Title: Sex, Dishonesty, and Psychotherapy
Description: Purpose: Honest disclosure about salient information is at the heart of the therapy process but sexual material has been found to be among the most frequently concealed types of content. Understanding why clients choose to be avoidant or explicitly dishonest about sexual topics may attune therapists to the types of concerns clients have when deciding whether or not to disclose this material, how non-disclosure or dishonesty about sex impacts therapy, and what would help clients be more honest about such material. This study directly queried clients who had been dishonest about four types of sexual content in order to learn how therapists can better promote honest disclosure about different domains of sex and sexuality. Method: As part of a comprehensive study of client “secrets and lies,” a sample of 798 outpatient therapy clients rated their dishonesty or honesty about four sexually related topics (“details of my sex life,” “my sexual desires or fantasies,” “my sexual orientation,” and “times I have cheated on a partner”) and completed measures about attitudes toward disclosure along with ratings of the therapeutic alliance.

Follow-up samples of clients who stated that a sexual topic had been hardest to talk about in therapy answered multiple-choice and open-text questions about their motivations for being dishonest with the therapist, how it impacted them in terms of therapy progress and feelings about the decision, and what they believed the therapist could do to help them be more honest about this topic. Results: Two types of sexual content – “details of my sex life” and “my sexual desires and fantasies” – were the most common topics of dishonesty across the whole sample. Dishonesty about sex tended to manifest in total avoidance of the topic in therapy. Approximately 80% of clients indicated that their motivation for dishonesty was to avoid shame or embarrassment, while smaller numbers reported concerns about how the therapist would react to the disclosure. These clients cited worries about being stigmatized or judged, or felt unsure that the therapist would understand or be able to help; some referred to their belief that the therapy relationship could be jeopardized if they were more disclosing, a particularly salient theme for those who had been dishonest about sexual orientation and sexual fantasies.

Based on a multiple choice format, a majority stated that their dishonesty about sexual issues had “no effect” but in an open-text format, a majority described more negative impacts, mainly the inability to address a relevant topic. A significant number of clients felt conflicted, guilty, or regretful about being dishonest, though some felt largely neutral; very few had positive feelings. When asked what would help facilitate honesty, about 80% of clients stated their wish for the therapist to “ask directly.” Some differences occurred in terms of specific facilitators based on topic. For instance, clients who had concealed a more overtly sexual topic (e.g., “details of my sex life” and “my sexual desires or fantasies”) wanted the therapist to normalize or provide a rationale for why it would be helpful to disclose; clients who concealed their sexual orientation wished for the therapist to display cultural competence and to ensure the safety of the relationship; and clients concealing infidelity were unsure if there was anything the therapist could do.

Limitations: The findings of this study may be limited in its generalizability due to a few key factors. First, the sample contained a majority of highly educated Caucasian female clients, which mirrors the therapy-seeking population but may not accurately reflect the concerns of male or minority clients. Second, it was comprised solely of individuals who were willing to speak more about their experience in therapy, while the follow-up samples contained respondents who identified that a sexual topic had been hardest to talk about in therapy. Finally, self-report data is by its very nature limited by the willingness of clients to answer accurately. As such, it is unclear how these data extend to the general or clinical population more broadly. Conclusions: The concerns expressed by clients suggest that shame and the anticipation of a negative therapist reaction primarily motivate sexual dishonesty, and that direct inquiry by the therapist can help alleviate both of these interconnected worries by signaling that sex is a welcomed topic of disclosure.

These findings also indicate the high prevalence of dishonesty about a spectrum of sexual topics and highlight the way that clients tend to avoid these discussions, which further supports the need for more active therapist intervention to frame the rationale and normalize honest discussion about clinically relevant sexual material.