Preventing Our Systems from Causing Further Harm

By David S. Prescott, LCSW, LICSW

There have been several news items recently that should cause anyone concern. Fortunately, they illuminate activities that can be improved under the right conditions. Just as sexual abuse is preventable, so we can also ensure that our interventions do not cause further harm to clients who have sexually abused and/or been abused. In this author’s opinion, it is crucial that we recognize what we’re up against, where our failures are, and talk about them.

On August 1, 2024, the US Justice Department issued a report finding unconstitutional conditions at five Texas juvenile justice facilities. The report can be heartbreaking to read (including failure to protect children from sexual abuse and exposing them to excessive force). However, it is not the only report of its kind. Lawsuits involving numerous other facilities around the country are ongoing.

On September 4, 2024, the US Justice Department announced a civil rights investigation into sexual abuse by correctional staff at two California prisons for women. From the press release: “Concern about the physical safety of people inside California women’s prisons is not new,” said U.S. Attorney Phillip A. Talbert for the Eastern District of California. “Media coverage, state audits, advocates’ efforts and private litigation have sought to draw attention to an issue often unseen by many in the community. This investigation responds to those concerns and will aim to ensure that California is meeting its constitutional duty to incarcerated individuals.” Whatever the crimes that led to their incarceration, it is difficult to imagine a more vulnerable group of individuals in the absence of the proper policies and supervisory practices.

On September 9, 2024, the New York Times ran a piece titled, To the World, He Is an Anti-Trafficking Hero. Women Tell a Different Story. It involves Tim Ballard, who, as the article describes, is a former Homeland Security agent. The article points out that Mr. Ballard built his nonprofit, Operation Underground Railroad, at a time when awareness of child sex trafficking was gaining greater currency: “High-profile cases — some of them appallingly real, some of them inventions of conspiracy theorists — drove outrage about minors being forced into sexual servitude.” At the same time, the Times reports, he was grooming, manipulating, harassing, and sexually assaulting women. The Mormon Church described his activities as “morally unacceptable.”

Perhaps of interest to professionals skilled in identifying client excuse-making, Mr. Ballard is quoted as responding to these allegations, saying “I just find it so sad that everybody who has come out with negative smears, lies, lawfare — they are accomplices to child trafficking,” he said in an online video. “Their actions are causing children to suffer, to be raped, to be tortured.” It is as though he is the hero of his own story, and it is his detractors who are the abusers.

A striking aspect of these news items of recent weeks is how they have occurred in diverse locations. These abuses appear not to be bound to one location or political jurisdiction. Meanwhile, other shocking situations have come to light that should concern therapists seeking to serve virtually any client.

On August 25, 2024, ProPublica published an investigation into the activities of insurance companies, titled “Why I left the network.” It outlines the numerous difficulties that psychotherapists have had trying to be reimbursed for their services. The article describes payment delays and “claw backs” (in which the insurers determine that they are unhappy with the therapist’s documentation and take their payment back, sometimes long after the service was provided), among other activities that to an outsider would appear to be a nearly hostile work environment. As many have observed, it may be that there is not a shortage of therapists so much as a shortage of therapists willing to work in accordance with insurers’ demands.

In a similar vein, a September 10, 2024, media account describes how therapy patients are stopping treatment after insurance companies have required “pre-payment reviews.” To paraphrase from the article: The interruption in treatment comes after one insurance company began subjecting thousands of payments to a “pre-payment audit” in the last several months. After the session takes place, the out-of-network psychiatrist or therapist is paid by the patient (usually) and the patient submits the bill for reimbursement, to the insurance company. But the subsidiary managing health services for the insurer, sends a letter to clinician and patient saying it wants detailed records for a “pre-payment review” before sending money. No reason is given.

Meanwhile, a September 9, 2024 data breach has resulted in notification of nearly one million Medicare recipients that their medical information was compromised. Perhaps the most frightening recent news item, however, was a September 1, 2024, exposé in the New York Times, titled How a Leading Chain of Psychiatric Hospitals Traps Patients. It describes how these hospitals conspire to keep patients in their care for considerable sums of money, often using legal actions to extend stays.

Why blog about these things? All these events point to opportunities for us to improve practice as well as the ease with which clients and clinicians alike can suffer. In an era when so many professionals are seeking out evidence-based approaches for ending abuse, we also need to acknowledge how our clients’ environments are sometimes traumagenic and our funding sources less reliable. As one ATSA progenitor once observed, “I’d like to retire from this field someday because I want to and not because I’m forced out by circumstances.”

Every reader cares about preventing sexual abuse, and across the recent decades, we’ve seen just how possible this is. Many forms of prevention exist, including by focusing on society at large, on people who are at-risk to abuse or be abused, and on preventing further abuse through empirically sound supervision and treatment. Now it’s time to aid prevention efforts by focusing on preventing our whole field from becoming abusive to clients and ensuring that professionals have the opportunity to actually do the work without excessive and unnecessary obstruction.

It has been over 50 years since the Stanford Prison Experiment illustrated what can happen under the wrong circumstances. My hope is that we can take what we’ve learned and better advocate for safe spaces for clients and professionals alike.