Structural Family Therapy Case Study: Addressing School Refusal in the Richardson Family

If an 11-year-old child came into your office refusing to attend school—and not having gone regularly for almost a year—what would you do? The parents have tried everything: contacting the police, consulting multiple therapists, using threats, yelling, and even bribery. Nothing has worked, and now they're sitting in your office for family therapy. Welcome to this Structural Family Therapy Case Study on school refusal.

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I’m Oliver, a couples and family therapist in Los Angeles, and I am passionate about family systems. In this post, I will walk you through a primarily fictitious but representative family crisis as a case study using structural family therapy principles. You’ll see how we collect systemic data from the first session, gather insights from an enactment, and create a family map. Finally, I’ll share how to convert those observations into a hypothesis, a treatment plan, and targeted interventions.

An example of a Strategic Family Therapy case: The Richardsons

Let’s introduce the Richardson family, our case study subjects:

• David (47) and Sarah (45) are the parents.
• They have two children: Alex (11) and Marcus (19). Marcus is currently away at college.

The parents have been married for about 20 years. Sarah used to be an elementary school teacher before the kids were born. She took time off to raise them, given that David’s job provided sufficient income. Occasionally, she still substitutes at the local school, remaining very aware of educational issues due to her teaching background.

David works for a well-known tech company, traveling frequently for work. He is the primary breadwinner and takes his responsibilities seriously. That often leaves Sarah at home managing the day-to-day family challenges, including the crisis with Alex, who refuses to go to school.

Understanding Structural Family Therapy

In structural family therapy, we often refer to the child with the “problem” as the IP (Identified Patient)—the person everyone identifies as “having the issue.” However, the fundamental assumption in structural family therapy is that the problem usually lies in the entire family’s structure rather than a single individual.

The Presenting Problem

Alex, who is nearly 12 years old, is the identified patient. He started complaining about school nearly a year ago, citing reasons like having no friends and disliking his teachers. Over time, he has developed distressing physical symptoms such as vomiting and abdominal pain. Doctors have found no medical cause for these symptoms; notably, they tend to appear right before he has to go to school.

Meet the Family Members

Sarah (Mom, 45)

• Former elementary school teacher.
• Mostly a stay-at-home mom now.
• Very conscious of her children’s education, likely due to her background in teaching.

David (Dad, 47)

• Works for a famous tech company.
• Travels often for work.
• Primary breadwinner and takes that role seriously.

Alex (Son, 11)

• The identified patient refusing to attend school.
• Complains of physical symptoms (vomiting, abdominal pain).
• Symptoms are triggered by anything related to school.

Marcus (Older Brother, 19)

• Away at college, not typically present in the home.

Initial Observations and Family Dynamics

Session One Observations
When the Richardson family arrived for their first session, several things immediately stood out:

1. Entrance and Seating
   
   
• Alex was ushered in by his father, with Sarah following behind picking up Alex’s coat.
• Both parents appeared anxious; they briefly smiled at me as they came in.
• Dad looked to Mom, motioned to the sofa, and both waited for Alex to decide where to sit. Alex finally chose to sit next to Mom, while Dad sat on a separate sofa closer to me and began talking.
2. Body Language and Interaction
   
   
• Alex and Mom appeared quite anxious, avoided direct eye contact, and seemed to mirror each other’s emotions.
• Dad seemed to take charge, explaining the family's situation in a somewhat scripted manner.
3. Parental Roles
   
   
• Dad dominated much of the conversation, whereas Mom and Alex contributed only intermittently.
• Their descriptions of the day-to-day battles—coaxing Alex to attend school, dealing with his vomiting episodes—were given in a calm, measured tone, contrasting with the severity of the problem.

An example of enactment in structural family therapy: Spontaneous Enactments

Midway through the session, Alex announced he needed to use the bathroom. I intentionally looked away, allowing the family to handle it without my direct interference—a small technique known as a spontaneous enactment. This gave me real data on how they operate as a family:

• Immediately, both parents jumped up to assist Alex.
• Mom led him out of the office.
• Dad then followed, leaving the session to check on them.
• They all returned later to report that Alex had thrown up once again.

This brief moment shed light on the boundaries within the family. Observing how the entire family mobilizes around Alex—particularly when he experiences distress—offers clues about the porous emotional boundaries that may exist between parent and child.

Pop Quiz: Boundaries

Based on how Mom and Dad both rushed to attend to Alex (even standing outside the bathroom), do you think their boundaries are:

• Porous
• Healthy
• Rigid

In this scenario, they seem to be porous, indicating that the parents might have difficulty maintaining a clear separation from Alex’s experiences. It is understandable to want to care for a child in distress, but the level and immediacy of their intervention suggests an enmeshment where they share his emotional state too intensely.

Creating a Structural Family Map

A family map is one of my favorite tools in systemic family work. It helps identify:

1. Who holds power in the family.
2. How subsystems are organized.
3. The nature of boundaries (porous, rigid, or healthy).

Ideal Family Structure

In a healthy family map, the parental subsystem is at the top, with a clear boundary separating them from the children’s subsystem. Here’s a simple representation of what we’d hope to see:

The Richardson Map

In the Richardson case:

• Dad appears more dominant in terms of speaking for the family.
• Mom is closely aligned with Alex, possibly indicating emotional enmeshment.
• Dad’s physical and emotional distance (due to work travel) complicates their hierarchy.

Marcus is away at college, so we situate him further outside the family system for now. Alex is the sole minor at home, and his symptoms seem to hold significant power over the entire structure.

Circular Questioning to Identify Patterns

Circular questions help reveal the patterns in family interactions. They illuminate how each person’s behavior affects and is affected by others in a cyclical process. Some of the questions I asked included:

1. “Mom, when Alex is having a tough morning before school, who does he go to first for help? And then what happens?”
2. “Dad, do you agree with that? Do you get involved or do you tend to stay out of it?”
3. “When Alex isn’t feeling well, how does this change everyone’s day? Who has to adjust their schedule the most? What about work commitments?”
4. “Alex, parents have to be part boss and part friend. What percentage boss and what percentage friend are each of your parents?”

These questions revealed that Alex’s anxiety triggers a well-practiced sequence:

• Mom tries to soothe him and convince him to go to school.
• Alex then retreats to the bathroom, often locking the door.
• Dad gets called in if he is around, but any confrontational approach quickly escalates into vomiting.

Over time, the school staff also backed off to avoid provoking Alex’s physical symptoms. In other words, everyone is tiptoeing around Alex’s distress, reinforcing the school refusal cycle.

Breaking Down the Family’s Problem Cycle

The problem cycle looks like this:

1. Alex experiences anxiety about school.
2. He retreats to the bathroom, triggering physical symptoms like vomiting.
3. Parents fear exacerbating those symptoms, so they back off from pushing him to attend school.
4. Alex stays home, which reinforces the idea that if he’s anxious or sick, he does not go to school.
5. This cycle intensifies, increasing anxiety about the next school day.

The family’s attempt to avoid distress is entirely understandable—no one wants their child to suffer. Unfortunately, this avoidance inadvertently empowers the symptoms to control everyone’s routine.

Formulating the Hypothesis

Using observations, circular questioning, and family mapping, I ran the data through my “hypothesis generator,” focusing on five aspects of family systems: Problem, Process, Proximity, Power, and Patterns.

1. Problem: School refusal accompanied by physical symptoms (vomiting, stomach pain). Although framed as Alex’s problem, it is maintained by the family’s accommodation of these symptoms.
2. Process: Parents try to solve the problem by backing off, inadvertently reinforcing it. Mom soothes; Dad’s frustration is peripheral yet not effective. The family orients around avoiding Alex’s distress.
3. Proximity:
• Mom and Alex appear enmeshed, sharing emotional states (porous boundaries).
• Dad is physically and emotionally distant due to work travel.
• Marcus is out of state, creating an additional shift in the family dynamic.
4. Power: Dad initially appears "in charge," but Alex’s symptoms truly hold the power. The parents, especially Mom, hesitate to assert authority for fear of triggering vomiting or anxiety.
5. Patterns: Alex’s anxiety → attempts at soothing → bathroom retreat → vomiting → parental retreat → no school → anxiety builds for the next day.

This cycle may represent a family that has not adapted to multiple life transitions—such as Marcus leaving home and Alex entering adolescence. The intense child-focused environment also suggests there could be avoidance of deeper marital or personal issues between Mom and Dad.

an example of unbalancing in structural family therapy?Moving Toward Healthy Family Structure

The ultimate goal is to reorganize the family so that it looks more like a functional structure. Specifically:

1. Reframing the Problem
   
   
• Help the family see that this is not merely about Alex’s “sickness” but about how the family as a system responds to it.
• Show them they have more agency than they realize; the existing narrative of “nothing works” is limiting their options.

• Unbalancing The Hierarchy

• This would involve steps to stop Mom from being so involved,
• Brign Dad closer into parenting
• And most importantly, lowering the power and influence Alex’s symptoms  have 
•  
1. Reestablishing Parental Hierarchy
   
   
• Guide Mom and Dad to align on boundaries, consequences, and follow-through.
• Reduce the power Alex’s symptoms hold over daily routines.
• Implement some “tough love” strategies where appropriate.
2. Strengthening Boundaries
   
   
• Encourage Mom to find interests and activities beyond parenting to reduce her overfocus on Alex.
• Invite Dad to be more emotionally present, bridging physical and emotional distance.
• Clearly separate the parental subsystem from the child subsystem.
3. Potential Inclusion of the Older Brother
   
   
• If Marcus comes home during a break, his involvement in a session could be beneficial.
• Explore how Marcus’s absence has reshaped family dynamics.

These steps are integral for helping the Richardsons escape the entrenched cycle of school refusal. By shifting the focus from “fixing Alex” to realigning the family structure, we can empower the parents and reduce Alex’s reliance on symptomatic behavior for emotional security.

Next Steps and Conclusion

This has been an overview of how to conceptualize school refusal through the lens of structural family therapy. If you want a deeper dive into specific interventions and how to execute them in session, let me know! I am open to creating a follow-up post detailing the techniques I would use with the Richardson family.

If you found this helpful and are interested in more structured learning, consider my Structural Family Systems Step-by-Step course, where I go into even more depth and provide comprehensive resources like handouts, a family assessment tool, and a PDF of my favorite circular questions.

In the meantime, feel free to comment, share your thoughts, or ask questions. I love hearing from fellow clinicians and students interested in family systems. Until next time, remember: family structure, boundaries, and hierarchy are at the core of understanding (and resolving) so many of the challenges we see in therapy.

Thanks for reading!