Gender Conformity and Suicide: A Case Study Integrating Structural Family Therapy and Satir Experiential Therapy

Abstract

Recent studies have shown that suicidality among transgender youth are 3.6 times more likely to report suicidal ideation and 3.2 times more likely to attempt suicide compared with cisgender youth. To alleviate the suicide rates among transgender youth, research suggests the need for family-based interventions. This case study explores the integration of structural family therapy and the Satir growth model to increase connection and support within the family, while also creating clear boundaries that are protective and growth-enhancing. This study provides a session by session overview of how the therapist integrated the models while working with the entire family unit.

Keywords

suicidality transgender family therapy family-based intervention

1 Theoretical and Research Basis for Treatment

Suicide is one of the leading causes of death across all age groups, and the sharpest increase in suicide rates occur between adolescence and young adulthood (World Health Organization [WHO], 2017). More specifically, suicidality among transgender youth is severe as recent studies have reported that, compared with cisgender youth (gender identity corresponds with assigned sex at birth), transgender youth are more than 3.6 times more likely to report suicidal ideation and 3.2 times more likely to attempt suicide (Reisner, Vetters, et al., 2015). Other studies have estimated that transgender youth have higher rates of depression, self-harm, and suicidality when compared with cisgender youth (Connolly et al., 2016).

Transgender, trans, or gender nonconforming behaviors (TGNC) are terms used to describe a person whose personal identity and gender do not align with their assigned sex at birth (Grossman et al., 2016). This includes individuals whose gender identity corresponds with the other sex (i.e., an individual who was assigned female at birth but who identifies as a boy or male). Despite the increase in acknowledging the TGNC community in society, safety and protection are foreign concepts to TGNC youth as they are more likely to report violence victimization (e.g., forced to have sexual intercourse) when compared with cisgender youth (Johns et al., 2019). As TGNC youth navigate the discrimination and lack of safety in society, they are also faced with a lack of connection at school, and more importantly, their family (Newcomb et al., 2019). In an effort to alleviate the suicide rates among the youth population, some research suggests the need for family-based interventions (Frey & Hunt, 2017); however, much of this research is not specific to LGBTQ-IA (lesbian, gay, bisexual, transgender, queer/questioning, intersex, and asexual) youth but rather emphasizes a general sample of adolescents. This case study seeks to illustrate the utilization of effective family-based interventions with a TGNC youth struggling with suicidality.

Transgender Youth and Suicidality

Among the LGBTQ-IA youth population, higher rates of suicidality correlate with underlying mental health concerns (Russell & Fish, 2016). A TGNC youth may present with high suicidality with underlying depressive and anxiety symptoms (Baams et al., 2015). One study specifically examining TGNC youth at an adolescent urban community health center illustrated that TGNC youth were at a greater risk of 2 to 3 times for depression, anxiety disorder, and suicide attempts when compared with cisgender groups (Reisner, Greytak, et al., 2015). Furthermore, TGNC youth face harassment and fear of rejection on a daily basis, which in turn may lead to emotional and social problems (Russell & Fish, 2016). For example, a study that surveyed TGNC students found that a majority of the students (N = 709) reported experiencing verbal harassment (60.9%), physical harassment (32.5%), and physical assault (e.g., hit, kicked, or injured with a weapon) (15.5%) based on their sexual orientation and gender expression (Kosciw et al., 2014).

TGNC youth experience numerous challenges in society as well as the potential for opposition and rejection from their family (Russell & Fish, 2016). Numerous TGNC youth may lack clarity on whether their parents will support and accept their gender expression, which often leads to psychological stress (Simons et al., 2013). A study that examined the perceptions of ambiguity around acceptance and support within a TGNC youth’s family found that higher perceptions of ambiguity link to higher rates of psychological stress (e.g., anxiety, depression; Catalpa & McGuire, 2018). Developing evidence suggests that there are connections between family support and overall well-being for TGNC youth (Katz-Wise et al., 2017). According to the minority stress model, experiences of oppression, victimization, rejection, and transgender-related stigma accrue over time, eventually leading to poor physical and mental health, which may include suicidality (Bockting et al., 2013). Although these studies highlight the severity of suicidality and minority stresses among TGNC youth, the direct means for helping reduce suicidality and minority stress remains elusive (Grossman et al., 2016).

Intervention of TGNC Youth With Suicidal Ideation

Although research has grown tremendously related to the health of TGNC youth, there is still limited research regarding mental health (Connolly et al., 2016). TGNC youth often experience discrimination and oppression, as well as a lack of competent and affirmative care in mental health settings (Grant et al., 2011). This discrimination and oppression present in mental health settings fosters a lack of trust, which in turn hinders TGNC youth from seeking help and viewing their therapist as an advocate (Barker & Wylie, 2008).

A majority of treatments for TGNC youth focus on working primarily with the TGNC youth rather than including the entire family (Coolhart & Shipman, 2017). When a TGNC youth presents to therapy with suicidality, treatment approaches often begin with transgender affirmative practice and a comprehensive psychological exam followed by behavioral interventions that may progress to the steps for gender reassignment surgery (Shumer & Spack, 2013). Gender-affirming therapy is an approach where mental health professionals advocate for and believe that clinicians should not consider pathology when working with diverse gender-expressions and identities (Shires et al., 2018). For example, a study that utilized cognitive behavioral therapy (CBT) integrated a transgender affirmative approach (TA-CBT) and found that this approach helped reduce depressive symptoms and suicidality among a TGNC who presented with high suicidal ideation (Austin & Craig, 2015). Similarly, other studies that have utilized a gender-affirming approach found that psychological functioning improved, and emotional and behavioral problems were less after a year of treatment (Colizzi et al., 2014). Although some of these interventions are effective, some studies suggest the need for family-based interventions as research has found that TGNC youth who experience family rejection are more likely to have higher suicide attempts (57%) when compared with participants who report strong family connection (31%; Grant et al., 2011).

Overall, a major criticism of the most common treatment approaches when working with TGNC youth who present with suicidality is that therapy does not include the family, which may perpetuate the lack of connection and support within their family (Austin, & Craig, 2015). In contrast, structural family therapy emphasizes utilizing the entire family to create change and restructure the family to promote growth for all individuals (Minuchin & Fishman, 1981). Previous research has found that parental acceptance predicts reduced depression in the TGNC youth population (Bariola et al., 2015). Structural family therapy emphasizes increasing parental support by creating clear boundaries that are protective and growth enhancing, to increase a TGNC youth’s well-being (Katz-Wise et al., 2017). This approach can be helpful to TGNC youth who are faced daily with a hostile society that hinders growth as structural family therapy emphasizes the need to boost family support.

TGNC youth struggle to find places and people where they can authentically share their gender expression (Reisner, Vetters, et al., 2015). Virginia Satir’s human growth model (e.g., Satir experiential therapy) values authentic self-expression and avoids viewing sexuality based on societal norms (Satir et al., 1991). Furthermore, Satir experiential therapy has been widely utilized with the LGBTQ-IA population (Gehart, 2016), as this approach acknowledges the ever so present societal discrimination and helps clients find safe people and places to express their authentic selves (Pachankis & Bernstein, 2012). For example, a therapist may begin as a safe and gender-affirming person for the TGNC youth to help other family members learn how to provide a gender-affirming environment at home (Coolhart & Shipman, 2017). This is crucial as research has shown that when TGNC youth experience constant rejection, then they are more likely to report suicidal ideation (Russell & Fish, 2016). Although evidence in support of family therapy is limited when treating suicidality among TGNC youth (Healy & Allen, 2019), structural family therapy coupled with Satir experiential therapy challenges the societal narrative that places blame and pathology on TGNC youth while learning how to embrace their authentic selves with family support.

2 Case Introduction

Dave, a 15-year-old transgender male, and his family were referred to a community mental health clinic after Dave expressed suicidal thoughts to his sister. Dave disclosed that he transitioned female to male 2 years ago, despite his biological father’s reluctance to acknowledge his transition. Dave also reported that his biological father still calls him by his female birth name. Currently, Dave lives with his sister, Stephanie, a 22-year-old bisexual female; his mother, Mary; and Bill, his stepdad. Dave’s parents divorced several years ago, and Dave’s biological father remains distant. Mary moved across the country to be close to Stephanie as she attended college. Dave’s mother and stepdad described feeling helpless as Dave expressed suicidal thoughts. Overall, the family expressed their support for Dave’s treatment, stating that they would be willing to attend therapy sessions with Dave.

3 Presenting Complaints

During the intake session, Dave’s parents began by talking about Dave’s recurring suicidal thoughts, which led to admission to the hospital. Dave has struggled with the recent move to this conservative region. In addition, as a transgender teen in this region, Mary reported that Dave experiences bullying at school from teachers and students who refuse to acknowledge his gender expression.

After listening to his parents talk about the presenting complaint, Dave expressed that he is not getting the emotional support he desires. Mary and Bill reported that they attempt to provide Dave with emotional support but often find themselves struggling with these conversations. Dave described that his parents do not support his decision to fully transition with hormone therapy and legally change his name. According to his report, the suicidal thoughts typically occur when he feels a lack of support. He said that he notices the suicidal thoughts are intense when his parents try to discipline him because he disagrees with their parenting style. Most of the time, Dave refuses to do his homework and spends his weekends with his friends. Overall, Dave said that he wants support in living life as a male without suicidal thoughts.

4 History

Mary and Bill described Dave as a defiant teenager as they listed that he does not do his schoolwork, often talks back to them, and refuses to help out around the house. Dave’s mother noted that there had been several times when Dave’s stepfather has tried to discipline, but Dave refuses to listen. Dave’s parents expressed concern about him finding support in the LGBTQ-IA community as the majority of his friends are over 21 years old. Mary reported that Dave’s interest in school has dropped since he has begun to spend the majority of his time with his new friends. When parents approach Dave about these concerns, Mary and Bill reported that he becomes defensive and explains that these are the first friends that accept his gender identity. Mary reported that these arguments had intensified the distance between her and Dave. Mary also reported that when she tries to enforce the family rules, Dave becomes angry and demands that he spend time with his friends for the entire weekend. Dave also reported that these fights, along with the lack of support he feels around being able to use hormone therapy, have led to him not feeling connected to his family.

Mary and Dave expressed that the move was a fresh start as Mary remarried to Bill a little over a year ago, and Dave began his transition from female to male. Despite the move, Dave found the gender transition to be difficult in this conservative region and began cutting himself as a way to cope. Dave reported that he takes alprazolam (e.g., antidepressant medication) to help with his depressive symptoms and self-harming behaviors. At the time of treatment, Dave reported that he stopped taking this medication about 4 months ago as he told his parents he did not like how they made him feel lethargic. Parents also reported that the suicidal thoughts have intensified once again. Stephanie, Dave’s primary connection and support in the family, has attempted to help Dave with his depression and lack of connection in this region.

Dave’s suicidal thoughts and self-harming behaviors, discovered a year ago, led to his hospitalization. This hospitalization helped stabilize Dave and provided him with ways to cope with his depressive symptoms. Despite the newly developed coping strategies, Dave found himself still struggling with depressive symptoms and intense desires to self-harm. In the last month, Dave expressed to Stephanie that he is having thoughts of hurting himself and that he fears he will act on his suicidal thoughts.

5 Assessment

Dave and his parents completed the required intake paperwork, which included the Outcome Questions Youth scale (OQ-Y0) and the Brief Symptom Inventory scale (BSI). The OQ-YO is a brief multifaceted outcome assessment tool created to understand the behavioral and individual experience of youth, and how they function as part of society (Dunn et al., 2005). Dave’s response to the item, “Looking back over the last week, including today, I think about suicide or feel I would be better off dead” was a 5, almost always. The BSI is an assessment that measures psychological distress and psychiatric symptoms in individuals (Broday & Mason, 1991). Dave’s response to the items, “During the past 7 days, how distressed were you by thoughts of ending your life” and “During the past 7 days, how much were you distressed by feeling hopeless about the future” was a 4, extremely. To further assess and establish the intensity of suicidality, the therapist conducted a suicide assessment in the intake session. The following questions were asked: On a scale from 1 to 10 (1 being not going to happen and 10 being I will carry out my plan to commit suicide), how likely are you to commit suicide this next week, do you have a plan for how you would commit suicide, do you have any friends or family members that have attempted or committed suicide, and what means do you currently have to complete suicide? It should be noted that the therapist continued to utilize this scale in every session with Dave to assess for suicidality.

In addition, to the OQ-YO and BSI, the family completed several other assessment measures that emphasize family relationships. Dave completed the General Family Functioning scale, that asked about his relationship with his family. Example items included, “In times of crisis, we can turn to each other for support,” and “We confide in each other” where Dave could report on a scale from 0 (strongly disagree) to 5 (strongly agree). Dave rated both of these items at 0 (strongly disagree) as well as other items that asked about connection and support in the family. This assessment illustrated the lack of emotional connection present in this family’s structure and how this may contribute to Dave’s suicidal ideation. The therapist began to conceptualize this case from a Satir experiential lens as the emotional suppression and lack of connection was evident.

Based on the clinical interview and assessments in the intake session, the following Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) diagnoses were made:

296.21 (F32) Major depressive disorder, single episode

302.85 (F64.1) Gender Dysphoria in Adolescents and Adults

Dave’s symptoms met the criteria for major depressive disorder and gender dysphoria. He reported that during the week leading up to the intake session, he had suicidal thoughts every day. In addition, Dave reported that for the past month he has felt depressed, exhausted, loss of interest in school, and a lack of confidence. Dave reported that he believed his depressive symptoms related to his desire to be a male. Mary and Bill also reported that Dave’s grades have begun to slip drastically and generally reports not enjoying school.

Much of the concerns the parents expressed during assessment displayed that the parent’s focus is on Dave and his need to conform to their worldview. The interactions between Dave and his mom and stepfather led the therapist to wonder about the power, hierarchy, and boundaries present in the family structure as Dave seemed disengaged when his parents talked about the problem. Dave’s disengagement led the therapist to transition into joining and accommodating, a notable aspect of structural family therapy that emphasizes the need to connect with clients. The therapist recognized Dave’s disengagement and shifted the focus to learning about Dave’s likes and dislikes.

6 Case Conceptualization

Dave struggled to identify the intensity of the suicidal thoughts as well as the triggers that led him to cut and attempting suicide. Previous attempts at the hospital to stop these behaviors had failed, and Dave’s parents felt lost as to how to help Dave with his depressive symptoms, suicidal thoughts, and self-harming behaviors. Dave’s connection in his family has been negatively impacted by the oppression and discrimination he has experienced within his family and society as he transitioned from female to male. Overall, Dave desired more support and connection, which ultimately led to the therapist including the entire family in treatment.

The therapist conceptualized the case from two different perspectives. First, a structural family therapy perspective as Mary and Bill expressed their inability to enforce discipline and connect with Dave. Structural family therapists hold the following assumptions about families: (a) problems reside within the family structure, (b) the spousal and parental subsystem should be the hierarchy, and (c) boundaries in a family system are vital for well-being and function (Parker & Molteni, 2017). Ultimately, with the use of structural family therapy, the therapist had a goal to challenge the rigid thinking of family members to allow alternative ways of looking at the problem and ways of dealing with each other, and the family boundaries are more flexible (Carter, 2011; Sim, 2007). Second, the therapist integrated structural family therapy with Satir experiential therapy as Mary and Bill expressed the correlation between their self-esteem and being successful parents. In addition, Dave stated that the lack of communication in his family impacted his self-esteem. Satir experiential therapy believes that an individual’s coping is related to their level of self-worth. Self-worth also impacts the way we communicate with others (Satir et al., 1991).

As Mary and Bill expressed their frustrations with enforcing discipline and Dave’s refusal to comply, it became evident that there was no clear hierarchy in place despite attempts by the parents to establish power. This hierarchy imbalance illustrated by Mary and Bill labeling themselves as parents who had failed, which has led to them allowing Dave to do what he wants with no consequences.

Throughout therapy, it became apparent that as the therapist attempted to shift the problem from being placed on Dave to residing within the family structure, Mary and Bill rejected this idea and continued to direct the blame toward Dave. This led the therapist to hypothesize that Mary and Bill’s self-worth correlates with the confidence in their parenting skills. The therapist noted the need to utilize Satir experiential therapy to increase self-worth within the family. As previously discussed, the parents blamed Dave for many of their problems; this blaming stance aligns with Satir’s belief that when we have low self-worth, we feel the need to defend and protect ourselves, which in turn leads to us blaming others (Satir et al., 1991). Therapy initially began with a structural lens, but as the blaming stances utilized by Mary and Bill increased when pushed to acknowledge the problem residing within the family structure, the therapist began utilizing Satir interventions to help achieve the desired changes.

When it comes to creating change, structural family therapy and Satir experiential therapy both emphasize interventions that focus on family interactions. Structural family therapy utilizes enactments to both assess and alter the problematic interactional patterns present in the family. Enactments provide the family with an opportunity to increase engagement and parental effectiveness, which in turn increases competence and self-worth (Minuchin & Fishman, 1981). Similarly, Satir experiential therapy utilizes family sculpting to assess and modify family interactions. Family sculpting allows each family member to sculpt each person’s role in the family, which provides a powerful symbolic depiction of the family process from each member’s point of view (Satir, 1988). Overall, both approaches emphasize changing family interactions, while Minuchin creates change through the family structure and Satir believes that an internal shift in an individual leads to changes to the family system.

Treatment Plan

The overall goal for therapy was to help Dave eliminate suicidal thoughts through gaining support and connection with his family. Therapy involved using the following interventions from both models of therapy to achieve stated goals:

Joining: central to success in both structural and experiential models is a sound therapeutic alliance (Minuchin et al., 2014; Rude & Bates, 2005). Joining is an attitude of empathy and acceptance a therapist takes on from the first moment of therapy to termination.

Raising the intensity: used to help the family “hear” the message of change. This can be done by a focus on specific messages and the use of repetition, focusing on individual members of the system, and by resisting the family pulling the therapist into the system (Minuchin & Fishman, 1981).

Boundary making: a technique used by structural therapists to target over-involvement or under-involvement to soften rigid boundaries or strengthen diffuse boundaries. By actively setting boundaries in session, the therapist disrupts interactional patterns and allows the family to experience each other differently. By moving the seats the family sits in, silencing a family member during an enactment, blocking interruptions, and asking questions that highlight the problem, a therapist can restructure the boundaries (Minuchin & Fishman, 1981).

Challenging worldviews: also known as challenging the reality. By externalizing the symptom away from the system, a therapist can also challenge the reality of the family by introducing doubt, encouraging curiosity, instilling hope, and presenting alternatives ways of viewing the problem (Minuchin et al., 2014; Sim, 2007).

Self-mandala: describes the holistic concept of the resources (i.e., spiritual, emotional, sensual, nutritional, interactional, contextual, physical, intellectual) that are universal to all humans (Satir et al., 1991).

Enactments: a central intervention that Minuchin utilized in his work are enactments. In the session, a therapist may encourage the family to act out a problem or to engage in a conversation. During the enactment, the therapist may act as an observer watching the patterns play out in front of him. The therapist may also introduce alternative ways of interacting by coaching the family through the enactment (Minuchin et al., 2014).

Parts party: used to identify the inner resources of clients. Then transform them into being useful to the client and integrate the resources into the individual’s everyday life (Satir et al., 1991).

Although Dave’s parents requested individual therapy for Dave to have a safe space to talk, the therapist suggested that family sessions occur every other week and then individual therapy would take place on the other weeks. Therapist made this decision so that the client will have his safe space, while also providing a space to grow as a family, where many of the problems reside.

7 Course of Treatment and Assessment of Progress

Sessions 1 and 2

The intake session focused on joining with Dave and his parents, developing a working counseling relationship, assessing the family structure, and conducting an in-depth suicide assessment. Therapy began by assessing the relationships between Dave, Mary, and Bill by asking each member to talk about how they view the family and the presenting problem. During these sessions, the therapist focused on the interactions and who possessed the power in the family (Minuchin et al., 2014). Based on the initial interactions, the therapist theorized that Dave holds power as parents expressed feeling lost and confused. Assessing the family through a structural lens allowed the therapist to observe how the family responded to stress. For example, this lens demonstrated the reaction of the system to having an external party interact with the existing hierarchy, next it provided the therapist an opportunity to understand what the family rules were surrounding emotions and communication patterns, and it further allowed the therapist to assess if the family was in fact in a disengaged state. The session then shifted from assessing the family structure to conducting an in-depth suicide assessment.

During the suicide assessment, Dave reported that he has had recurrent suicidal thoughts the past week with no active plan to act on those thoughts. Per clinic policy, the therapist completed a safety plan. The subsequent session included assessing the boundaries between the parental subsystem and sibling subsystem. Boundary assessment brings forth whether there is a clear boundary between subsystems (Minuchin & Fishman, 1981). Boundary assessment, particularly questions assessing the parental hierarchy, helps identify the habitual interaction patterns that are maintaining the problem (Minuchin & Fishman, 1981). To accomplish boundary assessment, the therapist asked the family to process their recent move and Dave’s transition from female to male. By asking the family to have these conversations, the therapist assessed the current parental hierarchy and boundaries between subsystems that were influencing the current problem. As Mary and Bill discussed their parenting, the therapist asked about the ways they communicate with Dave. They shared the difficulties they are currently having when trying to communicate with Dave. For example, they reported attempting to have conversations with Dave about his friends, but Dave views this as them trying to control his life.

Mary and Bill expressed their desire to be informed about where and whom Dave spends his time as this region is known for directing discrimination toward the LGBTQ-IA population. In addition to these concerns, Mary and Bill also expressed concern regarding Dave’s desire to paint his nails and wear high heels as he views his gender identity as fluid. This often led to intense fights as Mary and Bill were worried about Dave experiencing bullying, and Dave viewed this as his parents rejecting his gender identity.

Mary and Bill shared other times when they have attempted to talk to Dave about completing his homework but are met with resistance. Mary and Bill admit that they are supportive of Dave’s transition, but they feel like failures as parents, which has led to them ignoring Dave’s depression. At the end of the session, Dave, Mary, Bill, and the therapist agree that increasing connection, increasing self-worth, and reducing suicidality were the goals for treatment.

Theoretical integration

The therapist theorized that the family structure did not allow for connection, bringing in the need to create boundary changes. The therapist believed that these goals would work simultaneously; as the family structure was balanced, it would also allow for greater connection.

Sessions 3 and 4: Individual Sessions

Session 3 was the first individual session that occurred with Dave. The main focus of this session was to join with the client and gain his trust. As part of the attitude of joining, the therapist gave Dave the space to share his transition story and his journey with depression.

The therapist further explored Dave’s self-esteem throughout his transition journey. Dave shared that his struggles with depression have been constant, but only recently has the depression felt overwhelming. Dave attributed the overwhelming depressive symptoms to leaving a place where he spent his entire life. He described that his depression often leads to thoughts of feeling worthless and that the messages he receives from school and family members reinforce these thoughts.

Theoretical integration

Through the depiction of this journey, it became apparent that Dave was not congruent, as evidenced by him struggling to appreciate the unique aspects of himself, resistance to trusting anyone, and an unwillingness to be vulnerable. This incongruence led to Dave utilizing the placating communication stance in all his relationships to mask his low self-esteem. Dave’s placating stance often involved dismissing feelings of worth, blaming himself, and hiding his problems for fear of becoming a burden to others. The therapist was able to conceptualize Dave’s communication stance as he talked about his transition story and how this contributes to the recurrent suicidal thoughts.

Self-worth is a manifestation of the coping skills that are in place (Satir et al., 1991), as such the therapist and Dave spent Session 4 focusing on Dave’s current coping skills and exploring what other coping strategies he could begin to utilize at home. Dave reported that for the past few months, his primary coping skill had been avoidance, which has manifested in him staying his room for long hours and cutting his arm for a sense of relief. He used to have a passion for painting, writing music, listening to punk rock music, and playing the guitar, but as the depressive symptoms as well as thoughts of worthlessness increased, his interest in those activities have diminished. This led the therapist to utilize Satir’s four dysfunctional communication stances, specifically the placater communication stance, to help Dave confront the feelings of worthlessness. Satir et al. (1991) defines the placater communication stance as an attempt to avoid or cover up uncomfortable truths, which in turn hinders self-acceptance and connecting with others. To change this communication stance and create an internal boundary with his negative thoughts, the therapist asked Dave to write a letter to challenge these negative thoughts. With this letter, the therapist was working to externalize the symptom (Minuchin et al., 2014). An externalized problem allows the therapist to challenge the reality of the symptom. The therapist utilized a common experiential technique, the empty chair, where the client read the letter to the externalized symptom outlining how he views the symptom and the role the symptom will now play. The “empty chair” technique is an experiential intervention used to heal internal splits a client may be experiencing. The technique is useful in helping clients access deeper emotions and find meaning in the internal split (Rude & Bates, 2005).

Session 5: Family Session

To demonstrate the communication and behavior patterns, the therapist utilized an experiential intervention with ropes. The therapist gave each member of the family a rope that connects to another member of the family. The family’s task is to keep the ropes from getting tight. The therapist then had them move around the room in ways that created the ropes to get tangled and tight to demonstrate how one person’s reactions lead to stress placed on all of the ropes (Satir & Baldwin, 1983). Despite the family recognizing that they all influence each other, the parents stayed in a blaming communication stance (Satir et al., 1991), stating, “Life would be a whole lot less stressful if Dave would just get his stuff together.”

Theoretical integration

Although the family was able to recognize the influence they have on each other, this statement by Dave’s parents demonstrated the lack of support present in the family. Specifically, Dave’s parents believed that change needs to occur through him rather than acknowledging the need for change within themselves. This intervention illustrated the anxiety present when pushing for closeness in the family, which in turn hinders the growth and change necessary for the family (Minuchin & Fishman, 1981). When the focus turned to the parents, their defensive stances become apparent, and they utilize a blame coping stance to protect their self-worth (Satir et al., 1991).

Session 6: Individual Session

Session 6 began with a suicide assessment. Dave reported that his suicidal thoughts were at a 4 out of 10, with 1 being having no suicidal thoughts. The thoughts were a little higher this week because he had broken up with his girlfriend and feared that he was falling back into a depressive state. Although the therapist normalized Dave’s emotions around the breakup, the therapist failed to address the difficulties present in finding a romantic partner due to their identity. In these moments, therapist must validate the complexities and difficulties present when TGNC youth experience rejection in romantic relationships (Austin & Craig, 2015).

Dave reported that he wrote music lyrics rather than cutting himself when he was feeling intense emotions this past week. The therapist validated Dave’s strength to restrain from cutting and utilize another coping strategy. This restraint is a notable example of how Dave was developing a congruent attitude in his treatment of self. Dave saw the value within himself to utilize his coping skills, and coping skills are a manifestation of one’s self-worth (Satir et al., 1991). After Dave expressed how he has coped this past week, the therapist assessed Dave’s ability to utilize his parents as a resource this past week. Dave reported that no support was felt from his family this past week as he struggled with his breakup. Dave expressed that he would like his parents to be his primary support rather than his friends; this was a surprise to the therapist as Dave had previously expressed that his friends were his main source of support. Dave then expressed that he does not feel comfortable talking to his parents about his self-worth or how empty he feels inside.

Theoretical integration

This critical conversation helped clarify the lack of connection in the family and how this contributes to Dave’s low self-worth. Sessions that Dave described the highest suicidality, he also described a desire to feel more connected to his family.

Sessions 7 and 8: Psychoeducation With Parents

Based on Dave’s report in the previous session, the therapist began to challenge the structure of the parental subsystem and hierarchy. Restructuring the parental subsystem, particularly to be the hierarchy in the family system, helps children feel safe and secure as it creates a boundary between child and parents (Minuchin & Fishman, 1981). Structural family therapy focuses on restructuring the family system, which emphasizes creating a system that maintains the power and hierarchy that promotes healthy interactions in the family (Carter, 2011; Sim, 2007). As previously discussed, when the therapist utilized restructuring techniques, Mary and Bill pushed against this notion. Based on this push back, the therapist shifted toward utilizing Satir interventions that would increase Mary’s and Bill’s self-esteem in an attempt to lower their defenses and enhance their competency in being able to maintain power and hierarchy. To accomplish this, the therapist validated the ways Mary and Bill support Dave; this validation helped increase their self-worth. The therapist then asked them to process the ways they can increase their support and connection with Dave. As they further discussed ways to increase support and connection, the therapist emphasized the need for establishing boundaries while also taking a risk to create connection with Dave. At this point in the session, the parents expressed fear of setting boundaries for Dave, “What if we set boundaries or say something that leads him to kill himself?” Illustrating the power Dave holds in the family and how this contributes to the presenting problem. Families often only feel safe by maintaining the status quo (Satir et al., 1991), even if that status quo is dysfunctional. Fear of losing Dave and not having control still felt safer than their son killing himself because they push against the status quo.

In the next session, the therapist focused on helping the parents move from the blamer communication stance to seeking connection with Dave. The blamer communication stance is known for feeling lost and isolated while blaming others for their stressful feelings (Satir et al., 1991). Mary and Bill have reported feeling lost, and when asked about the connection in the family, they place blame on Dave as he consistently wants to spend time with his friends. Moving from dysfunctional communication stances involves asking individuals to engage in new experiences and begin learning new concepts (Satir & Baldwin, 1983). In Dave’s case, the therapist was looking for ways for the entire family to have new experiences that lead to fostering support and connection. For example, Mary and Bill reported that Dave refuses to spend time with them, which often leads them to allow him to spend the entire weekend with his friends. Again, these moments displayed the incongruence present within the family. Dave expressed his desire to have support but then at times finds himself avoiding opportunities for his family to provide support. To assist the parents in pushing against the status quo, the therapist worked with the family to set a specific time on the weekend where the family spends time together.

Sessions 9–13: Family Sessions

In subsequent sessions, the therapist utilized enactments (Minuchin & Fishman, 1981) to increase connection, communication, and vulnerability. In this session, the therapist asked the family to enact a time that involved having a conversation about spending time together. As the family enacted a conversation from this past week, the therapist observed Dave diverting his eye contact toward the ground as Mary and Bill attempted to talk to him about only wanting to spend time with his friends. The therapist decided to pause the enactment and point out the blaming stance and placater stance that was currently present in the family conversation. Pointing out these stances helped Mary and Bill acknowledge the need to shift from a blaming stance to acknowledging how the current family structure was contributing to Dave’s suicide attempts.

During the following sessions, the therapist continued to utilize enactments to help the family see their transactional patterns and find new ways to communicate. For example, the family enacted a stressful situation that occurred the previous week and was able to point out the blame and avoidance present in their interactions. After these insightful enactments, the therapist proceeded with restructuring the family. To restructure the family, the therapist placed Dave next to him and asked Mary and Bill to move their chairs across from Dave to illustrate the parental subsystem as the hierarchy. The therapist began to talk about current interactional patterns in the family and asked Dave to share what he needs to utilize his parents as a resource. Mary and Bill were able to listen and validate Dave’s need from a non-blaming stance. Overall, these conversations in treatment led to symptom reduction and an increase in family connection.

Session 14: Suicide Attempt

Session 14 began with Mary and Bill reporting that Dave had attempted suicide this past week and that Dave had spent a few days in the hospital for observation. This session’s focus shifted from family to conducting an in-depth suicide assessment with Dave. The therapist met with Dave individually to assess for suicidality and the events that led up to the suicide attempt. Dave reported that he had made a “gay” joke earlier in the day with his friends, leading to an intense argument. The therapist acknowledged that Dave’s behavior was incongruent with his values and beliefs, as Dave has previously reported feeling upset when other people make jokes about the LGBTQ-IA+ population.

As Dave further described the events leading to the suicide attempt, he had spent the entire weekend out with his friends despite his parent’s request for him to return home. Dave’s actions angered his parents, who then shifted into a blaming stance and banned from leaving the house the next weekend. Dave expressed that these events compiled were intense and overwhelming, which led him to self-harm, cutting on his wrist, and when that did not provide the relief he was seeking he took about thirty 500 mg Advil to numb the pain. The therapist reviewed Dave’s safety plan and processed ways Dave could utilize his resources in the coming week if he becomes overwhelmed again.

Toward the end of the session, the therapist met with Mary and Bill to process the suicide attempt. They reported feeling helpless, and this attempt validated their fear of setting boundaries with Dave. Mary began crying, stating that she is a failure as a mother, leading Bill to return to the status quo of avoiding emotion. Instead of comforting his wife, Bill was examining the hand sanitizer and let the therapist know that it is currently expired.

According to Minuchin and Fishman (1981), as the reconstruction of the family structure takes place, some family members may be initially startled by the changes and begin to resist. Therefore, the therapist validated the parent’s frustrations while also ensuring that as the family structure begins to change, Dave will be resistant to these changes and push to go back to the original family structure.

Theoretical integration

Dave was resistant to the change that was happening in the system. As the homeostasis of the system was changing, Dave felt uncomfortable not having control over his parents that he once had. During the sessions leading up to this attempt, it was apparent that the parents focus on exerting more control over Dave without developing a connection with him. As the parents were attempting to establish healthier boundaries for the system, they created rigid boundaries that did not allow for connection. As Mary and Bill attempted to parent Dave from the new position in the hierarchy without clear boundaries, their worst fear came about, Dave attempted suicide. This attempt became a catalyst for the therapist to help the parents recognize that just having boundaries and a hierarchy does not mean establishing rules and discipline but also supporting each other (Sim, 2007).

Sessions 15–21: Family Sessions

In the following sessions, the therapist utilized experiential interventions to target emotional transactions and facilitate emotional expression through coaching to increase family connection. Therefore, the therapist focused on creating experiences in treatment to help the parents express their love and concern while also establishing boundaries with Dave. For example, during one of the sessions that involved a new experience with coaching, the therapist asked Dave to sit across from his parents as they expressed their concern and fears about his suicidality. As the parents expressed their concern and fears, the therapist paused them occasionally, allowing Dave the space to express his current emotions after hearing how much his parents care for him. Mary and Bill then were coached on presenting the boundaries and structure they agreed on for Dave in a loving manner.

Theoretical integration

The therapists believed increasing connection would reduce suicide ideation and promote experiences that allow the family to have the conversations that move toward healing. Satir et al. (1991) teaches that creating change occurs by helping clients see new possibilities through experiences related to the presenting problem. The therapist’s role involves coaching the family to express emotion throughout these new experiences. This experience illustrated the new possibilities within the family and the need for emotional expression to create change. The following session focused on creating experiences that helped the family express emotion and share their needs.

Toward the end of Session 21, the therapist noticed a significant difference in the way the family was interacting with each other. For example, Dave, Mary, and Bill were laughing together as they talked about the time they were spending together. Dave reported that his mom helped him work on a painting project over the weekend. As the connection and support increased in the family, each family member reported an increase in their self-worth. Dave also reported in each session a decrease in his depressive symptoms as he reported being at a one on a suicide scale from 1 to 10 with 10 being the highest. This was a significant improvement as before he felt connected to his parents he reported having near-constant suicidal ideation that is no longer present. Overall, the family interactions shifted from blame and defensiveness to understanding, connection, and support.

While we did see improvement in the relationship between Dave and Bill, there was a barrier to improvement as Bill was not able to make it to Sessions 17, 18, 19, and 20. Bill acknowledged in Session 21 that he had seen an improvement at home and an improvement in the relationship between Mary and Dave, and he was still having difficulty communicating with Dave.

Session 22: Individual Session

Dave reported at the beginning of the session that he is a one out of ten on the scale used in previous sessions. As the family connection increased (see Figure 1), there was a notable improvement in Dave’s symptoms, as evidenced by Dave’s reports that he was playing games over the phone with his mom as they were on vacation and staying in contact with them voluntarily. Dave reported that he was no longer having suicidal thoughts and was enjoying spending time with his family. The ongoing interventions used to increase Dave’s self-worth were utilized in this individual session as Bill and Mary were currently on vacation together. More specifically, a self-mandala “parts party” was utilized to focus on Dave’s resources and self-worth. The self-mandala is an intervention that helps the client recognize the various parts of a human that need to be fulfilled (e.g., spiritual, emotional, sensual, nutritional, interactional, contextual, physical, intellectual) and how if we choose not to fulfill those parts, then our subconscious will in unhealthy ways (Satir et al., 1991). To help Dave, recognize how all the parts of the mandala interact, the therapist had him conduct a “parts party.” The therapist began with having Dave hold the ends of eight ropes while attaching the ropes to signs that represented the eight different parts on the mandala. As Dave was able to recognize his connection to each part, he then shared how he utilizes each part.

Figure 1.

Family Connection and Family Communication over the Course of Treatment.

As Dave talked about the various parts on his mandala, he reported feeling confident as this intervention helped him recognize the internal resources he currently utilizes, such as interactional. He recognized that as he improved his interactions with his family, his self-worth increased. In addition, he acknowledged that when he avoids his emotions, his self-worth drastically decreases. Dave reported that this intervention helped him recognize the need for utilizing all of his internal resources to increase his self-worth.

Sessions 23 and 24: Treatment Outcomes and Final Session

During the 23rd session, the therapist utilized an experiential activity to assess the family’s connection, communication, and support. Unfortunately, Bill was not able to attend this session because of a conflict with his job. The therapist had Dave and his mom individually create an obstacle course utilizing various objects and furniture in the therapy room. Then, the therapist wrapped a blindfold around Dave’s eyes and asked Mary to direct Dave through the obstacle course. After Dave completed the obstacle course, he then guided his mom. This activity illustrated the connection, communication, and support that Dave and Mary have developed throughout treatment. Dave and Mary reported that they feel connected and can communicate regularly now.

A change in the status quo was very apparent here, as demonstrated by the clear boundaries and an effective hierarchy now present in the family structure. Mary and Dave were now able to maintain congruence during emotionally charged conversations without fear and anxiety. Dave reported wanting to spend more time with his parents as the newly changed structure promoted growth, acceptance, and connection. Mary reported an increase in her self-esteem as she feels confident in maintaining clear boundaries for Dave.

As part of the 24th session, the therapists and family reviewed goals while celebrating the progress made throughout therapy. Dave reported that he feels connected with his mother and stepdad. As the entire family reported feeling connected, the therapist asked about the things they have been doing to be connected. Bill shared that everyone in the family is actively making an effort to spend time together. Dave was satisfied with his progress as he talked about the time he has spent with his parents over the past few weeks. At the beginning of treatment, Dave reported struggling with suicidal thoughts every day. By the end of treatment, he had gone almost 2 months without suicidal thoughts. Dave said that he was no longer struggling with suicidal thoughts. He also reported that his self-worth has increased, and with the connection and support he has with his family, he will be able to manage suicidal thoughts if they arise in the future. The structural approach helped Mary and Bill develop a clear distinction between the parental and sibling subsystem, which in turn led to a family structure that promoted growth for all members. The utilization of Satir experiential therapy helped to increase self-worth for all family members. After increasing self-worth and family connection, Dave’s suicidal thoughts significantly reduced. In the last session, Dave, Mary, and Bill identified a plan to continue connecting as a family with additional activities and times they can spend together.

8 Complicating Factors

No significant complicating factors identified in this case.

9 Access and Barriers to Care

A significant barrier to conducting family therapy sessions was Bill’s work schedule. Bill reported that his work schedule was not consistent and at times was required to stay at work longer with little notice. Bill’s work schedule often prohibited the family from scheduling at a time where every member could be present. Accordingly, the therapist often found out at the time of the session who would be in attendance, which impacted the family interventions the therapist had planned for that night.

10 Follow-Up

At the time of termination, Dave agreed to contact the clinic if he noticed any of the warning signs that he discussed with his therapist. Dave has not contacted the clinic or therapist since termination. However, this case ultimately lacks follow-up data from the client, which may limit the findings presented.

11 Treatment Implications of the Case

Dave’s treatment response shows significant improvement throughout therapy and illustrates the utilization of family-based interventions. Several studies have noted that gender-affirming practices paired with CBT interventions are effective in treating TGNC youth who present with suicidality (Austin & Craig, 2015). An important factor to consider in treating suicidality among TGNC youth, however, is the correlation between suicide attempts and family rejection (Grant et al., 2011). Like Dave, TGNC youth who struggle with suicidal ideation and suicide attempts report the desire to have connection and support as they transition but are unable to identify safe people in their life. This case highlights the integration of structural family therapy with Satir experiential therapy in successfully helping a family become a place of connection, support, and safety to reduce suicidality. Through boundary-making, re-establishing the parental hierarchy, and utilizing Satir interventions to promote self-worth, a TGNC youth’s family becomes the connection and support they desire and need. It is important to note that when the parents attempted to implement boundaries without a focus on being able to create a supportive environment that allowed for growth, Dave attempted suicide. The parents first created rigid boundaries overcompensating for the power they had not held previously which led to even more feelings of isolation in Dave. Utilizing both structural family therapy and Satir interventions helped the parents to see the need for both connection and boundaries.

This case emphasizes the need for an established parental hierarchy when working with TGNC youth struggling with suicidality. In this case study, helping Dave’s parents establish a secure parental hierarchy with boundaries and safety was vital, not only in establishing safety for Dave but, more importantly, creating the connection he was not receiving at school. The therapist’s utilization of creating new experiences for the family to share their emotions was a central factor in Dave’s ability to express his need for connection with his parents, which ultimately helped reduce his suicidal thoughts.

Dave’s case also illustrates the importance of using Satir experiential interventions to increase self-worth. This is a necessary component of therapy with clients such as Dave, who have received messages from society that they are unworthy. In addition, these interventions create a new experience for Dave, as the therapist provided a safe space for Dave to openly talk about the oppression and discrimination he has experienced. When the therapist was able to utilize interventions that created safety within his family, Dave acquired his need for connection as well as the support he needed.

Finally, when treating a TGNC youth with high suicidality, it is crucial to assess the underlying experiences, thoughts, and feelings that are catapulting the suicidality. For example, the therapist’s assessment with Dave led to information about the discrimination he is experiencing at school and how this contributes to his suicidality. The therapist used this information to help Dave gain connection and support from his parents. Furthermore, this information was crucial in how the therapist proceeded with creating safety in treatment for Dave to share vulnerable information with his parents.

12 Recommendations to Clinicians and Students

This case study illustrates the critical component of including the entire family when working with a TGNC youth that presents with suicidality. More importantly, it highlights the need to utilize family-based interventions that focus on building support, connection, and safety within the family to reduce suicidality. Therapists can recommend the entire family be present as the first step in therapy, followed by integrating structural family therapy and Satir experiential therapy to establish support and connection to ultimately reduce suicidality.

When utilizing structural family therapy and Satir experiential therapy interventions to treat suicidality, the therapist should be aware of the oppression, discrimination, and transgender-related stigma TGNC youth often experience in society (Russell & Fish, 2016). Furthermore, therapists should assess the TGNC youth’s experiences with their family, specifically, the support or lack of support they have received from their family. Thus, the initial sessions should focus on developing a safety plan and assessing whom the TGNC youth identifies as supportive and safe. For example, the therapist began by assessing the family dynamics and transitioned to utilizing interventions that build support and positive self-concept to reduce suicidality.

Overall, one of the key challenges to providing therapy to TGNC youth is the limited resources available as well as the lack of trans-specific clinical skills and training within helping professions (Heck et al., 2015). In addition, there are fewer resources available for TGNC youth who are unable to medically transition due to finances or lack of family support (Shumer & Spack, 2013). Therefore, the therapist working with TGNC youth who present with suicidality should seek training and resources to become affirming and competent therapists for a population that desperately needs a place of safety, connection, and support.

Footnotes

Acknowledgements

The authors would like to thank the client for his bravery as he allowed the therapist to walk alongside him during a difficult time in his life. The authors would also like to thank the client’s mother and stepfather, as they actively supported the client and ensured his safety throughout the course of therapy.

Authors’ Note

Lindsey G. Hawkins is now affiliated with Northern Illinois Univeristy, DeKalb, USA.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Justin S. Romney

Author Biographies

Justin S. Romney is a licensed marriage and family therapist associate and currently a PhD student at Texas Tech University studying Couple, Marriage, and Family Therapy. He has a strong interest in helping families to develop the structure that will help families deal with high-stress situations such as having a child diagnosed with autism, dealing with the loss of a child, and dealing with suicide ideation.

Lindsey G. Hawkins is a licensed marriage and family therapist associate currently completing her final year of academic coursework in the Couple, Marriage, and Family Therapy PhD Program at Texas Tech University. She has strong clinical and research interest in trauma and mental health disorders. She also has a strong interest in the application of structural family therapy to meet client needs when working with trauma and mental health disorders.

Kristy L. Soloski, assistant professor, is a licensed marriage and family therapy associate, a licensed chemical dependency counselor, and an American Association for Marriage and Family Therapy (AAMFT)–approved supervisor. She is a faculty member in the Couple, Marriage, and Family Therapy Program at Texas Tech University. Her research centers on family and other systemic factors related to the development of problematic substance use. She has a special interest in clinical work and research that is sensitive to, respects, and considers the unique needs of diverse populations.

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