The importance of paying attention to relationships

May 2018

EDITORIAL: The importance of paying attention to relationships

Vol. 30. No. 2

We live in a paradoxical world. One of the paradoxes is what is happening to relationships in our society and the lack of attention that psychiatry pays to them. By relationship I do not mean the incessant flow of messages and pictures over the many social media platforms. These are social contacts that may have little meaning and could actually worsen relationships among human beings or even have a negative impact on mental health.1 In social terms, a relationship is a close association or bond between two or more individuals and includes kinship, friendship, marriage, and romantic or sexual involvement.

Relationship plays an important role in many mental disorders. As Chambliss and McLeer2 write, “Clinicians cannot understand a per­son’s symptoms out of the context of the individual’s social relationships. Relational problems can precipitate, exacerbate, or perpetuate psychiatric symptoms by their effects on neurobiological and psychological processes” (p 2469). DSM-53 states in similar terms that, “Key relationships, especially intimate adult partner relationships and parent/caregiver-child relationships, have a significant impact on the health of the individuals in these relationships. These relationships can be health promoting and pro­tective, neutral, or detrimental to health outcomes. In the extreme, these close relationships can be associated with maltreatment or neglect, which has significant medical and psychological consequences for the affected individual. A relational problem may come to clinical attention either as the reason that the individual seeks health care or as a problem that affects the course, prognosis, or treatment of the individual’s mental or other medical disorder” (p 715).

These are important and highly relevant clinical issues. I recall two psychiatrists who, decades ago, developed a suicide hotline in Czechoslovakia. Both were amazed that the majority of calls to the hotline involved relational problems, namely marital issues. One of them was so struck by this that he researched relationships and published a number of books on this topic. These days, psychiatrists, with rare exceptions, no longer study relationships or pay much attention to them. We no longer require training in this area. Requirement of at least some experience in marital (or couples) ther­apy has disappeared from the purview of psychiatry.4 Experience with family therapy, with the exception of child and adolescent psychiatry training, is also gone. Trainees, in my experience, limit what they ask about relationship(s) by simply asking whether their patients are married or are partnered. They do not ask about the quality of the patient’s relationships, about reasons for divorce or separation, or about the patient’s relation­ship with his or her children and siblings. We know and emphasize that the doctor–patient relationship (“thera­peutic alliance”) is the best predictor of psychotherapy outcomes, yet I am not convinced that our field properly trains residents on how to develop meaningful doctor– patient relationships. A major textbook2 devotes 8 out of 4,520 pages to relational problems. DSM-5 includes 2 pages of “Relational Problems” in Section III under “Other Conditions That May Be a Focus of Clinical Attention.” In developing DSM-5, there were no work groups that addressed relational problems.

Why is this happening? Is it because our nomencla­ture clearly states that relational problems are not mental disorders3 (p 715)? Or is it because there is no reimburs­able code for any patient’s relational problems, or that addressing relational problems offers little financial com­pensation? Yet, as mentioned, relationship problems may have profound effects on the course, prognosis, and treatment of other mental disorders. Human relations are, in a way, intertwined with mental disorders.

It is time to pay more attention to one of the cru­cial factors of human existence. Our approach to relationship(s) and related problems has to change. Otherwise, we will lose yet another human aspect of psychiatry. And let’s face it: Homo sapiens are basi­cally homo socialis, although not in social media terms or framing.


Richard Balon, MD
Departments of Psychiatry and Behavioral Neurosciences and Anesthesiology
Wayne State University
Tolan Park Building, 3rd floor
3901 Chrysler Service Drive
Detroit, MI 48201 USA

[email protected]



  1. Østergaard SD. Taking Facebook at face value: why the use of social media may cause mental disorder. Acta Psychiatr Scand. 2017;136: 439-440.
  2. Chambliss RB, McLeer SV. Relational problems. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s comprehensive textbook of psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins. 2009;2469-2478.
  3. Diagnostic and statistical manual of mental disorders, 5th ed. Arlington, VA: American Psychiatric Association; 2013.
  4. Balon R. Quo vadis, Psychiatry? Ann Clin Psychiatry 2015;27:161-162.