Literature Reviews

Responding to intergenerational psychological trauma: A literature review paper on the place of Family Constellation Therapy
John Hurley, PhD; Margarete Koenning, BA; Angeline Bray, Grad. Dip.

There is a literature review paper that critically examines the Family Constellation Therapy (FCT) approach as a potential therapy option for responding to intergenerational trauma

Responding to intergenerational psychological trauma: A literature review paper on the place of Family Constellation Therapy

John Hurley, PhD, credentialed mental health nurse, School of Health and Human Sciences, Southern Cross University, NSW; Margarete Koenning, BA (Social Work), certified gestalt therapist, Family and systemic constellation trainer; Angeline Bray, Grad. Dip. Mental Health Nursing, gestalt therapist and credentialed mental health nurse, Headspace Coffs Harbour, NSW

Background: Psychological Trauma

Psychological trauma emerges through an experienced adversity that has a lasting detriment to an individual’s mental, social or emotional wellbeing (Substance Abuse and Mental Health Service Administration, 2018). It has been long recognised as a complex construct, with some differentiation being made between experiencing one-off adversities (Type 1 trauma) or repeated complex traumas (Type 2 trauma) (Herman, 1992). Psychological trauma remains a global mental health challenge triggered by common events such as road accidents (Benjet et al., 2016), non-partner violence (Abrahams et al., 2014) and inter-partner violence, all of which have high rates of occurrence and generate significant mental health problems (Lagdon, Armour & Stringer, 2014). Additionally, the impacts of human rights abuse have been well acknowledged as generating psychological harm and mental health disorders as well as physical health issues (Johnson et al., 2010). Up to two thirds of those receiving in-patient mental health care in Australia have been exposed to trauma (Kezelman & Stavropoulos, 2012; Mental Health Coordinating Council, 2013) with the mental health workforce being identified as being underprepared to respond to their needs (Wilson, Hurley & Hutchinson, 2017). The capacity of the workforce is further challenged by the fact that unresolved trauma can be perpetrated discreetly through household neglect or abuse by parents or other caregivers, as well as through more overt events such as war (Van der Kolk, 2014).

Psychological trauma has been long identified as having an intergenerational component in which the effects of unresolved trauma are passed from generation to generation (Hirsch, 2001). The mechanisms of transference have been proposed to occur through history telling (Hirsch, 2001), maternal behaviour influencing hormonal and metabolic infant processes (Yehuda & Bierer, 2009), and maternal psychosocial factors (Folger et al., 2017), as well as compromised paternal attachment, poor emotional regulation and fearful messaging from traumatised parents (Berthelot et al., 2015). There is now also evidence from epigenetic research that when trauma occurs chemical changes take place in DNA, altering the way that genes function (Wolynn, 2016) and in turn modifying cognition, emotional regulation and behaviour (Jawaid, Roszkowski & Mansuy, 2018).

Inter-generational trauma hence has biological, developmental and constructivist mechanisms of transmission and can be experienced on both individual and collective levels (Cook et al., 2017). Within families bound by intense loyalties, the trauma can be experienced as inherited remnants of incomplete attempts to accommodate the traumatising experience. The emergent impacts of these traumas are increasingly understood as having a complexity exceeding that contained within the post-traumatic stress disorder diagnostic classification. Trauma induced impairment can found across the spectrum of psychological functioning including attachment behaviours, affect regulation, and behavioural control, as well as self-concept, cognition and consciousness (Cook et al., 2017).

Despite such complexity, therapeutic responses to psychological trauma in Australian mental health contexts are clustered around an arguably narrow range of medicalised therapies delivered to the person directly involved with the traumatic events. Treatment responses are also compromised by the fragmented and uncoordinated funding streams provided by state and federal governments (McFarlane & Bryant, 2017). Recommended treatment guidelines include cognitive behavioural therapy (CBT) or CBT in combination with selective serotonin uptake inhibitor medication (Australian Centre for Posttraumatic Mental Health, 2013). Cusack et al (2016), in their meta-analysis of treatment efficacy for Post-Traumatic Stress Syndrome, also identified eye movement desensitisation and reprocessing as well as CBT and derivatives of CBT as having strong to moderate evidence of efficacy. However, given that psychological trauma is complex and heterogeneous in nature (Cloitre, 2015), there is arguably a need to explore other therapy approaches.

Phenomenological and existential therapies such as Family Constellation Therapy (FCT) and gestalt therapy have long struggled for recognition within health systems dominated by psychological approaches that prioritise technique over relationship within therapy (Hurley, Barrett & Reet, 2006). However, CBT’s recent adoption of mindfulness and emergent evidence of the quantifiable influence of the therapeutic alliance on the efficacy of psychological treatments (Goldsmith, Lewis, Dunn & Bentall, 2015) suggest that a wider range of psychotherapies could be useful for those experiencing psychological trauma. Indeed, given the common factors theory (Drisko, 2004) that views most therapies as sharing effective characteristics rather than any one approach having uniquely superior procedures, the case for exploring treatment options for trauma is evident.

There is a growing understanding that therapeutic responses to psychological trauma generally, and inter-generational trauma more specifically, need to adopt a broader approach than intervening with the traumatised individual in isolation from their family systems (Orlans & Levy, 2014). Inter-generational approaches to psychological therapy generally, and in response to psychological trauma more particularly, appear indicated given growing understanding that the impacts of traumatic events can include subsequent generations. Maternal stress when pregnant has been shown to significantly impact infant neurodevelopment (Bergman, Sarkar, Glover & O’Connor, 2010), potentially positioning the infant for a lifetime of psychological challenges. Precursor cells in both eggs and sperm can be influenced by trauma that can then be inherited or passed on to subsequent generations (Yehuda, Bell, Bierer & Schmeidler, 2008). Additionally, studies of holocaust survivors suggest that trauma is inherited by the next generation at the level of the DNA (Vialou, Feng, Robison & Nestler, 2013) and that the children of those exposed to trauma have higher rates of conditions such as Post Traumatic Stress Disorder (Yehuda et al., 2014).

Considering this evidence, the underpinning tenets of family systems theory appear to present a wider interpretation of how to respond to psychological trauma. This theory seeks to understand an individual within the context of their family as being a single emotional unit influencing all members of that family (Haefner, 2014; Rothbaum, Rosen, Ujiie & Uchida, 2002).

Family Constellation Therapy in Practice

Family Constellation Therapy (FCT) is usually undertaken in a group setting and is individually focussed in that other family members are not required to be present. Its goal is to provide the client with an opportunity to expand their understanding of the conflicts and dysfunctions they have within their family system and to then explore new ways of being within that system (Hunger et al., 2014). This is achieved by the client, supported by a therapist, constructing what is usually a three generational representation of their family system. When constructing and observing the system there is a focus upon the client’s pre-conceptual sensory phenomenological “knowing” of the constellation and this allows the client to fully experience their internalised family structures in this external representation. This systemic constellation is, in effect, a spatial representation of a family system, with a boundary or phenomenological field (Birkenkrahe, 2009).

FCT groups are usually of around fifteen people with members volunteering to “place” a part of their wider family system. The therapist seeks only limited information about those within the system and of key events before the client selects members of the group to represent family members; these are sculpted or placed in relationship to each other, reflective of their current experiences of the family. The client then, in true experiential approaches, seeks to experience the formed constellation of their family system in the here and now, rather than cognitively interpreting that which they now see. This offers an opportunity for the client to have greater self-awareness of their internalised understandings of the inter-generational relational entanglements within their own family system.

This may result in further restructuring of the constellation, including the client taking their place within it and seeking to redress the disruptions within the family system through what FCT calls “healing sentences” (Stiefel, Harris & Zollmann, 2002). FCT works with the factual events, structures and relationships within a represented three generational family system, and healing sentences spoken by the client compassionately reflect the truth of what that system needs. Enacting such compassionate truth has been shown to stimulate neural pathway activity in regions of the brain associated with social interactions and positive affect such as the media orbitofrontal cortex (Klimecki, Leiberg, Lamm & Singer, 2012).

While there are some similarities between FCT and psychodrama in terms of the constructions of systems and the underpinning phenomenological philosophy, McQuillin and Welford (2013) identify the key differences, including that psychodrama work is undertaken in the “now” of the client’s life while FCT work is situated in the client’s ancestry. This latter point is important in the consideration of inter-generational trauma. Another important distinction is that while the forming of constellations is coached in psychodrama, this does not occur in FCT: participants are representing family members with little or no information and are reporting the phenomenology emerging from their experiences.

Family Constellation Therapy: Theoretical Underpinnings

Family systems theory is a key structure that binds FCT, which is embedded in the wider field of family systems therapy with defining additional components from existential phenomenology and Zulu culture. Family therapies originate from a diverse background of theoretical structures with contextualised family therapy (Boszormenyi-Nagy & Krasner, 1986) and experiential family therapy (Satir,1987) having the most influence within FCT. Contextualised family therapy places an emphasis on relational ethics and achieving a balance of indebtedness and entitlements within a family system (Boszormenyi-Nagy & Krasner, 1986). Experiential family therapy, by comparison, has an emphasis on reconstructing family systems through congruent communication (Satir & Baldwin, 1983).

Bert Hellinger (1925– ) is the seminal figure in the development of FCT, which is open to adaptation and integration with other psychotherapeutic approaches. Hellinger was influenced by an eclectic range of existential therapies, psychoanalysis and family sculpture and lived for many years as a catholic priest with the Zulus in Africa. This latter experience directly influenced his construction of FCT through the incorporation, into FCT, of the Zulu reverence toward their ancestors, whom they believe are an active presence in their daily lives. Additionally, Hellinger incorporated the African tribal principle of ‘Ubunto’ into FCT. In essence, Ubunto is the belief that humanity shares a mutual bond of inter-connectedness. In turn, the person with Ubunto is seen as having self-assuredness and inter-personal availability to others stemming from this sense of belonging and connectedness (Sulamoyo, 2010).

FCT is also informed by phenomenology, which has made contributions to a range of psychotherapies including person-centred therapy, psychodrama and gestalt therapy (Cohen, 2006). More specifically, FCT reflects hermeneutic phenomenology, and also resonates with existentialism’s philosophical attention toward existence and that humans make their own meaning in life. Hermeneutic phenomenology places a focus on the exploration of “Being” and seeks to interpret, rather than simply describe, phenomena emerging from lived experience (Titchen & Hobson, 2005).

Hellinger (2001) reflected a phenomenological interpretative approach toward “Being” (Schutz & Luckmann, 1973) through acknowledging that individuals will often sense experiences they themselves do not recognise, necessitating interpretation of emerging data. Hellinger’s phenomenological stance is a search for understanding through first reaching an inner stillness, undistracted by conscious and active attainment of knowledge. Primarily this application of phenomenology requires that the client is prepared to be open to having experiences that heighten their awareness, and also to offer new meaning toward phenomena. Within FCT, such new awareness and meanings are in the context of the client in relationship to their family system. This has particular significance to FCT in the forming of ancestral constellations. Such constellations are three dimensional representations of family systems that are pre-reflectively experienced, allowing for new understandings to spontaneously emerge with minimal conscious reaching for cognitive understanding. This experiential method of family constellations brings into awareness the often repetitive traumatic patterns of the family system that have not been seen, or that have been denied.

Hellinger, Weber and Beaumont (1998) forward the following key principles as being active
within FCT:

• Family systems have an unconscious group conscience regulating innocence and guilt.
• All family members have a right to belong.
• Parents give while children receive.
• Individuals have precedence within families systems according to time spent within the system.
• There is a flow of love from ancestors to decedents necessitating that there is reciprocal respect shown to ancestor.
• Each of us is seen as being born as a small soul or entity into a larger family entity in which we are free to live self-responsible lives while simultaneously being connected to our roots. (Hogeland, 2010; Sethi, 2008).

Disruptions to these underpinning principles will often emerge as psychological trauma experienced by younger members of the system. However, it is the responsibility of the current generation to take responsibility for their own fate and to find peace within the wider family structures (Hellinger, Weber & Beaumont, 1998), rather than seeking to solve the disruptions within previous generations of the system.

Family Constellation Therapy: a Review of the Literature

To evaluate evidence for the efficacy of FCT, a review of the international peer reviewed literature was undertaken on April 10th, 2017.

Search Strategy

Databases searched included Academic Search Premier, The Allied and Complementary Medicine Database, CINAHL Plus with Full Text, Education Research Complete, ERIC, Humanities International Complete, MEDLINE with Full Text, Psychology and Behavioral Sciences Collection and PsycINFO.

The key words used in the search strategy included (TI “family constellation*” OR AB “family constellation*” OR SU “family constellation*”) OR (TI “system constellation*” OR AB “system constellation*” OR SU “system constellation*”) AND (TI therapy OR AB therapy OR SU therapy).

Results

When papers were narrow by language (English) there were 185 results that dropped to 141 after duplicates were removed. All 141 abstracts were then hand-searched and read for relevance to the topic of Family Constellation Therapy. 124 papers were discarded as these referred to Alder’s systemic family therapy approach or derivatives thereof. 15 abstracts remained, with the abstracts re-read to ensure relevance. 1 book chapter, 2 doctoral studies and 1 book were within those results, leaving 11 peer-reviewed journal articles published in the period 2002–2016.

Narrative Findings

The reviewed papers can be organised into three groups. First are those papers that predominantly outlined and critically described the FCT approach: Cohen, 2006; Crawford, 2013; Sethi, 2008; and Stiefel et al., 2002. Second are a group of papers that sought to integrate FCT with other psychotherapeutic approaches: Fidyk, 2016; McQuillin & Welford, 2013; and Welford, 2014. The third and final group were those offering research findings exclusively on FCT: Hunger et al., 2014; Hunger et al., 2017; and Weinhold et al., 2013.

FCT is not without critics. Talarczyk (2011) offers a largely opinion-based critique of FCT from the ethical perspective of Polish psychotherapists. This critique highlights the divergent nature of psychotherapies globally and argues that the principles of FCT are partly incongruent with traditional ethical understandings of psychotherapy. The limited literature used to support this argument is, arguably, inadequately applied to build a solid case for this view, which was not found elsewhere in the available literature. Other authors such as McQuillin and Welford (2013) and Welford (2014), although supportive of FCT, also advance the view that the key principles or “order of love” have outdated gender perspectives.

Identifying FCT as a therapeutic intervention that has fused traditional family systems theory with existential phenomenology and Zulu ancestor reverence, Cohen’s (2006) mainly descriptive paper sought to introduce this approach into North American practice settings. He clarifies the components of FCT, particularly those of soul, consciousness and belonging within the context Hellinger applied them. In this context of FCT, soul situates the individual as being linked to a greater universal whole incorporating past, present and future. Connectivity is also apparent in the way in which FCT utilises the term conscience, which is understood as a group conscience that binds the family. Reflective of other transgenerational family therapy approaches, FCT adopts an inter-generational perspective to a family that can also be understood as adopting a multi-generational empathic understanding toward the individual (Crawford, 2013). Other opinion papers in this search such as Sethi (2008) and Stiefel et al. (2002) simply describe and highlight the characteristics of FCT with some emphasis toward its phenomenological underpinnings.

Fidyk (2016) highlights the therapeutic incompleteness of looking at an individual without also incorporating their wider family consciousness. His paper contrasts this to the complex impact that the Jungian familial unconscious has upon the individual. The paper contrasts FCT with Jungian therapy, including a claim that Jung also placed emphasis on the influences that the dead have upon the way the living attend to their existence. Fidyk (2016) acknowledges that the individual’s psyche disturbances have their origin in the family and collective ancestors, and that psychotherapy has often failed to account for this. McQuillin and Welford (2013) and Welford (2014) in their opinion papers also highlight the connectivity that FCT offers the client through working therapeutically with their family system. Importantly, they both identify FCT as an effective approach to respond to intergenerational trauma and grief. Additionally, McQuillin and Welford (2013) integrate many facets of transactional analysis theory into FCT, such as reframing intergenerational “don’t think” injunctions as passed-on shame from previous generations.

In their 2014 RCT study, Hunger et al focus on participants’ experiences of the relational ethics, trustworthiness and reciprocal fairness that underpins the work of FCT. They developed the Experience In Social Systems Questionnaire which covers personal and organisational domains building on four dimensions of Belonging, Autonomy, Accord, and Confidence. Findings four months post FCT showed statistical improvement across these dimensions compared with the waiting group. In their follow up study, Hunger et al, (2017) confirm the psychometric properties of their Experience in Personal Social Systems Questionnaire (EXISpers). The five factors are: the general Experience in Personal Social Systems and four dimensions of Belonging, Autonomy, Accord, and Confidence. The EXISpers is a research tool designed for circumstances whereby one person in a social system engages with FCT; it can also be used within organisational contexts. This wider view of social systems includes family and also friends where so assigned by the individual (Hunger et al., 2017). This tool will support ongoing empirical evaluations of FCT that lack a deep evidence base.

Finally, Weinhold et al. (2013) offer findings from a rare Randomized Controlled Trial (RCT) on FCT that showed improved psychological functioning at 2 weeks and 4 months post intervention for their general population participants. The modest effect size of improvements reflects the wider literature that situates FCT as being most useful as an adjunct to other therapies.

Discussion

There is clearly limited evidence in the international peer-reviewed literature on FCT for psychological trauma generally and inter-generational trauma more specifically. The strongest evidence emerges from the RCT style studies (Hunger et al., 2014; Weinhold et al., 2013), although Weinhold et al. (2013) were measuring general populations rather than those presenting for treatment. The EXISpers tool (Hunger et al., 2017) offers an arguably promising area to focus research attention, particularly in the context of psychological trauma. The positive findings in areas of social function around belonging, accord and autonomy, as well as confidence, arguably respond directly to the relational difficulties associated with disrupted attachment as a result of childhood trauma (Marusak et al., 2015). Additionally, the EXISpers measures outcomes specifically related to the individual within their family system, often the source of perpetuating the trauma (McQuillin & Welford, 2013).

The theoretical papers that outline FCT also suggest that this approach offers a unique opportunity for clients to experience, and gain insights into, their trauma. Case studies presented within these papers highlight that as the client is encouraged to pre-reflexively experience the witnessed constellation of their family system, they gain not only external concrete representation of their abstract or unconscious representations but also a subsequent opportunity to then work with the new, conscious understandings of their family system. The papers identified in this review also strongly identify FCT as being amendable for use in conjunction with other established therapeutic approaches (Fidyk, 2016; McQuillin & Welford,2013; Welford, 2014; and Sethi, 2008 ). These authors seemingly use FCT as a powerful mechanism to generate new client perspectives and to diminish the client’s self-blame and shame through situating the trauma as originating from and belonging to ancestors.

As FCT is theoretically derived from both contextualised family therapy (Boszormenyi-Nagy & Krasner, 1986) and experiential family therapy (Satir, 1987) there is a strong connection to the broader evidence supporting systemic therapeutic approaches for inter-generational trauma. FCT offers a restorative process for inter-generational trauma that echoes the earlier family systems work of Abrams (1999) whose therapeutic work on inter-generational trauma is focussed upon reaching back to previous generations. There are hidden dynamics in families that are often unconscious and unseen in the trauma response of the client, and that are most often not spoken of within the wider family system (Abrams, 1999). FCT seeks to include that which has been excluded, also to speak the truth of what has happened in the family, to restore connection, to add resources and to create strengthening inner images for the client. The process helps the client to cognitively understand that which could not be understood as a child and to voice that which had not been spoken of (Franke, 2017).

FCT does not directly evoke traumatic memories. It approaches the work from a safe, witnessing position, in a gradual and titrated way, and provides new corrective experiences. FCT, as with other systemic therapeutic approaches, views the whole family as one relational system (Minuchin, 1974). Consequently, therapeutic corrective experiences may focus on family members other than the identified client, or indeed the entire family system. Interventions aimed at resolving traumatised family members other than the identified trauma victim have been shown to have a positive impact on reducing intergenerational trauma transmission by improving social relating (Bachem, Levin, Zhou Zerach & Solomon, 2017).

Conclusion

Given the biological and sociological knowledge on inter-generational trauma that is emerging (Yehuda et al., 2014), there is arguably a growing foundation to support the original phenomenologically-based theories developed by Hellinger. The findings within the literature are limited, but do seem to suggest that FCT can be useful as an adjunct to other therapies or can be integrated within other approaches. Programmatic research thus is required to construct an evidence base around FCT. This requires both deductive and inductive approaches to increasing our knowledge. While Weinhold et al. (2013) and Hunger et al. (2017) are deductively measuring quantitative outcomes from FCT there is also a need to systematically improve inductive understandings of the lived experiences of FCT.

The RCT studies of FCT are occurring in the absence of a solid foundation of qualitative studies, with the majority of available evidence being case study based. Paradoxically for a phenomenologically-based therapy, there is a paucity of phenomenologically-designed qualitative studies on FCT. Such qualitative studies need to be undertaken to capture not only the contextualising existential components that impact upon these experiences but also to understand how those experiencing FCT have then successfully integrated those experiences with other therapies. Equally, the RCT-based studies are required to add validity to the case that funding arrangements for psychological therapies fail to reflect emergent understandings of inter-generational psychological distress.

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