By Esther Israel
October 10, 2018
It is an unfortunate reality that many so-called nonprofit mental health agencies place their bottom lines above competent care for their clients. They quote scary statistics about the opioid crisis, climbing suicide rates, Utah rape and sexual assault rates being higher than the national average, and a recent rise in domestic violence, to name a few. These scary statistics justify a need to expand services and training. Then so-called journalists publish policy articles as news promoting thinking errors [e.g., “Reports of domestic violence rise in UT, but that’s a good thing” [https://www.abc4.com/news/local-news/reports-of-domestic-violence-rise-in-ut-but-thats-a-good-thing/], [new link retrieved June 2021] and everyone is on board.
I have worked at several nonprofit and government agencies in Utah, providing mental health services. At one such job, I saw clients for individual, group and family mental health services. After seeing six therapy clients back to back, I was getting ready to leave for the day. One of my supervisors in an administrative position who was not a mental health worker approached me in my office and asked for my clinical data.
“What percentage of your clients would you say reported sexual assault? No personally identifying information, of course.”
This was a difficult question to answer. (1) The intake paperwork the agency assigned clinicians to complete with newly referred clients did not specifically list this query. (2) The agency advertised themselves as providers of sexual assault survivor services. (3) Direct service staff had never been included in conversations about what definitions of sexual assault to use.
It should also be of note that the Utah Code Annotated lists only aggravated sexual assault (76-5-405) under sexual offenses. There is no Utah state crime called sexual assault. The federal crime and definition of sexual assault is found in 10 U.S. Code § 920 - Art. 120. Rape and sexual assault generally. There are three components to sexual assault. (1) Commission of a sexual act (2) by one person to another (3) when the other person is not able to consent. A sleeping, unconscious, unaware, chemically impaired person, or someone with a known mental or physical condition are not capable of giving consent. With this definition, “(A) threatening or placing that other person in fear; (B) causing bodily harm to that other person; (C) making a fraudulent representation that the sexual act serves a professional purpose; or (D) inducing a belief by any artifice, pretense, or concealment that the person is another person” are four types of sexual assault.
With these legal examples of sexual assault, it is understandable that laypersons and clinicians conflate the concepts of sexual abuse, stalking, rape and physical assault with sexual assault, and use these legal terms interchangeably.
These are a few of many variables that I was aware of and couldn’t control in my capacity as a mental health therapist. I did not create the intake form. The intake form questions were not related to the client data I was required to later enter into a computer program. The services for sexual assault survivors were folded into the case management and emergency housing services clients received. Most of my supervisors and administrative staff believe masturbation to be harmful and a gynecological examination of the hymen [https://www.youtube.com/watch?v=Yx-LEPF2Ok4] [Viewers will have to sign in to Youtube confirm their age] could be used in court testimony of sexual assault cases. My conversations with colleagues about diversity of sexuality were largely met with blank stares and awkward compliments, like, “Oh, Esther. You’re so funny.”
My supervisor told me he was about to step into a meeting with the Board of Directors. He pressed me for a number as he made himself comfortable in my office while I was shutting down my computer and putting on my coat.
I replied, “Let me go through my files and see which of the clients I see weekly, self-identify as having experienced sexual assault.”
My supervisor settled into the chair that was last occupied by a client. “Oh, I just need a rough estimate. Like would you say it’s more than 50%?”
This was a good question posed to the wrong person at the wrong time. Plus, my supervisor wasn’t really asking me a question. Rather, he was conferring to me pressure to use the jargon de jour, i.e., evidence based, trauma informed, to convey the ramifications of my response. If I provided an answer that was below 50% or an answer that was not a number, then he could deem me trauma insensitive. In an age of hair-triggers and trigger warnings, being trauma insensitive is tantamount to suggesting that perpetrators are people.
I replied, “Let me quickly go through my files and see what I find.” I opened a cabinet drawer with the hard copy files of my active individual therapy clients. As I pulled out each file, my supervisor lost interest, got up, and went back to his office. I reviewed the notes I wrote in the intake questionnaire section that referred to previous trauma and counted the number of times that I documented a client volunteering to tell me about a sexual assault experience.
My personal definition of sexual assault at the time was very broad and encompassed sexual harassment. Interestingly and consistent with their treatment of sexuality, the Utah Criminal Code has no crime called sexual harassment. The Utah state code for harassment (76-5-106) qualifies this crime as a written or recorded communication that intends to frighten and harass another. (Fortunately for my supervisor, my negative experience of him verbally waylaying me from leaving work on time did not qualify him as an harasser.) The United States Equal Employment Opportunity Commission defines sexual harassment as harassment based on a person’s sex or harassment of a sexual nature.
Ten minutes later, I approached my supervisor in his office and reported the number. I clarified it was out of the data of active individual therapy client files. I explained the reasons why I thought that my number would not represent much about sexual assault rates. Notwithstanding my explanation, it was taken out of context and it was not qualified.
My supervisor latched onto the concept that the percentage was likely an underestimation, confirming what he wanted to hear, “So you’re saying that it’s probably close to 70%?
I responded, “I would be very happy to explain scientific data gathering and statistical analysis to you and the board. For example, if you want to collect information about sexual assault rates with our clients, you need to design a specific survey that operationalizes what you are studying, rather than use the clinical intake form which is designed for providing talk therapy services.”
I imagine that other mental health therapists in Utah and beyond get stretched in their job roles by supervisors and business administrators. Mental health therapists may find themselves performing the unforgiving task of helping superiors and non-mental health trained colleagues appreciate the benefits and limitations of psychotherapy for sexual trauma. Clinicians should, but do not, do well to correct erroneous beliefs and unrealistic expectations for mental health sexual trauma treatment and recovery. Likewise, very few to no researchers are rewarded for uncovering interactions between false assumptions, funding source pressures and political demands. When social science is applied at the personal, professional and systemic levels, benefits are anticipated in clients, clinicians, agencies, and the community at large. Why aren’t we seeing overall mental health improvement?
The legal, law enforcement, correctional and criminal justice professions in Utah are doing very well and cannot keep up with the volume of sex crimes and victims they are identifying. The funding to entrap and prosecute sex crimes seems to be unlimited whereas the funding to prevent and treat sex crimes is sparse. What are the legal and monetary connections, if any, between agencies that go after sexual perpetrators and agencies that allegedly provide services to victims of sex crimes?
I don’t know the answers to these questions. Based on my experiences working with people charged with sexual offenses and people who reportedly experienced sexual offenses, I do know that the incentives to identify bad guys and victims seem great in our current mental health care system and various legal and criminal justice organizations. This builds bias into service delivery by agencies that receive funds from federal, state and private sources. To reduce bias, and to promote competent, comprehensive and compassionate care, agencies should employ a third party to prepare their annual data. What could be a measure of agency and organizational accountability?
Bear with me as I take a sharp left turn… Perhaps we can envision agencies and organizations using data on their annual staff turnover rate to measure treatment accountability to the funding sources, community and clients. Regardless of variables contributing to staff attrition and termination, any number hovering at 20% suggests disorganization. Any staff turnover number hovering at 50% suggestions predatory practices. The former warrants intervention and the latter warrants investigation. This is especially true of agencies and organizations that rely on volunteers and student interns, employ part-time staff, and receive funding from multiple sources. Funding for services should be contingent on agency staff turnover rates rather than on statistical reports of agency clientele.
Related to this vision, I am floating a new idea of 4-year term limits for state job positions that involve approving and overseeing funding to agencies that provide services that the state is required to provide, and for administrative (not direct service) staff of agencies that accept federal, state and private donations. All direct services providers such as therapists, case workers and advocates, as well as consumers of mental health services should be on the hiring committees of their mental health agencies. This will revolutionize the incentives. It will give way for social science and effective policy to drive employment decisions and service provisions, rather than career and identity politics. It may also promote the writing of new state laws that reflect the behaviors and needs of the people.
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