Good advice for kids' bad behavior

Slate had a great article last week urging parents to take a deep breath and really think about whether it's worth the trouble to make their child's irritating-but-not-awful behavior change. It's written from a purely behaviorist perspective, and it covers the bases well: Most annoying behavior is relatively normal and goes away on its own in time.

There are lines to be drawn, of course, between behaviors that parents can endure and write off as "just a phase" versus behavior that is directly harmful (either to the child or others) and should be intervened upon. But those kinds of problems occur far less often than many parents think. Slate urges readers to tread lightly, and to anticipate some of the stages in a problem disappearing, including what mental health professionals call an "extinction burst."

Problematic behavior can be grown out of by adults, too, of course. Some mental illnesses, left untreated, have a surprisingly high rate of what researchers call "spontaneous remission" -- a fancy way of saying the problem goes away on its own. I'll return to that topic in some detain in an upcoming post.

There isn't much in the way of new research in the Slate article, but as an introduction of simple behavioral lessons for parents who feel at their wits' end, it's a nice piece.

New year, new Medicare efforts for MFTs

Will this be the year MFTs finally are included in Medicare? There are promising signs.

First, there is already momentum for adding MFTs to the list of accepted providers. MFTs have been on three bills, one in each of the past three Congresses, that successfully passed out of one legislative house. (Twice we've made it out of the House of Representatives, once out of the Senate.) So far, no bill to include MFTs in Medicare has survived both houses and made it to the President's desk. But with a new President, a new Congress, and a new public focus on health care reform, there looks to be a good window of opportunity.

There are two bills (HR1693 in the House, and its companion Senate bill, S671) already introduced in the current Congress that would bring MFTs into Medicare. Both are bipartisan efforts that have very low initial costs and are likely to lead to long-term savings as Medicare patients would be able to more easily receive early treatment for mental health disorders. Both have strong and growing support from key committee members in both houses.

In the larger conversation about health care reform, there is also good reason to be optimistic for the MFT profession. The body of knowledge supporting the clinical effectiveness and cost-effectiveness of our work continues to grow at a rapid pace, and with licensure now in 48 states and DC, the case for inclusion is stronger than ever.

I'll keep you posted as the bills move forward. Stay tuned to aamft.org for updates and calls-to-action, when contacts with specific legislators can help turn their votes.

Fringe practices: Neurolinguistic Programming

Neurolinguistic programming (NLP) is sometimes described as a combination of postmodern therapy and neurology. On a basic level, the model suggests there are clear connections that can be drawn between internal experience (neurology), language, and behavior. Based on these connections, it is theorized that changes in internal experience and/or language can quickly and dramatically impact behavior. These interactions are also recursive, so changing language can change internal experience -- a direct connection with postmodern therapies.

Trying to move past these general ideas into specifics of the model is quite challenging. NLP is sometimes described as "a set of techniques designed to make you better at what you do." You likely will not leave this long introduction to NLP with any better understanding of what it is or how it works than what you came in with. Looking elsewhere, we find a description of the model that sounds a lot like The Secret:

[NLP is based on the notion] that the words we use reflect an inner, subconscious perception of our problems. If these words and perceptions are inaccurate, as long as we continue to use them and to think of them, the underlying problem will persist. In other words, our attitudes are, in a sense, a self-fulfilling prophecy.

Part of the difficulty in determining what it is, exactly, that NLP therapists do is owed to the model's suggestion that therapy must be subjective. Therapists are then seen less as scientists, and more as artists. Therapy is not to be a prescribed order of techniques, but rather a process customized to each client that respects the clients' unique experiences.

However you define it, NLP today bears all the markers of a fringe practice in marriage and family therapy.

A small and dedicated group of practitioners. The UK association for NLP listed more than 50 training organizations and estimated that 150,000 people had been trained in the model in some way as of 2000 (Tosey & Mathison, 2003). This group primarily does not consist of psychotherapists, but rather involves "educators, managers, trainers, sales people, market researchers," and so on. While there are several training organizations in the US, the number of practitioners and academics involved in the model appears to be modest.

Expensive training. Training providers in NLP talk about the artistry of creating a therapy appropriate to each specific client, and that the trend in NLP is toward shorter trainings. Then they ask for $4,000 for a master practitioner training program.

Unrealistic claims of effectiveness. Therapy processes claim a lot of things, but this was the first time I had ever seen one actually claim to be magical:

Neuro-Linguistic Programming™ was specifically created in order to allow us to do magic by creating new ways of understanding how verbal and non-verbal communication affect the human brain. As such it presents us all with the opportunity to not only communicate better with others, but also learn how to gain more control over what we considered to be automatic functions of our own neurology.

The founders of the model, Richard Bandler and John Grinder, believed it to be effective for the complete range of psychological problems that therapists would encounter. Again, the model is vague on what exactly it is supposed to accomplish, although its adherents claim a strong foundation in client strengths, noting that "Each of us is a miracle waiting to happen."

Weak scientific support. The Wikipedia entry on NLP is blunt: "NLP has enjoyed little or no support from the scientific community. It continues to make no impact on mainstream academic psychology, and only limited impact on mainstream psychotherapy and counselling." In the presence of little empirical support -- and a number of articles that appear to actively discredit the usefulness of the model -- NLP adherents do what most fringe practitioners would do, which is to dismiss the research as poorly constructed or irrelevant. Like it or not, though, the effectiveness of any therapeutic model -- as established through research -- is vital to that model gaining legitimacy with payors and clients alike. For now, NLP lacks that research base, and the legitimacy it would provide.

So, is it worthwhile? Many practices that are now accepted started out as fringe practices, so the label is not always a derogatory one. All fields need some practices at the cutting edge -- some make it to broad acceptance and others are weeded out before they can get there. While it may be useful in other fields, NLP seems to be one edging toward being weeded out as a model for psychotherapy. Though the model has been around since the 1970s, clinical effectiveness simply has not been demonstrated, and NLP practitioners express active disinterest in such research. Perhaps it is because the model's ties to postmodernism leave the it too subjective to be truly testable.

As I detailed in an earlier post, my writings on fringe practices are not meant to advocate for or against their use. I hope instead to provide a relatively complete picture of the current state of these practices -- their level of acceptance in the profession and scientific community, their evident effectiveness, and why readers may or may not be interested in them. Comments are always welcomed.

REFERENCE

Tosey, P., & Mathison, J. (2003). Neuro-linguistic programming and learning theory: A response. The Curriculum Journal, 14(3), 371-388.

Why we (wrongly) believe praise doesn't work

I've been reading The Drunkard's Walk in fits and starts lately -- it's a good-not-great book about how randomness impacts our daily lives in ways large and small. In the words of OK Go, mediocre people do exceptional things all the time. But there's one piece I really enjoyed that shows immediate applicability to couple and family work: People think criticism works better than praise because of what the statistically-minded call regression to the mean.

Whenever someone does something exceptional, be it exceptionally good or exceptionally moronic, it draws our attention. A golfer may make a 100-foot putt, or a well-meaning driver may hit a squirrel darting across the road. In either case, the event is a combination of luck and skill, and the "luck" part is not likely to immediately repeat itself. Whether you praise the golfer or ignore her, she is not likely to make the next 100-foot putt. Similarly, you can scream at the driver who hit the squirrel or ignore him, and either way, he probably will not suffer such bad luck in the near future.

This is why we believe praise doesn't work. We expect that praise will lead to the immediate repetition of behavior that is at least in part lucky, and when it doesn't, we think the praise makes no difference.

To use the specific example in the book, a flight instructor had long ago given up on praising his students for flight tactics well done. If they did well, no amount of praise seemed to increase the odds they would do better next time. But if they did very poorly, after a good tongue-lashing they performed much better. The rub, of course, is that in all likelihood they would have performed much better anyway.

The lesson for therapists and clients alike, I think, is that the effects of praise and criticism are not immediate, and expecting them to provide immediate results sets you up for failure. If you want to see whether praise or criticism is really working, you need to look at the average of many performances over time, averaging them to get a clearer sense of te individual's skill level. Don't put much stock in a single act as a measure of overall skill.

Over the long term, praise does help in many ways, and criticism hurts. For couples, Gottman's famed 5-to-1 ratio is a good example. For individuals, there has been a good amount of research on the effects of criticism on self-esteem -- and performance. Seeing these long-term effects, though, means looking at averages and ignoring the occasional good or bad day.

With this in mind, the only reasonable course of action here is to close with some praise. Great job working your way through this post! I hope you found it rewarding. And, if you think this post was awful, well, odds are I'll do better next time.

MFT licensure: How do bad therapists stay licensed?

From students and colleagues alike, I often hear statements to the effect that "There are a lot of bad therapists out there." As I understand it, "bad" in this context has a variety of meanings, ranging from simply ineffective to downright unethical. At either end of that spectrum, though, the next question is usually the same: How do they stay licensed?

Let's start at the ineffectiveness end. No therapy is 100% effective, so providing therapy that doesn't work with some clients is normal. I've had my share of cases that did not go as well as I would have hoped. A therapist is only violating professional standards if they make false claims to clients about the likelihood of success with a particular treatment. Of course, it could be argued that a therapist is behaving unethically if they are far less effective in their work than the average therapist, but there is no reasonable way for a licensing board to gather that kind of information. So they attempt to ensure effectiveness by proxy, through such requirements as ongoing continuing education.

For therapists who are unethical in their practices, it may take years before unethical practitioners are investigated and their licenses disciplined. And even then, only the most egregious acts -- like sexual relationships with clients, insurance fraud, or repeated and knowing violations of confidentiality -- will actually result in a license being revoked. Reasons for this include that (1) licensing boards rarely can act in the absence of a complaint coming directly from an impacted client, and even clients who have suffered great harm are reluctant to complain; (2) because effective psychotherapy is so dependent on the protection of privacy between client and therapist, investigations are lengthy and costly, and may fail to find a pattern of therapist behavior even when it does exist; and (3) standards of the profession, including ethical standards and disciplinary guidelines, are predominantly set by members of the profession.

So what is a mental health consumer to do? Three things:

1, Caveat emptor. Licensure ensures that a therapist met minimal state standards for independent practice -- it is by no means a guarantee of effectiveness or up-to-date knowledge. Clients should ask lots of questions of prospective therapists, and if you do not feel fully comfortable with the person you are seeing, find someone else.

2, Demand accountability for effectiveness. The first session should focus on setting clear goals for therapy. From that point forward, you and the therapist share responsibility for getting there. It is not in your interest to continue spending time and money on methods that are not making a difference. Therapy does not always work quickly, but this is why it is so important to set clear and achievable goals, including some early-stage goals: You will have a quick yardstick of your ability to succeed with this therapist.

3, If you have been the victim of an unethical therapist, file a complaint. It is not especially unusual for colleagues to have a sense that a particular therapist is violating the law or professional standards, but licensing boards cannot investigate a feeling. They need to hear directly from someone who has suffered because of the unethical therapist's actions. For a variety of (understandable) reasons, many clients who have been victimized in this way never do make a report.