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.

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.

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).

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.