Honesty Fosters Trust

“When in the presence of someone with whom you have a bond, and to whom you have entrusted your feelings, it is hard to lie and get away with it. The truth just wants to come flowing out. This is especially the case when you are trying to hide your sadness or vulnerability. It is much easier to conceal sadness from a stranger or from someone you don’t trust.”

—Toshikazu Kawaguchi

A psychiatrist relies upon truth telling and trust to reach patients in meaningful ways, yet there are times when too much honesty may be harmful to the patient or the treatment. Conversely, without honesty there can be no trust between psychiatrist and patient, or between colleagues. By modeling honesty, along with compassion, confidentiality, and sincerity, the psychiatrist creates an environment in which the patient feels safe to be truthful, too. By modeling honesty in the workplace, including speaking up when we perceive microaggression or injustice, we foster an environment that is safer for others to be forthright, too.

Honesty is a virtue through which we show respect for others and is a basis for healthy relationships and institutional integrity. Aristotle defined virtue as a mean between two extremes of deficiency and excess, which are vices. When there is a deficiency of honesty, lying results, which erodes autonomy and trust. When there is an excess of honesty, rudeness emerges, which hurts feelings and may also erode trust. An ethical physician strives to uphold virtues, including honesty, in both personal and professional domains. Section 2 of the AMA’s Principles of Medical Ethics states, “A physician shall … be honest in all professional interactions.”

Mindful of Aristotle’s perspective on the vice of excessive honesty, a psychiatrist must distinguish between a helpful degree of truthfulness and information that may be harmful to the patient. An ethical psychiatrist is open and honest about the patient’s illness and treatment but refrains from overdisclosing details of the psychiatrist’s personal life. This is a fine balance that may vary somewhat from one psychiatrist to another depending on training and personality and that certainly will vary in our approach to individual patients depending on their ego strength and personal history.

Extremes of either overdisclosure or withholding may be harmful to the treatment. For example, a patient with tenuous object permanence may need to know the destination of the psychiatrist’s upcoming vacation to mentally project the psychiatrist into that space and retain a sense of connection. However, if that patient asks about the vacation upon the psychiatrist’s return, there is little clinical justification for more than a brief response before turning the topic back to the patient. Overdisclosure diverts the focus from the patient to the physician and may signal a shift in the relationship from a therapeutic one devoted to the patient’s health to a friendship that may require attention to both individuals’ needs. Although this may initially feel gratifying to both patient and clinician, it risks corrupting the treatment.

Supervision or consultation with a colleague before introducing a new element into the treatment is wise. Disclosing a personal illness, revealing a pregnancy, initiating a transfer of treatment because of retirement or a change in employment, and even announcing a vacation should be considered carefully. Timing, wording, and context are each important and may be different from one patient to the next.

Similarly, in our professional interactions with colleagues and coworkers, honesty is vital to workplace integrity. Looking the truth in the eye and speaking it take more courage than polite avoidance and circumspection. A psychiatrist who speaks up when a microaggression is perceived in a meeting, or who identifies policies that may be biased against some populations of patients or employees, or who supports another employee encountering gender-based harassment serves as a role model for truth telling. Given our experience at choosing our words carefully to convey just the right meaning and relative power within the structure of most institutions, psychiatrists are in an ideal position to address unethical behavior by shining the light of truth into a situation.

Honesty may be more difficult than prevarication, but it is worth the effort. Time spent reflecting on the words that speak the truth while avoiding harm exercises our discernment about how to speak to and relate with others in a truly constructive and therapeutic manner. In a future column, I will explore further some philosophical and spiritual ideas about the nature of honest speech. ■