How many times have we exclaimed in exasperation: "My family's driving me crazy"?
Until now, it was a mere figure of speech. By this time next year it could entitle you to free therapy.
That's because for some years now there has been a movement afoot in the mental health care field to include a diagnosis called "relational disorder" in the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), due out in
2013.
Relational disorders are defined as "persistent and painful patterns of feelings, behavior, and perceptions involving two or more partners in an important personal relationship." Typically, people suffering from relational disorders have problems with their primary support groups, notably their families.
The concept of relational disorders, like just about everything in diagnostic psychiatry these days, goes back a long way. In the nineteenth century psychiatrists in France coined the phrase "folie â deux" to describe a madness shared by two people.
In a relational disorder between two spouses, for example, while neither person might suffer from an individual disorder, the two could share one. Or as Time magazine put it in 2002, "I'm OK, you're OK, we're not OK."
By now you might be asking: So what?
Well, here's what: the new DSM, the latest in a series stretching back to 1952, ranks among the most important textbooks ever. Its impact affects almost all domains of everyday life, including government, health care, industry, education, the courts and the media.
If the authors of the DSM officially recognize a diagnosis it gives researchers a common vocabulary for studying mental conditions. This comes in handy when someone is researching psychological illnesses, whose causes and symptoms are much less clear than, say, cancer or heart disease.
Proponents of the RD diagnosis say research is on their side and that people with dysfunctional relationships fill up doctors' waiting rooms.
Yet perhaps most important is the fact that once a diagnosis makes it into the DSM, third party insurance in the United States normally will cover the costs of treatment. No wonder wags have called a DSM diagnosis "an insurance claim."
Now, I have no insider knowledge of DSM deliberations, so I can't say for certain that relational disorders will be included in the next volume. What I can tell you is that since the 1990s a group of researchers has been furiously lobbying the DSM's authors to accept RD as an official diagnosis.
I can also tell you that the marriage and family counseling profession tends to be behind this move. And you can well understand why. By the end of the twentieth century the MFC field had attained status as the fifth "core" mental health group. But at that very time managed care economics began dominating medicine, gutting third-party reimbursement for psychiatric services.
It became imperative for counselors and therapists to get the kind of problems they deal with in treatment recognized as genuine disorders in the DSM. If not, many would go broke.
As Peter Keefe of the University of Toronto's Department of Psychiatry noted in 2003, some suspect that the move to legitimize RD is a "gambit to loosen the purse strings of managed care providers."
DSM certification of RD could prove to be a cash cow for all of the professionals treating people from heartbroken marriages and feuding families. 800,000 U.S. couples a year visit offices for marital and family help. Do the math. Some people stand to make a lot of money.
Yet in the end analysis, perhaps the most disturbing aspect of consecrating relational disorders is that it is just the latest in a long series of events in the history of psychiatry which has seen professionals increasingly try to extend their authority into the private precincts of everyday life.
So if the next DSM does include RD, countless people will wake up one morning with a psychiatric disorder. And it'll have a lot more to do with professional self-interest than hard science.
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First, the most recent (January, 2012) special issue of the Journal of Marital and Family Therapy provides clear, substantial scientific evidence for the effectiveness of family systems and relational therapy.
Second, Mr. Dowbiggin seems to know little about healthcare and reimbursement in the US. Reimbursement is typically made on the basis of medical necessity, and not solely on diagnosis.
Third, the AAMFT and MFTs are involved in the field trials of the new DSM. However, there is not a category of relational diagnoses being used in the field trials.
Mr. Dowbiggin says, “Do the math.” I’m sorry to say that Mr. Dowbiggin’s blog and assertions simply do not add up.
For my full response, see: http://workgroup.aamft.org/ohana/blogs/posts.cfm?topic=7780810
Michael Bowers
Executive Director, AAMFT
Also, there's now a huge literature about how politicized the negotiations over each new edition of the DSM is. The stakes are big: each new DSM diagnosis can make a multi-million dollar difference. I can understand why Mr. Bowers wants to ignore these facts. I can't.
Fact: the DSM already includes a limited number of relational diagnoses. However, these diagnoses receive little, if any, reimbursement from third-party payers.
Do MFT's, social workers, and other mental health professionals who specialize in marital therapy stand to benefit from and expanded set of diagnostic criteria? Yes, possibly. But you make is sound like it is some kind of money-making scheme. Those MFT's are out to legitimize their profession! How dare they! The reality is that most MFT's have to battle with insurance companies to get any kind of recognition and payment for the work they do.
So we use inappropriate tools - individually-focused sciences/technologies of psychology and psychiatry to identify and treat what are essentially sociological and anthropological problems.
Consider our language:
I have psychological problems. (Sounds okay.)
We have sociological problems. (Sounds bizarre).
It's like a phobia around here that just because some people CHOOSE to work through their problems, everybody will be sent for re-education to the gulag.
:-)
I would hardly count that as even important.
Truth is, we are all collectivists, social beings. Focus upon the individual (as source of problems and solutions) is a major social problem in the United States. Focus upon individual allows society to engage in collective denial with respect to causes.
Unless you understand that, all your talk about sociology is completely empty because you don't understand the first thing about society.
The US, by the way, is a much better country to suffer from any of these and to get therapy (if you can afford it) than many others. In other countries, even in well educated European ones, psychological disorders are still much more stigmatised and treatment much less accessible than in the US. So, even though European societies, as a whole, are much more friendly to the individual, in terms of psycho-social and economic support, they are much less advanced in recognising that individuals can be "flawed" and in search of change of their psyche and that that search is NORMAL.
I am surprised you don't know that...
Also, while I appreciate and to some degree agree with the notion that one of the goals of counseling is improved quality of life -that's not the point of the article and in fact the concern is whether creating new disease states is wise.
Just what was I thinking? Of course, it is a silent disease! It is only tested by statistical likelihood and not by pathologists who can clearly see the deadly vascular consequences of long term hypertension in people who died from cardiovascular events. And, of course, medical papers like the following are completely made up:
http://www.ncbi.nlm.nih.gov/pubmed/6823683
Right. Please come back with a response when you are actually willing to talk about reality instead of your distorted notions of it.
I do agree about the point of the article though. It is NOT about actually discussing the problems of people who have difficult relationships. It is merely, yet another, hack piece about the DSM that is catering to the haters of psychology in general.
So basically the author here claims to know next to nothing about the DSM, but then qualifies it as "among the most important textbooks" (the DSM is a reference book, not a textbook, it does not teach science but allows those who practice psychology to apply a common set of comparable rules to the qualification of psychological disorders), only to tear it down based on knowledge that he does not have?
What the goat... ?
At the same time, having open discussions about whether or not it is reasonable to consider this healthcare makes sense. It should also be clear that this is not a "psychiatry" specific concerns - we now have millions of people being treated for illnesses that didn't exist 200 years ago - among them some very common conditions such as hypertension and hyperlipidemia. These are conditions that the medical/pharmaceutical establishment suggest are related to eventual poor outcomes - but that is clearly neither universally nor reliably so. Still - there's little argument about whether to treat them.
Does counseling reduce future poor outcomes? And for what? I think that's the bottom line question that ought to be front and center. Even if the malady is somewhat arbitrary and made up - if someone could demonstrate convincingly that those who participate do better, require less support in other ways, etc. - i say why not call it something?
"Does counseling reduce future poor outcomes?"
No, it doesn't... simply because counselling is not meant to "reduce poor outcomes" (what would those be in this case, to begin with... divorce?). Counselling simply tries to improve the quality of life for people who are seeking it and that, in many cases, works out just fine.
Adding more diagnosis' will only serve to throw more people onto disability, where their only disability is a crummy family.
Please.
Also, if history is any guide, adolescence will become a disorder. How many parent-child relationships are perfect in the teen years?
I agree with fatherdjohnson and the author. The purpose is not so much to actually help people, but rather to transfer wealth from productive people to leeches.
Nothing. In that case the other member who does, needs to solve the problem the best way they can. In many cases this means braking off the relationship. And that can be a perfectly fine result.
"Also, if history is any guide, adolescence will become a disorder. "
Why would that be? Because you need a strawman to set ablaze?
"How many parent-child relationships are perfect in the teen years?"
There are no perfect relationships to begin with, so that's just another strawman burning.
"The purpose is not so much to actually help people, but rather to transfer wealth from productive people to leeches. "
How surprising that you would say just that.
:-)
How did the human race ever survive before we learned that we all are just suffering from chemical imbalances that need to be relieved with man-made chemicals? Let's smooth out the ebbs and flows of emotions. No one needs those peaks and valleys anymore anyway. Let's just drug them all to a gentle sine wave. It works for me. I haven't felt joy or anger in decades. Just mildly pleasant and sometimes inadequate.
I commend Mr. Dowbiggin for being so forthright in his discussion of this subject, and calling a spade a spade.
When there's a sure buck to be made,
when there's one more opportunity for mental-health professionals to extend their influence over another area of our individual lives,
when relinquishing control is presented and promoted as exerting control,
well, thanks for the honest word about how this latest development brings us one step closer to being an underclass of perpetual patients exploited by the mental-health mafia.
You didn't discuss the details of this case, or the function of the DSM, or anything related to psychology, to begin with.
I get it that you hate the profession, but why should we care about your opinion if you don't even care to back it up with a single fact?
That being said, I still reserve the right to hold concerns about the creeping 'psychologization' of society, that is, the steady reductionism of all human thought, inclination, and interaction to the predetermined and not-always-neutral categories enshrined in DSM categories and thus accorded automatic prestige and authority.
Let's lay aside for one minute the undeniable economic implications of having ever larger chunks of human behavior brought under 'syndrome classifications' (how many ways can you spell 'bonanza'?), and just consider what it would mean if we ever reached the point where all human interaction, where all possible human opinion or mental inclination was subjected to and dictated by a set of increasingly collectivist definitions.
I raise this issue in these terms because I remember how, at the height of the Soviet era, Russian psychologists, at the establishment's bidding, classified political dissidence as a mental disorder, and people with unacceptable ideas were sentenced to mental hospitals.
And, for as much as we might like to chatter about freedom and personal liberty, at the ground level there has never been a more powerful pressure toward conformism than in our present day.
Try thinking of this as mediation, far less expensive than litigation. The cost of bad relationships is so high--especially when children--and their lifetime earnings-- are considered--that we all stand to benefit from having them treated. Suppose 1 of 20 marriages is salvaged before its stress impacts the ability of the couple involved to work, to conduct their lives without court involvement, whether through bankruptcy, divorce or custody issues. Suppose that 1 of 20 troubled marriages ends before the couple has children. Suppose another 1 of 20 divorces with children is civil enough to work out a custody arrangement without using the children as pawns, which involves the courts right away and predisposes those children to problems at school and with the law. We'd save in worker productivity, civil and criminal court, and many educational ways: counseling, tutoring or an extra year for children who have to repeat a grade.