Transcript for
Using genograms in infant mental health assessments
Lauren Keegan (00:00): The aim of a genogram isn’t to blame previous generations, it is just to have a bit of a wider lens of what was happening. And using it as a relational tool is probably unfamiliar to many clinicians, so we can use them to understand intergenerational trauma as well as attachment patterns. And so when we map out those several generations, we explore all the relationships.
Narrator (00:26): Welcome to the Emerging Minds Podcast.
Vicki Mansfield (00:32): Hi everyone, I’m Vicki Mansfield, Practice Development Officer. Today it’s my pleasure to be meeting with Lauren Keegan, psychologist, and talking with Lauren about how genograms can be used as relational assessment tools when we’re working with infant toddlers and families. So, welcome Lauren.
Lauren Keegan (00:50): Hello, thanks for having me.
Vicki Mansfield (00:52): Great to have you here. And Lauren, so our audience can get a little bit of context, can you tell us briefly about your background and experience in working in perinatal infant mental health?
Lauren Keegan (01:04): Yeah, sure. I am a registered psychologist, and I’ve worked in the perinatal and infant health sector for the past 12 years. Up until recently that was with New South Wales Health as a clinician working with women from conception through to 12, 24 months postpartum. Sometimes a little longer, working with women who’ve had two, three or more pregnancies in that time. And the perinatal work tends to be from a trauma-informed and attachment-based approach, so we’re supporting that relationship between mum and the baby while also treating mental health concerns and addressing past trauma, often from the mother’s own childhood experiences. This year I’ve moved into private practice in the Southern Highlands of New South Wales, where I’m going to continue working with perinatal women and their babies.
Vicki Mansfield (01:54): That’s exciting, and it’s great to have you meeting with us today and sharing your experiences and knowledge. So yeah, let’s jump into talking about genograms with you. How we might more purposefully use them in assessing family dynamics, and how they can help clinicians guide their assessment and formulation for infants and families. And I know that’s an area that you have lots of experience, and so it’s great to draw on that. In your practise, how are genograms useful assessment tool, and how particularly for perinatal infant mental health clients?
Lauren Keegan (02:30): They are a really powerful tool, and it’s especially useful in working with perinatal clients and families. So I mean, children, even unborn babies, they must always be considered in the context of their families, communities and culture, which is why the genogram is a natural starting place for even any child or adolescent assessment as well. Babies are not born as a blank slate as we were once led to believe, they come into the world ready to connect with the people in their lives. They bring to the world their own temperament, personality and DNA, which is influenced by generations past. And we know a lot more about epigenetics now, and that’s why it’s helpful to look into the past, which is what genograms can help us do.
(03:13): And when we gently make links to a client’s earlier experiences and the strategies they used to perhaps survive stressful or traumatic situations and how that may have been helpful as a child, we can also maybe show them that maybe those strategies aren’t that helpful now that they’re adults. And I guess often we have clients who come to us, and they ask us, “Why am I like this, why do I feel like this,” or, “Why is my child like this?” And the answers are often in their history. And as a clinician, they’re also a great organising tool too. They provide just like a natural structure to a therapeutic assessment, and it’s a collaborative process. So it opens up a conversation with clients in comparison to a formal mental health interview, and it’s also an easy way to help clients tell their stories and for them to build trust with us.
Vicki Mansfield (04:04): When you’re introducing a genogram to a family or to a client, how do you explain the purpose to them?
Lauren Keegan (04:13): I mean, we keep in mind that genograms are a collaborative process, we want to know who has been important in their lives. At the outset you set up that you’ll be working on a genogram together, I do this in my first appointment, other clinicians might do that in their second or a later appointment, it’s really up to you. I guess one of the gurus of genogram work in family therapy, her name’s Monica McGoldrick, and she introduces it by saying, “Why don’t you tell me a little about what brings you here? And then we’ll get some background questions so I can understand a bit about your situation.” And that’s just a nice way of kind of being upfront with them. And so the way that I set up an initial appointment, following introductions I’ll say, “Tell me a bit about why you’re here,” or I’ll reflect back what’s been noted in the referral.
(04:59): And I’ll say, “I’m going to ask you questions about your family and childhood, and I guess anything you don’t feel comfortable talking with me today, you just let me know and we’ll move on.” I say, “I’m going to start with a genogram, which is a bit like a family tree, and this just gives me a visual picture of who is in your family, who your supports are, and it helps me understand your early experiences,” which I find usually explains some of the struggles that new mums are having right now.
Vicki Mansfield (05:27): Yeah. And what stands out for me, Lauren, in you saying that is that you’re establishing safety by saying, “You know, if there’s an area you don’t want to talk about we can move on.”
Lauren Keegan (05:37): Yeah, absolutely. And I think that particularly for clients who’ve never been to therapy before it can be really overwhelming. And I think providing that structure, and then setting up that they don’t have to divulge everything in their life history in that first appointment is absolutely fine.
Vicki Mansfield (05:53):
So structure for the clinician, and also some containment for the client as well. Do you use them with individuals, or couples, or it could be both?
Lauren Keegan (06:02): Yeah. I mean, I’ve used them for both. I suppose my previous role, just due to resources and time, the focus has just been on mum. But if the presenting concerns are very much around the couple’s relationship, or the partner’s family are very involved with the family unit, then I would definitely include the partner’s family in the genogram that I’m working on with the mum. If you’re doing couple work, then I would absolutely do them for both because you get a really good picture of both their attachment patterns and relationship histories. Genograms can also be done with kids as young as three, and teenagers as well.
Vicki Mansfield (06:38): So there’s quite a lot of scope in that structure. And what helps you decide how wide a sort of net to cast in terms of what family information you’ll gather?
Lauren Keegan (06:50): Yeah, good question, because you can really uncover a can of worms and have so much to talk about. But I mean, ideally you want to go back three generations from the client, so if you’re working with mum that’s her parents and her grandparents. And so for the baby that’s actually four generations, that gives you a really good picture of their history, and really good insight into their family dynamics too. But even just going back two generations can be really useful as well. Sometimes it just comes down to time, some families are very large, there can be lots of siblings, lots of uncles and aunts, so it’s just clinical judgement and trying to identify who’s significant. And if there are a lot of relatives, then I’ll just ask who’s been significant in your life.
Vicki Mansfield (07:35): And so that’s where it’s relational, not just factual. Is there particular types of questions, or in your clinical experience particular areas of strengths or vulnerabilities that might be kind of featuring in those conversations?
Lauren Keegan (07:51): Yes. I guess as therapists we’re all kind of curious beings, so you are following your clinical judgement but you’re also following curiosity as well, follow where the client goes because that will be what’s important for them. But I guess you do start with your basic demographic information, which is how typically genograms are used. You start with your client, and if that’s the mum you start with her, if it’s the child you start with them, and you kind of build the genogram around them so that they are at the centre. With a young family you get name, age, location of mum and her partner, how many kids there are, all their ages, her parents’ details and her grandparents, siblings, and you’re just kind of mapping out who is on the genogram.
(08:35): And some people might choose to just map all these details out first and then dive deeper. I tend to do it as I go, so I’ll work on the immediate family, and then dig deeper, and then I’ll start to move my way back. But I’ll look at the couple, and the pregnancies, or the children first, so really diving into what’s happening, kind of their current and recent circumstances, and then go back a generation. So you then move kind of vertically, exploring the other generations in the family. In perinatal you want to start at the beginning, sketching that immediate family, about the partner and the pregnancies or the children. So in terms of the relationship I might ask, “How long have you been together, how did you meet, what was the relationship like in the beginning?
(09:19): “Have there been any pregnancies prior to this one, and any losses or terminations,” because they’re a very important part of their story. If they have other children I’ll go back and explore what was that pregnancy like, what was the birth like, what was that really postpartum period like, and that can give us good clues about the relationship they have with their other children. But, can also tell us whether there’ve been emotional difficulties with previous pregnancies or children that maybe wasn’t picked up, or they didn’t get help for, and then asking about this most recent or current pregnancy, was this planned? And you can just keep diving deeper, and like, “How did you feel when you found out, how did your partner feel, how do you feel now?
(10:00): “How do you feel about the gender, how is the pregnancy progressing?” If it’s postnatal we’ll ask about the birth. You’re not just rattling off all these questions, it’s just kind of a natural back and forth of them kind of expanding on how they felt at that moment.
Vicki Mansfield (10:14): Yeah, and I’ve heard it described recently as a dance. So you are weaving between the past and the present, and it sounds like you’re drawing on your understandings of things that might influence someone’s parenting, and adjustment, and relationships. But you’re being very much guided by the sounds of it about what the client’s giving you, and that curiosity around that, and dancing between here and now, and what they’re forthcoming with as well.
Lauren Keegan (10:45): You’re also setting up that structure that we’re going to talk about relationships, and how you feel about people in your life, and that’s important.
Vicki Mansfield (10:54): What type of relational curiosities do you have when it comes to the parents’, grandparents’ level of the genogram?
Lauren Keegan (11:05): I think using it as a relational tool is probably unfamiliar to many clinicians, so we can use them to understand intergenerational trauma as well as attachment patterns. And so when we map out those several generations we explore all the relationships, not just who’s in the family. If we’re looking at the client’s parents we’ll say, “What was your relationship like with your mum when you were younger, and what was your relationship like with your mum when you were an adolescent,” because that can be quite different. And then now as an adult, and that can be different again. And then the same for the father, and also for siblings as well, that those relationships change. And I guess we’re kind of looking for clues as to where the current struggles may be sourced from, you know?
(11:52): If there’s any kind of trauma, or losses, or just general life transitions like parents separating, or grandparents passing away, or a younger sibling being sick in hospital. Just little things that might not seem super important for that client looking back, but can give real clues as to how they learned to relate to people and how they learned to deal with their feelings. That would definitely be impacting their current life.
Vicki Mansfield (12:22): Yeah. And so starting to gain some understanding of the map of their relationships, but also what patterns they might have developed over their life, or experiences of relationships.
Lauren Keegan (12:34): Yes, absolutely. And I guess you could also think of it a bit like a spiderweb, you have the client in the middle and you’re kind of branching out on these little lines connecting with each person that’s on the map. Like talking about the relationship with the mum, but then also let’s jump ahead and look at what’s your relationship like with your grandmother. And then come back a step and be like, “What was your mum’s relationship like with her mum,” and trying to get some of that intergenerational information around the relationships as well.
Vicki Mansfield (13:02): Which is really quite rich. So how is it for clients to be doing that? Because I’d imagine that’s not something people have necessarily discussed, sometimes if they’ve had previous therapy maybe. But yeah, how is it for clients to engage in that, in your experience?
Lauren Keegan (13:18): That’s a good question. I mean, I guess it’s different for them in a way. But it does have a bit of a natural flow, so it’s not like they just kind of come in and sit down, you’re like, “Tell me about your early experiences.” We just kind of have the gradual… You’re gradually just stepping back and digging deeper, and I mean, I’ve probably only had a few clients who I’ve not been able to complete it with, and that’s just because of them presenting in crisis, or just being really kind of anxious and triggered.
Vicki Mansfield (13:50): Yeah, so respecting where their vulnerabilities might be. And you said earlier, thinking about from a trauma perspective as well, or being mindful of ensuring people stay in their kind of window of tolerance around what they’re discussing. And so in terms of the conversations about relationships, and this, as you said, may be not all one session. It might be over time and occur across a few sessions.
Lauren Keegan (14:16): I think it offers perspective, it’s almost like separating yourself a bit from your history. Because you can see it all mapped out in front of you, and when you go back several generations, and the client begins to understand their heritage, and perhaps have a greater understanding about why they were even parented a particular way, or why they may struggle with some of the things that they do now, and they may begin drawing their own links between the past and the present. But at the very least we’re kind of planting that seed, that that stuff back then is important to what’s happening now. And I guess for me as a clinician, if I can get a good understanding of those early years then it helps me with my formulation and the focus of therapy.
(15:01): So say they had an unpredictable early life and they now struggle with anxiety, I can make that link and share it with them. “You know, when you were younger you developed strategies to cope with your family situation, and those strategies were great at the time because they helped you have some sense of control over what was perhaps an unpredictable or scary situation. But now as an adult, those threats are not as present, and so those strategies are no longer helpful.” And that can be really reassuring for people that there’s not something kind of inherently wrong with them when they have knowledge and understanding about why they think, or feel, and do things, than with that awareness they can make choices to do things differently.
(15:47): Anxiety is a big one in pregnancy and the postpartum period, so many women who’ve kind of managed to successfully navigate life are suddenly overwhelmed by all of the uncertainty and unpredictability of motherhood. So if they know that they are someone who needs structure and information to feel in control because of their past experiences then we work to that strength. Rather than trying to change who they are, we look at how can we control what can be controlled, put some plans in place. And I guess one of the really powerful aspects of genograms is that it is a conversational tool, you’re not just rattling off a series of empty questions, like we said. It’s, you’re building rapport through a conversation, you’re showing interest in their family histories, and you’re reflecting back as you go interesting things that might come up. And you might take detours along the way, and that’s okay. The genograms provide us with that structure, but we also follow our client’s lead.
Vicki Mansfield (16:43): Your description of it gives this lovely sense, again, of a dance or a rhythm between the two of you, and that discovering together insights, and sometimes those insights might land by the sounds of it for some clients, sometimes it might not be the time for it to land. So it sounds like you’re always reflecting and thinking in the moment, but maybe after sessions as well as to… Yeah, so it’s a very reflective process for you as a clinician as well, by the sounds of it.
Lauren Keegan (17:12): Yeah, absolutely. And I think that comes with practise and experience too, but there’s certainly still times I won’t have my head completely around a situation after a first assessment. That’s not completely realistic, that we’ll have that all the time. But, you do start to see similar kind of patterns and themes. And I guess in perinatal it does help clients get some insight into their own parents’ experiences too, you know? On the genograms, “Oh, you know your father left home when you were three, and you had a younger brother, that must have been hard on your mum.” Also acknowledging that must have been hard on them, but kind of putting themselves in their parents’ shoes too can help them develop some perspective and empathy about their own parents.
(17:54): I think when we become parents ourselves it does bring up things from the way we were parented, what we might like to do similarly and what we might like to do differently, and we understand just how hard it is. But then we may also realise that there are choices we can make, choices that perhaps our own parents didn’t make, and that might be a bit triggering and bring up quite intense feelings from childhood. And I guess at the same time we have grandparents who are quite involved these days in baby care, and so parents are also navigating different viewpoints based on sociocultural and intergenerational changes. But it can provide just a different perspective as well on perhaps their childhood, and also on their parents too.
(18:37): And it’s probably important to note that the aim of a genogram isn’t to blame previous generations either, it is just to have a bit of a wider lens of what was happening. And some clients are quite angry about how their childhoods were, or about their parents, and just being able to say that they did what they could with the resources they had, and you’re here wanting to make a change, and you will be able to do things differently because you have an awareness that perhaps your parents or grandparents didn’t have.
Vicki Mansfield (19:08): Do you think there’s any particular considerations from sort of a trauma-informed lens, in terms of having those conversations as you flesh out a genogram?
Lauren Keegan (19:19): Yeah, it does require that kind of clinical judgement and reading your client’s cues. That if they do gloss over, or dismiss, or minimise something in their histories that might point to trauma, then you might want to come back to that later, either in the same session or in a later session. And I guess if we’re aware of a particular perpetrator of abuse, then we won’t want to kind of jump straight into, “What was your relationship like with them?” We might just want to have them on there, and that we might come to it if the client feels safe to do that.
Vicki Mansfield (19:48): Lauren, to summarise our discussion today, what do you think are the important takeaways?
Lauren Keegan (19:53): I think much of what we struggle with as adults can be explained by our early experiences, not everything obviously but a lot can. And I tell clients it helps me understand what’s going on for them, and the more deep diving we do into a family genogram the more understanding and clarity we’ll have over why someone experiences these struggles. And I suppose there are a lot of modalities that don’t concern themselves with the why, but when it comes to being a parent the why is important because babies and children are going to trigger us every day for the rest of our lives, and knowing why and what that looks like means we can make different choices. And so when we look at a genogram and the point in time we see a client, there is this opportunity here for transformation that will impact not just the client and their baby, but future generations. And that’s why the work that we do in perinatal is so rewarding.
Vicki Mansfield (20:54): That’s beautifully articulated, Lauren. Thanks so much for sharing your wisdom.
Lauren Keegan (21:00): Yeah, it’s been a pleasure chatting to you Vicki.
Narrator (21:03): Visit our website at www.emergingminds.com.au to access a range of resources to assist your practice. Brought to you by the National Workforce Centre for Child Mental Health, led by Emerging Minds. The National Workforce Centre for Child Mental Health is funded by the Australian Government Department of Health, under the National Support for Child and Youth Mental Health Program.