VOLUME 54 NUMBER 1
MARCH 2015
Editorial: Relational Diagnosis—An Idea Whose Time Has Come JAY L. LEBOW*
Fam Proc 54:1–5, 2015
T
his issue offers one of the most important collections of articles ever published by Family Process: a special section devoted to relational diagnosis. This section does not in any sense represent the birth of a new concept. Lyman Wynne, David Reiss, and colleagues launched a campaign to establish relational diagnosis in the DSM in the 1980s and 1990s (American Psychiatric Association and Task Force on DSM-IV, 1998) and, subsequent to that effort, Florence Kaslow edited an important book in which numerous contributors described many potential relational diagnoses (Kaslow, 1996). Wynne and colleagues even had success in spurring the inclusion of an axis as part of the DSM-IV (axis 5) focused on assigning a rating of family relational functioning based in “The Global Assessment of Relational Functioning” (Dausch, Miklowitz, & Richards, 1996; Group for the Advancement of Psychiatry Committee, 1996), an instrument they had developed. Yet all of these efforts were preliminary, a precursor to the more detailed scientific study of relational diagnosis. The special section in this issue edited by Marianne Wamboldt demonstrates the remarkable maturation of this body of work over the last two decades. A small group of investigators have asked the question, “What would a rigorous version of how to establish relational diagnosis look like?” and have provided a number of examples. The scope of this work is quite remarkable. They have conducted field studies across 41 international sites and interfaced with both the DSM-V and ICD-11 work groups. The importance of functioning at the level of the system (and its presentation as an alternative to an exclusive focus of what is going on within the individual) has been a cornerstone of family systems theory since its beginnings (Breunlin & Jacobsen, 2014; Combrinck-Graham, 2014; Lebow, 2014), but here we finally see the accumulation of evidence for the salience of various precisely operationalized relational problems. Although some continue to argue that the idea of diagnosis itself is antithetical to family systems concepts and best practice, that minority has shrunk over the years as the practical rele-
*Editor, Family Process, and Family Institute at Northwestern. Correspondence concerning this article should be addressed to Jay Lebow, Ph.D., Family Institute at Northwestern, 618 Library Place, Evanston, IL 60201. E-mail: [email protected]. 1
Family Process, Vol. 54, No. 1, 2015 © 2015 Family Process Institute doi: 10.1111/famp.12141
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FAMILY PROCESS
vance of work such as that described in this section transcends these arguments (Lebow, 2013; Wamboldt, 2013). The principal questions in focus for most today center on how best to form reliable and valid relational diagnoses rather than about whether such assessment is helpful. As Heyman, Slep, and Foran (2015) and Slep, Heyman, and Foran (2015) note in this issue, without a reliable system of assessing and diagnosing problems, such as partner violence or child maltreatment, even the most vital public health problems easily become consigned to secondary attention. Furthermore, having specific diagnoses also opens the door to better funding for treatments for those problems. In the first article in this series, Wamboldt, Kaslow, and Reiss (2015) provide us with a comprehensive overview of this work and its history, as well as its strengths and controversies. They point to the dramatic advances in this field of study, as well as the growth of numerous reliable and valid instruments that have been developed for assessing relational functioning. The subsequent articles describe work about four specific relational diagnoses in detail. Two of the articles focus on problems involving parents and children. Wamboldt, Cordaro, and Clarke (2015) describe efforts to establish criteria for the diagnosis of parent– child relational problem conducted in parallel with the field trial of child diagnoses for the DSM-V. They show that the criteria developed results in reliable and valid diagnosis of this ubiquitous problem. Slep et al. (2015) focus on child maltreatment. They point to the remarkably high prevalence rates of these demoralizing problems: 4–16% across studies within a single year, with rates in some countries reaching one third to half of families. Furthermore, they note that 35–64% of those who meet criteria for child maltreatment engage in more than one type of maltreatment. Like Wamboldt, Cordaro, & Clarke (2015), they show that the criteria they have developed result in the reliable and valid diagnosis of these problems. The remaining two articles center on adult problems in intimate relationships. Foran, Whisman, and Beach (2015) focus on intimate partner relational problem, a difficulty frequently encountered but often assessed in a very fuzzy and imprecise way. They provide answers to the question of what level of relational difficulty differentiates those in the “clinical” range from those within the “normal” range of complaints. They extend Beach and colleagues’ (Beach, Fincham, Amir, & Leonard, 2005) notion of establishing a taxonomic distinction between those who cross a threshold and those who do not to present a simple, reliable, and valid system for classification of this problem. Foran and colleagues also highlight the differences between the sorts of diagnoses made in medical contexts and by mental health providers, noting that 88% of medical providers make primary individual psychiatric diagnoses for those they treat, whereas mental health providers provide diagnoses that are more relational and less often centered on individual DSM categories. In the realm of diagnosis (and treatment), your template is your guide, and treatment contexts where relational problems are seen as off the menu do not focus on relational problems (Lebow & Gordon, 2006). Much as in the paper by Slep and colleagues about child maltreatment, Heyman et al. (2015) offer statistics in their paper about partner violence that should cause us to pause. Rates of significant partner violence range between 12% and 31% across countries with lifetime prevalence rates up to 61%. As with the other problems named here, they call our attention to the existence of what could readily be termed a major epidemic, if only these problems could be more widely recognized. They also show that variants of partner violence can be readily reliably and validly diagnosed, anchored in a combination of qualifying act and impact. The authors even demonstrate much higher reliability for the criteria they have created than those utilized in the DSM for a less specific operationalization of this problem across the 41 sites. The area of relational diagnosis is one in which there has been slow but steady progress over the last two decades. In parallel, as each of the authors note, there has been the www.FamilyProcess.org
LEBOW
/ 3
creation of effective evidence-based treatments focused on these specific problems (Baucom, Belus, Adelman, Fischer, & Paprocki, 2014; Darwiche & de Roten, 2015; Lebow, 2014; Lebow & Stroud, 2013; Retzlaff, von Sydow, Beher, Haun, & Schweitzer, 2013; von Sydow, Retzlaff, Beher, Haun, & Schweitzer, 2013; Von Sydow, Beher, Schweitzer, & Retzlaff, 2010), as well as sophisticated screening tools to assess these and similar problems (Jewell, Carr, Stratton, Lask, & Eisler, 2013; Mansfield, Keitner, & Dealy, 2015; Pinsof et al., 2009; Staccini, Tomba, Grandi, & Keitner, 2015). Relational diagnosis is not perfect. In their overview article, Wamboldt, Kaslow et al. (2015) point to the challenges as well as the strengths of relational diagnosis. Wamboldt, Cordaro et al. (2015) elaborate on the difficulties of deconstructing a relational problem from a child problem when, for example, a child is oppositional, regardless of parental behavior. In a related vein, there remain the problems of reliably assessing family difficulties when a family member displays a severe individual psychiatric or health diagnosis that renders usual ways of envisioning optimal family functioning less relevant (Doherty, McDaniel, & Hepworth, 2014; Hernandez, Barrio, & Yamada, 2013; Suro & Weisman de Mamani, 2013; Valdez, Padilla, Moore, & Maga~ na, 2013; Zhou, Yi, Zhang, & Wang, 2014). There are also complex issues about how to apply standards where cultural context and age sometimes makes a considerable difference (e.g., physical punishment) (Roberts et al., 2014). Yet, such challenges do not mitigate the importance of breaking down the present barrier that exists to the broader acceptance of relational diagnoses. Often today, the almost exclusive focus on individual diagnosis limits the provision of service to many, necessitates unnecessary individual diagnosis to obtain services, and affects treatment planning in ways that move the center of treatment away from the central systemic problem. Nothing has been said here yet about politics. Alas, the now strongly supported evidence-based concept of relational diagnosis put forward here is still in the process of fighting for recognition in care delivery systems predicated on an individual viewpoint of human problems. Yet, as noted by Wamboldt, Kaslow et al. (2015), the authors of this series of articles and others have had considerable success in promoting adoption of relational diagnoses, most especially in ICD-11. The solid foundation in science provided by articles such as these provides the infrastructure for argument in the arena of public policy, as this work helps move the field to clearer concepts and a more precise vocabulary. On a different note, we are very sad to have to add to the editorial in our last issue about the passing of many of the pioneers of family therapy, the death of another of the very few former editors of Family Process, Carol Anderson. Beyond serving as editor in chief of Family Process from 1999 to 2003, Carol made innumerable contributions to the field of family therapy, particularly her development of psycho-educational treatment approaches for families with members with schizophrenia. That work helped change the face of treatment of those with severe mental illness both by family therapists and more broadly in the mental health field. Carol also served as President of the American Family Therapy Academy (AFTA) and as the Administrator of the Western Psychiatric Institute and Clinic (WPIC) and Vice President for Patient and Family Psychiatric Services at the University of Pittsburgh Medical Center. In this capacity, she was one of the few family therapists in the United States to head up a large-scale academic, psychiatric treatment program. Carol was also universally loved and respected, and is already very much missed.
Fam. Proc., Vol. 54, March, 2015
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FAMILY PROCESS
REFERENCES American Psychiatric Association & Task Force on DSM-IV. (1998). Diagnostic and statistical manual of mental disorders: DSM-IV (4th ed.). Washington, DC: American Psychiatric Association. Baucom, D. H., Belus, J. M., Adelman, C. B., Fischer, M. S., & Paprocki, C. (2014). Couple-based interventions for psychopathology: A renewed direction for the field. Family Process, 53(3), 445–461. doi:10.1111/famp.12075. Beach, S. R., Fincham, F. D., Amir, N., & Leonard, K. E. (2005). The taxometrics of marriage: Is marital discord categorical? Journal of Family Psychology, 19(2), 276–285. Breunlin, D. C., & Jacobsen, E. (2014). Putting the “family” back into family therapy. Family Process, 53(3), 462–475. doi:10.1111/famp.12083. Combrinck-Graham, L. (2014). Being a family systems thinker: A psychiatrist’s personal odyssey. Family Process, 53(3), 476–488. doi:10.1111/famp.12090. Darwiche, J., & de Roten, Y. (2015). Couple and family treatments: Study quality and level of evidence. Family Process, 54(1), 138–159. doi:10.1111/famp.12106. Dausch, B. M., Miklowitz, D. J., & Richards, J. A. (1996). Global Assessment of Relational Functioning Scale (GARF): II. Reliability and validity in a sample of families of bipolar patients. Family Process, 35(2), 175–189. Doherty, W. J., McDaniel, S. H., & Hepworth, J. (2014). Contributions of medical family therapy to the changing health care system. Family Process, 53(3), 529–543. doi:10.1111/famp.12092. Foran, H. M., Whisman, M. A., & Beach, S. R. H. (2015). Intimate partner relationship distress in the DSM-5. Family Process, 54(1), 48–63. doi:10.1111/famp.12122. Group for the Advancement of Psychiatry Committee (1996). Global Assessment of Relational Functioning Scale (GARF): I. Background and Rationale. Family Process, 35(2), 155–172. doi:10.1111/j.1545-5300.1996.00155.x. Hernandez, M., Barrio, C., & Yamada, A.-M. (2013). Hope and burden among Latino families of adults with schizophrenia. Family Process, 52(4), 697–708. doi:10.1111/famp.12042. Heyman, R. E., Slep, A. M. S., & Foran, H. M. (2015). Enhanced definitions of intimate partner violence for DSM5 and ICD-11 may promote improved screening and treatment. Family Process, 54(1), 64–81. doi:10.1111/ famp.12121. Jewell, T., Carr, A., Stratton, P., Lask, J., & Eisler, I. (2013). Development of a children’s version of the SCORE index of family function and change. Family Process, 52(4), 673–684. doi:10.1111/famp.12044. Kaslow, F. W. (1996). Handbook of relational diagnosis and dysfunctional family patterns. New York: Wiley. Lebow, J. L. (2013). Editorial: DSM-V and family therapy. Family Process, 52(2), 155–160. doi:10.1111/ famp.12035. Lebow, J. L. (2014). Couple and family therapy: An integrative map of the territory. Washington, DC: APA Books. Lebow, J. L., & Gordon, K. C. (2006). You cannot choose what is not on the menu: Obstacles to and reasons for the inclusion of relational processes in the DSM-V: Comment on the special section. Journal of Family Psychology, 20(3), 432–437. Lebow, J., & Stroud, C. B. (2013). Family therapy. In G. Stricker, T. A. Widiger, & I. B. Weiner (Eds.), Handbook of psychology, Vol. 8: Clinical psychology (2nd ed., pp. 384–407). Hoboken, NJ: John Wiley & Sons Inc. Mansfield, A. K., Keitner, G. I., & Dealy, J. (2015). The family assessment device: An update. Family Process, 54(4), 82–93. doi:10.1111/famp.12080. Pinsof, W. M., Zinbarg, R. E., Lebow, J. L., Knobloch-Fedders, L. M., Durbin, E., Chambers, A. et al. (2009). Laying the foundation for progress research in family, couple, and individual therapy: The development and psychometric features of the initial Systemic Therapy Inventory of Change. Psychotherapy Research, 19(2), 143–156. doi:10.1080/10503300802669973. Retzlaff, R., von Sydow, K., Beher, S., Haun, M. W., & Schweitzer, J. (2013). The efficacy of systemic therapy for internalizing and other disorders of childhood and adolescence: A systematic review of 38 randomized trials. Family Process, 52(4), 619–652. doi:10.1111/famp.12041. Roberts, J., Abu-Baker, K., Diez Fern andez, C., Chong Garcia, N., Fredman, G., Kamya, H. et al. (2014). Up close: Family therapy challenges and innovations around the world. Family Process, 53(3), 544–576. doi:10.1111/ famp.12093. Slep, A. M. S., Heyman, R. E., & Foran, H. M. (2015). Child maltreatment in DSM-5 and ICD-11. Family Process, 54(1), 17–32. doi:10.1111/famp.12131. Staccini, L., Tomba, E., Grandi, S., & Keitner, G. I. (2015). The evaluation of family functioning by the family assessment device: A systematic review of studies in adult clinical populations. Family Process, 54(1), 94–115. doi:10.1111/famp.12098. Suro, G., & Weisman de Mamani, A. G. (2013). Burden, interdependence, ethnicity, and mental health in caregivers of patients with schizophrenia. Family Process, 52(2), 299–311. doi:10.1111/famp.12002. Valdez, C. R., Padilla, B., Moore, S. M., & Maga~ na, S. (2013). Feasibility, acceptability, and preliminary outcomes of the fortalezas familiares intervention for Latino families facing maternal depression. Family Process, 52(3), 394–410. doi:10.1111/famp.12033.
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Von Sydow, K., Retzlaff, R., Beher, S., Haun, M. W., & Schweitzer, J. (2013). The efficacy of systemic therapy for childhood and adolescent externalizing disorders: A systematic review of 47 RCT. Family Process, 52(4), 576– 618. doi:10.1111/famp.12047. Von Sydow, K., Beher, S., Schweitzer, J., & Retzlaff, R. (2010). The efficacy of systemic therapy with adult patients: A meta-content analysis of 38 randomized controlled trials. Family Process, 49(4), 457–485. doi:10.1111/j.1545-5300.2010.01334.x. Wamboldt, M. Z. (2013). Editorial: A brief thought about diagnostic systems and relationship patterns. Family Process, 52(2), 161–162. doi:10.1111/famp.12036. Wamboldt, M., Cordaro, A. Jr, & Clarke, D. (2015). Parent–Child Relational Problem: Field Trial Results, Changes in DSM-5, and Proposed Changes for ICD-11. Family Process, 54(1), 33–47. doi:10.1111/famp.12123. Wamboldt, M., Kaslow, N., & Reiss, D. (2015). Description of relational processes: Recent changes in DSM-5 and proposals for ICD-11. Family Process, 54(1), 6–16. doi:10.1111/famp.12120. Zhou, T., Yi, C., Zhang, X., & Wang, Y. (2014). Factors impacting the mental health of the caregivers of children with asthma in China: Effects of family socioeconomic status, symptoms control, proneness to shame, and family functioning. Family Process, 53(4), 717–730. doi:10.1111/famp.12099.
Fam. Proc., Vol. 54, March, 2015
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MARCH 2015
Editorial: Relational Diagnosis—An Idea Whose Time Has Come JAY L. LEBOW*
Fam Proc 54:1–5, 2015
T
his issue offers one of the most important collections of articles ever published by Family Process: a special section devoted to relational diagnosis. This section does not in any sense represent the birth of a new concept. Lyman Wynne, David Reiss, and colleagues launched a campaign to establish relational diagnosis in the DSM in the 1980s and 1990s (American Psychiatric Association and Task Force on DSM-IV, 1998) and, subsequent to that effort, Florence Kaslow edited an important book in which numerous contributors described many potential relational diagnoses (Kaslow, 1996). Wynne and colleagues even had success in spurring the inclusion of an axis as part of the DSM-IV (axis 5) focused on assigning a rating of family relational functioning based in “The Global Assessment of Relational Functioning” (Dausch, Miklowitz, & Richards, 1996; Group for the Advancement of Psychiatry Committee, 1996), an instrument they had developed. Yet all of these efforts were preliminary, a precursor to the more detailed scientific study of relational diagnosis. The special section in this issue edited by Marianne Wamboldt demonstrates the remarkable maturation of this body of work over the last two decades. A small group of investigators have asked the question, “What would a rigorous version of how to establish relational diagnosis look like?” and have provided a number of examples. The scope of this work is quite remarkable. They have conducted field studies across 41 international sites and interfaced with both the DSM-V and ICD-11 work groups. The importance of functioning at the level of the system (and its presentation as an alternative to an exclusive focus of what is going on within the individual) has been a cornerstone of family systems theory since its beginnings (Breunlin & Jacobsen, 2014; Combrinck-Graham, 2014; Lebow, 2014), but here we finally see the accumulation of evidence for the salience of various precisely operationalized relational problems. Although some continue to argue that the idea of diagnosis itself is antithetical to family systems concepts and best practice, that minority has shrunk over the years as the practical rele-
*Editor, Family Process, and Family Institute at Northwestern. Correspondence concerning this article should be addressed to Jay Lebow, Ph.D., Family Institute at Northwestern, 618 Library Place, Evanston, IL 60201. E-mail: [email protected]. 1
Family Process, Vol. 54, No. 1, 2015 © 2015 Family Process Institute doi: 10.1111/famp.12141
2 /
FAMILY PROCESS
vance of work such as that described in this section transcends these arguments (Lebow, 2013; Wamboldt, 2013). The principal questions in focus for most today center on how best to form reliable and valid relational diagnoses rather than about whether such assessment is helpful. As Heyman, Slep, and Foran (2015) and Slep, Heyman, and Foran (2015) note in this issue, without a reliable system of assessing and diagnosing problems, such as partner violence or child maltreatment, even the most vital public health problems easily become consigned to secondary attention. Furthermore, having specific diagnoses also opens the door to better funding for treatments for those problems. In the first article in this series, Wamboldt, Kaslow, and Reiss (2015) provide us with a comprehensive overview of this work and its history, as well as its strengths and controversies. They point to the dramatic advances in this field of study, as well as the growth of numerous reliable and valid instruments that have been developed for assessing relational functioning. The subsequent articles describe work about four specific relational diagnoses in detail. Two of the articles focus on problems involving parents and children. Wamboldt, Cordaro, and Clarke (2015) describe efforts to establish criteria for the diagnosis of parent– child relational problem conducted in parallel with the field trial of child diagnoses for the DSM-V. They show that the criteria developed results in reliable and valid diagnosis of this ubiquitous problem. Slep et al. (2015) focus on child maltreatment. They point to the remarkably high prevalence rates of these demoralizing problems: 4–16% across studies within a single year, with rates in some countries reaching one third to half of families. Furthermore, they note that 35–64% of those who meet criteria for child maltreatment engage in more than one type of maltreatment. Like Wamboldt, Cordaro, & Clarke (2015), they show that the criteria they have developed result in the reliable and valid diagnosis of these problems. The remaining two articles center on adult problems in intimate relationships. Foran, Whisman, and Beach (2015) focus on intimate partner relational problem, a difficulty frequently encountered but often assessed in a very fuzzy and imprecise way. They provide answers to the question of what level of relational difficulty differentiates those in the “clinical” range from those within the “normal” range of complaints. They extend Beach and colleagues’ (Beach, Fincham, Amir, & Leonard, 2005) notion of establishing a taxonomic distinction between those who cross a threshold and those who do not to present a simple, reliable, and valid system for classification of this problem. Foran and colleagues also highlight the differences between the sorts of diagnoses made in medical contexts and by mental health providers, noting that 88% of medical providers make primary individual psychiatric diagnoses for those they treat, whereas mental health providers provide diagnoses that are more relational and less often centered on individual DSM categories. In the realm of diagnosis (and treatment), your template is your guide, and treatment contexts where relational problems are seen as off the menu do not focus on relational problems (Lebow & Gordon, 2006). Much as in the paper by Slep and colleagues about child maltreatment, Heyman et al. (2015) offer statistics in their paper about partner violence that should cause us to pause. Rates of significant partner violence range between 12% and 31% across countries with lifetime prevalence rates up to 61%. As with the other problems named here, they call our attention to the existence of what could readily be termed a major epidemic, if only these problems could be more widely recognized. They also show that variants of partner violence can be readily reliably and validly diagnosed, anchored in a combination of qualifying act and impact. The authors even demonstrate much higher reliability for the criteria they have created than those utilized in the DSM for a less specific operationalization of this problem across the 41 sites. The area of relational diagnosis is one in which there has been slow but steady progress over the last two decades. In parallel, as each of the authors note, there has been the www.FamilyProcess.org
LEBOW
/ 3
creation of effective evidence-based treatments focused on these specific problems (Baucom, Belus, Adelman, Fischer, & Paprocki, 2014; Darwiche & de Roten, 2015; Lebow, 2014; Lebow & Stroud, 2013; Retzlaff, von Sydow, Beher, Haun, & Schweitzer, 2013; von Sydow, Retzlaff, Beher, Haun, & Schweitzer, 2013; Von Sydow, Beher, Schweitzer, & Retzlaff, 2010), as well as sophisticated screening tools to assess these and similar problems (Jewell, Carr, Stratton, Lask, & Eisler, 2013; Mansfield, Keitner, & Dealy, 2015; Pinsof et al., 2009; Staccini, Tomba, Grandi, & Keitner, 2015). Relational diagnosis is not perfect. In their overview article, Wamboldt, Kaslow et al. (2015) point to the challenges as well as the strengths of relational diagnosis. Wamboldt, Cordaro et al. (2015) elaborate on the difficulties of deconstructing a relational problem from a child problem when, for example, a child is oppositional, regardless of parental behavior. In a related vein, there remain the problems of reliably assessing family difficulties when a family member displays a severe individual psychiatric or health diagnosis that renders usual ways of envisioning optimal family functioning less relevant (Doherty, McDaniel, & Hepworth, 2014; Hernandez, Barrio, & Yamada, 2013; Suro & Weisman de Mamani, 2013; Valdez, Padilla, Moore, & Maga~ na, 2013; Zhou, Yi, Zhang, & Wang, 2014). There are also complex issues about how to apply standards where cultural context and age sometimes makes a considerable difference (e.g., physical punishment) (Roberts et al., 2014). Yet, such challenges do not mitigate the importance of breaking down the present barrier that exists to the broader acceptance of relational diagnoses. Often today, the almost exclusive focus on individual diagnosis limits the provision of service to many, necessitates unnecessary individual diagnosis to obtain services, and affects treatment planning in ways that move the center of treatment away from the central systemic problem. Nothing has been said here yet about politics. Alas, the now strongly supported evidence-based concept of relational diagnosis put forward here is still in the process of fighting for recognition in care delivery systems predicated on an individual viewpoint of human problems. Yet, as noted by Wamboldt, Kaslow et al. (2015), the authors of this series of articles and others have had considerable success in promoting adoption of relational diagnoses, most especially in ICD-11. The solid foundation in science provided by articles such as these provides the infrastructure for argument in the arena of public policy, as this work helps move the field to clearer concepts and a more precise vocabulary. On a different note, we are very sad to have to add to the editorial in our last issue about the passing of many of the pioneers of family therapy, the death of another of the very few former editors of Family Process, Carol Anderson. Beyond serving as editor in chief of Family Process from 1999 to 2003, Carol made innumerable contributions to the field of family therapy, particularly her development of psycho-educational treatment approaches for families with members with schizophrenia. That work helped change the face of treatment of those with severe mental illness both by family therapists and more broadly in the mental health field. Carol also served as President of the American Family Therapy Academy (AFTA) and as the Administrator of the Western Psychiatric Institute and Clinic (WPIC) and Vice President for Patient and Family Psychiatric Services at the University of Pittsburgh Medical Center. In this capacity, she was one of the few family therapists in the United States to head up a large-scale academic, psychiatric treatment program. Carol was also universally loved and respected, and is already very much missed.
Fam. Proc., Vol. 54, March, 2015
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FAMILY PROCESS
REFERENCES American Psychiatric Association & Task Force on DSM-IV. (1998). Diagnostic and statistical manual of mental disorders: DSM-IV (4th ed.). Washington, DC: American Psychiatric Association. Baucom, D. H., Belus, J. M., Adelman, C. B., Fischer, M. S., & Paprocki, C. (2014). Couple-based interventions for psychopathology: A renewed direction for the field. Family Process, 53(3), 445–461. doi:10.1111/famp.12075. Beach, S. R., Fincham, F. D., Amir, N., & Leonard, K. E. (2005). The taxometrics of marriage: Is marital discord categorical? Journal of Family Psychology, 19(2), 276–285. Breunlin, D. C., & Jacobsen, E. (2014). Putting the “family” back into family therapy. Family Process, 53(3), 462–475. doi:10.1111/famp.12083. Combrinck-Graham, L. (2014). Being a family systems thinker: A psychiatrist’s personal odyssey. Family Process, 53(3), 476–488. doi:10.1111/famp.12090. Darwiche, J., & de Roten, Y. (2015). Couple and family treatments: Study quality and level of evidence. Family Process, 54(1), 138–159. doi:10.1111/famp.12106. Dausch, B. M., Miklowitz, D. J., & Richards, J. A. (1996). Global Assessment of Relational Functioning Scale (GARF): II. Reliability and validity in a sample of families of bipolar patients. Family Process, 35(2), 175–189. Doherty, W. J., McDaniel, S. H., & Hepworth, J. (2014). Contributions of medical family therapy to the changing health care system. Family Process, 53(3), 529–543. doi:10.1111/famp.12092. Foran, H. M., Whisman, M. A., & Beach, S. R. H. (2015). Intimate partner relationship distress in the DSM-5. Family Process, 54(1), 48–63. doi:10.1111/famp.12122. Group for the Advancement of Psychiatry Committee (1996). Global Assessment of Relational Functioning Scale (GARF): I. Background and Rationale. Family Process, 35(2), 155–172. doi:10.1111/j.1545-5300.1996.00155.x. Hernandez, M., Barrio, C., & Yamada, A.-M. (2013). Hope and burden among Latino families of adults with schizophrenia. Family Process, 52(4), 697–708. doi:10.1111/famp.12042. Heyman, R. E., Slep, A. M. S., & Foran, H. M. (2015). Enhanced definitions of intimate partner violence for DSM5 and ICD-11 may promote improved screening and treatment. Family Process, 54(1), 64–81. doi:10.1111/ famp.12121. Jewell, T., Carr, A., Stratton, P., Lask, J., & Eisler, I. (2013). Development of a children’s version of the SCORE index of family function and change. Family Process, 52(4), 673–684. doi:10.1111/famp.12044. Kaslow, F. W. (1996). Handbook of relational diagnosis and dysfunctional family patterns. New York: Wiley. Lebow, J. L. (2013). Editorial: DSM-V and family therapy. Family Process, 52(2), 155–160. doi:10.1111/ famp.12035. Lebow, J. L. (2014). Couple and family therapy: An integrative map of the territory. Washington, DC: APA Books. Lebow, J. L., & Gordon, K. C. (2006). You cannot choose what is not on the menu: Obstacles to and reasons for the inclusion of relational processes in the DSM-V: Comment on the special section. Journal of Family Psychology, 20(3), 432–437. Lebow, J., & Stroud, C. B. (2013). Family therapy. In G. Stricker, T. A. Widiger, & I. B. Weiner (Eds.), Handbook of psychology, Vol. 8: Clinical psychology (2nd ed., pp. 384–407). Hoboken, NJ: John Wiley & Sons Inc. Mansfield, A. K., Keitner, G. I., & Dealy, J. (2015). The family assessment device: An update. Family Process, 54(4), 82–93. doi:10.1111/famp.12080. Pinsof, W. M., Zinbarg, R. E., Lebow, J. L., Knobloch-Fedders, L. M., Durbin, E., Chambers, A. et al. (2009). Laying the foundation for progress research in family, couple, and individual therapy: The development and psychometric features of the initial Systemic Therapy Inventory of Change. Psychotherapy Research, 19(2), 143–156. doi:10.1080/10503300802669973. Retzlaff, R., von Sydow, K., Beher, S., Haun, M. 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Fam. Proc., Vol. 54, March, 2015
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