Much has been written describing the intricacies of the supervisory setting in the teaching of psychotherapy to psychiatry residents and other trainees. Of the many conditions felt to be essential for a successful supervisory experience, perhaps none is more valued than the expectation that the trainee will provide an accurate account of whatever occurs in treatment sessions and will not deliberately withhold or distort either verbal or affective information. Arlow (
+1) has referred to this as a quality of reporting that is "open and honest," with "no intention to conceal the details of the vicissitudes of the therapeutic interaction." Despite expectations of honesty, misrepresentations of information by trainees does occur, so that, as Greben (
+2) has noted, not telling the supervisor what is really taking place in therapy is "commonly the case," resulting in a supervision that "must be considered to be, in a most important way, a failure."
In the following section, we will present excerpts from interviews with four psychiatry residents who were asked to recall situations in which they deliberately lied to their psychotherapy supervisors, misrepresenting or concealing either verbal case material or emotional responses experienced during patient sessions. We will then discuss aspects of the psychology of lying and the training experiences of psychiatric residents as they relate specifically to the challenge of maintaining honesty in the supervisory experience. Finally, we will offer suggestions to help administrators and supervisors minimize the occurrence of lying by their trainees.
A psychiatry resident describes a pattern of "editing everything" presented to a specific supervisor over a 2-year period. He notes having "deleted" from his session notes "everything that had to do with who I was, all my quirks, my personality, so that they were missing me. As a result, my process material consisted exclusively of statements made by the patient. I remember treating a medically-ill patient with whom I would laugh, sometimes through the entire 45 minutes, but I could never tell my supervisor what I did, because I felt she would criticize me for letting my personality enter the room. When this patient had to go into the medical hospital, I chose to see her there for a regularly scheduled session, but didn't tell my supervisor until later, because I thought she'd chastise me. At the time, I was having a difficult time dealing with my feelings about this patient's illness, but I didn't feel I could talk about myself with this supervisor."
"She always had a better way to do things than I did, and she would say that my ‘bad’ interventions would ‘offend’ the patient. I disagreed a lot of the time, but didn't think I could say this because I would sound defensive. So I just did my own thing and edited my notes. She never challenged that I did this, and so it went on for quite a while. Sometimes I used what she said, when I felt it would be helpful with what I was actually doing with this patient. I clearly lied to her about what was going on in my sessions, and I hated going to supervision for that reason. The whole time I felt she must know I'm more gregarious than I'm presenting myself, that I must be talking more, but it didn't come up. At one point, I let her know that she intimidated me, and we discussed it, which made the process a little easier.
"I admit I'm very sensitive. She once told me ‘you know more than you think,’ and she was probably right. I think it's my issue, that I can be insecure and not feel I know anything. This made it especially hard to work with her, in particular, because she was so critical. Editing my sessions made it possible for me to go to supervision at all, because it allowed her to do most of the talking. I wish I could have been more honest with her. At times, I tried to force myself, but I couldn't even remember what I had actually said in session. I think I just couldn't expose myself to her.
"I don't know if any of my patients suffered because I omitted parts of sessions, but I know I suffered. I later discussed the same cases with another supervisor, with whom I felt more comfortable talking about myself and my feelings, and it was a tremendous relief, because I didn't have to worry about being criticized. I could just be me."
Another resident reports a pattern of writing "creative process notes" that "sometimes reflected the specifics of the session and sometimes didn't." She states that "having to spend all that time writing up notes made me frustrated. I often found my mind wandering, so I would sometimes make up interchanges which I thought captured the gist of the session. But they were also kind of antiseptic, molded to the taste of the supervisor, and often were missing my more provocative or confronting statements. In these cases, my notes did not at all reflect the tone of the session. That was okay, though I knew it was a deception, because it protected me from too much exposure. I could minimize conflict with the supervisor, protect myself, and get to enjoy the deception a little, because I was the only one who knew the reality of the session. So only I could know whether I did well or not. Even if a supervisor judges me, I know that he may be judging something that never actually happened. Only I know."
"I've always had a hard time with some parts of the residency, especially being judged and not having much autonomy. Lying makes me feel better, in a sense, especially with supervisors who I feel are more critical. There were times when I thought I was cheating myself by not being more honest with supervisors, but I think I would have been too inhibited to do good work if I knew that everything I said in sessions would be exposed. That would make me too anxious. I think it has worked out for the better by getting supervision more on my own terms."
Another resident states that her "most common" lie is to omit from session notes the "advice" she gives to patients. "I had a patient who needed a job, but wasn't doing what he needed to find one. I told him he had to make an effort because he had no money. I didn't tell my supervisor about this, I edited it out. Something similar happened with another patient, when I spent an entire session helping him organize a presentation. I told my supervisor that he had ‘canceled’ the session, and that I had called him and left a message as a ‘follow-up,’ all of which were lies. We then had to talk about why he hadn't responded to my contacts, and I had to keep lying to cover up the first lie. I eventually told the supervisor that the patient ‘admitted’ forgetting the session, and that he ‘resisted’ talking about it. This was all a fabrication."
"I felt I had to lie because the supervisor wouldn't have approved of what I did, because he's analytically-oriented. It would have been more trouble than it was worth to tell the truth. The supervisor would have said what I did wasn't ‘properly dynamic.’ I felt what I did was right, and I didn't want to have to analyze the whole thing. It's not that I think my supervisor would have yelled at me if I told him the truth. It's just that he would have thought of me as ‘not with the program,’ and I would have seemed impulsive. I didn't want to have to defend myself; it wasn't worth the effort. Though, in the final analysis, I had to expend more energy lying to cover up what I did. I felt briefly guilty at the time, but not for long, since I thought my supervisor's stance on the whole thing was wrong."
"There have been other times I've lied when patients cancel or fail appointments. I don't tend to call them immediately afterward, but I don't want my supervisors to think I don't care, or that I'm a neglectful, bad resident. So I say I followed up when I didn't. I don't like having to do this, but it's better than having the supervisor think I'm lazy, or that I don't take good care of my patients, because it could affect my evaluations. I want people to like me and think I'm doing a good job. I don't want criticism, and lying minimizes the risk."
"As time has gone by, I find I lie less. I just say, ‘no, I didn't call.’ I'm more confident in myself. I also feel more comfortable accepting that not everything has ‘secret meaning.’ I also worry less about being criticized. The fact is, it won't be that long before I'm done here anyway."
This resident reports a pattern of "subversion" of the supervisory process that often "feels like lying." She notes arriving for supervision, then "seducing" the supervisor into "pleasant conversation," with the intent of avoiding addressing any material. She states that "sometimes entire sessions would pass without talking about patients at all. I actually felt there were times when the supervisor participated in this process, and it seemed like some kind of collusion."
"I never actually lied about patient material, but it felt like I was lying in the sense that I was there in theory to discuss patient sessions, but was actively avoiding doing so. In a way, my physical presence in the room was a sort of misrepresentation. I felt that this was fueled by a weariness about getting into the draining aspects of talking about process material. The whole thing could be so exhausting, worrying about how well I was doing, whether I was doing things right, and whether this particular supervisor would have positive things to say about me in the end. It's an overwhelming experience."
"In retrospect, I think trying to keep the conversation at a pleasant level also gives me a chance to become friends with the supervisor, and minimize the subordinate role. We could just talk like two normal people, without the rank. I think this was a way to avoid the anxiety of being judged and evaluated. Once I finally got into talking about patients, I felt I had already established a relationship that was protective against being completely vulnerable to some kind of cold assessment. I suppose the misrepresentation was a way to get this protection into place."
Lying in psychotherapy supervision may be examined as one example of the broader phenomenon of lying itself, which is ubiquitous in our culture, and has been addressed historically by philosophers, social scientists, and clerics, as well as by writers in the popular press (
+3). Lying has received intermittent attention in the formal psychiatric literature, though most often with special reference to its more extreme examples, like pseudologia fantastica. Nonetheless, a number of theories have been put forth concerning the meaning of lying in its less sensational forms.
In a discussion of children, Dithrich (
+4) has suggested that lying may offer protection from painful affects associated with failing to meet internal standards, and it can serve as a "defiant attack, implicitly belittling the importance of parental values and aspirations." Fenichel (
+5) has written that children lie to tell parents that "since you lie to me in your way, I shall lie to you in mine," and that "if it is possible to make people believe that unreal things are real, it is also possible that real, menacing things are unreal." Lying, in this sense, can be a response to anxiety around losing the love of important figures in the child's life and so may satisfy the infantile wish for control (
+6).
Both Anna Freud (
+7) and Piaget (
+8) have described lying as a normal part of development, designed to deny pain, promote defensive regression, or escape criticism or punishment. Smith (
+9) points out that once the child discovers he can deceive mother, he is progressing in his individuation, since "he then recognizes that his mind and that of his mother are not one... This correlates with the capacity to say No that Spitz (
+10) has elaborated upon and explains the maternal distress, when the mother discovers the first lie, as a grief reaction to the loss of the mother/child oneness."
In a review of truth-telling, Goldberg (
+11) describes the lie as an interpersonal "transaction," emphasizing Tausk's (
+12) suggestion that the period of assigning omniscience to the parents ends with the child's first successful lie and that the struggle to keep secrets from parents can be one of the "most powerful factors in the formation of the ego." In adolescence, this developmental process is recapitulated, with "fragmentation of the self," which may manifest as lying. Children may also "learn to lie" from parents who teach by example the value of disguising one's own purposes. Of interest, it is Goldberg's conclusion that the transition from adolescence to adulthood requires learning that "openness often is cruelty, and saying whatever is in one's mind is an indulgence that no adult can afford." (As Winnicott [
+13] has noted, "lying has its normative functions as well as its pathology, and so does telling the truth.")
Kohut (
+14,
+15) has suggested that a child's undetected lie reveals a shortcoming in the idealized, omniscient parent, and that the child forms healthy internal structure through the "successful, phase-appropriate loss of illusion or failure of idealization." Lies may also be a product of pressure from the grandiose self, allowing the liar to ascribe great achievements to himself or to an idealized parent object, reflecting either a need for narcissistic support from an aggrandized self-object, or relief from guilt generated by surpassing an idealized person (e.g., one's father) in accomplishments.
Ford (
+16) has examined the role of milieu and trauma in lying, emphasizing the importance of exposure to lying by others, including secrets in the household, hypocrisy, and even "myth" that may be misrepresented as fact. In abusive environments, lying may function as a form of repression or denial, helping to conceal that which otherwise could not be tolerated. (As Fenichel [
+17] has suggested, "the untrue begins to seem real and believable in the face of a believed lie, while the truth in turn may begin to feel untrue."). Lying may also function as an expression of power, a way to devalue others, or as a mechanism to regulate affect, providing partial gratification of an impulse concurrently with its own inhibition, resulting in an event that takes place safely in fantasy rather than in reality (
+18). In each of these cases, lying remains a willful activity, even though the content of and need for the lie may be influenced by unconscious processes.
Personality factors may also have an impact on lying, as in the "affective truth" of the hysteric, or the exhilaration experienced by a narcissistic character after "putting something over" on another person (
+19). Lying may enhance self-esteem in borderline personalities, allowing for the projection of guilt, and reflecting both poor impulse control and difficulty with frustration tolerance (
+20). Compulsive personalities may lie to protect the self from over-intrusiveness by others by withholding secret information about internal experience. In the case of antisocial characters, lying is a matter of definition and is often associated with a range of behaviors reflecting the need for repression and denial.
Weinshel (
+21) has described lies in the context of psychoanalysis as by-products of Oedipal or pre-Oedipal struggles that serve to express aggressive feelings toward parents (and, in the transference, toward the analyst), especially in retaliation for lies originally told to the patient. He urges that lying be addressed not as a moral issue, but rather as a kind of resistance, whereby the individual resorts to fabrication as a way of not dealing with otherwise-painful or potentially traumatic material.
+
Residency Training and the Supervisory Setting
If lying is best examined as a kind of transaction rather than solely a product of internal experience, then any understanding of lying in the supervisory setting requires an appreciation of the broader milieu in which it occurs.
The experience of graduate medical education has been extensively studied and found often to be accompanied by a range of stress-related symptoms, including anxiety, depression, substance abuse, and family dysfunction (
+22—
+26). Samuel et al. (
+27) have compared levels of stress experienced by several nonsurgical resident populations and found that psychiatry residents were twice as likely as other groups to have an elevated Beck Depression score. Although the meaning of this finding is unclear, it was acknowledged that there may be differences between the experiences of psychiatric trainees and other residents, including the possibility that psychiatrists were more likely to express and examine their feelings than other trainees.
Hales and Borus (
+28) have distinguished three phases of psychiatric residency training. The "beginning psychiatric training syndrome" is characterized by anxiety, psychosomatic symptoms, and depression, as the resident relinquishes his role as a practicing physician and find himself judged by how well he works with rather than for patients. This is followed by a mid-training period, associated with some increase in competence, but also with the addition of fresh demands to achieve expertise in many new areas at once, while remaining current in medical knowledge. The final year is characterized by a period of professional identity diffusion, wherein one-third of senior residents report "significant anxiety" and two-thirds, "painful depression" around decisions about future practice. This is attributed to the fact that psychiatric residents often have many role models, often in conflicting types of practices, so that there is no clear path to pursue for their own practice selection.
Halleck and Woods (
+29) have suggested that inadequate attention has been paid to the climate in which residents attempt supervision, resulting in a learning process frequently described as "painful." Trainees often work with seriously ill and economically disadvantaged patients who may show less motivation and ego strength than would be desirable for a learning situation; these patients may be unlikely to respond during the limited outpatient experience provided by most residency programs. Even when a resident accepts the limitations of his brief experience with patients, he may still feel inadequate and self- critical, and so be inclined either to see change where little exists (only to be later disappointed) or else be plagued by concerns about his abilities as compared with those of his colleagues. Since the neophyte has no assurance that he will ever become accomplished enough to help his patients improve, the resulting loss of narcissistic gratification can become an intense burden to bear.
Halleck and Woods (
+29) also address the risks associated with the role of the supervisor as "quasi- therapist," emphasizing that a resident in supervision may have his own conflicts and impulses exposed in the absence of the securities inherent is a truly therapeutic alliance. The supervisory setting offers no assurance of confidentiality, and supervisors often exercise much real power over the ultimate success of the residency. As a consequence, the resident may "consciously or unconsciously conceal a great deal, with a resultant increase in his guilt." Also, while training programs may emphasize well-accepted techniques, experienced therapists often depart from these, a fact they may not be inclined to share with supervisees. Thus, when the resident departs from traditional technique, he may do so "with much guilt and the need to conceal."
Sharaf and Levinson (
+30) have written about the "quest for omnipotence" on the part of psychiatric trainees, expanding on the views of Lewin (
+31) and Wheelis (
+32), who note that psychoanalytic candidates often endow their mentors with omniscience about psychodynamic matters. Psychiatric residents may also perceive their teachers as possessing a type of omnipotence, experiencing the supervisor as a charismatic figure who may, if all goes well, "bestow his treasures upon the resident." For such trainees, realistic modesty may be exaggerated into a "sense of emptiness, of being devoid of knowledge or inner resources." Primitive wishes may be activated as the resident struggles to learn the "therapeutic use of the self," a process requiring that he deal with the most intense emotions of his patients, even as he seeks to deal with similar processes within himself.
In adapting to the challenges of training, Halleck and Woods (
+29) argue that many residents
never seem to reach the potential they initially promised...as if in an effort to achieve some sort of equilibrium in the face of severe stress they say to themselves: ‘This is as far as I go and as good as I am going to be.’ Others may respond by developing personal philosophies which reduce their maximal effectiveness, but spare them incapacitating anxiety.
Similarly, Sharaf and Levinson (
+30) note the risk of "losing oneself in ineffectiveness, as when a desire to know everything prevents the learning of anything," and warns against "parroting" an idealized teacher without genuine identification or forming an individual identification so massive that learning divergent views becomes impossible.
Although lying is clearly a highly personal experience, there may be patterns of deception that can be identified among individuals who share a common experience. Lying among psychiatric residents in psychotherapy supervision is likely not a rare event; it may represent a by-product of the interaction of a vulnerable individual and a provocative situation.
The cases described suggest a number of explanations for misrepresentation. Perhaps most striking is the attempt to protect the self from the disruption of narcissistic equilibrium (and subsequent anxiety) associated with fantasies of either confronting or being damaged by the supervisor. Almost all residents interviewed verbalized fears ranging from disappointment to frank retaliation in the form of rebuke or poor evaluations as a consequence either of challenging a supervisor's suggestions or failing to meet his or her expectations. In this context, lying may function both as an expression of and a defense against the trainee's own retaliatory impulses, paralleling Weinshel's (
+21) descriptions of the function of lying in psychoanalysis.
Lying may also serve to set limits or boundaries within the supervisory setting, allowing the trainee to avoid what is described as the "effort" or "trouble" (again, anxiety) associated with the direct expression of affect or material that may have difficult symbolic meaning. Lying, in effect, becomes the equivalent of saying "I do not feel safe expressing this here; this is not my own treatment, and I will not risk too much in an evaluative environment which leaves me vulnerable."
The question of boundary-setting may have further meaning in a developmental context. It has been argued that medical training represents a kind of extended adolescence, as the trainee postpones the normal tasks of adulthood in the service of his education. If so, the residency period might be expected to be rife with issues of autonomy and individuation. Within such a setting, the lie may serve a function similar to its proposed role in early life, when it may help confirm the independent agency of the trainee (child) from the supervisor (parent) and, at the same time, test the supervisor's omniscience. The devaluation resulting from such a "failed" test may serve a developmental and self-regulatory function, helping the trainee prepare for the eventual need to manage his own affects (and intellect) as a separate therapist.
There may also be personality characteristics common to medical trainees that predispose toward the defensive use of lying. Gabbard (
+33) has written about the role of compulsivity, including the prevalence of obsessive and compulsive defenses, in the normal physician. Given the self-protective role of secrecy in the structure of such characters, it might be expected that the urge to maintain secrets about the self in supervision would be considerable. One might expect to see an increased reliance on unusual defenses, which may be more primitive, in the face of the more regressive periods of training. This may especially be the case as the resident is forced to confront his own impulses in the context of both his therapy with patients and in his supervision. In such an environment, lying may prove to be a most tempting way to manage difficult feelings.
The psychotherapy supervisor is placed in the difficult position of both stimulating and helping to manage aspects of the trainee's instinctual life, a challenge described by Greben (
+2) as having much in common with parenting. He suggests the resident "take in what the supervisor provides, retain that part that feels right and natural for himself, and let go of or reject that part that seems foreign or unnatural." This is described as best accomplished within the "good-enough" supervisory environment, in which the trainee feels supported and confident that the supervisor will not damn or shame him. If this is not the case, or if the resident feels unable to differ with a "directive" supervisor, he may not even attempt to act upon suggestions that seem foreign, but instead wind up either standing up openly against the supervisor, with all this implies, or else not telling him what is really taking place in the therapy. As Greben points out, "a tough teacher can communicate certain facts to his/her students, but cannot provide the milieu that is needed for learning in the supervisory experience."
In sum, supervisors must perform a complex and layered self—object function for trainees who may be stressed by a range of intellectual demands while simultaneously addressing difficult aspects of their instinctual lives, perhaps for the first time. Trainees may present in a somewhat regressed, or even, as Halleck has suggested, "decompensated" state, and look to supervisors to provide a range of affect-regulatory functions, even as they struggle to build a sense of separateness and autonomy. If a particular trainee's needs are especially intense, or a particular supervisor's capacity to function in these terms inadequate, the resulting conflict may be especially likely to activate defenses identified with lying, including repression and denial, and deception may become a dominant aspect of the supervision. Both of these situations appear to have been present in the case material, exemplified by trainees who felt especially vulnerable or inadequate, or who experienced their supervisor as cold, aloof ("psychoanalytic"), or punitive.
It is important to emphasize that even the most empathic supervisor may not be in a position to adequately support a trainee's needs if they are, for whatever reason, simply too great. In such a case, the supervisor may be viewed as distant or unsupportive regardless of his behavior, resulting in the trainee's use of lying either as a response to or a way to avoid regression. By the same token, it is possible for a trainee's other transference issues to be overwhelmingly intense and for personal enactments to occur within the context of the relationship with the supervisor, with similar results.
Arlow (
+1) has described the supervisory experience in psychoanalytic terms, quoting one of the Lewin and Ross (
+34) respondents, who notes that "what goes on [in supervision] is more frequently meritorious than shocking, but the intrusion of rivalry, paternalism, infantilization, dominance and submission struggles, plain ill-temper, etc., is all-too- often disquieting." Given this, he suggests that trainees may unconsciously shift from "reporting" data about their work with the patient to "experiencing the experience" of the patient, thus enacting a "transient identification," which itself reflects the patient's own oscillation between experiencing and reporting. The trainee may thus resort to defensive patterns consistent with lying as a form of identification with a patient who is doing the same, especially in the context of shared elements of instinctual life. In this way, the trainee who lies may be saying as much about himself, his patient, and their relationship, as he is about himself, his supervisor, and their relationship (parallel process).
The supervisory situation may therefore be viewed as a mirror of three distinct perspectives: the trainee's inner world, the patient's inner world, and the novel world they construct together. Arlow warns that although a patient's reactions to his therapist-in- training may be observed and studied in this way, supervision itself is not an appropriate forum for resolving the trainee's own unconscious conflicts. Because psychotherapy supervision will frequently stimulate trainee conflicts while offering little opportunity to resolve them, both supervisor and supervisee are challenged to create boundaries that will prevent undue regression and the mix of anxiety, defensive struggles, and risk for misrepresentation that may result. As Arlow notes, "a free and relaxed atmosphere and an accepting, judiciously critical attitude on the part of the supervisor make it possible for a dynamically and affectively accurate record of the therapeutic interchange to occur."
There are a host of other motivations for lying in the supervisory setting, some of which are reflected in the case material. Deliberate misrepresentations may reflect passive-aggression on the part of trainees in response to a range of anxieties, including perceptions of "abuse" (
+35) suffered at any point in medical (or other) education. In the context of a psychiatric training program, aggression expressed in this way may attain "cultural" significance as a response to shared regressive pressures. The more regressive the setting, the more pressure exists to effectively manage the emotions that are stimulated.
Lying in the supervision situation should be viewed as an interpersonal transaction, subject to all of the factors that influence transactions of other kinds. It may serve as a vehicle for impulse expression, a defense against impulse expression, or a combination, becoming, as it were, the equivalent of a symptom. In the face of regressive pressures, lying may reaffirm boundaries in a recapitulation of earlier individuation processes. In each case, the lie reflects the internal experience of the lie-teller as it is affected by the interplay of previous experience with the immediate external world, including, most immediately, the person to whom the lie is directed. It is within this matrix that the lie can serve to prevent narcissistic injury and so help maintain self-esteem.
In the case of psychotherapy supervision, the lie transaction occurs within a complex web of interacting experiences. These include the internal world of the trainee as it interacts with the residency training environment, the internal world of the trainee as it interacts with the therapeutic setting with patients, and the world of the trainee/patient-trainee dyad as it both responds to and makes demands from a given supervisor. Any of these interactions may be highly charged, subjecting the trainee to regressive pressures and impulses, which may be either directly expressed, as in an aggressive lie, or else modified by defensive or limit-setting processes, which may themselves be expressed in various forms of "secret- keeping" or deception.
Lying in psychotherapy supervision represents a failure on the part of the trainee to manage his or her impulses and affects in more adaptive ways. Such a failure may reflect limitations in a particular trainee's capacity to manage affects, as well as being a result of inadequate external supports. The ability of the supervisor to provide an adequate holding environment in the face of the regressive pressures of training is a key factor in avoiding the pitfalls associated with misrepresenting case material. With this in mind, supervisors, administrators, and trainees may wish to consider the following when designing or undertaking a supervisory process.
Of course, any of these interventions may be applied to non-psychotherapy supervisions, as well, such as pharmacotherapy supervision, or oversight of inpatient, partial hospitalization, or other treatments. Controlled studies are required to measure the actual prevalence of misrepresentation by trainees in supervision and to assess the effectiveness of specific preventive measures.
Weinshel has argued that lying by patients in psychotherapy is best viewed not as a moral issue, but as a therapeutic one that, if addressed, can actually be of value in the therapeutic process. The challenge falls to trainees and supervisors to identify lying in an objective and investigative light, and work together to understand its meaning within the context of the many internal and interpersonal experiences involved. The persistence of lying in a given supervision represents an especially graphic failure of this process and the ultimate breakdown of the supervisory situation. Although the loss of any supervision to the ravages of lying and distortion is an inexcusable waste in an era of scarce resources, even more disturbing is the failure to attempt its prevention in the first place. As one of the residents noted grimly about the unpleasantness of lying, "the fact is, it won't be that long before I'm done here anyway." Avoiding such nihilism should be the highest priority for anyone involved in the complex and rewarding work of training psychotherapists.