Whose conscience matters?

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When can a therapist decide their own morals and values outweigh those of their clients?

The AAMFT has kindly made my article on conscience clause laws in mental health the cover story for the September issue of Family Therapy Magazine. You can read the article here if you’re an AAMFT member.

Of course I’m biased here, but I think you’ll find it worth the read. While I’ve written about the topic a few times here on the blog (most recently, I wrote about conscience clause laws being considered in Washington, Texas, Arizona, and Michigan), my focus here has been much narrower than it is in the magazine. In the FTM piece I take a broad look at the issue, from the origins of conscience clauses to the best arguments for and against them. While these laws are often spurred by a desire to protect religious practitioners, you don’t need to be religious to be impacted by them, and you might be surprised at what the laws would appear to allow:

Most conscience clause laws are so broadly written that they could allow […] therapists to refuse to treat sexually active unmarried couples, or therapists morally opposed to immigration to refuse treatment to clients based on nationality, even in a mental health emergency.

Is this a price worth paying to protect therapists’ moral views? My skepticism is raised when considering that the religious practitioners and legislators backing these bills often seem to have a desire to legitimize discrimination against gay and lesbian clients. So, you know, that’s not okay. But the issue isn’t black and white, as I hope the magazine article illustrates.

In addition to the main article, a sidebar I had written about conscience clause laws being considered or adopted in various states around the country was transformed into a really cool national map infographic. I wish I could take credit for that — it’s great visual layout — but that’s all magazine staff. Check it out.

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I have another article in the works proposing a way therapists could consider the appropriateness of a conscience-based referral, within the fuzzy boundaries of existing law and the existing AAMFT Code of Ethics. So stay tuned for that (for several months, in all likelihood, but I’ll keep you updated).

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

No, counseling psychology is not a terrible major in college

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Of course salary numbers in mental health look bad when you leave out people with the graduate degrees necessary to practice.

US CurrencyNPR ran a story last month punctuated by a graph of the highest- and lowest-earning college majors. The worst on the list, by far, was Counseling Psychology. Those who majored in Counseling Psych brought in a median income of under $30,000 per year.

No one gets into mental health care for the money, but the numbers were a black eye for the Counseling field — the American Counseling Association has even responded by commissioning its own study of salaries among its members.

But there was a big problem with that original chart, one that the researchers themselves had noted but which was often ignored in discussions of their findings: It didn’t include people with graduate degrees.

In just about any mental health field, you need at least a master’s degree to practice. Those who don’t take that extra step are often limited to very basic, entry-level jobs with little hope for advancement.

So NPR is back this week with another chart, one that includes graduate-degree earners. And Counseling Psychology no longer shows up on the list of the 10 lowest-earning undergraduate majors. Counseling Psych majors get a big bump in median incomes when you include those who go on to advanced degrees, as should be expected.

Notably, social work stayed in the bottom 10, even when those who get their graduate degrees are included. Their median incomes went from just under $40,000 a year (with graduate degree earners excluded) to about $45,000 a year (with graduate degree earners included).

It’s hard to place family therapy here, since MFTs come from a wide variety of undergraduate majors, most commonly (but by no means exclusively) psychology or family studies. For MFT salary data, the best place to start is this Bureau of Labor Statistics page.

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

Is “relationship orientation” a thing?

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A session on plural families at last week’s AAMFT Annual Conference in Portland used the term as a parallel to sexual orientation.

Teens from polygamous families
One of the workshops I attended at last week’s AAMFT Annual Conference focused on “plural families” — family structures that involve more than two partners and their children. The presenters argued that members of these families (seen most often in the US in Colorado, Nevada, and Utah, in offshoots of the Mormon church, which officially banned polygamy more than 120 years ago) may well wind up in a family therapist’s office, and that the therapist needs to be prepared to work with the realities of their complex family structures.

The presentation was fascinating, and appropriately non-controversial: These presenters were not arguing that a plural family structure was right or wrong, just that it exists, and that therapists may be confronted with it. Fair enough.

What piqued my interest was their use of the term “relationship orientation” to describe one’s leanings toward monogamous or polygamous relationships. Are we moving toward considering a preference for monogamy or polygamy as simply one more demographic variable, not subject to change and worthy of equal respect in all its forms?

In a pair of essays for Slate, Michael Carey (a pseudonym) has argued that exact thing. He first suggests that, like gays and lesbians, polyamorists often feel compelled to hide their relationships even from close family members for fear of judgment or even expulsion — and that the lack of societal acceptance reflects prejudice. In the second, he notes that half to two-thirds of polyamorists do not experience their relationship orientation as a choice. (These numbers are from Carey’s experience, and he doesn’t pretend they are research-based.) For this majority, their “innate personality traits make it very difficult to live happily in a monogamous relationship but relatively easy to be happy in an open one.”

Don’t focus too much on that word “innate,” though. How much of a desire for polyamory is nature and how much of it is nurture isn’t especially important when arguing for moral acceptance of poly relationships, Carey argues:

Nobody ever claimed that Mildred and Richard Loving were born with some kind of overwhelming predisposition to prefer partners of another race and that they thus couldn’t marry somebody of their own race. Choosing an interracial partner was, and is, a choice. So what? The correct response to the nature vs. nurture question is: There’s no way to know for sure, and it doesn’t matter. What matters is that people love each other, treat each other with respect, and live happy, productive lives.

Now, I should be up front about my own moral place here. I have no problem with poly relationships as long as there is no dishonesty involved and no one is getting hurt (at least, no more so than happens in the normal course of monogamous relationships). What concerns me here is where the parallel leads us. If “relationship orientation” is as inflexible as we now understand sexual orientation to be, and if participants in poly relationships are not being any more or less moral than anyone else, do we have a societal moral obligation to honor poly relationships with equal status as monogamous ones (whether straight or gay)?

In other words, do we owe them plural marriage?

The overwhelming science on gay and lesbian couples show that they and their children are harmed by societal discrimination and suffer from being unable to marry in a wide variety of ways. This is in spite of the fact that children of same-sex couples are just as healthy as those from straight couples.

The situation is different for poly marriage. While there may be many exceptions, poly relationships are generally understood to be oppressive to women, and polygamous families and cultures may have negative outcomes for children on a variety of measures. So there is ample reason to take a very cautious approach to polyamorists pushing for societal acceptance.

Status of polygamy worldwide
Legal status of polygamy worldwide (click the image for full details)

I’ll admit I have never been a big believer in the “slippery slope” line of reasoning, which essentially argues that if you raise the speed limit from 55 to 65, then you’re going to have to raise it to 200. You don’t, of course; raising it again even to 70 would be a different debate. Slippery slope arguments are often nonsensical fear tactics used to argue for the status quo, by suggesting that the alternative is an extreme alternate reality that no one has actually suggested. Applied to gay marriage, some argued that it would somehow logically follow that if we allowed same-sex couples to marry, we would then have to allow people to marry box turtles.

It is debatable whether re-legalizing polygamy equates with raising the speed limit to 70, or whether it would be more like raising the limit to 200. For now, I’m looking at it more like 200 — a radical and potentially damaging change.

But lots of people once felt that way about gay marriage, too. And it seems the language debate we once had around sexual orientation being a preference, a lifestyle, or an orientation is starting to replicate itself for plural families. As we saw with gay marriage, the outcome of the language debate has a lot to do with shaping what happens next.

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

On family therapists who oppose using the DSM-5

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Doctor discussing diagnosis with patientOkay, a bit of a rant today. In the family therapy world, I often hear criticism of the Diagnostic and Statistical Manual of Mental Disorders, the diagnostic guide published by the American Psychiatric Association and currently on its fifth edition (DSM-5). This usually comes from students first learning about the DSM and its history, and in those students the criticism is often based more on anxiety than on any real substantive problem with the book.

Students are understandably anxious when confronted with the complexity of diagnosis and the power that comes with being able to diagnose a client as mentally ill. Unfortunately, I see too many MFTs who never get past that initial anxiety, and use it as an excuse for avoiding the DSM well into their professional careers. I don’t begrudge anyone their anxiety, I just wish people would own it for what it is (kind of like with licensing exams), instead of making up or latching onto an easily-refuted argument against learning and using the DSM appropriately.

The arguments against DSM use that I hear in the MFT world tend to reflect poor understanding of both the DSM and family therapy. Those arguments typically fall into three groups, listed here with their easy counters:

  1. “The DSM is based on individuals, and I work with families.” The DSM offers labels for common sets of symptoms. That is, it gives you a quick name for sets of problematic behaviors that often occur together. It is agnostic about the source of those symptoms. It does not, contrary to some therapists’ opinions, make a presumption that the source of suffering lies within the individual. The way the DSM is written, depression could be caused by something within an individual, by problems in couple or family functioning, or by aliens. You’re free to maintain your systemic ideas about how depression often originates and is sustained (ideas I agree with, just so we’re clear) without any concern that these ideas conflict with the DSM. They don’t. Furthermore, a good systemic therapist does not ignore individual functioning; indeed, one needs to be keenly aware of how individuals are functioning within a system in order to understand the system itself.

  2. “A diagnosis is just a label, and I don’t like labeling people.” Nonsense. Any time you call someone by their name, you are using a label for them. Labeling is a good and healthy and awesome thing that we do in human societies to keep language relatively efficient. If you really hate labels, and prefer to capture the whole essence of things (many of those I have heard say they avoid the DSM say that they do so to better capture the “whole person”), then when you go home tonight I want you to announce to whomever is close by that for dinner you will be having semolina, flour, eggs, and water, all formed, cut into long needle shapes, and dried, and then resoftened in boiling water for a few minutes, topped with pulverized tomatoes that have themselves been heated and mixed with spices and possibly some kind of meat or cut mushrooms. Served steaming hot! Then you can take pride, when they tell you “um, that’s spaghetti,” that you have captured the entire essence of the pasta. You’ve also needlessly wasted everyone’s time.

    Listen, use of a label doesn’t constrain you to only using that label, nor does it mean the label is all there is of someone. I hope that when doing therapy, you really do maintain a thorough sense of your clients’ strengths and resources and personalities far beyond what you can gather from a simple diagnosis. But use the label too. It is essential for other health care providers, who may need to know the nature of someone’s symptoms very quickly (like in an emergency), that you know enough about symptoms and diagnoses that you can tell them, without taking the next 15 minutes to describe someone’s essence as a human being.

  3. “The DSM is pathologizing, and I try to focus in therapy on depathologizing behavior.” I have the most empathy for this argument, as family therapists are particularly inclined to see even diagnosable behaviors as adaptive to their context. But it still falls pretty flat. Yes, the DSM is pathologizing, insofar as it describes symptom clusters as mental disorders. Expanding criteria for mental illness contributes to what Szasz labels the medicalization of everyday life. And there is much to be said about the misuse of DSM diagnoses across cultures.

    But go back to the first argument here. Remember, the DSM is agnostic as to the source of symptoms. The fact that the behaviors that together add up to a diagnosis of, say, depression are actually adaptive responses to family dysfunction does not make the diagnostic label incorrect — the individual really is displaying those symptoms — and it doesn’t mean that the individual should not receive treatment. Indeed, one of the upsides of broadening diagnostic criteria is that they allow people to receive treatment, often paid for by their insurance company, when they previously could not have. In other words, that individual diagnostic label (which, again, is just a description for a symptom set, not a theory about the cause of the symptoms) is often the very thing that allows you to treat the system.

There are larger debates to be had about the role of the DSM in mental health care, and even more broadly, how our entire health care system is structured around diagnosis and dysfunction rather than a foundation of keeping people well. And there certainly is plenty to criticize about the DSM. But for where we are now, let’s all agree that (1) diagnosing is important enough that it’s okay to be anxious about it, and (2) the act of assessing and diagnosing an accordance with the DSM is in no way inconsistent with family systems work. In fact, it’s a requirement for doing that work well.

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Your comments are welcome. You can post them in the comments below, by email to ben[at]bencaldwell[dot]com, or on my Twitter feed. You’ll also find a some very insightful comments on this article over on my Facebook page.

Proposed new MFT accreditation standards eliminate vague religious exemption

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If adopted, the draft COAMFTE standards would require all programs to teach LGBTQ-affirmative practices.

W-classroomThe public comment period closes Wednesday on the draft version of new accreditation standards for graduate programs in marriage and family therapy. The Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE) is proposing some major changes from current standards:

  • The draft standards would restore the 500-client-contact-hour requirement for practicum. Under the current, version 11.0 standards, programs can require fewer hours as long as they have evidence to show that their practicum results in students being competent to practice at the master’s level. This vague standard has left different accredited programs using different experience requirements, which can be confusing to state licensing boards who want to know how much practical experience they can reasonably expect to be included in graduate degrees.

  • The draft standards separate accreditation requirements into “eligibility standards” and “accreditation standards.” As it is now, the Commission makes its decisions based on the full scope of information presented to them. Programs that meet most but not all standards may still be granted accreditation, with stipulations — requirements that the program comes into full compliance with the standards within a year. This proposed split into eligibility and accreditation standards arguably makes the accreditation bar a bit higher: Programs that fail to meet even one of the eligibility standards would not be eligible for accreditation, regardless of their performance on the other standards.

  • The draft standards would go back to a singular, mandatory core curriculum for all accredited programs. Of course, programs would remain free to add on to this core curriculum as they see fit, but all accredited programs would be required to have the same core set of coursework.

  • Perhaps what is most notable in the draft standards is what is missing: The draft standards remove COAMFTE’s current vague, blanket exemption for religious programs. The exemption, present in the current COAMFTE standards (p. 3), says

    Religiously affiliated institutions that have core beliefs directed toward conduct within their communities are entitled to protect those beliefs.

    It has never been clear to me what that is supposed to mean in practice, but the way I read it, any religious-based program that wants COAMFTE accreditation but isn’t in tune with any part of the standards was free to ignore that part of the standards, as long as they could tie their objection to their religious beliefs. Under the proposed new standards, not only would that clause go away, but the required curriculum would include at least three semester units on

    diversity, power, privilege and oppression as they relate to race, age, gender, ethnicity, sexual orientation, gender identity, socioeconomic status, disability, health status, religious and spiritual practices, nation of origin or other relevant social categories throughout the curriculum. It includes practice with diverse, international, multicultural, marginalized, and/or underserved communities, including LGTBQ affirmative practices. [emphasis in original]

    It is much clearer what the new standards would mean: Every COAMFTE-accredited program would need to teach its students how to work with LGBTQ clients in a positive, affirming way, and an appreciation for the harm such clients suffer from living in a heterosexist society.

To me, these are all good and necessary changes. First, as to the hours and curriculum changes: I hear chatter among MFTs around the country that licensing boards haven’t known what to do with the current COAMFTE standards. Those current standards are so flexible that licensing boards don’t necessarily know what they’re getting when someone comes to them with a COAMFTE-accredited degree. The draft standards, if adopted, would bring back greater consistency in content across programs and could restore state boards’ confidence in maintaining COAMFTE accreditation as the standard educational requirement for licensure.

Second, as to the removal of the religious exception: I’ve written previously about the struggles some religious therapists face when trying to work with LGBT clients, and the debate there is far from settled. But accredited programs can and should teach affirmative practices. The debate here should be restricted to how a therapist balances their values with client needs in the therapy room, not about whether the therapist can be exempted from exposure to affirmative techniques or to the suffering LGBTQ clients genuinely experience.

There’s only one thing COAMFTE didn’t included that I wish they would: Require MFT programs to be more transparent about cost.

COAMFTE will be reviewing comments on the proposed changes this fall. If adopted, the new standards would likely take effect in 2014 for new accreditations and be phased in for those programs already accredited.