Ross, B. & Cobb, K. (1990). Family nursing. A nursing process approach. Redwood City, CA: Addison-Wesley. pp. 168-176.
Hoffman (1981) discusses the importance of focusing on the individual within the context of a multi-generational family in an effort to modify a situation or the dynamics in which a problem presents. The hope in this effort is that modification of the family or situational dynamics will allow the individuals involved to grow and develop in positive or health-promoting ways. She presents Bowen as the most influential person among those who believe that in order to relieve problem situations and achieve change, one must understand the historical perspective of the current situation.
Bowen suggests that current difficulties have their beginning in problems of previous family members who have been unable to separate or have experienced difficulty in separating from the "core" family. He believes that the current problem can be positively affected and perhaps solved if the persons in the current situation can be involved in revisiting the previous generations.
Revisiting Past Generations
This practice allows the current family members to identify patterns of problem behavior over past generations and, it is hoped, to recognize the impact of those behaviors and their hold on the present. Such visualization allows the recognition and, it is hoped, the unlocking of this hold. He emphasizes, therefore, the searching out of clues from members of the extended family, especially from older generations, to attempt to trace a pattern and, when possible, to alter that pattern. In an effort to do this he uses the genogram, a visual depiction of the family tree going back to past generations and extending horizontally to current relationships with the client nuclear family as the starting point.
Relationships and Positions of Family Members
Guerin and Pendagast discuss the genogram and its use in some detail in their text. They define the genogram as "a structural diagram of a family's three-generational relationship system." A number of symbols are used to illustrate relationships (see Figure 7.1). Using these symbols, together with other factual data, a diagram is drawn that shows the relationships and positions of each family member. The names, ages, and dates of marriages, deaths, divorces, and births are filled in. Other pertinent facts about relationships can also be gathered and included, such as physical location of family members, frequency and type of contact, and significant events in relationships or degrees and types of tension. Emotional cutoffs, stressful issues, and degree of openness or closure in relationships may surface. This will help the caregiver and the involved family or family member to form a picture of the family's characteristics.
Physical Location and Contact of Family Members
The physical location of the family members and frequency and type of contact may be very important according to Guerin (1976). Physical distance may be used to solve relationship problems, and at the same time, physical distance among family members is one indicator of how much particular persons can be counted on as a support network for others in the family. There are families, termed "cohesive" by Guerin, who live within walking distance of most members of their extended family throughout their lives. The "explosive" family has family members living in widely disparate sections of city, state, and beyond and would see very close living arrangements as oppressive. Such information as who calls whom, who visits whom, and who writes to whom and how often can also be Important. Is there a family member who is the communicator, the family "switchboard," who keeps a cohesive family together? What are the "toxic issues," such as death of a central family member, premature death of a young adult or child, or onset of serious illness, and how are these dealt with? Are they discussed, discussed with some individuals and not with others, or not spoken of at all?
Maturational crises and catastrophic events can place a family at a crossroad. The choices a family makes in dealing with such events (eg, the oldest child leaving for college, a youngest child's marriage, the loss of a child in war or accident) may reshape the future structure and relationships of the family (Guerin, 1976). As indicated earlier, the genogram may serve as a tool to facilitate the implementation of planned care as well as for gathering data. Families are essential to the construction of the genogram. As they participate in its development, they become actively involved with each other as well as in the process of recalling and confronting family members both near and far, both living and deceased. Fears, anxieties, frustrations, and anger may surface and be resolved as the family constructs and expands the diagram of who they are as a family and how they became who they are today.
Emotional Patterns in Families
The symbolic representations of emotional relationships are done with the addition of dates of marriages to be written on the horizontal lines between couples and ages to be written inside the symbol representing a particular individual. Dates of deaths and divorces are described as especially important, as are those of marriages, since such events may have great impact on the family. Such events may open or close off lines of communication, foster closer contact, or sever ties between other family members. Nichols also describes the importance of geographic location of various groups or individuals in a family system. However, he makes the point that it is quite possible to live in the same community and be separated by emotional distance. In today's career-oriented world, individuals may choose to live where opportunities are best in terms of professional opportunities, a choice that may have little to do with family emotional ties. Nevertheless, geographic distribution of family members does offer some clue to underlying emotional patterns in families. Nichols also observes that the genogram is only "a skeleton" that serves as the form on which important information about the family, the "flesh," must be placed. He discusses the importance of exploring relationships, emotional boundaries, critical conflicts, and the amount of openness in families. "Filling out the genogram is not an end in itself, nor is it a simple matter" (Nichols, 1984).
In working with the family to fill in the "flesh" of the genogram, one must recognize that the family members may know some of the information, but not all. An individual's report about his or her experiences may also reflect at times his or her personal ideas of what should be rather than what is. It is important to ask for descriptions of relationships rather than conclusions about them. One might better ask. "Where do you live?" "Where do your parents live?" "How often do you visit, write, or call?" rather than "Do you have a good relationship with your parent or parents?" Nichols (1984) sees cultural, ethnic, and religious relationships with community and social networks as important information. Such information as the nature of the work that family members do may be important. According to Nichols (1984), an individual cut off from his or her extended family may become fused to his or her nuclear family. Similarly, a family cut off from social and community ties may become meshed in their own concerns, fears, and anxieties, with limited outside resources to assist them in handling their stress. Much of this information can be captured and shown diagrammatically in the eco-map, which will be discussed later.
Instructions for Drawing a Genogram
A genogram is a diagram of a family tree that includes social data. It generally covers three or more generations and "records genealogical relationships, major family events, occupations, losses, family migrations and dispersal, identifications and role assignments, and information about alignments and communication patterns" (Hartman, 1978). It is best to use a large sheet of paper to avoid crowding. Clear visualization is essential to allow examination.
Use of Symbols
The key used for a genogram follows conventions of genetic and genealogic charts:
A male is indicated by a square, a female by a circle. If the sex of a person is unknown, this is indicated by a triangle. A marital pair is shown in Figure 7.2.
A somewhat more complex family is shown in Figure 7.3.
If there is a particular identified patient in the family, that person is shown with a double line as shown in Figure 7.4.
An "X" is placed inside the figures if a person has died. Birth and death dates are written above the figure, the birthdate to the right, the date of death to the left. The age at the time of death is written in the symbol. Figure 7.4 includes symbols representing a male who died at age 32 and a female who died at age 12. Figure 7.4 also includes symbols for pregnancy, stillbirth, spontaneous abortion, and induced abortion.
The relationships between individuals are shown as follows.
Two persons who are married are shown connected by a line that goes horizontal connecting a square to a circle (except for a same-sex marriage). The husband is shown on the left, and the wife is shown on the right. A slash along the connecting line indicates a separation of the couple; a double slash indicates a divorce. Multiple marriages can be shown by adding those persons identified as past spouses to one or both sides of the diagram of the current couple or marital pair. Unmarried couples may be shown in a similar manner using a dotted line. The dates shown would be the date they married or started living together. When dates are not known to be accurate, a question mark next to a date indicates it is an approximation (see Figures 7.5 and 7.6).
If a couple has children, the symbol for each child is added by drawing a line down from the horizontal line connecting the couple. The offspring are generally drawn from the oldest child on the left to the youngest on the right. A foster or adopted child may be shown by using a dotted line, and twins may be shown by using a converging line at the parental line. Identical twins may be shown by a line connecting the symbols of the twins (see Figure 7.6). A person who is a significant individual in a household but not a part of the family by birth may be shown by placing the appropriate gender symbol in close proximity to the family. The symbol is then encompassed within the dotted line that identifies the household of individuals directly involved in the provision of care.
Describing the types of relationships between family members in terms of closeness or distance and conflicted and/or cut off can also be shown diagrammatically. Different types of lines may be drawn to represent the type of relationship or emotional climate that exists between two persons. (Figure 7.7) Figures 7.3, 7.4, 7.5, and 7.6 summarize the symbols used in genograms. It is helpful to draw a dotted line around the family members of the household with which you are working.
Including Other Information
Using the described building blocks, the family may be shown within the context of contemporary generations of siblings and cousins or back through several generations. Other information may be filled in on the chart to portray traditions and patterns. Hartman (1978) discussed the significance of different types of information. For example, names may be quite significant. Naming patterns may bring to the surface
identifications that are of much importance. Obtaining first and middle names may help to identify where a particular family member fits into the family and what expectations and displacements have been placed on that person.
Hartman (1978) describes a situation in which the meanings and connections only became visible after much careful exploration. A young man who was having some difficulty in working through a complex tie with his mother was charting his genogram. His name was Tony. As he reviewed his history, he revealed that his American soldier father had met his mother while overseas. They had moved to the United States immediately after their marriage. The political events during the following time period resulted in the wife's being completely cut off from her family. Tony was their firstborn child, one year after their marriage. When asked who he was named after, he said "I wasn't named after anyone in the family. I was named after St. Anthony, the Patron of Lost Objects" (Hartman, 1978). The implication seemed dramatically clear, if indeed his name was chosen in the light of its meaning: Tony was named for his mother's lost family!
Genograms may bring to the surface many pertinent observations. Dates of births and deaths may indicate family longevity and family losses. The ages of family members when major events occurred (eg. births, deaths, changes in place of residence or job) may be important. Sibling position may be important, as might be charting major immigrations or migrations of family members and periods of change, upheaval, and loss. For example, have all family members of a given generation stayed within a small radius, except perhaps for one individual in each generation who moves away? The impact on the family if this individual is in need of health care or if this person's assistance is needed in providing such care could be significant.
Simple facts about members' health and causes of death may provide an overview of family health status and reveal the way families see their future. Family expectations can indeed lead a family toward the anticipated events.
Communication patterns can also be shown. Parts of the family about which individuals have little information may show "cutoffs," portions of the family with little or no contact with the rest of the family members. These individuals may be separated from the remaining family members for a number of reasons. They may indicate conflict, loss, or family secrets. Such removal of self and significant others may be done to protect family members from some painful experience or a conflict of some kind. Often some unfinished business between individuals will leave persons out of touch with important aspects of family and perhaps even of themselves (Hartman, 1978). A sample genogram may be seen in Figure 7.8.
The Use of the Genogram
The genogram can serve multiple purposes. Working together in the development of a genogram not only provides an effective tool for gathering family data but also provides a visual portrayal of the family system that may allow both the family members and the caregiver to understand better their family system and its relationship to current concerns. Reviewing the genogram with a client may facilitate the identification of the sources of marital or parent-child conflict and increase understanding between married couples and children as they recognize "old family issues" that are affecting the current family situation.
Use With the Elderly
Hartman (1978) sees the genogram as an invaluable tool in working with the aging. Elderly persons working with the genogram can use the tool to organize memories, reminisce, and experience their lives, themselves, as an important link between the past and the present. Review of such a tool may help them see that the family history demonstrates continuity. The genogram allows elderly persons to see the generative process and to see the life span of the family as reaching far back into the past and on into the future even when a single life span may be brief. The staff of a nursing home have been encouraged to work with family members of the residents and teach them how to build genograms. The family members in turn have helped the aged relatives reconnect with their family story. This experience of sharing the development of the genogram has been a positive experience for both the young family member and the elderly relative.
Tool for Obtaining a Health History
The genogram has also proved useful in hospital settings as a means to gather health history. Patterns of illness and attitudes toward health that surface may provide support and direction for health teaching, health screening, and preventive intervention. Similar use could no doubt be made in community health settings, outpatient departments, and other agencies where nurses have the opportunity to interact with family members for the purpose of health promotion and health supervision.
Child welfare agencies have used the genogram as a part of adoptive home studies as a means of clarifying why a couple views their family as incomplete and what role this child is intended to play in completing that family. Natural parents have also completed genograms as a part of the adoption process in one agency. The completion of the genogram was viewed as very meaningful by these parents, a process by which they could give something of themselves to their child. This was seen as a means of having available information an adopted child might want someday. As the issue of open adoption continues to be discussed, this approach provides a means of gathering significant data during this interim when the question of access to adoption records is being settled (Hartman, 1978).