Wednesday, November 12, 2014

Systograms, beyond Genograms and Sociograms



Systograms, beyond Genograms
and Sociograms


A proposal of symbols and conventions for use in service-based systemic therapies and consultation


Words: 2664
Key Words: Family therapy, Systemic thinking, Genograms, behaviour, mediator analysis
Running Title: Systograms, beyond Genograms and sociograms
Author: Jack Dikian

Abstract
Background: Despite the widespread use of genograms by family therapists, psychologists and other practitioners, it wasn’t until the 1980s when a more generally agreed-upon practice and diagraming convention came to be accepted. Even amongst practitioners with similar theoretical orientations there was only a lose consensus about what specific information to seek, how to record it, and what it all meant. Result: More recently there has been an increase in the recognition and use of systemic therapies and methods to augment more traditional behaviour assessment, clinical formulation and case consultation. Genograms and sociograms have been used effectively to support and facilitate such approaches as in the case of systemic consultation (Rhodes et al. 2013). Conclusion: Despite the growing use of genograms the set of diagrammatic symbols and conventions (McGoldrick., et al) has not necessarily kept in step with this systemic thinking and therapies. An extended set of symbols, relational markers and conventions may assist in recording and presenting structures associated with more formal support service systems. This paper describes the need for this from the point of view of a clinical practitioner working extensively in service systems that provide clinical and other supports to people with Intellectual disability. As well, this paper proposes an extended set of symbols, relational markers and conventions. Discussion: It is conceivable that these extensions may also have utility in a wide range of study including for example organisational, industrial and social psychology.

Introduction
Contemporary standardised Genogram conventions, also know as a McGoldrick-Gerson study (Jolly et al., 1980), a Lapidus Schematic (Jolly et al., 1980), or a Family Diagram (Butler, 2008) most commonly adopted by practitioners were developed by a group of leading proponents of genograms from family therapy and family medicine, including such people as Murray Bowen, Jack Froom, and Jack Medalie in the early 1980s. They become a part of a committee organised by the North American Primary Care Research Group. Monica McGoldrick, a family therapist, together with colleagues at The Multicultural Family Institute (2009) of New Jersey created the genogram as a diagnostic tool, and as a method for helping families recognise patterns in their past and present. This, as well as standardised genogram conventions are well presented by Monica McGoldrick, Randy Gerson, and Sylvia Shellenberger in GENOGRAMS, Assessment and Interventions, 2nd edition, 1999.

The application of Genograms is now diverse. They are effective in marriage and family practice settings, health care, social work, addictions treatment and other fields. Genograms have been used to research a family's pattern of poverty and wealth and even in career counselling where career family trees can be constructed to show patterns of careers or hobbies that have persisted in a long line of relatives.

Randy Gerson (Conolly, C, p. 84) refers to the genogram as the "supreme integrative tool" for understanding families, the "royal road to both the family system and the inner world of the individuals in that family.” Genograms are also used when describing more formal support systems. Systemic therapies and systemic consultation (McNamee & Gergen 2002) are good examples.  At the same time there has been a growing recognition (and use) of systemic methods or therapies to augment more traditional behaviour analysis and behaviour change techniques especially when working with individuals with an intellectual disability. In our work (Rhodes et al. 2011) with clients with intellectual disability, their carers and clinicians; we amongst other things, constructed a model that serves to develop the clinicians’ appreciation for the potential interpersonal dynamics that may restrain behaviour change.  This model has been developed over the past six years by the Systemic Consultation Reflecting Team at the Statewide Behaviour Intervention Service (Statewide BIS; Department of Ageing, Disability and Home Care, Sydney, Australia) and supported by Associated Professor Paul Rhodes from the University Of Sydney. The practice of co-constructing genograms and socograms (Moreno, J 1934) during the “Systemic Consultation” has been an integral element as the reflective team work through what is often complex dynamics of systems (e.g. family, schools, work places, respite centres, large residential settings and other professionally supported service systems.)
Whilst the increased utility of systemic therapies has been regarded valuable (Rhodes et al. 2013) genogram symbols and conventions have not necessarily kept in step with this practice. Extending the set of symbols and diagraming conventions may better assist in recording and presenting structures associated with more formal support service systems.

This paper presents a brief account of systemic methods as used in the support of people with intellectual disability as well as proposing a number of additional symbols to reflect the relational dynamics of formal support systems intended to augment those as defined by McGoldrick and others.

Background
Behavioural analysis (La Vigna & Donnellan 1986) has contributed significantly to clinical practice in intellectual disabilities, providing a rigorous, positive and ethical approach to behaviour change. Over the enduring years research has established that both desirable and undesirable behaviours are learned through interactions with the social and physical environment (Alberto & Troutman 1982). The crucial role mediators play (those people charged to support an individual with intellectual disability such as carers)  in assessment, intervention design and on-going monitoring of support plans such as behaviour support plans, lifestyle plans, and risk plans is well documented. Acknowledging that those who spend the most time with the client are often the best sources of information and even, more often than professionals like to think, the place where a more complete understanding of the individual is most likely to be found.  

Acknowledging caregivers (formal and informal) as one of the key therapeutic supports for people with intellectual disabilities is now well understood. Practitioners are educated from the knowledge gained by caregivers and in turn educate those persons with the helpful knowledge, skills and attitudes practitioners might hold as a result of their specialist training and experience. This form of knowledge exchange and knowledge enhancement now forms the philosophical basis of the mediator model of therapeutic intervention (Birnbaum, 1981). Exploring the interactions of recurrent patterns of interaction amongst mediators, between mediators and people with an intellectual disability and other stakeholders as well as how they are sometimes guided by certain beliefs and values is an important step in ensuring greater efficacy of behaviour support work.

At times the support system and/or the effectiveness of mediators may not match clients’ support needs adequately. Even when behaviour assessments and support plans are technically sound and well designed, they may be poorly implemented, not adhered to over time and/or suffer from the effect of a number of other systemic factors. A growing body of literature regarding the proficient implementation of and adherence to behaviour support plans (Alberto & Troutman 1982) stress the importance of service factors such as training, staff attitudes, resource availability, communication, knowledge and experience (Dikian, 2008). Dikian describes a phenomena he calls systemic empathy where service systems sometimes seek to understand client behaviours, as well as barriers and solutions to interventions from a systemic point of view rather than from a person centred lens. Patterns of behaviour can develop within care givers, management and other stakeholders as a consequence of client behaviours and these can become repetitive, circular and evolve over time. Exploring these interactions or patterns of behaviour can be aided using systemic therapy approaches partly supported through the use of genograms and sociograms in a team-based reflecting consultation.

Our work in systemic consultation (Rhodes et al. 2013) sought to introduce the teachings of family therapy to clinicians trained in behaviour support but not confident when intervening multi-stressed families and formal support systems. The goal was to support them to become more aware of the patterns of interactions and relationships across multiple settings that might restrain effective intervention.

A key tool used in systemic consultation is the sociogram. Sociograms are gradually drawn on a white board (see figure 1.) as the consult progresses. This allows for the visual representation of the network of relationships involved in the client’s life across the variety of subsystems involved, including family, school, clinical services, etc. The typical number of settings in a complex system has been around 5 or 6. The consultation process ensures that the more “needy” settings are identified and prioritized so that important and problematic settings are discussed within the allotted timeframe of the consultation. Typically, and particularly when the client is a child the family system is explored before other important settings such as the school, respite centre, and other professional services offering support.

Figure 1. Sociogram diagram example


Application

Once the basic demographic information of client and family is drawn as a genogram the consulting team begin to explore interactions that include the presenting problem or sequences (Breunlin & Schwartz, 1986). These sequences are manifestations of recurrent patterns of interaction that are sometimes guided by the beliefs of family members.

Those practitioners (such as psychologists, medical practitioners, speech therapists and behaviourists) involved in the client’s system are also represented. The exploration of other settings follows the same format as above. However the genogram is replaced by simple organisational charts outlining key people and their roles. Managers, school principals and medical practitioners might be represented at the top of the various hierarchies. It is critical to ask clinicians to include themselves in this process, promoting an awareness of their own interactions in potentially restraining change. Relational markers can also be used, although they will typically apply to working relationships rather than private ones. As the process progresses, questions will emerge that involve the interactions and relationships between members from different settings.

To date we have been using the standard set of genogram symbols and conventions to explore the extended family system as well as, crucially, the role and relationship of other key individuals or groups involved in the client’s life. These are typically professionals such as clinical practitioners, teachers, carers, advocates and other staff and managers. As mentioned the standard genogram is typically replaced by simple organisational charts outlining these people and their roles.

However, there are many scenarios found in formal settings that can not be easily represented using the standard genogram symbols, relational markers and conventions. These scenarios include:

1.     Staff members temporarily acting in different job roles
This scenario is not uncommon and presents both valuable as well as problematic consequences; staff members might not be willing or able to make long term decisions. These individuals are unable to explain or discuss actions taken by persons whose roles are being filled. It may be that these individuals have made significant inroads and progress in the role (for example developing good rapport with the client’s family when this was lacking previously) and there is a possibility that this work will not be maintained.

2.     Casual or agency staff filling job roles
The use of agency staff in all sectors of our workforce is significant (Voss et al. 2013) with some studies estimating that up to 48% of people use temporary agency work to improve their chances to find direct employment. It is possible that the agency workers may not have the sufficient client knowledge and the skills to provide the expected level of support. The capacity of these individual to work, initially, unsupervised might be unacceptable as is their ability to react to unforseen circumstances of rapidly escalating or challenging client behaviours. Their motivation to acquaint themselves with all the required client support material and the various protocols and routines might be lacking given their casual status.

3.     Job sharing and job splitting
Job-sharing typically involves one or more people filling a role at different times or days of the week. Job splitting involves dividing the tasks of the role between two or more part-time job holders. The impact of either of these sceneries may be that important client related information such as incidents or medication change is not always communicated promptly and accurately amongst these people thus resulting in gapes (sometimes serious) in the overall support provision.

4.     Unfilled positions
Key positions are sometimes left unfilled for a variety of reasons. As well as the obvious consequence of reduced support capability, this situation might suggest a number of other service support difficulties that exist. These may include budgetary constraints, difficulties in filling the role due to a limited available workforce especially in regional regions of the country, and/or difficulties in retaining staff.

5.     Skill and experience mismatches
The role (position description) might be inconsistent, or has become inconsistent with the specific support needs of the current client group and the service. It is also possible, for example that the individuals filling those roles might not have the sufficient skills, experience and or the desire to undertake their duties.

6.     Staff turnover
Many factors play a role in the staff turnover rate of an organisation. These can stem from either the employer or the employees. Wages, benefits, attendance, responsibilities, hazards and job performance are all factors that play significant roles in staff turnover. The workplace environment and staff morale are also important aspects. The impact of a high staff turnover is significant because as well as the cost incurred to replace employees, the continuity and consistency of support for the clients can become compromised. The lack of opportunity for clients to develop trust with employees may parallel a similar loss in other or earlier parts of their lives.

Systogram symbols

A number of symbols (see table 1.) are proposed to depict the kind of scenarios typically found in formal support systems above. Whilst the standard genogram symbol for a person (i.e. a client, a mother, an uncle) is typically shown as either a circle or a square (representing gender) the proposed systogram symbols place importance instead on roles or positions in an organisational context. How have, for example, various roles been filled, how well are roles matched with people and their skills, what positions have been left vacant, what roles are shared amongst two or more individuals, etc. are identified as possible system strengths and/or elements instead that are hindering the provision of support.

As with the conventions of genograms it is anticipated that staff identifying information is transcribed over these new symbols. Relevant relational markers linking roles with each other as well as linking roles with client and/or client groups are depicted as per accepted genogram markers. It is entirely conceivable for example that a hostile or fused relationship defines the relationship of two support members. The relationship between a particular staff member and a client might be close; however, that staff member’s working hours might have been recently reduced significantly.

Table 1. Symbols and relational markers



Conclusion

Despite the growing use of genograms the set of diagrammatic symbols and relational markers has not necessarily kept in step with the increasing use of systemic thinking and systemic therapies.  An extended set of symbols, relational markers and conventions may assist in recording and presenting structures associated with more formal support service systems. This paper describes the need for this from the point of view of a clinical practitioner working extensively in service systems that provide clinical and other supports to people with Intellectual disability. As well, this paper proposes an extended set of symbols, markers and conventions

Figure 2. Systogram diagram example




Features:
a.    All standard Genogram conventions are preserved. E.G. hostile/fused relations.
b.    Emphasis is placed on tracking the number and rate of employee turn-over.
c.     Important to capture any long-term employee absence.
d.    How well an employee’s skills match client needs is captured.
e.    Employee positions are gender independent.

Correspondence
Any correspondence should be directed to Jack Dikian at jdikian@me.com

Acknowledgments
The author would like to thank all those involved in developing, supporting, conducting and administrating the Systemic Consultation Clinic at Statewide Behaviour Intervention Service at the Department of Ageing, Disability and Home Care, Sydney, Australia. Lesley Whatson, Kate Brearley, Anders Hansson and Lucinda Mora for making this work possible.  Associated Professor Paul Rhodes (University Of Sydney) who without his guidance and couching this clinic may not  have reached and maintained the success it has achieved.

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