Adam Blatner, M.D.

September 26, 2002

A recent column by Walter Kirn in Time, the national news magazine (September 16, 2002, pg. 92), noted the controversy triggered by a report that a group of psychiatrists proposed adding the category of relational disorders to the official Diagnostic Manual. (This was also reported on by Shankar Vedantam of the Washington Post around September 7 or 8, 2002.) The column, alas, mocked psychiatry for its tendency to expand diagnoses, as if the field should ideally be much simpler.

As I see it, two levels of the function of diagnoses are being forced together. There would be no problem if people paid their own bills, the way they did back in the "good old days." Then, even crusty old Thomas Szasz, the gadfly and long-time critic of organized psychiatry, had no objection to a clear and informed contract. (He is a psychiatrist and a confirmed, vociferous libertarian.) This means, if you want to ask my opinion about your confusion or the possibility of your faulty thinking, and you're willing to pay me for it, in the fashion of a mixture of a business consultant, a personal coach, with an admixture of a measure of pastoral counseling, well, that's between you and me. Szasz' objection is that when something becomes labeled a "disease," it shifts its social significance: It entitles the "patient" to enter the realm of science, and scientific medicine. And scientific medicine addresses only those problems that can be demonstrated to fit within the model of a physiological dysfunction.

Of course, psychiatry addresses a field that traditionally and phenomenologically has had to deal with a blurred middle area, consisting of psychosomatic illnesses and behavioral disorders.
  – does a mildly brain-damaged person who, post-concussion, shows behavioral dyscontrol–i.e., explosive rage outbursts–merit a diagnosis for this, and possibly medical treatment?
    (Medical treatment includes coverage by third party payers, including insurance companies, the government, through Medicaid or Medicare, workman's compensation, or as part of a legal settlement. It also implies physical treatments, including medication, physical rehabilitation, etc.)
  – What is the proper status of psychosomatic illness? In Freud's time, it was hysteria (now called conversion disorders) or neurasthenia.
  – Several conditions previously thought of as primarily psychological, at least in the early part of the 20th Century, have been shown to be more physiological, such as Bipolar Disorder, Schizophrenia, and Obsessive-Compulsive Disorder. (But there are some who deny the physiological nature of those conditions.)
  – A number of conditions have some evidence of physiological components, but the question as to whether these are mere traits within a situation that is far more behaviorally conditioned and culturally sanctioned or even culturally created is a lively controversy– e.g., "hyperactivity" in children or adults (technically called ADHD), addictions and alcoholism, rage attacks (intermittent explosive disorders), etc.
  – A number of conditions are even more psycho-social in nature. Homosexuality, considered a disease by the official diagnostic manual until the mid-1970s, was removed from the manual by 1980. It was clearly a socio-political category, and a most instructive historical process. What is the status of the "gender-disordered" person, those who feel themselves to be psychologically at odds with their biological gender–men who feel they're really women, and vice versa. Should they be treated as a "disease" and have third party payers pay for extensive preparatory treatment, sex-reassignment surgery (an euphemism for radical castration or penile construction), and follow-up treatment? This was almost a fad for a while in the late 1970s, with many centers opening, and then closing as the fad passed. It still goes on.

Back to Relational Disorders and another aspect of diagnosis. The term "diagnosis" derives from the Greek word roots, dia- for transparency, as in diatom, diaphanaceous, and gnosis, related to the word know. To know through, to really understand. Any problem is subject to a process of analysis–taking it apart and looking at the pieces–and diagnosis, trying to make sense of what went wrong. Business problems, complex technical problems, why a play or a piece of music isn't "working"–all may be subject to a process of diagnosis. Now what is diagnosed is always subject to the then-current "maps" or theories of how things should be managed. Business or political problems in the 14th Century were diagnosed differently than in the 20th Century, because the ideal political or economic system was at a different socio-historical stage. Still, diagnosis using the best theories possible is all we can do, humbly recognizing that in time, in light of new discoveries, our diagnoses may be looked back on with a sense of how limited our consciousness was.
As for psychology and relational disorders. The idea is far from new. Undoubtedly, some of the early psychoanalysts alluded to it more or less directly, and the history of marital couple therapy began with a few pioneers in 1930s. J. L. Moreno, the inventor of psychodrama and a major pioneer of group psychotherapy and social psychology, noted the idea that relationships could be "sick" even if the people involved were otherwise "healthy," and even vice versa: Otherwise "sick" people could find themselves in a mutually supportive and "healthy" relationship!

Moreno's ideas may have influenced some of the pioneers of family therapy, but also there were developments in general science, namely, cybernetic theory, developed in the mid-1940s, and noting the nature of circularity and feedback in complex systems. By the 1950s, the idea that relationships themselves could be problematic became quite apparent. So, diagnostically, in the sense not of naming a disease or disorder, but just helping people think through what the heck was really going on, the idea of relational disorder was nothing new.

And in the world today, given no factor of third-party-payers or any need to label anyone or the family as a problem, it's often more effective to treat the relationship as "the problem" than to identify any single person as being more somehow to blame, weaker, defective, etc. When one person is so labeled, there is a corresponding tendency to dismiss, discount, excuse, patronize, and in other ways distort the relationship further. They can't help it. They're being wilfully bad in not trying harder. And the problem is that the person so identified might feel relieved or victimized, blamed, diminished, disrespected, or just not understood. Any of these actions, then, further distorts the multiple subtle power gradients in the relationship among all the people and also the surrounding social network of extended family, friends, social agencies, etc.

So relational disorder is a very useful tool, a practical way of working with a wide range of problems.


When the whole process becomes distorted by having to place a label, in order to obtain validation that the family system involved is worthy of exterior economic subsidy–third party payments–then another factor enters: How sick are you, really? Sick enough to want to get help? Hey, but if you're psychologically minded, and you know help is possible, your threshold for seeking help is low. If you're not psychologically minded, or in other ways prone to denial, you tend to avoid psychological counseling, psychiatric consultation, or even medical intervention until you've almost killed someone or yourself, or you've let the cancer eat up half your body, etc.

So then it becomes a matter of public policy at what level of dysfunction we want to draw the line. What level of problem is worthy of collective participation in the sense of okaying a subsidy. And where do you require an increasing assumption of responsibility. For a paper cut, we don't okay an emergency room visit. For a single tension headache, we don't okay the prescription of major opiate medicines.

You can move the threshold up or down. If you move it up, you ask people to pay for their own problems more. This doesn't mean that relationship disorder isn't a valid diagnosis, but it becomes one that doesn't classify for payment.

Wait a minute, now. This opens up the whole mess of psychiatric stigma. For a while there, in much of the mid-late 20th Century, because psychiatric problems were viewed as suitable for long-term psychoanalysis, an expensive and dubiously effective procedure, they became treated as diseases that could have limitations on the amount of time spent on them!  On the other hand, physical diseases like diabetes or emphysema or brain damage from motorcycle accidents associated with not wearing a helmet–these could cost ten or a hundred times as much money (collectively) and still be considered part of the collective welfare of medical insurance.

Of course psychiatrists objected, because as it became increasingly apparent that many psychiatric diseases, especially the major mental illnesses mentioned earlier, were much more like medical illnesses than simple family dysfunctions, this policy was grossly inequitable.

But what about the middle area? That's much stickier. If psychiatry seeks to have all of its diagnoses treated in the same social policy as the major mental illnesses, then it opens itself to a lowering of credibility across the board, because it's clear that certain kinds of diagnoses can be made for much milder conditions than other kinds of diagnoses; and also, especially with those in which there is a factor of addictive-like behavior, there comes to be the factor of personal responsibility!

For psychiatrists to claim to be entitled to payment for whatever kind of diagnosis they make and for whatever kind of treatment they want to deliver is just too arrogant and presumptuous. Does a CEO like Ken Lay deserve to be excused because of his being able to fit some docs' theory of what a narcissistic personality disorder might be?

Interestingly, it may be disingenous for the official Diagnostic and Statistical Manual to continue to claim to be a pure scientific document, designed for purposes of research. As with language usage, the way something is used in society may be a more realistic definition of what it is than however a word or document may have been intended to function to begin with, and in this case, the DSM is an agent of the collective, to define who is and who is not worthy of being paid for!

There may need to be two different Diagnostic Manuals, the other for how can we better think out the problems, and especially their tendency to be mixed, with many levels of human, biological, and even cultural factors operating. This real diagnostic manual then can get on with the additional complexity of continuous redefinition, because it is in only a partial (at best) way scientific, and cannot hope to pretend to be otherwise.

People do have problems in their coping with each other and the world only somewhat because of intrinsic disease or weakness (however that be defined), and mainly because the systems themselves are changing: We can hardly keep up with the challenge of educating youngsters to cope with a world that demands skills and knowledge that few teachers have themselves learned. Spiritual and other role value conflicts should not be underestimated in terms of the degrees of psychological distress they can cause.

And–here's that annoying reality–because we still know so much and yet so little about it or how to treat it–there is the reality of the inextricable capacity for the mind to affect the body as much as the body affects the mind. And how can that be approached scientifically and able to generate criteria so clear that we can all agree that for Mr. Smith, the problem becomes a "disease" worthy of full economic "third-party" support, but for Mrs. Jones, it's a matter of her "personal responsibility"?

So there it is. It really is a problem that requires a stepping back: It's not the problem of psychiatry itself, not a reflection of the limitations of a field that has made as much if not more progress than many of the other specialties in medicine. It's a problem of a society that hasn't figured out what it wants to do about the problem of personal responsibility?

How much money should we allocate to people who are sick because of their own choice of life style? This is a politically incorrect and vulnerable question even to ask! Should a person who has developed AIDS from a blood transfusion be given more economic and social support than one who got it from promiscuous sex or intravenous drug abuse? And what about the middle group? (These are those who are betwixt and between, such as a fellow who visited a prostitute one time. Or a person who was the unknowing partner of an HIV positive someone who was either dubious or deceptive.) (See my paper on this website on contemporary ethical questions.)

Ditto for problems caused mainly or partially by using drugs or alcohol, overeating, smoking, excessive salt consumption, orthopedic problems because of wearing high heels, disabilities due to not wearing helmets or seat belts, etc.  And it is this kind of collective ethical dilemma that then generates the socio-economic "inflammation" appearing in the field of psychiatry.

There's a relational disorder going on here: Is psychiatry the problem, the "identified patient," or is the problem better diagnosed as being among all the medical fields and the larger economic structures that are evolving to include them, and that need to have some limitations of expenditures?

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