Description of Relational Processes: Recent

Changes in DSM-5 and Proposals for ICD-11

MARIANNE WAMBOLDT*
NADINE KASLOW
DAVID REISS

Epidemiologic, prospective, and retrospective research confirms that family relational

variables are significant risk factors for the development of mental and physical health
problems in children as well as adults. In addition, relationships also play a moderating
role in the maintenance, exacerbation, or amelioration of chronic health problems.
Although acknowledgment of the importance of these variables in the pathophysiology of a
number of health conditions is reaching more prominence, the integration of assessments
of family factors as part of standard health care has made little progress. With the arrival
of the Affordable Care Act in the United States, there is a desire for earlier identification of
these risk factors, and the ability to implement prevention programs that reduce risk, and
enhance protective factors. On a global level, there is increased awareness of the health
impact of relational problems, for example, many countries have attempted to implement
programs to decrease domestic violence. More reliable and standardized assessments of key
relational processes will enhance both of these missions, and allow comparison of a variety
of prevention and intervention programs. This article discusses progress over the last decade in constructing more reliable definitions of relationship processes, how these have been
integrated into the Diagnostic and Statistical Manual 5th edition (DSM-5), and progress
toward implementation into the World Health Organizations International Classification
of Diseases (ICD-11).
Keywords: Relational Diagnoses; DSM-5; ICD-11
Fam Proc 54:616, 2015

WHY A SYSTEMATIC APPROACH TO RELATIONAL DIAGNOSIS?

asic and translational research explicating the role of key interpersonal relationships in the development, mediation, and moderation of many of our mental disorders has increased substantially over the past two decades (Beach et al., 2006). A few
categories of this research include retrospective risk assessments, such as the Adverse
Childhood Experiences (ACE) Study (Felitti et al., 1998); prospective environmental
studies which yield patterns of psychosocial risk variables associated with psychiatric
disorders (e.g., Copeland, Shanahan, Costello, & Angold, 2009a), and genetically
informed prospective studies (e.g., Caspi, Hariri, Holmes, Uher, & Moffitt, 2010;
Tienari et al., 2004; Uher et al., 2011) that document both direct effect of family vari*Psychiatry, Childrens Hospital Colorado, Aurora, CO.

Grady Health System, Atlanta, GA.

Child Study Center, Yale University, New Haven, CT.

Correspondence concerning this article should be addressed to Marianne Wamboldt, Psychiatry, Childrens Hospital Colorado, 13123 East 16th Ave., B130, Aurora, CO 80045. E-mail: marianne.wamboldt@
childrenscolorado.org.
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ables, independent of genetic influences, or an interaction between inherited risk

factors and family relationships that increase risk of mental disorders. Basic research
with animals is showing that early caregiving relationships can affect future behavior
changes via change in epigenetic marks (Meaney, 2010). In the United States, approximately 4860% of the population is at low risk from childhood stressors; approximately 3145% of the population has moderate, but variable risk; and approximately
79% of the population is at high risk (Copeland, Shanahan, Costello, & Angold,
2009b; Dube et al., 2001; Menard, Bandeen-Roche, & Chilcoat, 2004). This research
has led to a call for changing public health emphasis from a focus on lifestyle changes
in adults to identifying children at risk for health problems due to perinatal and early
childhood adversities (Shonkoff, Boyce, & McEwen, 2009).
In addition to identification of children at risk, however, there is great need to
design and implement focused interventions that may allay that risk. Genetically
informative prospective studies are documenting in a nuanced manner interactions
between genetic predispositions to disorders and parentchild relationships that may
exacerbate or ameliorate the progression of these disorders. Take, for example, the
work done on externalizing disorders in children. Persons with genetic risk for antisocial behavior may only develop those behaviors in the context of childhood abuse
or neglect (e.g., see Button, Scourfield, Martin, Purcell, & McGuffin, 2005). Moreover,
children with this genetic predisposition may also be more challenging to parent, and
evoke hostile reactions from their parents (of many studies that illustrate this effect,
see, e.g., Neiderhiser, Reiss, Hetherington, & Plomin, 1999). These parental reactions,
evoked by heritable features of the child, may then go on to influence subsequent
child psychopathology (consider, for example, Harold et al., 2013, and Fearon et al.,
2014). This information is extremely helpful in developing targeted interventions for
families.
Taken together, a variety of research studies re-emphasize the importance of accurately measuring family relational patterns to understand the complex interactions of
genes and environment in the promotion of health, or in the path to poorer health
outcomes (Wright & Saul, 2013). Systematic efforts to reduce or prevent illness would
require a reliable manner of screening for these risk factors as well as interventions
that may prevent the future deleterious health consequences. Both of these goals are
currently hampered by the lack of standardized means of assessing family relationships. The World Health Organizations (WHO) International Classification of Diseases
(ICD-10) as well as the American Psychiatric Associations (APA) Diagnostic and Statistical Manual (DSM-IV) systems had codes that captured some of these relationship
variables, but they were poorly organized and ill defined, and subsequently seldom
utilized in epidemiologic or clinical research. The DSM-5 has been modestly improved
in this regard, but much more is needed.
In this paper, we first summarize the history of various approaches to structured definitions of relationship problems. Next, we document our Workgroup on Relational Processes
efforts over the past decade to incorporate standardized definitions of relational problems
into the DSM-5 and hopefully into the ICD-11 as well. Finally, we discuss some of the
advantages and disadvantages of adapting a reliable system of evaluation of family problems.

HISTORY OF FAMILY PROCESSES ASSESSMENTS

Over the half century of family systems therapy, there have been a number of
approaches to classifying relationship patterns and levels of family functioning (Kaslow &
Patterson, 2006).
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Attempts to Influence the DSM

Family systems thinkers tried to provide input into the DSM-III revision in the late
1970s, but had little success. In 1987, a Task Force on (Family) Diagnosis and Classification emphasized the rationale for inclusion of relational diagnoses in DSM-IV. They listed
diagnoses that described various marital/partner and family dysfunctional patterns but
found it difficult to reach consensus. They endorsed the Global Assessment of Relational
Functioning (GARF) scale (Group for the Advancement of Psychiatry [GAP], 1996), which
was included in the DSM-IV as an Appendix item to be further tested. DSM-IV also
included a number of psychosocial issues that pertained to the patient which were listed
on Axis IV. Many of these were taken from the ICD-10 (World Health Organization, 2010)
and many included relationship concerns. Finally, DSM-IV included some relational problems in the section Other Conditions that may be a Focus of Clinical Attention, but these
entities lacked criteria sets, due to perception of the editors that research had not yet
defined thresholds for caseness of these problems.

Parallel to, but Separate from, the DSM System

Some systems were developed separate from but parallel to the DSM system. The best
example of this is from the National Center for Clinical Infant Programs, which developed
a diagnostic system to describe mental health issues in very young children. Originally
published in 1994, the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-3) was the first developmentally based system for diagnosing mental health and developmental disorders in infants and toddlers
(Zero to Three, 1994). It was revised in 2005 (Zero to Three, 2005) to incorporate empirical
research and clinical practice, and had a specific goal to Understand how relationships
and environmental factors contribute to mental health and developmental disorders. . ..
In this system, Axis II is the Relationship Classification, which is used to understand the
meaning of behaviors within each specific childcaregiver relationship, as children this
young can appear very different with different caregivers. Relationship disorders include
several patterns (Overinvolved; Under-involved; Anxious/Tense; Angry/Hostile; Mixed
Relationship Disorder; Abusive). Each highlights a relational pattern that includes descriptors of behavior, affect, and psychological involvement for the caregiver and the child.
This system is utilized by the majority of early childhood treatment centers in the United
States, and gives common codes for research and to guide treatment interventions (Egger
& Emde, 2011). Although research on reliability of this system is early, studies with clinical samples suggest good inter-rater reliability when assessing medical record information, and good concordance where DC:0-3 and DSM-IV overlapped (Frankel, Boyum, &
Harmon, 2004).

Bucking the DSM

Finally, Karl Tomm, MD, and associates at the University of Calgary devised a system
of their own, Interpersonal Patterns, or IPscope (Tomm, St. George, Wulff, & Strong,
2014) to assess familial relational patterns in the clients of their clinic. This system codes
for six major types of interpersonal patterns (IPs): Pathologizing IPs, Wellness IPs, Healing IPs, Deteriorating IPs, Transforming IPs, and Socio-cultural IPs. They define IPs as
repetitive or recurrent interactions between two or more persons distinguished by an
observer that highlights the coupling between two classes of behaviors, attitudes, feelings,
ideas or beliefs and that tend to be mutually reinforcing. Furthermore, they state that
the qualitative mental health differences between families lie in which interpersonal
patterns predominate, not with the families themselves. In other words, they diagnose
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interpersonal patterns, not families. They rate the presence or absence of various IPs, as
well as their severity levels. By showing their administration that this rating was reliable,
and correlated with the length of needed therapy, they were able to replace the DSM
system with the IPscope system.

PROCESS OF INCORPORATING RELATIONAL PROBLEMS INTO DSM-5

AND ICD-11
At the very start of the DSM-5 revision process, leaders of the APA and the National
Institutes of Mental Health (NIMH) convened a meeting to review the problems with
DSM-IV and the prospects of major revision. A major impetus of the meeting was recognizing a number of areas that had been relatively or absolutely neglected in DSM-IV, including failures to systematically assess disability associated with mental disorders, continued
dissatisfaction with the diagnoses of personality disorders, the absence of any guidance
from research on biological processes, and the failure to deal with relationship assessment.
Michael First, M.D., a leader in the development of DSM-IV, was a strong advocate for
relational assessment and invited David Reiss, MD, to this and subsequent DSM-5 planning meetings. Reiss and First wrote an evidence-based chapter in A research agenda for
DSM-V (Kupfer, First, & Regier, 2002) on two of the major gaps that were identified:
personality disorders and relational disorders. A second evidence-based chapter entitled
Why Relationship Disorders were not included in DSM-IV was co-authored by Reiss and
Robert Emde, M.D. (Reiss & Emde, 2003).
These initial events established a durable strategy to: (1) focus on a full inclusion of
relational assessments as a central component of the DSM concept; (2) develop a partnership between adult and child clinicians; and (3) base the approach on a rigorous
integration of basic social and biological research tied closely to evidence guided field
trials of relational diagnostic systems. Accordingly, Reiss assembled a Workgroup on
Relational Processes with these strategies in mind. It initially included Steve Beach,
Ph.D., Nadine Kaslow, Ph.D., Rick Heyman, Ph.D., and Marianne Wamboldt, M.D.
This group, with additional members over time, organized and held three separate
meetings. The Fetzer Foundation and NIMH supported the first two meetings. The
DSM-5 leadership appointed Michael First as the official DSM-5 liaison to this work
group.
The first meeting, Relational Processes and DSM-V: Neuroscience, Assessment, Prevention, and Intervention, was held March 2005, and attended by the steering committee of
the DSM-5 as well as numerous National Institutes of Health (NIH)-funded scientists,
and key members of various family therapy and mental health organizations. This meeting presented basic science and clinical science results implicating relational variables
into the pathophysiology of mental illnesses, as well as in the moderating of these illnesses. The proceedings from this meeting were published by the APA Press (Beach et al.,
2006). The directors of the DSM-5 process gave permission to hold a second meeting to
form recommendations that were to improve nosology and assessment in DSM-5 by incorporating relationship processes, and to propose field trials or re-analyses of existing databases that would clarify criteria for DSM-5.
The second meeting, Relational Processes and DSM-V: Revising current nosology
and improving assessment was held in May 2007 and attended by some of the DSM-5
directors, as well as representatives from National Institute of Alcoholism and Alcohol
Abuse (NIAAA) and the National Institute on Drug Abuse (NIDA). There were several
key concerns and issues addressed. The first was the concept of whether a Disorder
needed to reside in an individual, rather than a relationship. Language was modified
to consider Relational Syndromes that would: (1) describe patterns that produce
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clinically recognizable sets of symptoms; (2) be associated with serious distress and
malignant disruption of personal functioning; (3) have evidence of underlying psychological and/or biological processes; and (4) deserve clinical attention in the absence of
any other currently recognized mental disorder. Syndromes would be differentiated
from Relational Risk Factors, which could also be included. Relational Risk Factors
were defined as relational processes that: (1) are associated with negative outcomes of
established mental or physical disorders; (2) increase the risk of relapse for specific
disorders; and (3) in and of themselves may not interfere with personal functioning or
deserve clinical intervention. A second distinction was whether the relational process
reflected a categorical diagnosis versus a continuous dimension. Prevention efforts
may be better supported with continuous constructs. Finally, the proposal was that
relational patterns could be parsed into whether they were general (i.e., harmful in all
circumstances) or specific (only salient when accompanied by certain other conditions),
and whether they met criteria for a syndrome or were a risk factor.
Discussions at this meeting included a wide variety of mechanisms to include relational
processes in the DSM-5. The first, requiring the best evidence, was to list conditions that
could meet standards for syndromes on Axis I under a category of Relational Syndromes.
A second option was to propose more explicit criteria or descriptors for Vcodes that did
not yet have enough information to qualify as a syndrome. Third, there was a proposal to
include relationship processes into the descriptions of certain Axis I disorders, or as specifiers of disorders. Examples would include Major Depression with or without intimate
partner discord, for those disorders where there was evidence that treatment outcomes
would differ for those specified groups (Whisman & Baucom, 2012). Finally, a section of
General Risk Factors could be incorporated into something like the DSM-IVs Axis IV, but
would have specific relationship risks such as high conflict or over-involvement in the
family, or poor parental monitoring. These schema were described more fully in a later
publication (Wamboldt et al., 2010).
The second goal of the meeting was to consider what existing data could be utilized to
collect field trial information, or what type of field trials may be designed to further examine some of these constructs. One member of the group, Heyman and his colleagues, had
already been involved with large field trials of relational syndromes, in particular maltreatment of children and of intimate adult partners, through a collaboration with the
United States Air Force. Among other things, their work showed that improving criteria
for some of these V codes so that they were more reliably diagnosed reduced recidivism
among perpetrators within the Air Force. Their field trial data were re-examined to demonstrate how these particular constructs would have enough validity to be included in the
DSM-5 or ICD-11 (Heyman et al., 2009). Another of our group, Wamboldt, was involved as
the Principal Investigator for one of the DSM-5 Field trial sites for childhood disorders.
She and her colleagues were able to add testing of a criterion set for ParentChild
Relationship Disorder into the same framework for testing patients within their site
(Wamboldt, Cordaro, & Clarke, 2015).
In parallel with these efforts, major disputes began to emerge in work elsewhere in
DSM-5. For example, there was a rift on the diagnosis of autism that led to resignations,
public debates, immense press coverage, and concerns that linger to this day. Less publicized, but equally intense, was a dispute between those advocating for dimensional diagnoses of personality disorders and those wishing to retain the elements of the current
nominal categories. Finally, as the new DSM headed to press, the Director of NIMH indicated that the institute had invested sizable public funding on an alternate system of psychiatric assessments organized around neural circuits and behavioral processes that cut
across the DSM disease categories (Cuthbert & Insel, 2013). Relational assessment took a
back seat during this period. In the end, some improvement on descriptions of relational
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problems was accepted into a subordinate section on additional clinical problems, but did
not include the criteria recommended by the Workgroup on Relational Processes.
Concurrently, the World Health Organization (WHO) was working on a major revision
of the ICD. The ICD is the global standard for classifying diseases and related health problems. Its significance for diagnosis and treatment of physical and mental illness, and for
understanding global disease trends, cannot be overstated. Physicians, other health workers, hospitals, ministries of health, and health information systems around the world use
it. The 11th revision of the ICD will reflect the many scientific and conceptual advances in
medicine and health since the last major revision, in 1990. Members of the Mental Health
Committee working on revisions to ICD-11 were already working with the DSM-5 group
to harmonize DSM-5 codes with what will become ICD-11 codes. Members of the Mental
Health Committee were interested in hearing about more specific definitions of relationship processes, however, this group is dedicated to world health, and wanted to ensure
that any criteria would be applicable in a wide variety of cultures, including high-, medium-, and low-income nations. The WHO had already invested a considerable effort on
documenting violence toward women in a large sample of countries, and was particularly
interested to learn how more reliable criteria may help in their effort to establish prevalence rates, with the goal of implementing interventions to reduce these rates (World
Health Organization, 2013).
With generous funding from the Fetzer Institute and the Eranos Institute, the
group organized a third conference, held in October 2010 in Ascona, Switzerland. The
intent of the meeting was to foster greater cross-cultural and interdisciplinary understanding of the challenges to primary relationships faced by humans around the globe.
Organized and led by Geoffrey Reed, Ph.D., participants included clinical and family
psychologists, psychiatrists and researchers from the United States, China, South
Africa, Lebanon, Finland, and Australia, as well as officials from the WHO specializing in mental health, external causes of injury, violence prevention, and reproductive
health. Fields of expertise included parentchild relationships, child maltreatment,
intimate partner relationships and intimate partner violence, genetics, health systems
research, and disease classification.
This meeting generated enthusiasm for improving the descriptions of relational processes for the ICD-11. A proposal was endorsed to synchronize the relationship codes
found in different sections with a similar set of criteria. For example, violence toward an
adult partner was noted in sections typically used by Emergency Department workers,
Obstetricians, and Mental Health providers, and all were different. The new organization
would put similar verbiage and descriptors in each of these sections for coding that used
the same criteria. The group made suggestions to re-organize some of the other relationship codes, for example, sibling relationship problem, but did not yet have enough
evidence to provide in-depth criteria for many of these codes. Instead, the group focused
primarily on two important sets of relationships: intimate adult partner relationships and
parent/caregiver child relationships. Criteria for both relationship distress and varieties
of maltreatment were revised to be consistent with the ICD formats, and to be appropriate
for a wide variety of cultural settings. Specific evidence-based tools for reliable and standard assessment of these relational patterns were discussed and vetted. The papers presented at this meeting are published in a text (Foran et al., 2013), and the appendixes
include the standard assessment tools.

REVISION OF RELATIONSHIP VARIABLES FOR ICD-11

Currently, the WHO is sponsoring an Electronic Field Trial for Relationship Problems
and Maltreatment. The design of the field trial is intended to include a wide variety of
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professionals from across the globe. Approximately, 10,000 mental health and primary
care professionals from more than 100 countries have already registered to be part of the
trial to date. In addition to English, the current study is likely to be run in Japanese,
Spanish, Chinese, French, and possibly Russian. This field trial will test the definitions
for relationship problems and maltreatment that were formulated at the Ascona meeting
and are presented in the above book. This study will investigate the degree to which the
addition of relationship problems and maltreatment definitions provide clinicians valueadded information for diagnosis, case conceptualization, and treatment planning.
More specifically, the field trial will assess whether revised relational problem criteria
result in more reliable coding for relational problems than the ICD-10 criteria; whether
inclusion of relational problems criteria result in more reliable mental health diagnosis
and reduce over-diagnosis of mental health problems; whether the revised relationship
problems and maltreatment codes provide clinically useful information for case conceptualization and treatment recommendations. Some of these questions will be answered by
comparison of clinician ratings of identical vignettes when utilizing the ICD-10 relationship descriptors versus the new proposed descriptors. Others will be answered by analysis
of clinician responses to a variety of utility questions similar to those used in the DSM-5
field trials.
Disorders to be tested include Intimate Partner Relationship Distress, Intimate Partner Physical Abuse, Intimate Partner Psychological Abuse, ParentChild Relationship
Problem, Child Physical Abuse, Child Neglect, and Child Psychological Abuse. As this
field trial will test more specific criteria for the selected relationship problems than
what is included in the DSM-5, pending the results of the field trial, the ICD-11 may
include more specific criteria for these disorders than does the DSM-5 currently. Based
on a personal communication from David Kupfer, M.D., the DSM will be updated digitally in the future, and thus these tested criteria may yet be added to the DSM in the
future.

SUMMARY
For over a decade, the Workgroup on Relational Processes has been documenting the
basic and translational research that shows relational processes to be critical in understanding the progression of psychiatric symptoms. While many relationships may be
important, the group has focused primarily on two: the parent (caregiver)child relationship and the adult intimate partner relationship. There is ample evidence from basic animal models through clinical research to indicate that these relationships are involved
with the development, mediation, and moderation of a number of psychopathological processes (Beach et al., 2006). Our group has proposed that each of these key relationships be
understood on a continuum, acknowledging that relationships may shift from protective
or supportive to less than optimal, and at some points into definitively maladaptive, for
example, maltreatment syndromes.
In organizing our recommendations, we have followed a DSM approach unabashedly.
This is true in two important respects. We have developed a descriptive system that is
agnostic to any particular family theory and have articulated observable criteria by which
a relational problem can be identified. Implicit in our work is the use of the same categorical approach as DSM. Does or does not this relationship have a problem? While none of
us wants to be an advocate for DSM-5 or the ICD-11, there are some very practical reasons
for agnostic, categorical, and polythetic nosologies. The idea is not to capture the nuances
of family dynamics that are crucial for sophisticated treatment. The use of a diagnostic
system such as ours comes well before such an appraisal in the unfolding contact between
the health care provider and family.
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ADVANTAGES AND DISADVANTAGES OF A RELATIONAL DIAGNOSTIC SYSTEM

Advantages
Better links with systems of health care
The Affordable Care Act in the United States has encouraged the early identification of
persons at risk of health problems due to environmental problems, including relationship
risk factors, and appropriate preventive interventions (Patterson & Vakili, 2014). If our
health care system were to work optimally, primary care health providers would be taught
how to implement clinically feasible screens for relationship problems that may pose a risk
to the health of their patient. Ideally, the family therapy field would engage in creating
and offering treatment programs to which the primary care providers could refer their
patients. Having a nationally or internationally agreed upon definition of what constitutes
a relational problem of sufficient intensity that treatment (whether preventive or ameliorative) is indicated would promote integration of relationship problems, and relational
interventions, into mainstream health care.
Improved teaching about families in health care education
Whether family therapists agree with the DSM system or not, in the United States it is
taught in most mental health fields, and a DSM diagnosis is required as part of the assessment process. For billing purposes, an ICD code is mandated, and is used as part of the
inter-professional discussion of patients, especially in medical contexts. Hence, most students are well versed in the DSM and ICD approaches, but rarely in a relationship assessment approach. If fuller and more specific definitions of relational problems were included
in the DSM and ICD, medical students, psychiatric and primary care residents, psychology, and masters level trainees would be encouraged to acquire skills to do a simple family
evaluation.
Enhanced research
Having detailed, reliable, and standardized assessments of relationship processes are
essential for research both on etiology of relational problems and on their treatment. They
can be used for the standard disease burden statistics now routinely compiled in both
developing and developed countries, which could be helpful in cross-national comparisons
of health systems and would be of considerable value in health economics. For example,
they can be used to make accurate estimates of cost offsets for care of family interventions.
Reliable and standardized assessments are crucial for epidemiological studies that seek to
clarify the role of family relationships in the pathogenesis of both medical and psychiatric
disorders.

Disadvantages
Perceived blame
Family clinicians have many well-founded objections to standard classifications of family problems. Not only do they lack nuance, but more seriously, may impair the important
collaboration between families and clinicians. For example, the use of a diagnostic system
may turn a family into a case and the clinician into an expert. Moreover, highly sensitive to the social context of their work, family clinicians are equally sensitive to the risk of
labeling both individuals and families as sick or problematic, and do not want to undermine family strengths and resilience. Family behaviors that are highly adaptive to stressful environments can easily end up in a category of relational problem. A good example is
high protection and decisive discipline of children living in dangerous neighborhoods.
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Parents that prohibit their children from playing unsupervised in the street and punish
them harshly for breaking that rule, leading to child dissatisfaction with the parent, may
meet criteria for a parentchild relationship problem unless the specific social context is
taken into account. It is unlikely that child or intimate partner maltreatment would be
seen to be adaptive in any situation.
Stigma
Stigma against persons with mental health problems has been long-standing, and has
not improved with more biologic explanations and treatment options (Schomerus et al.,
2012). Proposing that there may be a role for pathological relationships in the etiology or
maintenance of such disorders may lead to more stigma for patients with mental illness
and their families, as it may appear that they have control over the illness. In a similar
manner, patients suffering from lung cancer face more stigma about their illness than do
patients with other types of cancer (Chambers et al., 2012).
Payment
Another very salient concern for practitioners regards the parity issues of reimbursement for mental health services. We already have difficulty obtaining adequate reimbursements for mental illnesses diagnosed in individuals; how will we hope to be
reimbursed for treating relational patterns? Hopefully in the United States, the Affordable
Care Acts provision for better parity for mental health concerns will alleviate some of this
problem. Indeed, some insurers that are paid on a capitated basis already recognize the
importance of relationship problems and encourage practitioners to assess for and treat
these issues (e.g., see ValueOptions). In countries with federally supported health care,
this is not as much of an issue.
Validity
A reasonable criticism would be that we do not have an adequate research base to
validate these relationship patterns as impairing or promoting the adaptation of family
members, and when and in what circumstances they may be either. In the past, families were often blamed for disorders in their children, for example, frigid mothering
causing autism, which has been shown to be an error, but left great harm. We would
not want a diagnostic system to undermine a clinical stance of openness, acceptance,
and working with families to help understand their experiences, hopefully to relieve
suffering. However, every field needs to take steps to move forward in a systematic
manner to validate the hypotheses and determine evidence to support or refute their
hypotheses. Without starting to reliably describe the patterns we treat, we will be
unable to move forward. We are convinced that the descriptions we have recommended
for DSM and ICD will be revised and improved as more research accumulates, and that
these descriptions are not the final truth.
In conclusion, evidence suggests that reliable, standard, and internationally useful criteria for the definition of a number of relational problems will advance the goal of
improved relational, physical, and mental health. The proposals for these criteria that are
described in this issue are based on substantial empirical evidence and have already benefitted from a broad international review (Foran et al., 2013). Nonethless, they represent
initial steps toward advancing clear and valid criteria in the DSM and ICD nomenclatures. Further refinements will be enhanced by the results of the WHO sponsored field
trial which will include clinicians from a wide variety of countries, and lend data to help
with further cultural refinements. Now is the time for clinicians, educators, and researchers to review with care these new criteria, and actively participate in their continuing
development.
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