Relational Diagnoses and the DSM

In our understanding of family systems, we have long known that dysfunctional relational patterns often lie at the root of our patients’ problems. But to what extent should family diagnoses be incorporated into the DSM?

I sat down with Dr. Marianne Z. Wamboldt to explore these issues. Dr. Wamboldt, a child psychiatrist, is chair of the board of the Family Process Institute. She also holds the Leslie and William Vollbracht Family Chair in Stress and Anxiety Disorders at the University of Colorado, Denver, and serves as professor and vice chair in the department of psychiatry in the medical school.

Marianne Wamboldt: So why exactly do you oppose the inclusion of family diagnoses in the DSM?

Alison Heru: I don’t like the labeling of families. I like helping families understand their strengths and helping them work out their problems. I don’t see family problems as psychiatric problems.

MW: I think it is important that we have a way of measuring and classifying what we see, so that we know what we are talking about and that we can measure whether or not we have success in what we are doing.

AH: I agree that these goals are important. However, I think we can use tools like the GARF (Global Assessment of Relational Functioning) or other measuring devices, to do this. I don’t think we need to go as far as including measurements of family functioning in the DSM.

MW: Did you know the GARF is included in DSM-IV-TR already? What is the difference between the GARF and the DSM?

AH: The GARF is good and useful, like the GAF (Global Assessment Scale) in that it gives you a way to describe functioning on a range from healthy to unhealthy, without defining a pathological state. When you put something in the DSM, you are saying it is a disease. You are saying something about etiology.

MW: Not necessarily. In the DSM-IV, ADHD is a description of behavior; there is no attempt to talk about causality. We had hoped that the DSM-5 could start talking about causality, but most of the research is not yet ready. In the meantime, having a clear definition of what we are treating is useful for researchers as well as clinicians. Having a universal description is helpful for everyone.

AH: I agree that a universal description is good, but I still think that more harm than good comes from including family diagnoses in the DSM. I just don’t see families needing to be labeled as pathological. I understand your point, but I think that the repercussions of having a family diagnosis in the DSM outweigh the benefits. The DSM is used in all kinds of ways. In the court system, it is described as "The Psychiatrist’s Bible." If a family diagnosis is in the DSM, then it becomes an "illness" with all the repercussions that come from that label.

MW: However, if it is not in the DSM, many insurance companies won’t pay for the treatment, and persons in the family get labeled with some other diagnosis in order to get therapy. Moreover, if you label something and talk about it, stigma is reduced. Think about cancer and how we used to think about it. It used to be feared, and people with cancer were isolated. That is not what we want for psychiatry and family problems.

AH: I understand that view, but I think that the analogy with cancer is not accurate. Cancer research is well funded, and cancer in many instances can be cured. Mental illnesses have not seen this kind of support, funding, or understanding. In fact, funding has been drastically cut, and the prisons are full of people with mental illness. People now think about mental illness and crime together.

MW: When cancer research started, it was first to try to find commonalities among the many illnesses people with cancer had. The first treatment efforts improved conditions only a very little, but it was by using each effort and tweaking treatment again and again that the field moved forward to where it is today.

AH: I also heard (from Dr. Carl C. Bell of the University of Illinois at Chicago) about a study that showed that stigma was actually increased after the community was educated that psychiatric illnesses are biological illnesses. Before the educational intervention, people with mental illness were seen in the community as odd or quirky and accepted as "different." After the study, these same people were shunned by the community as having an immutable biological disease.

MW: What about child mistreatment? Don’t you think that would be good to include in the DSM? What about domestic violence? And there is a big push to include parental alienation syndrome. What do you think about that?

AH: I don’t see these as psychiatric illnesses, [they are] more social or criminal problems. I don’t think couples with IPV [interpersonal violence] would come for treatment if they knew that they would be labeled by the insurance companies or doctors. I think the parental alienation syndrome is also not a good thing to put in the DSM, whatever the science (or not) behind it. It is a social problem that parents do bad things to their children. I do not see that as a psychiatric issue.

MW: But we treat these people. They come to us for help, and we try to help them. I think it is better to have clear definition that is well thought out and scientifically based, rather than just vague and impressionistic. Relational problems have been written about for years. There is a huge literature on this topic. I think that the evidence for many relational processes that lead to morbidity is at least as good, if not better, than many diagnoses in the DSM-IV.

AH: I agree. However, my conclusion is that we should take things OUT of the DSM that don’t belong there and prevent social or criminal diagnoses from going into the DSM.

MW: How are we going to measure and be scientific about our work?

AH: I think we can do that without using the DSM. Why is the DSM so important? I also don’t think we should let insurance companies dictate how we think about what we do.

MW: Insurance companies pay for treating persons with some diagnoses, but not other diagnoses. For example, in some states, they do not pay for treatment for ADHD, which is extensively researched to be a primarily heritable illness, responsive to medications more than even very intensive psychotherapeutic interventions, and quite disabling for some youth. The DSM has to be used for more than merely what insurance companies decide what to do with it. It originally began as a method of reliably describing patients that psychiatrists were treating, so as to share knowledge about the illnesses, what worked, and what did not work. The [people behind the] ICD-9, 10, and now 11, also think that relational disorders are important to include. We don’t want to be a country left behind!

AH: A good question is, "What is the DSM for?"

MW: To provide a framework for us to diagnose and treat mental illness.

AH: Should it not just focus on biological disease? That is my preference of a system that calls itself a disease manual.

MW: But that is not what the DSM is. It reflects the biopsychosocial model and includes behaviors and clusters of symptoms that are a focus of treatment.

AH: I am not a biological psychiatrist; (I’m) more of a social and family psychiatrist, but I see the DSM as being a biological manual. I think it is hard to categorize social and family behaviors that can be pathological in one situation or culture and not in another. Take expressed emotion (EE). Research in Japan has found that two components of high EE – high criticism and high overinvolvement – need to be parsed out and that families benefit from specific treatments, depending on which component of high EE is present. I don’t think that relational diagnoses are fixed enough. This is another argument.

MW: So how do you see us communicating and working on this problem without a good system of description?

AH: Well, I think we can continue as we have, using these constructs but not embedding them in the DSM. I don’t think that is necessary. I think it might be better to get diagnoses that are subjective or significantly influenced by the prevailing culture out of the DSM.

MW: I would argue that many illnesses, let alone psychiatric disorders in the DSM, are significantly influenced by the prevailing culture. Read "The Spirit Catches You and You Fall Down" (New York: Farrar, Straus and Giroux, 2012), which illustrates the different cultural beliefs of the Hmong (who think the spirit moves a child) from Western medicine (which diagnoses epilepsy). If relational diagnoses are not in the DSM, many therapists will not think about relationships and will not have them as a focus for change.

AH: I think that is an assumption that is not proven.

MW: If relational disorders are in the DSM, then practitioners are more likely to think of them, and faculty are more likely to teach them to new clinicians.

AH: Yes, but think of them as a pathological entity and then we are back where we were 50 years ago – pathologizing families.

MW: I disagree with that. With education and knowledge about effective family interventions, stigma can be reduced, and people can access the treatments they need!

AH: This is a good argument that our field needs to engage in. Better measurement and reduced stigma are the benefits that you see from including relational problems in the DSM.

MW: Yes, and you see this as unnecessary labeling that might be used against families.

AH: Yes. I also think that relational diagnoses are more fluid than biological diagnoses and that we are not ready, and may never be ready, to carve these out as definitive immutable constructs.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver. 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.

In our understanding of family systems, we have long known that dysfunctional relational patterns often lie at the root of our patients’ problems. But to what extent should family diagnoses be incorporated into the DSM?

I sat down with Dr. Marianne Z. Wamboldt to explore these issues. Dr. Wamboldt, a child psychiatrist, is chair of the board of the Family Process Institute. She also holds the Leslie and William Vollbracht Family Chair in Stress and Anxiety Disorders at the University of Colorado, Denver, and serves as professor and vice chair in the department of psychiatry in the medical school.

Marianne Wamboldt: So why exactly do you oppose the inclusion of family diagnoses in the DSM?

Alison Heru: I don’t like the labeling of families. I like helping families understand their strengths and helping them work out their problems. I don’t see family problems as psychiatric problems.

MW: I think it is important that we have a way of measuring and classifying what we see, so that we know what we are talking about and that we can measure whether or not we have success in what we are doing.

AH: I agree that these goals are important. However, I think we can use tools like the GARF (Global Assessment of Relational Functioning) or other measuring devices, to do this. I don’t think we need to go as far as including measurements of family functioning in the DSM.

MW: Did you know the GARF is included in DSM-IV-TR already? What is the difference between the GARF and the DSM?

AH: The GARF is good and useful, like the GAF (Global Assessment Scale) in that it gives you a way to describe functioning on a range from healthy to unhealthy, without defining a pathological state. When you put something in the DSM, you are saying it is a disease. You are saying something about etiology.

MW: Not necessarily. In the DSM-IV, ADHD is a description of behavior; there is no attempt to talk about causality. We had hoped that the DSM-5 could start talking about causality, but most of the research is not yet ready. In the meantime, having a clear definition of what we are treating is useful for researchers as well as clinicians. Having a universal description is helpful for everyone.

AH: I agree that a universal description is good, but I still think that more harm than good comes from including family diagnoses in the DSM. I just don’t see families needing to be labeled as pathological. I understand your point, but I think that the repercussions of having a family diagnosis in the DSM outweigh the benefits. The DSM is used in all kinds of ways. In the court system, it is described as "The Psychiatrist’s Bible." If a family diagnosis is in the DSM, then it becomes an "illness" with all the repercussions that come from that label.

MW: However, if it is not in the DSM, many insurance companies won’t pay for the treatment, and persons in the family get labeled with some other diagnosis in order to get therapy. Moreover, if you label something and talk about it, stigma is reduced. Think about cancer and how we used to think about it. It used to be feared, and people with cancer were isolated. That is not what we want for psychiatry and family problems.

AH: I understand that view, but I think that the analogy with cancer is not accurate. Cancer research is well funded, and cancer in many instances can be cured. Mental illnesses have not seen this kind of support, funding, or understanding. In fact, funding has been drastically cut, and the prisons are full of people with mental illness. People now think about mental illness and crime together.

MW: When cancer research started, it was first to try to find commonalities among the many illnesses people with cancer had. The first treatment efforts improved conditions only a very little, but it was by using each effort and tweaking treatment again and again that the field moved forward to where it is today.

AH: I also heard (from Dr. Carl C. Bell of the University of Illinois at Chicago) about a study that showed that stigma was actually increased after the community was educated that psychiatric illnesses are biological illnesses. Before the educational intervention, people with mental illness were seen in the community as odd or quirky and accepted as "different." After the study, these same people were shunned by the community as having an immutable biological disease.

MW: What about child mistreatment? Don’t you think that would be good to include in the DSM? What about domestic violence? And there is a big push to include parental alienation syndrome. What do you think about that?

AH: I don’t see these as psychiatric illnesses, [they are] more social or criminal problems. I don’t think couples with IPV [interpersonal violence] would come for treatment if they knew that they would be labeled by the insurance companies or doctors. I think the parental alienation syndrome is also not a good thing to put in the DSM, whatever the science (or not) behind it. It is a social problem that parents do bad things to their children. I do not see that as a psychiatric issue.

MW: But we treat these people. They come to us for help, and we try to help them. I think it is better to have clear definition that is well thought out and scientifically based, rather than just vague and impressionistic. Relational problems have been written about for years. There is a huge literature on this topic. I think that the evidence for many relational processes that lead to morbidity is at least as good, if not better, than many diagnoses in the DSM-IV.

AH: I agree. However, my conclusion is that we should take things OUT of the DSM that don’t belong there and prevent social or criminal diagnoses from going into the DSM.

MW: How are we going to measure and be scientific about our work?

AH: I think we can do that without using the DSM. Why is the DSM so important? I also don’t think we should let insurance companies dictate how we think about what we do.

MW: Insurance companies pay for treating persons with some diagnoses, but not other diagnoses. For example, in some states, they do not pay for treatment for ADHD, which is extensively researched to be a primarily heritable illness, responsive to medications more than even very intensive psychotherapeutic interventions, and quite disabling for some youth. The DSM has to be used for more than merely what insurance companies decide what to do with it. It originally began as a method of reliably describing patients that psychiatrists were treating, so as to share knowledge about the illnesses, what worked, and what did not work. The [people behind the] ICD-9, 10, and now 11, also think that relational disorders are important to include. We don’t want to be a country left behind!

AH: A good question is, "What is the DSM for?"

MW: To provide a framework for us to diagnose and treat mental illness.

AH: Should it not just focus on biological disease? That is my preference of a system that calls itself a disease manual.

MW: But that is not what the DSM is. It reflects the biopsychosocial model and includes behaviors and clusters of symptoms that are a focus of treatment.

AH: I am not a biological psychiatrist; (I’m) more of a social and family psychiatrist, but I see the DSM as being a biological manual. I think it is hard to categorize social and family behaviors that can be pathological in one situation or culture and not in another. Take expressed emotion (EE). Research in Japan has found that two components of high EE – high criticism and high overinvolvement – need to be parsed out and that families benefit from specific treatments, depending on which component of high EE is present. I don’t think that relational diagnoses are fixed enough. This is another argument.

MW: So how do you see us communicating and working on this problem without a good system of description?

AH: Well, I think we can continue as we have, using these constructs but not embedding them in the DSM. I don’t think that is necessary. I think it might be better to get diagnoses that are subjective or significantly influenced by the prevailing culture out of the DSM.

MW: I would argue that many illnesses, let alone psychiatric disorders in the DSM, are significantly influenced by the prevailing culture. Read "The Spirit Catches You and You Fall Down" (New York: Farrar, Straus and Giroux, 2012), which illustrates the different cultural beliefs of the Hmong (who think the spirit moves a child) from Western medicine (which diagnoses epilepsy). If relational diagnoses are not in the DSM, many therapists will not think about relationships and will not have them as a focus for change.

AH: I think that is an assumption that is not proven.

MW: If relational disorders are in the DSM, then practitioners are more likely to think of them, and faculty are more likely to teach them to new clinicians.

AH: Yes, but think of them as a pathological entity and then we are back where we were 50 years ago – pathologizing families.

MW: I disagree with that. With education and knowledge about effective family interventions, stigma can be reduced, and people can access the treatments they need!

AH: This is a good argument that our field needs to engage in. Better measurement and reduced stigma are the benefits that you see from including relational problems in the DSM.

MW: Yes, and you see this as unnecessary labeling that might be used against families.

AH: Yes. I also think that relational diagnoses are more fluid than biological diagnoses and that we are not ready, and may never be ready, to carve these out as definitive immutable constructs.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver. 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.

In our understanding of family systems, we have long known that dysfunctional relational patterns often lie at the root of our patients’ problems. But to what extent should family diagnoses be incorporated into the DSM?

I sat down with Dr. Marianne Z. Wamboldt to explore these issues. Dr. Wamboldt, a child psychiatrist, is chair of the board of the Family Process Institute. She also holds the Leslie and William Vollbracht Family Chair in Stress and Anxiety Disorders at the University of Colorado, Denver, and serves as professor and vice chair in the department of psychiatry in the medical school.

Marianne Wamboldt: So why exactly do you oppose the inclusion of family diagnoses in the DSM?

Alison Heru: I don’t like the labeling of families. I like helping families understand their strengths and helping them work out their problems. I don’t see family problems as psychiatric problems.

MW: I think it is important that we have a way of measuring and classifying what we see, so that we know what we are talking about and that we can measure whether or not we have success in what we are doing.

AH: I agree that these goals are important. However, I think we can use tools like the GARF (Global Assessment of Relational Functioning) or other measuring devices, to do this. I don’t think we need to go as far as including measurements of family functioning in the DSM.

MW: Did you know the GARF is included in DSM-IV-TR already? What is the difference between the GARF and the DSM?

AH: The GARF is good and useful, like the GAF (Global Assessment Scale) in that it gives you a way to describe functioning on a range from healthy to unhealthy, without defining a pathological state. When you put something in the DSM, you are saying it is a disease. You are saying something about etiology.

MW: Not necessarily. In the DSM-IV, ADHD is a description of behavior; there is no attempt to talk about causality. We had hoped that the DSM-5 could start talking about causality, but most of the research is not yet ready. In the meantime, having a clear definition of what we are treating is useful for researchers as well as clinicians. Having a universal description is helpful for everyone.

AH: I agree that a universal description is good, but I still think that more harm than good comes from including family diagnoses in the DSM. I just don’t see families needing to be labeled as pathological. I understand your point, but I think that the repercussions of having a family diagnosis in the DSM outweigh the benefits. The DSM is used in all kinds of ways. In the court system, it is described as "The Psychiatrist’s Bible." If a family diagnosis is in the DSM, then it becomes an "illness" with all the repercussions that come from that label.

MW: However, if it is not in the DSM, many insurance companies won’t pay for the treatment, and persons in the family get labeled with some other diagnosis in order to get therapy. Moreover, if you label something and talk about it, stigma is reduced. Think about cancer and how we used to think about it. It used to be feared, and people with cancer were isolated. That is not what we want for psychiatry and family problems.

AH: I understand that view, but I think that the analogy with cancer is not accurate. Cancer research is well funded, and cancer in many instances can be cured. Mental illnesses have not seen this kind of support, funding, or understanding. In fact, funding has been drastically cut, and the prisons are full of people with mental illness. People now think about mental illness and crime together.

MW: When cancer research started, it was first to try to find commonalities among the many illnesses people with cancer had. The first treatment efforts improved conditions only a very little, but it was by using each effort and tweaking treatment again and again that the field moved forward to where it is today.

AH: I also heard (from Dr. Carl C. Bell of the University of Illinois at Chicago) about a study that showed that stigma was actually increased after the community was educated that psychiatric illnesses are biological illnesses. Before the educational intervention, people with mental illness were seen in the community as odd or quirky and accepted as "different." After the study, these same people were shunned by the community as having an immutable biological disease.

MW: What about child mistreatment? Don’t you think that would be good to include in the DSM? What about domestic violence? And there is a big push to include parental alienation syndrome. What do you think about that?

AH: I don’t see these as psychiatric illnesses, [they are] more social or criminal problems. I don’t think couples with IPV [interpersonal violence] would come for treatment if they knew that they would be labeled by the insurance companies or doctors. I think the parental alienation syndrome is also not a good thing to put in the DSM, whatever the science (or not) behind it. It is a social problem that parents do bad things to their children. I do not see that as a psychiatric issue.

MW: But we treat these people. They come to us for help, and we try to help them. I think it is better to have clear definition that is well thought out and scientifically based, rather than just vague and impressionistic. Relational problems have been written about for years. There is a huge literature on this topic. I think that the evidence for many relational processes that lead to morbidity is at least as good, if not better, than many diagnoses in the DSM-IV.

AH: I agree. However, my conclusion is that we should take things OUT of the DSM that don’t belong there and prevent social or criminal diagnoses from going into the DSM.

MW: How are we going to measure and be scientific about our work?

AH: I think we can do that without using the DSM. Why is the DSM so important? I also don’t think we should let insurance companies dictate how we think about what we do.

MW: Insurance companies pay for treating persons with some diagnoses, but not other diagnoses. For example, in some states, they do not pay for treatment for ADHD, which is extensively researched to be a primarily heritable illness, responsive to medications more than even very intensive psychotherapeutic interventions, and quite disabling for some youth. The DSM has to be used for more than merely what insurance companies decide what to do with it. It originally began as a method of reliably describing patients that psychiatrists were treating, so as to share knowledge about the illnesses, what worked, and what did not work. The [people behind the] ICD-9, 10, and now 11, also think that relational disorders are important to include. We don’t want to be a country left behind!

AH: A good question is, "What is the DSM for?"

MW: To provide a framework for us to diagnose and treat mental illness.

AH: Should it not just focus on biological disease? That is my preference of a system that calls itself a disease manual.

MW: But that is not what the DSM is. It reflects the biopsychosocial model and includes behaviors and clusters of symptoms that are a focus of treatment.

AH: I am not a biological psychiatrist; (I’m) more of a social and family psychiatrist, but I see the DSM as being a biological manual. I think it is hard to categorize social and family behaviors that can be pathological in one situation or culture and not in another. Take expressed emotion (EE). Research in Japan has found that two components of high EE – high criticism and high overinvolvement – need to be parsed out and that families benefit from specific treatments, depending on which component of high EE is present. I don’t think that relational diagnoses are fixed enough. This is another argument.

MW: So how do you see us communicating and working on this problem without a good system of description?

AH: Well, I think we can continue as we have, using these constructs but not embedding them in the DSM. I don’t think that is necessary. I think it might be better to get diagnoses that are subjective or significantly influenced by the prevailing culture out of the DSM.

MW: I would argue that many illnesses, let alone psychiatric disorders in the DSM, are significantly influenced by the prevailing culture. Read "The Spirit Catches You and You Fall Down" (New York: Farrar, Straus and Giroux, 2012), which illustrates the different cultural beliefs of the Hmong (who think the spirit moves a child) from Western medicine (which diagnoses epilepsy). If relational diagnoses are not in the DSM, many therapists will not think about relationships and will not have them as a focus for change.

AH: I think that is an assumption that is not proven.

MW: If relational disorders are in the DSM, then practitioners are more likely to think of them, and faculty are more likely to teach them to new clinicians.

AH: Yes, but think of them as a pathological entity and then we are back where we were 50 years ago – pathologizing families.

MW: I disagree with that. With education and knowledge about effective family interventions, stigma can be reduced, and people can access the treatments they need!

AH: This is a good argument that our field needs to engage in. Better measurement and reduced stigma are the benefits that you see from including relational problems in the DSM.

MW: Yes, and you see this as unnecessary labeling that might be used against families.

AH: Yes. I also think that relational diagnoses are more fluid than biological diagnoses and that we are not ready, and may never be ready, to carve these out as definitive immutable constructs.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver. 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.