Given that I thought I’d cultivated my listening skills, it was uncharacteristic of me to so abruptly interrupt a patient who felt compelled to plead his court case of a criminal charge in group therapy. We in group, of course, were experiencing the very common occurrence of denial.

As part of a program in a largely forensic mental institution, our clinicians are primarily working with individuals convicted of some offense and admitted under the “guilty except for insanity” (GEI) determination. More specifically, my team’s sex offender treatment program works with those who have a sex offense conviction in their history and/or have been sexually assaultive or otherwise sexually inappropriate in the hospital.

Yet to take it out of the forensic arena, most counselors will have any number of client cases in which some form of denial may also play a central role. We see denial and so-called “resistance” in couples counseling, in family counseling and when working with any age and circumstance. We witness denial in issues of death and dying or with clients and families dealing with serious or terminal illness. And what counselor working in the drug and alcohol, gambling and other addictions field wouldn’t agree that denial is a hallmark in that client population? Ultimately, whatever level of denial we experience may be perceived as resistance and a barrier to treatment.

 

There are all kinds

While there are multiple types and levels of denial, most are ultimately rooted in avoiding or mitigating responsibility and accountability, generally more along the lines of minimizing or redefining behavior. Yet I have worked with some clients who engage in denial of facts, especially in the initial sessions. This is the classic denial of their offense or some other behavior. It’s also the very common default or impulsive defense mechanism among many of us, especially at a young age (“No, I didn’t break that window”).

In the case of the patient I interrupted, he not only denied the offense (a rape charge), he also denied any transgression in his entire life. Further, he was more focused on pleading his case with the group members and clinicians than on his treatment.

More common, however, are all the other types of denial. Many sex offenders with whom I have worked will engage in denial of impact or harm (“I only fondled her”), even if they admit to their offense. I see this often in cases of attempted rape, wherein the prevailing, and mistaken, attitude is often that there is less trauma if there was no penetration.

Yet we see that same perspective in other forms of rationalization (“Children are resilient; he’ll forget it”), in couples and family disagreements (“It’s always drama with her, so we don’t take her threats of suicide seriously”) and with other situations. Those who work with grief and bereavement will very likely identify with the upset client whose friends, family members or other acquaintances deliver minimizing and rather dismissive statements such as “time to move on,” “don’t dwell on it,” “get over it” and, of course, the trite “time will heal.”

Denial of intent is another common excuse (“It got out of control”). In my work, I’m often subjected to a curious phrase regarding date rape: “There we were … and it just happened,” thus jettisoning the fantasizing, the grooming and all the other behaviors that led up to a life-altering result.

Denial of responsibility, which is related to denial of intent, does not necessarily deny behavior, but is more along the lines of shifting blame. An example most of us have heard, particularly in working with children, is “He started it first.” In a more bizarre example, however, I had a client who was talking about a college female who was raped. His comment was, “Well, it happened in a fraternity. She should have known what was going to happen because that’s what happens at frat houses.”

There are many other types of denial, of course, including a minimizing form — denial of frequency (“It only happened once”) — and denial of fantasy (“I only fantasize about my girlfriend in a healthy way”). That fantasy example was voiced by a hypersexual patient who had molested many young boys over the years. He was engaging in impression management to impart an image of his engaging only in appropriate fantasies.

 

Do I really need this?

One important form of denial affects almost all counselors and other clinicians: denial of treatment need. Many clients with whom I’ve worked say, “I’ve learned my lesson. I’ll never do that again.” While they may genuinely believe that, what they’re overlooking is that they may not have examined the circumstances that led to their offenses, their triggers and risk factors and, thus, what interventions to use. Yet this type of denial isn’t the sole property of those who have engaged in some form of criminal activity.

Many counselors in various settings deal with individuals who have been “coerced” into making appointments. It may be someone with gambling, alcohol or other addictions forced into treatment by families, friends or even a workplace supervisor. It may be someone who had a “dirty” urinalysis at work and was suspended until he or she engaged in some mandatory employee assistance program (EAP) sessions. Few of these individuals show up feeling the need for treatment, especially if it was not their choice.

Often, resistant clients show up in family counseling. These may be teenagers or others with behavioral issues, or a spouse with relationship problems, depression, sexual dysfunction or other presentations. Many of these clients feel that they don’t need counseling, or even if they agree to the need, they are embarrassed to be seeking mental health counseling. Stigma exacerbates a natural tendency to deny.

Many of the individuals pushed into counseling may feel that the problem is with their partner, their parents or with other relatives or friends. Even among those who admit to some level of treatment need or recognize a problem, many prefer to participate in the multibillion-dollar self-help industry of books and videos. Yet is that so very different from those who deny a disease or who think that they can lose weight or otherwise regain some level of health on their own through use of a book or video? The question remains whether an individual who feels confident in self-healing is still engaging in a form of denial. Perhaps so, but with placebo or other effect in place, does it matter if the outcomes are positive?

It may be important to explore why denial occurs in our clients, but a key question is whether denial is a deal killer in treatment. It may seem, for instance, that working with an offender who denies his or her crime is a barrier, but there are many who would disagree with that premise.

 

Does it matter?

In the world of sex offender treatment, most community-based and residential programs in the United States consider taking responsibility for offenses a key component of treatment. That would be defined as a disclosure or admission at least approximating police and victim reports, even if the offender minimizes or engages in other forms of denial. Use of polygraphs is also a common practice. In fact, it is generally a condition of parole.

By comparison, no Canadian sex offender programs require full admission of guilt, and one report indicates that only approximately 26 percent of Canadian community-based programs require any offense disclosure at all (McGrath, Cumming, Burchard, Zeoli, & Ellerby, 2010). That may seem counterintuitive. After all, how can one deal with any situation — whether offense-related or not — if the client denies its occurrence? The answer may rest in what we as clinicians are seeking, both in mining for information helpful in therapy and as an outcome.

But does it matter? While it would seem logical that issues are difficult to address if denied, in the sex offender world at least, data are indicating very little correlation between denial and recidivism. Some, in fact, would point out that denial is an indicator that the offender is well aware, and ashamed, that the act was inappropriate or deviant, in addition to being illegal. In such cases, perhaps our clinical attention is distracted by their denial and should be emphasized elsewhere (e.g., social skills, healthy relationships, etc.).

For those clinicians who believe that client denial does matter, some point to other contributing factors to denial, including the milieu. For instance, in group therapy, it’s reasonable to believe that initial denial would be both common and understandable, particularly with an individual newly introduced to the group. Safety and trust must generally be established. It’s the rare client who is willing to share his or her failures in front of strangers.

Yet one source of help is when the newer clients in group realize that there are others in the same boat, that they’re not alone and that there is support. While this is one of the many advantages of group therapy, a step-up approach with motivational interviewing and alliance-building in individual sessions may be required.

Even in smaller situations such as couples counseling, the sharing may be difficult at first. Yet there are also other dynamics involved in couples and family counseling, such as clients seeking support for “their side,” the fight over “right and wrong,” couples utilizing other techniques (e.g., manipulation) and the perceived or actual issues (even if they aren’t obvious to the clients).

 

Who’s responsible?

It’s far too easy for many of us to say that a client is “in denial” or “resistant.” As stated earlier, many U.S.-based sex offender programs require accountability, including reasonable admission of offenses, with the implication that treatment could be withheld if the offender refuses or resists.

Whether or not it matters may be determined on an individual basis. If it is deemed important, and if there is resistance, might this not be a responsivity issue? And if so, should we not be responsible ourselves as the clinicians?

Our program here is on a risk/needs/responsivity model. Simply put, higher-risk patients receive more intense treatment than those assessed at lower risk. Patient needs, including dynamic risk factors, are addressed as important factors in treatment. Responsivity is an indication of the patient’s response to and/or acceptance and digestion of the treatment approach, as well as a measure of the clinician’s ability to provide the service that will be most accepted.

So while we may feel justified in indicating that a patient’s intransigence is a barrier to treatment, are we not responsible on some level for treatment failure if we are not experiencing a response? And if we assume that responsibility, is it not our task to continue the search for treatment to which the patient may respond? Can we achieve a measurable outcome even in the face of denial? Obviously, some programs believe so. But how?

In a forensic setting, we’re seeking risk mitigation — simply put, to achieve a goal of returning the patient to the community without that individual committing another offense. But can risk mitigation be achieved even if the patient refuses to take responsibility for his offenses? Perhaps so if we’re able to work with the patient to discuss all the circumstances and other factors surrounding the offense. I call this the “backdoor approach.”

For instance, if a patient is willing to discuss what was going on in his or her life prior to, during and even after an offense — even without admitting to an offense — we may be able to identify and point out behavioral patterns and/or circumstances that would be considered potentially contributory to an offense. For example, while not necessarily an excuse for offending, if the patient states that he or she was on methamphetamine or other substances, a risk factor emerges.

I have had patients indicate that their offenses occurred after a break-up or during a rough period in a relationship. Regardless of whether one believes that watching pornography is pre-offense behavior, many have indicated that they turned more and more to porn after a break-up or during a period of no sexual activity, and sought other outlets. Alcohol and drug use has been cited as one of the more common outlets.

Of course, in our setting in a mental institution, there are also contributory situations of a patient going off medication or otherwise decompensating, leading to offense-related behavior. Stress and other situations can be explored, patterns noted and, thus, risk factors identified. Even in cases in which the offense is denied, the patient is often able to see what situations set up as being more risk-related scenarios — and thus their vulnerabilities. Risk mitigation can then be effected on some level by addressing the vulnerabilities through appropriate interventions.

This same approach would be viable in couples counseling, family counseling and other similar forms of counseling. In short, we can examine environmental and other issues that trigger emotions, thoughts and consequential behavior in our clients. This approach relates to a form of mindfulness in which clients can step away and look at external influences, perhaps setting aside blame and personalized issues in the process.

 

Ethical issues

While considering the reasons for denial, and strategies to achieve some outcome, the topic is not without some ethical issues. The preamble of the 2014 ACA Code of Ethics reads in part:

“These professional values provide a conceptual basis for the ethical principles enumerated below. These principles are the foundation for ethical behavior and decision making. The fundamental principles of professional ethical behavior are

• autonomy, or fostering the right to control the direction of one’s life;

• nonmaleficence, or avoiding actions that cause harm;

• beneficence, or working for the good of the individual and society by promoting mental health and well-being;

• justice, or treating individuals equitably and fostering fairness and equality;

• fidelity, or honoring commitments and keeping promises, including fulfilling one’s responsibilities of trust in professional relationships; and

• veracity, or dealing truthfully with individuals with whom counselors come into professional contact.”

In attempts to deal with denial, are there iatrogenic factors present in our demand for disclosure that would constitute maleficence? And where do we stand, and how would we know, if the person indeed did not commit an offense? If, in our cases, a denier passes a polygraph, does that carry any weight, notwithstanding admissibility (or not) in court, police reports or other materials?

Would it be ethical to “treat” someone for something they did not do; or do we treat based upon all the other findings, regardless of the client’s adamant stance? Are we out of our scope of practice if drawn into the legal questions? We must be mindful of these ACA ethics standards:

 

B.1.b. Respect for Privacy

Counselors respect the privacy of prospective and current clients. Counselors request private information from clients only when it is beneficial to the counseling process.

 

B.1.c. Respect for Confidentiality

Counselors protect the confidential information of prospective and current clients. Counselors disclose information only with appropriate consent or with sound legal or ethical justification.

 

B.2.e. Minimal Disclosure

To the extent possible, clients are informed before confidential information is disclosed and are involved in the disclosure decision-making process. When circumstances require the disclosure of confidential information, only essential information is revealed.

 

These questions may all lead to what boundaries we draw regarding working with denial. It is likely an easier decision when there is no denial of fact, but rather the more often expected “lesser” denials. Yet, as in all cases, we must consider potential iatrogenic effects. When we consider how very much we detest denial in our society, and yet forgive confession, it behooves us to explore our goal as counselors when denial is a key factor.

We might want to examine whether our goal is an outcome we can achieve by other means, or whether we are so outraged at the “lies” that we become committed to “breaking” someone.

 

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Michael Hubbard is a mental health specialist with the sex offender treatment program at Oregon State Hospital in Salem, Ore. Contact him at Michael.Hubbard@state.or.us.

 

For related reading, see Hubbard’s article from the April 2014 issue of Counseling Today: Sex offender therapy: A battle on multiple fronts