Posted by Amy: Here’s an interesting case about what can happen when family dysfunction meets disease:
Brianna, a sweet-looking, lanky 22-year old, had been referred to me by her family physician because of her depression, along her inconsistent management of her diabetes. Diagnosed with Type I diabetes at 8 years old, Brianna knew the diabetes world inside-out, but she still struggled to get her sugars under control.
I enjoyed working with Brianna a great deal. Smart and self-aware, she was finishing his degree in theatre and hoped to make her career as an actor. The middle child of three, her older brother lived in the city and worked in “finance”; I’m never quite sure what that means, except that they focus on making a lot of money. Her younger sister, still in high school, lived at home with her parents. Brianna’s parents lived in a neighboring state where her Dad was a university philosophy professor and her mom was a specialist in Early Childhood Education.
Throughout my sessions with Brianna, her struggles with her parents figured prominently. She was confused as to how to establish her autonomy with them, including around her diabetic care. 
Sometimes she felt like a kid, and at other times she felt like she should have all the answers. While the process of growing into adulthood is a normally clumsy matter, Brianna’s struggles seemed to have something specifically to do with her family’s dynamics. She described some chronic tensions between her parents, and her mother’s periodic bouts of drinking. Brianna worried about her folks, and felt stressed by her relationship with them. I believed this was the major source of her depression. I suggested a family meeting. The family agreed to come in.
The Family Session: I felt the tension in the air as the family seated themselves in my office. Articulate and well-meaning people, there was a stiff quality in how they related to one another. The first eruption came when Mom talked to Brianna about her worries about her daughter’s inconsistent attention to her diabetes. Brianna and her siblings immediately attacked their mother for being too “abrasive”, too “intense”.
My first mental flag went up. Mom’s concern was realistic, and she expressed her concern with feeling and emotion, not at all “over-the-top”. In fact, her distress was well-founded, since Brianna’s self-care was episodic and somewhat free-wheeling. Dad then chimed in, echoing the kids’ refrain, something about how Mom “doesn’t calibrate her reactions, but she means well”. His patronizing comment, hiding behind the veneer of the calm voice of reason, looked to me like a well-honed pattern of which this intelligent family was unaware.
My family therapy teacher Sal Minuchin used to say that when a child is taller than a parent he/she is sitting on the other parent’s shoulders. In this case, these kids sat on Dad’s shoulders, with Mom disqualified as an “alarmist”. As we talked further, I saw that Mom was small in this family. I commented wryly that if Mom cried “fire”, the rest of the family would have to see the evidence before they evacuated. She was suspect until proven innocent.
I began to talk openly, but with caring, about these patterns as they emerged in the session. Mom and Dad–-believers in the benefit of psychotherapy–- both had their own individual therapists. Dad talked about how he often experienced Mom as “too emotional”, and felt overwhelmed when she was too “intense”. Dad seemed afraid of his own emotionality, and he talked a bit about his “chaotic” upbringing. I think he felt that he had to keep his wife’s emotions in check. And it looked like Brianna’s mom had given up fighting with her husband; I think she felt out-classed. Brianna’s parents had unconsciously enlisted their children in this unresolved impasse.
I continued to emphasize Mom’s good judgement and praise her emotional freedom. She spoke quietly about her frustration at feeling “unheard”. First by her husband, then by her kids. The opening of these tensions, while empowering Mom, had an almost immediate therapeutic effect. These were thoughtful people, trapped in patterns that were unrewarding and unproductive. Dad said he wished they had family therapy when Brianna was young. It “could have saved us years of grief.”
Brianna’s confusion over how seriously to take her diabetes was born in this parental dysfunction. She remembered how her mother would try to get her to avoid sweets, but her dad’s attitude toward her cookie-mongering was “What’s the big deal? Let the kid have a cookie”. The parent’s mutual and unresolved dance: Mom=Too Intense and Anxious, Dad=”Calm” and Rational, played itself out again and again around Brianna’s diabetes. This young girl couldn’t escape the confusing message about how to care for herself.
To the family’s credit, they responded to this session by starting to do things differently. Shortly after our meeting Dad apparently became an activist around Brianna’s diabetes, contacting her physician and other’s involved in her care. He said he wanted to make sure he was “updated” on the latest numbers so he could help with problems if they arose. Brianna’s family physician called me to complain about the father’s “intrusiveness”: I explained that this was progress for the family, and Brianna. In fact, the father’s interest was key to Brianna’s developing a healthier desire to care for herself. The doctor got it.
I continued to meet with Brianna for several months, until she decided to enroll in a Conservatory for the Performing Arts in another state. During this time, her diabetic care became more consistent, as she addressed her diabetes more openly and deliberately. While not yet perfect, the numbers indicating control of her diabetes were better than they’d been. She had finally begun taking care of herself.
And Brianna’s phone conversations with her mother changed. In the past her Mother would emotionally withdraw if Brianna challenged her. With her new confidence, Mom now pushed back if Brianna said something she didn’t like. Brianna reported this new development with pleasure in her voice. She had a Mom who seemed more able to stand up for her own point of view. And Brianna now had a Dad who was a bit of a pain in the neck regarding her diabetic care. But Brianna didn’t fight it: She was finally getting the kind of care she needed. And it felt good.