The power of the genogram

Matthew Adam
Introduction Vignettes mother, uncertain about how to react.
Recently, while working in my professional Family 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 attention 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. The
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 attempts by over- overwhelmingly powerful and frightening
Th roughout my clinical training I dosing on paracetamol. After a few months and the young girls visibly withdrew inside
understood the genogram’s value as Jessica’s mood lifted 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 patterns or scripts self-harm and it was decided that home leave Family 2
in families, often 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, attended a family
formulation of hypotheses which would, community and the family often returned Jes- therapy session with her mother and
of course, form the framework for the sica back to the unit distraught and angry. sister. The family had attended 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. There
setting 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 ‘family tree’. For many families, and younger sister attended 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 attend 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 attend 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 influential stranger and may be reticent to speak about experiences they had. They spoke briefly
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 significant events in the family.
before and serve to define the family they would allow me to complete a genogram, They 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. These 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 The 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 getting Jessica’s history and which neither daughter been an ‘unplanned mistake’ and that her ear-
The power of the genogram

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
difficult 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
different events. At the time of meeting with was conceived when she was raped by a oldest sister, Sally and her husband after 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 difficult stories, but I family rejecting her outright and abolishing husband. Both Suzanne and her sister asked
had little awareness that in being complicit her from the family home. their mother to explain what had happened,
in joining in this intervention, both families With this new information surfacing that they had differing 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. The 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. There 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
The genogram was nearing completion delay may further entrench a family’s desire that for me, the genogram placed me in a
and Kathy briefly stated that her divorce to ‘hold on’ to stories that may influence position of power over the women in the
from Suzanne and Emily’s father had been how an outsider might perceive them. room. The telling of the family history was
messy and taken five 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 family therapy 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 matter was entirely too divide, that in both cases I was the male in uncontainable
The power of the genogram

difficult 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 flood 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 difficult, family therapy could
and did not believe it should continue. differentials developed as a result of be helpful to them. Recognising that
implementing this intervention, certainly sensitivity to the family’s vulnerability
Reflections 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 The families physical and emotional Rudi Dallos’s (2004) ideas on ‘attachment
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
the family began to trust in the process they
Working with
managed to speak openly about subjects that
were once ‘off-limits’. As the families found
their way in understanding themselves
marginalised families:
they drew on their beliefs and stories of
internal and familial strength to carry them
through those difficult, but much needed
“Can you do that without
conversations.
These experiences have helped me in
recognising that utilising the simplicity of
breaking too many eggs?”
the genogram with difficult and complex
families can often render them feeling Carlos J. Sanchez
uncontained, vulnerable and exposed.
But in divulging such difficult and painful It is an art to develop specific 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 difficult and sometimes you are a two-year-old with in the interactions of the family living in
often 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 deficits the parents and/or authority figures
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 fixing 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
Working with marginalised families: “Can you do that without breaking too many eggs?”

apply to the genogram. receptive to the therapist who shows adopt a functioning style that reinforced
That 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 different agencies/
reality without having agreed upon their described how some families manage the mental health providers.
influence over when the story-telling presence of many institutions when they Things have to be done differently
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 different 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 conflict-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 effectiveness of a particular first 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
Therapeutic Ends. New York: Norton.
the family unit. We are proposing shifting need to be on time; otherwise I can’t work with
the center of attention from the family unit you”.
Matthew Adam completed his qualification 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
– Stafford. 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 five 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