Denial in the Assessment and Treatment of Sexual Offenders

1. Denial in the Assessment and Treatment of Sexual Offenders Jackson TayBosley, Psy.D. Rutgers University Behavioral Health Care

2. Old View: An offender who denies his sexual offense is automatically seen as a higher risk for sexual reoffense.

3. Why the old view? • Human reaction: Clinician & PO sense of right and wrong. • “He’s not only a sex offender but a lying, sneaky sex offender.” • Presents a difficult situation in treatment. • Can’t talk about an offense he didn’t commit. • Can be poisonous in group therapy. • Makes assessment difficult. • But, what are the “facts”?

4. What Does The Research Say?

5. Meta-analysis • Hanson & Bussiere (1998) • Took studies by others - (k=29, n=11,294) • Calculated effect sizes for different factors • Hanson & Morton-Bourgon (2004) • Added more studies - (k=95, n=31,216) • Strongest Predictors: • Sexual deviancy predicts sexual recidivism. • Antisociality predicts violent/any recidivism.

6. Hanson et. al. findings- • Client presentation has little relationship with recidivism. • Psychological issues, low motivation for treatment, lack of remorse/victim empathy • Denial did not affect recidivism. • But, treatment completion reduces recidivism (40%). • Being kicked out of treatment increases recidivism (200%).

7. Caveats • Lund (2000) looked at criteria for denial used by the seven different studies in the Hanson, et. al meta-analysis. • (Categorical) deniers excluded from treatment in most programs. • Definitions of denial varied from study to study. • When (in treatment) “denial” is determined makes a difference (at Intake – at completion of treatment, or ?).

8. Implications • Denial (however defined) might not affect sexual recidivism. • Research efforts to that point had not determined if denial affects recidivism. • Denial as a barrier to treatment entry does affect recidivism (it raises it). • Denial contributes to problems in treatment compliance and is a relevant treatment issue. • More research findings needed -

9. Levenson & Macgowan (2004) • Looked at relationship between denial and engagement in treatment and treatment progress (n=61). • Denial = inverse relationship with treatment engagement and progress. • “Supports current standards of practice that maintains that admitting to the crime is a necessary condition for progress…” • Denial is reasonable treatment target.

10. Nunes, Hanson, Firestone, Moulden, Greenberg & Bradford (2007) • Wanted to look specifically at denial as a factor in recidivism (n=1052). • Denial still did not predict recidivism in total sample. • But: • Low risk offenders + denial = higher risk. • Higher risk offenders + denial = lower risk. • Incest offenders + denial = higher risk.

11. Langton, Barbaree, Harkins, Arenovich, McNamee, Peacock, Dalton, Hansen, Luong & Marcon (2008) • Looked at post-treatment denial & recidivism (n=436). • Separated denial into categorical and continuous scale. • Categorical denial did not predict recidivism. • High risk offenders + high minimization = higher recidivism. • Failure to complete treatment, risk score and PCL-R (factor 2) = higher recidivism.

12. Harkins, Beech & Goodwill, (2010) • Wanted to look at denial, motivation for treatment and recidivism risk (n = 180). • High risk offenders + total denial = lower risk of recidivism. • Low risk offenders in denial reoffended more, but results non-significant. • Denying risk for reoffense = lower recid. • Acknowledging high risk = higher recid.

13. Pake & Wilson (2010) • Looked at establishing normative data on denial construct with SVP population. • Examined several instruments: • Facets of Sexual Offender Denial • Denial Scale for Male Incest Offenders • Denial and Minimization Checklist • Used Denial and Minimization Scale (DAMS) to obtain SVP norms (n=140). • Now, what?

14. Levenson (2011) • Raised ethical questions related to treatment of SOs in denial. • APA and NASW ethical codes value client self-determination (mandated Tx?). • Empirical literature supports addressing denial in treatment (responsivity issue). • Denial not a categorical construct – “continuum of cognitive distortions” that require therapeutic attention.

15. Looman, Abracen & Ghebrie (2012) • Looked at higher-risk offenders (n=210). • Post-treatment denial is associated with Factor 1 in PCL-R. • Moderate risk offender in denial at pre-treatment = higher risk. • Post Treatment, high risk offenders + denial = higher recidivism. • For moderate and low risk offenders, denial did not raise (or lower) risk.

16. So, what is denial? • Can be seen as a binary variable. • “I swear to God, I didn’t do it.” • Or, “yes I did it.” • Can be seen as a multi-dimensional variable (rationalizations, minimizations). • “Yeah, I did it, but…..” • Can be dynamic variable (changes over time). • Measured pre-treatment, post-treatment

17. Denial (Psychological) • Primitive defense mechanism. • Lack of awareness due to stressful association with issue/incident/object. • Uncomfortable with the fact - it is denied. • First stage of coping. • Once a person acquires emotional resources, they incorporate the painful fact into reality. • PTSD – denial might not be conscious.

18. Denial • Most of what we call “denial” is simply lying due to fear of consequences. • Aware of the truth, we claim the opposite. • “Lying to yourself” is psychological denial. • Confabulation is lying due to a mental illness. • Lying to others is: “bald (or bare) faced” lie, an untruth, “white” lie, “bullshit”, an exaggeration, fib, fabrication, perjury, misrepresentation, etc.

19. So, what is denial? (Cont.) • Denial is a “treatment-interfering factor”. • We don’t have specific treatment protocols proven to reduce denial. • Denial has not been proven to raise recidivism with all sex offenders. • Denial seems to be associated with increased recidivism with some offenders. • Low risk offenders • Incest offenders

20. New View: Denial does not necessarily raise recidivism risk of sexual offenders. It has different effects on different offenders, sometimes raising risk, and sometimes lowering risk.

21. Denial in Assessment • Makes it harder to get information regarding offense (causative factors, precursors, contextual issues, etc.) • Makes risk assessment process more complex and less exact. • Risk predictions based on assumptions – if charges are true… and if not... • Risk based on collateral materials – charge sheets, victims statements, etc.

22. Polygraph • It is intrusive and intimidating. • Still legally questionable. • Undeniable deterrent for some offenders. • Not a deterrent for other offenders. • Effective tool for breaking through denial. • Is most accurate with single issue test. • Increases rate of successful completion of supervision.

23. Effective Tactics in Addressing Denial in Treatment • Preparatory program (Marshall) • Pre-Treatment groups (deniers groups) • Motivational Interviewing/enhancing motivation and investment in treatment • Treatment readiness groups • Surreptitious focus on denial – without heavy confrontation and threats • “Face saving” strategies.

24. Effective Tactics in Addressing Denial in Treatment (Cont.) • Understand the purpose of denial for that specific offender. • Recognizing denial as a “normal” (and common) process in human interactions. • Get comfortable with never knowing for sure whether an offense was committed or not. • Not focusing on denial as a primary or necessary issue in treatment.

25. Ineffective Tactics in Addressing Denial in Treatment • Harsh or consistent confrontation is not conducive to breaking through denial. • Name-calling, goading, etc. is antithetical to good treatment. • Excluding client from treatment (bad for clients, bad for society). • Too many deniers (in a group) can make it hard for others to take responsibility.

26. Denial and Specific Circumstances • Discharge from treatment for negative (obstructionistic) behavior in therapy. • “I’m not a sex offender and all this treatment stuff is crap. I’m not going to be in treatment with these guys – they are horrible.” • Refusal to cooperate with treatment or supervision requirements. • “I’m not a sex offender so you can’t tell me I can’t go to the mall/park or wherever I want.”

27. Take Home Message • Denial is common among sex offenders. • Denial does not usually raise the risk of sexual reoffense. * • Denial should not exclude anyone from treatment. * • Careful management of treatment situations is needed when an individual in group is denying his/her sexual offense.

28. Take Home Message (Cont.) • Denial is vexing for the therapist and PO, but is not a major problem in the system. • It is a reasonable issue to address in treatment (carefully) because it interferes with treatment participation/investment. • We have to be careful not to make offenders in denial more dangerous by denying them treatment.

29. Treatment Context • Correctional programming should be provided according to the principles of Risk/Need/Responsivity. • Risk – highest risk = most intensive treatment • Need – treat issues that contribute to sexual recidivism (Stable & Acute-2007 items) • Responsivity–Treatment that meets clients where they are. • Good Lives Model involves clients in treatment planning and implementation.

30. Treatment Context (Cont.) • Motivational Interviewing enlists participants into the therapy process. • Overcome treatment resistance with concern. • Develop working alliance. • Harder in the short term – easier in the long. • Separate treatment systems for deniers and admitters (difficult to implement). • Gentle, supportive challenging is the key.

31. Treatment Context (Cont.) • Modern treatment for sexual offenders is evolving from a harsh, confrontational style to a more supportive model. • It is still based on Cognitive Behavioral concepts, but focuses on teaching our clients new ways to live a healthy lifestyle. • And, it involves the clients in their own therapeutic process, using a collaborative approach.

33. Bibliography (Chronological order) • Hanson, R. K., & Bussière, M. T. (1998). Predicting relapse: A meta-analysis of sexual offender recidivism studies. Journal of Consulting and Clinical Psychology, 66, 348-362. • Hanson, R.K., & Morton-Bourgon, K. (2005). The characteristics of persistent sexual offenders: A meta-analysis of recidivism studies. Journal of Consulting and Clinical Psychology, 73, 1154-1163. • Lund, C.A. (2000). Predictors of sexual recidivism: Did meta-analysis clarify the role and relevance of denial? Sexual Abuse: Journal of Research and Treatment, 12, 275-287. • Levenson, J. S. & Mcgowan, M.J. (2004). Engagement, denial and treatment progress among sex offenders in group therapy. Sexual Abuse: Journal of Research and Treatment, 16, 49-63. • Nunes, K. L., Hanson, R. K., Firestone, P., Moulden, H. M., Greenberg, D. M., & Bradford, J. M. (2007). Denial predicts recidivism for some sexual offenders. Sexual Abuse: A Journal of Research and Treatment, 19, 91-105.

34. Bibliography (Cont.) • Langton, C. M., Barbaree, H. E., Harkins L., Arenovich, T., McNamee, J., Peacock, E. J., Dalton, A., Hansen, K. T., Luong, D. & Marcon, H. (2008). Denial and minimization among sexual offenders: Posttreatment presentation and association with sexual recidivism. Criminal Justice and Behavior, 35, 69-98. • Nunes, K. L. & Cortoni, F. (2008). Dropout from sex-offender treatment and dimensions of risk of sexual recidivism. Criminal Justice and Behavior, 35, 24-48. • Yates, P. M. (2009). Is sexual offender denial related to sex offense risk and recidivism: A review of treatment implications. Psychology, Crime and Law, Special Issue: Cognition and Emotion, 15, 183-199. • Harkins, L., Beech, A. R. & Goodwill, A. M. (2010). Examining the influence of denial, motivation and risk on sexual recidivism. Sexual Abuse: Journal of Research and Treatment, 22, 78-94.

35. Bibliography(Cont.) • Pake, D. R. & Wilson, R. J. (2010). Normative data set for evaluating civilly committed sexual offenders using the Denial and Minimization Scale (DAMS). Open Access Journal of Forensic Psychology, 2, 379-395. • Levenson, J. S. (2011). “But I didn’t do it!”: Ethical treatment of sex offenders in denial. Sexual Abuse: Journal of Research and Treatment, 23, 346-364. • Looman, J., Abracen, J. & Ghebrie, S. (2012). Denial and recidivism among high risk, treated sexual offenders. Poster Session at 2012 ATSA conference,

36. Contact Information Jackson TayBosley, Psy.D. Clinician Administrator Specialized Sexual Offender Treatment Services Rutgers University Behavioral Health Care Whittlesey Road P.O. Box 863 Trenton, New Jersey 08625 (201) 259-5228 (609) 984-6280

37. DENIAL • James R Reynolds, PhD(908)872-3099jimrey1@gmail.com

38. Marshall et al (2010) note that it:“is now generally accepted in the field of sexual offender treatment that denial is not a relevant treatment target because of the fact that it does not predict reoffending (p 120)”

39. What’s the Problem: Determining Denial Comparing an offender’s account to the victim’s account of the offense is problematic for several reasons: Victims make mistakes Innocent individuals confess and plead guilty Innocent individuals are convicted

40. Problem: Polygraphs cannot identify the truth • Polygraphs cannot sort the truth from mistakes, exaggerations, false confessions, pleas, and accusations • Research varies regarding the effectiveness of polygraphs • Rate of error ranges from 10 to 50 percent depending on the subject and type of polygraph used.

41. Does kicking people out of treatment due to “denial” solve the problem? • Smith, Goggin, & Gendreau, 2002 Conclusions: • Incarceration sanctions did not produce decreases in recidivism • there were tentative indications that increasing lengths of incarceration were associated with slightly greater increases in recidivism

42. History of Full Disclosure RequirementBehaviorism - Deviant sexual activities reflect deviant sexual interestsModifying sexual interests requires full disclosure to be effectiveRelapse Prevention – Identify ALL risky situations needed to be effectiveNo evidence that full disclosure correlates with lower reoffending

43. Remaking Relapse Prevention and Treatment Paradigms Research not supportive of RP as effective model except for those who “get” treatment Influence of positive psychology Good Lives Model Motivational Interviewing

44. Positive Psychology Strengths-based Approach oriented - not avoidance Supports autonomy, relatedness, and competence Embraces resilience Focuses on protective factors

45. Good Lives ModelNine Key Areas Optimal Health Knowledge Mastery in Work/Play Autonomy Inner Peace Relatedness Creativity Spirituality Happiness

46. Motivational Interviewing Collaboration Evocation Autonomy Express Empathy Enhance ambivalence Roll with resistance Support self-efficacy

47. Does Kicking People Out of Treatment Solve the “Denial” Problem? First do no harm Now that these “deniers” are worse From incarceration… From being noncompleters… Let’s start treating them in the community…

48. Levenson 2011 Analysis Methodology problems To reject deniers from treatment is to prevent an opportunity for change, and might be unethical. On the other hand, some might argue that it is difficult, if not impossible to treat a client for a problem which he says he does not have, and that to do so might be unethical.

49. Harkins, Beech, & Goodwill, 2010 What Else May Be Going On? Believe self to be low risk DECREASED recidivism Believe self to be high risk INCREASED recidivism

50. Why Might Denial Mitigate Risk? Perhaps denial is actually a healthy response to offending. The offender denies because he knows that sexual assault is wrong and it is his shame and concern about the perceptions of others that lead him to deny the crime.