Discussion

Over the last decade, this topic has received a great deal of attention (Hughes et al., Reference Hughes, Hope, Reader and Rice2002; Wood-Mitchell et al., Reference Wood-Mitchell, Waterworth, Stephenson and James2006, Reference Wood-Mitchell, Mackenzie, Cunningham and James2007; Mitchell, Reference Mitchell2014). Past research has been characterized by conflicting opinions and little acceptance of lies (Schermer, Reference Schermer2007). Indeed, when the authors first introduced the topic into their work, in addition to criticism (Müller-Hergl, Reference Müller-Hergl2007), fellow therapists would occasionally walk out of sessions in opposition to the content of the material being debated. Therefore this study indicates an increasing degree of acceptability regarding the use of lies within clinical psychology. First of all, clinicians have shown that even prior to the delivery of training they had an awareness of the use of lies within care settings and that lies could be helpful with PWD. It was also noteworthy to see, that even prior to training, there was a trend for psychologists to see themselves as having a role in teaching others to lie more effectively. This study has highlighted that our training module helped clinicians to recognize that they lie more frequently than they had initially thought. It appears from the qualitative findings that statements they previously would not have labelled as a lie, were now recognized as deceptive practices (and thus appropriately relabelled). Indeed, from observations of the participants during the teaching it was evident that many began to recognize that they were routinely – ‘going along with a PWD's incorrect belief’; ‘redirecting people's attention via a partial truth’; ‘bending the truth’. Via our training, participants began to recognize the practical and ethical complexities associated with using lies. In particular they started to see the relevance of formulating the lies within a person-centred conceptualization, and ensuring the lies were used consistently and collectively by the carers and families. For example, the participants were taught that a ‘good’ lie needs to be consistent with the person's historical script or personal schema. So telling a person who constantly asks to see her deceased husband that he's gone fishing is only effective if the husband actually fished. Indeed, if the husband never fished, even someone with moderate–late stage dementia would recognize this, and realize they were being lied to. The person would then ponder why we were lying about her husband's whereabouts, and she may think – ‘Has he left me?’ ‘Is he having an affair!’ Such thoughts are likely to lead to agitation and possibly aggression (see James and Jackman, Reference James and Jackman2017, for full review). Thus it seems our workshop gave participants an opportunity to recognize that there is a need to teach carers how to lie effectively from a person-centred perspective.

It is evident that the educational module, and particularly the use of the DVD, served to highlight the complexities associated with the topic. Indeed, we believe the greater appreciation of the complexity of lying as a communication tool, as illustrated in the case material of the DVD, was a key reason why there was such a significant change in Q3. Mackenzie and colleagues (Mackenzie and James, 2010; Mackenzie, Reference Mackenzie2013) have already produced a set of guides for carers on the use of therapeutic lies (James et al., Reference James, Wood-Mitchell, Waterworth, Mackenzie and Cunningham2006; Table 1). These guidelines were recently updated in a study undertaken with psychiatrists (Culley et al., Reference Culley, Barber, Hope and James2013).

The current guidelines are outlined in Table 2.

Table 2. Guidelines adapted from James et al. (Reference James, Wood-Mitchell, Waterworth, Mackenzie and Cunningham2006)

One of the main developers of the guidelines (Mackenzie, Reference Mackenzie2013), has provided a protocol on how lies should be used. She suggests that lies should only be used as a last resort, and only after the trialling of less controversial strategies, such as: (i) meeting the person's perceived needs; (ii) simulation of their needs; (iii) distraction, and then finally (iv) therapeutic lying (James and Jackman, Reference James and Jackman2017).

When one looks at these guidelines (Table 2), one may be struck by the complexity involved in delivering a therapeutic lie. As such, the level of intricacy may further support the need for clinicians to become involved in the teaching and supervision of this controversial form of communication. Notwithstanding the more positive perceptions towards therapeutic lying, it is important to recognize that there are numerous ethical problems associated with the phenomenon. These problems are discussed in detail elsewhere (Müller-Hergl, Reference Müller-Hergl2007). Such difficulties are chiefly concerned with perceived treachery (Kitwood, Reference Kitwood1997), manipulation and damage to autonomy (Müller-Hergl, Reference Müller-Hergl2007) and untrustworthy practices (General Medical Council, 2013). A good example of the debates occurring in this area is illustrated in a short series of articles in the journal Nursing Ethics (Mitchell, Reference Mitchell2014; Brannelly and Whitewood, Reference Brannelly and Whitewood2014); the second article is a commentary on the first. Mitchell describes a case in which a lie is told to a person with dementia in order for the patient to accept medication. Problems occur, however, because not all of the nurses are willing to tell the lie, leading to sub-therapeutic treatment. Mitchell believes that the case highlights a clash between the concepts of beneficence and veracity, and asks whether lying is even legal. He thinks that a case can be made for the occasional use of a lie, but he believes ‘. . . it will be difficult for any nursing professional to advocate for the routine use of therapeutic lying irrespective of beneficent principles’ (p. 845). In response to the first article, Brannelly and Whitewood advocate examining the case through an ethics approach informed by Tronto's integrity of care framework (Moral Boundaries, 1993; Caring Democaracy Markets Equality and Justice, 2013). In this approach each clinical case needs to be examined under five headings: competence, responsibility, attentiveness, responsibility and solidarity. The authors illustrate their use of the framework via their own case study. Interestingly, the ethical treatment of choice using the Tronto approach leads them to employ covert medicating, which we would argue is also a form of deception, and therefore a type of therapeutic lying. The current authors are using the Tronto framework to examine practices on NHS in-patient wards. A nurse, undertaking a PhD, will be analysing the use of lies as part of her clinical practice on the wards. To our knowledge this will be the first ecologically valid assessment of lies in a care setting; prior to this the research has mainly used questionnaires, debriefs and qualitative approaches.

It is relevant to note that the present study mainly examined the opinions of psychologists, which clearly limits its generalizability. However, this was a deliberate selection strategy because previous work on lying had been done with this population (Elvish et al., Reference Elvish, James and Milne2010). Yet, in truth, there is no specific reason to believe that other professions should not take the lead in the training and supervision of this topic. In an attempt to maintain anonymity the authors did not obtain demographic data with respect to the participants; such an omission means that we are unable to undertake a more sophisticated analysis of the data. For example, differences in opinions may occur with experience, age or gender. Analyses of such factors should occur in future studies, particularly ones using larger populations. Before summarizing it is important to stress that the current findings do not mean that our participants endorsed the use of lies, rather it suggests the participants were keen to support having greater clarity around what is meant by lying, and what constitutes ‘therapeutic lying’. Furthermore, the brief study calls for training in the pros and cons, usage and ethics, of lying.

The project has implications for clinical practice, and it highlights the communication dilemmas faced by many clinicians providing hands-on care to people with dementia. Good communication is at the heart of all effective care, but problems can occur when the person being cared for has a different view of his/her current reality to the carer. Should the carer try to bring people into their ‘correct’ reality, or empathize with the world view in which PWDs may incorrectly perceive themselves to be fitter, competent and a member of a rich interpersonal network? This debate is similar to the ongoing discussions about the pros and cons of using reality orientation (RO; Spector et al., Reference Spector, Orrell, Davies and Woods2002) techniques in dementia care. The argument with RO is whether we should attempt to orientate people to the caregiver's reality as opposed to validating them in their time-shifted view, which may be providing a sense of comfort and security? Such questions require more systematic investigation, stressing the need for clinicians and researchers to work together to develop empirically informed communication and interaction strategies (James, Reference James2015). Once we have a better understanding of communication techniques we would be able to develop teaching programmes to increase our abilities to engage with people with dementia and de-escalate problematic situations. The present work also calls into question whether we need to revise clinical and professional guidelines, firstly because the findings (James et al., Reference James, Wood-Mitchell, Waterworth, Mackenzie and Cunningham2006) inform us that the recommendations on deception are being flouted in everyday practice, and secondly, it is recognized that in a number of specific situations lies may be beneficial and therapeutic.