Montana becomes 50th state to license MFTs

Montana governor Brian Schweitzer made his state the 50th to enact marriage and family therapist licensure last week, when he signed SB271 creating the MFT license there.

Congratulations, Montana MFTs! With a nation of MFT licensure laws complete, this should add great momentum to the push for MFTs to be included in federal programs, including Medicare and No Child Left Behind.

It is also worth pausing to reflect on just what an accomplishment this is — I’ll post more on this later in the week.

Montana could complete nation of MFT licensure

The state legislatures in Montana and West Virginia have each now passed bills (Montana bill | West Virginia bill) that would create Marriage and Family Therapist licensure in those states. If Montana’s bill is signed by the governor, the country could be complete: MFT licensure would exist in each of the 50 states, and the District of Columbia.

The governor of West Virginia has formally approved the MFT bill there. It is unclear when the state will actually begin issuing MFT licenses, because the board has some rulemaking to do, but it may happen as early as next year.

The Montana bill was sent to the governor April 22; he has 10 days to sign or veto it, or it becomes law automatically. It’s not fully clear, at least from what I can find, whether the governor will sign it; the Montana chapter of NASW has opposed MFT licensure there, and the governor has been busy with his veto pen. Still, improving public safety in mental health services, as well as access to care, through MFT licensure would be a good way to demonstrate to Montana residents that mental health issues are important, even when budget limitations prevent expanding services.

Stay tuned…

Calculating the divorce rate

My Twitter (@benjamincaldwel) went all atwitter a couple of days ago with news that Russia’s divorce rate peaked in 2002 at more than 800 divorces for every 1000 marriages. Does this mean the country has a whopping 80% divorce rate?

In a word, no. While there are lots of ways to calculate the divorce rate, each of them flawed in some way, simply comparing one year’s number of divorces with the same year’s number of marriages is among the worst ways to do it. From a 2005 New York Times article on the topic, which also debunks the longstanding myth that half of US marriages end in divorce:

[Researchers note that] the people who are divorcing in any given year are not the same as those who are marrying, and that the statistic is virtually useless in understanding divorce rates. In fact, they say, studies find that the divorce rate in the United States has never reached one in every two marriages, and new research suggests that, with rates now declining, it probably never will.

Russia’s actual divorce rate is surely high, and does appear to be higher than the US. But I would ballpark Russia’s divorce rate in the 50-60% range for couples getting married this year. I’ll explain how I got there momentarily.

The difficulty in calculating the divorce rate is that it necessarily involves speculation. The only way to avoid some kind of speculating would be if you took a sample of people married in the same year (1930, let’s say) and then waited for everyone married that year to have their marriages end, either through death or divorce. You’d get a pretty accurate rate that way, you would just have to wait a long time to get it.

Most of us are interested in more current numbers. For example, how many of the couples getting married this year (or at least, some year in the not-too-distant past) can we expect to see end their marriages in divorce? Since not all of those couples have divorced yet, we’re into speculative territory.

What some researchers do is what they call a “life table” approach. They may take an estimate of the time frame in which half of divorces occur — usually between 0 and about 7 years of marriage, though the exact timeframe varies — and work from there. For example, let’s say we have a sample of 100 US couples married in 2002, and of those 21 have divorced as of today. If we have reason to believe that half of the couples married in 2002 who will divorce have now done so, we could estimate the divorce rate for couples married in 2002 to be around 42%. But that is an educated guess. We don’t really know where that midway point of divorces takes place, we just guess based on past history and currently identifiable trends. And if we want really current numbers, like an estimate for couples who are only now getting married, we need to be even more speculative: We now must also guess about where that midpoint in the distribution of divorces is going to be. Such an approach, even when done as well as possible at the time, runs an inherent risk of making you look foolish in retrospect.

Further complicating matters, divorce rates are influenced by a variety of factors, some more easily predictible than others. Demographic, economic, and other social changes are just three examples, and all of these have had major impacts on Russia in the past two decades.

Ultimately, no one knows precisely what the divorce rate for couples marrying this year will be, because it’s all based on speculation about possible future divorces that haven’t happened yet.

Now, back to Russia. As I said at the beginning of this post, even though they can document 800 or more divorces per 1000 marriages in 2002, that is absolutely, unequivocably not an 80% divorce rate. It is an inappropriate comparison of two very different cohorts. The population is different. That same article on Russia notes that from 1980 to 2005, the number of marriages decreased by one-fourth. So, relative to the population of couples available to be married, the population of couples available to be divorced has been growing significantly.

For the purposes of demonstration, I’m going to make up some numbers to show how flawed it is to compare a given year’s number of marriages with that same year’s number of divorces to try to calculate a divorce rate.

First, let’s assume an actual divorce rate of 60%, and that the rate breaks down to 10% per year in the 1st through 6th years of marriage. (This is wrong, of course, but used for demonstration purposes.) Second, let’s assume that the marriage rate declined 25% from 1988 to 2002, and declined evenly in that time. This is a small exaggeration, since the actual 1/4 decline took from 1980 to 2005. Finally, let’s assume the actual divorce rate had held constant at 60% since the dawn of time. If we use 1333.3 marriages in 1988 as our starting number (you can use any number there, since it’s the percentages that matter), what we would see would look something like this:

1995
Marriages: 1167
Divorces: 750
Apparent divorce rate: 64.29%
Actual divorce rate: 60%
Difference: 4.29%

2002
Marriages: 1000
Divorces: 650
Apparent divorce rate: 65%
Actual divorce rate: 60%
Difference: 5.00%

Three key points here: 1, notice how this exaggerates the “apparent” divorce rate for those simply comparing the number of marriages to the number of divorces in a specific year. 2, notice how the systematic exaggeration of the “apparent” divorce rate as compared with the actual divorce rate gets worse over time. This is always going to be true when the marriage rate is in decline. 3, our process here assumed that all divorces were done by the seventh year of marriage because it makes the math easier. Making this more real by assuming that half of divorces are done by the seventh year of marriage, and the other half take place at gradually dwindling frequency rates after that, would make the systematic exaggeration of the “apparent” divorce rate much worse.

We can demonstrate this with a different set of assumptions. Let’s again assume a 60% divorce rate since the dawn of time, but now let’s assume a more realistic distribution of those divorces. Let’s say that half of divorces take place in years one through six, and the other half are evenly distributed between years 7 and 16 of marriage. Let’s assume the same marriage rate decline as what’s actually scientifically justified — 25% from 1980 to 2005. Starting from a good-for-easy-math number of 2000 marriages in 1980, we then see numbers that look like this:

1996
Marriages: 1680
Divorces: 1096
Apparent divorce rate: 65.36%
Actual divorce rate: 60%
Difference: 5.36%

2002
Marriages: 1560
Divorces: 1026
Apparent divorce rate: 65.77%
Actual divorce rate: 60%
Difference: 5.77%

These show that the “apparent” and actual divorce rates are not the same thing, and they show how comparing one year’s number of marriages with the same year’s number of divorces creates worse comparisons over time. Admittedly, they do not account for the full scope of that 800-versus-1000 number. I say the actual current rate is in the 50-60% range because (1) by presuming an end point to divorces after a specific number of years, my examples here do more to deflate the difference in actual-vs-apparent divorce rates than to inflate them; the distinction becomes greater when you model the numbers in ways that more closely approximate reality. And (2) these statistical models do not account for other social and economic changes in Russia that may be throwing off the divorce curve, that is, how divorces are distributed over time among those couples who do divorce. With those in mind, I would ballpark the expected divorce rate for couples getting married in Russia this year in the 50-to-60 percent neighborhood, though again, social and economic conditions can influence the numbers greatly in either direction.

Thankfully, there are lots of people out there who do this kind of work for a living, and can do both the detail work and the explantion better than I can. Andrew Cherlin and David Popenoe are two worth reading. More information on the flaws inherent in estimating divorce rates is here.

Texas lawsuit challenges MFT diagnosis of mental illness

Updated 9/7/2011 – Updated link to legal document.

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The Texas Board of MFT Examiners has been sued (summary | legal document) by the Texas Medical Association, alleging that MFTs should not have the authority to make diagnoses of mental illnesses. The case has the potential to set a dangerous precent for mental health care nationwide.

At issue is a proposed Texas rule that would simply make MFTs’ ability to diagnose explicit. In every state where MFT licensure exists, MFTs routinely assess, diagnose, and treat mental illness. The terminology in statute may differ from state to state, but these tasks are part of MFT practice in every state. When the TMA initially raised concerns about making this ability explicit in the Texas MFT scope, the licensing board dismissed their concern, noting

The inclusion of the term “diagnosis” in §801.44(r) does not expand the scope of practice of marriage and family therapy into the practice of medicine, but accurately reflects the scope of practice of marriage and family therapy.

So what gives?

Physicians are trying to expand their exclusive control of medicine. Under the guise of “protecting the public,” the Texas Medical Association and its sister organizations in other states are not just seeking to keep non-physician healthcare providers from expanding their scope of practice, but are actually seeking to actively roll back existing practices. In Texas, the medical association was successful in keeping podiatrists from expanding their scope to include the ankle.

What’s different in the MFT case is that family therapists were making no effort at all to expand their scope of practice.

What’s clear about the Texas case is that if the TMA wins, it would absolutely not be serving the best interest of patients. Texas already has a severe shortage of psychiatrists, as well as a shortage of mental health care workers generally. Marriage and family therapists receive specific training and supervised experience in the assessment, diagnosis, and treatment of mental illness. Restricting who can diagnose mental illness by removing MFTs from that task would only make it harder for patients to access clinically appropriate care.

An update on the lawsuit from the Fall 2008 Houston Association of MFTs’ newsletter can be found here. The Texas Association for Marriage and Family Therapy is working diligently to help the licensing board defend against the lawsuit. If you would like to help, the best way is to donate to the TAMFT Political Action Committee.

Men a threat to politics, safety

Apparently when I was in Hong Kong, men became a lot more dangerous.

First, we have Tracy Clark-Flory at Salon — whose work is often very good, including defending men against unfair stereotypes — uncritically repeating an insinuation that Chinese men are all sex criminals in waiting.

Second, we have the San Francisco Chronicle uncritically repeating a claim that “a disproportionate number of unattached, unmarried men is a recipe for all kinds of violence.” I’m not trying to argue against what is a demographic reality — single men are much more likely to commit violent crime than women or married men. But the argument that single men are inherently criminal, or that violence is the inevitable result of a rise in single men in a population, is false and discriminatory. An abundance of men does not automatically lead to “all kinds of violence,” as cultures have resolved population imbalances in many different ways. In the US, the delaying of marriage has increased the proportion of unmarried men in the population, without a correlating spike in crime (though it could be argued that unmarried young men are skill likely to be attached, even in less committed relationships).

Finally, Newsweek, in a thoughtful and well-informed piece on how demographics intersect with unemployment, worries that “Obama and Congress could face millions of angry and disillusioned, unemployed men.”

The third example, of course, is not in the same category as the first two; suggesting that men might be angered to the point of voting politicians out of office is very different from suggesting they are all violent, sex-starved thugs who will attack if given the opportunity. But seriously, what gives? When did men become such a problem?

Apparently the question of what to do with unmarried men elicits fear far beyond China. Author Kay Hymowitz (who, I should note, wrote a book to which I gave a mostly good review some time ago) has lamented that even in the US, young men are “lingering in a hormonal limbo between adolescence and adulthood, shunning marriage and children, and whiling away their leisure hours with South Park reruns.”

Are single men really such a problem? Is Hymowitz’s picture — if it were true, which I think is debatable — something to be feared? As a single man, I’m trying to avoid an overrun of countertransference here; I’d welcome your thoughts in the comments.

Update: Another suggestion that men are simply failing: this CNN story is a perfect candidate for Slate’s Bogus Trend Watch, as it provides no reliable statistics or other actual evidence of a sociological trend. It suggests that women, seeking emotional connections they are not finding with men, are leaving men to enter relationships with other women.

Good advice for kids’ bad behavior

Slate had a great article last week urging parents to take a deep breath and really think about whether it’s worth the trouble to make their child’s irritating-but-not-awful behavior change. It’s written from a purely behaviorist perspective, and it covers the bases well: Most annoying behavior is relatively normal and goes away on its own in time.

There are lines to be drawn, of course, between behaviors that parents can endure and write off as “just a phase” versus behavior that is directly harmful (either to the child or others) and should be intervened upon. But those kinds of problems occur far less often than many parents think. Slate urges readers to tread lightly, and to anticipate some of the stages in a problem disappearing, including what mental health professionals call an “extinction burst.”

Problematic behavior can be grown out of by adults, too, of course. Some mental illnesses, left untreated, have a surprisingly high rate of what researchers call “spontaneous remission” — a fancy way of saying the problem goes away on its own. I’ll return to that topic in some detain in an upcoming post.

There isn’t much in the way of new research in the Slate article, but as an introduction of simple behavioral lessons for parents who feel at their wits’ end, it’s a nice piece.

New year, new Medicare efforts for MFTs

Will this be the year MFTs finally are included in Medicare? There are promising signs.

First, there is already momentum for adding MFTs to the list of accepted providers. MFTs have been on three bills, one in each of the past three Congresses, that successfully passed out of one legislative house. (Twice we’ve made it out of the House of Representatives, once out of the Senate.) So far, no bill to include MFTs in Medicare has survived both houses and made it to the President’s desk. But with a new President, a new Congress, and a new public focus on health care reform, there looks to be a good window of opportunity.

There are two bills (HR1693 in the House, and its companion Senate bill, S671) already introduced in the current Congress that would bring MFTs into Medicare. Both are bipartisan efforts that have very low initial costs and are likely to lead to long-term savings as Medicare patients would be able to more easily receive early treatment for mental health disorders. Both have strong and growing support from key committee members in both houses.

In the larger conversation about health care reform, there is also good reason to be optimistic for the MFT profession. The body of knowledge supporting the clinical effectiveness and cost-effectiveness of our work continues to grow at a rapid pace, and with licensure now in 48 states and DC, the case for inclusion is stronger than ever.

I’ll keep you posted as the bills move forward. Stay tuned to aamft.org for updates and calls-to-action, when contacts with specific legislators can help turn their votes.

Fringe practices: Neurolinguistic Programming

Neurolinguistic programming (NLP) is sometimes described as a combination of postmodern therapy and neurology. On a basic level, the model suggests there are clear connections that can be drawn between internal experience (neurology), language, and behavior. Based on these connections, it is theorized that changes in internal experience and/or language can quickly and dramatically impact behavior. These interactions are also recursive, so changing language can change internal experience — a direct connection with postmodern therapies.

Trying to move past these general ideas into specifics of the model is quite challenging. NLP is sometimes described as “a set of techniques designed to make you better at what you do.” You likely will not leave this long introduction to NLP with any better understanding of what it is or how it works than what you came in with. Looking elsewhere, we find a description of the model that sounds a lot like The Secret:

[NLP is based on the notion] that the words we use reflect an inner, subconscious perception of our problems. If these words and perceptions are inaccurate, as long as we continue to use them and to think of them, the underlying problem will persist. In other words, our attitudes are, in a sense, a self-fulfilling prophecy.

Part of the difficulty in determining what it is, exactly, that NLP therapists do is owed to the model’s suggestion that therapy must be subjective. Therapists are then seen less as scientists, and more as artists. Therapy is not to be a prescribed order of techniques, but rather a process customized to each client that respects the clients’ unique experiences.

However you define it, NLP today bears all the markers of a fringe practice in marriage and family therapy.

A small and dedicated group of practitioners. The UK association for NLP listed more than 50 training organizations and estimated that 150,000 people had been trained in the model in some way as of 2000 (Tosey & Mathison, 2003). This group primarily does not consist of psychotherapists, but rather involves “educators, managers, trainers, sales people, market researchers,” and so on. While there are several training organizations in the US, the number of practitioners and academics involved in the model appears to be modest.

Expensive training. Training providers in NLP talk about the artistry of creating a therapy appropriate to each specific client, and that the trend in NLP is toward shorter trainings. Then they ask for $4,000 for a master practitioner training program.

Unrealistic claims of effectiveness. Therapy processes claim a lot of things, but this was the first time I had ever seen one actually claim to be magical:

Neuro-Linguistic Programming™ was specifically created in order to allow us to do magic by creating new ways of understanding how verbal and non-verbal communication affect the human brain. As such it presents us all with the opportunity to not only communicate better with others, but also learn how to gain more control over what we considered to be automatic functions of our own neurology.

The founders of the model, Richard Bandler and John Grinder, believed it to be effective for the complete range of psychological problems that therapists would encounter. Again, the model is vague on what exactly it is supposed to accomplish, although its adherents claim a strong foundation in client strengths, noting that “Each of us is a miracle waiting to happen.”

Weak scientific support. The Wikipedia entry on NLP is blunt: “NLP has enjoyed little or no support from the scientific community. It continues to make no impact on mainstream academic psychology, and only limited impact on mainstream psychotherapy and counselling.” In the presence of little empirical support — and a number of articles that appear to actively discredit the usefulness of the model — NLP adherents do what most fringe practitioners would do, which is to dismiss the research as poorly constructed or irrelevant. Like it or not, though, the effectiveness of any therapeutic model — as established through research — is vital to that model gaining legitimacy with payors and clients alike. For now, NLP lacks that research base, and the legitimacy it would provide.

So, is it worthwhile? Many practices that are now accepted started out as fringe practices, so the label is not always a derogatory one. All fields need some practices at the cutting edge — some make it to broad acceptance and others are weeded out before they can get there. While it may be useful in other fields, NLP seems to be one edging toward being weeded out as a model for psychotherapy. Though the model has been around since the 1970s, clinical effectiveness simply has not been demonstrated, and NLP practitioners express active disinterest in such research. Perhaps it is because the model’s ties to postmodernism leave the it too subjective to be truly testable.

As I detailed in an earlier post, my writings on fringe practices are not meant to advocate for or against their use. I hope instead to provide a relatively complete picture of the current state of these practices — their level of acceptance in the profession and scientific community, their evident effectiveness, and why readers may or may not be interested in them. Comments are always welcomed.

REFERENCE

Tosey, P., & Mathison, J. (2003). Neuro-linguistic programming and learning theory: A response. The Curriculum Journal, 14(3), 371-388.

Why we (wrongly) believe praise doesn’t work

I’ve been reading The Drunkard’s Walk in fits and starts lately — it’s a good-not-great book about how randomness impacts our daily lives in ways large and small. In the words of OK Go, mediocre people do exceptional things all the time. But there’s one piece I really enjoyed that shows immediate applicability to couple and family work: People think criticism works better than praise because of what the statistically-minded call regression to the mean.

Whenever someone does something exceptional, be it exceptionally good or exceptionally moronic, it draws our attention. A golfer may make a 100-foot putt, or a well-meaning driver may hit a squirrel darting across the road. In either case, the event is a combination of luck and skill, and the “luck” part is not likely to immediately repeat itself. Whether you praise the golfer or ignore her, she is not likely to make the next 100-foot putt. Similarly, you can scream at the driver who hit the squirrel or ignore him, and either way, he probably will not suffer such bad luck in the near future.

This is why we believe praise doesn’t work. We expect that praise will lead to the immediate repetition of behavior that is at least in part lucky, and when it doesn’t, we think the praise makes no difference.

To use the specific example in the book, a flight instructor had long ago given up on praising his students for flight tactics well done. If they did well, no amount of praise seemed to increase the odds they would do better next time. But if they did very poorly, after a good tongue-lashing they performed much better. The rub, of course, is that in all likelihood they would have performed much better anyway.

The lesson for therapists and clients alike, I think, is that the effects of praise and criticism are not immediate, and expecting them to provide immediate results sets you up for failure. If you want to see whether praise or criticism is really working, you need to look at the average of many performances over time, averaging them to get a clearer sense of te individual’s skill level. Don’t put much stock in a single act as a measure of overall skill.

Over the long term, praise does help in many ways, and criticism hurts. For couples, Gottman’s famed 5-to-1 ratio is a good example. For individuals, there has been a good amount of research on the effects of criticism on self-esteem — and performance. Seeing these long-term effects, though, means looking at averages and ignoring the occasional good or bad day.

With this in mind, the only reasonable course of action here is to close with some praise. Great job working your way through this post! I hope you found it rewarding. And, if you think this post was awful, well, odds are I’ll do better next time.

How do bad therapists stay licensed?

From students and colleagues alike, I often hear statements to the effect that “There are a lot of bad therapists out there.” As I understand it, “bad” in this context has a variety of meanings, ranging from simply ineffective to downright unethical. At either end of that spectrum, though, the next question is usually the same: How do they stay licensed?

Let’s start at the ineffectiveness end. No therapy is 100% effective, so providing therapy that doesn’t work with some clients is normal. I’ve had my share of cases that did not go as well as I would have hoped. A therapist is only violating professional standards if they make false claims to clients about the likelihood of success with a particular treatment. Of course, it could be argued that a therapist is behaving unethically if they are far less effective in their work than the average therapist, but there is no reasonable way for a licensing board to gather that kind of information. So they attempt to ensure effectiveness by proxy, through such requirements as ongoing continuing education.

For therapists who are unethical in their practices, it may take years before unethical practitioners are investigated and their licenses disciplined. And even then, only the most egregious acts — like sexual relationships with clients, insurance fraud, or repeated and knowing violations of confidentiality — will actually result in a license being revoked. Reasons for this include that (1) licensing boards rarely can act in the absence of a complaint coming directly from an impacted client, and even clients who have suffered great harm are reluctant to complain; (2) because effective psychotherapy is so dependent on the protection of privacy between client and therapist, investigations are lengthy and costly, and may fail to find a pattern of therapist behavior even when it does exist; and (3) standards of the profession, including ethical standards and disciplinary guidelines, are predominantly set by members of the profession.

So what is a mental health consumer to do? Three things:

1, Caveat emptor. Licensure ensures that a therapist met minimal state standards for independent practice — it is by no means a guarantee of effectiveness or up-to-date knowledge. Clients should ask lots of questions of prospective therapists, and if you do not feel fully comfortable with the person you are seeing, find someone else.

2, Demand accountability for effectiveness. The first session should focus on setting clear goals for therapy. From that point forward, you and the therapist share responsibility for getting there. It is not in your interest to continue spending time and money on methods that are not making a difference. Therapy does not always work quickly, but this is why it is so important to set clear and achievable goals, including some early-stage goals: You will have a quick yardstick of your ability to succeed with this therapist.

3, If you have been the victim of an unethical therapist, file a complaint. It is not especially unusual for colleagues to have a sense that a particular therapist is violating the law or professional standards, but licensing boards cannot investigate a feeling. They need to hear directly from someone who has suffered because of the unethical therapist’s actions. For a variety of (understandable) reasons, many clients who have been victimized in this way never do make a report.