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 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.


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.

Marriage and the economy

Slate engaged in a bit of a bogus trend story earlier this week, usually something the online magazine makes a habit of mocking. Under the title “Unwashed coffee mugs,” the story aims to educate us on the toll that the faltering economy has taken on marriages.

Let’s start with what the article gets right: 82 percent of the recession’s job losses have been suffered by men. As of last year, 25 percent of wives out-earned their husbands, a number that almost certainly has climbed with recent layoffs. And time-use data does indeed show that after men lose their jobs, they don’t suddenly find themselves inspired to do more housework; instead, “they spend more time sleeping, watching TV, and looking for a job.”

Getting to what that means for marriage, of course, is trickier.

To be sure, money is a common source of conflict in marriages. But the actual effects of recession on divorce rates are not that large:

Census Bureau figures show that over the past 2 1/2 decades, recessions have had only minor effects on divorce rates, which have been slowly waning since the early ’80s after 20 years of steadily rising. Those trajectories have been influenced more by the rise of the women’s movement and women’s earning power, lower fertility and changes in divorce laws than by dour Dows. The only recorded spike in divorces in the past 75 years came right after World War II.

Expect to see a lot more speculation about money and marriage over the next few months — it’s a common (and easy) theme to strike in writing about family life. But bear in mind that there are contradictory forces on families in a recession; they may suffer greater stress as a result of financial woes, sure. They also may be more likely to come together as a family to make it through a difficult time. Beware of stories that draw conclusions beyond what their data can support.

MFTs (finally) earn job classification with Veterans Affairs (VA)

My friends at AAMFT Government Affairs have great news: The Department of Veterans Affairs (VA) has finally approved a new job category for marriage and family therapists (MFTs)! This has been a long time in the making, as the VA had dragged its heels since the law mandating such a job category was enacted in December 2006.

Partial text from the AAMFT letter to members follows.

Despite the uncertain timeframe for necessary next steps within the VA, the AAMFT will continue to advocate on behalf of the MFT profession to see that there is swift and fair resolution to final VA implementation. The AAMFT will be working alongside the VA Human Resources’ office to formalize the establishment of new qualification standards for these emerging VA positions. They have indicated that they will seek counsel with our professional organization moving forward as an MFT subject matter expert for the actual development of these classification standards.

Ever since Public Law 109-461 (the Veterans Benefits, Health Care, and Information Technology Act) was signed back in December of 2006, the AAMFT has been vigilant in pushing for its resolution and enactment, allowing veterans’ around the country access to the services of MFTs. Over the last few months, AAMFT joined forces with the American Counseling Association (ACA) and the American Mental Health Counselor’s Association (AMHCA). In recent weeks, the California Association for Marriage and Family Therapy (CAMFT) also signed onto the united front of AAMFT, ACA and AMHCA. These latest initiatives have been aimed at getting Congress to vocally express its desire for “the will of law” to be adhered through swift VA implementation of MFT and Licensed Professional Counselors (LPCs).

Government to compare treatment effectiveness

There’s an interesting slice of the federal stimulus bill aimed to improve health care, according to this morning’s New York Times. In the interest of improving the quality of health care in the US, and reducing its cost, the government will spend up to $1.1 billion “to compare drugs, surgery, and other ways of treating specific conditions.” Those “other ways” include both talk therapy and “watchful waiting” for some conditions.

The money is a response to the soaring cost of health care, which will account for a quarter of the Gross Domestic Product by 2025 without major changes. Several forms of family therapy have been established as cost-effective treatments for specific conditions, but these treatments have failed to gain as much attention (or use) as they arguably should.

Critics of the program, according to the article, worry that it would lead to the rationing of some treatments, or their disallowance. Doctors, however, seem to largely favor increased research that will give them more direct guidance on how and when to choose one form of treatment over another.

Count me with the doctors. Family therapy works, and is often as good as (if not better than) individual therapy in treating specific conditions. Depression is a great example. We know couple therapy can be used in the treatment of depression, but have little guidance as to when couple therapy would be preferable to individual treatment. Any research that can help inform that decision is a good thing.

Fringe practices: Thought Field Therapy

This is the first of a series of posts I’ll be writing on practices at the fringes of the field of marriage and family therapy. Generally speaking, these practices lack sound scientific backing, yet make fantastical claims about effectiveness. They usually are practiced by a small (and often highly devoted) group of practitioners. They also often require expensive training.

Bear in mind that the lack of a scientific backing does not mean that a practice is necessarily ineffective, or that it is not valuable. All new treatment models start out without a strong research base, and then build legitimacy through a combination of research and clinical experiences. Some well-accepted models, like Narrative Therapy, by their nature cannot be studied in traditional clinical trials. They build scientific legitimacy through qualitative study and process research.

Information on fringe procedures is typically presented in a one-sided manner. You usually get either the sales pitch for the procedure, or all the arguments against it. My intent is not to advocate for or against the use of these procedures, but rather to provide a complete picture of both sides. As always, I welcome your comments.

Thought Field Therapy (TFT) seeks to create healing by repetitive motions (such as tapping) on several “acupressure points” on the body, primarily on the hands, face, and upper body. Patients are also often instructed to visualize a distressing situation as they engage in repetitive behaviors, such as repeating a phrase or counting. A summary of a brief trauma treatment sequence is available here.

Claims of effectiveness. Proponents focus on the impact of TFT on heart rate variability (HRV), considering HRV an indicator of overall health and mortality. They suggest TFT is the only known treatment to dramatically impact HRV. The treatment is said to dramatically impact other conditions as well, offering

immediate relief for PTSD, addictions, phobias, fears and anxieties by directly treating the blockage in the energy flow created by a disturbing thought pattern.

TFT practitioners claim that thousands of clients have been treated successfully with TFT without side effects. They claim effectiveness rates of up to 97 percent. The practice of TFT is usually done in person, but Roger Callahan, the US psychologist who developed TFT, claims that TFT “voice technology” treatments done by phone can stop atrial fibrillation in a matter of minutes. He claims six such successful treatments. His company also produces a quarterly publication, The Thought Journal, with case studies of successful treatments submitted by practitioners.

Lack of sound scientific backing. The Thought Journal is labeled a “journal,” but is not subject to the peer review process or publication standards of accepted academic journals. Overreliance on testimonials and anecdotal evidence in the absence of scientific study is one of the defining characteristics of a pseudoscience. Controlled research is lacking, which is why the American Psychological Association has deemed TFT to be without scientific support. Five articles on the method were published without peer review in the Journal of Clinical Psychology in 2001 — and in each case, the articles were deemed uninterpretable due to major methodological flaws. James Herbert, a psychology professor who wrote a review of the existing TFT research, found the scientific backing for the treatment to be “basically nonexistent” and that there is “no evidence it does what it claims to do.” Since 1999, the APA has refused to grant continuing education credit to its members for TFT training, and there has been at least one instance of a psychologist sanctioned by the state licensing board for using TFT and making inflated claims about its effectiveness. There is some emerging research on “energy psychology” techniques, though their effectiveness appears to be based more on the relationship between client and therapist than on the techniques themselves.

A small and devoted group of practitioners. The lack of supporting evidence is no deterrent to proponents of the method. (Shifting the burden of proof to those disproving a model’s effectiveness is another characteristic of a pseudoscience.) TFT training centers exist at various locations around the country. TFT practitioners can be located through directories on the TFT web site.

Expensive training. Callahan charges $100,000 for training in “voice technology,” which is considered the highest training level in TFT. This training is completed in three days of one-on-one work with Callahan. The TFT web site lists 14 individuals other than Callahan who practice at this level.

Is it useful? For some, yes. I highly doubt that the many case studies of success with TFT are fictional. The question becomes, what is it about TFT that is working for many clients? Is it the sequences of behavior? Is it the relationship with a caring and concerned professional? Is it a placebo effect generated by the simple promise of a fast and effective cure without side effects? Here is where the burden of scientific proof falls on the proponents of the model, to prove that their techniques are somehow different from, and superior to (or at least as good as) accepted models. It is a burden they have not met.

However, in cases where other methods of treatment have not worked, clients may be interested in pursuing alternative methods like TFT. Whether licensed professionals — who should be working from positions of scientific support wherever possible, and making only cautious claims of likely effectiveness — should offer such treatment is a more complicated ethical question.