An adult's psychological health and sense of well-being depend to a significant degree on the quality of his or her important relationships—that is, on patterns of interaction with a partner and children, parents and siblings, and friends and colleagues. Problems in the interaction between any of these significant others can lead to clinical symptoms and impaired functioning among one or more members of the relational unit. Relational problems may be a focus of clinical attention (1) when a relational unit is distressed and dysfunctional or threatened with dissolution and (2) when the relational problems precede, accompany, or follow other psychiatric or medical disorders. Indeed, other medical or psychiatric symptoms can be influenced by the relational context of the patient. Conversely, the functioning of a relational unit is affected by a member's general and other medical or psychiatric illness. Relational disorders require a different clinical approach than other disorders. Instead of focusing primarily on the link between symptoms, signs, and the workings of the individual mind, the clinician must also focus on interactions between the individuals involved and how these interactions are related to the general and other medical or psychiatric symptoms in a meaningful way.
Definition
According to the text revision of the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), relational problems are patterns of interaction between members of a relational unit that are associated with symptoms or significantly impaired functioning in one or more individual members or with significantly impaired functioning of the relational unit itself. DSM-IV-TR distinguishes five categories of relational problems: (1) relational problem related to a mental or general medical condition; (2) parent–child relational problem; (3) partner relational problem; (4) sibling relational problem; and (5) relational problem not otherwise specified.
Epidemiology
No reliable figures are available on the prevalence of relational problems. They can be assumed to be ubiquitous; however, most relational problems resolve without professional intervention. The nature, frequency, and effects of the problem on those involved are elements that must be considered before a diagnosis of relational problem is made. For example, divorce, which occurs in just under 50 percent of marriages, is a problem between partners that is resolved through the legal remedy of divorce and need not be diagnosed as a relational problem. If the persons cannot resolve their disputation and continue to live together in a sadomasochistic or pathologically depressed relationship with unhappiness and abuse, then they should be so labeled. Relationship problems between involved persons that cannot be resolved by friends, family, or clergy require professional intervention by psychiatrists, clinical psychologists, social workers, and other mental health professionals.
Relational Problem Related to a Mental Disorder or General Medical Condition
According to DSM-IV-TR, the category of relational problem related to a mental disorder or general medical condition “should be used when the focus of clinical attention is a pattern of impaired interaction associated with a psychiatric disorder or a general medical condition in a family member.â€
Studies indicate that satisfying relationships may have a health-protective influence, whereas relationship distress tends to be associated with an increased incidence of illness. The influence of relational systems on health has been explained through psychophysiological mechanisms that link the intense emotions generated in human attachment systems to vascular reactivity and immune processes. Thus, stress-related psychological or physical symptoms can be an expression of family dysfunction.
Adults must often assume responsibility for caring for aging parents while they are still caring for their own children, and this dual obligation can create stress. When adults take care of their parents, both parties must adapt to a reversal of their former roles, and the caretakers not only face the potential loss of their parents, but also must cope with evidence of their own mortality.
Some caretakers abuse their aging parents—a problem that is now receiving attention. Abuse is most likely to occur when the caretaking offspring have substance abuse problems, are under economic stress, and have no relief from their caretaking duties, or when the parent is bedridden or has a chronic illness requiring constant nursing attention. More women are abused than men, and most abuse occurs in persons over age 75.
The development of a chronic illness in a family member stresses the family system and requires adaptation by both the sick person and the other family members. The person who has become sick must frequently face a loss of autonomy, an increased sense of vulnerability, and sometimes a taxing medical regimen. The other family members must experience the loss of the person as he or she was before the illness, and they usually have substantial caretaking responsibility—for example, in debilitating neurological diseases, including dementia of
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the Alzheimer's type, and in diseases such as acquired immunodeficiency syndrome (AIDS) and cancer. In these cases, the whole family must deal with the stress of prospective death as well as the current illness. Some families use the anger engendered by such situations to create support organizations, increase public awareness of the disease, and rally around the sick member. But chronic illness frequently produces depression in family members and can cause them to withdraw from, or attack, one another. The burden of caring for ill family members falls disproportionately on the women in a family—mothers, daughters, and daughters-in-law.
Chronic emotional illness also requires major adaptations by families. For instance, family members may react with chaos or fear to the psychotic productions of a family member with schizophrenia. The regression, exaggerated emotions, frequent hospitalizations, and economic and social dependence of a person with schizophrenia can stress the family system. Family members may react with hostile feelings (referred to as expressed emotion) that are associated with a poor prognosis for the person who is sick. Similarly, a family member with bipolar I disorder can disrupt a family, particularly during manic episodes.
Family devastation can occur when illness (1) suddenly strikes a previously healthy person, (2) occurs earlier than expected in the life cycle (some impairment of physical capacities is expected in old age, although many older persons are healthy), (3) affects the economic stability of the family, and (4) when little can be done to improve or ease the condition of the sick family member.
Parent–Child Relational Problem
Parents differ widely in sensing the needs of their infants. Some quickly note their child's moods and needs; others are slow to respond. Parental responsiveness interacts with the child's temperament to affect the quality of the attachment between child and parent. According to DSM-IV-TR, the diagnosis of parent–child relational problem applies when the focus of clinical attention is a pattern of interaction between parent and child that is associated with clinically significant impairment in individual or family functioning or with clinically significant symptoms. Examples include impaired communication, overprotection, and inadequate discipline.
Research on parenting skills has isolated two major dimensions: (1) a permissive-restrictive dimension and (2) a warm-and-accepting versus cold-and-hostile dimension. A typology that separates parents on these dimensions distinguishes between authoritarian (restrictive and cold), permissive (minimally restrictive and accepting), and authoritative (restrictive as needed, but also warm and accepting) parenting styles. Children of authoritarian parents tend to be withdrawn or conflicted; those of permissive parents are likely to be more aggressive, impulsive, and low achievers; and children of authoritative parents seem to function at the highest level, socially and cognitively. Yet, switching from an authoritarian to a permissive mode may create a negative reinforcement pattern.
Difficulties in many situations stress the usual parent–child interaction. Substantial evidence indicates that marital discord leads to problems in children, from depression and withdrawal to conduct disorder and poor performance at school. This negative effect may be partly mediated through triangulation of the parent–child relationships, which is a process in which conflicted parents attempt to win the sympathy and support of their child, who is recruited by one parent as an ally in the struggle with the partner. Divorces and remarriages stress the parent–child relationship and may create painful loyalty conflicts. Stepparents often find it difficult to assume a parental role and may resent the special relationship that exists between their new marital partner and the children from that partner's previous marriages. The resentment of a stepparent by a stepchild and the favoring of a natural child are usual reactions in a new family's initial phases of adjustment. When a second child is born, both familial stress and happiness may result, although happiness is the dominant emotion in most families. The birth of a child can also be troublesome when parents had adopted a child in the belief that they were infertile. Single-parent families usually consist of a mother and children, and their relationship is often affected by financial and emotional problems.
Other situations that can produce a parent–child problem are the development of fatal, crippling, or chronic illness, such as leukemia, epilepsy, sickle-cell anemia, or spinal cord injury, in either parent or child. The birth of a child with congenital defects, such as cerebral palsy, blindness, and deafness, may also produce parent–child problems. These situations, which are not rare, challenge the emotional resources of those involved. Parents and child must face present and potential loss and must adjust their day-to-day lives physically, economically, and emotionally. These situations can strain the healthiest families and produce parent–child problems not only with the sick person but also with the unaffected family members. In a family with a severely sick child, parents may resent, prefer, or neglect the other children because the ill child requires so much time and attention.
Parents with children who have emotional disorders face particular problems, depending on the child's illness. In families with a child with schizophrenia, family treatment is beneficial and improves the social adjustment of the patient. Similarly, family therapy is useful when a child has a mood disorder. In families with a substance-abusing child or adolescent, family involvement is crucial to help control the drug-seeking behavior and to allow family members to verbalize the feelings of frustration and anger that are invariably present.
Normal developmental crises can also be related to parent–child problems. For instance, adolescence is a time of frequent conflict, as the adolescent resists rules and demands increasing autonomy, and, at the same time, elicits protective control by displaying immature and dangerous behavior.
The parents of sons aged 18, 15, and 11 years presented with distress about the behavior of their middle child. The family had been cohesive with satisfactory relationships among all members until 6 months before this consultation. At that time, the 15-year-old began seeing a girl from a comparatively unsupervised household. Frequent arguments had developed between parents and son regarding going out on school nights, curfews, and neglect of schoolwork. The son's combativeness and lowered academic achievement upset his parents a great deal. They had not experienced similar conflicts with their oldest child. The adolescent, however, maintained a good relationship with his siblings and friends, was not a behavior problem at school, continued to participate on the school basketball team, and was not a substance user.
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Day Care Centers
Quality of care during the first 3 years of life is crucial to neuropsychological development. A 1997 study from the National Institute of Child Health and Human Development indicated that day care was not harmful to children, when the caregivers and day care teachers provided consistent, empathetic, nurturing care. Not all day care centers can meet that level of care, however, especially those located in poor urban areas. Children receiving less than optimal caring exhibit decreased intellectual and verbal skills that indicate delayed neurocognitive development. They may also become irritable, anxious, or depressed, which interferes with the parent–child bonding experience, and they are less assertive and less effectively toilet trained by the age of 5.
Currently, more than 55 percent of women are in the work force, many of whom have no choice but to place their children in day care centers. Approximately 40 percent of entering medical students are women; few medical centers, however, make adequate provisions for on-site day care centers for their students or staff. Similarly, corporations need to provide on-site, high-quality care for the children of their employees. Not only will that approach benefit the children, but also corporate economic benefits will accrue as a result of reduced absenteeism, increased productivity, and happier working mothers. Such programs have the added benefit of decreasing stresses on marriages.
Partner Relational Problem
According to DSM-IV-TR, clinicians should use the category partner relational problem when the focus of clinical attention is a pattern of interaction between the spouses or partners. These patterns are characterized by negative communication (e.g., criticisms), distorted communication (e.g., unrealistic expectations), or noncommunication (e.g., withdrawal), associated with clinically significant impairment in individual or family functioning or symptoms in one or both partners.
When persons have partner relational problems, psychiatrists must assess whether a patient's distress arises from the relationship or from a mental disorder. Mental disorders are more common in single persons—those who never married or who are widowed, separated, or divorced—than among married persons. Clinicians should evaluate developmental, sexual, and occupational and relationship histories, for purposes of diagnosis. (Divorce is discussed in Chapter 2, Section 2.4, and couples therapy is discussed in Chapter 35, Section 35.4.)
Marriage demands a sustained level of adaptation from both partners. In a troubled marriage, a therapist can encourage the partners to explore areas such as the extent of communication between the partners, their ways of solving disputes, their attitudes toward child-bearing and child-rearing, their relationships with their in-laws, their attitudes toward social life, their handling of finances, and their sexual interaction. The birth of a child, an abortion or miscarriage, economic stresses, moves to new areas, episodes of illness, major career changes, and any situations that involve a significant change in marital roles can precipitate stressful periods in a relationship. Illness in a child exerts the greatest strain on a marriage, and marriages in which a child has died through illness or accident more often than not end in divorce. Complaints of lifelong anorgasmia or impotence by marital partners usually indicate intrapsychic problems, although sexual dissatisfaction is involved in many cases of marital maladjustment.
Adjustment to marital roles can be a problem when partners are from different backgrounds and have grown up with different value systems. For example, members of low socioeconomic status groups perceive a wife as making most of the decisions in the family, and they accept physical punishment as a way to discipline children. Middle-class persons perceive family decision-making processes as shared, with the husband often being the final arbiter, and they prefer to discipline children verbally. Problems involving conflicts in values, adjustment to new roles, and poor communication are handled most effectively when therapist and partners examine the couple's relationship, as in marital therapy.
Epidemiological surveys show that unhappy marriages are a risk factor for major depressive disorder. Marital discord also affects physical health. For example, in a study of women aged 30 to 65 years with coronary artery disease, marital stress worsened the prognosis 2.9 times for recurrent coronary events. Marital conflict was also associated with a 46 percent higher relative death risk among female patients having hemodialysis, and with elevations in serum epinephrine, norepinephrine, and corticotrophin levels in both men and women. In one study, high levels of hostile marital behavior were associated with slower healing of wounds, lower production of proinflammatory cytokines, and higher cytokine production in peripheral blood. Overall, women show greater psychological and physiological responsiveness to conflict than men.
Physician Marriages
Physicians have a higher risk of divorce than other occupational groups. The incidence of divorce among physicians is about 25 to 30 percent. Specialty choice influenced divorce. The highest rate of divorce occurred in psychiatrists (50 percent), followed by surgeons (33 percent) and internists, pediatricians, and pathologists (31 percent). The average age at first marriage was 26 years among all groups.
It is not clear why physicians are at high risk for divorce. Factors implicated include the stresses of dealing with dying patients, making life-and-death decisions, working long hours, and the constant risk of malpractice litigation. Such stressors may predispose physicians to a variety of emotional ills, with the most common being depression and substance abuse, including alcoholism. Such persons generally cannot deal with the complex interactions required to maintain successful long-term relationships of any kind, and marriage requires the most interpersonal skills of all.
Sibling Relational Problem
According to DSM-IV-TR, the category of sibling relational problem “should be used when the focus of clinical attention is a pattern of interaction between siblings, associated with clinically significant impairment of family functioning, or symptoms in one or more of the siblings.â€
Sibling relationships tend to be characterized by competition, comparison, and cooperation. Intense sibling rivalry can occur with the birth of a child and can persist as the
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children grow up, compete for parental approval, and measure their accomplishments against one another. Alliances between siblings are equally common. Siblings may learn to protect one another against parental control or aggression. In households with three children, one pair tends to become closely involved with one another, leaving the extra child in the position of outsider.
Relational problems can arise when siblings are not treated equally; for instance, when one child is being idealized, while another is cast in the role of the family scapegoat. Differences in gender roles and expectations expressed by the parents can underlie sibling rivalry. Parent–child relationships also are dependent on personality interactions. A child's resentment directed at a parental figure or a child's own disavowed dark emotions can be projected onto a sibling and can fuel an intense hate relationship.
A child's general, other medical or psychiatric condition always stresses the sibling relationships. Parental concern and attention to the sick child can elicit envy in the siblings. In addition, chronic disability can leave the sick child feeling devalued and rejected by siblings, and the latter may develop a sense of superiority and may feel embarrassed about having a disabled sister or brother.
Relational Problem not Otherwise Specified
According to DSM-IV-TR, the category of relational problem not otherwise specified “should be used when the focus of clinical attention is on relational problems not classifiable by any of the specific problems above (e.g., difficulties with superiors and coworkers).â€
People, across the life cycle, may become involved in relational problems with leaders and others in their community at large. In such relationships, conflicts are common and can bring about stress-related symptoms. Many relational problems of children occur in the school setting and involve peers. Impaired peer relationships can be the chief complaint in attention-deficit or conduct disorders, as well as in depressive and other psychiatric disorders of childhood, adolescence, and adulthood.
Racial, ethnic, and religious prejudices and ignorance cause problems in interpersonal relationships. In the workplace and in communities at large, sexual harassment is often a combination of inappropriate sexual interactions, inappropriate displays of abuse of power and dominance, and expressions of negative gender stereotypes, primarily toward women and gay men, although also toward children and adolescents of both sexes.
