Is the Relational Approach to Diagnosis Possible or Desirable?

The American Family Therapy Academy recently issued a policy statement protesting the DSM-5, and asks the American Psychiatric Association to consider the importance of relational and family context to psychiatric diagnoses.

AFTA, a multidisciplinary group, does not support the current revision of the DSM, stating that it "continues a long history of ignoring research and excluding vital contributions of nonpsychiatric mental health disciplines." This statement refers to the substantial body of research concerning the role of relational factors in mental health and mental illness, and also refers to the large number of effective family treatments, including, but not limited to, family therapy.

The academy criticizes the DSM’s use of the biomedical model and its omission of the role of family and sociocultural contexts on well-being. AFTA states that the DSM "delegitimizes the focus on relationship, life stage, community, and access to power and resources." AFTA points out that the DSM fails to take into account culture, class and ‘destructive unjust social factors,’ such as poverty, hunger, homelessness, violence, racism, and other forms of oppression. AFTA considers these factors to be important in reaching a diagnosis that accurately describes patients.

Many psychiatrists, especially family, social, and cultural psychiatrists, agree with AFTA’s position. Several family researchers and family psychiatrists have been pushing for many years to get relational diagnoses included in the DSM-IV and the DSM-5 (J. Fam. Psychol. 2006;20:359-68), citing decades of excellent research into relational diagnoses. Their attempts are supported by nonmedical health care professionals who complain that they cannot get paid by insurance companies for treating families. However, putting any diagnosis in the DSM so the insurance companies get paid is a backward way of thinking. Any diagnostic system of American psychiatry should not be framed or influenced by financial organizations that want to ration health care.

Some psychiatrists who contributed to the DSM offer the disclaimer that "they do not mean this to be a bible." However, the DSM is frequently used "as a bible," for example, in the courts. More importantly, reductionist diagnostic descriptions in the DSM narrow the public’s and the professionals’ thinking about psychological difficulties, and, by extrapolation, limit the conceptualization of what types of interventions might be helpful.

For example, describing psychiatric illnesses as biological leads to the assumption that biological interventions are needed. If an illness is defined using a biopsychosocial explanation, however, this broader understanding leads to a wider array of possible treatments. A psychiatric diagnostic system should recognize all the factors that are known to contribute to psychological health and illness to be of most use in patient care.

There is also a strong argument for not including relational diagnoses in the DSM. The argument is this: Relational factors are process factors, rather than static factors. For example, expressed emotion (EE) is not a characteristic of a family but rather a description of family distress that arises as a result of living with a disease. It is a description of a family process. Providing psychoeducation to a distressed family substantially reduces the level of EE and the subsequent risk of patient relapse. EE is a measure of relational process. If EE is entered into the DSM, there is a danger of its being seen as a static entity.

A delicate balance exists between the utilitarian need for a system of diagnoses and the risk of overdefining people and their relationships as "pathological." It was not that long ago that we pathologized homosexuality and described the entity of the "schizophrenogenic mother."

Dr. Larry Freeman, a member of the Association of Family Psychiatrists, adds: "Be wary of a pressure beyond medical circles to utilize psychiatry as a force for social control. I do a great deal of workers’ [compensation], and so-called ‘preexisting conditions’ are commonly framed as the "cause" of a worker’s emotional response to injury, and therefore, [the worker’s] current psychiatric conditions are not accepted as a consequence of the original injury event.

"Be careful that we do not enable this distortion further in our efforts to include context and history."

How should we include patient contexts such as violence, abuse, trauma, poverty, injustice, or relational dysfunction? How do we acknowledge that these factors play a significant role in the lives of our patients? For children, this is especially important as treatment often focuses on changing or stabilizing their environment, and ensuring that there is adequate attachment and nurturance.

How do we ensure that these relationships and contexts are adequately defined so we can monitor the effectiveness (or not) of interventions? AFTA supports the creation of a work group that will focus on developing an alternative to the DSM for the conceptualization of emotional distress. David Elkins, Ph.D., is planning an international summit in 2013 with representatives from all therapist groups to discuss the feasibility of such a system.

Another way forward is to develop a diagnostic system that focuses on health. The Global Assessment of Functioning (GAF), describes with reasonable accuracy a person’s individual level of functioning on a scale of 1 to 100. The Global Assessment of Relational Functioning (GARF) describes the health of a relationship on a scale of 1-100. Using these scales, pathology and health coexist on a continuum, with anchors throughout the scale. These systems are currently crude instruments, but imagine how much better they could become if they were the focus of research, clinical trials, etc.

There will always be the need for individual diagnoses, where the melancholic continues to suffer despite having an excellent social and family context, and there will always be cases where we cannot decide if the patient is ill unto himself or if his illness is informed by the context of his life.

But consider the inverse, the person who is optimistic and functional in spite of the dire context of his life, people who hold beliefs, convictions, and so on that raise them above their life circumstances. (Think of visionaries like Gandhi or Mandela). In the same way, there are relationships that function well, despite the presence of adversity. How do we develop a system that aspires to "health" instead of pathology? The American health care system (or rather its illness care system) needs to morph into true health care with a focus on prevention on both an individual and relational front.

For additional information, see Relational Processes and DSM-V: Neuroscience, Assessment, Prevention, and Treatment (Washington: American Psychiatric Association Publishing, 2006).

Dr. Alison Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

The American Family Therapy Academy recently issued a policy statement protesting the DSM-5, and asks the American Psychiatric Association to consider the importance of relational and family context to psychiatric diagnoses.

AFTA, a multidisciplinary group, does not support the current revision of the DSM, stating that it "continues a long history of ignoring research and excluding vital contributions of nonpsychiatric mental health disciplines." This statement refers to the substantial body of research concerning the role of relational factors in mental health and mental illness, and also refers to the large number of effective family treatments, including, but not limited to, family therapy.

The academy criticizes the DSM’s use of the biomedical model and its omission of the role of family and sociocultural contexts on well-being. AFTA states that the DSM "delegitimizes the focus on relationship, life stage, community, and access to power and resources." AFTA points out that the DSM fails to take into account culture, class and ‘destructive unjust social factors,’ such as poverty, hunger, homelessness, violence, racism, and other forms of oppression. AFTA considers these factors to be important in reaching a diagnosis that accurately describes patients.

Many psychiatrists, especially family, social, and cultural psychiatrists, agree with AFTA’s position. Several family researchers and family psychiatrists have been pushing for many years to get relational diagnoses included in the DSM-IV and the DSM-5 (J. Fam. Psychol. 2006;20:359-68), citing decades of excellent research into relational diagnoses. Their attempts are supported by nonmedical health care professionals who complain that they cannot get paid by insurance companies for treating families. However, putting any diagnosis in the DSM so the insurance companies get paid is a backward way of thinking. Any diagnostic system of American psychiatry should not be framed or influenced by financial organizations that want to ration health care.

Some psychiatrists who contributed to the DSM offer the disclaimer that "they do not mean this to be a bible." However, the DSM is frequently used "as a bible," for example, in the courts. More importantly, reductionist diagnostic descriptions in the DSM narrow the public’s and the professionals’ thinking about psychological difficulties, and, by extrapolation, limit the conceptualization of what types of interventions might be helpful.

For example, describing psychiatric illnesses as biological leads to the assumption that biological interventions are needed. If an illness is defined using a biopsychosocial explanation, however, this broader understanding leads to a wider array of possible treatments. A psychiatric diagnostic system should recognize all the factors that are known to contribute to psychological health and illness to be of most use in patient care.

There is also a strong argument for not including relational diagnoses in the DSM. The argument is this: Relational factors are process factors, rather than static factors. For example, expressed emotion (EE) is not a characteristic of a family but rather a description of family distress that arises as a result of living with a disease. It is a description of a family process. Providing psychoeducation to a distressed family substantially reduces the level of EE and the subsequent risk of patient relapse. EE is a measure of relational process. If EE is entered into the DSM, there is a danger of its being seen as a static entity.

A delicate balance exists between the utilitarian need for a system of diagnoses and the risk of overdefining people and their relationships as "pathological." It was not that long ago that we pathologized homosexuality and described the entity of the "schizophrenogenic mother."

Dr. Larry Freeman, a member of the Association of Family Psychiatrists, adds: "Be wary of a pressure beyond medical circles to utilize psychiatry as a force for social control. I do a great deal of workers’ [compensation], and so-called ‘preexisting conditions’ are commonly framed as the "cause" of a worker’s emotional response to injury, and therefore, [the worker’s] current psychiatric conditions are not accepted as a consequence of the original injury event.

"Be careful that we do not enable this distortion further in our efforts to include context and history."

How should we include patient contexts such as violence, abuse, trauma, poverty, injustice, or relational dysfunction? How do we acknowledge that these factors play a significant role in the lives of our patients? For children, this is especially important as treatment often focuses on changing or stabilizing their environment, and ensuring that there is adequate attachment and nurturance.

How do we ensure that these relationships and contexts are adequately defined so we can monitor the effectiveness (or not) of interventions? AFTA supports the creation of a work group that will focus on developing an alternative to the DSM for the conceptualization of emotional distress. David Elkins, Ph.D., is planning an international summit in 2013 with representatives from all therapist groups to discuss the feasibility of such a system.

Another way forward is to develop a diagnostic system that focuses on health. The Global Assessment of Functioning (GAF), describes with reasonable accuracy a person’s individual level of functioning on a scale of 1 to 100. The Global Assessment of Relational Functioning (GARF) describes the health of a relationship on a scale of 1-100. Using these scales, pathology and health coexist on a continuum, with anchors throughout the scale. These systems are currently crude instruments, but imagine how much better they could become if they were the focus of research, clinical trials, etc.

There will always be the need for individual diagnoses, where the melancholic continues to suffer despite having an excellent social and family context, and there will always be cases where we cannot decide if the patient is ill unto himself or if his illness is informed by the context of his life.

But consider the inverse, the person who is optimistic and functional in spite of the dire context of his life, people who hold beliefs, convictions, and so on that raise them above their life circumstances. (Think of visionaries like Gandhi or Mandela). In the same way, there are relationships that function well, despite the presence of adversity. How do we develop a system that aspires to "health" instead of pathology? The American health care system (or rather its illness care system) needs to morph into true health care with a focus on prevention on both an individual and relational front.

For additional information, see Relational Processes and DSM-V: Neuroscience, Assessment, Prevention, and Treatment (Washington: American Psychiatric Association Publishing, 2006).

Dr. Alison Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

The American Family Therapy Academy recently issued a policy statement protesting the DSM-5, and asks the American Psychiatric Association to consider the importance of relational and family context to psychiatric diagnoses.

AFTA, a multidisciplinary group, does not support the current revision of the DSM, stating that it "continues a long history of ignoring research and excluding vital contributions of nonpsychiatric mental health disciplines." This statement refers to the substantial body of research concerning the role of relational factors in mental health and mental illness, and also refers to the large number of effective family treatments, including, but not limited to, family therapy.

The academy criticizes the DSM’s use of the biomedical model and its omission of the role of family and sociocultural contexts on well-being. AFTA states that the DSM "delegitimizes the focus on relationship, life stage, community, and access to power and resources." AFTA points out that the DSM fails to take into account culture, class and ‘destructive unjust social factors,’ such as poverty, hunger, homelessness, violence, racism, and other forms of oppression. AFTA considers these factors to be important in reaching a diagnosis that accurately describes patients.

Many psychiatrists, especially family, social, and cultural psychiatrists, agree with AFTA’s position. Several family researchers and family psychiatrists have been pushing for many years to get relational diagnoses included in the DSM-IV and the DSM-5 (J. Fam. Psychol. 2006;20:359-68), citing decades of excellent research into relational diagnoses. Their attempts are supported by nonmedical health care professionals who complain that they cannot get paid by insurance companies for treating families. However, putting any diagnosis in the DSM so the insurance companies get paid is a backward way of thinking. Any diagnostic system of American psychiatry should not be framed or influenced by financial organizations that want to ration health care.

Some psychiatrists who contributed to the DSM offer the disclaimer that "they do not mean this to be a bible." However, the DSM is frequently used "as a bible," for example, in the courts. More importantly, reductionist diagnostic descriptions in the DSM narrow the public’s and the professionals’ thinking about psychological difficulties, and, by extrapolation, limit the conceptualization of what types of interventions might be helpful.

For example, describing psychiatric illnesses as biological leads to the assumption that biological interventions are needed. If an illness is defined using a biopsychosocial explanation, however, this broader understanding leads to a wider array of possible treatments. A psychiatric diagnostic system should recognize all the factors that are known to contribute to psychological health and illness to be of most use in patient care.

There is also a strong argument for not including relational diagnoses in the DSM. The argument is this: Relational factors are process factors, rather than static factors. For example, expressed emotion (EE) is not a characteristic of a family but rather a description of family distress that arises as a result of living with a disease. It is a description of a family process. Providing psychoeducation to a distressed family substantially reduces the level of EE and the subsequent risk of patient relapse. EE is a measure of relational process. If EE is entered into the DSM, there is a danger of its being seen as a static entity.

A delicate balance exists between the utilitarian need for a system of diagnoses and the risk of overdefining people and their relationships as "pathological." It was not that long ago that we pathologized homosexuality and described the entity of the "schizophrenogenic mother."

Dr. Larry Freeman, a member of the Association of Family Psychiatrists, adds: "Be wary of a pressure beyond medical circles to utilize psychiatry as a force for social control. I do a great deal of workers’ [compensation], and so-called ‘preexisting conditions’ are commonly framed as the "cause" of a worker’s emotional response to injury, and therefore, [the worker’s] current psychiatric conditions are not accepted as a consequence of the original injury event.

"Be careful that we do not enable this distortion further in our efforts to include context and history."

How should we include patient contexts such as violence, abuse, trauma, poverty, injustice, or relational dysfunction? How do we acknowledge that these factors play a significant role in the lives of our patients? For children, this is especially important as treatment often focuses on changing or stabilizing their environment, and ensuring that there is adequate attachment and nurturance.

How do we ensure that these relationships and contexts are adequately defined so we can monitor the effectiveness (or not) of interventions? AFTA supports the creation of a work group that will focus on developing an alternative to the DSM for the conceptualization of emotional distress. David Elkins, Ph.D., is planning an international summit in 2013 with representatives from all therapist groups to discuss the feasibility of such a system.

Another way forward is to develop a diagnostic system that focuses on health. The Global Assessment of Functioning (GAF), describes with reasonable accuracy a person’s individual level of functioning on a scale of 1 to 100. The Global Assessment of Relational Functioning (GARF) describes the health of a relationship on a scale of 1-100. Using these scales, pathology and health coexist on a continuum, with anchors throughout the scale. These systems are currently crude instruments, but imagine how much better they could become if they were the focus of research, clinical trials, etc.

There will always be the need for individual diagnoses, where the melancholic continues to suffer despite having an excellent social and family context, and there will always be cases where we cannot decide if the patient is ill unto himself or if his illness is informed by the context of his life.

But consider the inverse, the person who is optimistic and functional in spite of the dire context of his life, people who hold beliefs, convictions, and so on that raise them above their life circumstances. (Think of visionaries like Gandhi or Mandela). In the same way, there are relationships that function well, despite the presence of adversity. How do we develop a system that aspires to "health" instead of pathology? The American health care system (or rather its illness care system) needs to morph into true health care with a focus on prevention on both an individual and relational front.

For additional information, see Relational Processes and DSM-V: Neuroscience, Assessment, Prevention, and Treatment (Washington: American Psychiatric Association Publishing, 2006).

Dr. Alison Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.