Open Letter to Nick Smith, Minister for ACC

A letter from the New Zealand Association of Psychotherapists

ACC Changes in Funding of Sexual Abuse Counselling

24 August 2009

Dear Minister, we speak for the members of the New Zealand Association of Psychotherapists as well as for other counsellors and therapists who have lent their support to presenting this document to you.
Over the last two weeks ACC has presented providers of sexual abuse counselling and psychotherapy services with imminent changes in delivery of sexual abuse counselling effective from 14 September 2009. These changes have been made without consultation with relevant professional bodies. Even groups that have been in dialogue with ACC about improving services (TOAH NNEST: Te Ohaakii a Hine-National Network Ending Sexual Violence Together, and SCAG: Sensitive Claims Advisory Group) have not been consulted.
The planned changes have sent shockwaves of disbelief through the counselling/therapeutic and survivor communities. The Minister for ACC will have been aware of these changes. We would like the opportunity to present a different point of view and have some vital questions answered.

Legacies Of Childhood Sexual Abuse (CSA)
Sexual abuse takes many forms, it can be a single episode involving someone who is ordinarily healthy and well functioning; it can be multiple episodes in the context of physical violence; it can take place in childhood over long periods and in single episodes. Our concern, in addressing the proposed ACC changes, is mainly with those who suffer most deeply from the experience of abuse, most especially those who have suffered abuse as children or from continued abuse as adults. This is not to minimise the effects of frequently highly traumatic events occurring to adults.
The sexual abuse of children causes the arrest or disruption of the development of the self leading to complex clinical presentation of impaired performance of ‘self-functions’ such as cognition, autonomy, selfresponsibility, emotional regulation, distress tolerance, identity, and social functioning (1) (2) (3) (4). For this reason the onset of abuse is significant (earlier onset leads to more severe problems) whereas people who are abused later in life show less severe problems. Survivors receiving counselling or therapy early in childhood show little or no disturbance later on. When CSA goes untreated survivors problems accumulate over the years leading to impairments in self-regulation, social functioning, occupational functioning, cognitive disturbances due to abuse-based beliefs, and shattering of internal psychological functioning. The cost of sexual abuse to the individual and to New Zealand society was estimated in 2001 to be $2,465m annually (5) and is probably higher for 2009.

ACC’s Responsibility For Victims Of Sexual Abuse
Independent of the question as to whether ACC is the best agency to provide services for survivors of sexual abuse, current regulation (IPRC 2001) demands that ACC “is to enhance the public good and reinforce the social contract represented by the first accident compensation scheme by providing for a fair and sustainable scheme for managing personal injury that has, as its overriding goals, minimising both the overall incidence of injury in the community, and the impact of injury on the community (including economic, social, and personal costs)”

Comment: Under the proposed changes ACC will not meet required responsibilities set out in the act! According to ACC 's injury statistics counselling/medical fees are about $2m for 2008 (6). The costs of financial entitlements such as Independence Allowance and Weekly Compensation raise the total claimantrelated costs to $19m. Costs for running the Sensitive Claims Unit alone are about $30m. It is clear that the costs of adMinistering the organisation exceed by far the services it is supposed to fund.

Question For The Minister: How does the Minister justify the expenditure of a system where the administration of services is 1 ½ times the cost of the service it administers; and where is the Minister’s commitment to improve funding for services and prune the top-heavy administration?

Comment: To make huge changes in the recovery pathways of mainly female victims of sexual abuse by relying only on one study which was funded by ACC is highly questionable. A study burdened with such funding bias can hardly be deemed trustworthy (7).

Comment: Studies conducted by world experts (1) (8) (2) (9) (10) (3) (11) as well as New Zealand research (12) have delivered evidence that the therapy relationship is the main factor behind positive outcomes. The provision and/or restoration of social support is a major buffer against the destructive force of stress and trauma. Social support and closeness with others helps survivors with the integration of difficult experiences and are vital for survivors’ recovery (3) (12) (13). “Emotional attachment is probably the primary protection against feelings of helplessness and meaninglessness; it is essential for biological survival in children, and without it, existential meaning is unthinkable in adults”(11).
Within the therapeutic relationship survivors’ recovery involves the (re)establishment of trust, development of self-confidence, development of social connections, meaning, hope, and self-agency. This will and always has taken time (2). These qualities can not be gained through a drug, a book, or in short term work of a few months. Recovery from sexual abuse can not be compared to a broken leg which heals by itself in 6 weeks. Recovery from sexual abuse takes place through caring and supportive interactions with others (2) (14) (12). However, these studies seem not to have been considered or given adequate weight.

Question For The Minister: How is the Minister going to convince the public and survivors of sexual abuse that he has considered a broad range of paradigms before he sanctions budget cuts that will impact detrimentally on CSA victims’ quality of life?

Much of the research that leads to a preference for short term intervention focuses on isolated symptoms i.e. depression without looking at underlying causes. This may work in controlled situations where study participants are carefully selected to meet well-defined inclusion and exclusion criteria; it is certainly not working for many survivors of CSA. That this paradigm is not working for survivors of CSA is shown in the public mental health system (32)(12). Between 50-80% of patients in psychiatric care have a history of sexual abuse that is not acknowledged and not considered in their treatment (15) (16) (17)(33). Public mental health treats symptoms e.g. depression with drugs and short term therapeutic input (if at all), a route ACC is now proposing. The ballooning costs for mental health show that this approach is not very effective. Instead patients are sentenced to a life of misery and poor social and occupational functioning. (12)

Comment: Up to this point ACC has failed to explain on what grounds the decision has been made to propose and then hurriedly push through a change in clinical pathway especially as ACC has not collected any outcome data regarding the quality of currently provided counselling services. (18)

Question For The Minister: What is the Minister’s basis for the assumptions that the current clinical pathway is not satisfactory?

Survivors of sexual abuse are marginalised in the following ways according to the statutes of the act:

1. establishing as a primary function of the Corporation the promotion of measures to reduce the incidence and severity of personal injury:

Comment: ACC has cut the funding for prevention education from $170,000 2006/2007 to $27,000 estimated for 2008/2009 (19).

Question For The Minister: How does the Minister explain these cuts given John Key’s speech (15) in April 2008 at the Sensible Sentencing Trust Victims Conference where he promised substantial increase of funds for victims of crimes? Are CSA survivors no longer considered victims of crime? How is the Minister going to justify the continuous victimisation of CSA survivors?

Comment: The new scheme requires vulnerable clients to visit three different therapists in the first five sessions. Research has shown that attending assessments and telling one’s sensitive and painful life story to a stranger is retraumatising (12).

Question For the Minister: How will the Minister guarantee that the process will not increase the severity of personal injury?

2. Providing for a framework for the collection, co-ordination, and analysis of injury-related information:

Comment: The client is required to reveal sensitive personal data to three different professionals in the first five sessions. Not only has research shown this to be re-traumatising (12), it also violates clients’ rights to privacy (Right 1 + 7 ACC Code of Claimants Rights) and the IPRC 2001 Act. Being granted a maximum of 16 hours (of which four will be for discussing progress reports) will effectively end the hope of recovery from CSA for many and will mean great struggle for survivors. This violates the IPRC 2001 Act that requires that the primary focus of ACC should be on rehabilitation to restore health, independence, and participation.
The assessor/provider split has been favoured by many managed care agencies overseas because it alleviates bureaucrats’ fear of assessment bias (therapists could over-diagnose to feather their own nest). Besides being insulting and causing significant interference with the therapeutic process (12) (20) (21) (22), assessor/provider split is not practical because the therapist responsible and liable for the outcome of treatment will need to make their own assessment and plan the treatment to work effectively.

Question For The Minister: How does the Minister envisage the clients being kept safe? Who should, according to the Minister, be liable and responsible for potential self-harm, suicide or psychiatric emergency, or any other form of harm that could befall the client?

3. ensuring that, where injuries occur, the Corporation's primary focus should be on rehabilitation with the goal of achieving an appropriate quality of life through the provision of entitlements that restores to the maximum practicable extent a claimant's health, independence, and participation:

Comment: Childhood sexual abuse (CSA) causes the arrest of self-development and interrupts healthy selffunctions leading to common symptoms such as mood disorders, anxiety disorders, or dissociative disorders (1). Ethical and professional practice has to address the cause of the symptoms to assure lasting improvement. A treatment protocol based on symptom reduction will not be able to rehabilitate clients with self-disturbances (1) (12) (3). Cancer is not treated with paracetamol, although it may help with the headaches.
Trauma specialists have conclusively demonstrated that persons abused in their childhood suffer complicated problems that often require long-term treatment (1) (19) (7) (3). About 90% of counselling for sexual abuse in New Zealand has been provided by counsellors and psychotherapists (18) in the last 20 years. They unanimously agree that it will be impossible for most survivors of CSA to complete their rehabilitation within 20 hours. They have delivered good and cheap services which in 2004/05 did not even come near $1m. (12) That deserves respect and not the patronizing restrictions imposed by ACC.

Question For The Minister: How does the Minister justify the marginalisation of two respectable professions who have done 90% of the CSA work in the last 20 years by refusing them their due recognition? How does the Minister justify that counsellors and psychotherapists are regulated by psychologists and psychiatrists, two professions who don’t even have sexual abuse training in their compulsory training curriculum and whose practical experience is limited to only 10% of the total ACC work? Furthermore, how will the Minister justify survivors of sexual abuse not being given the opportunity for recovery and thereby passing on the detrimental effects of trauma to their children?

4. ensuring positive claimant interactions with the Corporation through the development and operation of a Code of ACC Claimants' Rights:

Comment: According to the IPRC, Section 27, a mental injury means a clinically significant behavioural, cognitive, or psychological dysfunction. This is interpreted by ACC as “Mental injuries (as defined in Section 27 of the IPRC Act) must meet the criteria outlined in “The Diagnostic and Statistical Manual (DSM-IV™) of the American Psychiatric Association" in order to be eligible for ACC cover”.

Question For The Minister: Who authorised ACC to convert a clinically significant dysfunction into a DSM-IV diagnosis?

This effectively excludes survivors from accessing ACC funding for counselling who may have significant impairment in daily functioning yet not qualify for a DSM-IV diagnosis. Those who do fit DSM criteria will be disadvantaged and could be re-traumatised by seeing numerous health workers, being offered limited time with a counsellor, and then being referred on to public mental health services who even now don’t have the capacity to address CSA.
Receiving a diagnosis of mental illness is also problematic because it effectively shifts the responsibility for abuse away from the perpetrator (a crime was perpetrated causing a context specific response) towards the victim (she needs to see a shrink, she is crazy) (2). Failing to place psychiatric disturbances in the context of abuse is discounting the violation and injustice survivors have experienced (2) (20). Both the discounting and the pathologising of their trauma symptoms by attaching the label of mental illness is a withholding of survivors’ rights to have the injustice of the abuse recognised and to receive treatment that leads to recovery (12) (23).

Question For The Minister: How does the Minister justify that victims of sexual abuse are discriminated by being labelled mentally ill?

5. ensuring that persons who suffered personal injuries before the commencement of this Act continue to receive entitlements where appropriate.”

Comment: After 16 hours of therapy/counselling the client will be referred to public mental health service who don’t provide counselling, or to a psychologist for a maximum of 10 hours focused work. The new changes do not guarantee that clients will receive their due entitlements for recovery. Clients do not primarily seek financial compensation, they seek to be able to live a life worth living. The new scheme does not provide that opportunity.

Question For The Minister: How does the Minister plan to respond to victims of CSA who struggle to make ends meet financially, mentally, and emotionally knowing that he has sanctioned the cut of services of mainly female victims of crime while other sectors receive additional funding?

Conclusion
Counselling and psychotherapy have a long history of practice embedded in ethical values that include commitment to the physical and emotional well being of clients, their right to confidentiality, privacy, selfdetermination, and a secure therapeutic working relationship (NZAP, 1986). As Saakvitne and Abrahamson stated “The goal of psychotherapy is to understand the complex meaning of psychological and interpersonal events, largely through the creation of meaning in the therapeutic relationship” (24). In working with those suffering mental injury from sexual abuse, psychotherapists work towards repairing the internal sense of self and functioning that has been shattered by abusive experiences.
Research has repeatedly confirmed that 40% of positive outcome in therapy is due to client factors, 30% is due to the relationship between client and therapist, 15% is ascribed to the placebo effect, and only 15% of outcome is due to therapeutic modalities, and training (25) (26). It is nonsensical to construct a complete new approach to dealing with CSA around a questionable benefit of 15% given that meta-studies have proven that all therapeutic approaches are equally effective as long as therapist and client can establish a working therapeutic relationship.
Improvement would not come about by restricting hours that are clinically justified but by enabling a collaborative working environment in which the different services recognise each others qualities and support each other in the fight against sexual abuse and child abuse. It needs to be kept in mind that counselling is not the big expense in the ACC Sensitive Claims Unit. Instead, the surveillance mechanisms put in place give very much the impression of paranoia that led to millions being spent to save $500,000. This does not make good business sense and would probably be impossible in the private corporate world.
Rather than setting up a complicated system of separate people doing assessment, treatment, and review of treatment those counsellors who do not already use assessment and diagnostic tools could be encouraged and taught to do so. Many psychotherapists who currently provide services to Sensitive Claims Unit are practiced in assessment and treatment planning.
Our concern is for the well-being of those who have been victims of abuse, as children and as adults. Counsellors and psychotherapists may feel some financial effect with the new regulations, but they will be able to compensate for any income losses they may suffer. The tragedy is that clients do not have that luxury. Unless they can afford to pay privately for their counselling, they will be marginalised being bereft of recovery from sexual abuse and the attainment of quality of life, something the Minister and many others who will read this paper take for granted.
It is not enough for the society to be horrified at the number of children who get abused and killed in this country. Society needs to set aside funds to help victims of sexual abuse to rehabilitate so they can provide for their children and grandchildren and break the hideous cycle of abuse.
We, the undersigned, request on behalf of the organisation we represent that the Minister halts the implementation of the proposed changes and meets with CSA survivors and with the representatives of those who have worked at the coal face of sexual abuse recovery to hear our views, to increase his understanding of the complexity of the problem, and to support policies that reflect the social responsibilities the government has towards victims of childhood sexual abuse.

Eileen Birch (President NZAP)
Susan Hawthorne (NZAP SCAG representative)
Dr Gudrun Frerichs
Miriam van Dingenen
Sean Manning
Ondra Williams
Lesley King
Suzanne Johnson (Chair of Public Issues NZAP Council)

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