Ben Caldwell

The upside of overdiagnosis

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Yes, we’re pathologizing everyday life. But that also makes it easier to ask for — and get — help.                                                                                                                                                                                                                                                                                                            

DepressionThere’s a nice column on PsychCentral today asking the question, “Are we over-diagnosed and over-medicated?” Author Linda Sapadin isn’t asking whether we are diagnosing people who fail to actually meet diagnostic criteria; that’s also worth debating, but not the point here. She’s challenging the diagnostic criteria themselves. Her voice adds to the chorus of those concerned about changes coming in the DSM-5 this May, particularly those that will make it easier to diagnose a grieving person as having major depressive disorder.

There are clear downsides to broadening the diagnostic criteria for any mental health disorder. Such a shift means that more people who are functioning within normal ranges (which is not to say they are functioning well, mind you; we’re talking about people who are still suffering, it is just that the suffering is common) will qualify for a diagnosis and then receive treatment. This adds to our growing healthcare costs. It arouses skepticism of the overall legitimacy of mental health care, leading some to wonder whether these changes are driven (at least in part) by pharmaceutical companies looking for new people to sell drugs to. It also risks sending the message to more people that they are mentally ill, that there is something wrong with them, when in actuality their functioning is quite normal and their suffering would possibly resolve on its own without treatment.

But such discussion is incomplete unless we also look at the upside of broadening diagnostic criteria. Just because a person’s suffering is within normal ranges does not mean we should refuse, as a mental health field, to make help available. Bereavement is a prime example. Not everyone who is grieving the loss of a loved one needs medication. But for those who cannot seem to resolve their grief, those who feel genuine struggle and suffering, those who want treatment to help them function better — broader diagnostic criteria makes it more likely that they will be able to get treatment and have it paid for through their insurance.

It’s also possible that having broader diagnostic criteria can help reduce the stigma of a mental health diagnosis. If we looked at these diagnoses as more like colds (almost everyone gets them sometimes) and less like the plague (rare and frightening), it would be easier to publicly discuss one’s mental health struggles without shame.

I realize there is more to this, and I’ll confess I’m not yet sure where I land on many of the DSM-5 changes. There are reasonable questions to be asked about whether someone should be able to receive mental health treatment (particularly on someone else’s dime, whether that someone else is the taxpayer or other members of their health plan) simply because they feel they need it. Widespread use of psychotropic medications has serious public health and environmental consequences. And the national shortage of well-trained mental health workers means our system is already strained by current diagnostic criteria. But anyone who presumes that broader diagnostic criteria are automatically bad is failing to consider the whole picture. There are some potential benefits of allowing more people who at the edges of normal functioning to qualify for diagnoses.

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The DSM-5 comes out in May; you can learn more about it here. Your comments are welcome. You can email me at ben[at]bencaldwell[dot]com, post a comment below, or find me on Twitter @benjamincaldwel.

Northcentral University becomes first mostly-online program to earn COAMFTE accreditation

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Their masters program uses practicum site supervisors as co-instructors, meeting COAMFTE’s requirement for in-person education.                                                                                                                                                                                                                                                                                                            

Books-aj.svg aj ashton 01The Commission on Accreditation for Marriage and Family Therapy Education announced just before the holiday that Northcentral University, one of five online programs (or in their case, mostly-online programs) I discussed in this recent post, has become the first such program to earn COAMFTE accreditation. (Here’s why COAMFTE accreditation matters to students.)

As I mentioned previously, they appear to use practicum site supervisors as co-instructors for the practicum class, thus meeting the COAMFTE requirement (page 8) that at least some instruction in any accredited program be provided in person.

This is a milestone for graduate education in MFT, though I will confess I am not quite sure what meaning to put to it. That’s a longer discussion I’ll put in another post. For now, my hearty congratulations to the faculty, staff and students at Northcentral for a significant achievement!

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In the interest of full disclosure, I have served in the past as a COAMFTE Site Visitor, but I had no involvement with the accreditation process for Northcentral and have no affiliation with that university.

Your comments are welcome. You can email me at ben[at]bencaldwell[dot]com, post a comment below, or find me on Twitter @benjamincaldwel.

Online MFT programs

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Are you interested in getting your marriage and family therapy degree through an online program? Here are five MFT programs that are mostly or fully online.                                                                                                                                                                                                                                                                                                            

Computer and screenOnline education holds the promise of extending the reach of marriage and family therapy training. Champions of these programs argue that they make advanced education available to those who otherwise might not have access to it, due to scheduling, geographic, or other barriers. It is possible that the growth of online MFT programs will particularly help bring cultural diversity and rural practitioners into our community of licensees.

Of course, there are also general concerns about online education, including dropout rates, profit motives (as many online schools are for-profit), and overall effectiveness.

In the MFT field, online education seems to be an especially challenging proposition: We need to train practitioners in the art and science of relating, face-to-face, in a way that will heal clients and their family relationships. That is a skill set, and one that would seem to require a fair amount of face-to-face interaction to be best developed, shaped, and observed.

Online graduate programs in MFT are experimenting with a number of creative ways to resolve this dilemma — and also keep themselves eligible for COAMFTE accreditation. COAMFTE has tried to walk a difficult middle ground in its educational standards, saying that MFT programs can employ some distance education but not be fully online; since “fully” means “fully,” it would seem a program could get around the letter of this requirement simply by requiring a one-hour meeting on campus at some point during the educational process. But many of the online MFT programs appear to be genuinely interested in maximizing the potential benefits of online education alongside a recognition of the need for in-person work to develop relational skills. As such, many have integrated in-person events and coursework into their online curricula.

Below you will find a list of five MFT programs that are mostly or fully online. Some things to know about all of these programs: 1, As of early December 2012, none of them have yet earned COAMFTE accreditation. (Here’s why COAMFTE accreditation matters to you.) That is only one consideration in choosing the right MFT program, but it is worth considering. [Update 2013: Northcentral is now COAMFTE-accredited.] 2, The information here is drawn from the universities’ web sites. Information can change quickly. 3, Any cost statements do not include books, supplies, living expenses, or the cost of travel or lodging for any required in-person events. 4, It is always the responsibility of the student to ensure their academic program will meet the requirements for licensure in the state where they wish to be licensed; check with your state’s licensing board before choosing a program and remain up-to-date as state requirements change. 5, States typically require hours of supervised experience in a clinic setting as part of the graduate degree; the schools also have this requirement, and offer varying levels of assistance in locating placements. 6, And of course, requirements and costs can change quickly; the information here is as of December 2012, and you should check with the schools for current information.

  • Touro University Worldwide is based in Woodland Hills, CA and has been rapidly growing their Master of Arts in Marriage and Family Therapy program. Part of this is due to cost; at $500 per unit, Touro’s program is less expensive than some of their competitors. Their 60-semester-unit program is delivered in eight-week terms (six of them per year). This program is fully online.

  • Northcentral University is widely considered a pioneer in online MFT education. Members of their faculty have spoken at past AAMFT Annual Conferences about their efforts to comply with COAMFTE standards [Update 2013: Northcentral is now COAMFTE-accredited]; it looks to me like they do so by utilizing site supervisors as co-instructors with university mentors for the practicum courses, which would then be considered in-person instruction. The Northcentral MA in MFT program is a 45-semester-unit program that can be bumped to 48 or 60 units for those living in states requiring more units for licensure. They also offer a PhD in MFT that requires an additional 72 semester units.

  • Capella University offers a Master of Science degree in Marriage and Family Counseling/Therapy. They have quickly grown this program to national prominence and notably earned CACREP accreditation. To their credit, they list cost information plainly and prominently on their site: Their 92-quarter-unit degree, at $458 per credit, will run about $40,000 in total tuition. The program requires two six-day colloquia in to accompany the online instruction. Like many online schools, Capella is for-profit, which may or may not matter to you. (I’ll do a separate post in the next few months on non-profit versus for-profit schools.)

  • Liberty University promises an affordable online MFT masters degree with a Christian perspective. They advertise themselves as the nation’s largest private, nonprofit online university. Their MFT program requires four one-week intensives to accompany the online instruction. Unfortunately, the information on their web site is surprisingly thin — I could not locate a program plan (curriculum) or specific cost information anywhere on their site.

  • Cal Southern University offers a Marriage and Family Therapy concentration within its Master of Arts in Psychology program. This 63-semester-unit program is entirely online.

There are other online programs out there as well, I’m sure. Feel free to share info on them in the comments, and I’ll update this post every once in a while with more recent additions.

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Your comments are welcomed; you can email me at ben[at]bencaldwell[dot]com, post a comment below, or find me on Twitter @bcmft. I regret that I cannot answer every comment personally, but I do chime in on the comments when I can!

California’s complicated new elder abuse reporting law

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California law has changed dramatically for mandated reporters of suspected elder or dependent adult abuse. The good news: The changes only impact some instances of abuse. The bad news: The law is a needlessly complex mess.                                                                                                                                                                                                                                                                                                            

Elderly couple with ear muffsWhile the California legislative process often works quite well — witness the passage of SB1172 — a pair of other bills that got far less attention this year will also impact the practices of MFTs, LCSWs, and LPCCs (and all psychotherapists) in the state.

California’s requirements for mandated reporting of elder and dependent adult abuse have changed significantly. These changes have already taken effect, because one of the bills putting the changes into place was marked as emergency legislation. The new law replaces what had been a single standard for when and to whom reports are sent with five different standards based on the specifics of the situation — specifics that, under the law, mandated reporters are not required to investigate.

“Wait, what?” is a fully appropriate response here.

Assembly Bill 40 began in 2011 as a response to an information-sharing problem. When elder or dependent adult abuse takes place in a long-term care facility (such as a nursing home), mandated reporters could report to either law enforcement or the county ombudsperson (a sort of resident advocate for those in long-term care). However, there were problems with information-sharing between ombudspersons and law enforcement, so AB40 initially would have required mandated reporters to send their written reports of suspected abuse to both.

It was a dumb and expensive way to solve the information-sharing problem, forcing therapists to take the time to make duplicate reports rather than just fixing the information flow between ombudspersons and law enforcement. Some of California’s mental health professionals jumped in to oppose the measure.

But it moved forward anyway, with the support of ombudspersons and law enforcement organizations. AB40 was amended many times through its journey through the legislature, and many of the same changes were proposed in Senate Bill 1051. Where the process ended is this:

As of today (because SB1051 was marked emergency legislation, it took effect September 27, 2012, immediately upon the Governor’s signature), mandated telephone reports of suspected elder or dependent adult abuse in California must be made “immediately or as soon as practicably possible” in some cases, “immediately, and no later than within two hours” in others, and within 24 hours in others. Written reports must be sent to various combinations of law enforcement, adult protective services, county ombudspersons, and facilities’ licensing agencies — requiring triplicate reporting in some instances. Filing reports via Internet appears to be allowed in some instances and not others. And the acceptable time frames for written reports will now vary as well, from 2 hours to two working days. These combinations are based on:

  • Whether the abuse took place in a long-term care facility
  • Whether the abuse was physical abuse
  • Whether the abuse resulted in serious bodily injury
  • Whether the abuse was caused by a resident with a physician’s diagnosis of dementia

For the problems that existed with the old standard, at least mandated reporters could be reasonably expected to know who they needed to report to, and when. The new standards are simply too complex to be held in memory, and will likely result in many reports being sent to the wrong places at the wrong times.

It’s bad law.

But it is currently the law of California. So mandated reporters will need to be able to determine where their reports should go and when.