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.

Angry moms, inside therapy and out

Are mothers, inside and outside of therapy, generally angry at their husbands?

Outside of therapy, moms are surprisingly angry at dads. Such is the finding of a investigation, which looked at 1,000 married mothers to get a sense of their relationships. They found that almost half of moms became furious with their husbands once a week or more. (Salon’s Abigail Kramer comments articulately on the piece.)

Meanwhile, back at the office, MFTs see a lot of angry moms as well. According to the aptly titled “What’s Wrong with These People? Clinicians’ Views of Clinical Couples” in the January Journal of Marital and Family Therapy, MFT students and faculty alike expect wives in therapy to complain, criticize, and blame their husbands for the problems that bring them into therapy. The therapists were no kinder to clinical husbands, who they expected to be hostile, fight to get the last word in, and tell their wives what to do.

What gives? Are wives so mad, and dads so bad?

Let’s start with the JMFT article. If we’re trying to get a handle on how clinicians view their clients as being different from average, non-clinical couples, then that’s the comparison you should make. This article asked MFT faculty and students to compare typical clinical couples with ideal husbands and wives, and so it makes perfect sense that against that backdrop, clinical couples would be expected to show all the negative traits listed above.

MFTs do not expect their clinical couples to be ideal, and they would be dumb to have such an expectation — most ideal couples, if they even exist, probably are not in therapy. MFTs view their clinical couples as less than ideal. That makes sense. Does that mean MFTs view their clients as any different from the rest of the population? We can’t answer that based on this article.

Now, the piece is a bit tougher to crack. It’s safe to say the results are sensationalized to get media attention, but there still seems to be a lot of anger shown in the raw data — how did that happen?

There are lots of reasons to take the article with a giant, truck-sized grain of salt. For one, we don’t know how the questions were really asked, just how the author spun them. To wit: “Lots of moms — 40 percent — are also angry that their husbands seem clueless about the best way to take care of kids.” I don’t know how that question was asked, but I’ll put down five bucks that says the survey question was not, “Are you angry that your husband seems clueless about the best way to take care of kids?”

For another, the article highlights the most angry responses, even when those are in the minority. The quote above is a great example. So, 40 percent of moms feel this way? What about the 60 percent who don’t? These moms are not highlighted in the article, not given the chance to discuss at length the quality of parenting their husbands do. Such highlighting of a minority position is consistent throughout the article, most laughably when “33% of moms say their husbands aren’t shouldering equal responsibility and are less concerned than they are about their children’s basic needs.” The other two-thirds sound a lot more representative.

Finally, there’s not much information on the sampling method. We’re told it’s nationally representative, but just because that is true geographically or demographically does not mean it is true in terms of attitudes. You could do a survey of drug users that is “nationally representative,” but that doesn’t mean their attitudes on parenting would represent the attitudes of the nation as a whole.

It is not my intent to be entirely dismissive of either piece. I just think they need to be considered in the right context. There’s not enough here to conclude that moms are really that mad, that dads are really that bad, or that their therapists are really all that judgmental.

Aging: MFTs and geriatric clients

Interesting piece in the new American Journal of Family Therapy on marriage and family therapists’ training to work with geriatric populations. MFTs’ interest in working with older clients correlated with knowledge about the topic — no surprise there — and MFTs generally believed that specialized training would be beneficial.

Unfortunately, there’s not much in the way of specialized training available, particularly gerontology training that is specific to MFT. Some programs offer gerontology certificates or even full gerontology degrees, but usually in the context of a clinical psychology program.

There is surely a need for more. By 2030, more than 20% of the population will be over age 65. And they have needs that MFTs are well-suited to address:

[T]here are unique mental health and family issues among the elderly that require specific knowledge and training. For example, health problems, many of them being chronic, are common among the elderly. Thus, differentiating health issues from somatic symptoms commonly associated with depression becomes crucial[…] In addition, therapists need to know how to deal with unique family dynamics associated with older family members, such as widowhood, caregiving, and decisions about end-of-life care for a loved one (Yorgason, Miller, & White, 2009, p. 29, emphasis added).

AAMFT’s Family Therapy Magazine has done an outstanding job covering aging issues, with special sections on “Our Aging Selves” (November/December 2002), “Perspectives on Death & Dying” (March/April 2005), and “Retirement” (January/February 2007). There is not a shortage of information available. Possibly the most interesting piece of the new AJFT study is that the MFTs who work with older populations generally believe they got adequate training to do so, but they hunger for more. Who will answer the call?

Myths about marriage

Based on current research, which of the following statements do you think is true?

  • Single people are at greater risk of violence than married people.
  • College-educated women are more likely to get married than women with less education.
  • Married people have more sex than single people, and find their sex lives more emotionally satisfying than single people find theirs to be.

(The answer is at the bottom of this post.) I’m lead author on a study in the Oct-Dec 2008 American Journal of Family Therapy on the subject of myths about marriage. Based on a survey of more than 200 marriage and family therapists (MFTs) in California, we as a profession are not as up-to-date on things as we probably should be: The average MFT correctly identified less than 10 myths out of 21. On some items — including the first two items above — less than one in ten MFTs got the answer right.

We are an older profession demographically. The average age of respondents in the survey was above 50. And, in decades of practice, the research underlying what we do advances far beyond what we were taught in graduate school. It can be difficult to keep up with all of these advances in the midst of a full-time job seeing clients, and this is why most states mandate that we receive continuing education; in California, we’re required to complete 36 hours of CE every two years.

I came away from this study wondering about two things: One, what we can do better to keep therapists informed of research advances? Members of AAMFT get the association’s magazine and its journal, both of which provide up-to-date information on the best research in the field. Unfortunately, only about 10 percent of California MFTs are members. Are there other, better ways to get the word out when science advances? And two, how does this impact therapy? The short answer is it may not. Especially if the therapist is using a well-manualized treatment model, it could be argued that the therapist’s understanding of research is not all that important. Still, I find it hard to believe that what a therapist thinks they know about marriage sneaks into therapy in small ways — the little nudges we give our clients through the questions we ask, the nonverbal signals we give, and the homework we assign. If I believe (incorrectly) that a child is better off in a stepfamily than in a single-parent home, might I subtly nudge a couple considering becoming a stepfamily to tie the knot before they are prepared to do so?

The current study will soon be replicated with multiple professions, to see how MFTs compare with social workers, psychologists, and professional counselors. It will be interesting to see whether one’s professional orientation makes a difference in what we think we know.

The answer, by the way: All three statements are true.

MFT licensure: Why 3,000 hours?

Whenever I get into conversations about the MFT licensure process, and how it differs from one state to another, similar questions come up. Earlier I addressed the fundamental question of whether license examinations make for better therapists. Another common question I hear: Why do we require 3,000 hours of supervised, prelicensed experience for MFT licensure?

(Making things more complicated, why do some states require more? California uses the 3,000-hour standard, though we categorize those hours in a goofy way. Arizona, like a handful of other states, requires 3,200 hours. At one time, New Jersey required more than twice that. They don’t now.)

It’s mostly political. As MFTs have advanced licensure around the country, we have made every effort to cooperate with other professional groups and ensure that licensure really does serve its purpose, which is to protect the public from untrained or unscrupulous professionals. Working with other professions and with the legislatures in each state has required various compromises, and most states have settled on about 3,000 hours of supervised experience as one of the requirements for licensure.

Of course, there’s no evidence that MFTs are unable to practice effectively on their own with 2,999 hours of experience and suddenly experience a magical transformation at the 3,000th hour. But there is a significant growth process, personally and professionally, that takes place during the prelicensed experience. And in most states it has been generally agreed that around 3,000 hours — that is, about two years of full-time, supervised experience — is long enough for MFTs to learn to effectively practice without supervision.

There is also a gatekeeping role supervisors play during the prelicensed time, as they can help determine whether a supervisee is unfit for the profession. Those within and outside of the profession have generally come to terms that two years of full-time supervision is long enough for that gatekeeping need to also be addressed.

While some states are moving toward standardizing their MFT licensure requirements with others, it’s interesting to note that the current trend appears to be toward making licensure easier in the mental health professions. In California, the licensing board is seeking provisions to allow MFT Interns to count client-centered advocacy among their supervised experience. Psychologists are going for an even bolder change, arguing that their 1,500-hour, postdoctoral internship is unnecessary. There is certainly a mental health workforce shortage in this country, though I will leave it to others to debate whether making licensure easier is an ideal solution.

Holiday family myths

Suicides do not increase at Christmas. No matter what newspapers say. Witness the findings of a 27-year study:

Even people with family relationship problems were less inclined to attempt to hurt themselves during the holidays. “These findings are contrary to the popular view that Christmas is a time of stress and arguments,” [Oxford researcher Helen] Bergen says. Perhaps, she says, problems within the nuclear family ease up instead of intensify when the extended family is around.

Like suicide, domestic violence has its annual peaks — and not at the holidays. While there is conflicting information about the relationship between domestic violence and the holidays, best to avoid fearmongering in the absence of actual data.

These are two especially persistent holiday myths about family life. The best scientific evidence suggests that mental health improves for our nation as a whole over the holidays, that family interaction and support actually makes us happier and better-functioning. Yet we’re bombarded, year after year, with stories about how families make us crazy.

I suppose stories of families making us better might not sell so well, and to be sure, family interactions are complicated and sometimes difficult. But for more people than not, on balance, family time is a blessing.

I’ll be taking some family time over the next couple of weeks, returning in January. See you then.