There are many terms that address the notion of truthfulness within the context of assessment, treatment and rehabilitation, including denial, problem minimization, misrepresentation and equivocation. The prevalence of denial among patients and offenders is extensively discussed in the psychological literature (Marshall, Thornton, Marshall, Fernandez, & Mann, 2001; Brake & Shannon, 1997; Barbaree, 1991; Schlank & Shaw, 1996). The impact the Truthfulness Scale score has on other scale or test scores is contingent upon the severity of denial or untruthfulness. In assessment, socially desirable responding impacts assessment results when respondents attempt to portray themselves in an overly favorable light (Blanchett, Robinson, Alksnis & Sarin, 1997).

Awareness of truthfulness scales (measures) increased with the release of the Minnesota Multiphasic Personality Inventory (MMPI) almost six decades ago. Soon thereafter, socially-desirable responding was demonstrated to impact assessment results (Stoeber, 2001; McBurney, 1994; Alexander, Somerfield & Ensminger, 1993; Paulhus, 1991). Truthfulness Scale conceptualization began in earnest with the idea of self-response accuracy. Test users wanted to be sure that respondent's self-report answers were truthful. Evaluators and assessors need to know if they can rely upon the test data being accurate. In other words, can the respondent's self-report answers be trusted? Research also shows that truthfulness is a factor in diagnosis, treatment effectiveness and recidivism. Because denial is thought to be an important component of assessment and rehabilitative outcomes, various measures have been developed to augment its identification (Schneider & Wright, 2001; Eccles, Stringer, & Marshall, 1997). While some assessments focus on general truthfulness (denial) and others are specific to an offense or problem (Tierney & McCabe, 2001), before denial can be addressed and worked through, it must first be identified.

Client (patient or offender) truthfulness has been associated with more positive treatment outcomes in some individuals (Barber, et. al., 2001; Simpson 2004). Problem minimization has also been linked to lack of treatment progress (Murphy & Baxter, 1997); treatment dropout (Daly & Peloski, 2000; Evans, Libo & Hser, 2009); and offender recidivism (Nunes, Hanson, Firestone, Moulden, Greenberg & Bradford, 2007; Kropp, Hart, Webster & Eaves, 1995; Grann & Wedin, 2002). Some researchers (Baldwin & Roys, 1998; Grossman & Cavanaugh, 1990 Haywood & Grossman, 1994; Haywood, Grossman & Hardy, 1993; Nugent & Kroner, 1996; Sefarbi, 1990) have suggested that client denial should be eliminated prior to commencing treatment, whereas others argue that offenders should not be excluded from starting treatment due to their denial (Maletzky, 1996). Despite different views on the role of denial at treatment intake, reductions in denial are associated with increased likelihood of treatment success (O'Donohue & Letourneau, 1993). Denial reduction methods include use of survivor reports, directed group work, or addressing cognitive distortions that may cause denial (Schneider & Wright, 2004). Historically, traditional treatment methods (especially in substance abuse treatment) were intense, confrontational and stress-inducing with the goal of breaking down client denial and resistance, however, more contemporary treatment models often take a more non-threatening approach (Sciacca, 1997.)

Study and treatment of sex offenders very often incorporates identifying and addressing denial (Schneider & Wright, 2004). Most people are reluctant to discuss their sexual behavior, so researchers often expect adults to underreport sex-related behaviors. This is further complicated by socially-desirable responding, which may be a factor in why some age and ethnic groups can be prone to over-reporting sexual behaviors (Alexander, Somerfield & Ensminger, 1993). A key factor that can impact socially-desirable responding in terms of sexual behavior is the type of terminology used in test items. Some age and ethnic groups respond more openly to sex-related questions when anatomical terms are used as opposed to vernacular (Brenner, Billy, & Grady, 2003). Because sexual behavior is a sensitive topic, a test that specifically assesses respondents' truthfulness and denial in terms of sex-related test items is particularly useful in sex offender assessment (Khandaker, 2010).

The concept of denial in sex offenders can take many forms, including classifying offenders in terms of whether or not they are in denial, or viewing denial in various forms and dimensions, e.g. denial of the offense, denying that they need treatment, denouncing that harm was caused to the victim, denial of intention to commit the offense, etc. (Gibbons, Volder & Casey, 2003). Barbaree (1991) defined denial and problem minimization as different levels of the same self-protective cognition. Denial is categorical and extreme refutation of facts, whereas minimization is associated with shifting responsibility, making excuses or downplaying the impact of their offenses on their victims (Barbaree, 1991).

In their 1995 study, Happel and Auffrey found that incarcerated sex offenders that admit to their sexually deviate behavior and sex offenses are a rarity. Sex offenders tend to rationalize their behavior by blaming the victim or by claiming that their victims somehow benefited from being sexually victimized. Fear of disapproval from others, shame, guilt and avoidance of responsibility are other factors associated with sex offender denial (Happel & Auffrey, 1995). Whether a sex offender denies or accepts responsibility for their deviate behavior is indicative of their motivation to actively participate in treatment. In some sex offenders (i.e. child molesters), denial can occur in the form of cognitive distortions that are believed to play a role in sustaining sexually deviant behaviors (Marshall & Eccles, 1991). Winn (1996) emphasizes that it is important for mental health professionals providing therapy to sex offenders to remember that denial is often a reflex of self-preservation. Many people in general, including sex offenders do not react positively to confrontation and denial is a subconscious or conscious means of self-protection. Viewing lack of truthfulness as a protective behavior can facilitate finding effective ways to address it (Winn, 1996). Assessing denial over the course of treatment also has heuristic value in that it can help staff maintain treatment focus (Newsome & Ditzler, 1993).

As multidimensional as denial is (Barrett, Sykes, & Byrnes, 1986; Brake & Shannon, 1997; Happel & Auffrey, 1995; Laflen & Sturm, 1994; Langevin, 1988; Orlando, 1998; Salter, 1988; Trepper & Barrett, 1989), truthfulness is equally multifaceted. Yet, client truthfulness (and denial) is integral to accurate assessment, testing and evaluation, and to effective treatment and rehabilitation. Consequently, truthfulness will continue to be studied in the future.

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