Ben Caldwell

Health care reform likely to benefit most MFTs

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At this point, it’s too early to know exactly what a final health care reform bill will look like — there are still several different proposals coming out of several different Congressional committees. However the final legislative package winds up looking, if health care reform is passed, most MFTs are likely to benefit. The only questions are “How?” and “How much?” Individual MFTs can gave tremendous impact on the answers to those questions.

Individual health insurance coverage. Most MFTs work either in private practices and/or in small businesses (including nonprofit organizations) that may or may not offer health benefits. For these therapists, insurance is often both expensive (see Kaiser Family Foundation chart, left) and difficult to come by. AAMFT does its part in helping members locate insurance options, but can’t do much when it comes to controlling costs. Health care reform is almost certain to help this large proportion of MFTs by making health care more affordable and removing barriers to coverage (e.g. pre-existing medical conditions).

Medicare reimbursement. Multiple House and Senate bills this year include provisions that would make MFTs eligible for reimbursement through Medicare. These bills may eventually be absorbed into the large-scale reform bills — indeed, one such bill (HR3200) already includes specific provisions for bringing MFTs and LPCs into Medicare — and if so, it will be vital that the provisions for including MFTs are kept. However, Medicare inclusion is currently less certain. AAMFT, AMHCA, ACA, and CAMFT are working together to counter the inaccurate claims of opponents, and are likely to need your help in the coming weeks to preserve this important part of health care reform. Stay tuned. The profession has made great strides in the past several years toward Medicare reimbursement, and with luck, this will be the year when our work pays off.

Does it matter that 80% of MFT interns are women?

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If you have been to see a therapist lately, I’d bet good money I can guess the therapist’s gender based on their licensure. You saw a psychiatrist? Probably male (75 percent as of 1996, though declining since). Anything else? Probably female. The shift among psychologists has been most overwhelming: 72 percent of 2005 doctorates were women, compared to just over 20 percent in 1970. Clinical social workers, professional counselors, and family therapists are all likely to be women.

It would be naive, at best, to say that women are more naturally drawn than men to “helping professions.” Lots of professions could be categorized as “helping,” including surgery — one profession that is still fairly gender-balanced. So what actually causes the discrepancies in psychotherapy?

Education. In social work and family therapy, the female majority continues to swell, due in no small part to larger trends in education. Women are now significantly more likely than men to start college, finish college, and go on to graduate school. In California, among those who have their graduate degrees and are working toward licensure as MFTs, a whopping 83 percent are women. An even larger 86 percent of those working toward clinical social work licenses are women.

Money. Are men staying out of these professions for simple economic reasons, the same reasons they seem to stay away from craft-selling web sites? Perhaps. Some evidence suggests that as professions shift toward higher proportions of women, pay rates in those professions decrease. If men are making career choices based on improving their chances of good pay, family therapy is something of a gamble. Pay averaged about $55,000 per year as of 2002, but varies widely based on work setting. It is certainly possible to make a six-figure salary in the psychotherapy world — I know some who were able to do so even very early in their careers — but it is not common.

Attitudes. Women in medical school in the UK demonstrate more positive attitudes toward mental illness, psychiatry, and psychiatric patients than men do. This mirrors findings from the general population in the US, where men are more likely than women to see mental illness as a personal failure. This issue gets more complicated once other gender stereotypes are thrown into the mix: In one recent study, men and women were both less likely to view “gender-typical” mental health symptoms (a man with alcoholism, a woman with depression) as genuine mental disturbances, and less inclined to help, compared with gender-atypical symptoms.

Relational factors. More than men, women in the US believe it is their responsibility to be caretakers of relationships. This element alone may be enough to explain the disproportionate gender balance in psychotherapy, as women appear to be more attuned to relational issues generally and health issues specifically.

All of these possible explanations lead us to the bigger question: So what?

Does it matter that such a large majority of therapists, especially early-career therapists, are women?

In a word, yes. It matters. It matters because graduate school continues to become more expensive, and if the genderization of the field puts downward pressure on salaries as noted above, it may become harder for therapists to make a living.

It matters because men already are unlikely to come to therapy in spite of its likely benefits; male therapists (and this is certainly arguable) may be better able to convince men to come to therapy, and to stay in therapy long enough to benefit.

It also matters because of the larger message it sends — if men and women truly share responsibility for the success of their marriages and families, how is that message reinforced with a marriage and family therapy profession that is practiced largely by women, for female clients?

Of course, none of this should be read as a value statement about therapists of either gender. We are seeing in the MFT world a trend mirrored throughout higher education and social services professions. It is important that we start asking now what this genderization will mean, whether it is a trend worth trying to change in MFT (certainly not a foregone conclusion; this could be well argued either way), and if so, how that might be done. I welcome your thoughts.

CAMFT director apologies for articles opposing same-sex marriage

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In a message on the organization’s web site, CAMFT Executive Director Mary Riemersma has apologized for the association’s publication of several articles opposing same-sex marriage. The apology is sincere, but the bigger issue remains: CAMFT is alone in the mental health world in its refusal to seriously address same-sex marriage.

As background, CAMFT (the California Association of Marriage and Family Therapists, which is has no affiliation with AAMFT or its California Division) has been harshly and rightly criticized by members, educational institutions, and in the media for their failure to make any kind of comment on same-sex marriage. Every other major mental health organization (APA | American Psychiatric Association | NASW | AAMFT) has taken a stand on the issue, and it is especially relevant to marriage and family therapists. The CAMFT board response has been underwhelming in the face of such criticism, issuing only a broad non-discrimination statement (members only) that sidestepped the important questions entirely.

In order to look like they were doing something on the issue without actually doing anything about it, CAMFT chose to publish a variety of articles supporting and opposing same-sex marriage in the May/June 2009 issue of its magazine, The Therapist. The sections were accompanied by a clear statement that while the articles presented a variety of viewpoints, the organization was not endorsing any of them.

The “pro” articles in the magazine were largely culled from scientific journals, as the science around the issue is quite clear. The origin of the “con” articles is unclear. Whatever their origin, their logic was horrible, and their arguments ranged from the potentially-worth-discussing to the blatantly homophobic and inflammatory.

Executive Director Mary Riemersma has now apologized for the publication of the “con” articles, and the entire issue of the magazine has been removed from their web site. (The next logical question, “Why were the ‘pro’ articles removed too, when there wasn’t a problem with them?” actually is answered in CAMFT’s non-stance on the issue. Leaving up the “pro” articles while taking down the “con” would appear to be endorsing the pro-same-sex-marriage point of view. As long as CAMFT is refusing to take a position, they were obligated to take down both sides.) The apology, which appears on the organization’s web site but is restricted to members, reads:

I am sorry that the objectionable articles appeared in the prior issue of The Therapist and that many found them offensive. I too found them distasteful and did not think they were credible. We were trying to create a balance of views and there was a paucity of articles submitted opposing marriage equality. If I had it to do over, we would have rejected the articles. Our ethics for the profession do not condone homophobia, I do not tolerate homophobia, and neither does the CAMFT Board. Let me know what we can do to overcome the unintended harm that some believe we have caused.

It’s not an outstanding apology, as apologies go (the phrase “these articles were homophobic,” or anything to that effect, is conspicuously absent, and “some believe” is a little grating), but it’s about as far as Riemersma can go. She’s responsible for the operations of the magazine, but the board determines CAMFT policies. And by staying silent on such an important issue, the CAMFT board wades father out of the mental health mainstream by the day, and harms the reputation of the profession of marriage and family therapy around the country.

Who will apologize for that?

Update: Apparently — and to their great credit — CAMFT will.

The short, successful relationship?

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In the Sex and the City movie, lead character Carrie Bradshaw narrates something to the effect of “Not all great love stories are novels. Some are short stories. But they are just as filled with love.” Can a relationship with a short life span be properly labeled a success?

It’s not just a philosophical question. Marriage and family therapists must regularly wrestle with the question of how “pro-marriage” or “pro-relationship” to be with their clients. We balance the ethical requirement, to respect clients’ freedom to make their own decisions about their relationships, with the research base for our field, which shows that (1) people live happier, healthier, and wealthier lives when they stay married, and (2) a large majority of couples who stay together through difficult times report strong marital satisfaction five years later.

In my own practice, I am unabashedly pro-relationship. I tell clients who come in for Emotionally Focused Therapy that I will work to preserve and improve their relationship until they call me off, no matter how desperate the situation may seem. Final decisions on whether to stay together are always up to them, but they need to know what I believe and how I work — another ethical responsibility, this one for informed consent.

In “A Vindication of Love,” Christina Nehring argues that short, passionate relationships are no less noble, and may be more so, than the modern standard of a long-term, companionate marriage. Passionate relationships, even if brief, force one to live in the moment, to experience life in a deeper, more mindful way than is possible when planning out a long-term coexistence. Meghan O’Rourke at Slate was not convinced, and I tend to side with her.

Still, the topic leads me to think about the couples who come to me for therapy. Of course, many come in seeking to restore or strengthen their mutual sense of security and stability in the relationship, to ensure they can make it over the long term. But there are also those who seek exactly what Nehring vindicates: Immediacy, passion, feeling. These couples often have security in spades — they have a strong commitment to each other (and, often, their children). What they want is to get out of that long-term mindset and back into the intense, spinning experience that, ironically, may have led to the conception of said children.

There’s nothing wrong with either goal, of course. And as therapists, we’re able to accommodate either, though I would readily admit therapy tends more toward the restoring-security side than the restoring-passion. (With notable exceptions.) But in either case, we’re talking about therapeutic processes designed to maintain and strengthen a long-term relationship. I’ve never had a client openly tell me, “I would happily trade the security I feel now for a little excitement,” possibly because they believe it sounds immature or hedonistic. Yet that precise willingness is often reflected in their behavior, through affairs or other kinds of risk-taking that may enliven the moment but damage the primary relationship. So therapy sometimes will seek to heighten excitement or intimacy without negatively impacting the couple’s security — see “Mating in Captivity” — a trade that some couples find difficult if not impossible.

The careful balance between excitement and security is often a challenge for one person on his or her own, and becomes even more complicated when two people, whose needs change over time, are involved. A short relationship can be filled with love, and could be labeled a success if it meets the goals and desires of both partners — of that I’m sure. Whether short, risky relationships are a worthwhile goal for therapy… that’s a whole different question, and much harder to answer.

CAMFT articles supporting traditional marriage: A detailed response

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CAMFT’s latest issue of The Therapist claims to provide a somewhat balanced look at perspectives for and against same-sex marriage. The articles opposing same-sex marriage deserve a detailed response.

Full disclosure: I personally support same-sex marriage, and also believe a meaningful argument can be made against it, based primarily on the strange intertwining of marriage as both a religious and governmental institution. As you’ll see below, I believe there are genuine ethical issues that will need clarification from mental health associations as gay marriage moves forward, to ensure that religious counselors are not discriminated against. In other words, there is a worthwhile discussion to be had here, on issues of ethics, law, and spirituality. Unfortunately, most of the articles presented in CAMFT’s magazine feature irrelevant or inaccurate arguments, which is too bad. I’ve previously discussed why I believe the “debate” as CAMFT presents it is fundamentally flawed, but that was more of a broad-brush response. Below are more detailed responses to each article in the “Supporting Traditional Marriage” section.

An Inside Look at Gay Parenting

The lead article in the section details one woman’s horrific childhood with a father who had horrible boundaries around his daughter and many male partners, but notably, stayed in a heterosexual marriage. Without a doubt, she genuinely suffered in her home, and I feel for her. Her plight, though, cannot be taken as an indictment of all gay parents any more than one case of horribly abusive, boundary-free heterosexual parenting can be taken as an indictment of all mother-father couplings. The author’s experience was clearly very painful, but it is not the norm for any parents, gay or straight. It also does nothing to advance the marriage argument, given that her mother and father apparently remained married through the traumatic childhood she recounts.

Developments Ensuing Upon the Legal Recognition of Same-Sex Marriage in Massachusetts

To his credit, author Scott FitzGibbon gets his facts mostly right, and his article is well-referenced from relatively objective sources. I simply don’t understand his alarmism.

As legalization of same-sex marriage in Massachusetts was arriving, Boston Public Schools developed a zero-tolerance policy for hate speech, including speech that would result in bias against gay or lesbian students. (“Bias” being a fairly vague term, the Boston policy has since been clarified to apply only to speech or action that results in a “hostile or discriminatory environment,” a fairly important fact to be excluded from the article.) Zero-tolerance policies are generally bad policies, but this policy is neither especially egregious nor especially gay-friendly. Yes, teachers would be subject to discipline if their speech or actions resulted in a hostile environment against gay or lesbian students. They would be equally subject to discipline if their speech resulted in a hostile environment against straight students, or religious students. It’s bad policy, but it’s equal treatment.

The US District Court for Massachusetts has held that the state’s schools have a responsibility to present students with materials that will foster respect for diversity. While the decision focused on same-sex families, its principles apply equally to religious diversity. FitzGibbon warns of the “absence of a reference to promoting critical thought,” as though teaching respect for diversity somehow excludes critical thinking; again, consider the parallel with religious diversity. Schools should be teaching students to honor and respect classmates whose religious viewpoints differ from their own. School is not the place for students to be taught that one religious viewpoint is better than another. The ruling seems both appropriate and appropriately limited.

Apparently readers are supposed to be shocked and alarmed by a partial transcript of a teacher providing eighth-graders with medically accurate sex education. I wasn’t. That kind of open discussion is exactly what reduces unwanted pregnancies and sexually transmitted disease. If it reduces stigma for gay students at the same time, all the better.

The author goes on to equate same-sex marriage with abortion:

“which, like same-sex marriage, was imposed by the courts against the wishes of many Americans, and in conflict with the religion and morality by which many citizens have been guided, and which has therefore been made available through school clinics without parental involvement.”

This is inaccurate – schools don’t provide abortions through school clinics, they typically don’t even provide contraceptives; and parental notification/consent laws for abortion are the norm, not the exception – but more importantly, this is irrelevant. The only connections between abortion, comprehensive sex education, and gay marriage appear to be that the author doesn’t like any of them.

The article concludes with its second reference to Parker v Hurley, a Massachusetts case where a parent sought to have his child excluded from (or at least that he have notification of) “any materials or discussions featuring sexual orientation, same-sex unions, or homosexuality.” In other words, the parent wanted to remove his child from any and all activities that even acknowledged the existence of gay and lesbian people. The father’s argument was rejected in court because it’s ridiculous on its face. Should any child be kept out of, or a parent given pre-notification of, all classroom discussions or activities that acknowledge the existence of African-Americans? Or that acknowledge the existence of Baptists? Of course not. No matter how strong one’s racial, sexual orientation, or religious bias, you can’t avoid the existence of those who differ from you.

Treating Marriage as Discrimination Threatens Religious Counselors and Therapists

I know, like, and greatly respect co-author Jerry Harris, and I think there is a valid argument to be made about the possibility that some therapists could be unduly punished if non-discrimination clauses in ethical codes are improperly applied. Harris and coauthor William Duncan make their case using flawed case examples.

An Eastern Michigan student was supposedly dismissed from her counseling program because she refused to affirm a client’s homosexuality. Contrary to what the article suggests, the student was not dismissed over her religious beliefs; the university would have honored the student’s religious assertion if she were consistent with it. She was actually dismissed for violating the ACA ethical code (by selectively using her religious beliefs to justify refusing treatment to gay clients, but saying she would willingly treat those involved with abortion, child abuse, or murder), and then saying she didn’t think the ethical code applied to her. “Who’s the ACA to tell me what to do,” a quote from the student, are magic words pretty much guaranteed to get anyone kicked out of their graduate program. A lawsuit is pending.

Separately, a Purdue student suffered “continually poor treatment” because of his opposition to same-sex marriage. This case is not cited and I could locate no other discussion of it in print or online. Even if true, every student has a right to their own opinions, but no right to expect that other students will agree with those opinions or like them; in this case, the only harm the student appeared to suffer was social ostracizing.

The authors state that

“Conflicts with religious liberties will be unavoidable when the state and professional governing bodies begin to endorse the idea that same-sex marriage or equivalent unions are mandated by principles of non-discrimination.”

While conflicts may be inevitable, resolutions are certainly possible. APA and NASW have clearly endorsed the notion that refusing to allow same-sex couples to marry is discrimination, and they have strong subgroups of religiously-oriented professionals.

The ethical committees of each professional association do, certainly, need to provide greater clarity on when a therapist’s refusal to treat clients based on the therapist’s religious belief is discriminatory, and when it is simply proper clinical care reflective of the therapist’s scope of competence. Taken at face value, I agree with Harris and Duncan that some of the therapists discussed here may have faced consequences they shouldn’t have. But that ethical clarity can be provided, and we can move forward.

I see here a legitimate concern about the consequences of gay marriage, and how we can ensure that religious therapists will be able to continue to practice in accordance with their beliefs. But I believe that concern can be resolved to everyone’s satisfaction, and I’m not convinced that it amounts to an argument against the existence of gay marriage.

Gay Marriage and Injustice

In case we needed a reminder that The Therapist is not a scholarly publication, here we have an article that mentions lots of studies while giving full references for exactly none of them. Author Walter Schumm starts by moving the target (emphasis in original):

“The argument for gay marriage is not about marriage but about benefits… The question is whether they [gay and lesbian couples] should be entitled to the same benefits granted to married mixed-gender couples.”

If that were the question, it could be settled with civil unions. Gay and lesbian couples want marriage.

After making a slew of arguments completely irrelevant to what he says is the question at hand (at least one of which, the notion that gay parents are more likely to have gay children, has been thoroughly and repeatedly debunked), Schumm settles on the notion that same-sex couples do not have or raise children as often as opposite-sex couples, so they do not provide the same benefit to society and should not be supported in the same manner.

Two problems here. One, it’s an equally valid argument for keeping the elderly or the infertile from marrying, and I don’t see Schumm or anyone else opposed to gay marriage encouraging those additional restrictions. Two, for many gay and lesbian couples, they don’t raise children because they’re not allowed to, which presents a beautifully circular argument: Because same-sex couples are not given equal benefits under the law, they can not raise children as often as heterosexual couples. Because same-sex couples do not raise children as often as heterosexual couples, they should not be given equal benefits under the law. This is not an argument that makes enough sense to be debated.

Same-Sex Marriage: Not in the Best Interest of Children

“Proponents of same-sex marriage believe love is all children really need.” This is fundamentally not true, and another logical fallacy. At least this article aims to look scientific, with dozens of references. However, the scientific community is largely in agreement that gay parenting is not harmful to children, and many in the community believe that allowing gay parents to marry will improve family stability and child functioning, not undermine it. For much more thorough, and more scientific, summaries of the research than what this article contains, just flip to the “Supporting Same-Sex Marriage” section of the same magazine. Or, see the following: ACLU summary (starts on page 24, runs for 50 pages) | APA 2005 research summary | APA policy statements | AAMFT consumer update (brief) | AAMFT task force full report (members only).

Among the few reliable research findings presented here and in Schumm’s article, many of the comparisons are not related to the discussion at hand, a point well-made at the Independent Gay Forum:

“[W]hether or not gay marriage is allowed, children will continue to be raised by gay parents. The only question is, Will these children be raised in homes that may enjoy the protections and benefits of marriage? If it’s better for children to be raised by a married opposite-sex couple than by an unmarried opposite-sex couple, it would surely be better for children to be raised by a married same-sex couple than by an unmarried same-sex couple. That’s the relevant comparison, not the comparison of married straight couples to gay couples. If it’s really concern for children that’s motivating opponents of gay marriage, they ought to rethink their conclusion. They should be pounding the table for gay marriage.”

Proposition 8 and the Attack on the Religious

Author Austin Nimocks starts by asserting that no matter what one’s religious beliefs, he or she is accorded the right to “hold those beliefs and order your life accordingly.” No argument there. He goes on to cite an example of someone forced from his role because his views opposing gay marriage became a distraction — a phenomenon that cuts both ways, though I tend to agree that it’s unfair on either end.

Nimocks goes on to cite the case of a marriage counselor in Georgia fired from her position for refusing to counsel a same-sex couple(1); it’s also one of the cases Harris and Duncan cite, and I would respond the same way here: There is a genuine ethical issue that professional associations will need to resolve in ensuring they do not simply exchange one form of discrimination (against same-sex clients) for another (against religious therapists). It is resolvable, and doesn’t advance or detract from arguments around gay marriage.

Most of the article, in fact, isn’t relevant to the marriage argument; it’s just fear-mongering. Gay marriage, he asserts, will lead religious therapists to be fired from their jobs, perhaps sued by clients. Yet of all the case examples in both this and the Harris & Duncan article, only one of them took place in a state where same-sex marriage was legal. So it’s unclear how these articles advance the argument against such legalization.

Ultimately, religious leaders of various faiths in Massachusetts have said that the legalization of gay marriage has not impacted their religious freedom.

Why Marriage Matters

It’s about the children, writes William Jeynes. He warns

“Same-sex marriage will mean the law, the government, and and the public schools of California will educate the next generation that our older marriage tradition was based on bigotry and was discriminatory.”

It was discriminatory, and we already teach precisely that: Our older marriage tradition was based on bigotry and discrimination. Ending race-based restrictions on marriage did not destroy the institution of marriage or weaken families. Instead, after Loving v Virginia, interracial couples who would not have enjoyed the institutional support of marriage were able to receive it, and I know of no one who in restrospect believes that Supreme Court ruling was a bad one.

Ironically, Jeynes goes on to make an argument that works better as an argument in favor of gay marriage than one in opposition: “Marriage, as it has existed through countless centuries, has stood as an institutional act of compassion that protects the present and future welfare of children and promotes physical and mental health.” I agree wholeheartedly. If you want to protect the welfare of thousands of children who now lack certain protections, let their gay parents get married.

Excerpts from the Amicus Brief of Iowa

This section from an amicus (“friend of the court”) brief submitted by about a dozen academics is straightforward enough, discussing the historical context of marriage as a union designed around procreation. This argument is demonstrably false, and more importantly: it lost. The Iowa Supreme Court decision takes apart the research cited in the amicus brief in far greater detail than I could here, so I’ll simply direct you there.

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So we’re left with a section of articles that distort facts, make irrelevant arguments, and would be quickly rejected by any kind of scholarly journal. Yet these articles are given equal time and weight with peer-reviewed, scientific articles supporting gay marriage that are copied from academic journals, as the though the two somehow have equal validity (or, on a more basic level, quality). A meaningful discussion could have taken place here, with religious articles as a counterweight to the scientific ones; but that isn’t what is presented. Too bad. Genuinely written articles on the difficulties religious therapists have when confronted by a situation where they need to balance their empathy with their religion — those would have been worth reading.

Footnote:

(1) There is some source material online in both the Eastern Michigan case and the Georgia case.
Eastern Michigan: News story 1 | News story 2 | Transcript of formal hearing | Letter dismissing student from program | Lawsuit.
Georgia: Initial legal complaint | News story