Family therapy is based on the theory that healthy systems prevent psychological maladjustment. When the family system functions properly, adequate support is available for individuals in the family to make necessary adjustments to most stressors in life. If the stressors are extreme when self, family, and community resources are weak, symptoms are likely to develop in at least one member of the family system. When resources are sufficiently strengthened, symptoms generally disappear, as the individual is now able to respond effectively to stress and/or demands for change. Intervening to strengthen family functioning resources is the most efficient access point because family members then continue on a daily basis to provide the needed support for the individual(s) under stress. If the cause of the stress is within the family functioning, such as family violence, the patterns of dysfunction must be interrupted and displaced with healthy patterns. Family therapists believe that focusing only on the external symptoms caused by internal system stress is misleading and ineffective.
The association of family functioning and individual symptoms has been defined on four levels (Kaslow 1996):
- The problem is solely in the family functioning and is not manifesting individual symptoms in family members.
- The problem is primarily in the family functioning but individual symptoms are clearly resulting from the family problem.
- The problem is primarily individual but does have critical family functioning components to effectively understand and treat.
- The problem is primarily individual but treating the family functioning component greatly enhances the treatment outcome.
Even if the family functioning is not the cause of the problem, it is a vital component to planning effective treatment. Insurance companies authorizing treatment have not yet understood this. They still require diagnoses based on individual symptoms described in the Diagnostic and Statistical Manual of Mental Disorders.
Understanding the DSM-IV Classification System
The Diagnostic and Statistical Manual of Mental Disorders (DSM) classification system of the American Psychiatric Association (APA) attempts to unify language about mental disorders. This classification system developed from the need to collect statistical information. Roots of the DSM reach back before the publication of the first DSM in 1952 as a clinical parallel of the International Classification of Diseases (ICD-6) adopted by the World Health Organization (WHO) in 1948. Nineteenth-century census data did not have adequate categories to describe mental illnesses. In 1917, the APA expanded the classification concept to gathering uniform statistics across mental hospitals. After World War II, the Veterans Administration expanded the nomenclature developed by the APA to include more outpatient presentations of servicemen and veterans. This clinical utility focus continued and incorporated more research with each publication: DSM-I in 1952, DSM-II in 1968, DSM-III in 1980, DSM-III-R in 1987, DSM-IV in 1994, and DSM-IVTR in 2000. Unfortunately, the wide acceptance of the DSM as the full and complete picture of mental illness overlooks the value of family therapy theories regarding the underlying diagnosis and treatment of symptomatic behavior.
DSM-IV is designed to facilitate clinical and research shared language. Special efforts have been made to address the impact of culture: where relevant, a special paragraph is devoted to cultural variations within the text describing each diagnosis; the appendix includes a description of culturally related syndromes that have not been included in the DSM classification system; and the appendix includes a brief discussion of steps the clinician can take in determining impact of culture on the diagnosis. The DSM-IV is organized for making diagnoses using the following guidelines:
- Axis I: Clinical disorders and other conditions that may be a focus of clinical attention (including V codes);
- Axis II: Personality disorders and mental retardation;
- Axis III: General medical conditions;
- Axis IV: Psychosocial and environmental problems; and
- Axis V: Global assessment of functioning scale (GAF).
Perhaps because of the DSM's roots in the medical model and its wide acceptance as the standard, current insurance coverage of behavioral health/mental illness as a medical problem, and the relatively new systems theory and research, a true family systems model of understanding mental illness has not yet been included in the DSM classification. Axis IV identifies psychosocial and environmental problems that may affect diagnosis and treatment, but insurance companies will not provide coverage without an Axis I diagnosis. Family problems are identified on Axis IV in the category Problems with Primary Support Group. Family functioning problems can be identified on Axis I with diagnoses under the category Other Conditions That May Be a Focus of Clinical Attention; however, the V codes V61.20 (Parent-Child Relational Problem), V61.1 (Partner Relational Problem), V61.8 (Sibling Relational Problem), V61.21 (Child Abuse), and V61.1 (Adult Abuse) alone are generally not considered to be medical problems covered by insurance. The policies of insurance companies tend to shape the thinking of clinicians and consequently researchers. Thus, a linear medical model of simplistic static answers to complex dynamic problems is reinforced.
In preparation for the DSM-IV, work began among professionals (Group for the Advancement of Psychiatry (GAP) Committee on the Family 1996; Kaslow 1993) to construct new classification schemas for family functioning. Work begun by the 1986 GAP Committee on the Family—later joined by the Coalition on Family Diagnosis (with members from fourteen different organizations)— resulted in the Global Assessment of Relational Functioning (GARF) being included in the DSM-IV appendix under the category Criteria Sets and Axes Provided for Further Study. The two new schemas for family functioning were a rated comprehensive range of functioning (the GARF as a dimensionalized rating parallel to the GAF individual functioning now used on Axis V) and a categorical identification of functioning (Classification of Relational Diagnoses [CORD]) parallel to the discrete descriptive diagnoses of individual disorders now used on Axes I and II). (For more on GARF and these classification schemas, see next section, below.) However, work on the CORD was not completed in time for DSM-IV. Recommendations in the DSM-IV note that the GARF can be included along with the GAF on Axis V. This inclusion was a significant change in attitude of the APA; professionals recognized the need for the development of a systems method for understanding mental illness. However, the challenge has fallen to family therapists to provide the necessary research to verify the concepts in systemic diagnosis/assessment and treatment/intervention before DSM-V is published.
As the only truly systemic family relations diagnostic tool to be included in the DSM-IV, the GARF was developed by leaders in the field of family assessment. It was intended to be simple to learn and use. However, a basic understanding of family systems functioning seems to be necessary in order to accurately interpret the rating. In the DSM-IV (1996) appendix describing the GARF, the dimensionalized scale (1–100) is grouped into five twenty-point categories ranging from, at the top of the scale, "81–100 Overall. Relational unit is functioning satisfactorily from self-report of participants and from perspectives of observers" (p. 758) to "1–20 Overall. Relational unit has become too dysfunctional to retain continuity of contact and attachment" (p. 759) at the bottom. These ratings are based on three basic variables that describe system functioning (DSM-IV 1994, p. 758):
- Problem solving—skills in negotiating goals, rules, and routines; adaptability to stress; communication skills; ability to resolve conflict.
- Organization—maintenance of interpersonal roles, subsystem boundaries, and hierarchical functioning; coalitions and distribution of power, control, and responsibility.
- Emotional climate—tone and range of feelings; quality of caring, empathy, involvement, and attachment/commitment; sharing of values; mutual affective responsiveness, respect, and regard; quality of sexual functioning.
These variables may be considered the organizational structure of a system with certain rules about who does what, when, where, and why; the communication processes that develop, sustain, and adapt those structural guidelines; and the emotional result of family members feeling safe, supported, heard, and understood. Lynelle Yingling and her colleagues (1998) helped pilot test the GARF for the DSM-IV, and continued research on the GARF in the doctoral clinic for Ph.D. interns in family therapy at Texas A&M University-Commerce. Clinical experience indicated that the GARF had greater usefulness when the three variables were measured separately rather than being combined as a global rating as directed in the DSM-IV. Models of family therapy intervention strategies can be correlated with each of the variables. When the organizational structure is unstable or rigidly distorted, working to get the structure realigned and stabilized is the goal of therapy. Examples of distortion are the parentification of children, unequal spousal power resulting in overt or covert power struggles, and adults still being tied to their biological parents in a child role rather than free to act as adults. When the structure is functioning normally but the communication skills are weak, focusing on learning to communicate effectively is the therapeutic goal. Several models have been developed to enhance open, clear, understandable, and accepted communication among family members. When both of those system dimensions are in need of help, all relevant goals for system change are integrated into the therapy. When the system is functioning normally, the Axis I symptoms of depression/substance abuse (from not being able to communicate fears and feel heard), anxiety (from organizational instability), and conduct disorder/family violence (from organizational distortion) will likely disappear. Axis II personality disorders (possibly from being raised in a chaotic family system) are much more difficult to eliminate because the relational patterns have been deeply engrained in the developmental process during childhood.
Family Therapy Theorists' Concerns About Using the DSM Diagnosis System
Because family therapists provide services for clients covered by insurance contracts, family therapy effectiveness is limited by the requirements of the insurance company to assign an individual diagnosis in order to be paid. In family therapy theory, a primary goal is to reframe the presenting individual symptom as a family system problem that takes the blame off the individual and creates a team approach for solving the problem. Placing an individual diagnosis on the insurance claim runs counter to successfully depathologizing and reframing the problem. If the family therapist tries to explain the reason for an individual diagnosis, the communication does not make logical sense to the client, thus creating dysfunctional communication in the therapist-client system. If an individual in the family does not meet criteria for an individual DSM diagnosis but the therapy will not be covered without a diagnosis, what is the therapist to do?
The courts are another payer requiring the use of DSM in order to be accepted as a professional. Scientific evidence is required to substantiate expert testimony in legal cases. The DSM system has the most scientific evidence of any classification system used. Thus, it is the preferred evidence resource in court.
Even if insurance companies and courts were enlightened about the efficiency of family therapy and accepted family functioning diagnoses as sufficient, many family therapists would see using a family diagnosis as unethical (Becvar and Becvar 2000; Denton 1989; Denton 1990; Strong 1993). According to the constructivist philosophy of family therapy, classifying human behavior is seen as limiting the possibilities for growth, and consequently harmful. Using a pathology-based medical model—such as the DSM—is even more limiting in effect. Another dilemma is the lack of consensus among family therapists on how to diagnose family functioning. One goal of the GARF development was to create a consensus in the field concerning an accepted model of family assessment.
Continuous Improvement Options
If there is an inherent tension between family therapists and the current DSM-IV requirements, how can the tension be resolved? One option is to work within the DSM system to incorporate family assessment using the GARF and the CORD, as well as enhancement of Axis IV psychosocial stressor definitions. A unified effort will be required to achieve this goal in DSM-V. Another option is to develop a separate, parallel classification system. Several options are discussed in Florence Kaslow's (1996) Handbook of Relational Diagnosis and Dysfunctional Family Patterns. Perhaps a third option is for family therapists to abandon the use of diagnosing and participation in the current insurance and court testimony requirements (Becvar and Becvar 2000). Professionals could make a greater effort to educate insurance companies and courts about the efficiency of family therapy without diagnosis; some Employee Assistance Programs (EAP) accept this premise. If education were unsuccessful, moving away from payment by insurance and/or courts and accepting the financial risk of serving only self-paying clients would be a dramatic way for family therapists to make a statement consistent with systemic beliefs.
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lynelle c. yingling