Friday, September 9, 2022

Setting the Standard for Disclosure in Treatment

By David S. Prescott, LICSW

Recent weeks have seen at least three discussions in various forums of how – and whether – to treat individuals who are denying, minimizing, or simply don’t want to discuss their past behaviors. Where exactly do we set the bar for entering treatment? When one provider has stated strong recommendations for treatment that involves possible risks to others, is it ethical for another provider to treat something else at the client’s request, thereby very possibly not addressing what appear to be the more serious issues? Many practitioners have asked how they can hold a client accountable when they severely minimize their behaviors.

It's important to say from the outset that there are no clear answers, only more questions. Some programs require that clients be ready, willing, and able to discuss their past behaviors from the outset. All other things being equal, this can be unassailably standard practice, particularly in settings that can’t provide treatment to everyone who is referred. Of course, one might well ask: Are we missing opportunities to reduce risk among others who may look at first like they are denying or minimizing their actions when just below the surface they want to change but don’t yet know whether they can trust the treatment process.

The landmark 1998 meta-analysis by Karl Hanson and Monique Bussière found not only that denial was not a risk factor, but that failure to complete treatment is correlated to increased risk for sexual re-offense. The revelation that denial did not emerge as a risk factor continues to surprise professionals entering the field to this day, and many interesting papers have resulted from this finding. With some smaller exceptions, this overall finding has not changed. However, taken together, accepting someone into treatment who denies their offense and then terminating them adversely when they don’t confess may actually increase whatever risk is present. A more balanced approach is needed.

To that end, a number of approaches have emerged. In 2012, Ware & Mann recommended viewing disclosure as a process and not necessarily an event. They observed that there are many reasons why a person might not readily take responsibility for their actions and argued that over-emphasizing disclosure might actually be harmful. Still, clients who deny or minimize their actions can often be turned away by treatment providers who find their denial morally objectionable. Much has been written on these issues, including a recent paper by Ware & Blagden (2020).

One psychologist, in a recent training, summarized his thoughts about working with high-risk clients: “If they can disclose anything about what was happening at the time of their crime, I can work with them.” Others have described how working on the various criminogenic needs of each client even in the absence of disclosure might be sufficient to reduce risk (although one could not call it “abuse-specific treatment”).

What options are there? While a blog post cannot adequately cover what is available throughout the literature, some ideas for moving forward include:

Starting by conducting an assessment. In the arena of treating drug and alcohol use disorders, it is well known that simply engaging in an assessment can reduce substance use. Explorations around what it would mean for the client and their loved ones if s/he did disclose might yield useful avenues for further discussion. Some motivations for not disclosing are easier to overcome than others.

Likewise, it may simply be the case that the client becomes willing to disclose more information as the therapeutic process unfolds.

The therapist can use their knowledge of risk domains (for example, impulsivity, negative emotionality, suboptimal coping skills, etc.) to help the client build strengths that may protect against any further offending.

Important to remember is that simply being in treatment means that there is someone in the client’s life who can help them be aware of warning signs that something bad might be imminent (emotional collapse, financial issues, collapse of social supports, escalations of negative mood, etc.).

Even absent any discussion of past crimes, therapy could be a venue for discussing sexual health and responsibility, masculinity/femininity, etc. Building strengths in these areas could be a further protective factor.

What is that compelling treatment in the absence of any agreement on treatment goals or methods is likely doomed from the start. Further, a 2008 meta-analysis found that more coercive treatment methods were less likely to work.

In the end, each program and professional needs to confront many questions, including the potential harms of denying treatment to people who might benefit from it, and to what extent our own attitudes and beliefs may prevent effective treatment provision that can benefit clients, the community, and those who have been victimized alike.





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