How to Use Genograms in TherapyHave you wanted to know how to use genograms in your practice with patients?

Monica McGoldrick describes a powerful way of employing genograms with therapy patients in her book “The Genogram Casebook.” McGoldrick bases her work upon the family systems framework of Dr. Murray Bowen, as well as a number of theorists who have followed in his footsteps.

To construct a genogram, you use a combination of lines and symbols to depict how individuals are connected to their biological and legal kinship network, as well as their informal network of friends, pets and work connections.

Aside from the basic demographic and health information of patients’ primary people (and pets) in their lives, genograms may be used to illustrate the generational wounds that have taken place, as well as a trajectory of survival, resilience and hope.

Standard Symbols

Below are a few of the standard symbols:

  • Male = square; female = circle
  • Horizontal lines represent marriage
  • Vertical lines connect parents and children
  • Separation and divorce: one or two back slashes on horizontal marriage line
  • Conflicted relationship: zigzag lines
  • Distant relationship: dotted lines
  • Cut off/estranged: broken line
  • Overly close/fused: three solid lines

In addition to using a genogram, you may wish to employ a timeline, to easily note any key events and changes your patients mention such as births, marriages, divorces, illnesses, deaths, migrations/moves and traumas. A timeline can help both you and your clients get the big picture of all the key events that have transpired in their lives.

Periodically reviewing the timeline you’ve created with your clients may also aid them in remembering past stress points that have been forgotten because of their current focus on their presenting problem.

McGoldrick emphasizes the importance of highlighting your clients’ points of resilience and strength, even within their stories of trauma, to help bolster their inner strength.

In light of the importance of the therapeutic alliance in the success of your patients’ treatment, the process of filling out a genogram must be done artfully. On the one hand, there is a need to pose questions to better understand who they are, what their concerns are and what factors may be contributing to their current situation, as well as trying to learn what strengths and resources they may draw upon to help them thrive.

On the other hand, part of the art of therapy is timing your questions to flow in as natural a manner as possible from whatever the client is discussing or concerned about.

Key Areas of Interest

Below are some of the key areas of interest to cover with your clients:

Family Make-Up (some of these questions would be naturally covered as part of your intake process with a new client)

  • Relationship status
  • Whether have any children (and who is the other parent of each child)
  • Parents (age, education, health, residence)
  • Siblings (age, education, health employment, relationship status, residence)
  • Aunts, uncles and grandparents (age, education, health, residence)
  • Other important people in client’s life
  • Pets

History/Relationships

  • What type of relationship do you have with your children/parents (and others noted in genogram)? Use appropriate symbols to depict close connection, friction, sexual abuse, physical abuse, etc.
  • What painful losses or problems did family members have to face in the past?
  • What are some of the strengths and assets of the family?
  • What meaning do members give to their past stresses, and how may this relate to their cultural background?
  • Do members seek support from others within, or outside the family? Has anyone sought a therapist’s advice? Is seeking outside guidance viewed negatively?
  • What do you know about your parents, aunts, uncles and grandparents? Where did you and they grow up?

As you engage your clients around what troubles them, seek to understand their narrative of what came before their current problem, what (else) is happening and where they want to go in the future.

It is helpful to track their problem and family life cycle phase they are currently facing, through previous generations and their siblings. Typically, there will be other members who have had similar troubles at identical life cycles and bringing this to light will provide clues for how your clients may want to handle their current stresses.

Taking Power Back

Also, periodically review the genogram that you put together with your clients, to help them reconnect to who they are and see patterns in the other family members on their genogram. This practice will also give you an opportunity to emphasize to your clients that they are the experts and researchers on their lives and own families, a step that helps ensure that you maintain a healthy collaboration with your clients.

One of the goals in therapy is to help clients “take their power back” within their relationships, responding according to how they would like vs. reactively to what someone has said/done. To that end, the author recommends they avoid attacking, defending, placating or shutting down with others.

In the systemic way of viewing the world, the goal is to help your clients see their family members as individuals who had a particular story rather than as a failed or toxic member from whom it may be advisable to cut off. The process of differentiating from any parent requires learning as much as possible about him/her and this learning necessitates talking to any family members or friends who are alive who may be able to share their perspective on how a parent became that way.

As per McGoldrick, the systems prospective advocates protecting yourself as necessary from anyone who is relating in an abusive way while encouraging your willingness to open your heart if/when a relative is ready to engage in a respectful relationship.

Develop Your Own Family Genogram

It is recommended that we spend some time working on developing our own family genograms to avoid having our own issues played out with our clients. For example, if you grew up in a primary triangle with your mother against your father, you are likely to end up feeling comfortable colluding with a mother client and leaving the father client out of the picture.

When undertaking family exploration for yourself, the goal would be to understand your role in your family system and potentially change your own behavior, not the behavior of another member.

To do so, map out at minimum, information about three generations of your family. Next, note what information gaps exist and how you might try to go about filling them. Ancestry.com can be a helpful resource for any family that was in the U.S. before 1940.

We tend to make assumptions and judgments about others in our family based upon their behavior in relation to us and not by events that took place prior or apart from our experience of them.

Exploring your genogram history will enable you to start to making systemic sense of your family’s history over time and notice that things you assumed to be true are not always the case.

This type of exploration of imagining the experiences of your ancestors and current family and putting yourself in their shoes before you plan any meaningful systemic change is likely to facilitate your genogram work with your clients as you imagine your clients and their family members’ struggles with other members of their families.

Questions Regarding Your (Therapist’s) Family

  • What family patterns or themes are most likely to be triggers?
  • How might your family of origin experiences influence your relating to personality types you find difficult?
  • What family messages did you receive about interacting with those who are different from you? (such as race, gender, religion, disabilities etc.)
  • How did your family deal with difficult emotions (such as conflict, grief etc.)?
  • What were the major triangles in your family, and what steps might you take to de-triangle from any that still exist?
  • How might you want to change to be more yourself with your family?

Lastly, to see McGoldrick demonstrate the use of genograms in a couple of cases from her book, see: http://www.psychotherapy.net/McGoldrick.

Genograms: How to Use them With Your Therapy Clients
Click to see full-sized infographic

 

Reference

Reference: McGoldrick, M. (2016). The Genogram casebook: A Clinical companion to genograms: Assessment and intervention. New York, NY: W.W. Norton & Company.

Dorlee Michaeli, MBA, LMSW, is a therapist at an outpatient mental health clinic and fellow at a psychoanalytic training institute. She also works as a financial social work and social media consultant. You can find her at www.SocialWork.Career, twitter and instagram.