ABSTRACT | PDF

REVIEW ARTICLE

The use of family genogram in psychiatric social work practice

Gobinda Majhi1, Sadananda Reddy2, D Muralidhar3

1Asssistat Professor, Department of Psychiatric Social Work, NIMHANS, Bengaluru, Karnataka, India,  2Psychiatric Social Worker, Department of Psychiatric Social Work, NIMHANS, Bengaluru, Karnataka, India,  3Professor, Department of Psychiatric Social Work, NIMHANS, Bengaluru, Karnataka, India

Abstract

Genogram is a useful tool to gather information about the family and guide the clinical practitioner for intervention. This visual representation helps you to understand about the relationships and networks associated with the family. Genogram depicted through pictorial form used to illicit and display the three or more generational information tract the source of stressors and available resources. The purpose of drawing genogram is to map out the complex interpersonal relation present in the family and their biopsychosocial environment. It is a standard tool to assess the composition and structure of one’s family background, roles, pattern of communication, social interactions, and interrelationship with the environment. This tool helps the mental health professional to recognise visual representation of the individual, family, and disorders running in the family through specified coding or symbols in a snap shot observation. These symbols are graphical, circle, rectangular, dotted lines, straight lines, vertical lines, etc. In the present scenario, mental health professionals often ignore or underutilise these tools in assessment, diagnostic formulation, and as an intervention tool due to lack of time, inadequate knowledge about the application of tools in different situations. The current paper attempts to highlight about the orientation of genogram, history, and its utility in psychiatric social work practice in changing social scenario.

Keywords: Interpersonal Relations. Environment. Communication.

Correspondence: Dr. Gobinda Majhi, Department of Psychiatric Social Work, NIMHANS, Institute of National Importance, Bengaluru-560029, Karnataka, India. majhi.gobinda10@gmail.com

Received: 12 April 2016

Revised: 28 December 2017

Accepted: 28 December 2017

Epub: 30 March 2018

INTRODUCTION

Genogram is a useful tool to gather information about the family and guide the clinical practitioner for intervention. This visual representation helps you to understand about the relationships and networks associated with the family. Genogram depicted through pictorial form used to illicit and display three or more generational information tracts the source of stressors and available resources. The purpose of drawing genogram/family tree is to map out the complex interpersonal relation present in the family and their biopsychosocial environment. It is a standard tool to assess the composition and structure of one’s family background, roles, pattern of communication, social interactions, and interrelationship with the environment. This tool helps the mental health professionals to recognise visual representation of an individual or family problem through specified coding or symbols. It is a subjectively interpretive tool that help the clinician to generate tentative hypothesis for evaluation and intervention. It helps both clinician and client in a larger picture to view about the current and historical context. Genogram is a widely used tool for family assessment and intervention.[1-7] It has been proven successful as an intervention tool with individual, couples’ family, and marital therapy.[8] The use of genogram has changed over time, paradigm shifts from custodial care such as adoption or foster placements[9] in social service setting. Now, genograms have been used beyond family dynamics context.

Genogram use in social work practice is supported by social work profession’s knowledge present in the field with core value and ethical standards. Larger benefit of this tool is that client would be introduced in an ambit of systems theory, which are fundamental for social work practice.[10] Such a ground principle can help practitioners to decide the sources of information that are creating problem in a system and determine the foci of interventions. Genograms have also been applied in education and religious counselling[11] as an intervention tool. It is a useful tool that displayed visually in a manner that anyone can understand what is happening in the multi-generational family homes.

Although, genogram’s basic structure and symbols have been accepted, there are some variations[12] that appear from one author to another. There is no agreement and uniformly acceptable symbols have not been worked out till date.[13] Hence, some authors do reuse the same symbols for different situations while others have ignored such special cases. Genogram construction was a major limitation to the reliability and validity.[1]

DEVELOPMENT AND STANDARDISATION OF GENOGRAM

In the 1960s, Murray Bowen and Jack Bradt, two family-oriented psychiatrists, first time employed family charts on blackboards or poster boards in their clinical and theoretical work with families.[14-16] Since then, no standardised genogram was made. Hence, considerable variations were observed in clinical practice as how to portray genogram in professional fields. In response to this diversity, McGoldrick and Gerson[8] formulated the first comprehensive standardisation for constructing and interpreting genograms based on concepts articulated by Bowen and other systems theorists. The information which they suggested to include in the genogram are name, gender, age, and death of the family members, etc.

Additional information may include education, occupation, chronic illnesses, social behaviours, nature of family relationships, emotional relationships, and social relationships. Some genograms also include information on disorders running in the family such as alcoholism, depression, diseases, alliances, and living situations, Genograms can vary significantly because there is no limitation as to what type of data can be included.

Basic genogram symbols

The standard symbols most of the authors accepted are presented in Figure 1.

 

Figure 1: Genogram symbols.

RULE TO BUILT GENOGRAM

While drawing the family genogram, these are the basic rules to be followed:

i.        Male should be drawn always at the left side whereas female is at the right position.

ii.      Assume male-female relationship to avoid the ambiguity rather male-male or female-female in drawing the family.

iii.    A spouse must be drawn in close to his/her partner and to maintain chronological order thereon for further onward partner.

iv.    According to birth order, children should be drawn left to right in horizontal line.

Standard genograms which are useful in psychiatric social work practice

Over time, various standard genograms were developed; both traditional genograms as well as newly developed genograms are useful for psychiatric social work practice. These are discussed briefly for better understanding of usefulness for psychiatric social work practice.

1. Vertical genogram

Vertical genogram is like a conventional genogram; it is more useful in strategic and solution focused family therapy. Usually vertical genogram addresses the issues of couple’s problem, in which relationship of couples used to be delineated through the use of horizontal and vertical lines across the family context and vertically through the generations respectively.[8] The vertical lines connect generations’ parents with children via a dotted vertical line. While portraying vertical genogram, additional information can be depicted like separation, divorce, friendship, death, twin, abortion, strong ties between family members, and negative interactional patterns among family members.[10]

2. Horizontal genogram

Horizontal genogram is also a part of traditional genogram. The significance of this genogram is that it would depict the relationship of same generation, such as aunty, uncle, cousin, etc. Horizontal genogram could also portray the extension from where the basic family group branch out within a generation, such as wife, sister, etc. Another example could be of polygamous families where one man lives with many women or vice versa. The horizontal lines place the family members of the same generation in same line. It usually denotes marital or common-law relationship. Chronological birth order being followed from left to right while depicting the children in the genogram.[10]

3. Timeline genogram

The timeline genogram has been used to map traditional genogram information with temporal aspects of past events.[17] In timeline genogram, positive and negative timelines are intentionally drawn so that all family members could easily understand the problems running in the family and how those problems have been resolved by extending mutual support. This would give them opportunity to think in positive and constructive manner. And also, it would ignite hope, trust, and boost the confidence among them. Further, it allows the family to construct a perspective of normal response to stress, rather than viewing themselves as failures across time.[18]

4. Colour-coded genogram

Colour-coded genogram has been used in all type of situations. However, Lewis[19] was first to use the colour-coded genogram in bulimic families. The colours used with bulimic families are the following-

Green: Overtly or covertly controlling.

Blue: Peace at all costs, peace-keeper.

Red: Freely expresses anger (appropriately or inappropriately).

Purple: Difficulty with separation.

Yellow: Sexual issues.

Black: Physical or mental health problem.

Brown: Body image distortion or obsession.

Orange: Alcohol or drug problem.

Dotted black: Perfectionism.

It is to explain that, once the family has drawn its genogram, the members are given a set of “magic markers” and a chart listing the items, as above. Thereafter, they would be asked to add appropriate colours to the squares and circles that represent the family. All these colouring events would happen with discussion, general agreement, and consensus among family members. Lewis[19] quoted that colour-coding genogram provides clinicians with another additional tool for assessment and treatment technique with new modality.

5. Spiritual genogram

Frame[20] created a spiritual genogram. It is an analogous of traditional genograms which provide three generational visual representation about spiritual affiliation information of a family.[21] This genogram also displays the family composition and structure of at least three generations,[22-24] and depicts how spirituality passes on to next generation by delineating with specific symbol. The spiritual genogram intents to see the connectivity and affiliation of individuals with respect to religious preference, ties, and sentiment attached with the family.

Social workers should explain the options to clients and allow them to select the colours of spiritually meaningful events and colour it according to their spiritual preferences. Also, help them guide to draw the family members spiritually closely associated among themselves.

Spiritual conflict can be portrayed if any such kind is present in the family.[17] Most of the family members use spirituality as the technique of coping skills.[25]

6. Sexual genogram

Hof and Berman[26] were the first to write about the sexual genogram. The original sexual genogram is not structurally different from a traditional genogram - both look at individual data, transgenerational issues, and relationships.

However, in current dynamic and complex society, translating and interpreting the sexual behaviour is a complex phenomenon, socio-cultural factors play a vital role with regards to sexuality issues. Hof and Berman[26] have suggested six contents that are to be addressed while assessing the experience of sexuality and intimacy in the family of origin both within and between generations. Those are:

1) Overt/covert messages regarding sexuality/intimacy and masculinity/femininity,

2) Sexuality/intimacy communication and behaviours,

3) Sexual secrets,

4) Information still missing and how this might be gathered,

5) Partner’s perception of each other’s sexual genograms, and

6) Wishes about changing the individual’s/couple’s genogram.

Complexities appear in modern sexual genogram symbology and construction

Gender and gender expression are no longer as simplistic as it appears. Some of the complex phenomena including gender, sexual orientation and attraction, relationship lines, sexual communication and environment no longer get a general consensus with respect to sexual symbology for genogram. Following are the complexities with respect to symbology that needs to be developed and allotted in simplified and acceptable manner for clinical and therapeutic purpose for all professions:

  1. Transgender individuals,
  2. Transgender male to female,
  3. Transgender female to male,
  4. Plans for sex reassignment surgery (SRS), or completed SRS,
  5. Cross-dressing (dressing as opposite gender occasionally),
  6. People who live cross-gender (no intent to have SRS, but living and passing as preferred gender), and
  7. Drag kings/drag queens (people who dress as a caricature of the opposite gender often for entertainment).

“Gender queer,” which can include:

  1. Bigender/pangender (identifying as both man and woman),
  2. Genderless/agender (neither man nor woman),
  3. Genderfluid (moving between genders),
  4. Third gender or other-gendered (e.g. hijras in India).[27]

7. Military genogram

Weiss and colleagues[28] developed the military genogram. It is basically drawn for the purpose of assisting military personnel and their family in recognising intergenerational patterns, both barriers and strengths present in the family. Unlike civilian family, military family represents a unique culture that emphasises the adherence to specific guideline of conduct. Military families have the pressure to make a similar commitment to the military’s norms, beliefs, and traditions.[29] By using a military genogram, a clinician can provide an assessment of protective factors associated with the military life style and render mechanisms for intervention and resiliency building. Thus, appropriate mental healthcare services should not only be provided for the military personnel but also for his or her family.[28]

8. Cultural genogram

Cultural genogram was developed by Hardy and Loszloffy.[24] The cultural genogram is used as an educational tool to teach healthcare professionals. This genogram’s primary focus is to address structural aspect of patients’ and families’ cultural beliefs and practices. While rendering services, discrepancies are happening with professionals and clients as both of them are from different background with regards to their cultural beliefs, values, attitudes, and health practices.[30]

Therefore, mental health professionals should have to learn the diverse cultural values in order to avoid discrepancies. However, it is a challenging task for a professional to learn the diverse cultural beliefs and practices across the globe.[31]

9. Computer programmes

In current technologically advanced society, computer programmes and websites are readily made available. Most programmes have been developed to be used for therapists and other clinicians. Some of the website search engines are mentioned below for reference:

·         Genogram and Ecomap Software (http://www.smartdraw.com/specials/genogram.htm)

·         Genopro (http://www.genopro.com/genogram)

·         Family Health Portrait (https://familyhistory.hhs.gov/fhh-web/home.action)

·         WinGeno (http://www.wingeno.org/)

·         Genogram Analytics (http://www.genogramanalytics.com/index.html)

IMPLICATIONS OF GENOGRAM IN PSYCHIATRIC SOCIAL WORK PRACTICE

Genogram is a very useful tool for assessing family dynamics and helps clinician to guide for interventions. However, most of the psychiatric social workers may not prefer to select as an instrument to construct genogram because it is time-consuming and may be annoying to clients who are eager to move into problem resolution activities.[22] No one denied that genogram is well-suited for mental health professionals, particularly for psychiatric social workers. As it offers the clients new ways of thinking about their family. Hence, psychiatric social work practical intervention is guided through genogram to resolve problem encountered by family members directed to include:

De-triangulation of dysfunctional family relation

De-triangulation is the process where mental health practitioner consciously disrupts the dysfunctional relationship present in the family. In that process, construction of genogram would be encouraged to engage all family members in discussion so that they could recognise the alliance, coalition, or triangulation present in the family. The triangulation process would help the family members to open up from the complicated system where the reluctants explain their views and move towards functional alliance and tringles. In this process, social worker’s role is very important.[32] The social worker may ask family members to discuss themselves on that issue or may employ different techniques to reduce the differentiation present among the family members.

Educate families about present family patterns

To educate the family, genogram can be drawn to provide visual display of the family and the complexities existing in the family relationship. Many a time family members are resistant towards their attitude and behaviour as they do not admit such bevaviour complicated the family functioning. By observing genogram physically in diagrammatic format they would realise the magnitude of the problem and bargain within self for change.[10] Also, it will help in teaching families about the system processes through the genogram. The social worker helps each member to observe the self within system and to examine behaviour in terms of family context, rather than look each other’s relationship patterns, triangles, family balance and imbalance.[33-35] Genogram also helps in expanding family members’ narrow view of problem and help to resolve the family issue in a constructive manner.

Working with individual client or subsystem

The advantage of working with family system is that, social worker can selectively address the problem of an individual or subsystem of a family through mapping out the problem,[36] such as delineate family relation, relationship dynamic, and family structure. Participating in constructing genogram with client or family member itself is therapeutic in nature by itself.[37] In such process, intervention can be offered individually or conjoint manner by drawing genogram. Genogram often stimulates the process of life. It is not always required that all the family members should be part of the intervention offered to them. The practitioner helps the client observe the self in the systems and then reframe the relationship which is significant in terms of relationship building.[36]

Establishing emotional relationships

Several family assessment instruments are suitable as measures of change. The genogram can be used as an instrument to assess the family at intervals to see the desired change occurring or not. Genogram provides insight through picture depiction and delineated emotional bonds between family composition and alliance present in the social unit. Genogram allows the idea that can be conceptualised and connect for social networking present in the whole system,[38] negative and positive memories about family relationships,[39] about changing family roles and relationships in a group therapy context,[40] and level of cohesiveness present within a family. It is used as a lens to look at the source that can be utilised during difficult circumstances.

Conclusions

A genogram is a tool that fosters a family systems approach to patient care. Genograms give clinician a quick, integrated picture of patients’ biomedical and psychosocial histories. Genograms allow clinician/social worker to diagnose and manage difficult biopsychosocial problems that often are not been addressed using the traditional biomedical model. By using genogram, social networks can be enhanced for caregiving purpose, and promote and establish the unfounded facts present in the family.

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Majhi G, Reddy S, Muralidhar D. The use of family genogram in psychiatric social work practice. Open J Psychiatry Allied Sci. 2018 Mar 30. [Epub ahead of print]

Source of support: Nil. Declaration of interest: None.

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