Want to know how much that MFT degree will cost? Good luck

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Many family therapy programs make it surprisingly difficult to plan for your graduate education budget.                                                                                                                                                                                                                                                                                                            

US Currency; public domain imageIn my research for California Family Therapy Program Rankings, where I offer a roundup of information and rankings on 34 of California’s biggest marriage and family therapy (MFT) graduate programs, I was determined to get readers the most objective information on cost possible. The amount of money students invest in their graduate degrees is significant, and sometimes has to be a factor in choosing programs.

I figured gathering this information wouldn’t be easy, necessarily, but that most programs would publish some way of estimating total tuition cost on their web sites. For example, I might have to multiply a per-unit tuition cost, usually given on one page of a university’s site, with the total number of units in the MFT program, which typically would be on a separate page.

If only it were that simple.

Whether by accident or by design, MFT programs in California are often less than fully transparent in letting prospective students know how much they can expect to pay for their graduate degrees.

Consider San Diego State University as an example. Theirs is a very well-regarded, COAMFTE-accredited program. They’re probably pretty inexpensive, as master’s programs go, since they’re a state school. They even advertise themselves as the most affordable MFT program in San Diego, and I suspect that’s probably true. But if you want to know how much the program actually costs, you’re out of luck. The university web site provides tuition costs for a nine-month academic year ($8,032 for California residents, if you’re wondering), which puts SDSU right in line with the other state schools. But as the program web site notes, two summers are also needed to complete their two-year program, and if you want to know how much those cost, you have to start by fishing your way here, to a 2013 summer tuition document that tells you the cost of summer tuition depends on how many units you take. And how many summer units are required for the MFT program?

I never could find that.

The information just isn’t there, or at the very least, it isn’t easy to locate. Do those two summers add up to six units, or more like 20? At up to $644 per unit in the summer, that’s a pretty big blank space in a prospective student’s budget. I know universities need to put all kinds of cautionary notes on their program plans — classes may be full, scheduling and tuition are subject to change, and on and on — but how hard would it be to tell prospective students how the program is designed, such that they can reasonably estimate how much the whole thing will cost?

My point here isn’t to single out SDSU. Again, theirs is a good program; no matter how much their summers cost, SDSU’s program will still be cheaper than private institutions; and they are hardly the only school to make cost information on their MFT program opaque. (Several programs even provide a sort of illusion of transparency in tuition cost, openly stating how much they charge per semester or per year, but not saying how many of those it takes an average student to finish the program. A $15,000-per-year program designed to be completed in two years looks a lot less attractive — and a lot less affordable — if it turns out that it takes most students four years to actually complete it.) Of the 34 programs I reviewed for the book, there were several where it was not possible to even estimate the total tuition cost of the program based on information available on the program’s web site.

My point instead is this: Prospective MFT students need more and simpler disclosure of graduate program costs. And that means more than just stating tuition and fees, especially for programs that charge by semester or by quarter: it means providing clear estimates of how long the program will take to complete. Ideally those estimates would come with graduation data to back them up; join me if you will in gasping at Phoenix’s abysmal 10% completion rate 30 months after enrollment, but at least they publish it.

Perhaps programs are concerned that making cost information too front-and-center will lead to the same kind of race to the bottom we have seen in airline fares, where consumers’ cost-driven decision-making has led to declining service, crowded planes, airline bankruptcies, and even more opaque pricing. If so, I don’t think we’re giving prospective MFT students enough credit. They’re choosing where to get years of education that will set the stage for their whole careers, not a two-hour bus-ride-in-the-sky to Toledo. Let’s give them the information they need to budget wisely, and trust that they know cost is only one of many factors to consider when choosing a graduate MFT program.

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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.

Why cultural competence matters in MFT – and how to build yours

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Mental health professionals need to understand a variety of cultures (and, ideally, languages) to assess and diagnose properly.                                                                                                                                                                                                                                                                                                            

Globe image [public domain] via Wikimedia CommonsIf you are a mental health professional (or are in the process of becoming one), developing cultural competence will help ensure that you don’t mistakenly diagnose a culturally-appropriate behavior as some kind of mental illness. It will enable you to recognize the difference between a client who is ashamed and one who was simply taught to avoid eye contact. And most importantly, it will enable you to provide treatment within a client’s cultural context without imposing your own values, either intentionally or by mistake.

Cultural competence — that is, the ability to provide effective services to people from a wide variety of cultural backgrounds — gets built in a variety of ways. It is important to understand traditions and practices across a wide range of cultural groups, and you can’t possibly go to every single one of the places your clients will be from. In short, whether you ever travel or not, you need to internationalize your thinking.

But to really develop your cultural competence, you need to experience different cultures, both within and outside of your local area. To this end, many universities are ramping up their offerings (and their requirements) when it comes to truly experiencing the diversity of our world.

I teach in the Couple and Family Therapy Programs at Alliant International University in Los Angeles. To be sure, we are in one of the most diverse cities in the nation. Our student body reflects that, with students from a wide range of cultural, national, religious, and other traits that allow them to learn a great deal from one another when they share a classroom. Many of the benefits of study abroad can be achieved in classrooms just like ours. But a classroom is a controlled environment, and Alliant’s mission centers largely on both multiculturalism and internationalism, so we offer much more than just the classroom experience. We also offer cultural immersion experiences for our students in Mexico City, China, and India; we also have had students and faculty take part in a past Cambodia immersion.

The students who take advantage of these opportunities describe them as much more than professional development. They often describe them as life-changing.

Naturally, it is tough for faculty to teach from a fully-informed perspective if they have not travelled themselves. The need for cultural immersion is not limited to students, nor is it limited to a certain phase of one’s career. Times change and cultures change, and as professionals we need to stay in contact with these changes to best serve the clients with whom we work. In the past several years, I’ve been to Mexico City, Hong Kong, Costa Rica, and Europe, and many in our Alliant faculty have their own long list of recent travels. (As a group, we rack up a lot of frequent-flyer miles.) I can happily say that on each trip, I’ve learned far more about the local cultures than I ever could have understood from a book.

If you’re considering a career working in mental health, and are interested in developing your international and multicultural competence, I would strongly encourage you to check out Alliant’s programs. We have programs in six cities around California and in Mexico City, Tokyo, and Hong Kong. And many programs — including mine — are still accepting applications for this fall.

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

There will never be a lab test for some mental health disorders

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Because they aren’t really “disorders” when you consider the “symptoms” in context.                                                                                                                                                                                                                                                                                                            

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One of the first things any new student in family therapy learns about is the genius of the acting-out child. Children are keen observers of the world around them: If they learn that one kind of scream or cry or tantrum gets their parents’ attention where another kind does not, they are quick to do what works and give up on what doesn’t.

Children are also, for obvious reasons, incredibly observant of their parents’ relationship (whether to each other, or in blended or single-parent families, to the new partner). For kids, seeing their parents fighting can be utterly terrifying.

Some kids, in the midst of a parental argument, learn to stay out of the way. Other kids learn, even by accident, that a very good way to get the parents to stop arguing with each other is to break rules, scream, or otherwise behave inappropriately. Here is where acting out is so smart: if both parents get angry at the kid for misbehaving, at least they stop arguing with each other for a while.

For a child, the pain of having your parents angry at you may be far preferable to the terror experienced when watching them fight each other.

Of course, parents are often reluctant to see this. They may instead perceive such a child as “hard to handle,” “defiant,” or otherwise broken. In the worst cases, health care professionals buy into the parents’ descriptions, slapping diagnostic labels on the child. Labels like “attention-deficit hyperactivity disorder” or “oppositional defiant disorder” may accurately describe a child’s behavior, but they ignore the cause, and tend to focus attention on the child as the problem.

A skillful family therapist will assess not just the child but also the child’s entire social environment, including their family, to see whether the acting-out behavior is actually smart. If it is, then therapy focuses not on “curing” the acting out, but instead on making it no longer necessary. The family therapy field is rife with stories of children diagnosed with attention-deficit disorder, childhood bipolar disorder, or other mental illnesses who are rapidly “cured” once their parents start coming in to therapy sessions — especially if the parents are willing to work on their relationship with each other.)

Of course, we don’t stop being impacted by our social worlds when we become adults. Just as the acting-out child is often behaving in a way that is quite smart given their environment, adults who appear to have mental illnesses may be responding intelligently to the world around them. This may mean their behavior is a response to the work environment, social circle, family, or even larger society. For example, William Glasser suggests that at least some of the higher prevalence of depression among women might actually be a wise response to the impossibly high demands placed on women to be successful at work, at home, and socially, always with a smile on. For women who experience that pressure intensely, and do not feel they have a reasonable way of escaping or easing it, depression can be a quite reasonable way of checking out of that chase without having to actively fight social norms. (For clarity, Glasser is not suggesting blaming the depressed for their depression; he does argue that depressive behaviors are sometimes chosen, but goes on to say these choices are often not conscious. Depression may be an adaptive response to difficult circumstances, Glasser says, but it certainly is not ideal.)

Ultimately, whether we are talking about children, adolescents, or adults, it is often true that behavior that might look troubling or even “ill” in one context is actually quite helpful in another. In fact, sometimes taking on behaviors that appear crazy to others is actually the smartest thing to do. It’s evidence of good health and adaptability, not an underlying problem with the brain or body that any lab test could detect.

That’s why, for as much as I support the National Institutes of Mental Health’s effort to usher in a new era of hard science in mental health diagnosis (and usher out the behavior-based diagnoses of the DSM-5), I wonder who it will leave out in the cold. The simple fact is that many people who now (appropriately!) receive diagnoses and are eligible for insurance-covered treatment for mental disorders are not, in any physiologically-testable way, disordered. They are actually quite healthy. Their behavior makes perfect sense when understood in context.

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

National Institutes of Mental Health abandons DSM-5

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Just weeks before the new diagnostic manual is released, NIMH cites “lack of validity” and says “patients with mental disorders deserve better.”
                                                                                                                                                                                                                                                                                                           

PET-imageIn a surprising announcement just weeks before the scheduled release of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the US government’s mental health research arm has announced plans to stop using DSM categories in its work.

The National Institutes of Mental Health (NIMH) is the single largest funder of mental health research in the world. In his announcement last week explaining the decision, NIMH Director Thomas Insel wrote that “Symptoms alone rarely indicate the best choice of treatment.” While diagnositic categories based on clusters of symptoms — like the categories in the DSM — provide a common language that mental health care providers and researchers can use, these categories are more about that consistency in usage (i.e., reliability) than they are about clinical or research validity. Such symptom-based diagnosis, Insel argued, is now outdated in most other areas of medicine.

So NIMH is scrapping DSM categories when funding future research and is developing its own framework to “transform diagnosis by incorporating genetics, imaging [such as the PET scan pictured above], cognitive science, and other levels of information to lay the foundation for a new classification system,” according to Insel. For now, the new classification system is just a framework for research. But the clear intention is to make the DSM obsolete.

As a family therapist, I find the DSM-5 categories to be both useful and limited in the ways Insel described. They are a good tool for communicating with other professionals, but not especially useful for clients, beyond establishing that others may have similar suffering. I like the idea of a new classification system for mental disorders based on biology and verifiable laboratory tests (indeed, I think it’s overdue), and think it quite likely that such a system will strongly support systemic and relational therapies. The brain is a social organ, after all, and therapy creates verifiable physiological changes in the brain.

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

Washington, Texas, Arizona, Michigan weighing “conscience clause” laws

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Far-reaching laws would appear to place therapists’ religious values above anti-discrimination rules.

The Washington State Capitol
The states of Washington, Texas, Arizona, and Michigan have joined a growing list of states considering so-called “conscience clause” legislation, that would allow health care providers (including therapists) to refuse to treat specific types of clients based on the therapist’s religious beliefs. Kansas governor Sam Brownback signed such bill into law in March, and a Kentucky bill was passed into law earlier this year through an override of the Governor’s veto.

While some states have designed such bills specifically for health care settings, most of the recent conscience clause bills apply to all work settings that require state licensure or other involvement of state government. They use language very similar to that of the successful Kentucky bill:

“Government shall not substantially burden a person’s freedom of religion. The right to act or refuse to act in a manner motivated by a sincerely held religious belief may not be substantially burdened unless the government proves by clear and convincing evidence that it has a compelling governmental interest in infringing the specific act or refusal to act and has used the least restrictive means to further that interest. A ‘burden’ shall include indirect burdens such as withholding benefits, assessing penalties, or an exclusion from programs or access to facilities.”

As I mentioned in my earlier discussion of the Kentucky law, such language in any state would make it exceedingly difficult for marriage and family therapy graduate programs (if they receive state funding) to discipline or expel students who plainly state their intent to discriminate when providing therapy services. It would also mean that state licensure boards would have a high burden when attempting to discipline the license of a therapist who was discriminatory in their practice.

While written to protect religious freedom in broad terms, it can be argued that these laws are emerging with a more specific, if not directly spoken, purpose in mind: to allow religious business owners and health care providers to freely discriminate against gay and lesbian clients. That has certainly been a concern with the Kentucky religious freedom law. The Washington law, meanwhile, arose in response to a consumer protection lawsuit that the state’s Attorney General filed against a florist who had refused to provide flowers for a gay couple’s wedding (same-sex marriage is legal in Washington). The lawsuit argued that the florist, who cited religion in refusing to serve the couple, was illegally discriminating on the basis of sexual orientation.

The text of the proposed conscience clause legislation in Washington makes the target of the law clear once you know what the bolded language here means (emphasis added):

Nothing in this section may burden a person or religious organization’s freedom of religion including, but not limited to, the right of an individual or entity to deny services if providing those goods or services would be contrary to the individual’s or entity owner’s sincerely held religious beliefs, philosophical beliefs, or matters of conscience. This subsection does not apply to the denial of services to individuals recognized as a protected class under federal law applicable to the state as of the effective date of this section. The right to act or refuse to act in a manner motivated by a sincerely held religious belief, philosophical belief, or matter of conscience may not be burdened unless the government proves that it has a compelling governmental interest in infringing the specific act or refusal to act and has used the least restrictive means to further that interest.

Federal law currently prohibits discrimination against a variety of protected classes. Discrimination based on race, gender, disability, or nationality is prohibited under federal law, for example. But gays and lesbians are not a protected class in federal law. So the main impact of this bill would be to allow discrimination, based on religious belief or matters of conscience, against gay and lesbian clients.

Still, the broad wording of these laws allows for much farther-reaching impact. A commentary on the Washington proposal in the (Salem, OR) Statesman-Journal suggests that it could revive religious objections to mixed-race couples. The group Americans United for Separation of Church and State describes other acts that these bills appear to legalize:

A pharmacist could refuse to provide Plan B drugs to a rape victim. The owner of an apartment building could refuse to rent to an unmarried couple.

These examples and more can be applied to therapists and their clients, with the therapist either as discriminator or victim. A therapist under these laws may refuse to treat gay and lesbian clients. In states that leave out the federal law stipulation that Washington included, that therapist may also refuse to treat Mexicans, or Mormons, or any other group they see fit to turn away. Therapists working at hospitals, in group practices, or in other settings as employees might also be discriminated against at the moral whim of their employers, who would be able to summarily fire therapists who have premarital sex (or who don’t, if the employer decides that their personal morals favor premarital sex), or who identify as gay or lesbian. Each of these would be of questionable legality even under the new laws, because of the potentially overriding impact of federal anti-discrimination law, but they would appear to be clearly illegal in most instances under current law. Bringing the legality of such acts into question — inviting lawsuits to sort out the underlying issues, and placing a high burden on the state to justify any restriction of acts of morality or conscience — seems to be the idea.

Ultimately, if these and similar laws continue to pass around the country, the non-discrimination clause in the AAMFT Code of Ethics may best be considered moot. Any therapist with moral or religious beliefs that declare some people to be unequal could freely discriminate on the basis of race, gender, nationality, or any other basis without fear of any repercussions against their license. AAMFT could still act on an ethics complaint, even removing a therapist from the association. But the therapist would never need to inform clients that the complaint had happened, and could freely continue in practice as the state could not discipline their license.

Bills similar to the ones enacted in Kansas and Kentucky, and proposed in Washington and Tennessee, are now pending in several other states:

  • In Texas, a religious-freedom act already exists in state law, but Texas Senate Joint Resolution 4 would make that law part of the state Constitution.
  • Nevada Senate Bill 192 is similarly broad and has advanced through the Senate to the state Assembly.
  • In Arizona, Senate Bill 1178 has been amended from a bill on long-term disability into a broad religious-freedom measure.
  • And in Michigan, where religious-freedom legislation proposed in response to the Julea Ward case failed last year, a broader bill on religious freedom in health care (Michigan Senate Bill 136) is making progress. Among other changes, the Michigan bill would (quoting a Senate Committee Analysis) “Prohibit an employer from penalizing a health provider and prohibit a university, college, or educational institution from refusing admission to an individual or penalizing a student or member of its faculty or staff for expressing a conscientious objection or requesting an accommodation to avoid participating in a health care service.”

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Your comments are welcome. Post in the comments section below, by email to ben[at]bencaldwell.com, or through my Twitter feed.