Ben Caldwell

Non-groundbreaking study: People who work on an unhappy relationship sometimes succeed

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Couple TimeJust as you would with any “One simple trick” ad, you should be skeptical of a headline like this:

New Study Reveals Secret To Saving Your Marriage After Infidelity

Uh, yeah, no. HuffPo summarizes a recent UCLA/University of Washington study on couples who experienced infidelity. The study found:

Over the course of the study, 19 of the couples experienced infidelity by one or both partners. Of those couples who cheated, 74 percent revealed their infidelity before or during the study, while 26 percent kept it secret (it was later discovered by researchers).

That distinction became very important in determining which relationships survived. At the end of five years, 43 percent of couples who had revealed the infidelity were divorced compared to 80 percent of the couples whose infidelity was kept secret.

Leaving aside the time-shifting abilities couples apparently displayed here (if I’m reading that right, apparently some couples revealed before the study an instance of infidelity that happened during the study), those numbers are almost surely wrong. More than 19 couples probably experienced infidelity over that time, and however far the actual number is over 19, those couples didn’t tell the researchers about it ever.

Let’s presume that some couples experienced infidelity and the researchers never knew, either during or after the study. That’s not a stretch; many couples don’t report their infidelity, for a variety of reasons. Of these couples, of course some broke up and others stayed together. What would that do to results? Potentially quite a lot.

The report says that 80% of couples who kept their infidelity secret for a little while broke up. That sounds like a more formal way of saying four out of five, because it is literally four out of literally five. Such a small sample should immediately raise your skepticism. If even just three other couples in the study experienced infidelity, didn’t tell the researchers about it, and stayed together, the divorce rate for secret-keeping couples would drop to 50% — a rate that (statistically speaking) isn’t meaningfully different from the 43% divorce rate among couples in the study who revealed their affairs.

Even leaving aside the issues here about how much research participants can be trusted to self-report cheating, this is also an example (common in couples research) of mistaken assumptions about causation. The researchers here are suggesting that, quite often, acknowledged secret-keeping about infidelity led a marriage to break up. But it is just as plausible that the opposite is true: The breakup caused the secret to come out to the researchers. Neither partner would have as much reason to keep infidelity a secret once their relationship had ended.

Now, I can certainly tell you from my own clinical experience that for many couples who come to therapy, the full disclosure of infidelity is vital to keeping their marriage together. But I can also tell you that there are couples who experience infidelity, don’t reveal it to their partners, don’t go to therapy, and still stay together. Is one route better than the other (or at least likelier to lead to a lasting and happier marriage after cheating)? Perhaps. But this study, with its small sample sizes and its unjustified conclusions, doesn’t get us anywhere closer to knowing. All it actually tells us is what we already knew: That sometimes, couples who choose to work on their relationship after revealing an affair are indeed successful in keeping their marriage together.

Would anyone buy stock in a future therapist?

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CurrencyThere’s an interesting alternative to the student loan model of financing education floating around: In essence, sell stock in yourself.

On Wednesday, Senator Marco Rubio and Representative Tom Petri introduced legislation defining “income share agreements” (ISAs), which are basically contracts where investors could fund your education in exchange for a percentage of your future earnings. Under such agreements, which are expressly not loans, an investor could lay claim to a limit of 15 percent of your future income under a contract that could last no more than 30 years. (Those are just upper limits. Presumably most contracts would be shorter and have lower percentages of income involved.)

The idea is interesting, and worthy of consideration insofar as it transfers the risk associated with education funding away from the student and their family. One of the worst possible outcomes of taking out tens of thousands of dollars in student loans is then not being able to pay it back, either because you failed to finish your degree or, once you did, there simply weren’t enough well-paying jobs in your field. Changes in bankruptcy law have made it much more difficult to get out of student loan debt even in difficult circumstances. Under the proposed ISA rules, on the other hand, it would be the investor who would be out of luck, not the student.

Unfortunately, that doesn’t mean that selling stock in yourself is a good idea for a prospective student in the mental health professions of psychology, counseling, clinical social work, and family therapy. For one thing, private investors may simply not be willing to fund education that is long and expensive when they look at salary data in mental health. It seems much more likely that such investors would flock to students in more lucrative fields like business, engineering, technology, and medicine.

And even if some enterprising therapy students could attract investors willing to fund their education, the kind of system envisioned with ISAs holds the potential to be rather exploitive. Let’s say, for example, that you are unable to secure enough in student loans, so you turn to a private investor to fund your education. And — lucky you! — you find one willing to take on the risk. In exchange for $50,000 to fund your education, they ask for 10% of your income per year for the next 25 years.

To a hopeful student with no other options to fund schooling, that may be an attractive offer. From the outside, though, it just looks like a classier form of indentured servitude. It’s true that if you don’t complete your degree, you would not need to pay the money back. However, because these agreements define the investment as being in the individual, and not the specific career for which you received education funding, you would still owe a portion of what you make for the term of the agreement no matter what kind of work you wind up doing. Worse, if you do complete your degree, and you do find a well-paying job after graduation, you could easily wind up paying back four or five times the amount of the initial investment. Investors, after all, would understandably want their good investments to pay off bigger if they are taking all the risk for the bad investments.

If nothing else, I admire the creative thinking on Rubio’s and Petri’s part. (In fairness, it isn’t their original idea; startups like Upstart and Pave have been working on this model for some time.) There is certainly some merit in having the most successful students end up paying the most for their education, rather than further financially punishing those who struggle the most to find work or finish their degrees. However, as it applies in mental health, this kind of a funding vehicle seems like a band-aid at best. It would keep a supply of students coming in to overly long and expensive training programs, with primarily investors and universities profiting. We still need a viable long-term solution that makes graduate training in mental health accessible and affordable for those who prove they are capable of doing the work.

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Your comments here are welcome. You can post them in the comments below, or email me at ben[at]bencaldwell[dot]com.

Training in mental health is unreasonably long

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2010-07-20 Black windup alarm clock faceJust as a quick thought experiment, go over to this piece at Slate discussing medical training, and every time it references “medicine” change that to “mental health.” (Accordingly, change “physicians” and “doctors” to “therapists.”) You’ll find most of it applies perfectly. To wit:

Over the past century, there have been additions to, but few subtractions from, the training process. Residency and fellowship programs became longer and longer … and longer.

and

The long process doesn’t just weed out the incompetent and the lazy from the potential pool of physicians—it deters students who can’t pay for so many years of education or who need to make money quickly to support their families. That introduces a significant class bias into the physician population, depriving a large proportion of the population of doctors who understand their background, values, and challenges.

and

The fundamental problem here is that the argument between traditionalists and reformers [debating the appropriate length of training] is essentially theoretical — we are in an evidence vacuum.

In the time I’ve been in academia, I’ve watched as the requirements for training in mental health have increased dramatically. Family therapist training in California increased from 48 to 60 units based not on science but on workplace competitiveness. (MFTs were fighting clinical social workers for some of the same jobs, and since LCSWs need 60 units of training, MFTs couldn’t really argue that their training at 48 units was equivalent.) I’ve also watched as education in general has gotten much more expensive, and loans harder to come by. And I’ve been enlightened by learning that our 3,000-hour supervised training requirement is based entirely on tradition, and is in virtually no way linked to the science that we now have available (though admittedly, it isn’t much) on how therapist skill develops over time.

Our old apprenticeship model is broken. It’s as true in therapy as it is in medicine. It will be interesting to see how experimentation with medical training goes, as it can blaze the trail for similar efforts in other health care professions like ours. I’m just not sure we should be waiting for doctors to do it first.

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Your comments are welcome. You can post them in the comments below, by email to ben[at]bencaldwell[dot]com, or on my Twitter feed.

Wisconsin legislature supports mental health — just not therapy

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One of the more disturbing trends I’ve seen in the mental health landscape lately is policymakers voicing support for mental health care, but not actually providing funding for anything but medication and crisis intervention.
Lots of states reduced their funding for psychotherapy during the economic downturn, and now that the economy is slowly churning back to life, there seems little appetite to restore that money so that people struggling with mental illnesses who may not be actively in crisis can be seen regularly by a therapist.
Case in point: Wisconsin, where the state’s legislature this week sent Governor Scott Walker fully a dozen bills under the banner of promoting and expanding mental health care in the state. The bills will spend a total of $4 million over two years, and the Milwaukee Journal Sentinel report on the mental health bills begins by saying the money will be spent on “treatment,” among other things, which sounds great at first. But the details of the article make clear where the money’s going, and it isn’t to psychotherapy.
Many of the bills don’t actually spend much money at all. One bill, for example, would allow “children with severe emotional disabilities to get in-home treatment through taxpayer-funded Medicaid programs without first requiring them to fail in outpatient treatment, as currently required.”
That’s certainly laudable, and as is the case with most of these bills, I do think they’re important and worthy of support. (The only ones I’m less sure of policy-wise are those that make involuntary commitment easier.) Just pointing out that the state is focusing its money on just about everything but psychotherapy, in spite of reams of evidence that therapy works.
What are they actually spending those millions on? These:

  • $250,000 in grants for mental health crisis intervention teams of law enforcement officers.
  • $1.5 million in grants for physicians and psychiatrists to practice in rural areas.
  • $250,000 in grants for “respite centers” run by (non-therapist) peers, for those in a mental health or substance abuse crisis that warrants attention but not hospitalization.
  • $970,000 to expand a state program that helps find jobs for people with mental illnesses.
  • $250,000 a year for mobile intervention teams to respond to mental health crises in rural areas.

There you have it: More than $3 million on mental health care (expenses from the other bills bring the total to about $4m, according to the Journal Sentinel), spent entirely on crisis intervention, law enforcement, medical practitioners, and peer supports. Those are all worthy expenses, but psychotherapists get nothing? That seems sort of like building a house without a place to sleep: Missing not just a key component, but arguably the most essential component.I’m not from Wisconsin, so it may well be that therapists in the state are doing just fine, thankyouverymuch. But I doubt it. I would welcome Wisconsinites to weigh in.
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By the way, there’s of course a reasonable debate to be had about the overlap between “crisis intervention” and “therapy.” Psychotherapists do a fair amount of crisis work. My point is that no money is being put into even short-term psychotherapy beyond an immediate crisis, which typically means something life-threatening.
Your comments are welcome. You can post them in the comments below, by email to ben[at]bencaldwell[dot]com, or on my Twitter feed.