously or unconsciously put in a position of dishonesty in the treatment room due to his negative evaluation of himself. For example, one of the clients named Fahima said;

Figure 1: The categorization of the first axis regarding the position of dishonesty (clients).

"If something happened, what was my negative role, how lazy I was, how many mistakes I made and the reason was that I would finally purify myself, make myself look like a good person and reduce my guilt, or my conscience calm.

Another client named Nilo said;

"For example, in that relationship that I told you about, I was trying to show that that person is hurting me more than I, for example, have aggressive behaviour. I wasn't one to act aggressive, I think It was for that there so I could, I mean I needed help so badly and I felt like maybe even my therapist didn't understand how complicated (serious) the situation was! Maybe I wanted to make him understand this."

In out-individual category, the therapist's reaction it refers to the therapist's professional role in the treatment room that the effect of previous familiarity with the therapist on dishonesty, postponing treatment sessions, the role of therapeutic alliance in reducing dishonesty, the therapist's effective lack of empathy and the role of the feeling of security and trust in reducing dishonesty that these factors play a role in the dishonesty of references. For example, one of the clients called Hasti said;

"Once, when I had a counseling session, a third person called an intern came to the counseling session and I did a lot of hiding there. Concealment that, for example, I was not honest, well, I would be ashamed! For example, I was comfortable with my advisor! Unless, for example, there is a third person, even my wife, in the counseling session, I might be dishonest at times. But be the two of us, me and my advisor, not at all."

Another client named Rehi said;

"I was not dishonest. Because of the therapeutic alliance, I knew that the person sitting there is a very professional person. He is very professional in treatment and the conditions of the interview room were very safe, it was insulated, the sound did not go outside the room, I had seen this person's personality several times and I was confident. "I had no reason to be dishonest, to lie and to hide."

In the category of lived experiences in society, it refers to events that are fear of judgment, excessive alcohol consumption, harming others, obsessions, sexual and family issues That Most of the clients are placed with the challenge of choosing between honesty and dishonesty with the therapist due to negative experiences from society's evaluation. For example, one of the clients named Fariba said;

"Just the family issue and the fact that in the psychotherapy session, the therapist was already familiar and I didn't like to talk about it."

Another client named Elaha said;

"The reasons I told; now the feeling of being blamed, or the feeling of being judged. I think the topics are mostly in the same trait (feature) of my obsession, for example, there are some things in my mind, it was my mental default, but now I don't have them and now, in my married life or my personal life, I don't tell the therapist the truth, because I'm bothered, I'm under pressure from this thought, I have a problem with him, I didn't tell him this."

By coding and interviewing 23 clients in the second axis, the following concepts have been obtained, all of which are shown in Table 4.

Table 4: Concepts extracted from the second axis regarding the history of dishonesty.

As shown in Table 4, clients mentioned a number of concepts about the history of dishonesty (lying).

Most clients believe that lying does not benefit them in psychotherapy and their motivation to change their circumstances made them not lie to their therapist. Some clients did not reject the possibility of unknowing lying and they stated that in order to preserve their mental health, fear of judgment and fear of the therapist's lack of confidentiality, they were unknowingly dishonest.

The results of the analysis show that clients' motivation to treat issues and problems, effective therapeutic relationship and feeling of security in clients have a positive effect on reducing their dishonesty.

Concepts extracted from interviews with 23 clients in the second axis show that in this axis, most of the clients believed that lying in the treatment room is not beneficial for them and only some clients did not reject the possibility of unknowing lying and individual reasons including personality traits, motivation for treatment and the need for unconscious dishonesty to maintain mental health, also, external reasons, which include fear of judgment and fear of the therapist's lack of confidentiality, play a role in clients' dishonesty in the treatment room, which shows the important role of client's individual characteristics and client's motivation for treatment and also shows the important role of the therapist in playing his professional role to create an effective therapeutic relationship along with creating a sense of security in clients to control and reduce dishonesty in clients.

From the concepts extracted from the interviews with 23 clients in the second axis, the following categorization can be presented, all of which are shown in Table 5.

Table 5: Axes extracted from the second axis regarding the history of dishonesty (clients).

In this axis, two categories of concepts have been categorized, which include individual and outside Individual, where the individual category includes experiences related to therapeutic benefit and experiences of feeling and emotion and the extra-personal category includes experiences lived in society (Figure 2). In the individual category, experiences of feeling and emotion refer to events that are a person's personality traits, unconscious dishonesty and the necessity of dishonesty to maintain mental health that some clients have unconscious dishonesty due to negative self-evaluation, avoidance of related negative emotions and maintaining their own mental health. In the category of experiences related to therapeutic benefits, it refers to events that motivate clients to improve treatment and believe in the positive role of honesty in different situations, that the client prefers to be honest in the treatment room in any situation in order to progress the treatment and achieve the desired treatment results, which shows the important role of clients' individual characteristics and client's motivation for treatment. In the extra-personal category, experiences lived in society refer to events that are dishonest due to the fear of evaluation (judgment) and the fear of the therapist's lack of confidentiality, that some clients face the challenge of choosing between honesty and dishonesty with the therapist because they had negative experiences from the evaluation of community Persons, which indicates the important role of the therapist in playing his professional role to create an effective therapeutic relationship along with creating a sense of security in clients to control and reduce dishonesty in clients.

Figure 2: Categorization of the second axis regarding the history of dishonesty (clients).

By coding and interviewing 23 clients in the third axis, the following concepts have been obtained, all of which are shown in Table 6.

Table 6: Concepts extracted from the third axis regarding the difficulty in telling the truth.

As shown in Table 6, clients mentioned many concepts about the difficulty in retelling, some of which include; the issue of betrayal, rape, feelings of guilt, marital disputes, weak points, bitter past events, drug abuse, alcohol consumption, physical violence, etc.

The results of the analysis show that it is difficult for clients to tell some topics and this difficulty may lead to hiding the topic. Clients stated the cause of difficulty mostly because of avoiding experiencing negative emotions such as shame and humiliation and fear of evaluation (judgment).

From the concepts extracted from the interviews with 23 clients in the third axis, the following categorization can be presented, all of which are shown in Table 7.

Table 7: The axes extracted from the third axis regarding the difficulty in telling the truth (clients).

In this axis, we categorized two categories of concepts that are the reasons for the difficulty in retelling the issues from the point of view of clients and it includes Individual and extra-individual reasons, that the individual category includes sexual experiences, cognitive errors and feeling and emotional experiences and the extra-individual category includes the therapist's reaction and lived experiences in society (Figure 3). In the individual category, sexual experiences refer to details and events such as betrayal, rape, private marital relations, sexual relations outside the family center and sexual disorders which are difficult for client to retelling them. For example, one of the clients named Akram said;

Figure 3: Categorization of the third axis regarding the difficulty in the retelling truth (clients).

“Of that, my husband's to intercourse, it needs infinity. Then I could not say this until this time but in this meeting, I said that I got guidance from the doctor. Then I said, if there is anything, I will raise it, for human, it is much easier to solve this problem. Now that I said, I can do it more easily with their guidance, but I have not yet reached the complete and final stage in this way, but I was able to solve this problem to some extent.”

Another client by the name of Fariba said;

“It did not happen to me, now I want to say this issue but I feel that it can be difficult to recount, for example, rape, it can be a history of theft, if the patient has done it, or she did something wrong, it is difficult to retelling. Unless her tolerance threshold is too low and she can't bear it and doesn't tell anyone, she can trust her therapist and tell her. “

In the category of cognitive errors, it refers to the client's negative evaluation of herself in its functions, which are weaknesses and poor performance, incorrect performance, difficulty in expressing bitter events, love failure, physical injury and first failure, that it is difficult to express them because of a negative evaluation of the client from himself. For example, one of the clients named Majid said;

"It was very difficult for me to tell about my accident, I went to explain in a coma, I describe the events of my being a soldier. The good memories that were in the military service, those bitter memories, erased the good memories. It was hard for me to recount those good memories, because there were more bitter memories."

Another client named Fahima said;

“In my opinion, the subjects in which the client has a negative role, or, for example, in a story, she left little, or did something wrong, she blames herself, it is difficult to express it. If I'm myself, in this way, I think it's difficult to express it."

In the category of feeling and emotional, it points to the experience of events that lead to the arousal of feelings, that is difficulty in expressing feelings of humiliation, guilt, shame and extreme sadness, that it is difficult for the clients to express them. For example, one client named Nilo said;

“I think if something that I know my own defect, or when for example I know that I have hurt someone, maybe this, is difficult. I mean, I think it's difficult to retell it here. Where I have hurt someone in the past, or done something that I say is a defect, that feeling of shame is very difficult for me.”

Another client named Nilofar said;

“The deep expression of feelings, that an experience caused, that now may be very far or near, because we try to deny it and we don't know our feelings very well, when we are in the treatment session, we want to work deeply on that feeling, especially now in styles such as psychoanalysis, it is difficult to express it.”

In the outside Individual category, the therapist's reaction refers to the reasons why the therapist's professional role in the treatment room can make it difficult for clients to recount the subjects, which is the therapist's lack of confidentiality, familiarity with the therapist, lack of empathy and unaccepted topics, which causes difficulty in recounting the subjects.

For example, one of the clients named Fariba said;

“Maybe his relationship with his family is like this, for example, I want to set this example for myself on my behalf, regarding the family, the relationship he has with his father or mother, if it is not what he wants, it may be difficult to retell it to the therapist he knows.”

Another client named Rehi said;

“Regarding the difficulty in retelling issues that depend on the relationship between the therapist and the client, if the relationship is safe and there is no fear of judgment, a series of difficulties in retelling will be reduced. But if a person is worried about being judged, it means that it goes back to the problem and the personality traits of that person who is afraid of being judged, afraid of being rejected, or has projected the being judged by parents onto the therapist, it can be difficult to recount.”

In the category of lived experiences of society, it refers to events that are fear of evaluation, cultural taboos, stealing, violence, drug abuse, alcohol, family and marital disputes, that it is usually difficult for clients to express these subjects due to the fear of judgment. For example, one of the clients named Elaha said;

"Now, there were a series of internal issues about myself, about life, for example, as an example, I want to explain, somewhere, maybe I wanted to have another life. Or somewhere, perhaps I wished I was in a different situation now. For example, this was not a person, for example, I did not have this family, I was a different person, I was not here at all and these, in this situation, I was ashamed to say! I felt like that I was being judged, I was afraid to speak up."

Another client named Arzu said;

"For me personally, for example, sexual and family issues were very difficult to say. I think one of the reasons was that we were living in a small town and I was afraid that the psychologist would be dishonest. This was difficult for me to say."

Discussion

Since its inception, psychotherapy has always been considered a place where difficult truths can and should be revealed. Clients are advised to tell the truth, therapists are trained to deal with the inevitable resistances to clients' truth-telling and the result is often thought to depend on the joint effort of both to better understand previously hidden or distorted information. The researcher was interested in conducting research that would enable him to fully understand the nature of secrets and lies of psychotherapy clients. In fact, the researcher wants to know what kind of information clients hide or lie about. Why they resort to dishonesty and see them as consequences of their various efforts to keep information away from the prying eyes and ears of their therapist [13].

It seems that in psychotherapy, there is a delicate balance between the amount of necessary disclosure and the achievement of therapeutic benefit for clients and a significant minority affirm that they will share more if they feel that their psychotherapy progress has encountered an obstacle [2]. According to Baumann et al., study, clients often report that they chose to disclose a previous secret if they felt they could benefit from doing so or if keeping the secret would hinder progress [25]. Some studies showed that the client's feeling towards the therapist's trustworthiness determines whether they will reveal their truths and this issue shows the importance of a deep sense of security in the therapeutic alliance. As Kahn et al., explain, debriefing clients, sharing distress with others and providing a clinical rationale for disclosure that also addresses the importance of relational trust can be very helpful [26]. The conflict of concealment with the dual motivation of people, the desire to remain silent and the desire to disclose, causes strong feelings of ambivalence in clients [27]. Dishonesty can act as a functional coping mechanism by maintaining the client's sense of status quo or internal security and protects him from negative emotions [2].

Most therapists use the concept of tact therapy to explain why they hide information from their clients. In Curtis et al., study, they stated that 96% of therapists thought they were protecting them by deliberately withholding information from them in therapy, while they have been deceived [28]. Therapists most likely to admit dishonesty to clients are those who are predominantly older than 30 years of age in their clinic with 5 or more years of experience. In contrast, therapists who are dishonest are few, less than 30 years old and less than 5 years of experience (not yet licensed), working in clinics and hospitals. This may be because the first group is less scrutinized or because most of their dishonesty is tactful.

The results of the analysis in the first axis (The position of dishonesty) show that most of the clients were not honest with their therapist in emotional and feeling relationships, negative and wrong performance, excessive alcohol consumption, harming others, obsessions, subjects sexual and family and the reason for that told fear of judgment, shame, previous acquaintance with the therapist, Lack of therapist confidentiality and lack of effective empathy of the therapist. They believe that a good therapeutic relationship, assurance of the therapist's professional competence, assurance of confidentiality of the therapist and lack of previous acquaintance with the therapist outside the treatment room help to reveal more subjects. These findings it is aligned with the study of Patmore et al. [18]. That according to their findings, shame was the most common reason given for nondisclosure, particularly body-shame, shame of pathological behaviour and shame of the therapist's anticipated judgment. These findings are also it is aligned with the study of Farber et al., that, according to their findings, uncomfortable emotions (such as shame) often precede self-disclosure and are along with them [29]. Also, these findings are in aligned with Farber, study that based on its findings, almost all clients admit that they hid significant information from their therapist and or lied and some subjects about which clients hide their information more, it includes sex, their actual reactions to the therapist's comments, family secrets and suicidal thoughts [13].

The results of the analysis in the second axis (history of dishonesty (lying)) show that the clients believe that lying does not benefit them in psychotherapy and their motivation to change their conditions made them not lie to their therapist. Some clients did not reject the possibility of unknowing dishonesty and stated that they were unknowingly dishonest in order to preserve their mental health, fear of judgment and fear of the therapist's lack of confidentiality. These findings are in aligned with Farber, study that based on its findings, almost all clients admit that they hid significant information from their therapist and or lied and some subjects about which clients hide their information more, it includes sex, their actual reactions to the therapist's comments, family secrets and suicidal thoughts [13]. These findings are also consistent with Blanchard study, based on its findings, nearly three-quarters of suicide concealers cited fear of practical consequences as the reason for not disclosing, that the most important of these fears was being hospitalized involuntarily, which the respondents considered as a possible result of telling the therapist about suicidal thoughts [10]. Less obvious motivations for secrecy, such as shame or embarrassment, were important but secondary concerns. Also, these findings are in aligned with the study of Love M, that according to its findings, almost 80% of clients whose motivation for dishonesty was to avoid shame or embarrassment and clients who concealed their sexual orientation tended to have the therapist demonstrate cultural competence to ensure the safety of the relationship and clients who were hiding infidelity weren't sure if the therapist could do anything [11]. But regarding lying, the findings of this study are not aligned with the findings of Farber, Blanchard, Love and Blanchard et al. [1,10,11,13]. It seems that in addition to clients' belief that lying has no therapeutic benefit for them and hinders the effectiveness of treatment, the cultural context of the society and religious teachings in clients have been an interfering factor for greater honesty in the treatment room. Also, the results of the analysis show that clients' motivation to treat issues and problems, effective therapeutic relationship and a sense of security in clients have a positive effect on reducing their dishonesty.

The results of the analysis in the third axis (Difficulty telling the truth) show that recounting sexual topics, weak points and poor performance, incorrect performance, difficulty in expressing bitter events, love failure, cultural taboo topics, stealing, violence, substance abuse and Alcohol, family and marital discord are difficult for clients and this difficulty may lead to concealment. Clients stated the cause of difficulty mostly because of avoiding experiencing negative feelings such as shame and humiliation and fear of evaluation (judgment).These findings are in aligned with the findings of Farber et al., that based on their findings, most clients felt that therapy is a safe place to disclose information, especially because of the good therapeutic relationship and disclosure in therapy facilitates subsequent disclosure to the therapist as well as family members and friends and that therapists should actively pursue material that is difficult to disclose [29]. Also, the results of the analysis in this axis show that clients prefer, do not tell about sex, rape, illicit relationship, feeling weak in self-confidence, poor performance, wrong performance, feeling and emotional relationship, feelings of inferiority, guilt, suicidal thoughts and family disputes and according to the conditions of the treatment, it is possible that the decision to no retelling these topics will remain in them until the end of the treatment period. These findings are in aligned with the study of Farber et al., according to their findings, 84% of respondents were not honest in expressing details of their sex life and suicidal thoughts and people who hide less, more report being honest or avoidant, because they don't want to divert their focus from what they feel [30]. Also, the results of the analysis in this axis show that most of the clients hid at least one issue from their therapist. These subjects, disturbing experiences have been, feelings of shame, poor performance, excessive alcohol consumption, suicidal thoughts and sexual issues. These findings are in aligned with the study of Love and Love et al. [2,11]. According to Love findings, two types of sexual content (details of my sexual life and sexual desires and fantasies) were the most common topics of dishonesty in the entire sample and dishonesty about sex appeared in complete avoidance of the topic in therapy [11]. Also, based on Love et al., study, 84% of respondents were not honest in expressing the details of their sex life and suicidal thoughts and also concealment may be an important variable in tailoring treatment to promote more and more honest disclosure [2]. Also, clients said the reason for this concealment is the possibility of being judged by the therapist, lack of trust in the therapist's confidentiality and avoidance of experiencing feeling shame. Clients believe that establishing a good therapeutic relationship, ensuring the therapist's professional competence and lack of previous acquaintance with the therapist outside the treatment room, can play a positive role in their more self-disclosure. These findings are also in line with the study of Love M, which based on its findings almost 80% of clients whose motive for dishonesty was to avoid shame or embarrassment and clients who concealed their sexual orientation tended to have the therapist demonstrate their cultural competence to ensure the safety of the relationship [11].

One of the vital tasks of psychotherapy is to provide an environment where the client can honestly express their feelings, thoughts and experiences. A relationship with another person who is caring and interested, confidential and private. However, clients often cannot tell the truth about some of the things that matter to them. They omit information, avoid certain topics entirely and sometimes, lie. Even clients who claim everything is better be revealed, again, they admit that they have secrets, which illustrates the difficult and delicate balance with which clients negotiate the prospect of speaking honestly with their therapist [7,25].

Dishonesty in the process of human social interaction has always been an inevitable thing and people will intentionally or unintentionally be dishonest in their social interactions according to the conditions and situations in which they are placed. But dishonesty in professional environments such as the treatment room according to the therapeutic interventions that take place and expectations that are expected due to the effectiveness of psychotherapy, it can be more sensitive. Considering that the behaviour of people is affected by the pattern of adaptation to the society and the experiences lived in the society and these same people enter the treatment room with this adaptation pattern and behavioural habits dishonesty in the treatment room was predictable, which the research literature and the findings of the present study have confirmed its inevitability. Based on the findings of the present study, insincerity of clients is an interfering factor on the effectiveness of treatment which has a negative effect on the treatment results but clients, even knowing this subject, consciously or unknowingly, they are not transparent and honest with their therapist about some topics and a factor that can influence the honesty of clients, the professional role of the therapist in establishing a strong therapeutic relationship and creating a safe environment for is their honest disclosure. Based on the findings of the current research, professional therapists use dishonesty not for personal gain, but sometimes to help clients and provide psychological support as a strategy. They believe that for some clients, according to their conditions and ability to accept and bear the realities of life, having dishonesty for the benefit of clients and the treatment process is necessary and necessary and when the therapist's dishonesty it can have negative effects on treatment which is for his personal benefit or the therapist does not have enough experience to use this strategy in the psychotherapy process. In the end, it should be noted that the client's honesty in the treatment room, in addition to the therapist's expertise, to his ability to establish a therapeutic relationship to create a safe environment for clients away from any feeling of prejudice and judgment is dependent.

Conclusion

The current research has faced limitations from the researcher's side and limitations beyond the researcher's responsibility which includes the lack of balanced access to clients in terms of gender, lack of access to internal sources and backgrounds due to the fact that this research was conducted for the first time inside the country and the lack of cooperation of the trustee departments and organizations in the field of counselling centres and the non-cooperation of the manager in charge of some counselling centres for the presence of the researcher in the centers, it is for the voluntary participation of the clients and it is suggested to researchers by constructing a standardized instrument for psychotherapy dishonesty, take action relative to its measurement.

Authors Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by “Hossein Alipour”. The first draft of the manuscript was written by “Hossein Alipour” and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Competing Interests

The authors have no relevant financial or non-financial interests to disclose.

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