The four biggest MFT Progress Notes posts of 2013

Ranked by page views.

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2013 was a big year here on the blog. I’ve crossed 250K pageviews, which is certainly humbling, and broke my monthly traffic record multiple times. Here are the four posts that drew the most eyeballs in 2013, counting down to the top:

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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.

Want to know how much that MFT degree will cost? Good luck

Many family therapy programs make it surprisingly difficult to plan for your graduate education budget.                                                                                                                                                                                                                                                                                                            

US Currency; public domain imageIn my research for California Family Therapy Program Rankings, where I offer a roundup of information and rankings on 34 of California’s biggest marriage and family therapy (MFT) graduate programs, I was determined to get readers the most objective information on cost possible. The amount of money students invest in their graduate degrees is significant, and sometimes has to be a factor in choosing programs.

I figured gathering this information wouldn’t be easy, necessarily, but that most programs would publish some way of estimating total tuition cost on their web sites. For example, I might have to multiply a per-unit tuition cost, usually given on one page of a university’s site, with the total number of units in the MFT program, which typically would be on a separate page.

If only it were that simple.

Whether by accident or by design, MFT programs in California are often less than fully transparent in letting prospective students know how much they can expect to pay for their graduate degrees.

Consider San Diego State University as an example. Theirs is a very well-regarded, COAMFTE-accredited program. They’re probably pretty inexpensive, as master’s programs go, since they’re a state school. They even advertise themselves as the most affordable MFT program in San Diego, and I suspect that’s probably true. But if you want to know how much the program actually costs, you’re out of luck. The university web site provides tuition costs for a nine-month academic year ($8,032 for California residents, if you’re wondering), which puts SDSU right in line with the other state schools. But as the program web site notes, two summers are also needed to complete their two-year program, and if you want to know how much those cost, you have to start by fishing your way here, to a 2013 summer tuition document that tells you the cost of summer tuition depends on how many units you take. And how many summer units are required for the MFT program?

I never could find that.

The information just isn’t there, or at the very least, it isn’t easy to locate. Do those two summers add up to six units, or more like 20? At up to $644 per unit in the summer, that’s a pretty big blank space in a prospective student’s budget. I know universities need to put all kinds of cautionary notes on their program plans — classes may be full, scheduling and tuition are subject to change, and on and on — but how hard would it be to tell prospective students how the program is designed, such that they can reasonably estimate how much the whole thing will cost?

My point here isn’t to single out SDSU. Again, theirs is a good program; no matter how much their summers cost, SDSU’s program will still be cheaper than private institutions; and they are hardly the only school to make cost information on their MFT program opaque. (Several programs even provide a sort of illusion of transparency in tuition cost, openly stating how much they charge per semester or per year, but not saying how many of those it takes an average student to finish the program. A $15,000-per-year program designed to be completed in two years looks a lot less attractive — and a lot less affordable — if it turns out that it takes most students four years to actually complete it.) Of the 34 programs I reviewed for the book, there were several where it was not possible to even estimate the total tuition cost of the program based on information available on the program’s web site.

My point instead is this: Prospective MFT students need more and simpler disclosure of graduate program costs. And that means more than just stating tuition and fees, especially for programs that charge by semester or by quarter: it means providing clear estimates of how long the program will take to complete. Ideally those estimates would come with graduation data to back them up; join me if you will in gasping at Phoenix’s abysmal 10% completion rate 30 months after enrollment, but at least they publish it.

Perhaps programs are concerned that making cost information too front-and-center will lead to the same kind of race to the bottom we have seen in airline fares, where consumers’ cost-driven decision-making has led to declining service, crowded planes, airline bankruptcies, and even more opaque pricing. If so, I don’t think we’re giving prospective MFT students enough credit. They’re choosing where to get years of education that will set the stage for their whole careers, not a two-hour bus-ride-in-the-sky to Toledo. Let’s give them the information they need to budget wisely, and trust that they know cost is only one of many factors to consider when choosing a graduate MFT program.

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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.