A case of family dysfunction and teenage suicide attempt:

Applicability of a family systems paradigm

Koopmans, Matthijs.
Adolescence. Roslyn Heights: Spring 1995.Tomo30, Nº 117; pg. 87, 8 pgs

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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A preliminary version of this paper was presented at the Annual Convention of the American Educational
Research Association, Atlanta, GA, April 12, 1993.