1. The use of Genograms in Safeguarding in Primary Care Dr Venetia Young GP, Penrith, Cumbria

2. The aim of today

3. Is transformation

4. Why Genograms? Combine biomedical and psychosocial information Are an excellent database for future reference Emphasise the clinician’s interest in the context of their patients lives Produce unexpected stories Make connections between people and events Trans-generational patterns of disease and problem behaviours Place presenting problem in a historical context. This can be non blaming and help to relieve shame Arouse curiosity in clinician and patient Diagnostic and therapeutic. They put the patient in the observer role of their own family drama Evidence of time saved: 4 times information from 20 minute interview

5. When genograms are useful  Presentation of distress  Feeling stuck  Wanting to widen your understanding  Heart-sink feeling  Illness history  Cultural migration  Domestic abuse

6. Why in safeguarding cases?  History of relationships and their quality  History of drug and alcohol problems  History of mental health problems  Which professionals are involved  Invisible children  Invisible men (Baby H)  Look for strengths and protective factors  More accurate referrals, with greater chance of appropriate response. Discussion with colleagues  Risk assessment: suicide, self and other harm

7. Cases. 1 Child Protection  7 year old boy presenting with distress after access visits to his father and his new partner.  Discussed with HV and SN at monthly meeting  Referral made to SSD

8. Case 2. Vulnerable adult at risk of financial abuse  Family known to have high expressed emotion  Young man has neurological problems, LD and occasional episodes of psychosis  Professional network walking on eggshells  Sister talks of sexual abuse by older brother and presents evidence.  Concerns re financial abuse as he has power of attorney  Discussed with other GP leads  Discussed with mental capacity expert  Meeting with care team and the above

9. Case 3. Domestic violence  39 year old Lithuanian woman with 3 presentations to MIU in last 6 months with bruises. Admits to being hit by husband  HV and SSD already involved in monitoring harm to the child  Presentation to primary care with lower abdominal pain and probable pelvic infection  Sister-in law dies and she wrecks the graveyard.  If you don’t tell anyone you can be my trusted doctor.

10. Case 3 continued  Power and control wheel  Marac questionnaire  Stress cycle  7/11 breathing  Discussion with HV and school nurse  Supervision  Liaison with CMHT, adult safeguarding lead in SSD and Children and families SW

11. Making the connection  Introducing the genogram, seeking consent and asking some questions  Who can you talk about your concerns to?  Who are most/least sympathetic?  Who do you try to keep how you feel a secret from?  What would happen if they found out?  Most families have someone with a drink problem. Who is it in yours?  What is the impact of the abuses you have suffered on family relationships?  What are your fears about leaving?  What should your fears about leaving be?  How do you keep yourself safe?  Who helps you to keep yourself safe?  What strengths do you have? Who taught you these?

12. The Art of lenses  Gender  Power  Religion  Illness  Culture  Ethnicity  Social class  Family patterns

13. Summing up  What do you notice about what we have drawn together?  Would you like to hear what I have noticed?  Does that make sense to you?  Would it be helpful to have a copy of this or talk about it with a member of your family/friend?  Create a plan  Breaking ‘bad news’ of referral

14. Patient views of the process of doing a genogram for safeguarding purposes  See their problems more clearly  Like having their lives explained in one go – quicker than some therapists get to in 10 sessions  Take their problem more seriously  Some vote with their feet – but only occasionally.

15. Practical considerations  Where to store the genogram  Confidentiality  Practice with your own genogram  Practice with easy patients – newly pregnant  Find a buddy to share learning experiences with.  Family therapist to support learning

16. References and links  Ten minutes for the family. Asen, Tomson, Tomson and Young 2004 Routledge  www.caada.org.uk www.caada.org.uk  RCGP guidelines on Domestic Violence  www.kwango.com www.kwango.com  www.cumbrialscb.com www.cumbrialscb.com