A case of family dysfunction and teenage suicide attempt: applicability of a family systems paradigm.

Koopmans, Matthijs

Family systems models have often been invoked in order to understand a variety of adjustment problems (Bowen, 1960; Minuchin, 1974), such as anorexia (Minuchin, Rosman, & Baker, 1978), and adolescent substance abuse (e.g., Pardeck, 1991). A significant body of empirical literature suggests that suicidal behavior in the teenage years is associated with family processes (Gispert, Wheeler, Marsh, & Davis, 1985; Herman & Hirshman, 1981; Humphrey, French, Niswander, & Casey, 1974; Kosby, Silburn, & Zubrick, 1986; Kreider & Motto, 1974; Molin, 1986; Paluszny, Davenport, & Kim, 1991; Pfeffer, Adams, Weiner, & Rosenberg, 1989; Rosenkrantz, 1978; Schaffer, 1974; Smith & Smith, 1976; Wenz, 1979; William & Lyons, 1976; Wright, 1982), but the question of whether the family systems framework provides a plausible explanation of teenage suicidal behavior has not been explored in great depth.

Resolving this question is of interest because it would enable us to specify how suicidal behavior in adolescence is linked to family contingencies. Moreover, it would enable is to further specify the range of applicability of family systems models. This paper seeks to determine whether existing hypotheses in the family systems literature on the relationship between family processes and mental health in general may be applicable to the suicidal behavior of teenagers in particular.

This analysis focuses on two aspects of the family that have been identified in the literature as dysfunctional processes and which have been linked to the adjustment problems of family members. First, Minuchin and Fishman's (1981) contention that the transgression of boundaries in the family has strong affective responses such as quilt and anxiety is considered. The question to be explored is whether teenage suicidal behavior can also be seen as such an affective response. Second, the applicability of Bateson, Jackson, Haley and Weakland's (1956) double bind hypothesis to teenage suicidal behavior is explored to assess whether teenage suicide can be seen as an indication that the youngster is caught up in contradictory interactive patterns in the family.

To address these questions, the connections between the two concepts within the family systems framework are assessed, and the case of one youngster's suicide attempts are discussed and placed in context to illustrate how double bind contingencies and boundary transgression may contribute to our understanding of how suicidal behavior occurs in adolescence.

Functional and Dysfunctional Family Processes

A systems approach assumes that within any given social unit, relatively autonomous subsystems are formed to optimize adaptive capacity of a larger system (Parsons, Bales, & Shils, 1953; Minuchin, 1974; Minuchin & Fishman, 1981). In families, subsystems typically are formed which define the family structure according to gender (e.g., an alliance which includes grandfather, father, and son), generation (grandparents vs. parents vs. children), and kinship (related vs. not related) (Minuchin & Fishman, 1981, Chap. 2). Family systems can be seen, then, as an overlapping set of alliances which each include certain individual members, and exclude certain others. These subsystems delineate the behavior of particular family members toward particular other family members. For example, a parent and child do not interact in the same way as a husband and wife. Patterns of inclusion and exclusion in the family do not exist in their own right, however, but are actively reinforced by the members of the family system through interaction; the existence of a spousal subsystem, for example, depends on whether two people in a family system actually behave as such. In part, then, the behavior of individuals is assumed to be determined by the structure of the family, while this structure, in turn, is partly determined by the behavior of the individuals who are part of it (Koopmans, 1993). By way of reinforcement of the inclusion patterns, families as well as their individual members create boundaries through which they grant themselves varying degrees of autonomy from, and belonging to, particular subsystems in the family (Minuchin & Fishman, 1981).

In order to be functional, the internal organization of families has to be defined and enforced in such a way that the family is able to carry out its basic functions, such as the care of the offspring and the prevention of incest (Levi-Strauss, 1963; 1969). Functionality in this sense involves the observance of the gender, generation, and kinship boundaries in the interaction among family members (Minuchin & Fishman, 1981). Family dysfunction, conversely, can be defined as a situation in which these distinctions are unclear, confused, or absent (Koopmans, 1992; 1993). If children rather than parents play the role of the primary caretaker, for example, that function is complicated by the confusion of generational boundaries (Kreider & Motto, 1974). Similarly, if sexual relations are maintained between siblings, or between children and their parents, the confusion of kinship boundaries violates incest codes.

A clear distinction of family relations is particularly important for children and adolescents, since the family or primary caretaking environment is the context in which they learn how family relations are classified (Fischer & Watson, 1981) and how these relations are behaviorally reinforced (Koopmans, 1992). In adolescence, moreover, the development toward independence involves a structural transition in which child-adult relations are redefined as adult-adult relations, a transition which, in itself, is typically accompanied by a confused perception of roles on the part of the youngster (Erikson, 1950; 1956).

The possibility that suicidal behavior in adolescence may be associated with role confusion in the family of origin in this sense has been suggested by Kreider and Motto (1974). However, with respect to teenage suicidal ideation and behavior, we have to know why role confusion could lead to suicidal behavior. One possible scenario may be that teenage suicide reflects an inability on the part of the attempter to communicate effectively with significant others as a result of double bind contingencies in the social environment, as has been suggested for schizophrenia by Bateson, Jackson, Haley, and Weakland (1956). Bateson et al. (1956), recognizing the often ambiguous communications in schizophrenic families, proposed the "double bind" hypothesis, which states that (1) contradictory statements in the interaction between persons, who maintain relationships of vital importance about the nature of those relations, renders them unable to respond to each other's basic needs, (2) that prolonged exposure to such communication ultimately detaches this inability from the contingent interactive cues, and (3) that persons caught in double bind situations may develop symptoms of schizophrenia. If the relations which are simultaneously affirmed and denied are of vital importance, the participants of the double bind interactions gradually learn to perceive their universe in double bind patterns. It is argued that the symptoms of schizophrenia reflect such a perceptual accommodation.

Although Bateson et al. are not specific about which particular family members are prone to schizophrenia in the event of double bind interactions, it can be inferred from their theory that the consequences of the simultaneous affirmation and denial of vital relationships is likely to be most dramatic for those who rely most on those relationships for their own preservation, that is, children and adolescents.

The notion that a threat of conflicting statements about relationships to the well-being of individuals locates double bind situations primarily in the family - where the reliance of individuals on those relationships is greatest. Denial of a caretaking relation to a young child, for example, directly threatens the child's survival.

Several attempts have been made to apply Bateson's theory to various clinical syndromes other than schizophrenia (see e.g., Blotcky, Tittler, & Friedman, 1982; Klessman & Klessman, 1983), but the applicability of the model to suicidal behavior in adolescence has not yet been explored.

A case vignette is presented here to illustrate how boundary transgression in the family and double bind interactions may be connected to suicidal behavior. The interview with this youngster was part of a more extensive exploratory study concerning the relation between suicide attempts of youngsters and family processes in a psychiatric inpatient population. The interview was semi-structured and focused on the perception of family relations by the identified patients.

A fifteen-year-old girl was referred to a psychiatric institution because of repeated suicide attempts, and because she became increasingly difficult to handle at home. Her school performance had declined significantly in the last year and a half before referral. In the year before admission to a psychiatric center, she made a total of five suicide attempts. In three instances, these attempts immediately followed quarrels at home; in two instances, they followed a breakup with a boyfriend. An only child, she lived with her mother and grandparents; her parents divorced when she was three years old, and both of her parents moved back to their own parents. The identified patient had been living with her mother and grandparents ever since. She is very close to her mother; they treated each other like sisters, and shared a bedroom. During the interview, she recognized that she and her mother were "the kids" in this family, and she bitterly resented the grandmother's interference in her education. The girl indicated that she wanted to move out of her grandmother's house and find an apartment so she could live with her mother. Her behavior was strongly situationally determined. At the psychiatric center, she was pleasant and sociable; at home, she remained difficult to handle.

Minuchin and Fishman's hypothesis that boundary transgression is accompanied by a strong affective response is illustrated in this case by the resentment of the identified patient toward the grandmother for interfering in her education. The behavior of the grandmother can be seen as boundary transgression in two ways. First, the boundary demarcating mother and child as a separate nuclear family is transgressed, and second, the mother-child alliance is transgressed by the grandmother.

Other instances of boundary transgression in this family are those in which the interaction in which mother and daughter disregard the generational boundary which separates them, such as the instances in which their interaction confirms a siblings alliance (i.e., they treat each other like sisters).

The double bind model would argue in this context that situations in which mother and daughter are ambiguous in their interaction as to whether they are of the same or different generation both affirm and deny a generational distinction. The joint reinforcement of mutually exclusive family roles (e.g., siblings and descent relations) constitutes a double bind situation since reinforcement of one type of relation (e.g., siblings) implies a denial of the other type of relation (e.g., parental).

One can take this one step further and argue that the behavior by the identified patient which asserts autonomy, conforms to the "siblings' alliance" between mother and child, whereas behavior by the patient which expresses the need for supervision, reinforces the mother-child alliance.

If seen as a message communicated to the caretakers, suicide attempts can be viewed as double bind communication as well, messages in which the need for autonomy and the need for parental supervision are simultaneously asserted (see also Kreider & Motto, 1974). The ambiguous nature of suicidal gestures also illustrate their counterproductiveness: they can be seen as an attempt to produce "first order change" (Watzlawick, Weakland, & Fish, 1974) - attempts which, in effect, reinforce existing constellations. In the case discussed, the suicidal gestures assert independence while at the same time stressing the need for caretaking and attention. In the family situation discussed, the ineffectiveness of the mother is underlined by the daughter's suicide attempt, which creates the "need" for additional supervision by the grandmother of both mother and child, while in all likelihood, this supervision has been instrumental in creating the double contingencies, and facilitating the transgression of boundaries to begin with.

DISCUSSION

The present analysis explored the idea that boundary transgressions and double bind interactions may be critical features of the families of suicide attempters, and that suicidal behavior in adolescence may in part reflect the resulting ambiguity in the relationship between the youngster and his or her caretaker(s).

The case discussed illustrates a possible scenario, wherein the occurrence of boundary transgressions is associated with the clarity with which kinship roles and relations are separated in the family. A clear separation of family roles may serve to prevent such transgressions from occurring. Conversely, transgressions in existing constellations or alliances may obfuscate family roles and relations in the interaction between family members.

The ambiguity that results from the confusion of kinship relations manifests itself in double bind interactions - interactions in which the simultaneous confirmation and denial of relations reflects a contradictory pattern of relations in the family. If the relations between the youngster and his or her caretakers is permeated by double bind interactions, it is not inconceivable that the youngster's behavior reflects the ambiguous properties of those interactions. With respect to anorexia nervosa in adolescence, Minuchin, Rosman, and Baker (1978) argued that symptomatic behavior can be seen as a simultaneous appeal for parental supervision, and an assertion of independence from the parents (see also Klessman and Klessman, 1983). Suicidal behavior in adolescence may contain a similar appeal (Kreider & Motto, 1974; Orbach, 1989).

Many factors that previously have been identified as predictors of suicidal behavior in adolescents can be seen as instances of double bind interaction and/or boundary transgression such as, for instance, lack of parental permissiveness in regard to dating (Wright, 1982), experience of incest (Herman & Hirshman (1981), norm confusion in the family (Wenz, 1979), loosening of family ties (McAnamy, 1979), overly close parent-child relationships (Molin, 1986), loss of intimacy (Rosenkrantz, 1978), more conflict and less effective interaction in the family (William & Lyons, 1976; Kosky, Silburn, & Zubrick, 1986), reversal of parent-child roles (Kreider & Motto, 1974), conflicts between mother and her own parents (Pfeffer, Adams, Weiner, & Rosenberg, 1989), and loss of family roles in childhood and adolescence (Humphrey, French, Niswander, & Casey, 1974).

A reported link between teenage suicidal behavior and family contingencies is not necessarily incompatible with the notion that individual characteristics such as aggression (Plutchik, van Praag, & Conte, 1989), depression (Connell & Meyer, 1991), strength of ego identity (Rosenkrantz, 1978), or feelings of helplessness (Pfeffer, 1981) contribute to suicidal behavior. From a family systems perspective, one would argue, however, that the contribution of such factors are mediated by family conflict. It remains to be determined by future research whether double bind, boundary transgression, or the confusion of family roles and relations more generally precede teenage suicidal behavior in a systematic fashion.

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