Which tool would help the nurse to understand a familys structure and relationships?

Family System: Genogram

The genogram gives the play therapist a visual representation of the family structure and history. A sample of the formats and symbols used to represent various familial relationships is included in the Intake form. The genogram should go back at least two generations and include all first-order relatives to provide as clear a picture of the family as possible. Several items should be specifically noted on the genogram.

All family members, living and dead, should be included. This means you may have to ask directly about miscarriages, stillborn infants, and children who died in infancy. Often, families do not mention these members as they are not currently a part of the family.

It may be useful to include unrelated persons who live in the same household as part of the genogram. Again, this will give a more complete picture of the family and the nature of their relationships.

Any hereditary or recurring illness, both medical and mental, should be noted. If necessary, the genogram should be expanded to show how these individuals fit into the family tree.

Intergenerational child abuse and/or substance abuse and/or mental illness should also be noted.

The genogram can be completed by hand and inserted into the ecosystemic intake, or it may be completed with one of several genogram computer programs now available, e.g., www.genogramanalytics.com; www.genogram.org; www.genopro.com. For additional information on creating genograms, see Genograms: Assessment and Intervention, 3rd edition (McGoldrick, Gerson, & Petry, 2008). This book includes a particularly useful chapter for play therapy treatment planning – Family Play Genograms, co-authored with Eliana Gil (Gil, McGoldrick, Gerson & Petry, 2008). In this version, miniature toys are incorporated into the family creation of a genogram. The genogram is first drawn on a large sheet of poster board or paper and should include all biological and legal members of the family, as well as any other people important in the family and even pets. Family members then select, from several miniature people, animals, and objects, an item to represent each person on the genogram, and take turns talking about their choices. With support, even children as young as 5 years old can engage in this activity. Once completed, the therapist can, with the family’s permission, take a picture of the genogram, creating a permanent record of the final product.

Case Example

5.07.5.1.1 Family genogram

The genogram is a frequently used method for identifying who is in the family, and what role important family members play with respect to one another. The conventional genogram includes biological family; however, genograms may also include individuals based on the function they serve within the family. For example, in our own work with inner city African-American families (Greenwood, Herves et al., 1995; Greenwood, Samuels, et al., 1995), defining “family” solely through biological relationships fails to represent the complex family/kinship network of these families. What is required is a more flexible approach to identifying family/kin that examines: (i) blood relation and/or extended kinship; (ii) perceived strength and duration of relation-ships; and (iii) perceived support—in either direction—(including financial, emotional, and instrumental help, e.g., who provides transportation, child care, and other types of assistance). In our experience, “family” often includes all individuals living within a household (except for roommates and transient “live-ins”) as well as other important significant others who may or may not be biologically related to one another.

The genogram is like a family tree in that it depicts all of the important relationships within the family. One of the most important reasons for constructing a genogram is to obtain a more complete picture of the family constellation. The genogram is a tool for systematically identifying who is in the family—getting around the common problem of some families not letting therapists know about key but conflicted or undesirable relations. Thus, the genogram can also be useful in helping the therapist depict adaptive and maladaptive family interactions (e.g., conflicted or supportive relations may be depicted using a jagged line or straight line).

There are many strategies for conducting genograms, and various symbols are used to denote meaningful relationships and/or roles within the family. Regardless of the strategy or symbols used, the genogram is an excellent method for organizing the complex interconnections between family members in a coherent, organized manner. The drawback of the genogram is that it is a “snapshot” of the family, and as such yields relatively little information about family interactions. In other words, the genogram tends to be static rather than dynamic. Genograms represent the first stage of the assessment process, and are often used to establish rapport and gather information about who are the potentially critical “players” in the youth's life. This information provides the context for further assessment into the dynamic interaction patterns that characterize the family members identified in the genogram.

2.12 The Community Genogram

The community genogram is another useful tool for gathering culturally encompassing client data (Ivey and Ivey, 1999). Indeed, the goal for using such a genogram is to bring cultural issues to the forefront in the assessment process and to focus on the positive resources that come from understanding the multiple components of one’s cultural experiences. Ivey and Ivey (1999) explicitly recommend that when helping clients construct community genograms, therapists should focus on stories of strength, rather than on problems. Such a focus often leads to client recollections of useful strategies they had relied upon in the past that can be implemented to help solve current issues.

The process of constructing a community genogram entails two major steps (Ivey and Ivey, 1999). First, clients should be instructed to develop a visual representation of the community in which they were primarily raised and/or the community support network that they are currently residing within. Client representations of such communities will vary from concrete pictures to more abstract or symbolic representations (see Figure 2.3 for an example of a completed community genogram). Once the community is drawn, the next step is to have clients draw themselves or a symbol of themselves within that community, followed by a representation of their family members’ places within that context. Then clients are instructed to place the most important or influential people or groups in their lives onto the community genogram and to connect the various individuals and groups to the client in such a way as to indicate which people are most influential (i.e., bold lines to represent stronger ties, dashed lines to represent more distant associations).

The second major step in the use of genograms includes helping the client to find images and to tell narratives of strengths based on the community representation that he or she previously developed. To find these positive resources, clients should be instructed to choose one community group or the family to focus upon. Once a focus group is chosen, clients are asked to develop and fully experience visual, auditory, or kinesthetic images that represent something positive about their connection to that community group. This step is repeated with at least two more positive images from different community groups. Therapists then engage clients in a discussion of what they learned, thought, and felt via the process of this genogram construction and reflection on positive images.

The process of constructing a community genogram is often very powerful and emotion-laden for clients. For therapists, the process typically provides a window into the unique cultural background of clients. Finally, constructing a community genogram leads to a “reservoir of positive experiences that can be drawn on to help you and the client throughout counseling” (Ivey and Ivey, 1999, p. 240). Indeed, placing the community genogram on the wall at each therapy session will further ensure that clients and therapists call upon the cultural strengths identified and remember to always consider multiple perspectives on any issue (Ivey and Ivey, 1999).

Genogram

The word genogram refers to a diagram illustrating a person’s family members, how they are related, and their medical history. The genogram allows the patient to see hereditary patterns of behavior and medical and psychological factors that run through families. In Network Support treatment, the genogram helps the patient see the presence of alcohol dependence across generations, and can motivate the person to break the cycle of addiction by increasing his/her social support for abstinence. In the session the therapist diagrams two or three generations of the patient’s family, starting with the patient’s own generation. The patient is asked about drinking in his/her parents, and grandparents, as well as siblings and cousins. The patient is also asked about the possibility that his/her children might be affected by alcohol dependence. Patterns of inheritance are explored, and the patient is confronted with the possible implications of these patterns. At the conclusion of the session, the patient is asked to develop options to deal with facts exposed by the genogram, including finding ways to stay sober.

Identifying Family Members: The Genogram

The genogram is a diagramming tool developed in genetic research and family medicine to help capture, on paper, all the persons in a family. A simplified sample is presented in Figure 22-7. In this figure, squares represent males and circles represent females. Solid lines indicate a marital or offspring bond. A solid line with a crossed line through it represents a separated relationship (e.g., divorce) and a solid line with zigzag cross lines through it represents a conflicted relationship. Deaths are indicated by crossing out the square or circle. Offspring are indicated in their birth order from left to right. The identified patient or person with SCI is indicated by an arrow. The primary care provider can be indicated by a symbol, such as a star. The names, ages, locations, and major health problems of each individual are indicated in or beside each square or circle. The genogram usually starts with the parents or grandparents.

This diagram shows that Bob, who has SCI, lives in Long Beach with his wife, Anne, and their two sons, Fred, age 10 years, and John, age 16 years. Bob is 46 years old and has had his SCI since 1980. Anne is his wife and his principal assistance, but she has rheumatoid arthritis. Bob's dad is alive, but has Alzheimer's disease; Bob's mother is deceased from cancer. Bob has two sisters but they live in different states. Bob was married once before, to Linda, and they had a child, Becky, who is 23 years old and is married to Tim.

This family is at high risk of considerable stress. Bob and Anne both have disabilities, Bob's father has Alzheimer's disease, and Bob and Anne's two children are still in school. This family system may hold together as long as additional stress does not occur. However, that is unlikely. Bob has a high-level injury. Bob's father will get worse, Anne's arthritis may flare and Bob may develop new problems as he ages. Bob's dad will probably need support from Bob or Anne because the other siblings are out of the state. The main point is that a genogram ensures that a picture of the family is captured, its strengths and vulnerabilities can be revealed, assessments can be made of at-risk members, and a plan to follow or assist them can be implemented.

Family History

In addition to structure, the process of constructing a genogram also can evoke information about key events in a family's history, such as births, divorces, and deaths. These past events provide a context for understanding the current functioning of the family. In addition, more subtle, subjective, longstanding interpersonal dynamics often persist within the family of origin, even as people grow older (Fingerman & Bermann, 2000; Rossi & Rossi, 1990; Whitbeck, Hoyt, & Huck, 1994). With their long emotional half-life, disappointments and slights, unresolved conflicts or outright abuse can flare up many decades later, complicating a family's ability to make decisions or engage in care at all (Qualls & Segal, 2003). On the other hand, reviewing important events in the family's history also can identify strengths in how families have coped with challenges in the past.

The Practice

In order to loosen the grip of the past on the present, the therapist uses several tools (including interpretation of transferential objects in the room, interpretation of projective identification, and the use of the genogram to make sense of generational transmission of issues). In family therapy, transferential interpretations are made among family members, rather than between the patient and the therapist, as occurs in individual therapy. For example, when Mr. Bean says “I guess I am not an expert when it comes to female problems,” the therapist may have asked, “Who made you feel that way in your family of origin?” When he reveals that he has felt this way since his sister's suicide, he comes to understand how an old lens distorts his current vision (i.e., he still feels so guilty about his sister's death that he does not feel entitled to weigh in with opinions about his daughter's anorexia).

Another important tool for dredging up the past is the interpretation of projective identification, which Zinner and Shapiro2 have defined as the process “by which members split off disavowed or cherished aspects of themselves and project them onto others within the family group.” This process generates intrapsychic peace at the expense of interpersonal conflict. For example, Mrs. Bean may disown her need to control her impulses by projecting her perfectionism onto Pam. Simultaneously, Pam can disown her anger by enraging her parents with her anorexia. As these unconscious projections occur reflexively, they are more difficult for the individual to recognize and to own. Put another way, each family member behaves in such a way as to elicit the very part of the self that has been disavowed and projected onto another family member. The purpose of these mutual projections is to keep old relationships alive by the reenactment of conflicts that parents had with their families of origin. Thus, when Mrs. Bean projects her perfectionism onto Pam, she re-creates the conflict she had with her own mother, who lacked tolerance of impulses that were not tightly controlled.

In part, the psychodynamic family therapist gathers and analyzes multigenerational transmission of issues through the use of a genogram (Figure 13-1), a visual representation of a family that maps at least three generations of that family's history. The genogram reveals patterns (of similarity and difference) across generations—and between the two sides of the family involving many domains: parent-child and sibling roles, symptomatic behavior, triadic patterns, developmental milestones, repetitive stressors, and cutoffs of family members.2

In addition, the genogram allows the clinician to look for any resonance between a current developmental issue and a similar one in a previous generation. This intersection of past with present anxiety may heighten the meaning and valence of a current problem.3 With the Bean family (including two adolescents), the developmental imperative is to work on separation; this is complicated by the catastrophic separations of previous adolescents. Their therapist might discover a multigenerational pattern of role reversals, where children nurture parents, as suggested by the repetition of failed attempts of adolescents to separate from their parents.

Brief Description of Interim Sessions

As indicated above, Table 15.2 depicts the topic, purpose, and one sample activity for each of the interim sessions. Session 2 deals with Step 1 of AA and is designed to help patients accept that they are dependent on alcohol and need to receive external help for the condition. The manual advises therapists that acceptance often occurs in stages and encourages them to exercise patience with clients who are working through the process.

Session 3 focuses on Steps 2 and 3 of AA. It aims to facilitate surrender of self-reliance and acceptance of the AA approach. Patients are asked questions for the purposes of reminding them how they have lost control over alcohol and prompting them to contemplate the benefits of abstinence, spirituality, and the social support of AA participants.

Session 4 aims to enhance the patients’ motivation to participate in AA. Therapists explain the greatest benefits accrue to those who participate fully in AA activities. Patients are encouraged to develop a supportive social network by asking participants for phone numbers and permission to call them. Many AA participants seek support, advice, and understanding through telephone conversations with other members. However, the use of the telephone for such conversations has been understudied.

Session 5, the first to cover an elective topic, leads patients through the process of developing a genogram for family alcoholism. The manual states that a genogram is intended “to reinforce the concept of alcoholism as a disease and to motivate the patient to break the cycle of addiction by working the AA program.” Though producing a genogram for family alcoholism would be expected to increase patients’ acceptance of their alcoholism and increase their motivation to change, it is unclear whether or not this notion has been confirmed through empirical methods. Among patients with a limited family history, the genogram exercise may serve instead to reduce acceptance of an alcohol problem and motivation to change.

Sessions 6, 7, and 8 are intended to facilitate continued abstinence and AA participation by attending to malleable risk factors for drinking that may operate in the patients’ lives. Accordingly, Session 6 covers ways that significant others may have intentionally or unintentionally encouraged the patients’ drinking behaviors. It may be conducted only with the patients or conjointly with their significant others. Session 7 illuminates how patients need to make changes in relation to certain people, places, and things that have contributed to their drinking. Session 8 emphasizes the importance of avoiding or minimizing adverse physical and emotional states such as hunger, anger, loneliness, and feeling tired.

Session 9 examines Steps 4 and 5 of AA, which, respectively, calls for constructing a moral inventory and sharing its contents with another person. The act of constructing a moral inventory of one’s strengths and limitations is presumed to produce more self-awareness and a balanced self-concept. The act of sharing the inventory is believed to relieve guilt and to promote trust in others. However, as with the genogram, the discrete effects of performing Steps 4 and 5 have not been carefully evaluated through empirical studies.

Session 10 is aimed toward assisting patients to develop a healthy lifestyle. Patients are asked to discuss how their alcohol use harmed their diet and restricted their involvement in exercise and hobbies. Patients are also asked to set goals for proper nutrition, exercise, and hobbies.

Session 11 is used for conjoint therapy or to repeat a core or an elective topic. If conducted as conjoint therapy with a significant other, the session may focus on the need for appropriate detachment. The manual indicates that significant others can appropriately detach by allowing the alcoholic-dependent persons in their lives to experience and manage the negative consequences of their drinking. Al-Anon is described as a resource that significant others can use to cope effectively with instances of alcohol dependence among family members and friends.

Assessment of children

The way in which a psychiatric history is taken and the child is examined will depend upon the age, confidence and language skills of the child. Much of the history will come from the parents, and children who are prepared to separate from their parents can then be seen alone. It is usually best to see adolescents alone and before their parents in order to establish a trusting relationship with them. The interview should take place in a relaxed and friendly atmosphere, with toys and drawing materials provided for children less than 10 years.

The history should include the following:

Presenting complaint – described by both the parent and child. It is important to lead up to asking the child about the presenting complaint gently, after gaining their confidence and talking about neutral topics.

Recent behaviour or emotional difficulties – including general health, mood, sleep, appetite, elimination, relationships, antisocial behaviours, fantasy life and play, and school behaviour.

Personal history – pregnancy, birth, milestones (motor, speech, feeding, toilet training, social behaviour), medical history, separations from parents, schools attended and progress in them.

Family structure and function – construction of a genogram is often useful (see Fig. 2 for the genogram constructed for the Case history, Liam). Relationships between family members should be asked about, and the interactions during the interview observed.

Temperamental traits – traits such as activity level, regularity of functions (sleep, bowels, eating), adaptability to new circumstances, willingness to approach new people or situations, quality and intensity of mood, quality of relationships within and outside the family, attention and persistence can be observed from a very young age.

A mental state examination of the child should be completed, although this will often rely on watching behaviour and play. The following should be considered:

Appearance – looking for any abnormality, bruises, cuts, or grazes and appropriateness of dress.

Behaviour – activity level, interactions with parents, motor function, attention and persistence with tasks.

Talk – articulation, vocabulary and use of language.

Mood – happy, elated, unhappy, depressed, anxious, hostile or resentful.

Thoughts – content of speech and fantasy life, for example by asking for three magic wishes.

The assessment should be completed with a physical examination and by speaking to other informants involved with the child or family, such as the family doctor, school teacher, educational psychologist, or social services. Investigations may be performed, most commonly intelligence tests and tests of academic attainment, such as standardised reading tests.

10.08.5.4.3 Assessment process

Once psychologists have begun to form a working alliance with the family, the assessment may begin. The psychologist who gathers family assessment data in a culturally sensitive manner communicates a respect of the cultural diversity of families (Hanson, Lynch, & Wayman, 1990). In conducting a family evaluation, the ways in which the family's culture impacts on their symptom presentation and interactional patterns must be considered (Zayas et al., 1996). Evaluators must be mindful of the ways in which their own culture may affect the assessment process. In addition to cultural biases influencing the assessment of intellectual, psychiatric, and behavioral functioning, these biases may impact upon the evaluator's perception and evaluation of family functioning (Canino & Spurlock, 1994; Dana, 1993). Given the growing literature on cultural considerations in assessing psychological symptoms and psychiatric conditions in people across the life span (e.g., Alarcon, 1995; American Psychiatric Association, 1994a; Canino & Spurlock, 1994; Gaw, 1993), and in diagnosing psychiatric disorders in the recent Diagnostic and statistical manual of mental disorders (4th ed.; DSM-IV) (American Psychiatric Association, 1994b), our comments on assessment only address considerations pertinent to families.

During the evaluation, the clinician must gather information about the ethnic, racial, and religious background of the family and data about the historical and current political, social, and economic conditions of the family's cultural group. The construct of a genogram may be useful (McGoldrick & Gerson, 1985). Genograms, which graphically provide personal data regarding individual members (e.g., ethnicity, religion, current residence), and information about family structure, relationships, and patterns, enable the psychologist and family to develop systemic hypotheses about family functioning and its connection to the larger family and sociocultural context.

Some therapists question the appropriate timing and nature of genogram construction with families from certain cultural groups. Boyd-Franklin (1989) asserted that with African-American families, genogram work may be most meaningful later in the treatment after trust has been established, rather than during the evaluation. Similarly, Odell et al. (1994)have noted that since constructing a genogram may elicit painful memories for many immigrant and refugee families, this technique may sabotage the development of the initial working alliance and thus may best be introduced during the intervention. For many families who have lost a loved one due to sociopolitical conditions (e.g., Holocaust survivors, Bosnian refugees), projective genogramming elicits effectively distressing) yet important information and feelings (F. W. Kaslow, 1995). Thus, while genograms may be an important assessment tool with families from most cultural groups, the family's cultural background should inform the timing of this task.

An assessment strategy related to the genogram, but devised for work with diverse family groups, is the culturagram (Congress, 1994). With the culturagram, psychologists glean information from the family regarding: reasons for immigration, length of time in the community, citizenship status, language spoken at home and in the community, health beliefs, major holidays, and values on family, education, work, gender roles, religion, and money. Constructing a culturagram enables clinicians to ascertain the effects of culture on the family system and to individualize ethnically similar families. As a result, clinicians are more culturally empathic and more able to empower the families with whom they work.

Enumerable tools and methodologies have been devised to assess multiple aspects of family functioning. These include self-report scales, micro- and macroanalytic coding schemas to code interactional patterns, and projective techniques (for review, see Fredman & Sherman, 1987; Jacob, 1987; L'Abate & Bagarozzi, 1993). Unfortunately, few of these measures or coding schemas have been developed, normed, or empirically tested for specific cultural groups, and thus their utility across groups remains questionable (Dana, 1993). In addition, generalizations about findings gleaned from using standard assessment protocols must be limited and made with caution. Given the scarcity of culture-free assessment strategies, the assessor must take the family's cultural context into account when interpreting findings from assessment protocols not standardized with the family's cultural group. This requires including an evaluation of culturally valid constructs (e.g., racial or ethnic identity, level of acculturation, belief systems, culture-specific syndromes) (Lasry & Sayegh, 1992; Phinney, 1990b). For example, the psychologist may use Gushue's (1993) recent adaptation of Parham and Helms (1985b) Black and White interaction model for assessing and working with families. This assessment strategy enables the clinician to incorporate cultural identity data in making an initial family assessment.

The final phase of the assessment process is problem definition and goal-setting. Cultural variables that may impact this phase include the role of authority, preferred decision-making strategies, the view of psychological problems and potential solutions, and culturally based values. Thus, with Latino families, the goals should address immediate and concrete concerns (Ho, 1987). These families prefer to focus on goals that affect family subsystems, particularly the parent-child subsystem, rather than individual family members or the marital dyad. When working with many Asian-American families, it is recommended that the goals be well-defined, objective, and address practical matters. Asian-American families prefer the therapist to be confident and active in the goal-setting process, while simultaneously communicating respect for the family (Ho, 1987). With Native American families, goal-setting should be collaborative. Given the value on interdependence in the Native American community, all relevant nuclear and extended family members should be included in setting intervention goals (Ho, 1987). When setting goals with low-income, African-American families, a mutual process should be assumed, with a focus on survival needs and the incorporation of an ecostructural framework (Ho, 1987).

In addition to setting goals specific to the given family, many culturally competent practitioners recommend that cultural intentionality and bicultural competence be defined as therapeutic goals for families across cultural groups who seek mental health services (Boyd-Franklin, 1989; Ivey, Ivey & Simek-Morgan, 1993; Szapocznik et al., 1984). Cultural intentionality refers to the ability to communicate competently with others within the cultural group and with individuals from multiple cultural backgrounds. Bicultural competence connotes the simultaneous processes of accommodating to the host culture and retaining aspects of the culture of origin.