From the AAMFT Research Conference: The one question that can improve depression treatment outcomes

by

A large number of clients who seek treatment for depression also are having difficulty in their marriages. New data suggests that one question can dramatically improve patient outcomes on both problems: Which came first?

That’s the finding Steven Beach, a professor at the University of Georgia, discussed at this weekend’s AAMFT Research Conference in Alexandria, VA. Research has shown for many years (1, 2) that marital satisfaction and depression can be greatly improved at the same time through couples treatment, regardless of which problem came first. However, new data from Beach and his colleagues suggests that when women are struggling with both depression and marital problems, individual therapy for depression will have negative effects on the relationship if the marital discord came first — suggesting worse outcomes for the depression as well.

Why should this matter to MFTs, who are eminently qualified to identify and treat both issues? Because most depressed people don’t start by seeking treatment from a family therapist. According to a 2009 NAMI survey on depression, people with depression usually receive treatment from their primary care physicians. Just 38% receive their primary depression treatment through a mental health professional of any kind. Physicians tend to treat depression with medication and/or referral for individual therapy. They rarely refer for couples therapy, in spite of the research supporting such referrals. The list of possible reasons for this disconnect is long, but some reasonable guesses include that physicians may not know the research, may not have a trusted marriage therapist to whom they can send clients, or simply may not think to ask depressed patients about relationship difficulties (an area of struggle patients may not bring up on their own).

Beach and his colleagues believe that the link between depression and relationship difficulty is so strong that physicians ought to screen for relationship problems whenever they are diagnosing a patient with depression and considering treatment options. They developed a simple 10-item screening measure for relationship problems, with an 11th question for those who show relationship difficulty: Which came first?

Notes: Two quick things about the research base here: 1, the studies of marital therapy to treat depression have universally, as best as I can tell, looked at depressed women. Whether the suggested treatment course and likely outcomes would be the same with depressed men is open to question. 2, while studies have looked at marital therapy and marital satisfaction, there is no reason to believe that non-married people in committed relationships have a different kind of link between depression and relationship difficulty. The screening instrument can be used for married and nonmarried couples alike.

UNLV’s MFT program will survive

by

This post was originally posted on June 5, 2010 under the headline “UNLV MFT program to close.” The original post follows. It is updated below. -bc

The Las Vegas Sun is reporting that the state’s Board of Regents has approved the closing of UNLV’s marriage and family therapy program. The decision was based on state budget cuts, which also have forced the closing of five other UNLV programs. This appears to be the first COAMFTE-accredited program to be shuttered due to state budget cuts.

Update 7-17-2010: As noted in the comments, the program has been saved thanks to some thoughtful maneuvering by its faculty. Though the MFT program will no longer have its own department, the program will continue under a new administrative structure. This is wonderful news to students, faculty, and colleagues alike. The UNLV program is the only COAMFTE-accredited program in the state and is vital to the region.

From the AAMFT Research Conference: Does marriage education work?

by

Marriage education (also known as relationship enhancement or RE) has gotten a big, warm spotlight lately. A recent big-deal writeup in the Washington Post hit on the high points: Marriage education programs are big business, they have a lot of federal money supporting them, and there’s not a lot of research on them. Do they work?

That was the basic question tackled yesterday by Howard Markman at the AAMFT Research Conference in Alexandria, VA. In general, it looks like the research base for such programs is growing but still fairly small relative to the number of RE programs in existence. Markman and his colleagues located 30 studies examining 21 different programs since 2002 — meaning that a large number of programs offered at the annual SmartMarriages conference have not been researched at all. The research that does exist is usually promising, but not definitive: programs are generally shown to produce short-term improvements in couple satisfaction and communication skills. However, there have not been studies addressing whether these programs actually do what they set out to do, reducing the risk that couples will eventually divorce over the long term.

The federal government has been running a huge study that should be able to offer clearer answers. Involving eight sites and more than 5,000 couples around the country, the Building Strong Families (BSF) project sponsored by the Administration for Children and Families is testing voluntary RE programs offered to unmarried couples who are expecting or recently had a baby. The project just released its 15-month follow-up data, and the news is not good:

When results are averaged across all programs, RE did not make couples more likely to stay together or get married. In addition, it did not improve couples’ relationship quality.

As Markman was quick to note, the news was not all bleak. It would be more accurate to say that couples didn’t finish the programs than it would be to say that the programs didn’t work; with the exception of the project’s Oklahoma site (which performed much better than other sites in a variety of ways), only 9% of couples completed at least 80% of the relationship enhancement curriculum offered to them. That’s a big problem. Where couples did tend to finish their program — at the Oklahoma site — they were more likely to still be together at the 15-month follow-up, and experienced a number of other measurable improvements as well. Furthermore, only the Oklahoma site used a program that included most of PREP, one of the best-known and more well-researched relationship enhancement programs around. Other sites used less established curricula.

The study will be releasing its 3-year follow-up data in 2012. As Markman noted, the 15-month followup may simply be too early to see the hoped-for impact on marriage that these programs would offer; by definition, preventing marriage breakup is a long-term goal. It is possible that changes will emerge over time. Until they do, however, RE programs will continue to face skepticism. Which is good, if it drives more research that will develop programs that really do ultimately meet their preventive goals.

San Diego County to get MFT stipend program

by

The San Diego MFT Consortium has been awarded a $350,000 grant to launch a stipend program for marriage and family therapy interns working in public mental health. The program will largely mirror the highly successful Los Angeles County MFT stipend program, which awards $18,500 stipends to MFT Interns who agree to work for at least one year in public mental health in an underserved area. More than half of the awardees in the LA program have been bilingual, helping meet a major need in the county’s mental health workforce.

I’ll add detail about the San Diego County program as it becomes available.

Can MFT interns pay for supervision?

by

Aaron Feldman is frustrated. He’s spent several months telling the BBS, AAMFT-CA, CAMFT, and anyone else who will listen that he can’t run a therapy business legally and be successful in the state of California. No one has told him he’s wrong.

The problem, which Aaron is trying to conquer while others mostly ignore, is California’s Labor Law. Depending on whom you ask, it might prohibit marriage and family therapist interns from paying their employers for supervision; if it actually does (CAMFT argues otherwise), then a significant number of clinics around the state would be in violation.

But the supervision issue could be only the beginning. Mental health clinics are no different from any other business in the eyes of state labor law. But when was the last time a clinic required its therapists to take at least a 10-minute break every two hours, or mandated a lunch break for shifts lasting beyond six hours? Each of those is a labor law requirement.

At the October 2009 meeting of the Board of Behavioral Sciences (BBS), the licensing board’s counsel was clear: Those who employ MFT interns are subject to labor laws just like any other employer, and “there is no scenario under which it would be appropriate for a supervisee to pay an employer for supervision.” The BBS has since elaborated on that position here. CAMFT has since put forth its contrasting interpretation of the law, arguing that it is perfectly legal for an intern to pay their employer for supervision, as long as the terms of the arrangement are agreed to by both parties, in writing, in advance.

It is the Labor Board‘s opinion — or perhaps ultimately a judge’s — that matters. And so far, the Labor Board has chosen to stay away from the issue, politely rebuffing requests to attend BBS meetings or issue any written statement on the question. For the Labor Board to address this issue directly, it appears, they will have to face a complaint from a disgruntled supervisee.

And that has been Aaron’s frustration. He doesn’t want to run his clinic in constant fear of becoming the test case. CAMFT has hinted that they might try to clear up the issue through legislation, but the odds of getting a bill passed if it looks in any way like a weakening of, or exemption from, state labor laws is slim.

Without a clear set of guidelines, what is an employer or agency to do? The lowest-risk approach appears to be to abide by the BBS stated opinion: Assume MFT interns, when they are employed (as opposed to volunteering), are subject to all labor laws, and act accordingly. In practical terms, this would require an employer to go the extra mile to make sure that interns are taking adequate breaks. Do not have interns pay for supervision. Ensure that, however interns’ pay is computed, it amounts to at least minimum wage once all the intern’s time (including time spent on supervision, marketing, administrative tasks, etc.) is taken into account. (Of course, I’m not a lawyer, so please do not construe this as legal advice; any employer with questions about labor law or its application should consult an attorney.)

The problem for Aaron, and anyone else trying to run a therapy business honestly, is that even if he chooses to play by all of the labor law rules, plenty of other employers are not. If Aaron abides by the labor law, he will need to either pay his employees less, or charge his clients more, than similar clinics. The extra burden could be enough to make his clinic, as a business, unsustainable. Until at least one disgruntled intern makes a test case out of it, those who disregard the labor law appear to be at a competitive advantage.