A relational view of DSM V: a care-rationing document?

Because DSM V the newest version of the Diagnostic and Statistical manual, sometimes referred to as the "bible of psychiatry" set to come out in May 2013, makes no mention of relationships, the relational perspective is that it is a flawed instrument. The whole discussion about what categories should and should not be included is off the mark. Nonetheless, as it currently dictates who will and who will not receive treatment, it is a force to be reckoned with.

Psychiatrist Daniel Carlat, in his book Unhinged: The Trouble with Psychiatry writes:

The tradition of psychological curiosity has been dying a gradual death, and the DSM is part cause, part consequence of this transformation of our profession. These days psychiatrists are less interested in ‘why’ and more interested in ‘what’.

In an excellent NYT piece on the subject, Not Diseases, but Categories of Suffering, the author states:

And as any psychiatrist involved in the making of the D.S.M. will freely tell you, the disorders listed in the book are not “real diseases,” at least not like measles or hepatitis. Instead, they are useful constructs that capture the ways that people commonly suffer.

He goes on to say that the problem with DSM is that it has been taken “too seriously.” This is reflected by the fact that even though these diagnoses are artificial constructs, they dictate who does and who does not receive treatment. In other words, if you meet diagnostic criteria you are suffering enough to get help. If not, you’re on your own.

Consider the new diagnostic category, voted on Saturday to be included in the new version: Disruptive Mood Dysregulation disorder. The boy I describe in the following story(details as always have been changed to protect privacy) may or may not meet the criteria for this label. Either way, he and his family are in trouble. Even asking the question of diagnostic category diverts us from the task of helping them.

Four-year-old David's mother, Alice, described him as "explosive." She told of a typical scene- a request to get ready for bed was met with a firm "no," and soon mother and child were head to head in battle. An hour later, David was kicking and screaming on the floor and Alice was crying, horrified with herself for having threatened to hit him. Similar scenes occured several times a day.

Rather than launching right in to "what to do" I took some time to listen to Alice's story while David played on the floor. Many things emerged, but most striking was the fact that the family had moved three times in the past year after David's father, Ron, lost his business, leaving the family in financial ruin. Ron had been severely depressed, but according to Alice, they were settled now and he had a good job. When I commented that it sounded like a very stressful year, she immediately responded with,"Yes, but we didn't let it affect David."

From my position, this clearly seemed impossible. Such an experience is inevitably stressful for a four-year-old child. But for some reason, Alice, who was an intelligent woman, did not see it. Perhaps she felt so much guilt, or even shame, about what had happened to her family that she could not let herself recognize this truth.

I saw my task at that moment as helping Alice to understand David's experience, to recognize that his increasingly frequent battles for control were likely in part due to feeling things were out of control for whole past year. But I needed help Alice recognize this without increasing her guilt and shame. It was a difficult and sensitive procedure.

When I saw them two weeks later, the explosive episodes had significantly decreased. Alice told me that his behavior no longer seemed so bewildering to her. Rather than getting angry, she listened to him, yet set more firm limits. She was delighted with the results and felt proud of her ability to regain a sense of joy and stability in her relationship with her son.

The research coming from the field of infant mental health offers a way to make sense of this change. It gives us a completely different model from DSM for both understanding and treatment.  Ed Tronick, a leading researcher in developmental psychology who is perhaps best known for developing the still face paradigm,  has described mutual regulation model.

The MRM(mutual regulation model) stipulates that caregivers/mothers and infants/children are linked subsystems of a dyadic system and each component, infant and caregiver/mother, regulate disorganization and its costs by a bidirectional process of behavioral signaling and receiving.

The still face paradigm, in which a mother interacts face to face with her infant as she usually would, then for a two minute period presents a completely still face, followed by a reunion episode of resumed face to face interaction, in Dr. Tronick's words "demonstrates the costliness of an experimental disruption of the mutual regulatory process...as it serves as a model for the stress inherent in normal interactions."

In other words, it is impossible to understand the behavior of a child without looking at the behavior in the context of this mutually regulating or dysregulating relationship.

Another leading researcher in the field, Arietta Slade, has written extensively about what is referred to as parental reflective functioning. This is also described as "holding a child's mind in mind."It  refers to a parent's capacity to reflect on the meaning of her child's behavior. Slade, along with other researchers, has shown how enhancing a parent's capacity for reflective functioning is associated with many positive outcomes for a child's emotional development, including flexibility, cognitive resourcefulness and the ability to manage complex social situation.

When things go well in my office, supporting a parent's efforts to reflect upon the meaning of her child's behavior, as I did with David, is simply the point of entry. Once the child feels understood, he becomes calm. Evidence indicates that this change is on a neurobiological basis, occurring at the level of the structures of the brain that produce stress hormones. 

When a child is calm, a parent begins to feel better about herself. In fact, often a child's out of control behavior itself produces a feeling of shame in a parent. When parent and child are more in control, this sense of shame decreases. In turn, when a parent feels less shame, and less stress, she can think more clearly. She is better able to reflect on the meaning of her child's behavior. In turn a child feels even more calm and in control. This is what is meant by mutual regulation.

Any parent-child pair who is suffering in this way deserves to get help.

DSM V might have some role if it is used simply as a way to guide thinking. One of its original aims was to offer a structure for clinicians to recognize similarities and differences among their patients and to talk to one another about them. (The DC 0-3,  a similar document, includes a relationship classification and offers a much more comprehensive model for understanding emotional problems.)

But that is not how it is used. It is essentially a document that rations care.  The issue of the elimination of the diagnosis of Asperger's is a complex one and beyond the scope of this post. However, the frequently made objection that people who have this diagnosis will no longer be eligible for help, supports this way of understanding the DSM. 

If DSM, then, is a care-rationing document, the solution is not to spend years refining the categories. The solution is to improve access to care.