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The Effectiveness of Family Constellation Therapy in Improving Mental Health: A Systematic Review

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Family/systemic constellation therapy is a short-term group intervention aiming to help clients better understand and then change their conflictive experiences within a social system (e.g., family). The aim of the present systematic review was to synthetize the empirical evidence on the tolerability and effectiveness of this intervention in improving mental health. The PsycINFO, Embase, MEDLINE, ISI Web of Science, Psyndex, PsycEXTRA, ProQuest Dissertations & Theses, The Cochrane Library, Google Scholar, and an intervention-specific organization's databases were searched for quantitative, prospective studies published in English, German, Spanish, French, Dutch or Hungarian up until April 2020. Out of 4,197 identified records, 67 were assessed for eligibility, with 12 studies fulfilling inclusion criteria (10 independent samples; altogether 568 participants). Outcome variables were diverse ranging from positive self-image through psychopathology to perceived quality of family relationships. Out of the 12 studies, nine showed statistically significant improvement postintervention. The studies showing no significant treatment benefit were of lower methodological quality. The random-effect meta-analysis-conducted on five studies in relation to general psychopathology-indicated a moderate effect (Hedges' g of 0.531, CI: 0.387-0.676). Authors of seven studies also investigated potential iatrogenic effects and four studies reported minor or moderate negative effects in a small proportion (5-8%) of participants that potentially could have been linked to the intervention. The data accumulated to date point into the direction that family constellation therapy is an effective intervention with significant mental health benefits in the general population; however, the quantity and overall quality of the evidence is low.
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THE EFFECTIVENESS OF FAMILY CONSTELLATION THERAPY
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This document is the pre-review version of the following article:
Konkolÿ Thege, B., Petroll, C., Rivas, C., & Scholtens, S. (in press).
The effectiveness of family constellation therapy in improving
mental health: A systematic review.
Family Process
, https://doi.org/10.1111/famp.12636
The revised, copy-edited and final version of this manuscript has been
published in Family Process at:
https://onlinelibrary.wiley.com/doi/10.1111/famp.12636
The present article version does not exactly replicate the authoritative
document published in Family Process.
THE EFFECTIVENESS OF FAMILY CONSTELLATION THERAPY
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Abstract
Family/systemic constellation therapy is a short-term group intervention aiming to help clients
better understand and then change their conflictive experiences within a social system (e.g.,
family). The aim of the present systematic review was to synthetize the empirical evidence on the
tolerability and effectiveness of this intervention in improving mental health. The PsycINFO,
Embase, MEDLINE, ISI Web of Science, Psyndex, PsycEXTRA, ProQuest Dissertations &
Theses, The Cochrane Library, Google Scholar, and an intervention-specific organization’s data
bases were searched for quantitative, prospective studies published in English, German, Spanish,
French, Dutch, or Hungarian up until April 2020. Out of 4,197 identified records, 67 were assessed
for eligibility, with 12 studies fulfilling inclusion criteria (10 independent samples; altogether 568
participants). Outcome variables were diverse ranging from positive self-image through
psychopathology to perceived quality of family relationships. Out of the 12 studies, 9 showed
statistically significant improvement post-intervention. The studies showing no significant
treatment benefit were of lower methodological quality. The random-effect meta-analysis
conducted on 5 studies in relation to general psychopathology indicated a moderate effect
(Hedges g of 0.531, CI: 0.3870.676). Authors of 7 studies also investigated potential iatrogenic
effects and 4 studies reported minor or moderate negative effects in a small proportion (5-8%) of
participants that potentially could have been linked to the intervention. The data accumulated to
date point into the direction that family constellation therapy is an effective intervention with
significant mental health benefits in the general population; however, the quantity and overall
quality of the evidence is low.
Keywords: family constellation, mental health, psychopathology, effectiveness, systematic review
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Introduction
Family / systemic constellation therapy is a short-term group intervention aiming to help clients
gain insights into and then change their inner image of a conflictual system and finally change
their behavior in relation to that same system (Hunger, Bornhäuser, Link, Schweitzer, & Weinhold,
2014). The system addressed is most often the family but alternatively other systems (e.g.,
workplace community, ego parts, victim-perpetrator dyads) can also be the target of the
intervention (in consideration of the tradition in clinical practice, the term ‘family constellation
therapy’ is used throughout the manuscript in this broader sense, also referring to therapeutic work
with systems other than the family). This form of therapy was developed in Germany in the early
‘90s integrating elements of – among others psychodrama, family sculptures, contextual therapy,
and certain South-African aboriginal traditions (Butollo, Franke, & Hellinger, 2017; D. B. Cohen,
2006; McQuillin & Welford, 2013; Stiefel, Harris, & Zollmann, 2002; Stones, 2006; Weber,
1993).
The intervention is typically administered in a group setting in which approximately 15-25
unrelated participants (i.e., participants are not members of the same system) meet for a one-time,
2-3-day, facilitator-led seminar/workshop. Each constellation starts with a brief interview between
the facilitator and active client to clarify the individual’s goal with the intervention. This is
followed by a joint decision about which members of the client’s system play an important role in
the issue presented and these are represented by other group members during the constellation
(Orban, 2008). The representatives (including the client’s representative) are positioned in the
room by the client initially, with spatial distances, angles, and body postures meant to correspond
to the client’s inner image of the system (“problem constellation”). This allows the facilitator to
identify the dynamics beneath the client’s presenting concern, while at the same time helps the
client reflect on their internal experience from a more objective, partially external point of view
(as they are observers and not participants at this point). This part of the process is non-verbal,
focusing on what participants begin to experience as being part of the structure created by the
active client. Next, the representatives are asked by the therapist about their physical sensations,
feelings, and thoughts they had while in their positions. Rearrangements, spatial adjustments, and
brief, ritualized conversations are made based on the principles of healthy functioning within a
system (Hellinger, 1994; Weber, 1993) until a constellation is identified that offers a resolution for
THE EFFECTIVENESS OF FAMILY CONSTELLATION THERAPY
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the active participant’s issue. Ideally this “solution constellation” provides a new framework for
the client to feel, think, and behave in the given system (Hunger, Weinhold, Bornhäuser, Link, &
Schweitzer, 2015).
Family constellation therapy has become particularly popular in Europe and South America
(even becoming a part of the public health care system in certain countries; Franco de Sá, Nogueira,
& De Almeida Guerra, 2019; Krüger & Schmidt-Michel, 2003; Mahr & Brömer, 2008) and is
rapidly expanding in North America and Asia as well (Choi & Oh, 2018; North American Systemic
Constellations, 2019a, 2019b; Pritzker & Duncan, 2019). Thousands of practitioners around the
world use this method (D. B. Cohen, 2006) and with the German professional association
‘Deutsche Gesellschaft für Systemaufstellungen‘ alone, more than 450 professionals are registered
currently. Compared to its widespread use by therapists of various theoretical and professional
backgrounds, little effort has been made to generate and critically evaluate empirical data
regarding the effectiveness of the intervention.
Family constellation therapy has been adjusted and delivered to a large variety of client
groups ranging from the general population (Broughton, 2006) through prisoners (D. B. Cohen,
2009) to different patient groups (e.g., Hausner, 2015; Jafferany et al., 2019; Nazarkiewicz &
Bourquin, 2017; Ramos & Ramos, 2019). However, the number of studies using empirical
methods to formally investigate the effectiveness or mechanisms of action of family constellation
therapy is small and dominated by qualitative (Chu, 2008; Franke, 1996; Georgiadou, 2012;
Häuser, Klein, & Schmidt-Keller, 1998; Junge, 1998) or mixed methods (Laireiter &
Mitterhuemer, 2011; Mahr & Brömer, 2008; Rieger & Stückemann, 1999) studies investigating
clients’ satisfaction with the intervention. Despite the often rapid and significant positive changes
family constellation therapy can produce in participants (Langlotz, 2005), there has been some
concern among health care professionals regarding the safety of this therapeutic approach (e.g., no
professional follow-up after the one-time workshop, which might be emotionally upsetting for
some participants; Nelles, 2005; Reuter, 2005; Schneider, 2010; Talarczyk, 2011).
For the above reasons, synthesizing and critically evaluating the available empirical data
regarding the effectiveness and tolerability of family constellation therapy is of high public health
importance not just in North America but also globally. To date, two systematic reviews have been
conducted on this intervention. Neither of them focused specifically on quantitative data regarding
mental health outcomes and they did not emphasize data on tolerability/safety of the intervention
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either. Further, the first review (Weinhold & Reinhard, 2014) summarized the research evidence
up to early 2012, while several high-quality studies have been published since then. In addition,
this review has been published as a book chapter written in German and is not available online
significantly limiting accessibility for a broader audience. Although the second review is more
recent and was published in English, it was restricted to English language, peer-reviewed papers,
which approach resulted in identifying merely 3 empirical studies to synthesize (Hurley,
Koenning, & Bray, 2018). Therefore, the goal of this study was to systematically review the
empirical evidence regarding family constellation therapy 1) focusing on quantitative data related
to mental health outcomes, 2) considering all the evidence accumulated to date, 3) considering
languages other than English as well, and 4) paying adequate attention to information related to
tolerability/safety.
Methods
The protocol of the present systematic review was registered in the International Prospective
Register of Systematic Reviews (PROSPERO) September 19, 2018 (# CRD42018109124). Given
the preliminary stage of empirical research on family constellation therapy and the strong emphasis
on locating all available evidence including the gray literature in the present study, the author
team was not able to predict at the time of registration if enough data on the same mental health
outcome would be reported. As a consequence, the study protocol included a narrative synthesis
only; finally however, a meta-analysis on non-diagnosis-specific psychopathology the single
variable considered by a large enough number of studies was also conducted.
Eligibility criteria
Studies included in the review met the following criteria: (1) quantitative studies with
a longitudinal study design (including at least 2 assessment points, at least one of which was
occurring before- and at least one of which was occurring after the intervention
1
) (2) that evaluated
the efficacy/effectiveness of family/systemic constellations on outcome measures of mental
1
For instance, a study on goal attainment was excluded as it investigated the main variables of interest only at the 2-
week and 4-month follow-up, while at baseline only qualitative data were collected about the participants’ goals
regarding the intervention (Bornhäuser & Wolff, 2014).
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health. Given the limited amount of empirical data, any indicators of mental health (e.g., well-
being, social functioning, psychopathology etc.) were considered as eligible outcome variables and
no restrictions were made on participant populations either (e.g., general population, psychiatric
in- or outpatients).
Exclusion criteria were: 1) studies without a precisely defined outcome, 2) qualitative and
case studies, 3) no description of study methodology or assessment tool, 4) no available full text,
and 5) study language other than English, German, Spanish, French, Dutch, or Hungarian. In the
case of mixed method studies (combination of qualitative and quantitative approaches), the
quantitative portion of the study was considered.
Search strategy and screening
To include both peer-reviewed and the gray literature as well, an extensive literature search was
conducted including the following databases: PsycINFO, Embase, MEDLINE, ISI Web of
Science, Psyndex, PsycEXTRA, ProQuest Dissertations & Theses, the Cochrane Library, and
Google Scholar. Considering the date of introduction of family/systemic constellations into the
clinical practice, the search was limited to studies published after the 1st of January 1993. The
electronic data base searches were completed initially on 8th August 2018 and updated on the 6th
of April 2020 and considered scientific works published in 6 languages (English, German, Spanish,
French, Dutch, and Hungarian). The search terms included Family Constellation(s)’, Systemic
Constellation(s)’, System Constellation(s)’ and ‘Structural Constellation(s)’ as well as their
grammatical variations and equivalents in the other five languages (the detailed list of search terms
can be found is Supplementary Table 1). To reduce the number of irrelevant hits (‘family
constellation’ is a common general term referring to the structure of a family), terms were searched
in the title of the publications in the case of Google Scholar; while in the rest of the data bases,
both the title and abstract was searched for the search terms.
In addition to traditional scientific databases, the database of the German Society of
Systemic Constellations (Deutsche Gesellschaft für Systemaufstellungen; DGfS), the largest
professional body devoted to the study and practice of the intervention, was also added to the pool
of records to screen. Reference list of included studies and studies citing the included studies in
Google Scholar were also screened for additional, potentially relevant records. The screening
process based on title and/or abstract was completed by different members of the author team
THE EFFECTIVENESS OF FAMILY CONSTELLATION THERAPY
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depending on the language of the record (one assessor per item). Eligibility based on (German
or English language) full text was assessed by the lead author, experienced in conducting
systematic reviews and having content expertise specific to the research and clinical applications
of the intervention.
Data extraction
Data extraction for all variables (including methodological quality) and for each eligible study was
completed by two independent researchers (both with former experience in conducting systematic
reviews) and discrepancies were resolved by reaching consensus. As part of the data extraction
process, the following variables were considered: publication type (peer reviewed journal article,
book / book chapter, thesis / dissertation, non-peer reviewed journal article, online report), study
design, sample size, country of study, type of sample (e.g., normal population vs. psychiatric
outpatients), sex composition (all male, all female or mixed; if mixed, percentage of female
participants), and age of respondents.
The data extraction also specified detailed methodological characteristics including
information regarding the control group (no-, convenience-, matched-, or randomized control
group), length of intervention, length of follow-up, training level and professional background of
intervention provider based on description in the article or personal website (e.g., psychiatrist with
several decades of experience with family constellation therapy, social worker novice in family
constellation therapy), intervention setting (private or public health care), outcome variables
(construct and assessment technique), and main results. A second, simplified variable to describe
overall results was also created with 2 response categories: statistically significant improvements
reported or not. Finally, data were also extracted on whether study authors assessed iatrogenic
effects (negative side effects not assessed, assessed and not found, assessed and found).
Study quality was assessed in a standardized way by the 2018 version of the Mixed
Methods Appraisal Tool (MMAT) (Hong et al., 2018). The advantage of this rating tool is that it
provides the opportunity to evaluate studies with different designs (i.e., qualitative-, quantitative
randomized controlled-, quantitative non-randomized-, quantitative descriptive-, and mixed-
methods studies). Each study is assessed according to two screening questions (identical across
study types) and 5 design-specific items. An ad hoc supplementary question was also added to the
MMAT to evaluate the quality of statistics as this aspect is not covered in the MMAT. Quality of
THE EFFECTIVENESS OF FAMILY CONSTELLATION THERAPY
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statistical analysis and data presentation was considered as appropriate if study authors 1) used
adequate statistical tests considering the research question and type of data, 2) reported detailed
results (value of test statistics, p value) of the statistical tests, and 3) reported effect size indicators
as well.
A summary score (ranging from 0 to 8) was also created to facilitate the comparison of
studies in terms of overall methodological quality regardless of their designs. This summary score
was calculated as the simple sum of the 2 screening and 5 design-specific items of the MMAT plus
the item on quality of statistics (adequate methodological characteristics on the given area coded
as 1, while inadequate methodological characteristics quantified as 0).
If effect size indicators were not reported but the published descriptive data allowed the
authors of the present study to calculate those, then the results of these calculations were added to
the report with a reference to the fact that these data were not part of the original publication but
calculated based on those. Where both effect size indicators and descriptive data allowing the
calculation of those were missing (altogether or for certain subgoups), three attempts were made
to gather the raw data from study authors. This effort was successful in two cases (Krüger &
Schmidt-Michel, 2003; Langlotz, 2006) and unsuccessful in another two cases (Höppner, 2006;
Sethi, 2009).
As a rule of thumb, we considered 0.2 as a threshold for small effect, 0.5 for moderate
effect, and 0.8 for large effect in case of Cohen’s d; and 0.01 as a threshold for small effect, 0.06
for moderate effect, and 0.14 for large effect in case of η2; while the corresponding thresholds for
r were 0.1, 0.3 and 0.5, respectively (J. Cohen, 1988). Finally, a formal statistical analysis (Mann-
Whitney test) was also conducted to examine if overall methodological quality (using the summary
score) was independent of the reported effectiveness of the intervention (using the simple study
conclusion variable: significant positive effects were reported or not). Effect size r was calculated
using the following formula: z/√n. The software Statistical Package for the Social Sciences,
Version 25 (IBM SPSS, 2017) was used for the analysis.
Quantitative synthesis (meta-analysis)
The most frequently reported outcome indicator in the included studies was an omnibus (not
diagnosis-specific) indicator of psychopathology; therefore, a meta-analysis was performed on the
five studies that evaluated the effectiveness of family constellation therapy in this regard. As
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different assessment tools (Global Severity Index of the SCL-90-R, Personality Assessment
Inventory, Positive and Negative Symptom Scale, and Outcome Questionnaire 45.2) and so scale
ranges were used in these studies, standardized difference in means (Hedges’ g) was used as the
effect size indicator. Where follow-up data from several assessment points were reported
(Langlotz, 2006; Weinhold et al., 2013), all data points were considered when computing the effect
size (for raw data entered into the analysis and time-point-level effect sizes, please see
Supplementary file ‘Raw meta-analysis data’). The intent of this analysis was to provide results
generalizable to comparable populations; and therefore, the random-effects model was employed
for the analysis. Given the significant differences across study designs, a subgroup analysis was
also performed using a dichotomous (controlled vs. non-controlled) study design variable as a
moderator.
Heterogeneity in effect sizes across studies was assessed with the Q and the I2 statistic. The
Q statistic provides a test of the null hypothesis that all studies in the analysis share a common
effect size. If all studies shared the same effect size, the expected value of Q would be equal to the
degrees of freedom. The I2 statistic provides a percentile estimate for the proportion of variance in
observed effects attributable to variance in true effects rather than sampling error.
Finally, two interval estimates were also calculated. In addition to the confidence interval
for the overall effect size (i.e., precision of the estimate), the prediction interval was also calculated
(based on τ as an estimate of the standard deviation of the true effect sizes) to estimate the true
effect size for the universe of populations represented by the studies included in the analyses. The
likelihood of publication bias was not analyzed as the low number of studies (n=5) did not make
such analyses plausible. The software Comprehensive Meta-Analysis, version 3 (CMA 3; Biostat
Inc., 2016) was used for these analyses.
Results
Qualitative synthesis
Background and intervention data. The traditional database search identified 1,790
records resulting in 1,283 records after deduplication. Database of the German Society of Systemic
Constellations contained 2,914 entries resulting in a total of 4,197 records to screen. At this stage,
4,130 records were excluded due to being unrelated to the target intervention or not containing
THE EFFECTIVENESS OF FAMILY CONSTELLATION THERAPY
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empirical data, resulting in 67 records to assess for eligibility. Based on the evaluation of the full
texts, further 55 studies were excluded (Figure 1).
Altogether, 12 studies met inclusion criteria representing 10 independent samples (3 papers
analyzed the same sample) with a total sample size of 568. Bibliographical data and reason for
exclusion for the 44 studies passing screening stage but failing to satisfy eligibility criteria are
available as supplementary material to this article. The vast majority of included studies were
conducted in Germany, while a single study was conducted in Australia, South Africa, and the UK
each. All but one study employed a mixed sample of men and women (mean percentage of
women=75.8%), with the exception of the study by Langlotz (2005) where information on the
participants’ gender was not reported. Most studies (n=5) were published as peer-reviewed journal
articles or theses/dissertations (n=3); however, 2 books and 2 online reports were also among the
included studies. The intervention was most often delivered in the format of a 2- or 3-day single
workshop, with two exceptions, where shorter (1 to 4 hour) workshops were held on a repeated
basis. More detailed description of the previously listed and additional variables (exact ratio of
women in the sample, age characteristics, exact length of follow-up time, training background of
intervention provider, and private vs. public setting of intervention delivery) are described in the
original data extraction tool published as online supplementary material to this article.
Methodological data. Most studies (n=7) had a single group, pre-post design, two studies
used a non-randomized controlled design, and two additional studies employed a randomized
controlled design (one of them reported in 2 papers). The post-intervention follow-up time ranged
from 0 (no follow-up after post-intervention assessment) to 12 months (M=16.8 weeks, SD=19.0
weeks). Inadequacy of methodological rigor was most frequent in relation to a lack of attempt to
control for confounders and conducting/reporting statistical analyses (e.g., no effect size
indicators). Methodological evaluation of each included study is reported in Table 2.
Outcome data. Most important characteristics of the study samples, the outcome variables
and the main results are summarized in Table 3. The included studies considered a large variety of
outcome variables ranging from indicators of overall psychological wellbeing and self-efficacy
through interpersonal relationships (mainly with a focus on family relationships) to
psychopathology (e.g., depression, overall psychopathology level). Out of the twelve studies
included, authors of nine studies reported statistically significant treatment benefits in connection
to participation in family constellation therapy with largely variable effect sizes (Table 3).
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The analysis examining the relationship between methodological quality and study
outcome indicated that those studies that reported statistically significant treatment benefits
(Mmethodology total score=6.11±0.17) were of significantly higher methodological quality (Mann-
Whitney U=3.00, p=0.041) than those not reporting significant, positive intervention outcomes
(Mmethodology total score=4.33±0.58). The magnitude of the difference was large (r=0.59).
Safety / tolerability. The small majority of studies (n=7) also explicitly investigated
iatrogenic effects emerging either attributed to the intervention by participants or merely occurring
during the follow-up time. Out of these 7 studies, authors of four studies reported minor or
moderate negative effects in a small proportion (5-8%) of participants that theoretically could have
been linked to participation in the intervention.
Langlotz (2005) described that some participants of the study reported becoming
emotionally upset, confused or exhausted during / immediately after the intervention, which these
participants considered as a necessary element of the intervention process. This author also
reported on intervention participants whose psychopathology scores increased significantly
immediately after the intervention (at the end of the 2-day workshop), but even in these cases, at
follow-up, scores decreased well below baseline scores. In another study, Langlotz (2006) reported
that out of the 21 intervention participants, 1 individual (4.8%) showed clinically significant
elevation in psychopathology scores immediately after the intervention. In this case, no follow-up
interview was conducted to clarify if the deterioration could have been linked to the intervention
or external factors (e.g., negative life event during the time of the workshop).
In Höppner’s study, all participants were offered the opportunity to contact a therapist on
the phone should they feel that the intervention destabilized them (Höppner, 2006). The author
reported that out of the 81 participants
2
, four individuals used this opportunity, three of whom only
wished to further elaborate on their interpretation of the intervention, while one participant (1.2%)
reported a drastic worsening in relation to an interpersonal relationship. The same author also
reported that according to the 5-month follow-up questionnaire, 4 individuals (5.0%) reported a
deterioriation in the subjective, overall evaluation of their condition.
2
The original sample consisted of 81 individuals. In Table 3 and 4, 70 is reported as sample size as this is the
number of participants about whom the author displayed enough data to allow the calculation of effect sizes.
THE EFFECTIVENESS OF FAMILY CONSTELLATION THERAPY
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Finally, in a study of 48 participants, 4 individuals (8.3%) reported negative outcomes or
side effects such as short-term, negative physical symptoms (n=1), intimate relationship break-up
(n=1), increased loneliness in the family (n=1), and workplace bullying (n=1), which respondents
linked to their participation in the intervention (Rieger & Stückemann, 1999).
Quantitative synthesis of data on psychopathology
The meta-analytic investigations resulted in a Hedges’ g of 0.53 (Table 4) indicating that
on average, psychopathological symptom scores of those who participated in the intervention
decreased 0.53 standard deviation (moderately strong effect) compared to their pre-intervention
scores or the control group depending on study design. The confidence interval for the effect size
ranged from 0.39 to 0.68 and the Z-value was 7.20 with a corresponding p-value of <0.001
suggesting that the null hypothesis i.e. that the effect size would be zero is to be rejected.
The Q-value was 2.79 with 4 degrees of freedom and a corresponding p-value of 0.595.
Thus, the observed dispersion was actually less than what would be expected by chance suggesting
that there is no evidence that the true effect size varies from study to study. The I2 statistic was 0%
indicating that none of the variance in observed effects reflects variance in true effects but that all
of it is due to sampling error. The variance of true effects in log units (τ2) was <0.001 and the
standard deviation of true effects in log units (τ) was <0.001 indicating that the between-study
variance is estimated as zero. The 95% prediction interval for the overall effect size was 0.296 to
0.753 indicating that in the universe of populations represented by the studies included in the
current analyses, the true effect size in 95% of cases would fall somewhere in this range.
The subgroup analysis indicated that the pooled effect size of studies with a controlled
design (g=0.50, CI=0.23-0.76) was not statistically different (Q=0.105, p=0.746) from that of
studies with an uncontrolled design (g=0.55, CI=0.37-0.72), indicating that the mean effect size is
in the moderate range both for studies with controlled and non-controlled designs.
Discussion
Intervention effectiveness
The goal of this study was to systematically gather and synthesize the quantitative evidence
regarding the effectiveness of family constellation therapy in terms of mental health outcomes.
THE EFFECTIVENESS OF FAMILY CONSTELLATION THERAPY
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Based on the results of this review, we can conclude that the quantity and overall quality of the
evidence is low, the latter mainly due to the frequently lacking control group and the typically
short follow-up period. Most likely, not independently from these facts, the majority of the
evidence has been published in outlets other than peer-reviewed journals. Importantly though, the
explorative analysis examining the relationship between methodological quality and study
outcomes indicated that those studies that reported treatment benefits were of higher
methodological quality suggesting that the evidence may be more convincing if additional higher
quality studies will be published.
Out of the 12 studies included in the present review, 9 showed significant treatment benefits
post-intervention. The outcome variables selected by study authors were quite diverse, which is
not surprising considering the major role current (Weissman, Markowitz, & Klerman, 2008) or the
internal representation of early (Young, Klosko, & Weishaar, 2003) interpersonal relationships
play in our bio-psycho-social health. The studies showing no significant treatment benefit reported
comparable effect sizes to those reported in the studies showing statistically significant treatment
benefit, suggesting that the former studies were underpowered (had too low sample sizes to detect
existing treatment effects).
The results of the meta-analysis on indices of general psychopathology from 5 studies with
comparable outcomes indicated a moderately strong treatment effect independently of the
controlled (n=2) or uncontrolled (n=3) nature of the study design. The variance of effect sizes
across studies was estimated to be zero, which is most likely an underestimate due to the low
number of studies included; most likely, the impact of this treatment also varies by population.
However, the present findings suggest that the variation in effects is minor; indicating that the
impact of the treatment for all comparable populations (self-selected participants from the general
population) falls close to the mean effect size reported here.
In summary, data from the included quantitative, prospective studies suggest that family
constellation therapy is a consistently and moderately effective intervention in the general
population to decrease psychopathological symptoms. These findings are parallel to the results of
retrospective effectiveness studies, which also indicated treatment benefit. For instance, in a study
of 57 Austrian respondents, approximately 2/3rd of participants reported increased happiness,
courage, optimism, and coping abilities as a result of the intervention (Jost, 2007), while in a study
of participants from Germany, 92% of the respondents reported that the intervention was helpful
THE EFFECTIVENESS OF FAMILY CONSTELLATION THERAPY
14
for them (Mraz, 2006). In a retrospective study of English-, French- and Russian speaking
participants, 87% of those who sought treatment for interpersonal difficulties (n=119) reported
that their problems resolved as the outcome of the intervention, while the same value in the case
of mental health issues (n=31) was 90% (Thomas, 2010). A study of 209 Hungarian participants
reported that out of 26 quality of life domains covered in the evaluation, participants experienced
statistically significant improvement in 23 areas after the intervention (Zseni et al., 2011). An
interesting aspect of this study was the investigation of the effect of problem severity, with analyses
indicating that the intervention was more effective among individuals with less severe mental
health or interpersonal relationship challenges (the same was reported by Höppner, 2006). Finally,
authors of a study examining a sample of 139 inpatient substance use treatment participants from
Germany reported that intervention participants completed the entire treatment regime with a
significantly higher likelihood (81%) than those who did not participate (50%) in family
constellation therapy (Mahr & Brömer, 2008).
Tolerability / safety
Considering theoretical concerns (Deutsche Gesellschaft für Systemische Therapie und
Familientherapie, 2003; Talarczyk, 2011) and anecdotic data on the risks of family constellation
therapy (Langlotz, 1998b, 2001), a major focus of our work was to summarize data on tolerability.
Altogether, authors of four studies reported minor or moderate negative effects in a small
proportion (5-8%) of participants that theoretically could have been linked to participation in the
intervention [Jost (2007) reported similar proportions (3.4%) in their retrospective study].
The non-intended effects / correlating events reported included ruptures in interpersonal
relationships, short-term somatic or mental health symptoms, or unfavorable change in other
problem areas the participants worked on during the intervention. The studies reviewed here
suggest that the often strong emotional responses family constellation therapy can generate in a
very condensed time frame can facilitate improvement but can also temporarily destabilize
individuals with less stable mental health status. This aspect of the results points towards the
importance of post-intervention screening and providing intervention participants with the
opportunity to receive professional mental health support to process their experience if needed
(Langlotz, 2005). It is also worthy of mentioning that in all of the studies where iatrogenic effects
were studied, the intervention provider was a psychologist or psychiatrist and also an expert in
THE EFFECTIVENESS OF FAMILY CONSTELLATION THERAPY
15
family constellation therapy (for details, see original data extraction tool published as online
supplementary material to this article). This leaves the question open, whether iatrogenic effects
are more prevalent or severe if the intervention is provided by less experienced / trained
professionals, an issue which deserves attention in future studies.
Strengths and limitations
A major strength of the present systematic review is the comprehensive search process including
a large number of data bases and six languages. In addition, this is the first study using meta-
analytic techniques in an attempt to quantitatively summarize outcome data in relation to family
constellation therapy. Further, two researchers independently assessed each included study
contributing to a higher reliability of the data extraction process. Finally, the review is based on
an a priori developed and publicly registered research protocol.
Despite these strengths, a number of limitations should be acknowledged as well. First,
both the electronic searches, the screening process and checking for eligibility criteria was
completed by one researcher only decreasing the reliability of these processes. Most importantly,
due to the often lacking controlled design, the possibility cannot be ruled out that the reported
beneficial changes are the results of external factors and not the intervention itself. However, as
studies with controlled designs indicated effect sizes similar to the combined effect of the meta-
analysis in relation to psychopathology, and as studies with numerous assessment points indicated
improvement right after the intervention (Langlotz, 2006) but not between the pre-intervention
assessment points (Höppner, 2006), it is plausible to assume that the results are truly indicative of
the effectiveness of family constellation therapy.
The overall low number of studies included (and the even lower number of peer-reviewed
publications among them) also limits the reliability of the findings. This is especially true for the
meta-analytic investigations, where it was not feasible to conduct an important aspect of meta-
analyses due to the low number of studies: the estimation of publication bias. It is worthy of
mentioning though that even with the Cochrane collaboration, the median number of studies
included into a systematic review is 3 (Davey, Turner, Clarke, & Higgins, 2011). Therefore, while
we are aware that the reliability of the findings is suboptimal due to the low amount of evidence
available, we argue that synthetizing these data is helpful and necessary to at least preliminarily
inform clinical practice and inspire further research.
THE EFFECTIVENESS OF FAMILY CONSTELLATION THERAPY
16
A further limitation of the present review is the lack of distinction made among subtypes
of family/systemic constellations: interventions provided in the studies reported on in this review
were considered as a homogenous, single type of intervention as empirical studies most often do
not specify the subtype of the intervention they investigated. However, there are numerous
subtypes (Langlotz, 2010; Nelles, 2007) and formats of delivery (e.g., 2-day single workshop vs.
repeated, few-hour sessions over the course of several weeks) for this form of group therapy and
their effectiveness might vary.
Future directions
Future authors interested in studying the effectiveness of family constellation therapy are
encouraged to replicate the previous findings in adequately powered investigations employing
controlled (preferably randomized controlled) designs and several intervention providers
simultaneously to allow the explicit examination of therapist effects. Studies with longer follow-
up time (6 months or more) could significantly contribute to our knowledge regarding the stability
of treatment benefits. In view of the ongoing debate on the safety of the intervention, further studies
with an explicit focus on tolerability could help us better understand in which populations and
under which conditions (e.g., therapist’s training background, length of debriefing, accessibility of
support post-intervention) can the intervention be delivered in a safe manner.
Considering the ongoing diversification within family constellation therapy, authors of
future studies are also encouraged to specify the mode of delivery and subtype of family/systemic
constellations they employ when reporting on the effectiveness of the intervention. In addition,
synthetizing the relatively large number of qualitative studies we have identified through our
searches (Fig 1; for detailed bibliographic data of these records, see Supplementary file ‘Excluded
items’) could also contribute to a better understanding of the effectiveness and treatment
mechanisms of family constellation therapy.
Finally, there is a huge gap between the theory and anecdotic evidence versus the solid
research data related to the application of family constellation therapy for a large variety of specific
mental disorders. Authors have described the use of this form of brief group therapy with clients
struggling with psychosomatic- (Baitinger, 1999; Elsner & Kölle, 2010; Hausner, 2015), eating-
(Bourquin, 2011), mood- (Asztalos, Angster, & Pusztai, 2011; Brink, 1998; Ramos & Ramos,
2019), anxiety- (Essen, 1998; Franke, 1996), substance use- (Döring-Meijer & Hellinger, 2000;
THE EFFECTIVENESS OF FAMILY CONSTELLATION THERAPY
17
Gemeinhardt, 2006; Ingwersen, 2000; Mahr & Brömer, 2008), trauma-related (Assel, 2009;
Nazarkiewicz & Bourquin, 2017; Ruppert, 2006) and even psychotic disorders (Hellinger, 2001;
Langlotz, 1998a; Ruppert, 2004; Weber & Drexler, 2002), while quantitative empirical research
to date has almost exclusively focused on samples from the general population. Therefore, there is
a clear need to formally investigate the efficacy / effectiveness and safety / tolerability of the
intervention in specific client / patient populations to better understand to whom family
constellation therapy can be beneficial on their journey toward recovery or simply a happier and
more fulfilling life.
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Table 1. Methodological characteristics of the studies included
Study
Design
MMAT
S2
MMAT
1
MMAT
2
MMAT
3
MMAT
4
MMAT
5
Statistics
Total
score
Geils & Edwards,
2018
single group,
pre-post
1
0
1
1
0
1
0
5
Goode, 2015
randomized-
controlled trial
1
1
1
0
0
0
0
4
Höppner, 2006
two-group, non-
randomized
crossover
1
1
1
1
0
1
0
6
Hunger et al., 2014
randomized-
controlled trial
1
1
1
1
0
1
1
7
Hunger et al., 2015
single group,
pre-post
1
1
1
1
0
1
1
7
Krüger & Schmidt-
Michel, 2003
two-group,
matched control
group design
1
1
1
1
1
1
0
7
Langlotz, 2005
single group,
pre-post
1
0
1
1
0
1
0
5
Langlotz, 2006
single group,
pre-post
1
0
1
0
0
1
0
4
THE EFFECTIVENESS OF FAMILY CONSTELLATION THERAPY
26
Rieger &
Stückemann, 1999
single group,
pre-post
1
1
1
1
0
1
1
7
Schumacher, 2000
single group,
pre-post
1
1
1
0
0
1
0
5
Sethi, 2009
single group,
pre-post
1
0
0
1
0
1
0
4
Weinhold et al., 2013
randomized-
controlled trial
1
1
1
1
0
1
1
7
† Marked studies are based on the same/partially overlapping sample
THE EFFECTIVENESS OF FAMILY CONSTELLATION THERAPY
27
Table 2. Sample characteristics, outcome variables, and main results of the studies included
Study
Sample
Outcome variables
(assessment tools)
Results
Treat-
ment
benefit
Geils &
Edwards,
2018
General
population
(n=8), South
Africa
Self-perceived intuition
(Types of Intuition
Scale)
No change in intuition scores (p=0.06; d=0.30) [considering
the magnitude of the effect size and the tendency toward
significance, this is most likely the result of insufficient
statistical power]
No
Goode, 2015
Nursing
students
(n=75), United
Kingdom
Fear of death
(Multidimensional Fear
of Death Scale)
No change in fear of death in either the intervention
(p=0.189, d=0.42) or the no-intervention control group
(p=0.810, d=0.08), improvement in the control group with
fear-of-death-specific intervention (p=0.002, d=0.96)
No
Höppner,
2006
General
population
(n=70),
Germany
Psychopathology (SCL-
90-R's global wellness
index); positive self-
image (Frankfurter
Selbstkonzeptskalen);
self-acceptance (Skala
zur Erfassung der
Selbstakzeptiurung);
general mental health
(Skalen zur Psychischen
Improvement in all but one target areas in the intervention
group: Psychopathology: p<0.001, d=0.46; positive self-
image: p<0.001, d=0.37; general mental health: p<0.001,
d=0.24; self-acceptance: p<0.001, d=35; self-doubt:
p<0.001, d=0.38; general self-efficacy: p=0.005, d=0.23,
external control beliefs: p=0.268, d=0.09, sense of
coherence: p<0.001, d=0.26.
No change in the control group (T1 vs. T3) in any areas.
Psychopathology: p=0.313, r=0.30; positive self-image:
p=0.213, r=0.38; general mental health: p=0.625, r=0.15;
Yes
THE EFFECTIVENESS OF FAMILY CONSTELLATION THERAPY
28
Study
Sample
Outcome variables
(assessment tools)
Results
Treat-
ment
benefit
Gesundheit); self-doubt
(Unsicherheits-
fragebogen); general
self-efficacy and
external control beliefs
(Fragebogen zu
Komptenz- und
Kontrollüberzeugungen)
, sense of coherence
(Fragebogen zur
Lebensorientierung)
self-acceptance: p=0.092, r=0.51; self-doubt: p=0.202,
r=0.39; general self-efficacy: p=0.590, r=0.16; external
control beliefs: p=0.798, r=0.08; sense of coherence:
p=0.878, r=0.05. Improvement in 3 areas in the control
group after receiving intervention (n=11). Psychopathology:
p=0.008, r=0.81; positive self-image: p=0.022, r=0.69;
general mental health: p=0.074, r=0.54; self-acceptance:
p=0.028, r=0.66; self-doubt: p=0.173, r=0.41; general self-
efficacy: p=0.358, r=0.28; external control beliefs: p=0.444,
r=0.23; sense of coherence: p=0.721, r=0.11
Hunger et
al., 2014
General
population
(n=208),
Germany
Perceived quality of
personal social system
(Experience in Social
Systems Questionnaire,
the Interpersonal
Problematic Relations
scale of the Outcome
Questionnaire and the
Larger improvement in the intervention group than in the
control group in all but one assessed target areas: belonging
(T2: p=0.021, d=0.32; T3: p=0.075, d=0.27), autonomy (T2:
p<0.001, d=0.62; T3: p<0.001, d=0.61), accord (T2:
p<0.001, d=0.59; T3: p=0.001, d=0.50), confidence (T2:
p<0.001, d=0.54; T3: p=0.031, d=0.38), experience in social
systems altogether (T2: p<0.001, d=0.61; T3: p<0.001,
d=0.53); interpersonal problematic relations (T2: p=0.035,
Yes
THE EFFECTIVENESS OF FAMILY CONSTELLATION THERAPY
29
Study
Sample
Outcome variables
(assessment tools)
Results
Treat-
ment
benefit
Interpersonal Problems
scale of the Tool for the
Evaluation of the
Psychotherapeutic
Progress)
d=0.32; T3: p=0.021, d=0.36); interpersonal problems (T2:
p=0.003, d=0.45; T3: p<.001, d=0.53)
Hunger et
al., 2015
General
population
(n=104),
Germany
Overall psychological
functioning (Outcome
Questionnaire); overall
psychological distress
(Questionnaire for the
Evaluation of Treatment
Progress); goal
attainment
(Incongruence
Questionnaire);
perceived quality of
personal social system
(personal domain of the
Improvement in all four areas: overall psychological
functioning (T2: p<0.001, d=0.41; T3: p<0.001, d=0.49);
overall psychological distress (T2: p<0.001, d=0.39; T3:
p=0.001, d=0.50); goal attainment (T2: p<0.001, d=0.35; T3:
p<0.001, d=0.44); perceived quality of personal social
system (T2: p<0.001, d=0.61; T3: p<0.001, d=0.57). Clinical
significance: depending on the indicator, reliable positive
change in 33-35% of participants at 8-month follow-up (T2)
and 33-40% at 12-month follow-up (T3)
Yes
THE EFFECTIVENESS OF FAMILY CONSTELLATION THERAPY
30
Study
Sample
Outcome variables
(assessment tools)
Results
Treat-
ment
benefit
Experience In Social
Systems Questionnaire)
Krüger &
Schmidt-
Michel,
2003
Psychiatric
outpatients with
a history of
psychiatric
hospitalization
(n=20),
Germany
Psychopathology
(Positive and Negative
Syndrome Scale;
PANSS)
Decrease in psychopathology scores in the intervention
group (p=0.016, d=0.71), while no significant decrease in
symptom scores in the control group (p=0.083, d=0.43). No
significant time x group interaction (p=0.239, η2=0.076)
most likely due to low statistical power (cf. width of
confidence interval for this study in the meta-analysis,
supplementary file 2)
Yes
Langlotz,
2005
General
population
(n=35),
Germany
Psychopathology
(Personality Assessment
Inventory)
Reduction in all 6 psychopathology domain scores: anxiety
(p<.001, d=0.82), depression (p<.001, d=0.69), paranoia
(p<.001, d=0.34), schizophrenia (p<.001, d=0.60),
borderline features (p<.001, d=0.84), suicidal ideation
(p<.001, d=0.49)
Yes
Langlotz,
2006
Individuals
with at least
two SCL-90R
scales showing
elevated values
Psychopathology (SCL-
90-R: somatization,
obsessive-compulsive,
interpersonal sensitivity,
depression, anxiety,
Decrease on psychopathology indicators at all 3 follow up
assessment points with the exception of phobic anxiety at T4:
somatization (T2: p=0.013, d=0.57; T3: p=0.001, d=0.54;
T4: p=0.004, d=0.59), obsessive-compulsive (T2: p<0.001,
d=0.95; T3: p=0.001, d=0.84; T4: p=0.001, d=0.87),
Yes
THE EFFECTIVENESS OF FAMILY CONSTELLATION THERAPY
31
Study
Sample
Outcome variables
(assessment tools)
Results
Treat-
ment
benefit
(n=21),
Germany
hostility, phobic
anxiety, paranoid
ideation, psychoticism,
global wellness index,
positive symptom
distress index, and
positive symptom total)
interpersonal sensitivity (T2: p=0.001, d=0.84; T3: p<0.001,
d=0.93; T4: p=0.001, d=0.86), depression (T2: p<0.001,
d=1.02; T3: p=0.004, d=0.77; T4: p=0.002, d=0.80), anxiety
(T2: p=0.010, d=0.74; T3: p=0.006, d=0.63; T4: p=0.001,
d=0.89), hostility (T2: p=0.004, d=0.98; T3: p=0.005,
d=0.79; T4: p=0.001, d=0.89), phobic anxiety (T2: p=0.014,
d=0.43; T3: p=0.038, d=0.43; T4: p=0.139, d=0.33),
paranoid ideation (T2: p=0.004, d=0.76; T3: p=0.002,
d=0.66; T4: p=0.001, d=0.73), psychoticism (T2: p=0.001,
d=0.88; T3: p=0.001, d=0.87; T4: p=0.001, d=0.83), global
wellness index (T2: p=0.001, d=1.00; T3: p<0.001, d=0.97;
T4: p=0.001, d=0.96), positive symptom distress index (T2:
p<0.001, d=1.14; T3: p=0.001, d=0.73; T4: p<0.001,
d=0.95), and positive symptom total (T2: p=0.004, d=0.71;
T3: p=0.001, d=0.81; T4: p=0.001, d=0.84)
Rieger &
Stückema
nn, 1999
General
population
(n=48),
Germany
Fatigue, depression,
anger, vigor (Profile of
Mood States), perceived
quality of family
Improvement in perceived relationship with mother
(autonomy: p<0.001, η=.64; attachment: p=0.003, η=.52), no
change in perceived relationship with father (autonomy:
p=.335, d=0.21; attachment: p=0.101, d=0.29), mixed results
Yes
THE EFFECTIVENESS OF FAMILY CONSTELLATION THERAPY
32
Study
Sample
Outcome variables
(assessment tools)
Results
Treat-
ment
benefit
relationships in terms of
attachment and
autonomy (Subjektives
Familienbild
Fragebogen)
regarding perceived relationship with spouse (autonomy:
p=0.043, η=.49; attachment: p=0.416, η=.52), mixed results
regarding perceived relationship with first child (autonomy:
p=.008, η=.78; attachment: p>0.999, d<0.01); no change in
perceived relationship with 2nd child (autonomy: p=.455,
d=0.14; attachment: p=0.881, d=0.02). Improvement in
relation to fatigue (p=0.004, d=0.91), depression (p=0.002,
d=0.99), vigor (p=0.008; d=0.55); no change in anger
(p=0.224, r=0.18)
Schumacher,
2000
General
population
(n=53),
Germany
Perceived quality of
family relationships in
terms of attachment and
autonomy (Subjektives
Familienbild
Fragebogen)
Improvement in perceived family relationships in terms of
autonomy (T2: p=0.006, d=.28; T3: p<0.001, d=.51) and
attachment (T2: p=0.001, d=.44; T3: p=0.020, d=.32)
Yes
Sethi, 200
General
population
(n=30),
Australia
Perceived quality of
family relationships and
wellbeing; both assessed
Improvement on both target areas between pre- and post-
intervention; however, formal statistical analyses of these
changes were not conducted and not enough descriptive data
were provided to allow the calculation of effect size
No
THE EFFECTIVENESS OF FAMILY CONSTELLATION THERAPY
33
Study
Sample
Outcome variables
(assessment tools)
Results
Treat-
ment
benefit
through ad hoc
questions
Weinhold et
al., 2013
General
population
(n=208),
Germany
Psychological
functioning (Outcome
Questionnaire 45.2),
distress (Questionnaire
for the Evaluation of
Treatment Progress),
motivational
incongruence
(Incongruence
Questionnaire)
Larger improvement in the intervention group than in the
control group on all three target areas: psychological
functioning (T2: p=0.003, d=0.45; T3: p=0.003, d=0.46),
distress (T2: p<0.001, d=0.51; T3: p=0.001, d=0.51),
motivational incongruence (T3: p<0.001, d=0.55; T3:
p<0.001, d=0.52)
Yes
Marked studies are based on the same/partially overlapping sample
Values in bold are calculated by the review authors based on raw data reported in the original article or provided by the authors of the
original studies (Dr. Krüger and Dr. Langlotz).
THE EFFECTIVENESS OF FAMILY CONSTELLATION THERAPY
34
Table 4. Results of the meta-analysis investigating the effectiveness of family constellation therapy on overall psychopathology
PANSS: Positive and Negative Syndrome Scale; PAI: Personality Assessment Inventory; SCL90-R / GSI: Global Severity Index
of the Symptom Checklist-90-R; OQ-45.2: Outcome Questionnaire 45.2
Group by
Design Study name Time point Statistics for each study Hedges's g and 95% CI
Hedges's Standard Lower Upper
g error Variance limit limit Z-Value p-Value
Controlled Krüger, 2003 (PANSS) Blank 0.531 0.445 0.198 -0.341 1.404 1.194 0.233
Controlled Weinhold, 2013 (OQ-45.2) Combined 0.491 0.140 0.020 0.216 0.766 3.502 0.000
Controlled 0.495 0.134 0.018 0.233 0.757 3.699 0.000
Non-controlled Höppner, 2006 (SCL90-R / GSI)Blank 0.451 0.114 0.013 0.227 0.675 3.946 0.000
Non-controlled Langlotz, 2005 (PAI) Blank 0.602 0.167 0.028 0.275 0.929 3.605 0.000
Non-controlled Langlotz, 2006 (SCL90-R / GSI)Combined 0.893 0.254 0.064 0.395 1.390 3.519 0.000
Non-controlled 0.547 0.088 0.008 0.374 0.720 6.187 0.000
Overall 0.531 0.074 0.005 0.387 0.676 7.202 0.000
-1.50 -0.75 0.00 0.75 1.50
Meta Analysis
Evaluation copy
THE EFFECTIVENESS OF FAMILY CONSTELLATION THERAPY
35
Figure 1. Overview (flow chart) of the study selection process
4,197 records screened
based on title and/or
abstract
507 duplicate records removed
1,790 records identified
through traditional data
base search
2,914 records identified through the data base of the
German Society for System Constellations
4,130 records excluded due to being unrelated to
family constellation therapy or being non-empirical
67 records assessed for
eligibility based on full
text
12 papers included in
evidence synthesis
55 records were excluded for the following reasons:
17 non-empirical studies (review, study
protocol, intervention description)
15 retrospective, qualitative studies
9 quantitative studies with retrospective / cross
sectional quantitative design
4 on data unrelated to effectiveness in terms of
mental health
3 duplicates of included records (e.g., book
chapter version of a journal article)
2 with unavailable full texts (1 conference
abstract and 1 dissertation)
2 case studies
1 study with no available data yet
1 study not related to the intervention
1 study in Chinese
... Family constellation seminars are becoming increasingly popular in solving various problems related to relationships and health (59). The number of English literature publications explaining the basics of this method and the peculiarities of use in different groups of patients is limited (59,60). ...
... Family constellation seminars are becoming increasingly popular in solving various problems related to relationships and health (59). The number of English literature publications explaining the basics of this method and the peculiarities of use in different groups of patients is limited (59,60). Recent randomized control clinical trials (61,62) have shown that FCS effectively help people manage family-related psychological issues especially connected with implicit interactions and family secrets. ...
... After interventions, representatives change their places, and finally, the optimal "solution constellation" should provide a new, more comfortable pattern of the family relationships for the client. In the "solution constellation, " the client is able to communicate and behave more efficiently in his/her personal social system (59). ...
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... Constellation techniques have been the subject of study and practice globally, with almost 20 countries mentioned in the abstracts of the publications evaluated (Fig. 4), including the continents of Africa, America, Asia, Europe, and Oceania. This method is popular in Europe and South America, even becoming a part of the public health care and law system in certain countries (Franco de Sá et al., 2019;Marino and Macedo, 2019) and is rapidly expanding in North America and Asia (Choi and Oh, 2018;Geils and Edwards, 2018;Pritzker and Duncan, 2019;Thege et al., 2021). ...
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... The method originates from family constellations, that is, the application of systemic constellations focused on the family system (Konkolÿ Thege et al. 2021;Roevens 2008;Weinhold et al. 2014) used in clinical counselling. Later, the method was further developed and applied to other social systems such as organisations (Stam 2012;Weber and Rosselet 2016). ...
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