Marriage and the economy

Slate engaged in a bit of a bogus trend story earlier this week, usually something the online magazine makes a habit of mocking. Under the title "Unwashed coffee mugs," the story aims to educate us on the toll that the faltering economy has taken on marriages.

Let's start with what the article gets right: 82 percent of the recession's job losses have been suffered by men. As of last year, 25 percent of wives out-earned their husbands, a number that almost certainly has climbed with recent layoffs. And time-use data does indeed show that after men lose their jobs, they don't suddenly find themselves inspired to do more housework; instead, "they spend more time sleeping, watching TV, and looking for a job."

Getting to what that means for marriage, of course, is trickier.

To be sure, money is a common source of conflict in marriages. But the actual effects of recession on divorce rates are not that large:

Census Bureau figures show that over the past 2 1/2 decades, recessions have had only minor effects on divorce rates, which have been slowly waning since the early '80s after 20 years of steadily rising. Those trajectories have been influenced more by the rise of the women's movement and women's earning power, lower fertility and changes in divorce laws than by dour Dows. The only recorded spike in divorces in the past 75 years came right after World War II.

Expect to see a lot more speculation about money and marriage over the next few months -- it's a common (and easy) theme to strike in writing about family life. But bear in mind that there are contradictory forces on families in a recession; they may suffer greater stress as a result of financial woes, sure. They also may be more likely to come together as a family to make it through a difficult time. Beware of stories that draw conclusions beyond what their data can support.

MFTs (finally) earn job classification with Veterans Affairs (VA)

My friends at AAMFT Government Affairs have great news: The Department of Veterans Affairs (VA) has finally approved a new job category for marriage and family therapists (MFTs)! This has been a long time in the making, as the VA had dragged its heels since the law mandating such a job category was enacted in December 2006.

Partial text from the AAMFT letter to members follows.

Despite the uncertain timeframe for necessary next steps within the VA, the AAMFT will continue to advocate on behalf of the MFT profession to see that there is swift and fair resolution to final VA implementation. The AAMFT will be working alongside the VA Human Resources' office to formalize the establishment of new qualification standards for these emerging VA positions. They have indicated that they will seek counsel with our professional organization moving forward as an MFT subject matter expert for the actual development of these classification standards.

Ever since Public Law 109-461 (the Veterans Benefits, Health Care, and Information Technology Act) was signed back in December of 2006, the AAMFT has been vigilant in pushing for its resolution and enactment, allowing veterans' around the country access to the services of MFTs. Over the last few months, AAMFT joined forces with the American Counseling Association (ACA) and the American Mental Health Counselor's Association (AMHCA). In recent weeks, the California Association for Marriage and Family Therapy (CAMFT) also signed onto the united front of AAMFT, ACA and AMHCA. These latest initiatives have been aimed at getting Congress to vocally express its desire for "the will of law" to be adhered through swift VA implementation of MFT and Licensed Professional Counselors (LPCs).

Government to compare treatment effectiveness

There's an interesting slice of the federal stimulus bill aimed to improve health care, according to this morning's New York Times. In the interest of improving the quality of health care in the US, and reducing its cost, the government will spend up to $1.1 billion "to compare drugs, surgery, and other ways of treating specific conditions." Those "other ways" include both talk therapy and "watchful waiting" for some conditions.

The money is a response to the soaring cost of health care, which will account for a quarter of the Gross Domestic Product by 2025 without major changes. Several forms of family therapy have been established as cost-effective treatments for specific conditions, but these treatments have failed to gain as much attention (or use) as they arguably should.

Critics of the program, according to the article, worry that it would lead to the rationing of some treatments, or their disallowance. Doctors, however, seem to largely favor increased research that will give them more direct guidance on how and when to choose one form of treatment over another.

Count me with the doctors. Family therapy works, and is often as good as (if not better than) individual therapy in treating specific conditions. Depression is a great example. We know couple therapy can be used in the treatment of depression, but have little guidance as to when couple therapy would be preferable to individual treatment. Any research that can help inform that decision is a good thing.

Fringe practices: Thought Field Therapy

This is the first of a series of posts I'll be writing on practices at the fringes of the field of marriage and family therapy. Generally speaking, these practices lack sound scientific backing, yet make fantastical claims about effectiveness. They usually are practiced by a small (and often highly devoted) group of practitioners. They also often require expensive training.

Bear in mind that the lack of a scientific backing does not mean that a practice is necessarily ineffective, or that it is not valuable. All new treatment models start out without a strong research base, and then build legitimacy through a combination of research and clinical experiences. Some well-accepted models, like Narrative Therapy, by their nature cannot be studied in traditional clinical trials. They build scientific legitimacy through qualitative study and process research.

Information on fringe procedures is typically presented in a one-sided manner. You usually get either the sales pitch for the procedure, or all the arguments against it. My intent is not to advocate for or against the use of these procedures, but rather to provide a complete picture of both sides. As always, I welcome your comments.

Thought Field Therapy (TFT) seeks to create healing by repetitive motions (such as tapping) on several "acupressure points" on the body, primarily on the hands, face, and upper body. Patients are also often instructed to visualize a distressing situation as they engage in repetitive behaviors, such as repeating a phrase or counting. A summary of a brief trauma treatment sequence is available here.

Claims of effectiveness. Proponents focus on the impact of TFT on heart rate variability (HRV), considering HRV an indicator of overall health and mortality. They suggest TFT is the only known treatment to dramatically impact HRV. The treatment is said to dramatically impact other conditions as well, offering

immediate relief for PTSD, addictions, phobias, fears and anxieties by directly treating the blockage in the energy flow created by a disturbing thought pattern.

TFT practitioners claim that thousands of clients have been treated successfully with TFT without side effects. They claim effectiveness rates of up to 97 percent. The practice of TFT is usually done in person, but Roger Callahan, the US psychologist who developed TFT, claims that TFT "voice technology" treatments done by phone can stop atrial fibrillation in a matter of minutes. He claims six such successful treatments. His company also produces a quarterly publication, The Thought Journal, with case studies of successful treatments submitted by practitioners.

Lack of sound scientific backing. The Thought Journal is labeled a "journal," but is not subject to the peer review process or publication standards of accepted academic journals. Overreliance on testimonials and anecdotal evidence in the absence of scientific study is one of the defining characteristics of a pseudoscience. Controlled research is lacking, which is why the American Psychological Association has deemed TFT to be without scientific support. Five articles on the method were published without peer review in the Journal of Clinical Psychology in 2001 -- and in each case, the articles were deemed uninterpretable due to major methodological flaws. James Herbert, a psychology professor who wrote a review of the existing TFT research, found the scientific backing for the treatment to be "basically nonexistent" and that there is "no evidence it does what it claims to do." Since 1999, the APA has refused to grant continuing education credit to its members for TFT training, and there has been at least one instance of a psychologist sanctioned by the state licensing board for using TFT and making inflated claims about its effectiveness. There is some emerging research on "energy psychology" techniques, though their effectiveness appears to be based more on the relationship between client and therapist than on the techniques themselves.

A small and devoted group of practitioners. The lack of supporting evidence is no deterrent to proponents of the method. (Shifting the burden of proof to those disproving a model's effectiveness is another characteristic of a pseudoscience.) TFT training centers exist at various locations around the country. TFT practitioners can be located through directories on the TFT web site.

Expensive training. Callahan charges $100,000 for training in "voice technology," which is considered the highest training level in TFT. This training is completed in three days of one-on-one work with Callahan. The TFT web site lists 14 individuals other than Callahan who practice at this level.

Is it useful? For some, yes. I highly doubt that the many case studies of success with TFT are fictional. The question becomes, what is it about TFT that is working for many clients? Is it the sequences of behavior? Is it the relationship with a caring and concerned professional? Is it a placebo effect generated by the simple promise of a fast and effective cure without side effects? Here is where the burden of scientific proof falls on the proponents of the model, to prove that their techniques are somehow different from, and superior to (or at least as good as) accepted models. It is a burden they have not met.

However, in cases where other methods of treatment have not worked, clients may be interested in pursuing alternative methods like TFT. Whether licensed professionals -- who should be working from positions of scientific support wherever possible, and making only cautious claims of likely effectiveness -- should offer such treatment is a complicated ethical question. I'll discuss that issue in a separate post in weeks to come.

MFT licensure: California

Ah, the Golden State. Home to me and half the licensed Marriage and Family Therapists in the country. And, in the eyes of the rest of the country, some pretty weird practices within the profession.

MFT licensure in California looks a lot different here than it does everywhere else. And it shouldn't have to, seeing as the profession itself -- that is, our scope of practice and competence -- is pretty much the same here as it is everywhere else.

What the heck is so different here, and why?

• Required curriculum. Most states require that MFTs have graduated from a COAMFTE-accredited program or demonstrable equivalent. Not so in California. Of our roughly 80 license-eligible graduate programs, only a handful are COAMFTE-accredited. Here, there are specific coursework requirements spelled out in state law, and these apply regardless of the program's accreditation status. This is partly due to history; California had MFT licensure long before there even was such a thing as COAMFTE accreditation.
   
• Supervisor qualifications. California is one of few states that does not require MFT trainees and interns to gather experience under an AAMFT Approved Supervisor. For those in California who may eventually leave the state, this is vital to know: Other states may not count hours you earned in California under a non-AAMFT-approved supervisor. In California, MFTs can be supervised by any licensed MFT, LCSW, or Psychologist with at least two years of licensure and a six-hour supervision course completed. The history here again goes back to California being the first state to adopt MFT licensure. There weren't AAMFT Approved Supervisors back then, and today, there aren't enough of them around the state to meet the supervision need.
   
• Hours of experience. If you ever want to know how loony California is in regulation of MFTs, it's this simple: You can get licensed as a marriage and family therapist in California without ever having seen a couple or family together in therapy. California categorizes hours of experience differently from any other state, lumping "Couples, families, and children" into the same category. Many fill the category by working only with individual children, which is antithetical to the field, but perfectly legal. As I understand it, the language of that category was changed a few years ago to say "and" instead of "or," in hopes that it would clarify an expectation that MFTs-in-training see all three. I've seen no noticeable effects of this change.
   
• Exam processes. California is the only state that licenses MFTs but does not use the National MFT Exam. California uses two state-run exams, the "Standard Written Exam" and the "Written Clinical Vignette." There's history here too, and it again can be taken back to early licensure here, but the link is more dubious. Several other states (Texas among them) had MFT licensure prior to the existence of the national exam, but they have moved toward unifying the profession and adopted the national exam.

So we end up with a split profession: There's California, with lower qualifications for supervisors, goofy ways of counting hours, and a unique set of MFT exams, and then there's the rest of the country, which follows much more consistent (though not entirely consistent) standards. What is an aspiring MFT to do?

As I've detailed in a previous post, there are a number of things to consider when choosing an MFT program, and location is a big one. Ideally, you should get your education and supervised experience at a COAMFTE-accredited program in the state where you ultimately plan to be licensed. At a minimum, though, you should attend a COAMFTE-accredited program, as such a degree is much more portable than one from a non-COAMFTE program.

I've also discussed previously what to do when you're thinking of moving your MFT license to another state. In brief, make very sure you know the requirements of the state you're moving to, before you move there.

As a footnote, there are efforts afoot to bring California more in line with the rest of the nation. I hope to be able to update you with good news on these efforts in the future.

Angry moms, inside therapy and out

Are mothers, inside and outside of therapy, generally angry at their husbands?

Outside of therapy, moms are surprisingly angry at dads. Such is the finding of a Parenting.com investigation, which looked at 1,000 married mothers to get a sense of their relationships. They found that almost half of moms became furious with their husbands once a week or more. (Salon's Abigail Kramer comments articulately on the Parenting.com piece.)

Meanwhile, back at the office, MFTs see a lot of angry moms as well. According to the aptly titled "What's Wrong with These People? Clinicians' Views of Clinical Couples" in the January Journal of Marital and Family Therapy, MFT students and faculty alike expect wives in therapy to complain, criticize, and blame their husbands for the problems that bring them into therapy. The therapists were no kinder to clinical husbands, who they expected to be hostile, fight to get the last word in, and tell their wives what to do.

What gives? Are wives so mad, and dads so bad?

Let's start with the JMFT article. If we're trying to get a handle on how clinicians view their clients as being different from average, non-clinical couples, then that's the comparison you should make. This article asked MFT faculty and students to compare typical clinical couples with ideal husbands and wives, and so it makes perfect sense that against that backdrop, clinical couples would be expected to show all the negative traits listed above.

MFTs do not expect their clinical couples to be ideal, and they would be dumb to have such an expectation -- most ideal couples, if they even exist, probably are not in therapy. MFTs view their clinical couples as less than ideal. That makes sense. Does that mean MFTs view their clients as any different from the rest of the population? We can't answer that based on this article.

Now, the Parenting.com piece is a bit tougher to crack. It's safe to say the results are sensationalized to get media attention, but there still seems to be a lot of anger shown in the raw data -- how did that happen?

There are lots of reasons to take the article with a giant, truck-sized grain of salt. For one, we don't know how the questions were really asked, just how the author spun them. To wit: "Lots of moms -- 40 percent -- are also angry that their husbands seem clueless about the best way to take care of kids." I don't know how that question was asked, but I'll put down five bucks that says the survey question was not, "Are you angry that your husband seems clueless about the best way to take care of kids?"

For another, the article highlights the most angry responses, even when those are in the minority. The quote above is a great example. So, 40 percent of moms feel this way? What about the 60 percent who don't? These moms are not highlighted in the article, not given the chance to discuss at length the quality of parenting their husbands do. Such highlighting of a minority position is consistent throughout the article, most laughably when "33% of moms say their husbands aren't shouldering equal responsibility and are less concerned than they are about their children's basic needs." The other two-thirds sound a lot more representative.

Finally, there's not much information on the sampling method. We're told it's nationally representative, but just because that is true geographically or demographically does not mean it is true in terms of attitudes. You could do a survey of drug users that is "nationally representative," but that doesn't mean their attitudes on parenting would represent the attitudes of the nation as a whole.

It is not my intent to be entirely dismissive of either piece. I just think they need to be considered in the right context. There's not enough here to conclude that moms are really that mad, that dads are really that bad, or that their therapists are really all that judgmental.