Dr. Carlos Sluzki - Articles

Plenary presentation at the XIII IFTA World Congress, Porto Alegre, Brasil, November 2001


Carlos E. Sluzki, MD

ABSTRACT: Demographic destabilization — population explosion, changes in family size, exiles, displacement and migrations by force or need — has a powerful negative effect on family well-being and health, as it debilitates its social support system and reduces its access to care precisely in periods of maximal stress and maximal need. A call for a political view of our practice and professional responsibility ensues.

While we family therapists — and therapist in general — are searching for models with some resemblance of stability and of universality, the world is experiencing extraordinary transformations around us. The train of change is accelerating exponentially while we run behind it hoping to catch the invariance.

In fact, the dramatic changes that are taking place worldwide in the demographic, socio-economic and environmental spheres are being described by an alarmed new generation of specialists in public health as a challenging threat to global health (Koop, Parsons and Schwarz, 2001). Hence, health policy experts are abandoning the microscope (a given defined disease-targets as main health threat to humankind, such as AIDS, cholera, Ebola virus, antibiotic resistant TB, or, not long ago and perhaps again in the near future, smallpox) in favor of a “macroscope” that seeks to specify those social variables that affect with increasingly heavier albeit unequal weight the quality of life of all the inhabitants of this planet.

A bird’s eye review of those variables yields a broad spectrum of social and economic inequalities and uneven distribution of resources that in turn trigger processes that become both cause and consequence of rampant global demographic destabilization, characterized by:

  • Population explosion — with a rather irregular distribution, as population increases in some countries, such as India, or Brazil, and decreases in others, such as Russia, or Albania (and will soon decrease in central Africa due to the unchecked AIDS epidemic);
  • Shifts in family size , with a substantial reduction by choice in First World countries, while the population of frail elders — that is increasing in numbers due to better healthcare — is expanding to the point that will soon exceed the capacity of working adults to support them; and a substantial expansion in many Third World countries — because of a relative decline in mother/infant mortality accompanied by both ignorance about contraception and cultural mandates toward a large progeny. This expansion is exceeding, in many countries, the capacity of adults to support their children, as well as the capacity of their country to feed its own inhabitants — the most dramatic example being the plight of sub-Sahara region;
  • Migration by force — currently there are some 50 million human beings forced by wars to live the lives of the refugees (in other countries than their own) or of the internally displaced (within their own countries), from Congo to Sudan to Afghanistan to Colombia;
  • Immigration due to economic need — not infrequently without proper documents, from Mexican into the US to Kurds and Turks into Germany to Albanian and North African into Italy. The frequently clandestine nature of their displacement weakens the capacity of these migrants to raise from the lowest ranks of the work force, and leaves them legally unprotected from exploitation, and without access to social resources such as health care and education;
  • Internal displacement due to economic need, from the impoverished countryside, such as the Brazilian North-East, or drought-stricken Somalia, or arid areas of Mexico, to the poverty trap of great metropolis such as Sao Paulo, Mexico DF, New Delhi, Chicago, and Cairo. To that should be added the increasingly frequent and fluid displacement of the more affluent population due to jobs specifications, promotions and changes.

All these factors not only weaken the cohesion of the local social support network and of the regional cultural norms and mores but alters the structure and function of the family — with an erosion of the resource of the extended family and an thinning of the surrounding social cocoon — , which in turn affects negatively the patterns of health and disease and, alas, the basic quality of life (cf., e.g., Berkman and Syme, 1979 and House, Robbins and Metzer, 1982).

As mentioned above, the key fuel for this demographic destabilization, and threatening both directly and indirectly family resourcefulness and health, lies in major economic disparities among countries, with the poor world — most of Africa, Latin America, and Asia — falling each time more behind the rich world — chiefly the industrialized nations of Europe and North America — , not to mention the dramatic regional and social class contrasts, even within the wealthiest countries. And, as it is well known, the much-tooted free-market economy and globalization only cements the economic imbalance between developed and developing countries, further compounded by corruption and the impossible burden of the external debt in the latter countries. The direct relation between poverty, malnutrition, disease and death are well known. The direct relation between poverty and deterioration of the family cohesion and resilience is also being increasingly acknowledged. Poverty has a devastating effect on people’s physical and emotional well-being, as it belies all resemblance of social contract, robs a sense of community, and weakens basic family functions such as the capacity of the adults to positively affect their own future and that of their children. The direct relation between abject poverty and hopelessness as well as hate against those who do not share their wealth has becoming clear for many only after the 9/11/02 terrorist attack on New York and Washington, expressive by the violence of its deadly expression.

Most critical processes that negatively affect quality of life and of health directly and indirectly associates with a weakening of family resilience and of the social fabric of reciprocal reliance, and are tied to socio-economic underprivilege. They includes, in no particular order:

  • infrastructure inadequacies — such as lack of clean water and contaminating sewage facilities, that constitute a daily threat for hundreds of millions of people;
  • under-attention to the vulnerabilities of women — with a maternal mortality rate 24 times higher in the poorest countries as compared to the most affluent, and its obvious effects on families, especially on children;
  • micro-environmental problems — including a new rampant problem with tuberculosis, syphilis, diphtheria, malaria in Russia, old unchecked diseases such as dengue in many Latin American countries, not to mention AIDS all over;
  • violence of epidemic proportions — domestic abuse, child abuse, child slavery, child soldiering, urban violence and street crime, political torture, bio-terrorism and, of course, tribal, regional, ethnic, and expanded wars.
  • seemingly unstoppable deterioration of our natural environment, with the predictable loss of resources for food and shelter;

Each and all these variables are part and parcel of the daily drama of life for countless millions, and hence should be kept present within our view of the world, lodged in the core of our daily personal and professional practices regardless of where in the planet we live. Each of them, alone or in combination, negatively impact the well-being of people, the structure and functions of the family, and the characteristics of their personal social network, essential contributor to personal identity and to physical and emotional health. Hence the “Families Imploding” of the title of this presentation. What follows explores more in detail some of these effects.

Regardless of mobile or sedentary, families in the dawn of the 21st. Century are evolving toward operating as an isolated functional unit, differentiated from the extended social fabric. And, as extended social networks act as protectors against stress, the more insular the family, the more likely that a crisis may occur (Sluzki, 1998)

Individuals tend to be unaware of the impact that the loss of their extended social network has on their daily life, and whatever new, scarce, natural connections they may have been recently established will not be activated when a crisis occurs — including those many crisis that could have been buffered by the active presence of a solid personal social network. Therefore, individuals and nuclear families are not only more exposed to potential crisis but more vulnerable to their full impact (Sluzki, 1996).

When a crisis occurs, members of these nuclear families, instead of reaching out to our prior extended resources, turn inward, utilizing each other as resources much beyond their own capabilities and prior experience. Of course, this takes place precisely when each is more overloaded and hence less available. Moreover, when failing to cope or to help, they experience that failure as product of their own incompetence.

There is a progressive dismantling of public welfare in the name of private enterprise and global competition (Bourdieu, 1988), especially in the industrialized nations and in most of the countries under their sphere of influence. But, due to the mystifying rhetoric that package those changes, the reduction of access is perceived by patients and families as product of their own inadequacies.

Geographic displacements — be it by choice of by force — entail a further loss of social bonds and social capital, that is, the “connections among individuals — social networks and the norms of reciprocity and trustworthiness that arise from them” (Putnam, 2000), which constitutes the strongest predictors of life satisfaction.

Each culture has its own style to foster and maintain social connections. Therefore, the explosion of cross-cultural (including rural-to-city) migrations place an increasing number of people, newcomers to a given culture and context, at disadvantage in terms of their skills to establish new social networks (except with other newcomers, which in terms acts both as an immediate support and as a hindrance of rooting.)

In any given community, there are comparatively fewer opportunities for newcomer adults than for children in terms of establishing community relations and activities. Hence, children will tend to develop network bonds at a greater speed than grownups — and frequently more in tune with elements of the new culture — , generating a lack of synchrony in the process of adaptation, and marked dissonance in the descriptions of their reality between generations.

In any given community there are different points of entry for women and for men in terms of accessing social networks, be they through work, neighbor contacts, children’ schooling, sports, or alcohol use. Hence, lack of synchrony is predictable for members of a couple in terms of social insertion, with predictable negative consequences for the couple’s relation (Sluzki, 1979)

The current huge refugee and internally displaced population — no less than 50 million, as already mentioned above — not only have suffered the alienation of forced uprooting but the dismemberment of their natural community but live in conditions that hinder the establishment of new social networks with any potential of resourcefulness and stability. Hence, these individuals and frequently truncated nuclear families are not only more prone and vulnerable to crisis precisely when all the external conditions are maximally stressing, but are unlearning social skills and reducing resilience when totally dependent on international help, or maximally victimized when not.

In sum, and acknowledging that this list of variables is incomplete, they all show a trend toward an expansion of needs and expectations centered in the nuclear family. At the same time, they show a weakening of family resources, including a substantial shrinking of the extended social cocoon and a weakening of social entitlements. Hence, drastically increasing demands are coupled with a dramatic decrease in natural and social resources. These colliding trends affect us, and those who consult us, in many ways. It takes our awareness of them to be able to spell out in each case how do they manifest themselves, not whether they do.

Clinical practice is frequently a soothing experience, as it provides us with the opportunity to contribute to enhance the quality of life of those families we work with (in general terms, we therapists are not particularly adept to evaluate our own quality of life, which is taken for granted and seldom questioned). Clinical practice in a private setting is, for many, additionally soothing because it allows us to live with the illusion of a closed, relatively harmonious microcosm. An increasing awareness of psychosocial variables, such as those discussed in this presentation, may destabilize that illusion. But placing the larger picture at center stage reminds us to keep our own personal and professional life at least minimally faithful to the sense of responsibility that comes from inscribing ourselves as a member of the human family, a belonging in which there are no bystanders.



  • Berkman, L.F. and L. Syme (1979): “Social networks, host resistance, and mortality: A nine-year follow-up study of Alameda County residents”. America Journal of Epidemiology, 109(2): 186-204
  • Bourdieu, P. (1998): Acts of Resistance: Against the Tyranny of the Market. New York, The New Press.
  • House, J.; C. Robbins; and H.Metzner (1982): “The association of social relations with mortality: Prospectiive evidence from the Tecumseh Community Health Study”. American Journal of Epidemiology, 116:123-40
  • Koop, CE, Parsons, CE and Schwarz, MR, Eds. (2001) Critical Issues in Global Health. San Francisco, California, Jossey-Bass.
  • Putnam, RD (2000): Bowling Alone: The Collapse and Revival of American Community. New York, Simon and Schuster.
  • Sluzki, CE (1979): “Migration and Family Conflict”. Family Process, 18(4): 379-390; and as a chapter in R.H. Moos, (ed.): Coping with Life Crisis: New Perspectives. New York: Plenum, 1985.
  • ———- (1992): “Network disruption and network reconstruction in the process of migration/relocation.” Family Systems Medicine 10(4): 359-365. An expanded version was published as “Migration and the disruption of the social network,” as a chapter in M. McGoldrick, Ed. (1998): Re-Visioning Family Therapy: Multicultural Systems Theory and Practice. New York, Guilford Press.
  • ———— (1996): La Red Social: Frontera de la Terapia Sistemica. Barcelona: Gedisa; and (in Portuguese) Sao Paulo: Casa do Psicologo, 1997.
  • Sprinkle, EH (2001): Review of “Critical Issues in Global Health”, edited by C.Everett Koop, Clarence E. Parsons, and M. Roy Schwarz. San Francisco, Calif., Jossey-Bass, 2001. JAMA, 286(13): 1641-2.
  • Widgren, J (1988): “The uprooted within the global context”. In D.Misarez, Ed.: Refugees-The Trauma of Exile. Dordrecht, Martinus Nijhoff Publishers.
  • W.H.O. (2001): Report of the Commission on Macroeconomics and Health, World Health Organization.


  1. Consider also Sprinkle (2001) lucid reworking/review of that book, which informs part of this presentation.
  2. Less than 150 years ago, the population of Europe constituted about one-third of the world’s habitants. And it is not that the natives — African, Latin American, or Australian aboriginal — were under-counted: reliable demographic reconstruction places 1850 Europe with 33% of the total number of inhabitants of the globe (Wildgern, 1988). Currently, Europe contains a mere 6%. It is estimated that — even accounting for the devastating effects of the AIDS epidemic and of interminable tribal wars, as is the case of most of central Africa — 10 years from now, Nigeria alone will have more inhabitants than all of Europe. Brazil, with its 180 millions inhabitants, has nowadays a population larger than the whole South America had some 50 years ago. India has surpassed last year its billionth inhabitant, one sixth of the world population.
  3. A change that has its pros (a decreased isolation and conservatism) and its cons (a loss of collective rituals and moral frames that curtail violence and fracturing, and an increase in social alienation).
  4. About U$13 is spent per person per year on health care in the world’s 60 poorest countries, including all sub-Saharan Africa, some Asian nations, and Haiti. In the industrialized world, by contrast, the average per capita spending on health is about $2000 per year, a figure more than doubled ($4500) for the United States. (WHO, 2001)
  5. In writing this I have chosen a more aseptic third person (“they”, “families”), but each of the following paragraphs could, and perhaps should, have be written in the first person (“we”, “our families”).