Fig. 7.1
Genogram
The proposal to create a genogram can be introduced by the doctor in the following way: “We have talked in detail about your problem. Now I would like to get an overview about the diseases that have occurred in your family. As you tell me about it, I will take notes together with you so that I can recall at a later time who is who.” By constructing a family genogram together, there will be numerous opportunities to enter into an in-depth discussion with the patient.
Practical Tip
Questions for the genogram
What diseases run in your family?
What “counts” as a disease?
Who is affected?
Who cares for the sick?
What does he/she get for it?
How did your family deal with illness and death?
What was the cause of death?
What coping strategies does your family use for illness, or grieving?
The creation of the genogram takes place in three steps:
1.
All members of a family and their relationships are recorded. It is started with the children or the couple as the core family. Then, grandparents are added. Overall, as far as possible, at least three generations should be included.
2.
In the second step, information about the family history is added: age, marriage, divorce, miscarriages, death, and serious diseases as well as critical family events.
3.
Finally, the quality of relationships among family members may be particularly highlighted.
The Family Dialogue in the Medical Context—Useful Strategies
In the medical context, McDaniel et al. (2005) suggest the therapeutic strategies listed below for couple or family dialogues.
Disease: An Explanation of the Diagnosis, Treatment, Disease Progression, Prognosis
The disease and its impact on the family members, rather than the family conflict as is the case in psychotherapeutic interviews, are at the center of the family dialogue in the medical context. The physician may begin with an explanation of the disease, its prognosis, and the probable course of the disease for the family. Then psychological and social interactions are related to the medical problems.
Inquiring About Medical History
If, as part of a family dialogue, we—the doctors—listen to the medical history of the patient and understand it, we enter the world of the patient and his/her family. In addition to the content of these stories, this approach builds trust for joint work with the family. Important questions in a family dialogue include:
How does the family cope with and overcome life events and life crises?
Are there typical patterns within the family on how to deal with illness?
Is there support across generations in dealing with the illness of a family member?
What are the constructions of reality in terms of etiology, course, and management of disease or successful healing strategies included in these stories?
Focus on Concerns of the Family
When dealing with a family coping with the stress of a serious illness, it is important not to criticize from the outset or disqualify their coping patterns even, when viewed from the outside, they appear to be rather dysfunctional. Instead, acknowledge their attempts to cope with the current situation and the contribution of individuals to maintain the continued functioning of the whole family. This approach serves to reduce blame and guilt and causes an immediate emotional relief.
Promotion of an Open Communication Between the Parties
Give the family time to process information about prognosis, disease progression, and the treatment plan. Offering the opportunity to continue the dialogue, encouraging them to also ask critical questions and express any objections.
It is particularly important to acknowledge that all family members are concerned, and to help them to express any possible feelings of dismay. Emotional reactions often result in strong uncertainty and helplessness among family members. Dealing with directly or indirectly expressed feelings helps the individual persons concerned. Confrontational statements should be avoided.
The Doctor as the Moderator
If the doctor understands his/her role in the family dialogue to be the moderator, without giving advice, an open exchange within the family can be encouraged. The family will feel they are able to promote and support the positive course of therapy for their loved one.
Phases of the Family Dialogue
Phase 1: Joining
Joining means to connect with each family member and to convey, that one cares to get to know his/her opinion. The dialogue starts after the doctor has greeted each one (even the younger family members) with a handshake, asked for the name, and perhaps the age of the individual family members.
Case Study (Continued)
“Joining 1”
Dr.: “Hello. Thank you all for coming today. I have seen you, Mrs. A., now several times and we have spoken about your illness. I thought it might be helpful to talk together with you and your family about the situation and see what impact the disease has on all of you. We can think together about how all of you can best support your mother and each other.”
(Continued)
As a next step, explain the focus of the conversation and how long it may last.
Case Study (Continued)
“Joining 2”
Dr.: “I have known you, Mrs. A., and you, Mr. A., for many years. However, I know your children just barely. Who would like to introduce the family a bit more in detail? Please again give me their names and ages? Maybe each of you can say a few words, about the person sitting next to him/her.”
(Continued)
Phase 2: Context and Task Clarification
Institutional context: Especially in the clinical context, it is important that the doctor responsible for the diagnostic and therapeutic process is directly involved in the joint family dialogue. Otherwise there is a high risk that the family will have to deal with varying professional perspectives on the disease and its consequences, which can lead to additional burden.
Mission clarification—different family caretakers: It should be clarified what other doctors, psychotherapists, and other health professionals are involved in the health problems of the whole family, and how these other professionals think about and assess the current crisis of the family.
Expectations of the family interview.
Case Study (Continued)
“Context and mission clarification”
“What needs to be discussed today, so that it was worth your while to come here?”Related posts:
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