Couple therapy effectively treats depression

Family Therapy Magazine, which is usually quite good, is simply outstanding this month. Highlighted by Michael Yapko’s “Skills or Pills? What MFTs Can Do Better than Antidepressant Medication,” the magazine examines some hard truths about depression, medication, and family therapy:

  • Antidepressants are no better than placebos. An extensive study of the six most popular antidepressants found that when unpublished trial data were combined with published trial data, “the benefit (of medication) falls below accepted criteria for clinical significance.”
  • Couple therapy is a promising treatment approach for depression. While more research needs to be done, Emotionally Focused Therapy and Behavioral Marital Therapy both appear to alleviate depression at least as much as individual therapy, while simultaneously improving the couple relationship.
  • Treatment for depression is very different in other parts of the world. Even other western, industrialized nations have found success in treating depression when it is de-medicalized. In other words, the whole person should be treated, not merely a set of depressive symptoms.

Perhaps most interesting — and depressing — in all of this is some discussion that therapy is winning the battle but losing the war. In other words, mounting evidence suggests that psychotherapy (and particularly systemic therapy) is a preferable treatment to antidepressants in the successful treatment of depression. Yet, the promise of relief in pill form, without substantial work, keeps Americans going back to the MD instead of the MFT. Antidepressants are now so widely prescribed that they show up in our drinking water.

If science alone will not turn the tide, what will? What do you think needs to happen to convince people that therapy is a better long-term fix for depression than pills?

Family intervention gives hope, second chances to prisoners

There’s a touching editorial in the current issue of the journal Family Process pleading for more widely-adopted systemic responses to incarceration.

It highlights a major paradox between science and practice: We know — not “suspect,” not “think,” but actually know, as much as is possible with science at any given time — that family-based programs to reduce recidivism are both clinically effective and cost-effective. But they remain in rare use. And ultimately, we all suffer: The US has the highest incarceration rate in the civilized world, one in nine young Black men is in prison at any given time, and elected officials still seek to score cheap points with a frightened populace by pledging to get “tough on crime.”

The following passage from the editorial is especially striking:

The average cost to keep a person in prison for a year in the United States is slightly over $23,000 (Liptak, 2008) – an amount that, for non-violent offenders, could easily cover tuition costs at many colleges. As but one example, the state of Arizona spends more to incarcerate Latinos and African-Americans than to educate these same populations at the state universities.

So, what is to be done? Again, there are interventions that we know will work, particularly for juvenile offenders. Among adults, educational and therapeutic programs are again known to work and to save taxpayers money. From Sen. Edward Kennedy’s (failed) 2007 Recidivism Reduction and Second Chance Act:

Recidivism for inmates who participate in prison education, vocation, and work programs have been found to be 20 to 60 percent lower than for nonparticipants. The Federal Bureau of Prisons found a 33- percent drop in recidivism among Federal prisoners who participated in vocational training.

Simply put, cries that we cannot afford such programs in difficult economic times are straw-man arguments — tough economic times should lead to greater use, not less, of programs that we know will reduce costs to the justice system without increasing crime. Family-based programs should be a part of this effort.

Why are divorce rates higher in cities than in rural areas?

Divorce rates are higher in cities than in rural areas. While many explanations for this have been proposed, a common one has been economic opportunity. City dwellers generally have higher incomes than their country counterparts, and perhaps can more easily afford to move on after a breakup.

Not so fast.

The publication of Barry Schwartz’s The Paradox of Choice led some to speculate that his thesis — in short, the more options you have to choose from, the less happy you will be with the choice you make — could apply to romantic relationships just as it could apply elsewhere. (Schwartz actually speculates a bit on this himself in the book.) In other words, city dwellers may be more likely to divorce not because they make more money, but because they have more and better alternatives to their current relationship readily available at all times. New evidence supports that idea.

In a study on speed dating, researchers found that as the size of the speed dating group increased, selections became more skewed toward just a few select participants. This happened, the researchers argue, because the daters were less willing to make tradeoffs — like accepting less physical attractiveness in exchange for greater intelligence — when presented with a greater variety of options.

Faced with too much choice, the authors argue, we resort to more crude decision-making techniques. To put it differently, it becomes all about looks. And when a choice of romantic partner is made solely on appearance, how likely is it to last?

I’m especially curious about how this applies to internet dating. Some sites go for quantity (, others for quality (eHarmony) in the matches they make. The sites that present quantity are more likely to be considered meat markets, where appearance is key. I’m led to wonder — if sought to create more lasting relationships (and thus higher marriage rates and lower divorce rates), would they actually be better served to limit the number of potential mates they show to members? Science seems to be saying yes.

A new genetic theory of mental disorders

Yesterday’s New York Times outlines a striking new theory of mental disorders. Put forward by Bernard Crespi and Christopher Badcock — neither of whom works in mental health — the theory goes roughly like this: Genes from the mother’s egg and father’s sperm compete for dominance in the offspring, in what the Times called an evolutionary tug-of-war.

A strong bias toward the father pushes a developing brain along the autistic spectrum, toward a fascination with objects, patterns, mechanical systems, at the expense of social development. A bias toward the mother moves the growing brain along what the researchers call the psychotic spectrum, toward hypersensitivity to mood, their own and others’. This, according to the theory, increases a child’s risk of developing schizophrenia later on, as well as mood problems like bipolar disorder and depression.

This is no less than a unifying theory of mental illness — a theory that puts all mental disorders onto the same spectrum. It naturally has its skeptics.

It does not account for various quirks of autism or schizophrenia, particularly the coexistence of both positive and negative symptoms found in both. Even critics, though, praise the theory for its creativity and plausability. And, though it is limited, there is some biological evidence to lend support to the theory.

Crespi’s name may sound familiar. A biologist by training, he has frequently waded into the murkier waters of sociology, focusing specifically on evolutionary influences in human behavior. In putting forward this theory of mental disorders, he teamed with Badcock, a sociologist. Family therapy has, throughout its existence as a profession, benefited from the contributions of outsiders. Psychology may now be getting a similar shot in the arm.

From the AAMFT Conference: Can you do effective therapy online?

There was much discussion at last week’s AAMFT Conference about online therapy: what it is, what the ethical standards are, and whether it can ever replace a therapy model where everyone is in the same room.

Beginning at the first question, the term “online therapy” is being used to reference a wide variety of approaches to offering therapeutic methods, from email to text messaging to online chat to videoconferencing. The most sophisticated model, offered by among others, pairs licensed therapists with clients via secure videoconferencing. Clients can use a simple webcam.

The ethical standards, while a bit more complicated, do not vary from the standards that always govern the field. They’re just harder to define and enforce. Confidentiality, for example, takes on a whole new level of importance when session data is being streamed across the internet. Furthermore, the constant accessibility that electronic communication offers — I’m rarely sans Blackberry — may create a “slippery slope” of boundary erosion through out-of-session emails, text messages, and so forth (Gutheil & Simon, 2005).

The final question is certainly the hardest: Can online therapy replace the traditional model of having all therapy participants — including the therapist — in the same room? Here’s at least some of what we seem to know so far, starting from attitudes and ending at outcomes. (Sorry for the lack of links, these are primarily restricted-access journal articles.)

  • Online therapy may bring in clients who would not ordinarily attend therapy. It’s easiest to think about this in regard to clients in rural settings, where a licensed therapist may be an hour’s drive away or more. But even in densely-populated areas, clients who believe there is a stigma associated with therapy or with their specific problem may be more willing to see a therapist online than in person (Nyazema, 2005).
  • The kids don’t like online therapy as much as you might think. In spite of strong computer literacy and great comfort in gathering information online, college students overall actually report negative attitudes toward seeking help online, and prefer face-to-face therapy (Chang, Chang, & Kim, 2002).
  • Online therapy is less dependent on therapeutic alliance. In face-to-face therapy, the quality of the relationship between therapist and client is strongly predictive of therapeutic outcome. In online therapy, there is still a connection between the two, but it is far weaker (Knaevelsrud & Maercker, 2006).
  • Online interventions work, but are rarely compared directly against face-to-face therapy. Online therapy has been shown effective in treating panic disorder, eating disorder, posttraumatic stress, and grief, and has shown promise for a range of other conditions (Rocklen, Zack, & Speyer, 2004). However, few studies have directly compared online therapy with face-to-face therapy, and those that do are by nature questionable. A therapist interacting online with a client will, necessarily, behave differently than a therapist in a face-to-face setting. Where differences exist, are they due to the computers themselves, or those related behavior changes on both ends?

I find myself continually torn about whether, and how, to advocate for the use of online therapy. As an educational tool, online interactions work well. As a therapeutic process, I’m less convinced — but that’s a “jury’s still out” less convinced, not an “I just don’t believe it” less convinced. Your thoughts are most welcome.


Chang, T., Chang, R., & Kim, N. Y. (2002, August). College students’ on-line help-seeking attitudes and behaviors. Poster presented at the annual meeting of the American Psychological Association, Chicago.

Gutheil, T. G., & Simon, R. I. (2005). E-mails, Extra-therapeutic Contact, and Early Boundary Problems: The Internet as a ‘Slippery Slope’. Psychiatric Annals, 35(12), 952-960.

Knaevelsrud, C., & Maercker, A. (2006). Does the quality of the working alliance predict treatment outcome in online psychotherapy for traumatized patients? Journal of Medical Internet Research, 8(4), no pagination specified.

Nyazema, N. D. (2005). HIV/AIDS stigma and shame: On-line psychotherapy. In N. S. Madu & S. Govender (Eds.), Mental health and psychotherapy in Africa, pp. 441-449. Sovenga, South Africa: UL Press of the University of Limpopo – Turfloop Campus.

Rocklen, A. B., Zack, J. S., & Speyer, C. (2004). Online therapy: Review of relevant definitions, debates, and current empirical support. Journal of Clinical Psychology, 60(3), 269-283.

Executive functioning: Smarter than intelligence?

I’m quickly becoming a fan of Wray Herbert, who writes the blog We’re Only Human. His posts are concise and interesting, and at the forefront of psychological science.

In a new piece for Newsweek, Herbert talks about “executive function,” a not-new concept being given new life through the educational system. It has shown promise as a method of bringing children (younger ones in particular) who otherwise may have difficulty attending to tasks up to speed in the classroom.

While apparently I attended much kinder schools than he did — I’ve never known of a kid being tagged with an antisocial personality label for simply being fidgety, as his lead paragraphs suggest — I will be particularly interested in seeing how some of these same methods work in trials as treatment for ADHD. Good stuff.

From the AAMFT Conference: The transformation of marriage

I’m in Memphis for the big AAMFT Conference, and today saw probably the best presentation in the 10-ish years I’ve been going to the thing.

I’ve always been a fan of the work of Stephanie Coontz, in particular her book “Marriage, a History: How love conquered marriage.” Today, though, rose her to another level. Racing through as much data as she could in a 55-minute speech, she covered far more ground than I can describe or even recall here, and pretty much ensured that I’ll be buying the conference recordings.
That said, she made a couple of statements that were especially notable. I’ll paraphrase as best as I can.
First, marriage as an institution is weaker than it was some decades ago. But the very forces that weaken marriage as an institution appear to also be strengthening the safety and fairness in marriage. For example: While the percentage of US residents who now say divorce is morally acceptable is at an all-time high (70%), so too are the percentages saying domestic violence and male adultery are morally unacceptable. As a country, we appear to be reaching consensus that a marriage plagued by abuse or adultery is a marriage worth leaving.
Second, parental anxiety and political hand-wringing about the time parents fail to spend with kids is probably misplaced. Yes, single mothers spend less time interacting with their children than married mothers do. But single mothers today actually spend more time interacting with their children than married mothers did in 1965. Both mothers and fathers spend more time with their kids, in fact. There is a cost: Parents only have so much time to give, and it appears that the extra time they spend with kids is coming at the expense of time alone, or more often, time with friends, neighbors, and other community influences. The very idea that the breakdown of “community” is linked to increases in parenting time is a radical one, but Coontz has the data to back it up.
She largely stayed away from politics, except to chastize both the left and the right for oversimplifying the dilemmas facing modern families and doing more posturing than working to really help families who could use it. All in all, a great presentation, and a great end to my conference. More on what I’ve seen this weekend soon.

Study: MFTs not as pro-marriage as you might think

The new issue of the Journal of Couple and Relationship Therapy is out, and it gives me the rare and happy opportunity to put in a plug for my own work. It includes a couple of surprises.

In a study I coauthored on marriage and family therapists’ attitudes toward marriage, MFTs suffered the same steady, age-related decline in positivity toward marriage previously seen among non-therapists. The big surprise was that experience doing couples therapy more than offset this decline. As therapists gained experience working with couples over the years, they grew more positive about marriage — a strong testament to the power of our field to influence clients and therapists alike.

So, ideally, if you want a supremely marriage-positive therapist, you should find someone who is about 30 years old and has about 40 years of experience.

Other findings in the new JCRT:

As an aside, I’ll be spending the rest of the week and the weekend at the AAMFT Annual Conference in Memphis, TN. I look forward to sharing what I learn upon my return to beautiful Los Angeles.

Internet Infidelity

The always-great Journal of Marital and Family Therapy is out this month with a special edition on MFT and Cyberspace. Among the findings:

  • MFTs should be aware that using the Internet as a social tool is now normal for kids and adolescents. There are assessment tools now available, including the Internet Sex Screening Test – Adolescent Version, to determine whether an adolescent’s behavior warrants treatment.
  • Just like in non-Internet relationships, men show greater concern over women’s sexual infidelity, and women show greater concern over men’s emotional infidelity.
  • Among a sample of university students, neither men nor women believed that a cybersex relationship implied a love relationship (or vice versa).
  • Over the past two years, therapists report an increased frequency of clients coming to therapy to address cybersex issues. Many therapists feel unprepared for this work.
  • Therapists apparently allow several biases to impact their assessment and treatment of internet infidelity cases. Therapist decisions are impacted by factors including the client’s gender, therapist’s age, therapist’s gender, therapist’s religiosity, and therapist’s personal experiences with infidelity. In regard to client gender, men are far more likely to be labeled “sex addicts” than are women engaging in identical behaviors.
  • For family members concerned about a loved one’s cybersex behavior, there is an empirically-supported and manualized method for bringing that person into treatment, known as the ARISE model.

All fascinating stuff. I’ve seen in my own practice a number of couples dealing with issues of internet infidelity over the past few years, and suspect that this will only become more common. It’s good to see our field pursuing assessment and treatment models that specifically address it.


Family Therapy Magazine gave extensive coverage to the autism epidemic in its May/June edition, focused (appropriately) on how therapists can help families with children who may be autistic.

Discussion of potential causes for autism is pretty limited:

There is no known single cause for autism, but it is generally accepted that it is caused by abnormalities in brain structure or function. Brain scans show differences in the shape and structure of the brain in children with autism versus neuro-typical children. Researchers are investigating a number of theories, including the link between heredity, genetics, and medical problems… Research indicates that other factors besides the genetic component are contributing to the rise in increasing occurrences of ASD, such as environmental toxins.

Again, it is appropriate that a magazine focused on treatment not get distracted by debates about causes. But there is a large number of very interesting, if not yet definitive, studies on what exactly causes autism spectrum disorders.

The most controversial potential culprit is thimerisol, a mercury-based preservative used in many childhood vaccines. The demonization of thimerisol was given a huge push thanks to this Rolling Stone article, which gave only passing mention to the fact that large-scale studies have pretty thoroughly debunked the idea.

It has also been argued that a potential cause is the vaccines themselves, which are much more numerous and on a much shorter schedule for children today than a generation or two ago.

One of the most interesting potential causes for autism is television.

Don’t misunderstand, I love Rock of Love as much as the next guy. But a 2006 Cornell study came up with some surprising conclusions, summarized well in Slate:

The researchers studied autism incidence in California, Oregon, Pennsylvania, and Washington state. They found that as cable television became common in California and Pennsylvania beginning around 1980, childhood autism rose more in the counties that had cable than in the counties that did not. They further found that in all the Western states, the more time toddlers spent in front of the television, the more likely they were to exhibit symptoms of autism disorders.

Notably, that Slate article was posted in October 2006 when the study came out; some two years later (July 28, 2008) it was Slate’s most emailed article, and continues to get regular cycles of attention.

Obviously, we’re talking about correlation here, not causation. When cable television comes to town, it does not arrive alone; it is typically evidence of increasing urbanization, which tends to involve a lot of other questionable influences in the environment as well. So we’re probably looking at two symptoms of the same (still unknown) cause.

Unless, of course, we are not. One of the leading theories of autism has to do with mirror neurons, those parts of the brain that light up as we watch others engage in specific activities, as though we were doing the activity ourselves. Mirror neurons are vital to learning through modeling, and in kids with autism, they do not respond in the same way that mirror neurons respond in non-autistic children.

I suspect — without proof, mind you — that in order to properly develop, mirror neurons require that the people we are watching in our formative years be responsive and interactive, engaging our active attention. In other words, be like parents. Cable television is regularly used as a babysitter, which is fine; my brother and I spent many an hour watching Thundercats and having breakfast while Mom was getting ready for work. But television is not responsive, and would seem far less likely to engage the mirror neurons than a real live person would.

In short, I’m far from being ready to blame television for autism, but there is a certain logic to the theory that fits well with some existing biological evidence. I’d welcome your thoughts.