Government to compare treatment effectiveness

There’s an interesting slice of the federal stimulus bill aimed to improve health care, according to this morning’s New York Times. In the interest of improving the quality of health care in the US, and reducing its cost, the government will spend up to $1.1 billion “to compare drugs, surgery, and other ways of treating specific conditions.” Those “other ways” include both talk therapy and “watchful waiting” for some conditions.

The money is a response to the soaring cost of health care, which will account for a quarter of the Gross Domestic Product by 2025 without major changes. Several forms of family therapy have been established as cost-effective treatments for specific conditions, but these treatments have failed to gain as much attention (or use) as they arguably should.

Critics of the program, according to the article, worry that it would lead to the rationing of some treatments, or their disallowance. Doctors, however, seem to largely favor increased research that will give them more direct guidance on how and when to choose one form of treatment over another.

Count me with the doctors. Family therapy works, and is often as good as (if not better than) individual therapy in treating specific conditions. Depression is a great example. We know couple therapy can be used in the treatment of depression, but have little guidance as to when couple therapy would be preferable to individual treatment. Any research that can help inform that decision is a good thing.

Fringe practices: Thought Field Therapy

This is the first of a series of posts I’ll be writing on practices at the fringes of the field of marriage and family therapy. Generally speaking, these practices lack sound scientific backing, yet make fantastical claims about effectiveness. They usually are practiced by a small (and often highly devoted) group of practitioners. They also often require expensive training.

Bear in mind that the lack of a scientific backing does not mean that a practice is necessarily ineffective, or that it is not valuable. All new treatment models start out without a strong research base, and then build legitimacy through a combination of research and clinical experiences. Some well-accepted models, like Narrative Therapy, by their nature cannot be studied in traditional clinical trials. They build scientific legitimacy through qualitative study and process research.

Information on fringe procedures is typically presented in a one-sided manner. You usually get either the sales pitch for the procedure, or all the arguments against it. My intent is not to advocate for or against the use of these procedures, but rather to provide a complete picture of both sides. As always, I welcome your comments.

Thought Field Therapy (TFT) seeks to create healing by repetitive motions (such as tapping) on several “acupressure points” on the body, primarily on the hands, face, and upper body. Patients are also often instructed to visualize a distressing situation as they engage in repetitive behaviors, such as repeating a phrase or counting. A summary of a brief trauma treatment sequence is available here.

Claims of effectiveness. Proponents focus on the impact of TFT on heart rate variability (HRV), considering HRV an indicator of overall health and mortality. They suggest TFT is the only known treatment to dramatically impact HRV. The treatment is said to dramatically impact other conditions as well, offering

immediate relief for PTSD, addictions, phobias, fears and anxieties by directly treating the blockage in the energy flow created by a disturbing thought pattern.

TFT practitioners claim that thousands of clients have been treated successfully with TFT without side effects. They claim effectiveness rates of up to 97 percent. The practice of TFT is usually done in person, but Roger Callahan, the US psychologist who developed TFT, claims that TFT “voice technology” treatments done by phone can stop atrial fibrillation in a matter of minutes. He claims six such successful treatments. His company also produces a quarterly publication, The Thought Journal, with case studies of successful treatments submitted by practitioners.

Lack of sound scientific backing. The Thought Journal is labeled a “journal,” but is not subject to the peer review process or publication standards of accepted academic journals. Overreliance on testimonials and anecdotal evidence in the absence of scientific study is one of the defining characteristics of a pseudoscience. Controlled research is lacking, which is why the American Psychological Association has deemed TFT to be without scientific support. Five articles on the method were published without peer review in the Journal of Clinical Psychology in 2001 — and in each case, the articles were deemed uninterpretable due to major methodological flaws. James Herbert, a psychology professor who wrote a review of the existing TFT research, found the scientific backing for the treatment to be “basically nonexistent” and that there is “no evidence it does what it claims to do.” Since 1999, the APA has refused to grant continuing education credit to its members for TFT training, and there has been at least one instance of a psychologist sanctioned by the state licensing board for using TFT and making inflated claims about its effectiveness. There is some emerging research on “energy psychology” techniques, though their effectiveness appears to be based more on the relationship between client and therapist than on the techniques themselves.

A small and devoted group of practitioners. The lack of supporting evidence is no deterrent to proponents of the method. (Shifting the burden of proof to those disproving a model’s effectiveness is another characteristic of a pseudoscience.) TFT training centers exist at various locations around the country. TFT practitioners can be located through directories on the TFT web site.

Expensive training. Callahan charges $100,000 for training in “voice technology,” which is considered the highest training level in TFT. This training is completed in three days of one-on-one work with Callahan. The TFT web site lists 14 individuals other than Callahan who practice at this level.

Is it useful? For some, yes. I highly doubt that the many case studies of success with TFT are fictional. The question becomes, what is it about TFT that is working for many clients? Is it the sequences of behavior? Is it the relationship with a caring and concerned professional? Is it a placebo effect generated by the simple promise of a fast and effective cure without side effects? Here is where the burden of scientific proof falls on the proponents of the model, to prove that their techniques are somehow different from, and superior to (or at least as good as) accepted models. It is a burden they have not met.

However, in cases where other methods of treatment have not worked, clients may be interested in pursuing alternative methods like TFT. Whether licensed professionals — who should be working from positions of scientific support wherever possible, and making only cautious claims of likely effectiveness — should offer such treatment is a more complicated ethical question.

Angry moms, inside therapy and out

Are mothers, inside and outside of therapy, generally angry at their husbands?

Outside of therapy, moms are surprisingly angry at dads. Such is the finding of a Parenting.com investigation, which looked at 1,000 married mothers to get a sense of their relationships. They found that almost half of moms became furious with their husbands once a week or more. (Salon’s Abigail Kramer comments articulately on the Parenting.com piece.)

Meanwhile, back at the office, MFTs see a lot of angry moms as well. According to the aptly titled “What’s Wrong with These People? Clinicians’ Views of Clinical Couples” in the January Journal of Marital and Family Therapy, MFT students and faculty alike expect wives in therapy to complain, criticize, and blame their husbands for the problems that bring them into therapy. The therapists were no kinder to clinical husbands, who they expected to be hostile, fight to get the last word in, and tell their wives what to do.

What gives? Are wives so mad, and dads so bad?

Let’s start with the JMFT article. If we’re trying to get a handle on how clinicians view their clients as being different from average, non-clinical couples, then that’s the comparison you should make. This article asked MFT faculty and students to compare typical clinical couples with ideal husbands and wives, and so it makes perfect sense that against that backdrop, clinical couples would be expected to show all the negative traits listed above.

MFTs do not expect their clinical couples to be ideal, and they would be dumb to have such an expectation — most ideal couples, if they even exist, probably are not in therapy. MFTs view their clinical couples as less than ideal. That makes sense. Does that mean MFTs view their clients as any different from the rest of the population? We can’t answer that based on this article.

Now, the Parenting.com piece is a bit tougher to crack. It’s safe to say the results are sensationalized to get media attention, but there still seems to be a lot of anger shown in the raw data — how did that happen?

There are lots of reasons to take the article with a giant, truck-sized grain of salt. For one, we don’t know how the questions were really asked, just how the author spun them. To wit: “Lots of moms — 40 percent — are also angry that their husbands seem clueless about the best way to take care of kids.” I don’t know how that question was asked, but I’ll put down five bucks that says the survey question was not, “Are you angry that your husband seems clueless about the best way to take care of kids?”

For another, the article highlights the most angry responses, even when those are in the minority. The quote above is a great example. So, 40 percent of moms feel this way? What about the 60 percent who don’t? These moms are not highlighted in the article, not given the chance to discuss at length the quality of parenting their husbands do. Such highlighting of a minority position is consistent throughout the article, most laughably when “33% of moms say their husbands aren’t shouldering equal responsibility and are less concerned than they are about their children’s basic needs.” The other two-thirds sound a lot more representative.

Finally, there’s not much information on the sampling method. We’re told it’s nationally representative, but just because that is true geographically or demographically does not mean it is true in terms of attitudes. You could do a survey of drug users that is “nationally representative,” but that doesn’t mean their attitudes on parenting would represent the attitudes of the nation as a whole.

It is not my intent to be entirely dismissive of either piece. I just think they need to be considered in the right context. There’s not enough here to conclude that moms are really that mad, that dads are really that bad, or that their therapists are really all that judgmental.

Aging: MFTs and geriatric clients

Interesting piece in the new American Journal of Family Therapy on marriage and family therapists’ training to work with geriatric populations. MFTs’ interest in working with older clients correlated with knowledge about the topic — no surprise there — and MFTs generally believed that specialized training would be beneficial.

Unfortunately, there’s not much in the way of specialized training available, particularly gerontology training that is specific to MFT. Some programs offer gerontology certificates or even full gerontology degrees, but usually in the context of a clinical psychology program.

There is surely a need for more. By 2030, more than 20% of the population will be over age 65. And they have needs that MFTs are well-suited to address:

[T]here are unique mental health and family issues among the elderly that require specific knowledge and training. For example, health problems, many of them being chronic, are common among the elderly. Thus, differentiating health issues from somatic symptoms commonly associated with depression becomes crucial[…] In addition, therapists need to know how to deal with unique family dynamics associated with older family members, such as widowhood, caregiving, and decisions about end-of-life care for a loved one (Yorgason, Miller, & White, 2009, p. 29, emphasis added).

AAMFT’s Family Therapy Magazine has done an outstanding job covering aging issues, with special sections on “Our Aging Selves” (November/December 2002), “Perspectives on Death & Dying” (March/April 2005), and “Retirement” (January/February 2007). There is not a shortage of information available. Possibly the most interesting piece of the new AJFT study is that the MFTs who work with older populations generally believe they got adequate training to do so, but they hunger for more. Who will answer the call?

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.

Holiday family myths

Suicides do not increase at Christmas. No matter what newspapers say. Witness the findings of a 27-year study:

Even people with family relationship problems were less inclined to attempt to hurt themselves during the holidays. “These findings are contrary to the popular view that Christmas is a time of stress and arguments,” [Oxford researcher Helen] Bergen says. Perhaps, she says, problems within the nuclear family ease up instead of intensify when the extended family is around.

Like suicide, domestic violence has its annual peaks — and not at the holidays. While there is conflicting information about the relationship between domestic violence and the holidays, best to avoid fearmongering in the absence of actual data.

These are two especially persistent holiday myths about family life. The best scientific evidence suggests that mental health improves for our nation as a whole over the holidays, that family interaction and support actually makes us happier and better-functioning. Yet we’re bombarded, year after year, with stories about how families make us crazy.

I suppose stories of families making us better might not sell so well, and to be sure, family interactions are complicated and sometimes difficult. But for more people than not, on balance, family time is a blessing.

I’ll be taking some family time over the next couple of weeks, returning in January. See you then.

Choice architecture in marriage and divorce

I’ve been reading the excellent “Nudge,” by Richard Thaler and Cass Sunstein, about the power of choice architecture. Their thesis is simple: Since human beings are prone to fairly predictable errors in decision-making, the process by which individuals are guided through decisions impacts the quality of the choices they ultimately make. By expecting the kinds of errors we all tend to make, it is possible to steer people toward better choices without in any way restricting their freedom and ability to choose.

Perhaps the best example of this is financial: We predictably do not plan very well for our long-term financial health. When employees have to actively choose (an “opt-in” plan) to become part of their company’s 401(k) plan, many fail to do so. This is true even when enrolling can generate an automatic pay raise — that is, free money — via the employer’s matching contributions. When the “default” option is changed to be automatic enrollment (“opt-out”), participation increases dramatically, and more employees save what they need to for retirement.

The implications for therapy, especially couple therapy, are significant. Decisions about marriage and divorce tend to be complex, one-time (we hope) decisions that can offer greatly delayed rewards and have limited immediate feedback — exactly the kinds of decisions that can benefit from Nudging. How can we nudge people to better choices, with the hope of ultimately lowering the divorce rate?

There’s marriage education, which produces significant short-term gains on a variety of relationship measures but has scant evidence of reducing actual divorce risk over the long term. Such programs as How to Avoid Marrying a Jerk (or Jerkette) seek to help people identify red flags early in relationships, and fix them so they do not lead to great dissatisfaction down the road. But these too have limited evidence of long-term effectiveness. (Which is not to say they do not work for their intended purpose, but rather that we do not know, yet, whether they work.)

There’s also “covenant marriage,” a well-intended but rarely-used option for couples in three states (Louisiana, Arkansas, and Arizona). Covenant marriages are harder to get into, and harder to get out of, though they do include some protections for victims of abuse. However, because covenant marriage is not the default option, couples largely do not bother with it. Furthermore, as with marriage education, there is limited evidence that covenant marriage, in and of itself, reduces divorce rates. Those couples who do engage in the covenant process tend to be more religious than others, and more religious couples are less likely to divorce no matter what kind of marriage they enter into.

And then there’s couples therapy. Many couples come to therapy after years of a dissatisfying marriage, wondering about whether to stay or go. Can they benefit from a nudge? The AAMFT Code of Ethics is clear that therapists should respect the autonomy of clients in making such decisions, but a number of prominent scholars in the field have suggested that therapists be up-front about their own values around marriage and divorce. There is even a referral service specifically limited to “marriage-friendly” therapists.

Of course, if we don’t know what choice is best, the question is moot. There’s no point in nudging someone if you are not sure what to nudge them toward. In questions of marriage and divorce, though, there are some choices that are pretty clearly helpful in creating wealth and happiness:

* Marry after age 20, and before having a child. Quoting William Galston, an adviser to the Clinton White House: “You need only do three things in this country to avoid poverty – finish high school, marry before having a child, and marry after the age of 20. Only 8 percent of the families who do this are poor; 79 percent of those who fail to do this are poor.”

* Once you get married, stay married. Many couples report their marriages go through rough times. If the couple stays together through those rough times, they are extremely likely to describe themselves as “satisfied” or “very satisfied” in their marriage seven years later. More than 90 percent of couples who describe their marriage as having been in serious trouble at some point in the marriage are glad they stayed together.

* If your relationship is weakening, marriage therapy can help. Emotionally Focused Therapy and Behavioral Marital Therapy are considered the two approaches most strongly supported by research; approximately 90 percent of couples who complete EFT will experience significant improvement.

Focusing specifically on these three points, therapists can serve as choice architects, guiding clients down the ideal path without forcing clients’ hands or overstepping the therapist’s ethical bounds.

When it comes to both couple and individual therapy, processes like Motivational Interviewing, which encourage a thoughtful consideration of all of the options available prior to taking action, can be greatly improved if therapists anticipate the kinds of errors clients are likely to make in projecting themselves forward in time. One of the biggest challenges with Motivational Interviewing is precisely that we can’t know in advance how our choices will turn out. Unless you’ve been divorced before, it is very difficult to imagine the myriad ways in which divorce might affect you and your family. I’ll expand on this in a future post, about applying choice architecture to individual therapy.

MFT scope of practice across the country

The Therapist magazine ventures outside of its home state this month for a look at licensing laws for MFTs around the nation. The article is written in legalese, but it does provide some interesting guidance about the remarkable consistency in practical scope around the country, even when the specific terminology differs.

To wit: MFT scope of practice laws in all 48 states (and DC) where licensure currently exists effectively allow MFTs to engage in the diagnosis and treatment of mental health disorders. (Michigan’s law has perhaps the most watered-down language — something local MFTs are working on changing — but MFTs do diagnose and treat mental disorders there.) However, minor differences in language have allowed for some tugs-of-war with other professions about whether MFTs can independently diagnose, and what the exact limitations are on what MFTs treat. Twenty-two states and the District of Columbia include the phrase “diagnosis and treatment” in their MFT scope laws; 14 states use the word “assessment” instead of “diagnosis” in that phrase, with five states preferring “evaluation” and two states going with “identification.”

Connecticut, Iowa, and Texas do not use the word “treatment,” going instead with “management,” “resolution,” and “remediation” of disorders, respectively. Other states use words like “modify” and “enhance.”

Similarly, MFTs can (and do) provide services to individuals (as well as couples and families) in all states that license MFTs, though the law is not always explicit. In 41 states and the District of Columbia, the law clearly states that MFTs can provide services to individuals. In other states, that ability can be clearly inferred from other language.

It’s a pleasant surprise, really, that the profession is so consistent across state boundaries. A marriage and family therapist in California really should be doing the same kinds of work as an MFT in Kansas.

Gay and lesbian parents

There’s been a lively discussion over the past couple of weeks about gay and lesbian parents, stemming from comments about California’s Proposition 8 (pro | con) on the listserv of the California Association of Marriage and Family Therapists (CAMFT).

As a quick clarification, CAMFT is a state-based professional association that is entirely separate from the American Association for Marriage and Family Therapy (AAMFT) and its California Division (AAMFT-CA). I, like many folks here in the Golden State, am a member of both CAMFT and AAMFT. Neither group has taken an official position on this proposition.

Even among MFTs, or perhaps especially among MFTs, emotions run high on Proposition 8, which was approved by voters but is headed for a court battle. The proposition was written to deny marriage to same-sex couples in California. It does not outlaw civil unions, but instead is specific to “marriage.”

Commenters on both sides of this issue on the CAMFT listserv have argued that research is on their side. The Yes-on-8 side has suggested that research supports “‘traditional’ families as the best and most psychologically stable environment for children.” Those opposed point out that “traditional” families have their share of psychological instability, which is technically true but fails to address the question at hand: Do children of gay and lesbian parents fare worse in life due to their parents’ sexual orientation?

In a word, no. The research is surprisingly unequivocal. Charlotte Patterson, of the University of Pennsylvania, in a peer-reviewed 2006 article in Current Directions in Psychological Science, sums it up nicely:

Studies using convenience samples, studies using samples drawn from known populations, and studies based on samples that are representative of larger populations all converge on similar conclusions. More than two decades of research has failed to reveal important differences in the adjustment or development of children or adolescents reared by same-sex couples compared to those reared by other-sex couples. Results of the research suggest that qualities of family relationships are more tightly linked with child outcomes than is parental sexual orientation.

I don’t especially like the hedging of language in the last sentence there; just because relationship qualities are more tightly linked with outcomes than parental orientation, that does not mean that parental orientation is not linked with outcomes at all. But, looking over the article itself, that just seems to be a poor turn of phrase. Studies simply do not support links between parental sexual orientation and child outcomes.

An American Psychological Association resolution passed in 2004 (Paige, 2005) is equally clear:

There is no scientific basis for concluding that lesbian mothers or gay fathers are unfit parents on the basis of their sexual orientation (Armesto, 2002; Patterson, 2000; Tasker & Golombok, 1997). On the contrary, results of research suggest that lesbian and gay parents are as likely as heterosexual parents to provide supportive and healthy environments for their children.

Research suggests that sexual identities (including gender identity, gender-role behavior, and sexual orientation) develop in much the same ways among children of lesbian mothers as they do among children of heterosexual parents (Patterson, 2004a). Studies of other aspects of personal development (including personality, self-concept, and conduct) similarly reveal few differences between children of lesbian mothers and children of heterosexual parents (Perrin, 2002; Stacey & Biblarz, 2001; Tasker, 1999). However, few data regarding these concerns are available for children of gay fathers (Patterson, 2004b). Evidence also suggests that children of lesbian and gay parents have normal social relationships with peers and adults (Patterson, 2000, 2004a; Perrin, 2002; Stacey & Biblarz, 2001; Tasker, 1999; Tasker & Golombok, 1997). The picture that emerges from research is one of general engagement in social life with peers, parents, family members, and friends. Fears about children of lesbian or gay parents being sexually abused by adults, ostracized by peers, or isolated in single-sex lesbian or gay communities have received no scientific support. Overall, results of research suggest that the development, adjustment, and well-being of children with lesbian and gay parents do not differ markedly from that of children with heterosexual parents.

Most recently, a meta-analysis of 19 studies examining outcomes for children raised in gay and lesbian households (Crowl, Ahn, & Baker, 2008) concluded:

[P]arent sexual orientation was not a salient predictor for children’s development.

In fact, this meta-analysis found only one area of statistically significant effect from same-sex parents: Those parents rated their relationships with their children as being better than heterosexual parents rated their own parent-child relationships.

All this said, professional organizations are usually wise to avoid taking stances on specific resolutions in an election cycle. With emotions running so high on both sides, any stance the organization would take is likely to lead to members defecting. Policy resolutions, like those adopted by APA and AAMFT, seem to be the better approach.

References

Crowl, A. L., Ahn, S., & Baker, J. (2008). A meta-analysis of developmental outcomes for children of same-sex and heterosexual parents. Journal of GLBT Family Studies, 4(3), 385-407.

Paige, R. U. (2005). Proceedings of the American Psychological Association, Incorporated, for the legislative year 2004. Minutes of the meeting of the Council of Representatives July 28 & 30, 2004, Honolulu, HI. Retrieved December 11, 2008, from the World Wide Web at http://www.apa.org/pi/lgbc/policy/parents.html.

Patterson, C. J. (2006). Children of gay and lesbian parents. Current Directions in Psychological Science, 15(5), 241-244.

Couple therapy effectively treats depression

Family Therapy Magazine, which is usually quite good, is simply outstanding this month. Highlighted by Michael Yapko’s “Skills or Pills? What MFTs Can Do Better than Antidepressant Medication,” the magazine examines some hard truths about depression, medication, and family therapy:

  • Antidepressants are no better than placebos. An extensive study of the six most popular antidepressants found that when unpublished trial data were combined with published trial data, “the benefit (of medication) falls below accepted criteria for clinical significance.”
  • Couple therapy is a promising treatment approach for depression. While more research needs to be done, Emotionally Focused Therapy and Behavioral Marital Therapy both appear to alleviate depression at least as much as individual therapy, while simultaneously improving the couple relationship.
  • Treatment for depression is very different in other parts of the world. Even other western, industrialized nations have found success in treating depression when it is de-medicalized. In other words, the whole person should be treated, not merely a set of depressive symptoms.

Perhaps most interesting — and depressing — in all of this is some discussion that therapy is winning the battle but losing the war. In other words, mounting evidence suggests that psychotherapy (and particularly systemic therapy) is a preferable treatment to antidepressants in the successful treatment of depression. Yet, the promise of relief in pill form, without substantial work, keeps Americans going back to the MD instead of the MFT. Antidepressants are now so widely prescribed that they show up in our drinking water.

If science alone will not turn the tide, what will? What do you think needs to happen to convince people that therapy is a better long-term fix for depression than pills?