Southern California PSYCHIATRIST March 2026

Masking and Makeup: Autism Spectrum Disorder in Women

by Vanessa Markgraf, MD, MS

If you were to close your eyes and think of a patient with autism, what would you see? Usually, people conjure images of a young boy with an insatiable interest in dinosaurs, trains, or both. Since its origins as a condition separate from schizophrenia in 1911, autism was believed to be a condition mostly experienced by men (NE Rosen, 2021). In the 1940’s Dr. Hans Asperger described a milder form in which patients had strong language but persistent social challenges, known as Asperger’s Syndrome. Next, Dr. Ole Ivar Lovaas, a clinical psychologist and UCLA professor, was credited with founding Applied Behavioral Analysis (ABA) intervention for autism. Incidentally, Dr. Lovaas was also a strong proponent of the extreme male brain theory, in which young boys were deemed to be “too masculine” based on an exaggeration of analytical systemizing and decreased “female traits” such as empathizing and social reciprocity (S Baron-Cohen, 2002).

Even with such an abridged version of Autism Spectrum Disorder’s complex history, it should come as no surprise that boys were diagnosed with autism at four times the rate as girls since the 1960’s. Newer studies, however, proport that the actual ratio could be closer to three to one (R Loomes, 2017) or less. Instead of innate differences in rates of autism by sex, more nuanced approaches suggest that these diagnostic differences could be influenced by diagnostic bias, differential socialization for boys versus girls that leads to increased camouflaging of symptoms in women, different special interests, and later diagnosis. We can check our own beliefs—if we are to image a young girl who loves makeup and color-coordinated clothes, does it evoke the same thoughts of autism as a young boy who loves trains? Additionally, with women “masking,” or camouflaging their autistic traits to fit in, it can become even more challenging to detect social and communication deficits. Researchers like Dr. Gray Atherton are challenging the status quo by detailing how implicit gender biases in prior autism research impact medical care and the understanding of this condition. Not only that, but some therapeutic methods employed by the Autism Research Institute are novel in their own right—games are being used to foster social and communication skills, showing us new ways to navigate the challenges that our patients experience.

If you too are an avid reader searching for books about the autistic experience from a non-male perspective, I hope that you enjoy “Autism in Heels” if you’re looking for a book about late-life autism diagnosis, “Odd Girl Out” if you want a fictional account that was adapted into a movie, “Unmasking Autism” for a non-binary perspective, or  a myriad of others (Arriving Late, A Little Less Broken, But Everyone Feels This Way, What I Mean When I Say I’m Autistic, How to Be Autistic, But You Don’t Look Autistic at All, and Women and Girls on the Autism Spectrum). Alternatively, if you prefer your media in comedy format, might I recommend watching Hannah Gadsby in Something Special. I will leave you with one final thought—while autism advocacy was previously represented with a puzzle piece, autistic adults have focused on changing the narrative—they are not “missing a piece.” Instead, many choose to use identity-first language (“autistic adult” instead of “adult with autism”) and share that they prefer a rainbow or gold infinity sign because their possibilities are limitless.

Common Factors and Methodological Issues in Psychotherapy Research

by Alex Lin, MD

I gave a presentation to the PGY-2 residents at the Olive View – UCLA residency on common factors last year.  Given national events, it may seem a bit quaint to focus on a subject that might be considered somewhat academic, but I found the material sufficiently interesting that I wanted to share it with SCPS members.

“Common factors” was first used by Saul Rosenzweig in 1936.  He asked, “[W]hat do these [presumably diverse] therapies actually have in common that makes them equally successful?”[1]   For the sake of answering this question, he assumed that all therapies are equally successful when competently performed.

No consensus exists on what constitutes common factors, but Bruce Wampold lists eight factors in his 2015 meta-analysis[2]; the article has since been cited nearly 2700 times, according to Google Scholar.  The factors and their respective effect sizes (Cohen’s d) are listed below².  The description I use for the effect size sometimes differs from the one Wampold himself uses for that specific factor (but does correspond with the general thresholds that Wampold lists earlier in the article).

• Alliance: d = 0.57 (just surpassing the threshold for a medium effect size)
• Goal consensus/agreement: d = 0.72 (medium, close to large)
• Empathy: d = 0.63 (medium)
• Positive regard/affirmation: d = 0.56 (medium)
• Congruence/genuineness: d = 0.49 (small, close to medium)
• Cultural adaptation: d = 0.32 (small)
• Expectation: d = 0.24 (small)
• Therapist effects: d = 0.32 (small in clinical trials but large in naturalistic studies)

None of the listed factors (including the therapeutic alliance, the most studied of the common factors) have a large effect size.

Wampold presents a graph in the article that ranks lists the various common factors by effect size that implies a relative importance of the common factors.  He also suggests that common factors are generally are more impactful than are specific factors (such as different types of psychotherapy) by citing small effect sizes that specific therapies, dismantling studies, and adherence and competence have on treatment outcome.

While looking for the data on common factors, I found an article by Pim Cuijpers et al. (cited over 1000 times) that challenges common-factor research (including Wampold’s work).  I found many of the arguments (which range from conceptual to statistical) to be compelling.

The first is that the majority of studies (at least for alliance, which is cited as the most studied and the most impactful common factor) are correlational.  In addition to correlation not being the same as causation, Cuijpers states,

Factor–outcome correlations or effect sizes based on correlational data cannot be used to determine the relative importance of these factors, let alone to inform us about the causal impact of therapy factors on outcome.[3]

Cuijpers notes that alliance seems to only account for 7.5% of treatment variance.³

Similar outcomes for different therapies do not necessarily indicate that common factors are more important than are specific ones.  Evidence indicating that a therapy is effective does not indicate how a therapy works or that the theoretical underpinnings of the therapy are produce the beneficial effects.  The way in which different therapies realize their effects may also differ, even if the outcomes are the same (just as there might be many different routes that led to the same destination).

Meta-analyses can be problematic because pooling data can result in the nuances of a highly complex process being lost because many meta-analyses do not compare types of therapy by types of disorders.[4]  Thus, even if different types of treatment might have similar outcomes, it would be inaccurate to state that “all therapies are equally effective [for] all disorders.”⁴

The individual studies themselves may also be problematic because of researcher allegiance.  Cuijpers describes researcher allegiance as follows:

“[B]elief in the superiority of a treatment [and] it usually also entails a belief in the superior validity of the theory of change that is associated with the treatment” (Leykin & DeRubeis 2009, p. 55). The assumption is that researchers with an allegiance toward one type of therapy are inclined to design or interpret the results of a comparative study in such a way that their preferred therapy is found to be superior to other therapies. This can be seen as a specific type of intellectual conflict of interest (Cristea & Ioannidis 2018).³

A review of 29 meta-analyses found a correlation of moderate effect size between researcher allegiance and outcome.[5]

However, it is unclear how research allegiance affects studies.  Many believe that researcher allegiance results in the preferred therapy being shown as superior to the comparator.  My own thought is that allegiance could potentially result in similar treatment outcomes when the prevailing belief is that the preferred treatment of the study authors is inferior to other, more evidence-based therapies; this is an issue with one, oft-cited paper showing that psychodynamic psychotherapy is as effective as CBT.[6]

Researcher allegiance is part of a larger problem with bias (which include issues with randomization, blinding, inclusion of all randomized patients in the analyses, and reporting of all outcomes)[citation, cuijpers].  Distressingly, Cuijpers determined that fewer than 30% of studies for depression and various anxiety disorders could be rated as having a low risk of bias.³

While poor-quality trials apparently tend overestimate treatment differences, the effect of poor-quality trials on comparative studies has not been examined, and, if poor quality studies were excluded, “even meta-analyses do not have enough power to detect smaller differences between therapies (Cuijpers 2016).” ³

Rosenzweig himself understood the potential methodological issues.  He wrote:

This assumption [that all therapies done competently have similar outcomes] is not well-founded, for certain forms of treatment are very likely better suited than others to certain types of cases. For the present, however, this likelihood, as well as the related problem of determining the criteria for applying one method rather than another to a given patient, will be intentionally disregarded. ¹

In discussing common and specific factors, it might be important to note that Lambert et al. created a pie chart in 1992 showing 30% of improvement in patients could be attributed to common factors, 15% to technique… and 40% to extratherapeutic factors (“spontaneous remission, fortuitous events, [and] social support”).[7]  However, even this pie chart is problematic.  Cuijpers notes that “the numbers in the chart are in fact no more than rough estimates of correlates based on impressions from the literature.  There is no empirical evidence to support the percentages given….”³

Multiple authors have suggested that, to truly discover the change mechanisms of therapy (and, indirectly, whether common factors truly are more impactful than are specific factors), future studies could look at testing various components of a therapy (dismantling studies) and examine within-person variance (e.g., change in the alliance over time, rather than simply “good” vs. “bad” alliance) to see if a change in a factor precedes a change in outcome.^3,[8]

I am not suggesting that common factors are unimportant.  I do think, however, that when common factors are taught to trainees, it is important to disclose that methodological issues involved in such research and that the common factors, at this point, are simply correlated with successful treatment outcome, rather than change factors themselves; that rank-ordering the factors is perhaps not quite supported by the data; that causal mechanisms are extremely difficult to prove; and that there are some intriguing ways in which to further improve such studies.

References

[1] Rosenzweig, S. (1936). Some implicit common factors in diverse methods of psychotherapy. American Journal of Orthopsychiatry, 6(3), 412–415.

[2] Wampold BE. How important are the common factors in psychotherapy? An update. World Psychiatry. 2015 Oct;14(3):270-7. doi: 10.1002/wps.20238. PMID: 26407772; PMCID: PMC4592639.

[3] Cuijpers P, Reijnders M, Huibers MJH. The Role of Common Factors in Psychotherapy Outcomes. Annu Rev Clin Psychol. 2019 May 7;15:207-231. doi: 10.1146/annurev-clinpsy-050718-095424. Epub 2018 Dec 14. PMID: 30550721.

[4] Wampold, Bruce & Mondin, Gregory & Moody, Marcia & Stich, Frederick & Benson, Kurt & Ahn, Hyun-nie. (1997). A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, “all must have prizes”. Psychological Bulletin – PSYCHOL BULL. 122. 203-215. 10.1037//0033-2909.122.3.203.

[5] Munder T, Brütsch O, Leonhart R, Gerger H, Barth J. Researcher allegiance in psychotherapy outcome research: an overview of reviews. Clin Psychol Rev. 2013 Jun;33(4):501-11. doi: 10.1016/j.cpr.2013.02.002. Epub 2013 Feb 21. PMID: 23500154.

[6] Fonagy P. The effectiveness of psychodynamic psychotherapies: An update. World Psychiatry. 2015 Jun;14(2):137-50. doi: 10.1002/wps.20235. PMID: 26043322; PMCID: PMC4471961.

[7] Lambert MJ. 1992. Psychotherapy outcome research: implications for integrative and eclectical therapists. In Handbook of Psychotherapy Integration, ed. JC Norcross, MR Goldfield, pp. 94–129. New York: Basic Books

[8] Kazdin AE. Understanding how and why psychotherapy leads to change. Psychother Res. 2009 Jul;19(4-5):418-28. doi: 10.1080/10503300802448899. PMID: 19034715.

Family Members in the Therapeutic Journey

by Jesus Zaragoza, MD

The topic of mental health among children and adolescents continues to draw major attention and rightfully so when considering the consequences of unresolved mental illness in these groups. In the most up to date data as reported by NAMI, approximately 16.5% of youth in the US ages 6-17 experience a mental health disorder per year. When these young individuals go without treatment, they are more likely than other groups to face underperformance in school, unemployment, homelessness, poor physical health outcomes, and suffer from higher rates of substance abuse and incarceration. Additionally, the need to address mental health issues in young Americans becomes even more important when considering that suicide is the 2^nd leading cause of death among people ages 10 to 24.

To understand the issue and determine appropriate solutions, one must look at the multiple contributing factors affecting the mental health of youth and their treatment. The biopsychosocial model tells us that mental health is shaped through the complex dynamic combination of factors such as genetics, family history, life experiences and traumas, socioeconomic status, and immediate environment. Among these multiple components, family stands out in its impact especially among the youth. Family members and caregivers have become essential members of the treatment team when it comes to the therapeutic journey of children and adolescents suffering from mental illness. In fact, over the last few decades psychiatry has evolved to incorporate an all-hands-on deck approach that engages the community, especially family members of patients, in hopes to improve outcomes. Family members play crucial roles by providing emotional support through listening and communication, encouraging healthy lifestyle habits, helping develop coping skills, and directly help clinicians by providing additional data points that go beyond the subjective being reported by the patients. These positive interventions have shown to reduce hospital admissions and duration of stay, improved compliance with medications and treatment plans, and lead to fewer relapses and duration between these.

However, attainment of these positive outcomes becomes challenging when considering the numerous barriers and limitations that families face. One major barrier is the lack of mental health knowledge. Many parents struggle to recognize early warning signs, understand symptoms, or navigate treatment options, which can delay or complicate access to appropriate care. In some cases, parents may have untreated mental health issues themselves, making it harder to provide emotional stability, consistency, or advocacy for their child. Cultural stigma further prevents families from seeking help, as some communities view mental illness as a personal weakness or something to hide, leading to fear of judgment or shame. Finally, communication difficulties—whether between parents and children, within the family unit, or with providers—can hinder understanding and trust, making it challenging to discuss symptoms openly or follow through with treatment recommendations. Together, these limitations create a complex environment in which families are trying to help but often feel overwhelmed, isolated, or unequipped, ultimately impacting a child’s ability to receive consistent and effective mental health support.

Although not all challenges may be easily addressed in a clinical setting, the multidisciplinary teams found in child and adolescent psychiatry are able to tackle one of the most important underlying themes, mental health education. A back-to-basics approach that focuses on building knowledge with attention to detail is essential for families raising children with mental illness because it equips them with the understanding and skills needed to provide effective, compassionate support. Education should go beyond simply naming a diagnosis. Clinical teams should strive to offer families a comprehensive picture that includes what the illness is, how it affects the child’s thoughts, emotions, and behaviors, and why those changes occur. Learning common symptoms helps families know what to expect and reduces fear of the unknown. Similarly, understanding causes and contributing factors such as genetics, brain chemistry, and environmental stressors can help decrease parental guilt or self-blame regarding a child’s mental illness. Education about treatment options—including therapy, medication, school support, and lifestyle interventions—also clarifies the family’s role in care and empowers them to actively participate in treatment planning. Discussing prognosis is equally important, as it helps families develop realistic expectations about the course of illness, recovery, and potential setbacks.

Another critical component of mental health education is helping families distinguish between symptoms of mental illness and maladaptive or willful behaviors. Families often struggle to interpret behaviors accurately, which can lead to frustration or inappropriate discipline. For example, maladaptive behaviors are often situational and influenced by immediate context, while mental health symptoms tend to be persistent, pervasive, and largely involuntary. A child refusing to go to school may be avoiding homework or peer conflict, but it may also signal depression, anxiety, or school-related trauma if the behavior is ongoing and accompanied by mood changes, sleep problems, or withdrawal. Understanding these differences allows families to respond with empathy rather than punishment, seek timely professional help, and create a more supportive home environment that promotes their child’s emotional well-being and long-term recovery. The distinguishing aspects between behaviors and possible symptoms of disease can be nuanced and highly specific to each case, as such thorough discussions during clinic visits with the family unit are needed to ensure appropriate interventions.

One additional and essential component that clinics can help facilitate is addressing caregiver support. Supporting family members of children and adolescents with mental illness is vital to reducing the emotional and psychological burden they often carry. Caregivers may experience chronic stress, fatigue, and feelings of isolation while trying to meet their child’s needs. Providing support helps validate their experiences and promotes resilience. One approach can be to help create networks of parent peers that allow families to feel heard, recognized, and less alone, while also offering opportunities to learn from shared experiences and practical coping strategies. Evidence demonstrates that creating these types of networks has translated to less parental anxiety, higher participation in care, increased levels of empowerment, and improved self-care. They can even address language and cultural barriers along with mental health stigma that is all too common.

The mental health care of children and adolescents requires an all-hands-on-deck approach by psychiatrists, psychologists, social workers, nursing staff, and family members. Active involvement through ongoing interdisciplinary conversation within the team and with family members is essential and is sure to help address gaps in care.

______________________________________________________________________________________

Centers for Disease Control and Prevention. (2025, June 5). Data and statistics on children’s mental health. U.S. Department of Health & Human Services. https://www.cdc.gov/children-mental-health/data-research/index.html CDC

National Alliance on Mental Illness. (n.d.). Mental health by the numbers. https://www.nami.org/about-mental-illness/mental-health-by-the-numbers/ NAMI

Nayak, S. S., Tobias, C., Wolfe, J., Roper, K., Méndez-Peñate, L., Moulin, C., Arty, M., Scoglio, A. A. J., Kelleher, A., Rue, J., Brigham, M., Bradshaw, T., Byars, N., Camacho, A., Douglas, S., & Molnar, B. E. (2022). Engaging and Supporting Young Children and their Families in Early Childhood Mental Health Services: The Role of the Family Partner. Community mental health journal, 58(1), 87–98. https://doi.org/10.1007/s10597-021-00796-8

Ong, H. S., Fernandez, P. A., & Lim, H. K. (2021). Family engagement as part of managing patients with mental illness in primary care. Singapore medical journal, 62(5), 213–219. https://doi.org/10.11622/smedj.2021057

Wang, S., Li, Q., Lu, J., Ran, H., Che, Y., Fang, D., Liang, X., Sun, H., Chen, L., Peng, J., Shi, Y., & Xiao, Y. (2023). Treatment Rates for Mental Disorders Among Children and Adolescents: A Systematic Review and Meta-Analysis. JAMA network open, 6(10), e2338174. https://doi.org/10.1001/jamanetworkopen.2023.38174

SCPS Members Presenting at APA San Francisco

The Annual Meeting of the American Psychiatric Association will take place May 16 – 20, 2026 in San Francisco, California.  We hope you can be there!  Please click here for registration and complete meeting information:
https://www.psychiatry.org/psychiatrists/meetings/annual-meeting/learning-opportunities

There will be over 400 scientific sessions and courses available.

Voluntary Contributions

Each year SCPS invites dues exempt Life Members to make voluntary contributions to the organization. SCPS is sincerely grateful for the generosity and dedication of our longstanding Life Members and offers up sincere thanks and appreciation. During 2025 the following Life Members voluntarily contributed to SCPS:

Distinguished Fellowship

Have you been a General or Fellow member for at least eight years?  If so, you may be eligible to apply for Distinguished Fellowship.

Distinguished Fellowship is awarded to outstanding psychiatrists who have made significant contributions to the psychiatric profession in at least five of the following areas: administration, teaching, scientific and scholarly publications, volunteering in mental health and medical activities of social significance, community involvement, as well as for clinical excellence. Distinguished Fellow is the highest membership honor the APA bestows upon members.

The application process takes almost a year and the 2026 cycle is about to begin.  For more information please go to https://www.psychiatry.org/membership/honorary-fellowship/dfapa

If you are interested in becoming a DFAPA and believe you might be eligible, please contact Mindi at socalpsychiatric@gmail.com

She will provide you with the form required for the first step in the process.

Information about SCPS Dues and Tax Deductibility

Your continued membership is of great value to SCPS and the California State Association of Psychiatrists (CSAP).

For 2026, 31.5% of your dues will go towards direct advocacy services. The remaining 68.5% may be written off as a business expense. Please consult your accountant regarding deductibility.

For 2025, 28.2% of your dues went towards direct advocacy services. The remaining 71.8% may be written off as a business expense. Please consult your accountant regarding deductibility.

We know that membership is a choice and we thank you for choosing to support your profession, your patients, and your colleagues.

Sincerely,

Ijeoma Ijeaku, M.D.
Chair, Membership Committee

January Council Highlights

by Roderick Shaner, MD

Meeting Date: January 8, 2026

Next Meeting: February 12, 2026, 7:00 PM (Zoom)

President’s Report – Dr. Kelly

• Career Day: Dr Kelly described excellent presentations by SCPS discussants and dynamic interactions with attendees at the event last month and others agreed. Council members discussed opportunities for increasing attendance in the future including augmenting direct content with residents through email or other social media, increasing engagement with SCPS by all residency directors, and encouraging the Program committee to consider having multiple Career Day locations per year in the future, perhaps with one in LA County and one in the IE.

• Bylaws Committee Report: Dr. Kelly presented the Bylaws Committee’s motion for Council to recommend an amendment to the Bylaws procedure for filling unexpected vacancies in the treasurer-elect position.

Passed Motion: That Council recommend a specific amendment of the SCPS Bylaws to change for the procedure for filling an unexpected vacancy in the Treasurer-Elect Position, and to place this change before SCPS on the next general election ballot with the accompanying explanation drafted by the Bylaws Committee.

• CA Task Force/Leadership Development: Dr. Kelly presented the recommendation from the GAC to explore forming a working group with Area 6 to identify and mentor candidates for APA and Area 6 offices who best align with California District Branch priorities. Dr. Silverman emphasized the need to engage with potential APA presidential candidates to ensure proactivity in top leadership positions.

Passed Motion: That Council request that the SCPS APA Leadership Task Force operationalize a proposal to develop an Area 6 DB workgroup to identify and mentor candidates for APA and Area 6 offices who best align with California District Branch priorities, and to bring this proposal back to Council.

President‑Elect’s Report – Dr. Halpin

• SCPS NAMI Meeting: Dr. Halpin discussed the upcoming SCPS/NAMI meeting, emphasizing the SCPS goal of fostering more connected discussions with NAMI members rather than relying heavily on SCPS presentations.
• Newsletter: Dr. Halpin highlighted the newsletter's progress, noting its increasingly conversational tone and contributions from various members

Treasurer’s Report – Mindi Thelen

• December Financials: The financial report presented by Mindi showed improved performance, with 2026 dues collection only $15,000 under budget compared to a potential shortfall in November, and total assets exceeding budget by $105,916, including a $24,000 increase in liquid assets. The report was accepted by Council.

Assembly Report – Dr. Silverman

• Meeting with Area 6 Council: Silverman reported that the APA representation taskforce had a robust discussion with Area 6 Council leadership to discuss SCPS’s suggested initiatives to improve California representation effectiveness at the APA Assembly and will continue to advocate for constructive changes. Dr. Ijeaku additionally proposed creating a more structured nominating committee within SCPS to identify potential candidates for both local and national positions earlier, and support for this was expressed.

Government Affairs – Drs. Wood/Halpin

• SCPS partnerships with, and endorsement of, other entities. After discussion concerning partnerships with other organizations on advocacy issues, especially with organizations who may have positions opposed to APA policies or activities, Dr. Rees proposed a motion to address the issue, which was then discussed and amended with input by several Council members.

Passed Motion: To form a federal issues task force to consider options for SCPS Council to address federal advocacy, including: 1) planning a town hall to discuss member concerns regarding federal issues and 2) evaluating relationships as necessary with other federal advocacy entities (e.g., Committee to Protect Public Mental Health), and make recommendations to council.

CSAP PAC/CSAP PAC Task Force

• CSAP PAC: Shaner reported that the CSAP PAC year end funds were approximately $69,000. During 2025, the PAC gave $8000 in political contributions and approximately $4500 in legal and other administrative expenses. He indicated that strategic planning regarding PAC contributions in 2026 would be heavily influenced by 2026 legislative bills.
• Joint meeting of DB Presidents and CSAP PAC reps: Halpin and Shaner indicated that the SCPS CSAP PAC workgroup would present proposals at the next meeting of the CSAP PAC Board/DC Presidents for purposes of developing and understanding of DB PAC contribution procedures and tracking to help ensure an effective, transparent, and equitably funded CSAP back.

Committee Reports

• Membership: Dr. Ijeaku reported one new member, who was ratified by Council.
• Private Practice: Dr. Goldenberg indicated that the committee is planning a “Private Practice 101” event for March, with further updates to come next month.
• AI in Psychiatry: Dr. Pylko reported that the AI and Social Media committees were collaborating to develop public service announcements on social media regarding potential risks and benefits of AI for mental health.
• Social Media: Dr. Rees asked Council members contributing to the newsletter to henceforth include a couple of lines or a brief paragraph suitable for Instagram captions.
• Disaster Committee: Mindi indicated that the committee was organizing a program for March 3^rd, with further information coming soon.
• Alternatives to Incarceration: Dr. Bindra indicated that an upcoming judges and Psychiatry Leadership Initiative event in Los Angeles was planned with downtown LA Court justices.