California LPCC law passes; should MFTs dually license?

Late in the evening of October 11, Governor Schwarzenegger signed California Senate Bill 788, adding Licensed Professional Clinical Counselors (LPCCs) to the state’s masters-level mental health professions, alongside MFTs and LCSWs. Licensure by grandparenting will take place over a six-month period in 2011, with routine licensure starting January 1, 2012. Should MFTs dually license?

For most, there would be no benefit, and significant added expense. Since licensure is inherently a state-based activity, there is no reason to believe that licensing as an LPCC will make one’s license more portable; in fact, a license obtained through grandparenting may have greater trouble getting recognized in another state. Add to that the still-unclear question of whether California will recognize national exams in counseling (national exams in MFT and Clinical Social Work are not recognized in the state), and the likelihood of a portability benefit grows even slimmer. The added expense of two renewal fees could be little more than wasted money.

There is, however, a legitimate reason why some MFTs may want to dually license: They want to reflect what their professional orientation has been all along. California was the first state in the US to license MFTs, and the last in the country to license LPCCs. As a result, some who work under the MFT license do so because that was the masters-level entry point into a career in mental health, and not because they particularly identify with systemic concepts. For those therapists, the Clinical Counselor license is probably a better fit.

They will not, however, want to switch over entirely. Counselors will enter the mental health marketplace in California more than four decades after MFTs did, and will need to fight for themselves every battle MFTs waged and won for recognition in hiring and reimbursement. They’ll be able to make up ground, but it will be many years before counselors can claim the kind of recognition and stature in the state that MFTs claim today, thanks to decades of good work by CAMFT and AAMFT.

Blogging the AAMFT Conference: Sunday

The AAMFT Annual Conference wrapped up Sunday morning, as the last die-hards snuck in one last 3-hour workshop before drifting up to the Sacramento airport and back home. I was a presenter on Sunday morning, but only if you use the word “presenter” loosely; I led a panel discussion on licensing exams.

Before you go into the automatic response (which is, I believe, “zzzzzzz”), you should know there was one significant piece of news to come out of it: California’s Board of Behavioral Sciences and the Association of Marital and Family Therapy Regulatory Boards, who develop the California and National MFT Exams respectively, have agreed to collaborate on their next occupational analyses. It’s a small step but a significant one, as it will at least allow for an apples-to-apples comparison of the practice of MFT in California versus around the rest of the country. That kind of comparison would be necessary in any discussion of California eventually moving toward use of the National MFT Exam — something I believe in very strongly.

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As is the case every year, I leave the conference energized, with many new research ideas, new potential collaborators, and new respect for the amazing work taking place in our field. I also leave Sacramento with renewed appreciation for just how clinically strong our Alliant students are and will be; it wasn’t at all unusual to see the best questions in any workshop — and often the best answers as well — coming from people with orange “Alliant” stickers on their badges. Great work, everyone. See you in Atlanta next September.

Blogging the AAMFT Conference: Saturday

Susan Johnson stole the show with her plenary presentation at the AAMFT Annual Conference in Sacramento today. Presenting without Powerpoint slides was itself refreshing, but she said several things in a far more eloquent manner than anyone else has this weekend. I’m paraphrasing, but here were a couple of my favorites:

  • Therapy needs higher goals than simply reducing conflict. We get better every day at actually creating new love and bonding.
  • Emotions have an exquisite logic to them that is not to be ignored or dismissed. For EFT or any other kind of therapy, clients should not expect that they need to leave their intellect at the door.
  • Connection with a partner soothes the brain. MRI studies show that an expectancy of shock is mediated when in physical contact with a partner.
  • When it comes to sex, research is clear: Practice *and* emotional connection make perfect.

The workshops I attended today were good informationally, but neither was put on by especially dynamic presenters. I learned about marital satisfaction instruments and online education, both of which are eminently practical — one of the things I like most about the conference.

The evening presentation by Dorothy Becvar was a nice review of the history of the field in terms of its concepts and contributions to mental health. A good (and brief) final plenary to a very good conference. I’ve heard that the other workshops were greatly varied this year in terms of quality, but that those that were good were incredibly good. The conference concludes tomorrow with a set of 3-hour workshops, including one I’ll be moderating on the licensing exam development process. More tomorrow.

Blogging the AAMFT Conference: Thursday/Friday

Today was the first full day of the AAMFT Annual Conference, which is in my former hometown of Sacramento. It’s been great catching up with old friends, colleagues, and students — this event has become as much a reunion for me as an educational experience. Still, I’ve learned a lot. Here’s what I’ve learned last night and today:

  • We’ve come a long way. The opening plenary on Thursday night was an appreciation of the history of our field, and a celebration of finally accomplishing licensure in all 50 states. Bruce Kuehl did a great job with it, and I may be adding clips from this to the MFT Theories course next year.
  • I need to start a Facebook group. I’ll call it “MFTers for Changing MFTers for Change.” But then a subgroup would probably spring up to try to change my group, and I don’t want that kind of trouble.
  • Family systems and psychoanalytic principles are not mutually exclusive. Okay, to be fair I already knew that. But Richard Scwartz’s presentation of Internal Family Systems made me believe this more strongly than I had before.
  • COAMFTE accreditation matters. I already knew this too, but now I have more evidence to back it up. Jeff Larson was kind enough to fill in for Russ Crane, and Jeff joined Mary Moline and I in presenting a workshop on the things that set COAMFTE programs apart. Jeff handled curriculum, pointing out that MFTs are required by licensure laws to get far more education and experience in family therapy than any other profession. Mary took on public mental health, reviewing how the COAMFTE programs in California and around the country are uniquely positioned to integrate changes in public mental health approaches like the recovery orientation. And I took on licensure, pointing out that graduates of COAMFTE-accredited programs get further, faster in the licensure process and are more likely to pass their exams than graduates of non-COAMFTE programs.

Overall, the AAMFT Annual Conference has again earned its spot as the most valuable and rewarding continuing education event I attend during the year. More tomorrow.

Blogging the AAMFT Conference

I’m headed to Sacramento on Thursday for this year’s AAMFT Annual Conference, where leaders in the field from around the world gather to share clinical and research insights. It’s a great event every year, and with plenary presentations from Bruce Kuehl, Richard Schwartz, Susan Johnson, and Dorothy Becvar, this year promises to be outstanding.

I’ll be posting as frequently as I can while I’m there; you can also tune into my Twitter feed (@benjamincaldwel) for additional — if very brief — commentary.

Therapists targeted by spam, scams

Therapists and counselors around the country have been targeted by scams via phone, email, and postal mail. Here are warnings on three of the most common recent ones.

The pre-payment scam. In a therapy-specific variation on an old scam, a therapist receives a call from someone looking to set up therapy for themselves or a family member, telling the therapist that the client is not yet in their city but will soon be arriving (usually for work or school). The caller asks to prepay for several sessions in advance, and mails a check. Within a few days, they call back to say the “client” has had an emergency change of plans, and the money needs to be refunded immediately. Only after the therapist has issued a refund do they discover the original check has bounced.

What to do: This scam could be stopped at several points in the process. 1) Don’t accept payment for services from someone you’ve never met in person. 2) If you do accept pre-payment, do not accept pre-payment for more than one session at a time (this at least limits your potential losses). 3) You may choose to not accept check payments at all; many therapists now accept fees via credit cards, which offer much better fraud protection. 4) If you do accept checks, your bank may allow for instant electronic check processing, so you’ll know right away if a check will not be covered by the issuing bank. 5) If you accept prepayment by mailed check — and again, it’s far better not to — have a clearly written refund policy that establishes your process and timeline for issuing refunds on services paid but not received. This may be part of your cancellation policy, which is related. 6) Never issue a refund before you have actually received the funds in your account.

The counselor scam. A privately-owned company called the American Psychotherapy Association (I will not link to their site because they don’t deserve the traffic, but you can Google it if you’re really interested) has been blanketing California with brochures promising MFTs that they can become “grandparented” into being a “Board Certified Professional Counselor.” The brochure appears to be carefully crafted to mislead MFTs into thinking that the certification might equate to LPC licensure (it does not and will not), without actually saying anything that is factually untrue. The organization does offer a Counselor Certification, and California MFTs can be “grandparented” into it. At least in the sense that the requirements for that designation will change if California eventually licenses professional clinical counselors, as it may soon do.

What to do: Look, I don’t know anything about the American Psychotherapy Association (not to be confused with the far better-known APA); they do have a few folks I highly respect on their board, they put on an annual conference, and they may well be a worthwhile organization. But this is a callous marketing effort designed more to take advantage of California MFTs’ lack of knowledge about how LPC licensure might work than anything else, and it greatly tarnishes their reputation in my eyes. If you receive their mailer, throw it away.

The “men’s movement” spam. On the CAMFT listserv, there have been several posts from therapists who received an email threatening to take action against them based on their name and contact information being listed on AllAboutCounseling.com, one of many sites that host therapy-related articles, blogs, and a therapist directory. (I’m naming them because they’re a victim here, though I would caution that this site was unknown to me before researching this post.) In the email that’s been going around, the attacker — who doesn’t deserve to be named or linked to — suggests that there are dangerous and false articles on the site, and that therapists should be fearful of associating themselves with it. Having reviewed what’s actually on the site, I can’t say it’s all that good, but it’s certainly no worse than what’s on a hundred other therapy- and counseling-oriented sites. What seems to have gotten this attacker’s anger up are the articles about women and women’s issues. He claims to be part of a “men’s movement,” but a men’s movement that uses threats to get its way does a massive disservice to the term “men’s movement” and to men in general.

What to do: This is a tough one. If you’re listed on the web site (and not that many are), you can ask to have your listing removed… but should you? That would seem to be giving in to the threat. On the other hand, if you leave your listing up, this guy could make good on his threat, spewing bile onto the internet and attempting to associate you with his attacks. Yes, his actions are wrong, threatening, juvenile bullying. But some therapists understandably want to be nowhere near anything that looks like controversy. Is it a battle you want to fight? That’s a judgment call.

Generally speaking, therapists can avoid scams like these by using common sense; if a prospective client sounds too good to be true, asks you to violate your own policies or standards, or raises other red flags for you, consult with colleagues, supervisors, and your professional associations. And if you’ve been the victim of any of these scams (or any others), the worst thing to do is stay silent out of embarrassment; that only allows these scams to continue. You serve the profession and the public well by alerting others to such risks.

CAMFT steps forward on same-sex marriage

At its board meeting in Sedona, AZ over the weekend, the California Association of Marriage and Family Therapists (CAMFT, not affiliated with AAMFT or its California Division) voted to support marriage equality for same-sex couples. This is a significant step forward for an association that had spent months struggling with the issue.

As a quick recap, CAMFT has been mired in controversy following their unwillingness to make any kind of statement about same-sex marriage or parenting. They made matters worse with a broad anti-discrimination statement that, while fine on its own, failed to address any of the relevant issues members had been asking CAMFT to address. Then they made matters worse again with the publication of several hateful and homophobic articles on the topic. Executive Director Mary Riemersma and the CAMFT Board both eventually apologized for the articles, and the California Therapists for Marriage Equality organized to try to push CAMFT toward a more socially and scientifically responsible stance.

Angela Kahn, who serves on the board of the Los Angeles chapter of CAMFT, reportedly gave an impassioned presentation to the statewide board in Sedona, systematically dismantling every possible reason for CAMFT’s continued silence on the issue. The board then voted 9-1 to endorse marriage equality.

Pending their permission, I’ll post the full text of the statement here.

I’m elated that CAMFT is be moving in the right direction, finally, on same-sex marriage. I am hopeful that the positive movement and responsiveness CAMFT is showing on same-sex marriage will extend to other areas as well.

Health care reform likely to benefit most MFTs

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?

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

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.