Setting Family Constellations in Children's Psychiatric Hospital - An Enrichment for the Therapeutic Work
By Thomas von Stosch
Translated by Ute Luppertz and Jane Peterson
Reproduced here from Praxis des Familien-Stellens with the kind permission of the publisher, Carl-Auer-Systeme Verlag.
In the non-residential area of the Children and Youth department, we admit children between ages of three and seven. Their problems are usually combined with multiple developmental difficulties with perception, speech and motor skills. The degree of their problem is so significant that they cannot achieve social adjustment (or integration) in kindergarden or pre-school. As part of the treatment, parents and employees of this department participate in a group where parents have the option of setting up their current family constellation and, if needed, their family of origin constellation. These family constellations are integrated into a comprehensive therapeutic and diagnostic process that is developed for each individual family. The constellations have an influence on the conversations with the family and the work with the child, they also give hints as to which therapeutic methods are indicated for the course of treatment.
I would like to elaborate on the above description by using selected case studies:
In the context of a meeting of "holding therapists" I met Bert Hellinger in 1991 for the first time. In a small circle I experienced how he sets families and works therapeutically. I've heard his opinions and experienced his therapy myself. This changed my life in private and professional realms. I experienced this meeting as great luck and I'm grateful for what I've received.
Back then I experienced something and after that there was no going back; as if I had begun to recognize the meaning of letters and learned how to read. When you master this you cannot not read any more. You cannot do anything else when letters appear even if you try really hard not to read them, you will.
When I meet families in my work today, then I also cannot return to my former experiences prior to constellations, and with every "case" I begin to deal with the forces of the systemic dynamic.
The meeting with Bert Hellinger did not mean that I threw my current work overboard and that I then practice only family constellations, but it did mean that I added a new view from a different perspective and that I have an expanded understanding for problems. After the first meeting I began to do family constellations in Stuttgart with Jirina Prekop. Another year went by including another workshop with Bert Hellinger and seeing additional constellations in different frameworks finally encouraged me to set constellations for families in my line of work.
In the Center for Psychiatry in Weinsberg (former psychiatric county clinic) there is a department for children and youth psychiatry. The department has three floors, whose clientele is differentiated by age: a floor for teenagers, a floor for school age children, and a floor for pre-schoolers.
I work as a psychologist on the floor for the pre-school children of age three to seven. The children are picked up at 9 AM in the morning by taxi from their homes and are taken home at 4 PM. We treat nine children with their families.
The children are primarily admitted for therapy because of
The children are treated in a time frame of four to ten months (average: six months.) The therapeutic team consists of three supervisor/care-givers, a teacher, a remedial teacher, a remedial assistant, a motor-skills teacher, a speech pathologist, a medical doctor and a psychologist. Each child has a designated supervisor/care-giver who is their primary reference throughout the therapy.
We understand our work as psychotherapy and support of child development. Besides remedial activities, person-focused group and individual therapy (von Stosch, 1988) and holding therapy (von Stosch, 1989), family constellations also have a place.
The treatment is divided into diagnostics, setting of therapy goals, therapy and follow up care. We work on the therapy goals jointly with the parents. The goals are the result of our findings and the parents' expectations and wishes. Multiple therapeutic interventions follow this. The boundary between diagnosis and therapy isn't as pronounced in day-to-day life; every diagnostic intervention has a certain therapeutic effect and leads to new diagnostic information. The goals can change in the course of a treatment session. (See figure 1.)
FIGURE 1. Scheme of the therapy operations in the non-residential area
I do not have to explain in detail the meaning of systemic entanglement and displacement related to the problems faced by children and their parents. According to my experiences to day, the symptoms of a child are easier to understand when the therapist knows the family dynamics.
Not all children who are treated in the day clinic have a difficult dynamic. Some come for remedial support and the parents need help to accept the disability of their child. For others it is about working on an early trauma caused by separation of child from parent. That is why clarification of the family system is part of the diagnostics.
In this diagnostic phase, I work initially with all parents on their geniogram. That's how I also get an overview. I draw the family tree and am interested in the roots of mother and father. That's how I also learn something about their family traditions.
The family tree goes back to the generation of the great-grandparents and includes all persons belonging to the system. I draw the system of origin of both parents. After the geniogram is done, the team consults and decides whether to recommend a constellation for the parents or not. We think family constellation is always indicated when we think of entanglement or displacement, when persons in the family are excluded or denigrated, or if we cannot understand the dynamics.
In the conversation with the parents about therapy goals and therapeutic interventions, we then talk for the first time about family constellations and how we do them. Sometimes there are difficulties in conveying this. Parents who have never heard anything about family constellations or have no idea about psychotherapy need time to understand how children can subconsciously take the place of excluded persons or situations, or how children will step into unresolved problems in the family and bring forgotten members or situations back into play.
When a person has been excluded from the present family, for instance, a family headed by a single mother or that has half-siblings, a next step in the course of the family conversation, is to let the children set up the system using puppets so that the excluded persons can be included in the therapy.
I use the puppets from the family system test (FAST by Thomas M. Gehring). These are puppets who have no emotional expression. There are men and women and couples. The couples are colored, the men and women colorless. If the man and woman puppets are the same color it means they belong together as a couple.
Setting a constellation with puppets offers the young children an opportunity to show how they view the family. They also experience who belongs to the family. The children very quickly understand how to set a constellation with puppets, and they know intuitively how to place them. I then ask the child how each person feels. The picture and the statements of the child become the theme of a follow-up conversation.
An example:
Marco, age 5, lives with his mother and her boyfriend. He came to us after he tried, but couldn't adjust to a day care center setting because of his developmental and social behavior problems. His father was Italian. The parents had separated after the mother recognized that the man didn't want to care for her and their child. She had loved the father of the child very much and gave herself permission to express the pain and grief about the separation. The mother saw in her child a deep sadness that she could not explain.
In the conversation I got her permission to do something with Marco that could help her understand her child. Marco set his family with puppets. He chose the boyfriend of the mother, himself and the mother. He did not answer the question, "Who is missing?" I turned to the mother, so that she could explain to her son who was missing. She was very moved, had tears in her eyes and said, "Your Papa!" Marco then added the father and set up the puppets. Father and mother looked at each other from a great distance. The child and the boyfriend of the mother stood, turned away. When asked what each person felt, he said, "Mama is sad." About himself, he said, "This one, too." "He doesn't feel anything and my papa is dead." (See Figure 2.)
FIGURE 2. Marco's family constellation.
| M = Mother | Mn = mother's boyfriend | |
| F = Father | Ma = Marco |
The mother took the child to her; she was very moved. I helped her to speak the truth to her child and to show him the past love she felt for his father. She connected with her pain about the unhappy relationship. Marco cried, too.
After he understood that his father is not dead, he said to his mother, "If I could do magic, then I would make him appear and then we would sit cozily on the sofa and we would talk." The mother acknowledged after this session the meaning of the father to the boy.
I do not set solution constellations with children, because I feel their feedback isn't authentic enough. I point out to the parents the upcoming group where they have the opportunity to set a constellation themselves. If parents aren't ready to do a constellation in the group because systemic thinking is foreign to them and the meaning of the constellation to their child's symptoms isn't clear to them, then I let them set up their system with puppets, too.
The family constellations happen in a group with parents and the therapeutic team, the care-givers of the children, movement and speech therapists, the medical colleague and myself. The children do not participate in the group, but sometimes there are older siblings. Usually the groups happen in the evenings. The meeting date emerges in the course of the therapeutic process as needed. The parents can set either the current family or their family of origin systems. Usually they begin with the current system.
We start with a round in which everyone names his or her issue, then we set constellations. The way we do it is like what we know from Bert Hellinger. The family constellations are also accompanied with "solution" sentences.
For the benefit of group process, it is advantageous when someone starts who already has "experience" with constellations. Those are parents who want to set a constellation for the second time, mostly their system of origin. When parents are inexperienced, first constellations can be difficult. They try to "do it right" or to find what is important. After the first constellation, this breaks the ice for the others. The group feels the common energy and grows together.
In general the experiences are encouraging. The constellations have enriched and added to the therapeutic possibilities, especially in the area of difficult familial problems. Each constellation gives a therapy goal in the form of a picture that emerges from the system's dynamics. This adds to the therapy goals that emerged from the family constellations.
Limitations that are caused by entanglements or displacements become therapeutically more accessible. Some of the childrens' disabilities can be traced back to insufficient nurturing or education. The parents are entangled with their own system is origin and constellations make it clear why they behave the way they do. When these entanglements or displacements are resolved the parents are free to recognize the needs of their child and to satisfy those. They are better able to undertake their responsibility to educate their children.
Family constellations help the parents and the therapist to get a broader view of the psychic disease of the child. When I say it simply, the sentence is, "The child is not sick, he is entangled." This becomes visible and experiential through the constellation. Thus, the family's whole context of thinking changes. The parents do not feel "incapable," "irresponsible," or "guilty," and their children are not "evil," "dumb," or "egotistical." The attributes change, feelings of guilt dissolve. The sentence, "I didn't know that" helps the parents to feel the pain and strengthens them, since they now know what to do. The picture of the constellation gives them a direction.
Parent conversations:
Daniel, age 5, suffers from an autistic syndrome. The parents are married. The family constellation shows the following picture. The child stands between father and mother. There is no good place for Daniel. (See Figure 3.)
FIGURE 3. Daniel's Family Constellation (Step 1)
| F = Father | M = Mother | D = Daniel |
The father of the mother was an alcoholic. Her mother stayed with him because of the children, but incited them against the father. She got a divorce after the children left home. The children excluded the father from their lives. The father lived in total isolation and sank into an alcoholic stupor. When he was added to the constellation, the boy became calmer and the special connection between the boy and his grandfather became visible. (See Figure 4.)
FIGURE 4. Daniel's Family Constellation (Step 2)
| Gf = Mother's Grandfather |
In the solution picture, the mother introduced the grandson to the grandfather. (See Figure 5.)
FIGURE 5. Daniel's Family Constellation (Step 3)
Further therapeutic intervention is oriented towards the solution of the constellation. I try in subsequent conversations to assist the family in unfolding the power of the solution image from the constellation. Some parents experience doubts about what they have seen and experienced and experienced in the constellation. They develop objections to the solution. They are ambivalent about whether to orient themselves in the direction shown by the solution image or whether they should follow their old belief system. They need further conversations in order to take the image and to process the experience. The therapist shows them the solution picture again. Some parents need a repetition of the solution sentences to "freshen up" the experiences they had. What was said in the constellation imprints itself only slowly, and needs renewal. For some parents forces begin to unfold within them to take responsibility, for instance in the child's education. They ask, for example, for educational guidance counseling.
The symptoms of a child don't show the area of conflict within the family or the dynamic that is operating. By setting a constellation the dynamic and its solution become visible and there are also indications for further therapeutic measures.
5.2.2.1 Holding therapy.
Holding therapy can only be used successfully if the child and his parents are not entangled or the identification has been dissolved. It is a psychotherapeutic modality which improves of the quality of bonding between parents and child, man and woman, and other family members. Its effectiveness becomes understandable by the meaning of holding and being held in a person's development. It makes conflict resolution and reconciliation possible.
First of all, the familial dynamic needs clarification so that a child who is representing an excluded person or problem in a system will not be held before he or she released from the entanglement. In other cases, the solution sentences from the constellation can come while holding the child. The child says, for instance to the father, "I am not your brother, I am your child."
An example:
In Tobias' case the geniogram initially did not give any indications of an entanglement. In the holding therapy that we used to establish bonding between parents and child, a difficult situation emerged. The boy raged in the arms of his father and the father cried. I did not understand the situation. The holding ended in exhaustion without a solution. The next day the father said that he has a son from a first union who he had given up for adoption. Thus, the holding situation became understandable in retrospect. The boy represented his brother. The father had the wrong child in his arms. In the family constellation of Tobias with his half brother became visible and could be resolved. The father could only partially put the solution into action. He told Tobias about his older brother, but didn't dare have the two of them meet.
The common experience of the constellations by parents and therapeutic team creates respect and appreciation. By being available for each other they create a climate of appreciation and trust which gives the parents the strength to face their destiny. They learn that they are not alone. It is a good form of human empathy. Appreciation and respect for the families also a fundamental consequence of the team's participation. The participation of the whole team makes it possible for everyone to see and acknowledge the dynamic, thus the solution is a symbol of the therapeutic goal. The image shows the direction the therapy will take. Difficulties during constellations can emerge if a caretaker of a child has a certain intent or wants to prove something in the constellation. The is the exception, and the therapist needs to be aware this is possible.
The constellation makes it possible for me, too, to get a deep insight into the system. In the beginning of my constellation work I could call Bert Hellinger when I needed help. Back then I had a little girl in therapy who was conceived during a sexual transgression by the stepfather of his handicapped step-daughter. The little girl was in bad shape. When I called Bert to get help understanding the system, his most important sentence to me was, "You have to take the father into your heart." In this therapy I didn't completely succeed with that. The effect of the sentence has continued to accompany me.
When I began using holding therapy in the clinic, and later with family constellations, the skepticism and criticism was quite large. By now, both methods are more accepted in my area of work. The fact that psychic diseases can be a symptom of entanglement and identification opens a whole new doorway in the psychiatric treatment of handicapped individuals. Family constellations can be this doorway.