Study: MFTs not as pro-marriage as you might think

The new issue of the Journal of Couple and Relationship Therapy is out, and it gives me the rare and happy opportunity to put in a plug for my own work. It includes a couple of surprises. In a study I coauthored on marriage and family therapists' attitudes toward marriage, MFTs suffered the same steady, age-related decline in positivity toward marriage previously seen among non-therapists. The big surprise was that experience doing couples therapy more than offset this decline. As therapists gained experience working with couples over the years, they grew more positive about marriage -- a strong testament to the power of our field to influence clients and therapists alike. So, ideally, if you want a supremely marriage-positive therapist, you should find someone who is about 30 years old and has about 40 years of experience. Other findings in the new JCRT:

• The RELATE test can identify fairly easily those couples at heightened risk of divorce, from the time before they even marry. Once couples are identified as being at-risk, they can be targeted with specific services. Some of the biggest roadblocks to strengthening the at-risk marriage: time and money. Lack of knowledge is a factor too. Score one for the marriage education movement.
• Demand-withdraw cycles of communication in couples are strongly linked with attachment style. Attachment-based therapies may be the best option for couples caught in such cycles. But then, we already knew that.
• Couples with internet access might benefit from specific writing tasks assigned as a part of the therapy. Emphasis here on "might," as this article is just a proposed process, and not an outcome evaluation.

As an aside, I'll be spending the rest of the week and the weekend at the AAMFT Annual Conference in Memphis, TN. I look forward to sharing what I learn upon my return to beautiful Los Angeles.

A voter guide for California MFTs

Many of the initiatives on which Californians will be voting next week will, either directly or indirectly, impact the work of marriage and family therapists. Here is a quick guide to how some of those impacts could play out, and how you might vote if you vote solely based on professional self-interest. There are plenty of other good arguments to be made for and against these items on other grounds, of course. Measure 3: Children's Hospital Bond Act. This act would provide almost $1 billion for the construction and renovation of children's hospitals around the state. Such hospitals are regular places of employment for MFTs, so it stands to reason that having more and better hospitals could mean having more, and more well-equipped, job opportunities within the profession. I would note, though, that the bonds are specifically for construction and furnishing -- by itself, this measure does not actually fund any positions. MFT Self-Interest Vote: Yes. Measure 5: Sentencing for Nonviolent Drug Offenses. Greatly expands treatment and rehabilitation, rather than imprisonment, for nonviolent drug offenders. Would provide great professional opportunities for MFTs in drug and alcohol treatment contexts. MFT Self-Interest Vote: Yes. Measure 8: State Constitutional Amendment Banning Gay Marriage. You probably either support the human-rights argument here or you support the religious one. I'm under no illusions that I'll be changing any minds, or that anyone will be casting their ballot on this measure based solely on professional self-interest. It's too emotionally charged of an issue. That said, consider that for MFTs who work with LGBT clients in places where gay marriage is not allowed, the very title of our license -- marriage and family therapist -- can be construed as confusing at best, discriminatory at worst. Who knows how many LGBT clients shy away from MFT services because they believe we do not work with their issues? I don't know, but I suspect the number is high. MFT Self-Interest Vote: No. I'll stay out of the presidential fray here, not out of disinterest but because too much is unclear in both candidates' proposals to sort out the likely real impacts on MFTs. Whatever your opinions on these important measures, please vote on election day.

Friday fun, musical edition

First off, everyone should be trained in CPR. It’s relatively simple and can be a lifesaver. It also conjures up a sweet disco beat. Second, do you like sushi? Perhaps your favorite is the California Roll, or the Philadelphia Roll. Me, I’ve been a longtime fan of a different kind of Roll. (OK, OK, this has been around for a while, but if you’re unfamiliar with the backstory, click here.) Finally -- and I'll try to keep the local stuff to a minimum -- as someone still fairly new to LA, I’m finding LA Weekly’s event calendar really useful. There’s a lot of good music in this town. Go figure.

Internet Infidelity

The always-great Journal of Marital and Family Therapy is out this month with a special edition on MFT and Cyberspace. Among the findings:

• MFTs should be aware that using the Internet as a social tool is now normal for kids and adolescents. There are assessment tools now available, including the Internet Sex Screening Test - Adolescent Version, to determine whether an adolescent's behavior warrants treatment.
• Just like in non-Internet relationships, men show greater concern over women's sexual infidelity, and women show greater concern over men's emotional infidelity.
• Among a sample of university students, neither men nor women believed that a cybersex relationship implied a love relationship (or vice versa).
• Over the past two years, therapists report an increased frequency of clients coming to therapy to address cybersex issues. Many therapists feel unprepared for this work.
• Therapists apparently allow several biases to impact their assessment and treatment of internet infidelity cases. Therapist decisions are impacted by factors including the client's gender, therapist's age, therapist's gender, therapist's religiosity, and therapist's personal experiences with infidelity. In regard to client gender, men are far more likely to be labeled "sex addicts" than are women engaging in identical behaviors.
• For family members concerned about a loved one's cybersex behavior, there is an empirically-supported and manualized method for bringing that person into treatment, known as the ARISE model.

All fascinating stuff. I've seen in my own practice a number of couples dealing with issues of internet infidelity over the past few years, and suspect that this will only become more common. It's good to see our field pursuing assessment and treatment models that specifically address it.

Autism

Family Therapy Magazine gave extensive coverage to the autism epidemic in its May/June edition, focused (appropriately) on how therapists can help families with children who may be autistic. Discussion of potential causes for autism is pretty limited:

There is no known single cause for autism, but it is generally accepted that it is caused by abnormalities in brain structure or function. Brain scans show differences in the shape and structure of the brain in children with autism versus neuro-typical children. Researchers are investigating a number of theories, including the link between heredity, genetics, and medical problems... Research indicates that other factors besides the genetic component are contributing to the rise in increasing occurrences of ASD, such as environmental toxins.

Again, it is appropriate that a magazine focused on treatment not get distracted by debates about causes. But there is a large number of very interesting, if not yet definitive, studies on what exactly causes autism spectrum disorders. The most controversial potential culprit is thimerisol, a mercury-based preservative used in many childhood vaccines. The demonization of thimerisol was given a huge push thanks to this Rolling Stone article, which gave only passing mention to the fact that large-scale studies have pretty thoroughly debunked the idea. It has also been argued that a potential cause is the vaccines themselves, which are much more numerous and on a much shorter schedule for children today than a generation or two ago. One of the most interesting potential causes for autism is television. Don't misunderstand, I love Rock of Love as much as the next guy. But a 2006 Cornell study came up with some surprising conclusions, summarized well in Slate:

The researchers studied autism incidence in California, Oregon, Pennsylvania, and Washington state. They found that as cable television became common in California and Pennsylvania beginning around 1980, childhood autism rose more in the counties that had cable than in the counties that did not. They further found that in all the Western states, the more time toddlers spent in front of the television, the more likely they were to exhibit symptoms of autism disorders.

Notably, that Slate article was posted in October 2006 when the study came out; some two years later (July 28, 2008) it was Slate's most emailed article, and continues to get regular cycles of attention. Obviously, we're talking about correlation here, not causation. When cable television comes to town, it does not arrive alone; it is typically evidence of increasing urbanization, which tends to involve a lot of other questionable influences in the environment as well. So we're probably looking at two symptoms of the same (still unknown) cause. Unless, of course, we are not. One of the leading theories of autism has to do with mirror neurons, those parts of the brain that light up as we watch others engage in specific activities, as though we were doing the activity ourselves. Mirror neurons are vital to learning through modeling, and in kids with autism, they do not respond in the same way that mirror neurons respond in non-autistic children. I suspect -- without proof, mind you -- that in order to properly develop, mirror neurons require that the people we are watching in our formative years be responsive and interactive, engaging our active attention. In other words, be like parents. Cable television is regularly used as a babysitter, which is fine; my brother and I spent many an hour watching Thundercats and having breakfast while Mom was getting ready for work. But television is not responsive, and would seem far less likely to engage the mirror neurons than a real live person would. In short, I'm far from being ready to blame television for autism, but there is a certain logic to the theory that fits well with some existing biological evidence. I'd welcome your thoughts.

License portability

Ah, to be a medical doctor. To only have to pass the boards once, and then be done with it. Forever. Marriage and family therapists -- who, at least in theory, practice the same art no matter where they roam -- are subject to a mishmash of licensure laws around the 50 states, with various requirements for education, experience, and examinations. Taking your MFT license to a new state can be a nightmare, as you may be forced to provide transcripts and syllabi from classes taken decades ago, register as an intern no matter how long you've been licensed, and in some states, go through another testing process. If you are considering ever moving to another state -- and even if you're not considering it now, most people eventually do -- here are five things you can do to make license portability easier.

1. Graduate from a COAMFTE-Accredited program. The education requirements of most states specify that in order to be licensed as an MFT, you must have gone to a COAMFTE-accredited program or a reasonable equivalent. Spare yourself the trouble of having to prove equivalency, which can be a tedious process.
2. Do your prelicensed hours under an AAMFT Approved Supervisor. In states that specifically require an AAMFT Approved Supervisor in order for licensure hours to count (North Carolina is one example among many), all supervisors go through the training. In states that do not require this, far fewer do. This presents some obvious problems if you move from a state that didn't require AAMFT-Approved supervision to one that does.
3. Get an early start with the state to which you're moving. Establishing educational equivalency and suitable experience for licensure in a new state can be very time-consuming. Most states have their requirements online, but you should contact the state licensing board directly to figure out exactly what paperwork you will need to file -- and who, in your current state, will need to sign off on it.
4. Don't stop at 3,000 hours of prelicensed experience. While this is the numerical requirement in many states, a number of states require more. Gathering 3,200 hours will make you a bit safer. Ideally, if you know what state you will be moving to early enough, you can craft your prelicensure experience to meet that state's standards.
5. Document well. Any time there is a disagreement about whether you have met a certain requirement in your new state, you will need documentation to back up your side. Keep careful documentation of your supervision, your education, and what types of hours you're doing (individual client contact, family client contact, supervision, etc.), as some states require hours to be specifically categorized. Naturally, not all states agree about what those categories should be. You may have exactly the education and experience your new state wants, but if you can't prove it, you will not get licensed there.

It's tempting to add a sixth rule here -- "Don't involve California" -- since some of the greatest difficulty in license portability in the country is experienced by those coming into or out of the Golden State. But we need more MFTs here, so if you're thinking about it, do come to California. Just prepare yourself, as California is the only state in the country that licenses MFTs without using the National MFT Exam. And our other California MFT license requirements can get a little goofy too.

Friday fun

On a sometimes-but-not-always basis, I'll use the last day of the week to clean out the old bookmarks closet, sharing things I hope you'll find useful, informative, or at least entertaining. I'll break in the space with mostly useful links, and over time include more fluff. I'm a huge fan of professional organizations, since they do so much to advance our field. AAMFT, CAMFT, IFTA, and NCFR are all great professional organizations (as is APA, of course). For those of you in California, MFTeducation.com is a statewide database of training events. It’s a bit sparse now, but events tend to be added in waves. If you’re booking travel to Memphis for AAMFT’s annual conference, or just looking for flights to visit family or friends over the holidays, here is a roundup of good, new cheap-airfare finders. Last but not least, this site is what couples therapy via crowdsourcing looks like. It falls solidly in the “time-waster” category, and I tend to find it more amusing than alarming. Have a great weekend!

Critical Incident Stress Debriefing

The print version of the LA Times in late July ran a story with the headline "Go Ahead, Hold It In." (The headline on the web version is a little less pithy.) Apparently new research suggests that emotional expression after a traumatic event is not as helpful as once thought:

"In the immediate aftermath of a collective trauma, it's perfectly healthy to not want to express your thoughts and feelings," [University of Buffalo Psychologist Mark Seery] says. In fact, it can do more harm than good. Some people have periods of what psychologists call "healthy denial." Like Scarlet O'Hara, they cope by promising themselves to think about it tomorrow. Being pushed to give voice to their worst reactions too soon could embed the worst of it in memory and cause them to dwell on the tragedy. And if they can't or won't talk, urging them to act against their instincts could make them think that something is wrong with them.

In the aftermath of major traumas like the September 11 terrorist attacks, shootings at Virginia Tech, or natural disasters, counselors and therapists are often brought in by the hundreds. They provide what is called Critical Incident Stress Debriefing, a process in which victims or family members, usually in a group setting, are encouraged to express their emotions and talk about their experiences around the event. The LA Times puts it politely in saying such work "has gotten ahead of the evidence on the best course of mental healthcare after a disaster." Unfortunately, we've known this for some time, and the CISD business is booming. This 2003 research summary in Psychological Science in the Public Interest summed up what we knew five years ago:

Although the majority of debriefed survivors describe the experience as helpful, there is no convincing evidence that debriefing reduces the incidence of PTSD, and some controlled studies suggest that it may impede natural recovery from trauma. Most studies show that individuals who receive debriefing fare no better than those who do not receive debriefing.

Two years later, in 2005, we had this summary of the state of CISD research:

The National Institute for Mental Health (NIMH), in conjunction with the Departments of Justice, Defense, Health and Human Services, Veterans Affairs and the American Red Cross, held a consensus conference on the mental health response to victims and survivors of mass violence. The researchers did not recommend CISM/CISD.

Finally, a 2006 article in the Review of General Psychology found that debriefing sessions accomplished nothing, good or bad, for those who participated in them. Certainly, the method has its defenders. There's a lively and mostly well-written defense of the field, dissecting many of the research findings (pro and con) about CISD here. You may want to skip to the end, where they discuss and attempt to refute the negative research, and address the issue of possible harm. All of this is not an attempt to diminish the importance of having mental health services available after a disaster. Some individuals experience very real difficulties in coping and can be helped. And localized systems can easily become overwhelmed. But a massive influx of counselors and therapists after a disaster, acting as though therapy is somehow a necessity for all involved, is probably not helpful. Getting back to the science, the whole debate on CISD reminds me a lot of the research-and-usage arc of the Drug Abuse Resistance Education (DARE) program in the 1980s and 1990s. DARE continued to be used for many years even after research had overwhelmingly declared it ineffective. Part of the reason for the continued use was that communities wanted to feel like they were doing something to combat adolescent drug use, even when they had clear evidence that their efforts were unproductive. (The fallback argument for DARE proponents, of course, begins with "If we helped even one child..." This argument ignores the studies that found DARE exposure actually increased later drug use among some groups.) Similarly, here, we as therapists want to feel like we can be helpful in the wake of a tragic or traumatic event. Those who employ, contract with, or call upon debriefers similarly want to feel like they are doing something good. But until we devise and validate a better way to offer services in the wake of a crisis, we may be better off to stand a bit farther to the sidelines, and simply say, we're here if you need us. References: Bledsoe, B. (2005). Trying to reason with hurricane season. Available online at http://www.jems.com/columnists/bledsoe/articles/15303/ . McNally RJ, Bryant RA, & Ehlers A. (2003). Does early psychological intervention promote recovery from posttraumatic stress? Psychological Science in the Public Interest. 4(2), 45-79.

Is marriage really for white people?

So reads the headline on this CNN.com story, a first-person account from one of the network's producers who was gathering information for their "Black In America" series. In it, she talks of her experience as an unmarried African-American woman who is hoping to be married someday. She also relates just one of the many startling statistics on the racial divide in marriage: 45 percent of African-American women have never been married, almost double the percentage of never-married white women. Kay Hymowitz, who wrote the spectacular-until-the-final-essay Marriage and Caste in America, put it a bit more directly:

When [fellow marriage researcher Stephanie Coontz] assures us that marriage is not on the verge of extinction, she’s right – if you’re white and went to college.

The white, college-educated crowd is especially likely to marry. That is, likely to marry someone else who is also white and college-educated. That white, college-educated couple will then probably proceed to have children (marriage and childbearing remain more closely linked in the white, college-educated community than elsewhere), and the children will eventually become college-educated. Presumably they will remain white. The separation of marriage from childbearing is particularly dramatic in the black community, Hymowitz adds, with about 70% of births to African-American women now occurring outside of marriage. Whatever your perspective on the issue, it is clear that marriage patterns are becoming more distinct among specific classes in the US, both ethnically and economically. Whether that means that "marriage" belongs on Stuff White People Like, I'm not sure. There's a great deal more research on marriage trends in the masterfully-done State of Our Unions report, published annually by the National Marriage Project at Rutgers. Recent editions have highlighted specific trends for focus, including the future of marriage in America, life without children, and which men marry and why. All are good reading.

An introduction

Welcome! I created this space when I realized how quickly things are changing for the profession of marriage and family therapy, both in California with legislation, and around the world through both scientific and regulatory advances. I'm Ben Caldwell, and I'll do my best to use this space for informative and timely discussion on topics important to our changing field. As I write this, I am a California-licensed Marriage and Family Therapist, an Assistant Professor and Site Director for the MFT master's degree program at Alliant International University in Los Angeles, and chair of the Legislative and Advocacy Committee for AAMFT-California Division. Each of these positions are sources of tremendous joy and learning for me. Of course, the opinions expressed here are my own. Unless explicitly labeled as such, the opinions expressed here do not in any way represent official positions of either Alliant or AAMFT-CA. I learn something new in this field every day. Some days, every hour. I'm sure that some items I post here will reflect my knowledge, and others my ignorance. Whether you are in or outside the field, your comments and questions will continue to educate me on how MFTs can best help couples and families in distress. If you have thoughts on what topics should be covered in this space, please post them in the comments thread.