Genograms are widely used in the training of counselors and therapists, and in the work of therapy with clients (McGoldrick et al. 1999). These visual mappings of three or four generations of a family are used to organize, clarify, and explore family and relationship data in therapy. As a heuristic tool (Coupland et al. 1995), the genogram is also useful for generating hypotheses for therapeutic interventions in clinical work. Genograms are used in varied ways: from career counseling to work with clients to explore issues of intimacy, sexuality and related problems, decision making, cultural factors, and spirituality (cf. Magnuson and Shaw 2003 for a comprehensive article on the various adaptations of the multifaceted genogram in clinical training and work). Based on the adaptability of the genogram, it appears that the genogram can be used to explore the multigenerational legacy of any focused issue in clinical work. Some practitioners, for example, have developed the money genogram with the specific purpose to facilitate discussion of money in couples’ counseling (Mumford and Weeks 2003). The rationale for its use is that in situations when money is a clinical problem, the genogram enables a focused discussion of money when it would otherwise be difficult for the clinician to probe or for the couple to raise the issue.

The versatility of the genogram and its usefulness in these multiple contexts suggest its potential applicability across diverse cultural contexts as well, and research on the use of genograms across cultures is beginning to be explored. For example, in their study of Black and White students in South Africa, Marchetti-Mercer and Cleaver (2000) concluded that “genograms can be a very useful tool in the context of a multicultural South Africa” (p. 74). The authors further observed: “Although perhaps developed as a tool for Western families, the genogram appeals to Black students because the extended family and its influence on the functioning of the individual are of prime importance to Black people” (p. 74). Chang and Yeh (1999) suggest that genogram work can be useful for Asians as a theoretical approach that emphasizes intergenerational dynamics, which is very much in line with the lived experience of Asian families where it is not uncommon for three generations to be living together. However, there are no studies that focus on the use of genograms in Asian contexts. This article contributes to the literature by exploring the ways in which the genogram can be an effective psychosocial tool for use with Asian families of diverse cultural heritages.

In this article, we illustrate the usefulness of genogram work with Asians, both in the clinical training of therapists and in assessment and intervention in therapy. Using the case studies of three Asian individuals originating from three different Asian countries (Malaysia, Japan, and Cambodia), we show how trainees and therapists can explore relationship patterns, major life events, illnesses, and migration history for effective assessment and intervention with ethnically diverse Asian clients. The authors, both Asians, had each constructed and presented their genograms as part of their clinical training and had found that genogram work was an instrumental part of their personal and professional development as therapists. In their initial work of exploring the use of genograms across cultures (Lim and Nakamoto 2005), the authors presented their genograms from both Malaysian and Japanese contexts at an international conference in Bangkok, Thailand. Subsequently, the first author conducted two genogram training sessions for mental health professionals in China. Survey responses from participants in all three training contexts were overwhelmingly positive and indicated the value of using genograms as a psychosocial tool in Asian contexts.

We elaborate on how the use of the genogram is culturally resonant with Asian cultures, how such work honors diversity and broadens creative areas of freedom, and how the genogram is an effectively triangling (Kerr and Bowen 1988) tool in the therapeutic process with Asian clients. Based on our own experience, we suggest that genogram work provides a unique opportunity for Asian family therapy trainees to gather family data and to do family-of-origin work that might not otherwise be culturally sanctioned. We also offer some practical considerations for the effective use of genograms in the Asian context through examples representing the lived experiences of the authors. Finally, the voices of Asian mental health workers working with ethnically diverse Asian groups in the three training contexts are reported through their written responses to a survey questionnaire on the effective use of genograms.

Asians with Diverse Cultural Heritages

The authors of this paper are both women who were born and raised in Asia. The first author is Malaysian Chinese, and the second is Japanese. Both had journeyed to the U.S. to complete their graduate studies and clinical training in mental health disciplines. They live and practice in the transnational spaces of East and West. Both use the genogram in their work with ethnically diverse clients in the U.S. and Asia and are committed to the integration of Eastern and Western thought and practices through culturally responsive therapy.

Narrator 1—Lim

Growing up in Malaysia in a traditional Chinese household that practiced ancestor worship and embodied Confucian ethics and philosophy in family relationships, at a very young age I was attuned to the importance of family and intergenerational transmission of relationship patterns in family dynamics. To instill filial piety in his ten children, my father had warned us regularly with this Fukien proverb Lok hor chui chiau tik! Literally translated it means “Raindrops drip (as from roof eaves), one drop following the other.” The central core of Confucian philosophy is the value of filial piety. My father taught us to honor one’s parents in absolute obedience lest we will inevitably be dishonored by our own children. His teaching parallels Boszormenyi-Nagy and Spark’s (1984) concept of the revolving slate in which patterns are replayed from one generation to the next.

Our family heritage can be traced back to Yongchun, a village in the Fukien Province in Southern China. According to my family’s recorded history, I am the 37th generation of the Lim family. I grew up as a third generation Malaysian Chinese in post-colonial Malaya, the eighth in a family of ten, with 13 members of my family representing three generations under one roof.

Narrator 2—Nakamoto

As a Japanese woman raised with Buddhist and Shinto beliefs, I grew up with four generations consisting of 11 members, living under one roof for the first 7 years of my life. Ancestor worship is an integral part of my family life. Each August, we observe our age-old family ritual of inviting our ancestors who have passed to come back home where we have a fire burning for three days in our garden as a welcome. My family taught me to honor our ancestors both by their example and by direct teaching. My great grandmother taught me that I am not alone, because all the ancestors are watching me.

My family’s recorded history stretches back to 25 generations. Not every Japanese family has a written record of their genealogy, but our family hired professionals to trace our genealogy. What we have now is 25 generations of family members graphically diagrammed on a large piece of paper measuring 20 × 20 ft. However, I am not represented in the diagram. When I first noticed my name missing from the recorded genealogy, I asked my mother why I was not represented. She explained to me that it was because I had not married and procreated; therefore, I had not fulfilled my family responsibility to continue the family line. I was sad. I felt as if I had no identity and place in the family. I was then in my late twenties. Four years ago, as part of my coursework in a counselor training program in the U.S., I constructed my genogram. The experience of constructing my genogram impacted me in a big way. I felt like I was in the center of the universe because I had a key place in this family diagram. I had identity, regardless of whether I was married or had a child. This was an important experience for me.

Genograms and Our Ancestral Heritages

We have found the genogram to be a useful tool in understanding family dynamics and how these dynamics impact us and our relationships today. In our own experience, we also have found that these visual mappings of family data, intergenerational legacies, and family relationship dynamics are trans-culturally useful. Although genograms originated in a western context, we find that they can be useful and especially effective for understanding family processes and for therapeutic interventions in diverse Asian cultural contexts.

Key familial issues arose out of our use of genograms in our therapeutic training, which we describe. The first author also illustrates her use of the genogram in her clinical work with an Asian client from Cambodia. Three Asian countries thus are represented in this analysis: Malaysia, Japan, and Cambodia. The first two represents Asian individuals in voluntary relocation. The third represents forced immigration due to war. While there are multiple themes in the genogram work of each of the three families represented, for the sake of brevity we focused on one salient therapeutic theme in each case.

Using her genogram, the first author shows how growing up in a heterogeneous Asian society, the experience of multiple migrations, and the issue of language transmission have affected family dynamics and ethnic identity in her multigenerational history. The second author, from a homogeneous Asian context, highlights her therapeutic issue of living under the fearful shadows of a family history of cancer, heightened by the scourge of the Hiroshima nuclear bombings. Her genogram work helped her to face and resolve her fears. The third genogram focuses on the story of Akara Vath (identity disguised), a 1.5 generation Asian American, born in a Thai refugee camp to parents who fled Cambodia and later resettled in the U.S. The salient theme here is how the intergenerational legacy of losses in the Killing Fields of Cambodia under the Khmer Rouge have impacted the generations that follow, even though members of the succeeding generation, now domiciled in the U.S., are physically far removed from any imminent danger. This case example shows how nodal events need to be acknowledged, intergenerational losses grieved, and human resiliencies and strengths affirmed so that the family unit can heal and find new meanings and beginnings. In these three case examples, the therapeutic tasks appear to be trans-culturally relevant, suggesting the universality of human healing and growth aspirations in situations of family challenges and suffering.

Case Study 1

“As a third generation Malaysian-Chinese and a first generation immigrant to the U.S., I am a transnational living in ambiguous transnational spaces. There is a chasm, an intergenerational disconnect that comes with the loss of shared language between my children and my mother.”

Case 1 refers to the genogram of the first author (Fig. 1) within the context of an Asian country that is heterogeneous. Malaysia is a multilingual and multiethnic society with a racial mix of subgroups, the main ones being the Malays (the largest population group who are Muslims), the Indians (originally from the Indian sub-continent, largely Hindus), and the Chinese (immigrants from China, mainly Buddhists and Daoists). The Lim genogram shows a family with multiple migrations and different languages predominant in each generation and the effect these have on ethnic identity and intergenerational relationships.

Fig. 1
figure 1

Family migrations and language transmisson

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Lim’s Narrative

My grandparents on both sides of the family were immigrants to Malaya (now Malaysia) during the great Chinese diaspora in the early nineteenth century. My grandmother had tiny bound feet. My grandparents spoke the Fukien dialect and as first generation immigrants to the Malay Peninsula, eked out their living by operating their sundry shops. They acquired enough spoken Malay to run their family business in the host country.

My parents were both first generation born Malayans. My father earned a High School Certificate, a great accomplishment in the 1930s for any young man in the days of British colonial rule. He was hired as a magistrate’s court interpreter, interpreting English and Malay into at least six different Chinese dialects and vice versa. My mother did not have a formal education and married my father at the age of 16 in an arranged marriage. This early marriage was a survival measure to protect young girls like my mother from the atrocities of rape and sexual slavery under the Japanese occupation of Malaya. My parents had ten children; I was the eighth child and the youngest girl. My father sent us all to English schools in the belief that we stood a better chance at success if we knew English and had access to government jobs. We grew up trilingual, speaking English, Fukien, and Malay.

With the political forces of nationalism, Malaysia gained its independence from British colonial rule in 1957 and Malay became the national language and the medium of instruction in schools. My children’s generation grew up speaking Malay and English. With each succeeding generation, our skills in Chinese decreased. My nuclear family is now domiciled in the U.S. Through the genogram, I became aware that in my nuclear family of five, we have three subsets of nuanced identities that present cultural variations, which influence our interactions and personal sense of identity. My husband and I are Overseas-born Chinese (OBC). My first two daughters are American-raised Chinese (ARC) and my youngest daughter is an American-born Chinese (ABC). Without the support of ethnic enclaves, my daughters are fluent only in English.

My family genogram brings into sharp focus the issues I face as an Asian family twice migrated from my ancestral homeland in China. The inability of my children to communicate with my mother because of the lack of a common language between them through this double migration has meant the loss of close bonds between grandmother and granddaughters, a bond that could have been mutually enriching to the two generations. This situation is not helped by the geographical distance that separates the two generations. The issue of where home is in a generational history marked by migration is, for me, a quintessential one. I am betwixt and between, and so are my children. Behind me is my extended family in the Malay and Chinese-speaking world, and with it the cultural context of being Chinese in a Malay world. I can navigate it with enough ease, but not my children. I realize that language is intricately bound to culture, and that loss of language is tantamount to a loss of one’s culture. Sacks (1989) suggests that “it is only through language that we enter fully into our human estate and culture, communicate freely with our fellows, acquire and share information” and if we cannot do this, we will be “bizarrely disabled and cut off” (p. 8). I see this happening for my children in the loss of their ethnic Fukien language. Loss of ethnic language fluency is associated with loss of ethnic identity, and an increase in fluency in the host language is associated with increased identification with the host country. One of the major tasks for my family is negotiating the challenge of defining our multiple ethnic identities due to our migratory lives and our transnational family ties, reflected in changes in language preferences and proficiency across different generations. These vertical transgenerational processes intersect with the horizontal cultural processes of globalization in shaping our family’s complex cultural identity (Lim 2008b).

Case Study 2

“As a Japanese woman, belonging to the 25th generation of the Nakamoto family from Hiroshima, and the sole child of my mother, I feel obligated to be married and have children. But I am fearful of establishing intimate relationships with a man because I think I might die from cancer.”

Case 2 illustrates the genogram of the second author (Fig. 2) within the context of a homogenous Asian culture. Japanese society is largely homogeneous and monolingual. Japanese recorded history can be traced back 2,500 years. The author’s family has a recorded ancestral history of 25 generations in Japan with no recent migration history. In fact, the family’s recorded history shows that the 25 generations of the Nakamoto family had lived in Hiroshima for the last 1,200 years. The Nakamoto genogram focuses on how a global event, the Hiroshima nuclear bombing, features strongly in the life of a Japanese woman from Hiroshima.

Fig. 2
figure 2

Hiroshima and the legacy of cancer

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Nakamoto’s Narrative

For people born and raised in Hiroshima after World War II, the fear of genetic abnormalities and an increased susceptibility to cancer are things that we must live with. It is still common today for parents from other parts of Japan to express concern when their children want to marry people from Hiroshima.

It was within this context that I started having obsessive thoughts about my own prospects for contracting cancer. A few years earlier my mother was diagnosed with breast cancer and had been told she had only 2 years to live. When some of her friends who had contracted cancer at the same time began to die, my mother may have projected her own health concerns on to me. One day she commented that her grandmother had contracted cancer in her 80s, her father in his 60s, she in her 40s, and perhaps I would be struck with cancer in my 30s. In addition, my father died of cancer when he was only 43. Looking at all of these factors, I started wondering whether I should even make long-term plans. Would it be fair of me to have children someday, when it would be possible that I might pass on this genetic legacy to them? Should I even consider marriage?

There are many variables involved in making decisions such as these, but the ones that affected me the most emotionally, such as regret at not knowing my father and fear about losing my mother, made it difficult for me to see things objectively. This is where I found the construction of my family genogram to be helpful. I worked on my genogram as a class assignment in my practicum class. This work allowed me to pause and take a hard look at my family situation. What I found was hopeful: Looking at the facts of my family history as they presented themselves, I found that most deaths in my family were caused by old age, accidents, or other diseases. For example, neither my great-grandmother, who died at the age of 96 from pneumonia, nor my grandfather, who died from a car accident, had died from their cancers. In addition, my mother, despite her grim prognosis, is still alive many years later and shows no signs of the recurrence of her disease. Only my father died of liver cancer, but as my parents were separated and I was not involved in his care, I have no idea what factors may have contributed to his death. Viewed in this light, instead of seeing a familial predisposition towards cancer, I began to understand that the occurrence of cancer in our family was not out of the ordinary. What was extraordinary, however, was the fact that, with the exception of my father, all of them had survived cancer. It is thus a story of family resiliency to me. With this change in discourse arising our of my genogram work, I found new hope and strength.

Case Study 3 (Identifying Information Changed to Protect Identity)

Akara Vath is a first generation Asian American of Cambodian heritage. She was a client of the first author. A student in a Master’s program in family therapy at a state university in Texas, she had come for therapy as part of her course requirement. Her presenting problem was her relationship with her fiancé, Chris. She reported, “I am dating Chris but he is getting frustrated with me. He tells me that I am not emotionally expressive with him. I tried but I don’t know how to change.” In the first session, Akara also revealed, “For years now, I have found it hard to relax. I also don’t know why—our family loves each other, but we seem to be angry and fighting all the time.”

Case 3 illustrates the relevance of genogram work for Akara Vath, 25, an Asian of Cambodian origin in the context of forced migration and war trauma (Fig. 3). I (Lim) began work on her genogram in the second session of therapy. As with all other clients, I had prepared her at the end of the first session by telling her that I would like to work with her on her family diagram in the next session. I explained that I would like to know more information about her family, which will help me know her better and what is important for her and her family. Akara was anxious because she wondered if she would know enough. I assured her that this was not a test and that we would work with what we had and that would be good enough.

Fig. 3
figure 3

The Killing Fields of Cambodia and intergenerational trauma. Relationship: , distant; , close; , conflicted; , divorced

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Akara did not have any family records because everything was destroyed during the war in Cambodia, but she was able to interview her mother and an uncle in Cambodia with whom she had recently connected. She had not been to Cambodia since her mother fled twenty years ago, but recently expressed her desire to visit her home country. In the twelve sessions that I worked with her, genogram work was an integral part of her therapy. Akara’s genogram was not constructed in one or two sessions, but information was added to the diagram each time Akara presented new information. I had the diagram on paper mounted on an easel and colored felt tip pens ready for use. This is reflective of how I work with genograms across all clients.

Clinical Work with Akara

Genogram work over the course of therapy showed the intergenerational transmission of war trauma. It became apparent how much the effects of intergenerational trauma had impacted the second generation although Akara and her family were now domiciled in the U.S. and far removed from the terrors of the Khmer Rouge. Akara’s mother, Chan, 47, was the lone survivor in her immediate family. Chan had four young children (ages 2 months, 2, 3, and 6 years) from her first marriage in Cambodia. None of her children survived the war. Her husband was shot before her eyes in the rice fields and her children wrest from her arms, screaming, before shots silenced them. Akara reported that her mother had survived by pretending to be dead. She then escaped to a refugee camp in Thailand, where she remarried and soon after, had two daughters, Anchaly and Akara. They were resettled in the U.S. after three years in the refugee camp. Life in the U.S. promised to be a haven; however, her parents’ marriage did not last. Akara recalled constant fighting in the family. Eventually her parents divorced. This was especially difficult for Anchaly, who blamed her mother for the divorce.

Akara reported that the relationships between her mother and her as well as that with Anchaly were very conflictual. Chan, traumatized by the murders of her first four children, emotionally distanced herself from her two daughters from the second marriage. In Akara’s words: “Mother would make sure we girls were physically provided for but was not emotionally available.” She would give us some money for the day, and then disappear only to come home late at night, preferring to spend time with her friends.” From a very young age, the two siblings learned to be very independent. They cooked, cleaned, and fended for themselves. They watched out for one another; however, while they cared for one another, their interactions were mostly conflictual and marked by emotional reactivity, especially hostility and volatile anger.

Understanding the family dynamics from a transgenerational perspective, it appeared that Chan, through the trauma of losing her first husband and her four young children in horrifying circumstances, had emotionally cut herself off from bonding both with Akara and Anchaly. This same pattern of emotional disconnect was repeated in the next generation in a situation where the two sisters, though needing each other, could not connect in emotionally healthy ways. This was isomorphic in Akara’s relationship with Chris, her fiancé, who expressed frustration that she was not able to show him emotional affection.

Therapeutic interventions consisted of looking at family losses and beginning to grieve these losses in the family’s generational history. These included the loss of homeland, the loss of her four little half-sisters whom Akara never had a chance to know, and the loss of the emotional availability of her mother as a result of war trauma. Prior to therapy, Akara had never talked about her family, especially the loss of her four little sisters, the circumstances surrounding her family’s refugee experiences, and the scary experiences she had as a young child seeing her parents fight constantly and then finally divorce. Akara reported: “I never even told my closest friends.” Therapy with genogram work helped Akara get in touch with her family history and her heritage of both resiliencies and intergenerational losses. The work was painful for her but allowed her the space to grieve her losses, and in Akara’s words, “to release the tears that I had been holding in for a very long time.”

Her relief from family secrets that were like hidden ghosts had a marked effect on her emotional well-being. Akara reported, “I feel myself being less anxious. I am a calmer person.” Therapy also involved teaching Akara some relaxation techniques and exploring with Akara new ways of relating with her fiancé. The work she did also affected her relationship with her sister and mother. In Bowenian (Bowen 1978) terms, the decrease in chronic anxiety suggested a more differentiated self, one who is able to relate to others in more emotionally-connected and less emotionally reactive ways.

Akara’s work has potential implications for her Cambodian people. In her words: “I feel for the Cambodian refugee community in the U.S. I also feel for my people in Cambodia. My plans are to go back to Cambodia to serve in a mental health capacity, perhaps to start a counseling center so that my skills as a therapist can be used to benefit the people in my country.”

The Use of Genograms in the Asian Context

We now describe the major reasons for the usefulness of the genogram in therapeutic work with Asian individuals, given their unique cultural and contextual variables in the Asian context.

Cultural Resonance

The genogram, as a psychosocial tool, was developed in the West but resonates culturally with Asians of diverse cultural heritages. Whether it is with Asian societies that are more heterogeneous (e.g., Malaysia and Singapore) or largely homogeneous (e.g., Japan and Korea); whether migrations are voluntary or forced (as in refugees from Cambodia and Myanmar), Asian cultures share a common collectivistic orientation with primacy of the family unit (Kagitcibasi 2005; Sue and Sue 2008). The mapping out of the ways in which members of the family are connected to one another reaffirms the value of family in cultures that prioritize family relationships. Malaysian culture has proverbs that attest to the cultural value of family unity. The Malay proverb, Air dicincang tak putus (literally translated: Water minced will not separate) conveys the teaching that family bonds are never severed by a quarrel. Biduk lalu kiambang bertaut affirms the resiliency of families in its message that like the seaweed that clings together after each passing boat separates them, so too a family will come together with the passing of each crisis. Negative proverbs such as Bunga dipetik perdu ditendang, which depicts one picking the flower but kicking the stem or trunk of the plant, culturally admonishes the man who loves his wife but dishonors his mother-in-law.

In Bowenian therapy (Bowen 1978), the therapist focuses on differentiation of self within the family system. This, together with sibling position and the balance of individuality and togetherness forces, have direct relevance for Asian families where one’s identity is organized around sibling position and where togetherness forces tend to offset individuality forces, a balance of which is optimal for healthy family functioning. The Bowenian understanding of togetherness and individuality forces, the distancer-pursuer relationship, and the overfunctioning-underfunctioning dynamic, resonates with the Daoist concept of balancing yin and yang forces. Sibling position (Toman 1961) organizes ones identity and influences family interactions in a big way in many, if not all, Asian families. In my family, I (Lim) for example, am known as Gor Chi (fifth sister) and Gor Ee (fifth auntie) to my nieces and nephews because I am the fifth daughter of my parents. I am known and called by my sibling order in the family hierarchy, not by my personal name. My oldest sister, the first in the sibling position of ten, is deferentially called Tua Chi (eldest sister). This sibling position carries overwhelming responsibility in the Chinese family system, with consequences for the relational dynamics in the family.

For most traditional Asian cultures, remembering and honoring ancestors (zŭxiān in Chinese culture) are large parts of their cultural heritage. The two authors have their recorded family genealogies as part of their family heritages. Whether one’s family history is oral or recorded, genogram work for Asian clients appears to be a natural extension of the kind of work that is esteemed and familiar. Daoist philosophical thought continues to influence East Asian (e.g., China, Korea, Japan) and much of Southeast Asian worldviews (e.g., Singapore, Malaysia). In Daoist cultural practice, departed ancestors are still an integral part of one’s extended family. Therefore, one lives mindful of the presence of those who have gone beyond. This is consonant with Lieberman’s (1998) concept of “transgenerational passage,” where the transmission of family tradition, customs, beliefs, and behaviors can occur not only directly from living relatives but also indirectly from absent or deceased relatives. In contextual family therapy, Nagy’s concept of the revolving slate (Boszormenyi-Nagy and Spark 1984) resonates with Asian societies with a transgeneration-conscious Confucian heritage, where family legacies are perceived as being transmitted in revolving slate fashion. Contextual therapy (Boszormenyi-Nagy and Ulrich 1981) with its attention to relational ethics, the balance of equitable fairness, is also a fit with Confucian ethics where, among other things, a “complete person” is deemed as one who can think of what is right in the face of temptation…and honor past promises” (Tsai 1996, p. 116).

Because genogram construction provides organization and structure to the therapy process, it is also culturally consonant with Asian clients who generally expect tangible outcomes and expect therapists to take an active role in therapy and to lead in structuring the process (Sue and Sue 2008). Meeting where most Asian clients are likely to be, the “expert” role that therapists initially assume helps bridge a cultural divide between Western trained therapists, who may believe in a more collaborative relationship, and their Asian clients who may be more accustomed to hierarchical relationships. Once a therapeutic relationship is built, the therapist can ease into a more collaborative role with the client, in keeping with the client’s readiness. This is a skill that therapists can cultivate in culturally responsive therapeutic work with their clients. The therapist is the expert in creating space and interventions for therapeutic work, collaborating with the client who is the expert regarding his/her life.

Honoring Diversity

Asians are a very diverse group of people, each with their own social and cultural location, influenced by historical, political, and global processes. Geographically, Asia includes countries encompassing East Asia (Japan, Korea, and China), South Asia (India, Bangladesh, Nepal, Bhutan, Maldives, Sri Lanka, and Pakistan) and South East Asia (Malaysia, Singapore, Thailand, Myanmar, Vietnam, Laos, Cambodia, Indonesia, Brunei, East Timor, and the Philippines). The immigrant Asian population in the U.S. includes those who relocated in different waves under different socio-cultural, political factors. Asians in America are the fastest growing among the different races and ethnic populations in the U.S. They consisted of 4.2% of the total U.S. population in 2000. Of the 11.9 million who identified themselves as Asian, 1.7 million reported a bicultural or multicultural heritage (U.S. Census Bureau 2000).

Scant attention has been paid to between-group and within group differences among Asian Americans (Uba 1994). Within the Asian group domiciled in America, there is a range of the degree of acculturation to Western norms and the degree of retention of traditional Asian norms. This also varies between the generations in any immigrant Asian family (Dinh and Nguyen 2006; Farver et al. 2002). The complexity increases in bicultural and multicultural Asian families. Asian couples may be hierarchical or egalitarian in their relationships; they may relate to their children in authoritarian or more democratic ways. My father, the indisputable head in the Lim family, raised his ten children in an authoritarian way, but my husband and I chose rather to raise our children with more expressions of warmth while being firm in our authority as parents. Other than generational differences, there may be chronological differences as well. For example, I (Lim) started out my marital relationship in traditionally hierarchical ways. Over time, my husband and I adopted a more egalitarian relationship, in keeping with our unique gifts.

Because of the great diversity within the Asian population, it is crucial that therapists avoid cookbook solutions in working with Asian clients and avoid stereotyping clients in their generalized ethnic groupings (Monk et al. 2008). As in all cultures, and especially with families impacted by immigration and the processes of acculturation, a timeless tradition does not exist (Foner 1997). An anthropological stance, where the therapist relates to the client from a place of curiosity, combined with attention to context and an understanding of family dynamics from multiple perspectives (Becvar 2008; Lieberman 1998), honors the multiculturalism in Asian families, either within the family or within the people group. Such a stance would be particularly useful where extended families are characterized by complex multigenerational kinships. The therapist, using the genogram as a versatile tool in systemically focusing on the family, resembles the anthropologist in being interested in the constructs of kinship, heritage, and sociality (Lieberman 1998).

The value of genogram work is that both emic and etic factors can emerge in an integrative fashion as each client’s genogram represents a narrative that is unique. Within the diversity of Asian populations, the genogram decreases the likelihood of generalized stereotypes because the client’s narrative is given space to emerge. Seen in this way, genograms provide the scaffolding for clients’ stories to be told and their voices to be heard from their unique perspectives and meaning systems. Genogram work with Asian populations honors the diversity of Asian groups because historical and socio-cultural contexts are honored. This is especially so when therapists take a decidedly multicultural perspective with a focus on the historical and socio-cultural context of the family, as in cultural or multicultural genograms, with attention to race, ethnicity, gender, immigration, social class, and spirituality (Estrada and Haney 1998; Hardy and Laszloffy 1995; Thomas 1998).

Broadening Creative Areas of Freedom

In families that value relational harmony, members characteristically limit emotional expression and avoid expressing conflicts and emotional tensions. Where the extended family consists of three generations living under one roof, family dynamics can increase in complexity. Growing up in an extended family of three generations, I (Lim) recall the difficult position my father was in when my grandmother triangled him in her disputes with my mother. True to the traditional Chinese value of filial piety, he aligned himself with his mother, honoring her, but at the expense of the spousal relationship and my mother’s well-being. Ho (1986) notes the psychological costs that may be incurred from aspects of a Confucian heritage that emphasizes strict filial piety and hierarchical relationships. Some authors question the kind of harmony that ensues from the legalistic ordering of familial relationships. Swartz (2002), for example, argues that the gendered hierarchy that exists in societies ruled by Confucian philosophy does not lead to harmony because harmony is a “state in which families could live together in a condition of mutual respect, equal reciprocity, and co-dignity” (p. 120). Where relationships are too rigidly prescribed and individuals in the family do not have creative freedom of being, pseudo-mutuality results. Genogram work, while culturally resonant with cultures that value family relationships, can also provide the means for families to explore their cultural narratives and broaden creative areas of freedom. A therapeutic stance that integrates intergenerational work while assuming a narrative and solution focused stance (Kuehl 1995) can be particularly helpful in both working with and challenging cultural norms that have become confining. The first author describes one such transformation in her culturally-normed gendered relationship:

The Asian family structure is traditionally hierarchical and patriarchal…. I…struggled with a discourse that seemed to confine and snuff out the life in me as a woman. While I was a new wife and a young mother in Malaysia and Singapore, I struggled with what it meant to be a woman in the multiplicity of my roles as daughter, wife, and mother, and a professional….(While in the U.S., my husband) and I went through a paradigm and practice shift in the way we perceived and embodied gender relationships: We discovered an alternative way of relating that was more respectful of each other’s gifting, opening up spaces for authenticity in our selves in relationship, and bringing together the best of what we each could offer. This mutuality was synergistic and transformed our marital relationship and family life. It is how we have modeled gender and marital relationships to our three daughters, each with their unique gifts and strengths…. This does not mean we do not value our traditional Chinese culture with its strong Confucian values; rather, we transform it in places and contexts where it is rigidified. We also learn to be adept in knowing how values, both eastern and western, are best applied in context. (Lim and Lim 2008, pp. 20–21)

In situations where it is taboo for families to express negative emotions or broach family secrets, psychosomatic symptoms often provide a valuable source of information for therapeutic work (Poot and Onnis 2001). These authors note that often there are traumatic events and themes of loss in the past of these families. Through the use of skillful therapeutic questions, genogram work can provide conversational space for talking the untalkable and this can be healing to the client. Like the money genogram (Mumford and Weeks 2003), the genogram can ease the discussion of sensitive topics.

Poot and Onnis (2001) report that genogram construction allows for the client and his or her family to understand the problem differently. The therapist, in opening up a new way of looking at the psychosomatic illness, broadens “the creative areas of freedom,” and helps the client and his/her family to understand “the complex meaning of the symptom and to free themselves from it” (p. 81). Within the given family structure, genogram work also can provide powerfully for the opening up of new possibilities for meaning and the construction of new stories. Exploring family legacies and the multigenerational transmission of problems can also reveal exceptions that the client may not have noticed previously. This happened for the second author (Nakamoto) when she was able to construct a family narrative based on resilience once she saw the exceptions to the family legacy of cancer. With new narratives, new hopes can be envisioned, new patterns of relating can emerge, giving rise to beneficial changes.

Genograms as Triangling in Therapeutic Process

Genogram work affords a unique triangling situation (therapist-client-genogram) that potentially stabilizes the therapist-client relationship by lowering client anxiety, providing a more culturally appropriate context for therapeutic work in situations where the client may not be comfortable talking about intimate personal and family matters. The collaborative effort of gathering and organizing the family data in a diagram on paper or a board has the effect of lessening the intensity of interpersonal exchange and eye-contact, entirely consistent with clients where prolonged eye contact may be unsettling. This may be particularly useful for Asian clients who may also respond well to the structured experience that genogram construction affords. The structure provides a safe holding space for difficult emotional material to be talked about. This was true of my work with Akara where the genogram mounted on an easel triangled us for effective work with emotionally charged material in the duration of therapy.

The high sense of respect that many Asian families tend to have for scholarly activities may mean that they perceive genogram work as part of one’s tangible professional work and therefore to be supported. Seen in this light, a genogram, as a third entity in the therapist-client relationship, is a welcome guest in the therapeutic triangle.

Genograms in Therapy Training as Unique Opportunity

Though individuals and families may be reluctant to talk about painful family events because of their desire for relational harmony, it has been our experience that parents and elders in Asian families often have been willing to share family stories, even to broach those that are taboo, when trainees seek information to construct their genograms as part of their course assignment. While a trainee in graduate school 12 years ago, I (Lim) had this experience in interviewing my father. He struggled with talking about his painful relationship with his estranged biological father but quietly noted: “I will give you the story here because this is for your course assignment. I want you to succeed in your education.” I have found this same story repeated with the families of each cohort of MFT student trainees, Asian or otherwise, who value education. It is directly related to the parents’ strong support for the educational success of their children even though the material may be emotionally difficult. For many Asian families, genogram assignments offer a reason important and valid enough for parents to transcend cultural and familial taboos. Traineeship represents an opportunity that most Asian students in mental health have—a unique opportunity to explore and to know their families’ cultural and generational legacies. The experience of self in the trainee’s generational history provides a rich context for experiential and transformational learning (Lim 2008a). The possibilities remain, that these trainees who work with their family of origin issues, unimpeded by family secrets and taboos, pass on a new family legacy to their children, thus laying new patterns in family relationships for the succeeding generations.

Practical Considerations

Initial Engagement

Beyond its usefulness in the collection of demographic data and information on family structure, some authors have found the genogram as a useful tool to engage families in the interview process. Simpson (2003), for example, reported the effective use of genograms in initially engaging families in her investigative phenomenological work with Chinese women and their families in Hong Kong. Her study involved exploring beliefs about diet and traditional Chinese medicine related to the breast cancer experience. In the beginning sessions of therapy, genograms can provide a structured and less threatening atmosphere for the therapist to form a therapeutic relationship with the client.

Clinical preparation for genogram work consists of making sure that materials are on hand. These consist of markers and whiteboard or paper mounted on an easel. In our experience, we observe that clients engage well with the genogram work when the diagram is visually accessible to them. Often, the diagram has a visual impact on clients. Genogram work can begin in the first session although in the authors’ work, genogram work typically occurs in the second session. Genogram work can be completed in one session or over a number of sessions, depending on the therapeutic process. There is a great deal of flexibility in how genograms can be used in the service of clients. What is important is that therapists know how to use the genogram and how to pace the work.

Within the clinical context of using genograms as an assessment and intervention tool with ethnically diverse families, some authors have cautioned that it is imperative that trust and a solid working alliance be formed first (e.g., Boyd-Franklin 1989). Others (e.g., Odell et al. 1994) advocate multicultural sensitivity in working with culturally diverse families, cautioning that techniques that are used in Western contexts, such as genogram work and family sculpting, can generate a lot of emotion. When genogram work uncovers nodal events in the family history, as in the case with Akara, it can open up big unhealed wounds, which the therapist must be skilled in helping the client work through.

Pacing

With care and sensitivity, therapists can decide to keep genogram information gathering to a certain level at the initial stage and to engage the client in in-depth work as the therapy progresses. Due to the diversity and complexity of Asian families, Lee and Mock (2005) recommend that the therapist also gather information on other socio-cultural variables such as the family’s ethnocultural heritage (both parental lines), immigration history and acculturation levels (if immigrants), basis of marriage (matched or romantic love), family leadership and decision making, sex-role differentiation, and spiritual influences on the lives of families. At this next level, given the need for sensitivity to culture, context, and timing, therapists can co-modulate the pace of genogram work with their clients, and clients can be asked to indicate to their therapists when they are not ready to share some aspects of their family history. This becomes a crucial part of the therapeutic process where clients are empowered to make their own decisions on their readiness to engage in difficult therapeutic material, regardless of whether it involves the use of the genogram or not. Such a therapeutic stance encourages therapists to be respectful of client decisions while striving to be ethically responsible and therapeutically competent.

Sensitivity to Socio-cultural and Political Context

Many Asian countries have been subject to war and political unrest. The effects of trauma due to war or political upheaval are likely to reverberate through the generations, much as the stories of Nakamoto and Akara show. Genogram work that unearths traumatic or intense emotional material in session can prove to be counterproductive if not sensitively managed or monitored. Culturally responsive therapy with Asians involves sensitivity to the socio-cultural and political contexts of the country of origin and/or domicile. For the Mainland Chinese, for example, the Cultural Revolution (1966–1976) was a socio-cultural and political event that had a massive impact on the Chinese people. Lim et al. in press) report that in Mainland China, this event can be used as a benchmark period, identifying three different generations of Chinese currently living: (1) those born prior to the Cultural Revolution and who were directly traumatized by the events; (2) those who are children of the Cultural Revolution, who may face secondary trauma; and (3) the generation born after the Cultural Revolution who was spared the trauma of this revolution but faces the pressures of modernization and economic prosperity. Effective genogram work with Mainland Chinese families necessarily includes attention to generational history organized around the Cultural Revolution, an important watershed era in Chinese history that continues to have an impact on the well-being of Mainland Chinese people. Another socio-cultural and political factor unique to China’s mental health context is its one-child policy. Situations of young women struggling with rejection due to being a girl and not the coveted son in the family may not be uncommon. An only child policy gives rise to the unique problem of the one child bearing the focused attention of six adults: two parents and four grandparents doting over their one grandchild on whom is placed all the generational hopes of two family lines. With the current swing back to a Confucian emphasis on education and entrance exams, the family’s and schools’ tendency to neglect the emotional and psychological development of their children often brings about a situation where graduates are ill-equipped in social skills in the work-place. Ken lao zhu is a Chinese term that denotes this socio-cultural and familial malaise where adult children fail to launch out into the working world and continue to depend on their parents. It symbolizes how families are impacted by the macro-systemic levels of governmental policies and political processes.

Mainland Chinese domiciled in the U.S. could be asylum seekers after the Tiananmen Square massacre, or they could be economic migrants if they are current new arrivals. Cambodian, Vietnamese, Laotian, and Hmong families are the Asian families now domiciled in the U.S. that have experienced war trauma and are involuntary immigrants in the U.S. They are likely to present a different set of therapeutic needs than Asian immigrants from East Asia (e.g., South Korea and Japan) and South Asia (e.g. India). Immigrants from these regions are mainly voluntary and motivated by economic reasons. While both sets of immigrants face the challenge of immigration and acculturation stresses, Southeast Asian refugees as a group present more severe mental health needs, with a prevalence of PTSD and major depression. Culling from her experience in working with Southeast Asian refugees, Ying (2001) asserts that establishing clinician credibility is an important task in effective work with the special needs of this population. The clinician establishes credibility when he or she is able to help with the immediate needs for symptom reduction and the practical resettlement needs of the refugees. Helping refugees work through the traumas suffered is an important area, which is often subsequent to attending to the immediate presenting problems.

Exploration of Meaning Systems

One of the attributes of the genogram is that it is easy and simple to use. Demographics, medical ailments, abuse of any nature, legal complications, emotional or mental challenges, family dynamics, spirituality, and family secrets and myths, can be noted easily by symbolic representation in the genogram. In assessing families across cultures, such kinds of information are applicable and relevant, although the meanings attached to particular facts may be different for each culture. Within the Malaysian population of the three main ethnic groupings (i.e. Chinese, Malay, and Indian), meaning systems vary greatly. A mental illness in a Malaysian Chinese family may be perceived as an imbalance of yin and yang, to be corrected by giving the client foods that will correct the energy imbalances. To a Malaysian Malay who practices folk Islam, he or she may believe that it is an evil spell cast by a jealous neighbor, and cured only by a counter-spell from a more powerful “bomoh” (Malaysian equivalent of shaman). Yet another Malaysian of Indian heritage, who practices Hinduism, may attribute it to one’s wrongdoings to be atoned on Thaipusam, the annual Hindu festival. Used in such diverse Asian contexts, even between groups in a country, genograms can provide an effective roadmap for the exploration of meaning systems in relation to the socio-cultural context of the family.

Asian Voices from the Field

This final section consists of written responses to surveys with 49 Asian counselors in three genogram training contexts. In all three training contexts, feedback on genogram work was highly positive. Numerical ratings on usefulness of the genogram were obtained for two of the training settings. At a 2007 training workshop on genograms for Mainland Chinese counselors in Shanghai, China, counselors (n = 12) gave an average rating of 8.8 on a scale of 1–10 (10 = most helpful) in response to the question of how they perceived the usefulness of the genogram in their therapeutic work with the mainland Chinese people. Asian mental health workers who responded to a survey (n = 14) at an international conference in Bangkok also gave high ratings in a survey on the usefulness of using genograms in each of their Asian contexts (Mean = 9.0 on a scale of 1–10, 10 = most helpful). The Asian participants represented the following ethnicities: Indonesian, Mainland Chinese, Thai, Malaysian Malay, Malaysian Chinese, Filipino, and Vietnamese. Domiciled in Asia, they worked in various mental health capacities with Malay, Chinese, Thai, Indian, Vietnamese, and Korean population groups. The participants voiced that due to lack of resources and expertise, counselors and therapists in Asia lacked adequate training in the use of genograms. The need exists for more training of local counselors and therapists who can not only use but adapt the genogram to the needs of people within their own cultural and social contexts.

A Thai mental health worker who had been actively involved in recovery work with the Thai community in Phuket after the 2004 tsunami indicated that genogram depiction of family losses of loved ones could be helpful for the sharing of individual family narratives at the community level. She felt that the visual nature of the genogram would be effective in the sharing of both individual and collective loss, which could be therapeutic in communal grief work in the aftermath of the tsunami. Another mental health professional, a Vietnamese, indicated that the genogram is useful in work with Vietnamese families, because they tend to be very complex, with the extended families of many generations under one roof. This is true for many Asian families, especially in the rural areas. The Mainland Chinese participants’ written comments in the 2007 survey on how the genogram is useful in the Chinese context suggested strongly that it is as an entry point for counseling in a culture where people tend to be restrained and not trust easily, especially after the aftermath of the Cultural Revolution. The Chinese have a saying, jia chou bu ke wai yang, which means “don’t tell others outside the family the shameful things in the family.” One participant observed that the genogram “helps clients open their thoughts,” and helps clients talk about the “family secrets hidden in his heart…”

Some of the Mainland Chinese practitioners’ suggestions for the effective use of genograms in a Mainland Chinese context included the following:

  • Know how to respect the elders in how you address each person on the genogram. Use the proper terms for both paternal and maternal lineages—do not use the names but the proper hierarchical names.

  • Know when to push and when to stop. Some may not tell you the truth. Instead of saying “no,” they may make up stories. Chinese people don’t want to tell you all the information except when they begin to trust you. So they may not easily open their hearts.

  • Don’t ask too fast or go too quickly, especially in families that are rigid and strict.

  • Many changes have happened in China in the last 100 years. Have to understand today’s China, today’s issues.

Among the 49 Asian respondents in the three training contexts, there is agreement that the genogram is effective in gathering family information, helps build the counseling relationship, and is an effective tool for understanding the client’s support system. They also strongly advocated for awareness and sensitivity to the taboos of the ethnic group, to hidden issues that clients do not want to talk about, such as abuse and trauma; for sensitive pacing of genogram work; for creating the space for clients to feel safe; and finally the need for counselors to have adequate training in the use of genograms. In all three training situations, the author(s) had modeled family-of-origin work through the use of their own genograms, consonant with Guerin and Fogarty’s (1972) assumption that this “demonstrates your willingness to be open about yourself, and personalizes the work.” These authors also observed that “the presentation to the trainee of your work on your own family gives him a frame of reference from which he can launch his own work” (p. 457). The Asians’ feedback in all three training contexts suggests the value of modeling such work, especially in a shame-based socio-cultural context where family and personal problems generally are not verbalized. Comments included: “Gives me a good role model and example on how to turn a family shame to a strength,” “Presenter’s openness was very helpful to me,” “Value how practical and applicable it is,” “The teacher’s personal experiences were very helpful to me,” and “Demonstration was very impactful.” These comments are consistent with findings that show the value of listening to genogram presentations in the training of family therapists in a Western context (Lim 2008a).

Supervisory Guidelines

Pedagogically, we recommend that supervisors explain to their trainees the rationale for genogram work and model for students their own work (Guerin and Fogarty 1972). Genogram work prepares trainees in their clinical work because it gives them the opportunity to analyze their own family structure and dynamics as well as their own family of origin issues. It also gets students working experientially with a clinical tool that can be used effectively in assessment and intervention with clients. Lim (2008a) reported the key role that the faculty supervisor plays in setting the example by being open to share her genogram work with a diverse group of trainees. Her study showed that supervisees benefited from both constructing and presenting their genograms as well as listening to the presentations of their peers. The initial findings from Asian participants in this study suggest that Asian trainees value such modeling of genogram work. It appears that openness entails some risks; however, the learning that ensues can be rewarding. How the supervisor manages difficult material and appropriate self-disclosure are instructional to trainees who will be working with similar processes in their clinical work.

Not unlike other training contexts, we postulate that genogram presentations would be an invaluable aspect of training in Asian contexts as well. Listening to genogram presentations such as those represented by the Lim, Nakamoto, and Vath families, would extend the breadth and depth of understanding of diverse cultural heritages and learning of family-of-origin issues, all of which are reflective of what clients may bring to the therapy room. In working with Asian supervisees, the authors recommend the supervisory approach that is outlined in the first author’s earlier study (Lim 2008a). In brief, trainees are instructed to draw a three-generational genogram and to interview at least two family members. Instructions on how to draw the genogram are based on McGoldrick et al. (1999) Genograms: Assessment and Intervention. In particular, students are asked to focus on the relationship dynamics and patterns in their families. Confidentiality is upheld in the supervision group and each trainee understands that he or she has a right to decide how much family information to reveal.

Conclusion

This article describes the effective use of the genogram in training and in therapeutic work with Asians from three different countries: Malaysia, Japan, and Cambodia, a small sample of the large number of Asian countries. The inclusion of three countries, however, illustrates the genogram’s usefulness and versatility in three distinct Asian contexts. Asian families are very diverse, from being heterogeneous and multi-lingual (Malaysia) to homogeneous and monolingual (Japan). Migrations vary from being voluntary to forced; the Vath family from Cambodia illustrates forced migration and its intergenerational consequences. Multiple migrations in heterogeneous contexts influence intergenerational language and cultural transmission, as in the Lim family’s twice migrated family history. This is in contrast with the Japanese context of homogeneity, illustrated by 25 generations of the Nakamoto family, spanning over 1,200 years, all living in one locale, Hiroshima. In all three genograms, socio-cultural and political contexts were important as they impacted family systems and their functioning. British colonial rule, the Hiroshima nuclear bombing, and the Cambodian Killing Fields were the macro-systemic forces that impacted the microsystems of each of the three families. The genogram provided a structure for the intersection of these systemic variables to be explored effectively both in training and in therapeutic work.

Responses from practitioners working in different Asian countries suggest that the genogram is a useful tool in therapeutic work with Asian individuals. The common theme in the cautions from ethnically diverse authors and in Asian voices from the field is the need for sensitivity to context as well as the need for trust, safety, and credibility. Genogram work is most productive when a good therapeutic alliance is fostered between therapist and client, and when there is cultural sensitivity to context and timing. There is a need for more Asian practitioners to be trained in the use of genograms as a psycho-social assessment and intervention tool. A training method where one models family-of-origin work using one’s own genogram appears to resonate well with Asian trainees.

Therapists working with Asian clients cross-culturally resemble “an anthropologist in a strange kinship system” (Lieberman 1998, p. 200). An anthropological stance (Becvar 2008) allows a therapist to be curious about such kinship systems with its rules and patterns and join with the family in creating a new narrative which broadens spaces for living. This is reflective of culturally responsive therapy with Asian clients in all their diversity.