The Psychosocial Effects of Systemic / Family Constellation

Family / systemic constellation therapy is a short-term group psychotherapy aiming to help clients better understand and resolve their conflicts within their personal systems, which in turn might lead to a decrease in psychopathological or functional somatic symptoms. The personal system addressed is most often the family but other inter- or intrapersonal systems (e.g., ego parts, victim-perpetrator dyads) can also be the target of the intervention; the term "family constellation therapy" is used throughout the manuscript in this broader sense. This therapeutic modality was developed in Germany in the early '90s integrating elements of - among others - psychodrama, family sculptures, contextual therapy, and certain South-African aboriginal traditions and has become particularly popular in Europe and South America and even became part of the public health care system in certain countries. Compared to its use by thousands of therapists of various theoretical and professional backgrounds all over the world, little effort has been made to generate empirical data regarding the effectiveness and safety of this intervention.

We believe that the large discrepancy between the relatively high level of penetration into the practice of complementary and alternative medicine versus the low quantity of evidence on effectiveness stems largely from academic psychology's reluctance to engage with at least two metaphysical / anthropological postulates of family constellation therapy. Firstly, the theory of family constellation therapy assumes that an individual's mental and physical health might be significantly influenced by major life events of other members of the personal system even if they lived generations before (e.g., the death of a mother during childbirth might have an effect on her descendants' anxiety level and reproductive success for several generations even if the original event has never been talked about in the descendant's life). While - due to recent developments in epigenetics and the better understanding of transgenerational trauma - this and similar concepts are less shocking to the academic community than they were 3-4 decades ago when family constellation therapy was developed, they are still in sharp contradiction with the common understanding that the etiological factors of any physical or mental illness are to be sought in bio-psycho-social events, situations, or conditions occurring or existing around and after the individual's conception.

The second distinctive feature is that the theory of family constellation therapy assumes that the life-altering, relevant pieces of information are 'stored' and somehow can be 'downloaded' not just automatically and unconsciously by the members of the same system but intentionally by outsiders as well. This accessibility of system-relevant information makes it possible that participants of the single-occasion intervention (who are unknown to each other) are able to perceive and verbalize thoughts, physical perceptions, emotions associated with the history of the system, often unknown even to the recipient of the given constellation. This somewhat 'mystical' re-presentation of unknown facts and hidden dynamics makes it possible for the recipient of the constellation to better understand the etiology of their mental or physical symptoms and intentionally change these very same dynamics. How this storage and access of system-relevant information occurs is highly debated and uncertain; the most-widely held explanation of these processes use the morphic / morphogenic field and -resonance concepts (cf. storage) of the biologist Rupert Sheldrake in combination with the function of mirror neurons (cf. way of accessing stored information by non-members of the system).

Regardless of whether we fully understand the exact mechanisms of action of a therapeutic modality and if its certain assumptions fit the contemporary paradigms of health sciences, we argue that collecting empirical data on an intervention's effectiveness and safety is a public health necessity, especially if it is so widely used as family constellation therapy (and it certainly could provide further impetus to the study of the mechanisms of action and the potential reconsideration of the accuracy of our paradigms).

The very limited number of previous prospective, peer-reviewed studies into family constellation therapy's therapeutic effectiveness reported that the intervention was effective in reducing general, non-diagnosis-specific psychopathology and psychological distress, decreasing the intensity of dermatological symptoms, as well as improving quality of life and functioning in interpersonal relationships. A recent systematic review summarizing both the peer-reviewed and the grey literature on family constellation therapy concluded that further studies into its effectiveness are greatly needed, especially if 1) using at least a mid-term time frame (≥6 months) to evaluate client outcomes, 2) employing active monitoring (not just passive surveillance) of potential iatrogenic effects, and 3) providing information on the presence or absence of therapist effects. The aim of the present study was to collect and analyze further data from the real life setting on family constellation therapy's effectiveness in improving mental health and its tolerability in line with these recommendations.