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.

The latest reality-TV "couple therapist"

-- UPDATED below --

It is one of my more unfortunate traits that I enjoy Rock of Love on the TV and Hot Chicks with Douchebags on the web (though the latter at least gets points for its philosophical references, which are actually often well-educated). Through these avenues, I hear there is a new "couples therapist" coming to VH1 (emphasis added):

We have all encountered them before: those strutting, preening, over confident alpha-males who lie, cheat, and treat their girlfriends like door mats. They are “tools,” and they desperately need a wake up call. VH1 and 495 Productions are taking 9 of these unsuspecting bad boys and sending them to relationship boot camp in a new series titled Tool Academy. The eight episode series, hosted by Jordan Murphy, is slated to premiere Sunday, January 11 at 10/9c.

The guys, all secretly nominated by their girlfriends, initially believe they are taking part in a competition in search of “Mr. Awesome.” But the tables are turned almost immediately and they quickly learn that they are actually recruits in the Tool Academy, where they will be schooled in proper boyfriend behavior—covering topics like honesty, fidelity, maturity, and communication with resident relationship counselor Trina Dolenz.

Look, lots of people make a living as relationship "coaches" and the like, and while I sometimes grumble about that, it's legally permissible -- so long as the person is not advertising themselves as a psychotherapist or claiming a license when they do not have one. The promotional material for Tool Academy, though, may very well cross the line. Dolenz is advertised here as a "couples therapist" who has run a "private practice" in "couples therapy" in Los Angeles -- which would appear to mean she needs (or needed) a California license. A quick check of the Board of Behavioral Sciences and Board of Psychology websites reveals she has never had one. So, it would appear that either the show's promotional materials are lying about her prior private practice in LA, or she broke the law in running that practice.

Dolenz's own web site -- which calls her a "TV Couples Therapist" -- certainly could mislead readers into thinking she is qualified to practice psychotherapy in California:

Trina Dolenz trained as a couples counselor in Cambridge, England, obtaining a graduate certificate in Marital and Couples counseling. She then went on to obtain a Relate Post Graduate Diploma in Couples Therapy, validated by the University of East London. Her continuing professional development has included further study in domestic violence and affairs. She had a large private practice in couples psychotherapy in London, until recently, when she moved back from England to Los Angeles.

Her legal "out" should anyone complain to the state at this point is pretty simple: She isn't advertising psychotherapy services to the general public. What she's doing is much like working for a company's Employee Assistance Program, where a license is beneficial but not technically necessary so long as you do not mislead clients about your licensure status. Still, I wonder how a "TV Couples Therapist" like her -- on a show like this -- will impact viewers' perceptions of couples therapy, and couples therapists. Having not yet seen the show, I'm trying to hold out some optimism. We'll see.

UPDATE: Having now seen the show's first two episodes, I feel some relief. Dolenz' "group therapy" basically has consisted of showing all the couples on the show some early interview and hidden camera footage of the guys, and then talking with them about it. Her comments and questions have been no different, really, than what any other couples therapist might ask. I remain a skeptic; given that her "professional opinion" determines who gets booted off the show each week, it seems pretty likely that she is subject to the whims of the producers. But it could be much, much worse. The show is comedic reality-TV cheese, not meaningful reality-tv drama.

MFT licensure: Why 3,000 hours?

Whenever I get into conversations about the MFT licensure process, and how it differs from one state to another, similar questions come up. Earlier I addressed the fundamental question of whether license examinations make for better therapists. Another common question I hear: Why do we require 3,000 hours of supervised, prelicensed experience for MFT licensure?

(Making things more complicated, why do some states require more? California uses the 3,000-hour standard, though we categorize those hours in a goofy way. Arizona, like a handful of other states, requires 3,200 hours. At one time, New Jersey required more than twice that. They don't now.)

It's mostly political. As MFTs have advanced licensure around the country, we have made every effort to cooperate with other professional groups and ensure that licensure really does serve its purpose, which is to protect the public from untrained or unscrupulous professionals. Working with other professions and with the legislatures in each state has required various compromises, and most states have settled on about 3,000 hours of supervised experience as one of the requirements for licensure.

Of course, there's no evidence that MFTs are unable to practice effectively on their own with 2,999 hours of experience and suddenly experience a magical transformation at the 3,000th hour. But there is a significant growth process, personally and professionally, that takes place during the prelicensed experience. And in most states it has been generally agreed that around 3,000 hours -- that is, about two years of full-time, supervised experience -- is long enough for MFTs to learn to effectively practice without supervision.

There is also a gatekeeping role supervisors play during the prelicensed time, as they can help determine whether a supervisee is unfit for the profession. Those within and outside of the profession have generally come to terms that two years of full-time supervision is long enough for that gatekeeping need to also be addressed.

While some states are moving toward standardizing their MFT licensure requirements with others, it's interesting to note that the current trend appears to be toward making licensure easier in the mental health professions. In California, the licensing board is seeking provisions to allow MFT Interns to count client-centered advocacy among their supervised experience. Psychologists are going for an even bolder change, arguing that their 1,500-hour, postdoctoral internship is unnecessary. There is certainly a mental health workforce shortage in this country, though I will leave it to others to debate whether making licensure easier is an ideal solution.