By Richard Trubo
Reviewed By Michael Smith
If you and your spouse seem to coexist in a state of constant conflict, with a marital relationship that's sinking faster than a capsized ship, your therapist could someday attach a formal diagnosis to your domestic dissension. The American Psychiatric Association (APA), the National Institute of Mental Health, and other agencies have raised the possibility that a new diagnosis -- called "relational disorders" -- might someday describe your spousal squabbling.
The proposed new diagnosis defines a relational disorder as "persistent and painful patterns of feelings, behaviors, and perceptions" among two or more people in an important personal relationship, such a husband and wife, or a parent and children.
According to psychiatrist Darrel Regier, MD, some psychiatrists and other therapists involved in couples and marital counseling have recommended that the new diagnosis be considered for possible incorporation into the professional bible of mental illnesses -- called the Diagnostic and Statistical Manual of Mental Disorders (DSM).
We are trying to determine if there is enough evidence and support for the diagnosis, says Regier, director of the APA's division of research. "Right now, it is just a 'condition' that is a reason for clinical contact, as opposed to a 'disorder' defined by explicit criteria."
A listing in the DSM would provide mental-health professionals with well-defined guidelines for diagnosing a "relational disorder," which would allow psychiatrists and other therapists to clearly identify cases needing treatment, says psychiatrist Michael First, MD. By including the diagnosis in the next DSM, and formally labeling it as a "disorder," it would "basically give it more prominence," says First, editor of the current edition of the DSM.
The interest in pursuing more research and giving more attention to "relational disorders" is not confined only to psychiatrists. "Many family psychologists have been working on this for years, and have been making the argument that certain kinds of family relationships, characterized by particular patterns of interactions, tend to be destructive of the mental health of individuals within the family," says Ronald Levant, EdD, former president of the division of family psychology of the American Psychological Association.
Changing the Focus
The DSM has been used by professionals for 50 years, and it has gone through several revisions. The next edition, DSM-V, is not expected to be published until 2010, and only after input about its contents is collected from hundreds of mental-health experts. Already, however, the possible inclusion of "relational disorders" in the manual is beginning to stir up discussion, and not only because it would label troubled relationships as pathological. The new diagnosis would also represent a clear paradigm shift in the way that mental illnesses are perceived. For the first time, a psychological disorder would be defined as involving two or more people, rather than just one.
"Today, the entire system is built upon the model that the dysfunction is in the individual," says First. "When a physician fills out medical records, he or she does so for an individual, and claims are submitted for an individual. So in that sense, the adoption of 'relational disorders' would be a different idea. It would shift the locus of the disorder from the individual to the relationship."
Of course, therapists have always taken into account the dynamics within a family unit, rather than concentrating solely on one person. But if the new diagnosis is eventually adopted, it would formally shift the focus to two or more people -- and perhaps pose some new problems in the process.
For example, Regier describes the following scenario. "If you were to place the responsibility for a dysfunctional relationship on both parties somewhat equally, and if there's a spouse involved who's being battered, there is the risk that somehow you're blaming the victim for contributing in some way to his or her own abuse," says Regier.
Levant, dean and professor at the Center for Psychological Studies at Nova Southeastern University in Fort Lauderdale, Fla., emphasizes that "domestic violence is a criminal act as well as part of a relationship. I think it's generally agreed that one has to identify the perpetrator and avoid assigning blame to the victim."
Some proponents of the new diagnosis point out that once the presence of a "relational disorder" is acknowledged, it will become clear to the married couple that it is their relationship that needs to be repaired, rather than one spouse or the other feeling under attack.
Many of the finer points of defining "relational disorders" would have to be clarified as the research in this area unfolds. For example, since even the healthiest relationships have ups and downs, how do you separate a normal bumpy relationship from a "disorder"? "It's not even clear that this delineation is doable," says First, although some mental-health professionals believe that if a couple's problems are both chronic as well as painful, they may cross the line and meet the criteria of a disorder.
Reaching consensus among mental-health professionals, however, may not be a slam dunk. When DSM-IV was in development, the diagnosis of "relational disorders" was discussed at that time, but the decision was made to return it to the drawing board because there wasn't enough research to either support or reject the new diagnosis. Then, as now, there were also concerns among some mental-health professionals that the definitions of illness and disease were simply being expanded too far.
Because of issues like these, most therapists are taking a wait-and-see approach at the moment, including those who may be directly involved in preparing the next DSM.
"Decisions regarding changes in the DSM are based on data, and there's going to have to be more research available to us when it's time to make a decision," says First, MD, associate professor of clinical psychiatry at Columbia University College of Physicians and Surgeons in New York City.
Published Dec. 9, 2002.
SOURCES: Darrel Regier, MD, director, division of research, American Psychiatric Association • Michael First, MD, editor, Diagnostic and Statistical Manual of Mental Disorders, and associate professor of clinical psychiatry, Columbia University College of Physicians and Surgeons, New York • Ronald Levant, EdD, former president, division of family psychology, American Psychological Association, and dean and professor, Center for Psychological Studies, Nova Southeastern University, Fort Lauderdale, Fla.
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