Making like Arnie when it comes to ACC

Which just means coming back, in a nod to the usefulness of sci-fi in everyday life.  It doesn’t mean I’ve become a right-wing bodybuilder in the months since I’ve blogged last.

I’m going to start by posting a summary I wrote a while back, somewhere else, about the ACC Clinical Pathway review.  Partly because I wrote a lot about this earlier, and partly because I’ve had several conversations with people who protested against the ACC Pathway when it was introduced who haven’t kept up with what happened next.  Mostly because the media have shut down on it, failing to report very much at all about what the Review of the Pathway showed.

And partly because anything that gets me hate postings on men’s rights websites just has to be blogged about. 

So here goes:

In October 2009 ACC designed a new process – a “Clinical Pathway” – for deciding the eligibility of people who had survived sexual violence for counseling from the ACC Sensitive Claims Unit.  This Pathway was described as unethical by the majority of the medical profession, counselors, sexual violence specialist agencies and survivors.  Many feared it would place unnecessary barriers in the way of survivors seeking often life-saving help.

What did the clinical pathway change? In October 2009 ACC interpreted the Accident Compensation Act 2001, for the first time, to require a DSM IV diagnosis for survivors of sexual violence.  This means all new claimants had to prove they had a diagnosable psychiatric disorder, which they could prove on balance of probabilities was caused by an event/s of sexual violence.  This diagnosis had to be made by a psychiatrist, clinical psychologist, or psychotherapist or medical practitioner trained in the use of DSM IV. A new “triage” step was introduced, and all claims examined by a clinical psychologist at ACC before a final decision was made.

Because of the public outcry, Nick Smith, Minister for ACC, announced the new Pathway would be reviewed by an independent group after six months to ensure it was meeting the Government’s expectations.  Nick Smith said “the needs of the victim are paramount”, and the new Pathway was not designed to cut costs.

The clinical pathway changes meant that more information was required of most claimants in order to decide if these criteria were met, and that this information was gathered, submitted and assessed by people who did not necessarily need to have any expertise in sexual violence.  Therapists argued that the worth of the therapeutic relationship was undermined, as was survivors’ autonomy in being able to select for themselves a suitably qualified counselor.  Counselors with sometimes decades long experience in working with survivors suddenly found themselves unable to assess claimants at all – because they were not trained in DSM IV.

The Review is now back – and condemns both the Pathway and ACC’s treatment of survivors over the last year.  Recommendations point ACC in a completely different direction and the good news is the Review is a public document, and ACC have already introduced some of the recommendations.   So it seems advocacy works.  The tragedy is that the sexual violence sector and survivors told ACC and the Government this last October – before two known survivors killed themselves when they were denied support, and many, many more gave up in hopelessness at the hostile process.

During the Review
The Review Panel recommended ACC fund up to 16 hours of therapeutic counseling and recovery support for all survivors.  This recommendation was accepted and actioned by ACC in August 2010.  This was very welcome – though it did not address those who had been turned down by ACC in the intervening months. 

ACC also responded to the Review process by promising to seek meaningful collaboration with the sexual violence sector through groups already established – and ignored in the implementation of this Pathway – by expanding the membership of the Sensitive Claims Advisory Group.

What is in the “Clinical Review of the ACC Sensitive Claims Clinical Pathway”?
The Review Panel accepted submissions[1] from organisations and individuals, including approximately 50 survivors of sexual violence, reviewed 68 ACC files of claimants, and analyzed ACC data relating to all claims lodged under the Pathway.  The resulting document says the Pathway was introduced too fast, with too little consultation, and without evidence.  It also says the Pathway has not improved outcomes for individual clients or groups, and finds a number of specific and serious problems.  Firstly, the Pathway has halved the number of claims submitted in the first three months of this year, presumably due to many survivors deciding they cannot face such an onerous process, and/or not wishing to have a mental health diagnosis attached to them forever.  The Review is also critical of ACC’s treatment and communications with survivors, which it describes as “often inappropriate and inadequate.”  Other problems include:

• Covering only those with a DSM IV diagnosis with “no good legislative or clinical reason to restrict access”
• Three quarters of claims have to go back for “more information”, due to the reduction in numbers of sessions allowed to assess a claimant, and requirement to determine if survivors met the more restrictive criteria.  More information might include medical reports or history, contact from employers or a survivor having to give details of sexual abuse/rape to an assessor on initial meeting. 
• Timeliness – 82% of claims in February and March 2010 took more than 90 days to decide – this is twice as high as before the Pathway was introduced.
• The “triage” step is supposed to take one day for children and adolescents.  In the files the Review analyzed, the median delay was five weeks, the longest ten months.
• The Pathway is also causing delays for people already in the ACC system, or returning for further counseling.

Recommendations
The Review offers 14 recommendations to ACC Minister Nick Smith, all of which insist on real engagement with sector experts and government agencies.  The Review advises Nick Smith to:

• Expand the 16 hours counseling universal allowance to those who have had claims turned down under the Pathway. 
• Use available evidence, which supports client-centred therapy, to design ACC’s decision-making processes around therapeutic support for survivors of sexual violence. 
• Expand “mental injury” beyond just a psychiatric diagnosis through discussion with experts
• Ensure ACC’s communication with survivors is urgently reviewed and becomes client-appropriate
• Design an appropriate accreditation process for assessing survivors for “mental injury” which ensures a well-trained workforce is able to meet quality standards
• Design provider auditing, monitoring, training and development to ensure that all processes are safe and effective for ACC and survivors of sexual violence
• Ensure children and adolescents are prioritized and that family/whanau can be involved where appropriate
• Recognize the dynamics of childhood sexual abuse as requiring, for most survivors, more than 16 hours of therapy for recovery
• Ensure that if a survivor must be assessed by someone who is not their treatment provider, this person is well-trained in sexual violence, and their usual treatment provider is involved in creating treatment plans

What happens next?
This is the crucial bit.  The Review asks for independent monitoring of ACC implementing these recommendations – which, given what a shambles this has been, is not surprising.  But how will this be done, by whom, and in the meantime, how well are survivors being treated?

What was the agenda here?
I quoted Nick Smith earlier in this piece, because despite the public discussions of ACC being too expensive, he has always stated that this Pathway was not about cost-cutting. 

There has been significant media coverage of a research paper ACC commissioned in 2005 by Dr Felicity Goodyear-Smith, who reviewed ACC files and found that psychologists saw ACC Sensitive Claims Unit clients an average of three sessions less than psychotherapists and counselors.  Which is interesting, given the new Pathway, in requiring a DSM IV diagnosis, also changed who is providing treatment to survivors – in favour of psychologists.

What is also interesting about this research is that it was not linked to outcomes for clients.  We don’t know if the clients who saw the psychologists were as happy, as fully recovered, as able to manage recurring symptoms of trauma, as the clients of the psychotherapists and counselors.  Dr Goodyear-Smith didn’t find this out.

We also don’t know if the kinds of sexual violence the clients were seeking support for were the same.  Which is critical – as on average someone recovering from recurring childhood sexual abuse will need more support than someone recovering from a one-off sexual assault.

Perhaps even more interesting though, is the author.  Dr Goodyear-Smith is the founder of COSA, Casualties of Sexual Abuse, an organisation that wants to see fewer convictions for sexual violence crimes because it argues many of those convicted are innocent.   She’s also the author of First Do No Harm, in which she argues “adult-child sex” can be harmless.

Dr Goodyear-Smith is married to John Potter, previously imprisoned for indecently assaulting two under-age girls, and the son of Centrepoint founder Bert Potter, also imprisoned for a variety of charges related to the Centrepoint community, including child sexual abuse.

 Whether Felicity Goodyear-Smith’s research was important in introducing this Pathway or not, according to the Review, it is not the first time it has been proposed to limit ACC funded therapeutic support to survivors with a psychiatric diagnosis.  In the past it has been through legislation – in 1991 the then National Government tried to change the legislation to “mental disorder”, but this was changed at Select Committee stage, where the term “mental injury” was preferred with additional explanation that survivors of sexual violence were covered for “mental or nervous shock” related to the sexual abuse. 

In 1998, the same National Government again changed the legislation structuring ACC, and this time “mental or nervous shock” was removed, leaving just “mental injury” as the grounds for support for survivors.  There is no suggestion, according to the Review, that at this time the intention was to limit “mental injury” to a DSM IV diagnosis, nor is this limitation accepted by the Review as acceptable as noted above even under this legislation. 

When we think about ensuring access to therapeutic support for survivors of sexual violence continues however, it might be wise to consider exactly when attacks for such provision have taken place. 

And we need to watch this space to make sure the excellent work of the Review continues, and an effective, safe and survivor-friendly therapeutic decision-making system results.

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[1]To be clear about my own lack of objectivity here, I wrote the submission for the Roundtable on Violence Against Women, which called for the Pathway to be scrapped and sustainable and holistic funding to be made available for sexual violence services.