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.

MFT licensure: Does testing raise quality?

Whenever I get into conversations about licensure, a number of the same questions keep coming up. I will be addressing these in a series of posts here. To start with, I'd like to tackle perhaps the most pesky, the-answer-should-be-obvious-but-isn't question: Do licensure examinations make for better therapists?

The complaint, heard often, is that licensure exams bear no resemblance to actual therapy, and reward good test-taking skills more than they reward the ability to, say, formulate a working systemic hypothesis about a family. Exams also may unfairly disadvantage those for whom English is a second language, which is especially unfortunate given the need for culturally competent mental health services seen across the country.

The first point is relatively easy to refute. Of course licensing examinations do not look like actual therapy -- they are not supposed to. They are designed to establish a floor for minimally competent practice, but they do not do this in a vacuum. The many hours of supervised experience one receives prior to licensure are a much better avenue for guiding, and ultimately ensuring, competent practice in the therapy room. Licensing exams focus on conceptualization: are you aware of state law, do you know crisis procedures, etc. Yes, these things could be tested in an in vivo process, but doing so is complicated, expensive, and extremely difficult to do objectively. So a multiple-choice exam, with all its imperfections, has a necessary and important role. Of course, test-taking skills will be rewarded; lots of events in a therapist's practice will be tests of various sorts, so I have no problem rewarding those who perform well in a structured and stressful environment.

The second point is more complex. The troubling effect an examination process can have on minority applicants is certainly seen in other professions:

[S]tate-mandated teacher testing is associated with increases in teacher wages, though we find no evidence of a corresponding increase in quality. Consistent with the fact that Hispanics have marked lower licensure scores than non-Hispanic Whites or Blacks, testing appears to reduce the fraction of new teachers who are Hispanic (Angrist & Guryan, 2008, p. 483)

Identification of factors associated with National Council Licensure Examination-Registered Nurse (NCLEX-RN) success is critical at public colleges of nursing with diverse student populations. ... Significant correlations were found between success in the NCLEX-RN and cumulative undergraduate nursing program grade point average, English as the primary language spoken at home, lack of family responsibilities or demands, lack of emotional distress, and sense of competency in critical thinking (Arathuzik & Aber, 1998, p. 119).

The easiest solution to this problem, at least as far as the exam process goes, is to offer licensing exams in multiple languages. However, there are major political and practical roadblocks to doing so. Politically, public preference for English and opposition to other languages in state programs seems to go in waves, but is unpredictable. As a practical limitation, some family therapy terms simply do not translate well to all languages, and any new version of the National MFT Exam would need to be re-normed and validated for each new language group. Looking beyond the test process itself, in some locations, the reporting responsibilities of family therapists (to report child abuse, for example) must be carried out in English, so language proficiency becomes a necessary and reasonable qualification for the license.

Ultimately, it can safely be said that the testing process (including the lengthy preparation for it that many MFTs go through) leads therapists to be more aware of the theories that guide their work and the laws that govern it. It is an objective way of establishing that the therapist's prior education and experience have provided them with at least a minimal level of competency in the profession. There is little to no scientific evidence, however, that the testing process, in and of itself, makes therapists more clinically effective.

References

Angrist, J. D., & Guryan, J. (2008). Does teacher testing raise teacher quality? Evidence from state certification requirements. Economics of Education Review, 27(5), 483-503.

Arathuzik, D. & Aber, C. (1998). Factors associated with national council licensure examination-registered nurse success. Journal of Professional Nursing, 14(2), 119-126.

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.

Where are the family therapy blogs?

At present, there are roughly 60,000 licensed marriage and family therapists across the U.S. Roughly half of them live in my home state, California. Surely some of these folks have blogs that focus on what's new in our field, no? To my surprise, and perhaps just reflecting a difficulty in finding them, there seem to be very few blogs dedicated to current happenings in the field. There is an abandoned MFT blog at fixmyfamily.com, and there are tagentially-related blogs that sometimes overlap MFT at marriagejunkie and Slate's Human Nature. Blogs written by MFTs for potential clients are certainly plentiful, but do not tend to focus on research findings (here are two examples). Some MFTs and MFT students also write their own personal blogs, which are often quite insightful but are focused more on the authors themselves than their chosen field. Psychology Today's blog center has a lot of authors, including a bunch of well-known names. And they do not even list a "Family" category. In the "Relationships" and "Child Development" categories, which seem to be as close as one can get, good luck finding a post that actually mentions research. (Though not technically a blog, I certainly am a fan of the SmartMarriages mailing list, and they post all of their archives online. It's specifically focused on marriage education, though, and at times can be actively opposed to couple therapy.) I'm hoping I'm missing something here. If I want to find other good blogs for keeping up with family therapy, and specifically with what is new or changing in the field, where should I go? Please feel free to provide links in the Comments, and I'll update this post once I've learned of a few good MFT blogs.

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?