The power of the genogram

Matthew Adam

Introduction Vignettes mother, uncertain about how to react. Recently, while working in my professional 1 Jessica’s mother stated that while neither context, a Tier 4 inpatient hospital, I was ‘Jessica’, a 16-year-old girl, had been sexually of her girls had heard these stories they struck by a bolt of metaphorical lightning abused by her father when she was 11 years needed to be told and that she explained that drew my att ention to the seemingly old until she was 14 years old. She had been that she harboured guilt and responsibility innocuous tool many family therapists use referred to the inpatient unit for deliberate and for Jessica’s subsequent abuse. Th e on a day-to-day basis, the genogram (Carter severe self-harming behaviour and for having family story had suddenly become & McGoldrick, 1998). made two serious suicide att empts by over- overwhelmingly powerful and frightening Th roughout my clinical training I dosing on paracetamol. Aft er a few months and the young girls visibly withdrew inside understood the genogram’s value as Jessica’s mood lift ed and she developed coping themselves for the duration of the session. an assessment tool, an opportunity to strategies to help her deal with her thoughts of develop an awareness of patt erns or scripts self-harm and it was decided that home leave Family 2 in , oft en trans-generationally, could begin. Visits home from the hospital ‘Suzanne’, a 16-year-old diagnosed and to use this feedback as a basis for the seemed to coincide with overdoses in the with anorexia nervosa, att ended a family formulation of hypotheses which would, community and the family oft en returned Jes- therapy session with her mother and of course, form the framework for the sica back to the unit distraught and angry. sister. Th e family had att ended one session therapist’s questions to the family. It has For the fi rst session with this family, I before but had not been able to discuss only been while working in a Tier 4 inpatient requested that as many family members as family relationships in that session. Th ere sett ing that I have been witness to the power possible be present and Jessica, her mother appeared to be a gap in the knowledge the of the ‘’. For many families, and younger sister att ended the session. professional system had about Suzanne’s the exercise of telling their stories to the Jessica’s mother’s boyfriend was unable to extended family and they were asked if they therapist is just an information gathering att end the session, but sent his apologies were happy for me to complete a genogram. exercise. But for some, the genogram is and hopes that he could att end subsequent As the session began, Suzanne and her an intervention that can be extremely sessions. Being conscious that Jessica sister, Emily, spoke about how they were powerful, thus negating it as an exercise in and her family were ostensibly meeting a protective of each other because of life understanding and making it an infl uential stranger and may be reticent to speak about experiences they had. Th ey spoke briefl y force upon the therapeutic process itself. sensitive issues related to the reasons Jessica about their parents divorce and that this had In taking a detailed account of a family’s was struggling, I decided to complete a sent Suzanne’s sister ‘off -the-rails’. As the history and the relationships that comprise genogram in the fi rst session in the hope family began telling their family narrative I that system, stories lived can indeed become of allowing the family to acclimate to the wondered if I might also construct a timeline stories told (White & Epston, 1990). In some therapeutic process and to ‘take it slow’. of events, to help me make sense of the instances the stories have been recounted I began by asking Jessica and her family if timings of the signifi cant events in the family. before and serve to defi ne the family they would allow me to complete a genogram, Th ey agreed and were soon telling the story functioning. But at other times some stories explaining the ideas behind the genogram. All of when they began to notice that Suzanne have never before been told to an outsider family members agreed to this form of story- was restricting her diet. Th ese stories were and the impact of elevating these unspoken telling and indicated in no way a discomfort connected to a maternal Aunt who had an narratives may leave a profound and lasting with this method of information-gathering. undiagnosed eating disorder, which lead the impression upon the family as a whole and As the session progressed and the genogram way for Suzanne’s mother to tell her stories. for each individual member (Roberts, 1994). became more complete, Jessica’s mother Th e youngest of three children, Suzanne’s In my work with two complex families, I began telling stories that resonated with mother, Kathy, explained that her birth had introduced the genogram as a way of gett ing Jessica’s history and which neither daughter been an ‘unplanned mistake’ and that her ear- to know the family and their history, to ‘warm had previously heard. Jessica’s mother liest memory was of her parents arguing about the context’ and to prepare the way for the revealed she had an older child whom she who had wanted her least. Her father had died diffi cult conversations that were certain had placed up for adoption three years before when she was 17 years old and she had never to be had. Indeed, what actually occurred Jessica’s birth. Jessica’s mother continued shared a close relationship with her mother or and what I expected to occur were two very telling her story and explained that this child sisters. Kathy had stopped seeing her second diff erent events. At the time of meeting with was conceived when she was raped by a oldest sister, Sally and her husband aft er an ‘in- these families, I had an awareness of a family maternal cousin, resulting in her immediate cident’ between Kathy’s husband and Sally’s protectiveness around diffi cult stories, but I family rejecting her outright and abolishing husband. Both Suzanne and her sister asked had litt le awareness that in being complicit her from the family home. their mother to explain what had happened, The power of the genogram in joining in this intervention, both families With this new information surfacing that they had diff ering accounts of the story would leave feeling exposed and vulnerable Jessica became quiet and agitated and from multiple sources but still did not know and desiring never ‘to do THAT’ again. her younger sister quietly sat next to her what had happened from their mother’s story. 30 Context June 2010 Four generations of men/boys in the Adam family.

Kathy refused to explain what had and how they function together as a unit. feeling anxious and worried. Being aware happened and queried what this story had to In my work, I fi nd that if I do not complete of this while in the room I tried helping the do with Suzanne’s illness. Th e conversation a thorough genogram within the fi rst three family move to a more sett le and manageable once again returned to the timeline of sessions of my work, the opportunity to place before lett ing them leave. But, it would events, where Suzanne remarked with a assess the family passes and the information be fair to say that in each case I was left certainty that her illness was the result of is harder to obtain in the later stages of the stunned by the power of the genogram. I her mother’s relationship with Michael. therapy. Th ere is an argument for delaying found myself in a position of disbelief, that Suzanne, Emily and Kathy spoke openly and the use of this therapeutic tool for later in the telling of a story would be so powerful as candidly about Michael and the confl ict that the work, surely the therapeutic relationship to make the family distrust the therapeutic had developed between Suzanne and her will have developed and trust and safety, process. I think it took me taking this mother as a result of the inevitable distance both essential to creating a secure base, may position of disbelief to allow me to consider this new relationship had created. beginning to take hold. But perhaps this what it was that actually happened. I realise Th e genogram was nearing completion delay may further entrench a family’s desire that for me, the genogram placed me in a and Kathy briefl y stated that her divorce to ‘hold on’ to stories that may infl uence position of power over the women in the from Suzanne and Emily’s father had been how an outsider might perceive them. room. Th e telling of the family history was messy and taken fi ve years. I summarised In both my case examples, the so powerful and I, having asked these stories the session, stating that the issues about genogram was provocative and made an to be told, became perceived as part of the men seemed important to this family when initial impression that oppressiveness of the stories. Kathy became visibly agitated and upset, was dangerous, not to be trusted, and expressed that she felt uncontained and uncontainable. I am aware of the gender Moving beyond the that the subject matt er was entirely too divide, that in both cases I was the male in uncontainable The power of the genogram of the power The diffi cult to explore and queried what any a room with three females. Being a male Confl icted in both these cases as to of this had to do with Suzanne when they therapist, I may have represented that ‘bad’ whether the process of constructing a should be future focused, before promptly man who had abused his power and taken genogram had been helpful to the family, leaving the room in a fl ood of tears. When so much from the women in each session, I hoped that I would be able to re-engage Kathy eventually returned she said that she manipulating my tool, the genogram, to the family and help them understand that was unsure this process would be helpful control. I have no doubt that such power though diffi cult, family therapy could and did not believe it should continue. diff erentials developed as a result of be helpful to them. Recognising that implementing this intervention, certainly sensitivity to the family’s vulnerability Refl ections it was evident before the end of the session would be a cornerstone to the development Completing a genogram early in the work with the second family. of the therapeutic relationship, I drew on with a family is important as it can provide Th e families physical and emotional Rudi Dallos’s (2004) ideas on ‘att achment a wealth of information about the family reactions to the telling of their stories left me narrative therapy’. Context June 2010 31 Creating a secure base in the therapeutic space was not immediate and took time but as Working with the family began to trust in the process they managed to speak openly about subjects that were once ‘off -limits’. As the families found marginalised families: their way in understanding themselves they drew on their beliefs and stories of internal and familial strength to carry them “Can you do that without through those diffi cult, but much needed conversations. Th ese experiences have helped me in breaking too many eggs?” recognising that utilising the simplicity of the genogram with diffi cult and complex families can oft en render them feeling C a r l o s J . S a n c h e z uncontained, vulnerable and exposed. But in divulging such diffi cult and painful It is an art to develop specifi c As early as 1967 Minuchin introduced the stories so early on in the therapeutic process, interventions in psychotherapy and family concept of disorganised families to describe families can draw upon their strengths and therapy. Sometimes you are a Picasso and the lack of consistency and unpredictability resiliencies to get through other diffi cult and sometimes you are a two-year-old with in the interactions of the family living in oft en more complicated conversations. a crayon and a wall. More than patience, poverty. He attributed it to psychological Much the same as a family sculpt can discipline and practice are needed to create defi cits the parents and/or authority fi gures be too powerful for a family, so too can a context for change. Just because you can within the family. At that time he did not completing a genogram and the subsequent identify a problem does not mean you are have the accumulated sociological evidence conversations that accompany it. Respectful closer to fi xing it. The title of this article is a that we have now. Thirty years later, while appreciation of a family’s history and warning to those working with marginalised working with the foster care system in New developing an awareness of the potential families when there are several social/ York City, Minuchin and Colapinto reported that each story has for bringing with it government institutions in their territory. that the external interference of protective powerful emotions are important skills to Usually the low-income families are services agencies forced some families to apply to the genogram. receptive to the therapist who shows adopt a functioning style that reinforced Th at a family can enter into an unspoken interest in them but this does not imply the interference. The family was no longer agreement with their family therapist to they want treatment. Jorge Colapinto accountable to its members, but to the divulge the stories that comprise their (1991), in his article Pretend Therapy, representatives of the diff erent agencies/ reality without having agreed upon their described how some families manage the mental health providers. infl uence over when the story-telling presence of many institutions when they Things have to be done diff erently should stop, or when a sensitive story is are imposed upon them. Colapinto wrote to assist the family in understanding being encroached upon, is an act that is so “ …many of these families go through the that as a unit they have some degree of extraordinarily powerful and potentially motions of therapy, keeping at least some accountability in resolving their problems harmful that the family therapist should of their appointments, minimally answering and avoiding the “pretend therapy”. The always consider how best to use such a tool. questions, may be even extolling the virtues formula requires a diff erent type of joining of two weeks of treatment, but not really from the usual pleasantries. References engaging in a therapeutic relationship”. It combines support and confrontation Bertrando, P. (2007) The Dialogical Therapist: Dialogue in Systemic Practice. London: Karnac. The literature suggests several avenues for as part of the relationship. The posture of Carter, B., McGoldrick, M. (Eds) (1998) The success: the proper utilisation of the self of confl ict-avoidance tends to perpetuate the Expanded Family Lifecycle: Individual, Family, and the therapist; the strength of the therapeutic same behaviours that brought the family Social Perspectives. (3rd Edition) New York: Allyn and Bacon. relationship; the need of the therapist to to the attention of the institutions in the Dallos, R. (2004) Attachment Narrative Therapy: believe in the eff ectiveness of a particular fi rst place. Sometimes you have to hang a Integrating ideas from narrative and attachment clinical model; and the right technique. villager to get the town’s attention. Once theory in systemic family therapy with eating disorders. Journal of Family Therapy, Vol. 26, 40-65. What is missing in all of the above is how this therapist admonished a parent who Roberts, J. (1994) Tales and Transformations: Stories institutions modulate what is going on. showed up late for a court hearing: “You are in Families and Family Therapy. New York: Norton. Traditionally, the point of departure is late. These are your children, not mine. You White, M. & Epston, D. (1990) Narrative Means to the family unit. We are proposing shifting need to be on time; otherwise I can’t work with Therapeutic Ends. New York: Norton. the center of attention from the family unit you”. Matthew Adam completed his qualifi cation to the “institutionalised families”. I use the The extension of support outside the at IFT in August 2008 and moved to term “institutionalised” to describe the therapeutic time is one of ways to building Shropshire with his wife. He works as a involvement of several public and private credibility and trust. The presence of the family therapist at Huntercombe Hospital agencies in the functioning of the family. therapist in court earned him the right Working with marginalised families: “Can you do that without breaking too many eggs?” – Staff ord. Since moving in 2008 they have It tends to capture the dependency of the to expect punctuality from the client. We had a recent addition to the family, Felix, who is now fi ve months old. family on the approval of the authorities to can’t go around treating these families as validate their own decisions. if they are going to drop dead any minute 32 Context June 2010