Reconnecting families

The genogram is an effective tool in family therapy, enabling a transgenerational perspective of the psychological and sociological environment in which families have developed.

by Dennis Neill

This article explores some of the ways in which therapists assess and work with families. Its focus is reconnection of family members through the use of genograms, and networking with other services. Family therapy draws on a long tradition of systemic models and thinking: the central therapeutic issues in family therapy remain centred on improving communication and finding paths to mending family difficulties. 

Systems and networking

Family therapists consider the context of families and individuals through family history, experiences and relationships. Families exist in a social, cultural, economic and environmental context. All these add up to create a meaning system, a place from which to view the world and other people.  Although the family is the main focus for therapy, family therapists are skilled networkers. Gaining access to resources from the health, education, social services and voluntary services can provide practical help to families and improve emotional health. It is hard to do therapy if the basic needs of a family are not met.

A major therapeutic tool of family therapy is the genogram, an extended family tree that includes relationship and network information. Genograms can incorporate sociograms (see box) and ecograms as a way of informing and empowering families. Genograms are not just a convenient means for family therapists to get a picture of who is in the family. Drawn up in collaboration with the family, they highlight current family relationships, relationships over time and across the generations. For instance, a father may see his present difficulties with his son reflected in his own relationship with his father at that age. Genograms enable this reflection in a simple and direct way. Because family therapists explore patterns over time, they include at least three generations in a genogram.

There is something very powerful about externalising family dynamics into a map of relationships. Drawing up the genogram is a great way to engage with families but it needs to be used sensitively because it is a powerful tool and powerful family dynamics are laid bare for all to see. Genogram work may take several sessions to complete. It can also, during therapy, be used as a tool to measure change.

The family

I have invented the family for this discussion but it is typical of many I see (see Fig 1). Their genogram shows the relationship cut-offs that have occurred between the new family and their previous families. Cut-offs are quite common around divorce, especially for men. When drawing up the genogram, it is important to consider the developmental needs of each generation in turn. The family life cycle model aids this process. Taking each generation at a time, helps build up a picture of what is happening in a clear and progressive way. I usually start with the children and work up to the grandparents.

The children

The diagram shows Jason is the referred child. He is self-harming, missing school, drinking alcohol and smoking cannabis. His brother and sister are reported to have no major difficulties. All Susan’s children are cut off from their grandparents and their father. Ben is cut off from his sister, half sister, mother and maternal grandparents. He chose to live with his father when his parent’s marriage ended.  He is quiet and withdrawn. There is tension between Ben and Jason.

Note the wide age range in the children. Their different levels of understanding will need to be considered when engaging the family.

The parents

All the parents are cut off from their previous partners. Susan is cut off from her parents. She has depression and is on medication. Richard has a bad back and cannot work. Richard and Susan have relationship difficulties and often argue.  Susan does not get on with Richard’s parents. She sees them as interfering and wanting to split her and Richard up.

Susan and Peter have had no contact for three years. Peter was violent to her and on one occasion to Jason. Social services became involved over the incident with Jason. Peter wanted contact with the children, but this was supervised by social services and contact broke down after a few months – he resented having to have his contact supervised. When contact was happening, it was at the paternal grandparents home. When Peter stopped having contact, it ended for them too. This had upset them very much. Susan is worried that Peter will disrupt the new family unit by sporadically asking for contact.

Richard and Chantel have not talked to each other for a year. They had difficulties over residence and contact issues. The court welfare service is involved in a long, bitter dispute over Bethany.

The grandparents

Apart from Richard’s parents, there is no contact with three sets of grandparents.  Susan has long-standing difficulties with her mother. They fell out with each other when Susan called in social services because of Peter’s assault on Jason. Susan felt unsupported by them. They believed that Peter, despite his faults, was trying to instil discipline and structure into the children’s lives.

Susan’s mother has heart disease. Her husband died suddenly about a year ago.  Susan did not go to the funeral and this only hardened feelings.

Susan’s children have no meaningful relationship with Richard’s parents. They are jealous of Ben’s contact with his grandparents and feel he is the family favourite, even to their own mother. Richard is not close to his parents and they were upset when he left Chantel for Susan. They felt he should have stayed with her for the children’s sake. On one occasion, when things were difficult between Susan and Richard, they offered to put Richard and Ben up with them. This upset Susan very much.

Others involved with the family

Social services were involved a number of years ago when Jason was assaulted by his father. The case was closed when contact between Peter and his children stopped. Recently, when Jason was found drunk in school, they reopened the case and a family support worker was assigned to Jason.

The education authority appointed an education welfare officer (EWO) on account of Jason’s poor school attendance. They are threatening legal action if his attendance does not improve. The school has developed a reintegration programme for Jason, but it does not appear to be working. The school is concerned because Ben is taking occasional days off school too and his work performance has deteriorated.

The child and adolescent mental health services became involved when Jason began self harming. They initiated a family and individual assessment. Following the assessment they have set up family therapy and individual counselling for Jason. Jason has missed many of his individual sessions. The family therapy sessions identified low mood and social withdrawal in Ben.

Adult mental health services are offering counselling and medication to Susan who is depressed. She has a long history of mental health problems.

Court Welfare Service is involved over a residency and contact dispute between Richard and Chantel. This is over where Bethany should live. Chantel will not allow contact between Richard and his daughter and Richard has stopped contact between Ben and his mother.

The family GP is actively involved. The children have a higher than normal rate of minor illness, Richard has chronic back pain and Susan has depression.

How to proceed?

The family therapist cannot work in a vacuum. Before considering how we might work with this family, it is worthwhile thinking about statutory responsibilities and networking issues. The Victoria Climbié Enquiry established the importance of clear communication between professionals and the overall management of complex cases. Because there are so many professionals involved in this case, it is important to establish who is doing what, what is being planned and who is responsible for the overall management and co-ordination of work. A multi-professionals meeting was called to establish just that. Social services took the lead role.

The most striking feature of this case is the number of cut-offs between and across the generations. The impact on family life was enormous and the difficulties which ensued have drawn in a number of agencies at great expense to the state.

The interesting thing about cut-offs in families is that there are usually people who act as go-betweens. These go-betweens can be children or adults. In this case there are two go-betweens: Jason and Ben. Jason is in fact seeing his father at the paternal grandparent’s house and visits his maternal grandmother. Ben is visiting his mother and sister at their home. These meetings are in secret. For these two children, the emotional burden of maintaining these secret relationships is great.  This information was established through individual work with Jason and Ben.

Ben

Ben feels torn between his parents and is upset at having to keep his feelings of loss about his mother and two sisters a secret from his father. He worries that if his father (Richard) finds out he would feel betrayed and react by sending Ben away to live with his mother. This cut-off is what Ben fears most. Ben has become withdrawn and depressed as a result of his upset over the divorce and subsequent parental animosity.

Jason

Jason is secretly visiting his father at the paternal grandparents. Despite this, he feels his father is not really interested in him. However, he enjoys contact with these grandparents. As well as seeing his father from time to time, he often visits his maternal grandmother. Since her husband’s death, she appears weaker and generally run down. When Claire, maternal aunt, recently married she moved away from the area. This meant the grandmother’s major carer was no longer available. Jason took on primary responsibility for looking after his grandmother.  He was worried she was dying. With no adult to talk to, he started taking time off school to look after her.

The outworking

As part of our work, maternal grandmother’s GP was contacted and an assessment of her needs arranged. A diagnosis of agitated depression was made. After treatment, she made a rapid recovery. This freed Jason of this particular worry and meant he could more easily return to school.

Jason and Ben were encouraged to discuss their concerns and feelings in family therapy sessions. These meetings highlighted the destructive effects of the cut-offs and allowed us to explore Susan’s feelings about her separation from her mother. The death of Susan’s father had reinforced the cut-off between her and her family. Susan had not attended the funeral. She was full of guilt about this, and in

reality, wanted reconciliation with her mother and sister.

Both Susan and Richard were unable to establish a dialogue with their previous partners.  However, they gave their blessing for the children to re-establish contact with their other parents and siblings. This meant Ben could see his mother, maternal grandparents and two sisters and that Jason, Sam and Kirsty re-established contact with their grandparents. A lot of work was focused on establishing clear contact arrangements.

The social worker was happy for Susan’s children to also see their father, Peter, at his grandparent’s house. She met with him and his parents to discuss contact arrangements. However, Peter’s relationship with his children remained problematic.

A meeting was arranged between Susan, her mother and sister (Claire) and contact was re-established. This was a difficult meeting. To support the changes, a follow-up meeting was arranged. Susan’s adult mental health worker was involved in these meetings. An interesting phenomenon became apparent from this meeting. Maternal grandmother had been cut off from her own mother for a long period of time and she believed her mother had fallen out with her parents too. This realisation gave Susan and her mother a theme to share.

The education authorities worked with Ben and Jason to reintegrate them into school. For Ben this was quite straightforward. Jason required more support and encouragement over a longer period of time. The Connexions service proved to be an important factor in Ben’s reintegration.

Later family therapy sessions focused on parenting issues between Susan and Richard. They continued to have some relationship difficulties, but their situation was made less stressful because the children were attending school and they agreed more over parenting issues. Susan felt happier now she had a better relationship with her family. Both parents saw how destructive the cut-offs had been in their family. They saw how these had been repeated throughout the generations. They were determined to prevent further cut-offs occurring, particularly with their own children. The importance of problem solving, compromise, clear communication and negotiating skills was stressed during our meetings. The parents took these on board and communication improved throughout the family.

The complexity of the family situation was reflected in the professional system.  The large number of professional agencies needed to be coordinated, to have good communication and work together in a focused and clear way.

Dennis Neill is a family therapist registered with AFT and UKCP, working in the NHS. www.familytherapy.org.uk. Email: dennis@familytherapy.org.uk.

Genogram: a diagram outlining the history of the behaviour patterns (divorce, abortion or suicide etc) of a family's members over several generations in order to recognise and understand past influences on current behaviour patterns and to identify repetitive patterns of behaviour. In other words, a psychological family tree.

Sociogram: a diagram representing the pattern of relationships between individuals in a group, usually expressed in terms of which persons they prefer to associate with.

Ecogram: The ecomap is a diagram of a social ‘solar system’, in which a family genogram is placed in the position of the sun, at the center, and other important people and institutions in their life space are depicted with circles around the center, like planets around the sun.

The Expanded Family Life Cycle: Individual, Family, and Social Perspectives: by Betty Carter, Monica McGoldrick 3rd edition Allyn & Bacon (28 Feb 2006)

Software to compose genograms and ecomaps is available from

http://www.genopro.com

http://www.interpersonaluniverse.net

Dennis Neill

Family Therapist

Family Therapy UK

1st May 2008