ACC Changes – implications for survivors of sexual crime

A speech by Eric Medcalf delivered at Crossroads Community Centre, Wellington

Sexual abuse in New Zealand is a scandal. ACC pulling back on services for survivors is a scandal.
They say it’s because of the law – that’s a SHAM. They say it’s because of scientific evidence – that’s a SHAM.
It’s about cutting costs and bullying the vulnerable.
Dr Smith has said publicly that the government has no plans to change ACC services to victims of sex crimes - yet the corporation for which he has overall responsibility has stated publicly that it is its policy to reduce the number of sensitive claims.
It would be wonderful if this were through a concerted campaign of prevention, which is ACC’s statutory obligation.
“There is an urgent need for the implementation of programmes for the primary prevention of child sexual abuse, and the provision of support and treatment for women who have experienced child sexual abuse,” says Dr Janet Fanslow of the Auckland University Faculty of Medical Sciences.
But the facts are that ACC is doing this through policies in which it has made it much more difficult for victims of sex crimes to gain the support they need. This will have repercussions for the health of New Zealand.
The effects of sexual abuse are well known in relation to individuals, but individuals are also members of families, workplaces, social and community groups. Untreated psychological trauma has its consequences. It’s not surprising then that sexual abuse histories are over-represented in prison and mental hospital populations, that we get bullying in workplaces, family breakdowns, community violence and vandalism.

Some facts about sexual abuse in New Zealand
A study by the University of Auckland indicates that about one in four New Zealand women have been victims of child sexual abuse before the age of 15. In the majority of cases one perpetrator was involved, usually a male family member, and around half of the women had experienced the abuse on more than one occasion. The average age of the victim at the start of the abuse was nine years old, with the average age of the abuser being 30. 488,792 New Zealand women have been subject to childhood sexual abuse.

• Researchers think that 1 in every 4 girls will be molested before her sixteenth birthday. One out of every 9 boys will be molested. (The Sexual Abuse of Children: Facts You Should Know – Mental Health Foundation of New Zealand pamphlet)
• 4-10% of children physically abused and 11-20% of children sexually abused (New Zealand Children’s Social Health Monitor 2009)

Some information about the ways that ACC works
ACC is built upon the Woodhouse Committee of 1967. It is a “no fault” system based on five basic principles:

• community responsibility
• comprehensive entitlement
• complete rehabilitation
• real compensation
• administrative efficiency

(A lot of good came out of 1967, not just Sergeant Pepper, Jim Hendrix and the Cream.) To make a claim there has to be an accident and an injury – if you have an accident and no injury then ACC will not be interested. If you have an injury, but no accident then likewise.
In the case of sexual abuse and assault Parliament has made it possible for victims of sex crimes to able to gain treatment and rehabilitation on the basis that the crime constitutes the “accident”, as long as there is also a mental injury. Since this has been the case victims of sex crimes have been able to make claims on the basis that they have described what happened to them and have been assessed by a professional counsellor, psychologist or psychotherapist as having a “a clinically significant behavioural, cognitive or psychological dysfunction”. This would have been an assessment of impairment, not illness; observable ways in which a person’s ordinary functioning is significantly impaired by the psychological consequences of abuse.
ACC services for survivors of sexual crimes have been the jewel in the crown of ACC. Since the inclusion of sexual abuse crimes in the early 1980s many thousands of survivors of sexual abuse have received ACC-funded treatment and rehabilitation. This service epitomises the Woodhouse principle that the ACC scheme is not just about insurance, it is also a arm of social welfare policy, with the good of New Zealanders at its heart.
We are now in a climate of cost cutting in the public sector and of turning ACC from an arm of health and welfare policy to an American-style managed care insurance company.  This will have implications across the board for New Zealanders. In the US kids no longer play American football because the health insurers demand so much in premiums. What will that mean for New Zealand kids' sporting activities?
To repeat myself: Dr Nick Smith has repeated stated that the National Government has no cost cutting agenda for ACC’s cover for mental injuries arising from sexual abuse. Yet ACC has publicly stated that it is their policy to reduce the number of sensitive claims. They are doing this by making it more difficult for survivors of sexual crimes to make a claim to ACC. ACC are:

1. Insisting on a full psychiatric diagnosis – citing a legal judgement which, they say, obliges them to do this.A diagnosis is a clinical tool to be used carefully and safely. It is not a legal test. This must be questioned by the lawyers and the law makers. Very few people will be available to make this diagnosis. To do this properly requires not only training in diagnostic procedures but also significant experience in sexual abuse treatment. This shortage will make it very difficult for survivors to gain access to these assessments, if they are not put off in advance by the coercion to comply – a direct parallel of the reality of sexual abuse.
2. Reducing the treatment hours, citing research from Massey University in support. But the research does not support this – ACC are misusing and misquoting scientific evidence to suit their cost cutting purposes. Massey University have distanced themselves from ACC’s claims and it is noticeable that ACC are no longer making reference to this $800,000 research study – it no longer suits their agenda.
3. Promoting and/or allowing administrative delays and inconsistencies. Claimants and treatment providers get confused messages about what they are supposed to do.
4. Declining claims on spurious grounds - some examples:
   

• Claimant came from a “dysfunctional family” (you don’t say?)
• Claimant was a psychiatric patient and was raped by another patient, therefore was "already mentally ill"
• Claimant didn’t have a GP therefore no GP notes available
• One client, recently applied for ACC, has completed initial sessions but is now likely to pull out – she is extremely afraid of being given a diagnosis and what this will mean for her future employment, mortgage, insurance, etc, prospects. She is also angry that she may need to tell her story again to someone else within a few months.
• “My client received several pages of questions from an ACC psychologist that were to be posted back before meeting him. She felt most anxious and daunted by the questions and needed support  as to how to answer. She also felt nauseous at being forced to meet a male and felt she was being 'punished'. My client reports it's for an assessment. She had 2-3 pages of questions - 1 page covering 150 questions. She laid it aside for 2/52 and then tackled it. She reports it was like an exam and was degrading. 'Äll my trauma was laid out in front of me and I could see visions of all the perpetrators. I felt yuck and exhausted afterwards.' Now, she feels 'labelled' and is 'angry'."
• A mental health social worker said that one of their clients was referred to ACC for child sexual abuse therapy by a mental health service psychiatrist after an assessment. ACC insisted the person see a second psychiatrist to distinguish mental illness due to chid sexual abuse rather than some other condition. Client objected and consequently self-harmed.
• From a counsellor in a small New Zealand town: "Last week I saw a client who had previous counselling with a local clinical psychologist. She chose to return to counselling with a psychotherapist because she felt the previous counselling did not go deep enough and she required more in depth work. I sent the return to counselling report in (I was told by the call centre that they were still accepting these) and the response she got had this to say: 'In order to determine further treatment for you, your claim will be reviewed by a Clinical Psychologist employed by us… following this review, we may be able to make a decision on your claim or we may need you to have an assessment with an independent psychologist or psychiatrist.' They then go on to say, 'We will write to you to let you know: what our decision is, or who you will be assessed by (the emphasis is mine) and what the assessment will involve.' There aren't many clinical psychs in this little town so it is likely that  she will need to return to the person she didn't want to return to. Will she have a say in this? And why can't they accept my own assessment of the situation?"

Skilled and experienced counsellors, psychologists and psychotherapists are considering whether they can continue to support a system which is causing harm to victims of crime. I believe that it is bullying that we are observing here. It has been well reported that ACC as a place of employment has a “bullying culture” (see Dominion Post 2/10/08).
This is now being extended to the bullying of some of our most vulnerable members of society. When ACC insist that all new claimants must have a full psychiatric assessment and a diagnosis of mental illness they are raising the bar to help for many thousands of people, women, children and men, who have suffered sexual abuse as children, or been sexually assaulted as adults. They are saying “prove to us you are mentally ill before we will give you any help”. This is insulting to victims of sex crimes. This also plays into the hands of abusers whose mantra is that “it doesn’t do any harm".
Dr Nick Smith is the Minister for ACC and Climate Change. He needs to watch out for the climate of public opinion - it’s changing rapidly and this government is digging a hole for itself in the minds of ordinary New Zealanders.

http://www.grantrobertson.co.nz/2009/12/01/eric-medcalf-speech-on-acc/

Protesters to picket Nick Smith

Press release from the End Rape Culture Now! Collective

After a successful Take Back the Night march on Friday 27th November, women's groups and survivors are geared up to protest the National Party's cuts to sexual abuse counselling.
On Nov 27th, about 60 people gathered at Albert Park, Auckland, for a Take Back the Night rally and then marched to Myers Park, to protest sexual violence. Speakers Leonie Morris (Auckland Women's Centre) and Kate Brady Kean (Auckland Sexual Abuse Help) critiqued new ACC policies which stop survivors accessing counselling that could save their lives.
Women and survivors pledged to demonstrate against Nick Smith's ACC policies on Monday 30th November. He will be urged to abandon ACC's new “clinical pathway” for sexual abuse counselling. The protest will be led by the End Rape Culture Now! Collective (ERCNC), Auckland branch.
Until 27 October 2009, ACC was the main counselling funder for survivors of sexual abuse, sexual assault or rape. ACC Minister Nick Smith said in Parliament that survivors' needs would be paramount to the ACC’s Sensitive Claims Unit new “clinical pathway”. However since October 27th, many survivors have been notified that their counselling applications have been declined.
"We have also seen information from the Roundtable on Violence Against Women (RVAW) and are absolutely shocked that ACC would blatantly undermine justice by refusing counselling." said ERCNC media spokesperson Eliana Darroch.
The RVAW letter mentions that since October 27th, sexual violence agencies and providers Doctors for Sexual Abuse Care, New Zealand Association of Psychotherapists, New Zealand Association of Counsellors and Aotearoa New Zealand Association of Social Workers have been hearing horrific examples which highlight dangers for survivors.
These include:

1. A woman raped on a psychiatric ward – ACC refused her counselling because she was considered mentally unwell at the time of the rape
2. A child sexually abused by an older child – ACC refused counselling calling the abuse “sexualized play, and unlikely to have been traumatic”
3. A woman in Rotorua being told to go to Tauranga for counselling, as there were no ACC registered counsellors locally.
4. Counsellors now report dramatic reductions in the numbers of survivors obtaining counselling for sexual violence. (www.roundtablevaw.org.nz)

"We support the RVAW in encouraging the public to write letters to MPs; we also feel a need to take another step with urgent action protesting Nick Smith's policies directly, because therapy does save lives." ERCNC spokesperson Eliana Darroch said. "Nick Smith says the policy will be reviewed in six months, but survivors do not have six months."
"Counselling is often the only way survivors can face the trauma of asking for justice. By making counselling impossible, the National Party, Nick Smith and ACC are sending a message that survivors will have no support, and thus perpetrators will have one more wall of protection against justice. And that's completely unethical."
ERCNC also recently organised nationwide protests in Auckland, Wellington, Christchurch and Dunedin and a hunger strike in Auckland, as well as Take Back the Night marches in Auckland and Wellington against rape and sexual violence.

http://www.scoop.co.nz/stories/PO0911/S00325.htm

DSAC concerns over new clinical pathway

Press release from DSAC

Doctors for Sexual Abuse Care (DSAC) support ACC’s overall intention to improve the quality of its funded services for individuals who have a mental injury arising from sexual assault/abuse. However, DSAC does not support the implementation of ACC’s new Clinical Pathway for Sensitive Claims as it currently stands.
This Pathway is a selective implementation of some parts of the Massey Guidelines. It was designed by ACC and introduced abruptly (design completed 19 October, effective from 28 October 2009) and without effective consultation and input from expert clinicians working in the area or with patient advocacy groups. It thus has some predictable flaws.
DSAC’s main concern is that the new Pathway has removed the ability of many individuals to access, in a timely manner, psychological support as a consequence of the crime committed against them/sexual assault.
DSAC does not support the new narrow definition of a DSM-IV diagnosed psychiatric illness as a requirement for cover. ACC has chosen this as its “preferred diagnostic tool.” Thus individuals have to see a New Zealand Registered Clinical Psychologist or Psychiatrist for a DSM-IV assessment prior to commencing counselling. ACC have indicated that “other registered health professionals” with “specific training and experience in mental health diagnostics” may be acceptable to ACC to provide a DSM-IV diagnosis. ACC also state that “competency in this and other domains of practice is a matter for registration authorities.” This leaves the professional bodies to solve a problem that ACC could have averted had they invested in a collaborative approach in the design of the Pathway.
Section 27 of the IPRC Act does not limit mental injury to a DSM-IV diagnosis. Instead it defines “mental injury” as “a clinically significant behavioural, cognitive or psychological dysfunction.” ACC have therefore recently indicated that they are open to using “alternative diagnostic tools.” Which alternative tools will be acceptable to ACC have not yet been defined. This means many mentally injured distressed patients who cannot access a DSM-IV diagnosis, or do not fit these limited criteria, are unable to receive ACC-funded psychological support in a timely manner.
As yet there are no guidelines in place indicating how children and adolescents who have been sexually abused, and who require intervention, will access psychological support. The DSM-IV classification system has severe limitations for children and adolescents.
DSAC also has significant concerns about the informed consent and the new procedures ACC is using to request disclosure of additional information by doctors immediately after a claim is lodged.
These concerns have been communicated to ACC on several occasions. Meanwhile DSAC is fielding enquiries from doctors seeking advice on what to advise patients alleging sexual assault as to how they are supposed to safely navigate the complex bureaucracy which is the “new pathway” in order to access psychological support. This advice is particularly needed for those doctors working in rural areas and small towns where local support agencies may not have the necessary “qualifications” which ACC require in order to make a DSM-IV diagnosis.

http://www.scoop.co.nz/stories/PO0911/S00270.htm

Is there anybody out there?

Press release from NCWNZ

Are there any professionals working in the field of treating victims of sex crimes, abuse or trauma in New Zealand supporting the ACC sensitive claims clinical pathway, questions the National Council of Women of New Zealand (NCWNZ).
“The Doctors for Sexual Abuse Care certainly don’t,” said Elizabeth Bang, NCWNZ National President. “Likewise Social Workers, Counsellors, Therapists, Psychotherapist, Clinical Psychologists, Specialist Sexual Violence Agencies (SSVAs), Community Support Agencies, such as the National Collective of Independent Women’s Refuges, Massey University, the NCWNZ and the average person on the street – are all singing from the same song-sheet. The assessment system needs to be rolled back to what was in place before the clinical pathway, the clinical pathway needs to be reviewed immediately, and ALL specialists in the field, academia, medicine, community representatives need to be invited to ACC’s consultation table.”
NCWNZ’s perspective on the clinical pathway is that the policy is blatantly discriminatory.
“An analysis according to the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) has been undertaken on what effects this policy has now and in the future,” said Elizabeth Bang. “The fact that fewer victims of trauma are presenting themselves for assessment and recovery ticks the first box in demonstrating the current clinical pathways are a discriminatory barrier.”
Women are the main users of ACC subsidised treatments for recovery. An estimated 30% of women in New Zealand will be victims of sex crimes. Within this group, many women will experience trauma, which requires treatment for them to recover and advance in life. Women are also the major providers of community-based sexual violence and victim support; the social work, therapist and counselling professions. No longer having the ability to provide an assessment undermines the viability and retention of these services. The DSM IV diagnostic tool, now used for assessments, classifies women as having mental illness, thereby limiting their access to insurance, mortgages, and advancement in employment.
NCWNZ believes that the sensitive claims “clinical pathway” causes the following direct and indirect discrimination under CEDAW:

• Article 3: limiting a women’s opportunity for functionality and advancement in all facets of life.
• Article 5: limiting a woman’s opportunity to modify the social and cultural patterns of conduct; no longer accessing essential skills to break cycles of violence, intergenerational dysfunctionality, which in the longer term may result in an increase in criminal behaviour in the community.
• Article 6: limiting youth’s ability to access recovery treatment (ECPAT: 64% of underage prostitutes have historically been victims of sex crime) and potentially increasing the level of prostitution and sexual exploitation with less youth/women moving out of the sex industry.
• Article 7: creating a financial barrier for women re-presenting for further recovery treatment, and reducing women’s participating in the formulation of government policy, holding public office and performing all public functions at all levels of government.
• Article 10: without recovery, fewer women will present themselves for continuing education. Potentially more girls will leave school in advance of completing their qualifications.
• • Article 11: limiting a woman’s opportunity for promotion in employment, increasing the likelihood of substandard performance, increasing the vulnerability to exploitation and sexual harassment, market shrinkage in the ‘recovery’ professions.
• Article 12: increasing teenage pregnancy, increasing levels of STI’s, increasing levels of self-harm and suicidal tendencies.
• Article 13: limiting economic opportunities, limiting the financial independence of ‘recovery’ professionals, limiting women’s ability to enjoy social life at an equal level to men’s.
• Article 14: women residing in rural areas are the sub-grouping most adversely affected by the changes implement through the clinical pathway. The level of discrimination increases further if they are also of Maori, Pacific or any other ethnicity, other than NZ-European.
• Article 16: limiting the ability of victims of sex crimes, who have experienced trauma, to recognise and break cycles of violence and poor functionality.

“The clinical pathway, without any professional support has literally imploded,” says Elizabeth Bang.
“NCWNZ encourages the Minister of ACC to take the necessary action that all believe he wishes to take. The Minister doesn’t have time to support this nonsense, it’s time to intervene,” concludes Elizabeth Bang.

http://www.scoop.co.nz/stories/PO0911/S00251.htm

Real reasons for change in abuse claims policy

Press release from the New Zealand Association of Counsellors

ACC comes clean about real reasons for change in sexual abuse claims policy
ACC Southern Manager Karen Walsh, speaking at Fairlie Lions Club on Thursday 19 November revealed that it is ACC policy to reduce the number of Sensitive Claims.
In October ACC introduced a new “pathway” which involves forcing claimants to undergo a psychiatric assessment prior to their claim being accepted. This policy has had the effect that ACC wants; a serious reduction in accepted claims. The Sensitive Claims Unit are declining claims in much greater numbers than previously and therefore preventing the victims of sexual crimes from getting the treatment and rehabilitation they need and are entitled to in the law.
"ACC have been using spurious excuses for these changes” said NZAC spokesperson Elayne Johnston; “first they said that the changes were made to comply with Guidelines produced by Massey University. This has not stood scrutiny and Massey have distanced themselves from ACC and the use of their name to support punitive policies”.
"As we suspected the real reasons for these changes have now been revealed, it is about money not the provision of services to victims of sex crimes.”
“In the meantime many victims of sexual crimes are suffering the humiliation of psychiatric diagnosis, or not coming forward at all. Many of those who continue to seek help are having their claims declined. This is the equivalent to not being believed, a common experience of both adult and child victims of sex crimes.”
“Every day I receive emails from members about clients’ claims that are being declined for a range of reasons that include:

Previous history of psychological problems

Inability to access GP’s notes

Claimant for childhood abuse being in a “dysfunctional family”.

Incident took place “too long ago”.

Members also report a significant drop in the number of people coming forward for help; I believe the new scheme is putting them off.”
“It is very difficult ethically for our members to be part of a system that has so much potential for harm” says NZAC Ethics Convener, Eric Medcalf. “That this system has been created by health professionals with their own ethical codes, all of which will direct that they “do no harm”, makes me sure that in the long run they are vulnerable to personal ethical investigation”.
It is time that the government recognised the sham of this ACC change and commissioned an enquiry into services for victims of sex crimes.

http://www.scoop.co.nz/stories/PO0911/S00234.htm