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 teen-age 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 an-orexia 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 (McAnarny, 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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