Professional associations’ responses to Orlando mass shooting

Photo courtesy Orlando PDThe aftermath of a tragedy is perhaps when the public needs professional associations in mental health the most. These groups can speak from their collective knowledge and wisdom about how to best cope with the trauma and find meaningful ways to contribute. Here are the major US mental health professional associations’ responses to this week’s mass shooting at a gay nightclub in Orlando, where 49 were killed and 53 others wounded.

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Psychotherapy’s dirty little secrets

wooden-chestAs tremendously effective as psychotherapy is, and as much as we try to help out students and new professionals, there are some things about working in this field that we don’t eagerly share. It’s not that we don’t want you to know, necessarily, it’s just… these things don’t look so good.

Here are three secrets we keep about the world of therapy. Each one is true, even if we don’t talk about them much.

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Hear me on the Talking Therapy podcast

Talking Therapy podcast episode 21A few weeks ago, I sat down with John Webber and RJ Thomas from the popular Talking Therapy podcast. We talked about license exams, the high cost of becoming a therapist, the importance of measuring outcomes, my book Saving Psychotherapy, and a lot more. It’s a wide-ranging interview, and I hope you find it interesting and informative.

You can find my specific episode on this page, or just directly download the mp3 here.

AAMFT’s proposed new ethics code makes a bold choice

Golden gavel 1, By walknboston (Flickr: Gavel) [CC-BY-2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia CommonsRomantic relationships with former clients or their family members would be prohibited… forever.

In the current working draft of the Code of Ethics for the American Association for Marriage and Family Therapy (AAMFT), there are a number of proposed changes worth discussing. Perhaps the most significant proposed change is in the rules about family therapists engaging in romantic relationships with former clients or their family members. The existing rule reads as follows — I know it’s long, but stick with me. Except for the title of the subprinciple, all emphasis mine:

1.5 Sexual Intimacy with Former Clients and Others. Sexual intimacy with former clients, their spouses or partners, or individuals who are known to be close relatives, guardians or significant others of clients is likely to be harmful and is therefore prohibited for two years following the termination of therapy or last professional contact. After the two years following the last professional contact or termination, in an effort to avoid exploiting the trust and dependency of clients, marriage and family therapists should not engage in sexual intimacy with former clients, or their spouses or partners. If therapists engage in sexual intimacy with former clients, or their spouses or partners, more than two years after termination or last professional contact, the burden shifts to the therapist to demonstrate that there has been no exploitation or injury to the former client, or their spouse or partner.

The proposed new rule is much simpler and more stark:

1.5 Sexual Intimacy with Former Clients and Others. Sexual intimacy with former clients or with known members of the client’s family system is prohibited.

Gone would be the current “two-year rule.” Under the current rule, a therapist could get into a sexual relationship with a client’s family member without fear of repercussions if two years have passed since the end of therapy. However, a therapist who engages in a sexual relationship with the former client or their partner is always at some level of risk; it is, after all, very hard to prove the negative, especially in mental health. If someone says they have suffered emotionally, as the result of a romantic relationship with their former therapist, it is a high bar for the therapist to prove otherwise. As such, the current code effectively discourages relationships with former clients or their partners forever. The proposed new rule would shift that discouragement into a clear prohibition, and extend its reach to include all known members of the client’s family system, not just their partners.

There is a potential problem with the application of a blanket rule like this. Consider the family therapist working in a rural area, who may run parenting groups or other workshops for their county — a not-uncommon situation, especially when the therapist may be the only licensed mental health provider in the county (or one of very few). That therapist would never be able to date anyone who had come to a single parenting class, a single therapy session, or a single workshop, even if decades had passed since then. And even if you’re on board with that part (I waffle; it’s easy for me to judge from a place like Los Angeles, but I wonder whether my view would be different living someplace else), bear in mind that the therapist also would never be able to date anyone who had a family member who had ever come to a single parenting class, a single therapy session, or a single workshop, no matter how many years ago.

By working in a rural area, a therapist would be systematically dismantling their dating pool.

This proposed AAMFT rule seems to me to be unduly punitive to those therapists working in rural areas (the same argument could be made, albeit a bit less strongly, for those working in insular communities in urban areas), especially those who do so for a long time. It is right and appropriate to demand that therapists not get romantically involved with former clients or their family members when the therapeutic relationship was recent enough to bring a certain “ick factor,” or any risk of harm or exploitation, into the dating relationship; extending the post-therapy prohibition on such relationships from the current two years to five or even ten would be fine with me, and it seems reasonable to include family members in addition to the client and their partner in that prohibition. But to tell a therapist she can’t date someone if she discovers that person’s aunt and uncle had come to her for two sessions of marriage counseling 20 years ago? That, to me, is going too far.

And it isn’t just me. When the American Counseling Association (which represents counselors of various forms, including LPCs and LPCCs) adopted their new Code of Ethics for this year, they kept their five-year prohibition on romantic relationships with former clients rather than moving to one that would last forever. The ACA language, I think, gets it right, by putting a high demand on counselors to consider (and, importantly, document that they considered) the risk of harm or exploitation before engaging in any such relationship, but stopping short of outlawing them for all time:

A.5.c. Sexual and/or Romantic Relationships With Former Clients
Sexual and/or romantic counselor-client interactions or relationships with former clients, their romantic partners, or their family members are prohibited for a period of 5 years following the last professional contact. This prohibition applies to both in-person and electronic interactions or relationships. Counselors, before engaging in sexual and/or romantic interactions or relationships with former clients, their romantic partners, or their family members, demonstrate forethought and document (in written form) whether the interaction or relationship can be viewed as exploitive in any way and/or whether there is still potential to harm the former client; in cases of potential exploitation and/or harm, the counselor avoids entering into such an interaction or relationship.

As a general rule, I really like the 2014 ACA Code, particularly for how well it handles issues related to technology. AAMFT could learn from the example. And while I have concerns about this particular piece, there is certainly much to like in the draft AAMFT code as well; as I said, more on that to come. The public comment period for the current AAMFT draft Code of Ethics goes through August 1.

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In the interest of full disclosure, I was part of a task force that developed recommendations for the 2012 update to the AAMFT Code. I had no involvement with the current working draft.

What do you think of the AAMFT draft? Your comments here are welcome. You can post them in the comments below, by email to ben[at]bencaldwell[dot]com, or on my Twitter feed.

New documentary tackles the divorce industry

DivorceCorp opens in January. It looks great — with one little caveat.

Image from the DivorceCorp web site, www.divorcecorp.com

Divorce is big business. Many people can have a hand in the divorce process: lawyers, mediators, custody evaluators, therapists, court systems, and others all say they want to help divorcing couples. And all want to be paid for their services. The entire system can suffer from what might rightly be called perverse incentives — strong pulls for people to act in ways that are more out of self-interest than the true long-term best interest of the couple they claim to be trying to help.

This is the thrust of the documentary DivorceCorp, opening in major cities January 10. The movie looks good and important. Dr. Drew narrates, and it features interviews with some well-known law experts, including Gloria Allred. Here’s the trailer:

More information on the film, including local theaters showing the film when it opens, can be found on the official DivorceCorp website.

One cautionary note, though: The opening statement in the trailer, “50% of all US marriages end in divorce,” is wrong. As you can read about in more detail over at the excellent DivorceSource web site, the US divorce rate probably never topped 41% and has been declining for several years. As Tara Parker-Pope documented quite well in her book For Better, divorce rates are especially low among those with at least a college education. Over Twitter, the film’s reps have said that there were bigger fish to fry, so to speak. I get that. They’re looking at an entire divorce industry, and my caution is with one statistic. I believe the social conversation about the divorce rate is one specific part of the larger social conversation about divorce that especially needs to change, for reasons I’ll save for a separate post, but don’t let that take you away from the big picture. I’m happy to support the film and eager to see it.

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Your comments are welcome. You can post them in the comments below, by email to ben[at]bencaldwell[dot]com, or on my Twitter feed.

How to make a better therapist

It isn’t experience, and it isn’t the kind of training we usually do.

I’m blogging this week from the Evolution of Psychotherapy Conference in Anaheim, where many of the world’s leaders in psychotherapy gather to discuss the state of the field and share new and innovative research findings.

Therapy is tremendously effective. The average treated client ends up better off than 80% of untreated people with similar problems. Psychotherapy for mental health problems is as effective as coronary bypass surgery for heart problems and four times as effective as flouride toothpaste in preventing dental problems. But we’re not getting better, Scott Miller said in yesterday’s opening workshop.

Miller summarizes our field’s efforts to figure this out thusly: We started by looking at our treatment models, hoping to build better techniques to reach better outcomes. This is where many training programs still live: We teach manualized, empirically-supported treatments in hopes that it will make for the most effective therapists. Except it doesn’t; the models formalize and standardize our work, but they don’t make us any more effective, according to outcome studies.

So we then moved to looking at common factors, those things that work across all theoretical models. But teaching common factors doesn’t seem to make us more effective, nor does it relieve the need to know specific models, since it is through those models that the common factors work. (My good friend Sean Davis has the leading text on common factors in couple and family therapy, and in it he makes the same point.)

So the focus then shifted to the study of outcomes rather than methods, and what we found was that some therapists consistently achieve better outcomes than their peers. That has moved the field into a close examination of excellence and expertise.

The findings there are striking, and I can’t do them full justice here — I’ll address the training issues in more detail in a future post. But the short version is this: We don’t spend a ton of time training students to do the things that actually seem to make them better therapists (“better” here meaning more effective). Miller cited a vast literature identifying deliberate practice — not just more hours seeing clients, but significant time focused on reviewing weaknesses in those sessions while not actively in them and then taking action to address those weaknesses — as the key task in making people more effective. What I hear in my therapy-teacher framework: We need to be doing a lot more videotaping.

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Your comments are welcome. You can post them in the comments below, by email to ben[at]bencaldwell[dot]com, or on my Twitter feed.

Is “relationship orientation” a thing?

A session on plural families at last week’s AAMFT Annual Conference in Portland used the term as a parallel to sexual orientation.

Teens from polygamous families
One of the workshops I attended at last week’s AAMFT Annual Conference focused on “plural families” — family structures that involve more than two partners and their children. The presenters argued that members of these families (seen most often in the US in Colorado, Nevada, and Utah, in offshoots of the Mormon church, which officially banned polygamy more than 120 years ago) may well wind up in a family therapist’s office, and that the therapist needs to be prepared to work with the realities of their complex family structures.

The presentation was fascinating, and appropriately non-controversial: These presenters were not arguing that a plural family structure was right or wrong, just that it exists, and that therapists may be confronted with it. Fair enough.

What piqued my interest was their use of the term “relationship orientation” to describe one’s leanings toward monogamous or polygamous relationships. Are we moving toward considering a preference for monogamy or polygamy as simply one more demographic variable, not subject to change and worthy of equal respect in all its forms?

In a pair of essays for Slate, Michael Carey (a pseudonym) has argued that exact thing. He first suggests that, like gays and lesbians, polyamorists often feel compelled to hide their relationships even from close family members for fear of judgment or even expulsion — and that the lack of societal acceptance reflects prejudice. In the second, he notes that half to two-thirds of polyamorists do not experience their relationship orientation as a choice. (These numbers are from Carey’s experience, and he doesn’t pretend they are research-based.) For this majority, their “innate personality traits make it very difficult to live happily in a monogamous relationship but relatively easy to be happy in an open one.”

Don’t focus too much on that word “innate,” though. How much of a desire for polyamory is nature and how much of it is nurture isn’t especially important when arguing for moral acceptance of poly relationships, Carey argues:

Nobody ever claimed that Mildred and Richard Loving were born with some kind of overwhelming predisposition to prefer partners of another race and that they thus couldn’t marry somebody of their own race. Choosing an interracial partner was, and is, a choice. So what? The correct response to the nature vs. nurture question is: There’s no way to know for sure, and it doesn’t matter. What matters is that people love each other, treat each other with respect, and live happy, productive lives.

Now, I should be up front about my own moral place here. I have no problem with poly relationships as long as there is no dishonesty involved and no one is getting hurt (at least, no more so than happens in the normal course of monogamous relationships). What concerns me here is where the parallel leads us. If “relationship orientation” is as inflexible as we now understand sexual orientation to be, and if participants in poly relationships are not being any more or less moral than anyone else, do we have a societal moral obligation to honor poly relationships with equal status as monogamous ones (whether straight or gay)?

In other words, do we owe them plural marriage?

The overwhelming science on gay and lesbian couples show that they and their children are harmed by societal discrimination and suffer from being unable to marry in a wide variety of ways. This is in spite of the fact that children of same-sex couples are just as healthy as those from straight couples.

The situation is different for poly marriage. While there may be many exceptions, poly relationships are generally understood to be oppressive to women, and polygamous families and cultures may have negative outcomes for children on a variety of measures. So there is ample reason to take a very cautious approach to polyamorists pushing for societal acceptance.

Status of polygamy worldwide
Legal status of polygamy worldwide (click the image for full details)

I’ll admit I have never been a big believer in the “slippery slope” line of reasoning, which essentially argues that if you raise the speed limit from 55 to 65, then you’re going to have to raise it to 200. You don’t, of course; raising it again even to 70 would be a different debate. Slippery slope arguments are often nonsensical fear tactics used to argue for the status quo, by suggesting that the alternative is an extreme alternate reality that no one has actually suggested. Applied to gay marriage, some argued that it would somehow logically follow that if we allowed same-sex couples to marry, we would then have to allow people to marry box turtles.

It is debatable whether re-legalizing polygamy equates with raising the speed limit to 70, or whether it would be more like raising the limit to 200. For now, I’m looking at it more like 200 — a radical and potentially damaging change.

But lots of people once felt that way about gay marriage, too. And it seems the language debate we once had around sexual orientation being a preference, a lifestyle, or an orientation is starting to replicate itself for plural families. As we saw with gay marriage, the outcome of the language debate has a lot to do with shaping what happens next.

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Your comments are welcome. You can post them in the comments below, by email to ben[at]bencaldwell[dot]com, or on my Twitter feed.