The purpose of this study is to investigate the psychosocial effects of systemic / family constellation. The method of systemic / family constellation refers to an approach which integrates ideas from family systems therapy with elements from psychodrama. The constellations are conducted in a group based seminar-setting, each seminar lasting two days.

Considering the very limited amount of empirical data on this method, the study design is a simple pre-post one with a 6-months follow-up. The study will be observational: the researchers will not manipulate who receives the intervention; instead they invite all clients (individuals from the general population) attending these therapeutic workshops run independently of the research process. Given the limited amount of evidence on this therapeutic method, special attention will be given to monitor potential adverse outcomes to establish intervention safety.

It is hypothesized that participation in a family constellation seminar might decrease potential psychological symptoms and will not result in adverse outcomes.

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

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

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

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

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

Inclusion Criteria:

• Self-referred and registered for a family constellation workshop with one of the therapists (clinical psychologist / psychiatrist) who were willing to collaborate with the researchers of the present study

Exclusion Criteria:

• Age under 18 years
• Currently suffers from a diagnosed mental disorder
• Participated actively (not merely as a "representative") in a family constellation intervention in the 12 months preceding baseline assessment

Individuals from the general population who seek help through family constellation seminars for various mild to moderate psychological symptoms.

The investigators have not requested permission from their study participants to make their data available to others to increase participants' sense of confidentiality and so willingness to participate in the study. As a consequence, in case of a data sharing request, the investigators would have to seek for additional explicit permission from the participants. As the investigators have committed to destroy participant contact data after finishing the study, the chances of such data sharing seem slim. However, the investigators are more than happy to conduct alternative analyses based on interested colleagues' suggestions / inquiry and share the raw output (including analytic syntax) of such analyses with those making the inquiry.

6 months postintervention

Two items were developed by the investigators to screen for adverse outcomes: "Have you experienced any negative change in relation to your mental or physical health during or since the family constellation workshop?". If respondents answered affirmatively, it was also asked if they believed the changes were associated with the intervention (yes/no/unsure). Below we report all adverse events, including those participants were sure were not related to the intervention.

The most important shortcoming of the present study is the non-controlled nature of its design and thus the possibility that the reported beneficial changes are the results of external factors. A further limitation of the present study is the low participation rate of men (even if it corresponds to anecdotic evidence on the real-life gender ratio of participants) and the large attrition rate limiting the generalizability of the findings to all family constellation participants.