therapyAs we grow into adulthood, each of us develops a personal comfort zone located on the continuum between paranoia and gullibility.  A few of us are highly suspicious by nature, a few are unwitting dupes; most of us are in between.  Mental health professionals are no exception, and it shows in our work.  Is a request for tranquilizers or stimulants legitimate, or are we abetting a substance abuser? When told of horrific past abuse, do we believe every word, or do we allow for possible exaggeration or distortion?  Credulity and skepticism exist in dynamic balance: too much of either impairs clinical work.

Our pride animates these assessments.  On the one hand, we see ourselves as sensitive and caring.  Empathy seems to require believing people’s stories, to be “on their side.”  On the other hand, we feel vulnerable and ashamed when fooled (as we sometimes are), and safer and proud of ourselves when we don’t fall for it.  Fueled by pride, proponents defend various points on the credulity continuum.  Some psychiatrists declare that they never prescribe tranquilizers because doing so invites manipulation by drug-seeking patients.  Conversely, some equally proud therapists never question the meaning of their clients’ cancellations, because doing so “lacks empathy.”

Like most doctors, I’m a critical thinker by nature.  This is a nice way of saying my comfort zone lies slightly closer to paranoid than gullible.  The perverse logic of the Freudian unconscious thus comes naturally to me.  Patients who claim complete marital satisfaction may be in denial, or at least recalling selectively.  Impassioned pronouncements of adoration may be “reaction formation,” telegraphing the exact opposite.  Dramatic hatred or disgust may hide a fascination, even an attraction.  The trick here, lest we treat our prejudice and not the real person in front of us, is to entertain such possibilities without becoming too attached to them.  It’s also important to distinguish empathy from blind agreement, belief, or endorsement.  I can empathize with a delusional person’s fear and panic without endorsing the delusions themselves.

A funny thing happened to me the other day.  A mental health professional in a remote land emailed me, seeking online psychotherapy for himself.  I was flattered that this colleague searched the world over and chose me.  He sought exactly the type of psychotherapy I like to conduct.  If not for distance — which would ultimately be a deal-breaker in any case, as I consider online therapy a poor substitute for the in-person kind — it seemed almost too good to be true.  Thus, wary of falling prey to my own pride and narcissism, I immediately suspected a scam.   After all, if something looks too good to be true, it probably is.  I imagined this email went to many therapists, and that it was a con, like those Nigerian emails that promise great riches and are now an internet cliche.  This is precisely what con artists do so well: appeal to one’s greed or pride.  They hook you, then reel you in.  I wasn’t going to let that happen.

As a savvy internet user, I knew just what to do.  I found the person online, and wrote him directly via his website.  I included the bogus email I received, to let this far-flung colleague know I wasn’t about to be taken in, and also that his identity was likely stolen for nefarious purposes.  I was rather proud of myself.

It turned out the original email was legitimate.  Adding injury to insult, I also violated the privacy of my correspondent, who doesn’t read his own website email.  I had unwittingly turned an earnest request into an awkward encounter by being too incredulous and self-protective.  In rushing to defend my pride against an imaginary threat, that very pride distanced me from someone who sought my help, and even hurt him.  It was an important and humbling lesson.

I sometimes share with patients that there is no disproving paranoia; it’s the safer stance at any moment.  Why ever let your guard down? Unfortunately this safety, which is sometimes only illusory in the end, comes at significant cost: isolation, viewing others as threats, constant fight-or-flight tension.  Sometimes this is the best self-protection we can muster in the aftermath of emotional abuse or betrayal.  However, it’s not the best we can do as human beings.  A degree of credulity, in contrast, brings vulnerability.  We can be hurt, humiliated, and diminished.  But it also allows relatedness, connection, and love.

In order for dynamic therapy to lead to change, psychotherapists must get caught up in our patients’ dynamics.  Not too much, such that we lose perspective and act like everyone else in the patient’s life.  Nor too little, such that no genuine connection or relatedness occurs.  Both parties ideally permit themselves enough credulity to be drawn into emotional engagement, while maintaining enough skepticism (or “observing ego”) to note what is happening.  Ideally, that is, for we therapists are the more obliged to maintain a watchful eye, and must balance credulity and critical thinking more carefully.

Logical argument is unlikely to convince the paranoid to be more credulous, nor the gullible to be more skeptical.  Our comfort zones are established early and unconsciously, based on emotion not logic.  The emotional power of dynamic psychotherapy and psychoanalysis, as well as close, healthy relationships in everyday life, can nudge our comfort zone in a direction that serves us better — and serves our patients better, if we happen to be psychotherapists ourselves.  Meanwhile, reflecting on prideful attachment to a particular stance on this continuum may offer us perspective and more flexibility.

Image courtesy of Ambro at

4 comments to Credulity

  • Dinah

    Ugh. I’m gullible and don’t often question patients about cancellations. And sometimes I give benzos, and sometimes standing benzos (either because the patient came to me on them or because my well-meaning prn turned into a low dose standing), but I do feel lousy when I turn away a prospective new patient because their Primary Care doc is suddenly uncomfortable prescribing their xanax and they’re’ looking for a script, nothing more. And you’re not me (and that’s probably a good thing) but if I had the website story, I would probably call the cross-country mental health professional and try to do damage control and hope I would not leave them too injured.

    • Hi Dinah,

      I don’t believe there’s a “right” place on the paranoid-gullible spectrum, except that both extremes are bad. I too prescribe standing (daily) benzos to some patients. As I commented on Shrink Rap, I think benzos are overly demonized. They don’t concern me to the degree that many other psych meds do. Nonetheless, their better use is intermittent, as I’m sure you’d agree.

      I also turn away prospective patients who are simply looking for a script, whether that script is a benzo, an SSRI, a stimulant, or something else. It’s just not my interest to be a med vendor.

      I exchanged further email with the person I mentioned, who told me the situation was ok, and they found someone else online.

  • Cynthia

    I love this post. I have heard the case of a psychologist who learned that what a patient had said to them in therapy was a lie. 100 percent incontrovertible lie. The therapist didn’t do research to learn this. The knowledge came as so much knowledge does, in the regular course of life or even unwanted. It was a lie on something crucial to the therapy. The therapist had to act as if they had never gotten the information of the lie. The option would have been to tell the truth, or drop the client. Any thoughts on this case besides you have to feel sorry for the client for lying and wrecking their own therapy? I bet it happens more and more in this era of easy social media.

    • Hi Cynthia,

      Thanks for writing, and Happy New Year. My policy is never to lie to patients. If I learn something inadvertently and it’s relevant to our work, I bring it up. Usually this happens after a family member calls to tell me something I “really ought to know” about my patient (often undisclosed substance abuse). I tell such callers that I’m duty-bound to share this knowledge with my patient. They often ask me not to, or at least not divulge how I learned it. But my relationship of trust is with my patient, not the caller. I always share what I learned, and most of the time how I learned it.

      I’m not on social media very much, and never “friend” or “connect” with patients. So I only ever learn things from third parties who want me to know. If I learned something on social media, I might have to disclose that I use that social media myself. It would be a dilemma, but on balance I’d probably share how I found out.

      In the case you described, I would share what I learned, maybe adding that I found out without any action or intent on my part. The patient could bolt in shame, which would be a pity. On the other hand, there could be great therapeutic value in exploring why the patient maintained the ruse. I’d encourage the patient to hang in and talk to me about it — and unless the lie affected me personally (e.g., wrote me bad checks for therapy), I honestly don’t believe I’d feel too betrayed by a patient who did this. Maybe some already have!

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