Dr. Mick Larson

Dr. Sloan Bruan Lorenzini

Welcome to the Sloan Continuing Education interview series. I'm Dr. Sloan Bruan Lorenzini, and today I'm joined by Dr. Mick Larson, a licensed marriage and family therapist who specializes in structural and strategic approaches to family therapy, particularly when a child in the system receives a behavioral health diagnosis. Mick, thanks for being here.

Dr. Mick Larson

Thank you, Sarah. This is a topic I'm really passionate about, and I appreciate the chance to dig into it with your audience.

Dr. Sloan Bruan Lorenzini

So let's start with the big picture. When a child receives a behavioral health diagnosis — whether it's ADHD, oppositional defiant disorder, an anxiety disorder — what do you typically see happen within the family system?

Dr. Mick Larson

The diagnosis almost always reorganizes the family, and usually not in ways that people recognize at first. What I see most often is that the family's hierarchy shifts. The diagnosed child moves to the center of the system. Parental attention, daily routines, even the emotional climate of the household — everything starts to orbit around managing that child's symptoms.

Dr. Sloan Bruan Lorenzini

And from a structural perspective, you'd say that reorganization itself becomes part of the clinical picture?

Dr. Mick Larson

Absolutely. Minuchin would say the family's transactional patterns have been disrupted. The parental subsystem may become enmeshed with the child subsystem — one or both parents start functioning more as symptom managers than as authority figures. You see the executive function of the parental dyad weaken, not because the parents are less capable, but because the diagnosis has recruited all of their energy into a reactive stance.

Dr. Sloan Bruan Lorenzini

That distinction is so important — reactive versus proactive parenting.

Dr. Mick Larson

It really is. And from a strategic therapy lens, you start to see what Jay Haley would call a rigid sequence. The child exhibits a behavior, the parents respond in a predictable way, the behavior escalates or persists, and the cycle repeats. The family gets locked into these interactional loops, and nobody can see the pattern from inside it.

Dr. Sloan Bruan Lorenzini

Which is exactly where a family therapist becomes essential.

Dr. Mick Larson

Right. And I want to be clear about something — the goal is never to minimize the diagnosis. A child with ADHD has a real neurobiological difference. A child with an anxiety disorder is genuinely suffering. But the structural therapist's job is to look at the relational context around that diagnosis. How has the family reorganized? Where are the boundaries? Is the parental subsystem still functioning? Are siblings being pulled into caretaking roles or acting out to get attention?

Because what often happens is the family develops what I'd call a "diagnosis-centered structure." Every decision runs through the filter of the diagnosed child's needs first. And paradoxically, that can actually make the child's symptoms worse, because now there's systemic reinforcement for the very behaviors everyone is trying to reduce.

Dr. Sloan Bruan Lorenzini

That paradox is something I think many clinicians underestimate.

Dr. Mick Larson

They do. And the families certainly don't see it coming.

Dr. Sloan Bruan Lorenzini

Let's move into the structural mapping piece. When you sit down with a family for the first time — say it's a two-parent household with a ten-year-old who's recently been diagnosed with ODD and a thirteen-year-old sibling — walk us through how you begin mapping the system.

Dr. Mick Larson

Great example. The first thing I'm doing is observing the enactment — who sits where, who speaks first, who looks at whom when a sensitive topic comes up. I'm not just listening to content; I'm watching process. Minuchin was very clear that structure reveals itself in interaction, not in self-report. So I'll often prompt an in-session conversation between the parents about a recent difficult episode and just observe.

Dr. Sloan Bruan Lorenzini

You're letting the structure show itself rather than asking about it.

Dr. Mick Larson

Exactly. And what typically emerges is a map. I'm looking for coalition patterns — is one parent aligned with the diagnosed child against the other parent? That's a cross-generational coalition, and it's one of the most destabilizing patterns we see. I'm looking at boundary clarity — is the parental boundary diffuse, meaning the kids are involved in executive decisions? Or is it rigid, where the parents are so disengaged that the children are essentially self-governing?

Dr. Sloan Bruan Lorenzini

And in families dealing with a behavioral health diagnosis, which pattern do you see more often?

Dr. Mick Larson

Diffuse boundaries, almost every time. The parents are so worried about the diagnosed child that they pull that child into the parental subsystem — consulting them on rules, negotiating consequences in the moment, walking on eggshells. The hierarchy flattens, and the child ends up holding more power in the system than is developmentally appropriate.

Dr. Sloan Bruan Lorenzini

Which can actually increase the child's anxiety, paradoxically.

Dr. Mick Larson

Precisely. Children need to feel contained by a competent parental system. When the hierarchy is unclear, even a child who appears to be seeking control is often deeply anxious underneath. Strategic interventions can be very useful here — we might prescribe a structured routine that restores parental authority without being punitive, or we might reframe the child's behavior in a way that shifts the parents out of their reactive cycle. The goal is always to restore the family's organizational health so the child can do the developmental work they need to do within a stable relational structure.

Dr. Sloan Bruan Lorenzini

I'd love to explore the parental experience more. You mentioned guilt earlier — can you unpack that?

Dr. Mick Larson

Parental guilt is enormous in these cases, and it drives a lot of the structural dysfunction. There's the guilt of "Did I cause this?" — especially with diagnoses like ODD or conduct disorder, where parents feel blamed by the diagnostic language itself. And then there's the guilt of "Am I doing enough?" which fuels what I call the over-accommodation trap.

Dr. Sloan Bruan Lorenzini

The over-accommodation trap — tell us more about that.

Dr. Mick Larson

It's when parents, out of genuine love and concern, remove every possible stressor from the child's environment. They stop setting limits because limits trigger meltdowns. They stop enforcing bedtimes. They excuse aggressive behavior toward siblings. Essentially, the family adapts entirely to the child's dysregulation rather than helping the child build tolerance.

Dr. Sloan Bruan Lorenzini

And that accommodation becomes its own maintaining factor for the symptoms.

Dr. Mick Larson

Exactly. Research by Eli Lebowitz at Yale has shown this very clearly with childhood anxiety — family accommodation predicts symptom severity above and beyond the child's individual factors. And what I add from a structural perspective is that over-accommodation doesn't just maintain the child's symptoms; it restructures the entire family. Siblings lose parental attention. The marital relationship erodes because the parents are in constant triage mode. The family's social world shrinks because outings become too stressful. It's a systemic cascade.

And the sibling piece is something I feel very strongly about — siblings in these families are often what I call the forgotten clients. The thirteen-year-old in our example may be carrying resentment, parentification, even their own emerging symptoms, and nobody in the system is tracking it because all the clinical attention is on the diagnosed child.

So in my work, I make it a point to bring sibling dynamics into the room early. I want to see how the sibling subsystem is functioning. Are the siblings still connected, or has the diagnosis driven a wedge? Is the older child being asked to be a co-manager of the younger child's behavior? That's a boundary violation that can have lasting developmental consequences.

From a strategic standpoint, I'm also looking at how the family's attempted solutions have become the problem. Parents try harder, accommodate more, monitor more closely — and the child's behavior doesn't improve, or it gets worse, because the solution itself is reinforcing the pattern. Watzlawick's "more of the same" principle is almost always at play.

So the therapeutic work involves helping families integrate the structural piece — restoring clear hierarchies, appropriate boundaries, functional subsystems — with the individual treatment the child is receiving. I collaborate closely with the child's individual therapist, their psychiatrist if medication is involved, and the school team. Because if the family work and the individual work are running on parallel tracks with no integration, you get contradictory messages. The child's therapist might be working on distress tolerance while the family system is organized around distress avoidance. That's a clinical conflict that can stall progress for months.

The integration piece requires good communication between providers, a shared case conceptualization, and honestly, some humility. Family therapists need to understand the individual clinical picture, and individual therapists need to appreciate the relational context. When both lenses are active and coordinated, the outcomes improve substantially.

Dr. Sloan Bruan Lorenzini

Mick, this has been an incredibly rich conversation. Any final thoughts for clinicians who are working with these families?

Dr. Mick Larson

I'd say remember that the family is the client's primary relational context. A diagnosis doesn't exist in a vacuum — it exists inside a system. If we only treat the identified patient without attending to the system, we're leaving the most powerful lever for change on the table. Structural and strategic approaches give us a map and a method for doing that work rigorously and respectfully.

Dr. Sloan Bruan Lorenzini

Dr. Mick Larson, thank you so much for your expertise today. This has been invaluable for our continuing education audience.

Dr. Mick Larson

My pleasure, Sarah. Thank you for having me.