Client assessment of the effectiveness of the systemic arrangement method (group short-term psychotherapy method)

Podnebesnaya Ekaterina Borisovna PhD in Psychology Psychologist, Center «Open reality» 123242, Russia, Moscow region, Moscow, lane. Volkov, 4, of. floor 4 Eka.pod@yandex.ru

The market of psychological services in our country is diverse. In addition to professional psychologists, a wide range of specialists and non-specialists provide assistance in this area. Recently, this state of affairs has begun to change. Russia is moving towards the inclusion of broad psychological assistance in the list of services provided under compulsory medical insurance. In this regard, research on the effectiveness of various modalities of psychotherapy is becoming particularly relevant. System placement is one of the most popular and at the same time one of the most controversial methods. And although many psychologists report on the successful experience of using constellations in their work ^{[5, 23, 7, 28, 27, 14, 13]}, The effectiveness of the method has not been evaluated in our country. Obtaining such an assessment is the purpose of this study. The novelty lies in the use of a statistically significant sample.

            Systemic placement is a method of short—term psychotherapy, introduced into widespread use by Bert Hellinger around the beginning of the 80s of the last century. The main concept of this method is the connection with the ancestors. The arrangements proceed from the fact that each person is a link in the chain of generations, part of his kind, and this unconscious connection affects his life. This method is also called "Hellinger arrangements", "family arrangements" or simply "arrangements".

            The term "family arrangements" has been used since the 1920s in the context of psychological and behavioral effects among family members. It was first used by Alfred Adler to denote the connection of each person with other members of their family system. One of the provisions of his work says that trauma can be inherited. This description can be considered a prototype of the arrangements ^[9].

             In form, the method of arrangement includes elements of psychodrama (I. Moreno) and family sculpture (V. Satyr). The concept of a "substitute" used in the arrangements also exists in both of these directions. In family sculpture, the therapist puts the client in a certain position or sets a certain direction of view through which he must experience a new experience. In psychodrama, the therapist and the client give certain instructions to the deputies - similar to the description of roles in the theater. These roles are then played until a possible solution is found. In contrast, Bert Hellinger did not direct what was happening and did not urge the deputies to do anything. The deputies in the arrangements do not pose, do not conduct a dialogue and do not play roles. The work is not with the client's ideas of what is and what should be, but with his unconscious. This is the essential difference between the arrangements and other psychodramatic methods. Information from the unconscious client is recognized by the substitutes in the form of bodily sensations and interpreted in accordance with the situation. The substitutes make a phenomenological entry into an altered state of consciousness, because in this operation the intention of consciousness directed at the body is fixed ^[8].

            There is also some similarity in the arrangements with Buzormeni-Nadia family therapy. Today's difficulties may be caused by injuries sustained by previous generations of the family, even if the victims are unaware of the original event. Hellinger called the relationship between present and past problems, which are not caused by direct personal experience, systemic entanglements ^[32]. "The systemic interweaving obeys the order according to which the bad must be redeemed by the bad, and the innocent are "younger" (or weaker) they are responsible for the actions of guilty "Elders" (or stronger ones) and atone for their sins" ^{[26, p. 16]}. Buzormeni-Nagy referred to this phenomenon by the term "invisible loyalty" ^[31]. Unlike Buzormeni-Nagy, who put the "right to vindictiveness" in the foreground, Hellinger does not call parents to account and does not point out to children their "arrogance" of the victim. He considers the same dynamics from a different angle - he looks at "how love flows" ^[12]. The problem is solved by focusing on the forgiveness of all members of the generic system ^[4].

            Today, the arrangements are an independent direction, original in its form and unique in content ^[6]. If at first the method was discussed only in a narrow circle of psychologists, psychotherapists and psychiatrists, then a few years later, it became one of the most popular psychotherapeutic approaches ^{[3, 16, 21, 29, 30]}, he gained recognition in medicine ^{[11, 24]}, in pedagogy ^[22], and also took a worthy place in the arsenal of business coaches and coaches ^{[15, 17, 18]}. Today, not only psychotherapists in practice, but also specialists in fundamental and applied psychology recognize that one of the most effective methods of working with the family context is a placement session ^[13].

            The appearance of this method in our country is associated with 2001. Then, for the first time, books on system arrangements were published in Russian: G. Weber's "Two Kinds of Happiness" ^[2] and B. Hellinger's "Orders of Love" ^[25].In the same year, Bert Hellinger came to Moscow and personally demonstrated the use of the method. And already in 2002, the Institute of Consulting and System Solutions opened the first program for training system placement consultants. Currently, the method is officially recognized by the Professional Psychotherapeutic League (PPL) and is included in the list of psychotherapeutic and consulting modalities.

            Research by domestic psychologists has shown that the use of the method of systemic arrangements gives positive results in working with persons released from prison ^[5]; with women with a history of the diagnosis of "infertility" ^[28]; with employees of special units of the Ministry of Internal Affairs of Russia ^[27]; with dysfunctional families with chemical dependence of one of the family members ^[14]; as well as when working with people who are in a state of maladjustment and depression ^[13].

            The effectiveness of systemic arrangements is the subject of this study. To evaluate it, a survey method was used among customers who had passed the placement. Subsequently, the data obtained were subjected to statistical analysis.

            Initially, the question arose whether it is possible to rely on the opinion of clients when evaluating the effectiveness of a psychotherapy method, to what extent such an assessment will reflect the actual state of affairs. Sometimes clients are devoid of objectivity and their positive feedback is explained by the hello-good-bye effect:  before psychotherapy, the patient tends to feel and describe his condition as difficult because he is looking for help, and saying goodbye to an attentive, sympathetic psychotherapist who is ready to help, spending money and time, keeping hope and not wanting to be ungrateful, the patient is inclined to believe that his condition has improved without objective improvement ^[1]. But ultimately, subjective improvement is the cornerstone for evaluating a therapist's performance. If the client subjectively feels better, then references to the absence of objective changes are useless ^{[20, p.107]}.

            In connection with the above, in this study, tests and techniques were intentionally excluded from evaluating the effectiveness of the placement method.  Only one question was addressed to clients: "Please rate the effectiveness of the last placement on a ten-point scale." This question was asked six months after the placement. This interval was not chosen by chance. Prior to this, spontaneous customer feedback was received about six months after the placement. It was then that many realized how much the state of their problem had changed. Noting at the same time that the process of change began much earlier. But either he was not aware of it, or the results were not so stunning that there would be a desire to share his successes with a psychotherapist.

            The study began in February 2022 and continues to this day. The arrangements are carried out by me on the basis of the Open Reality center in Moscow. A group of respondents who underwent appropriate therapy in the period from February 25, 2022 to March 3, 2023 (cluster selection or nest selection) was randomly selected from the general population of all clients of the placement method. Further, a continuous survey was conducted within this group by means of a survey. Gender and age characteristics were not taken into account, because in a quantitative study, compared with a qualitative one, it does not matter who is in front of you, all conclusions are based on the totality of respondents' answers and the material is collected in an impersonal form ^[4]. During the designated period, 50 placements were carried out. Initially, clients formulated a request, indicating which problem they needed help solving. 49 respondents who received this psychological assistance were interviewed six months after the end of therapy. One client considered it incorrect to evaluate the effectiveness of the placement now, since he is currently awaiting the results of solving his problem (awaiting a court decision). In total, 49 respondents were interviewed, which is a statistically significant amount that allows us to draw intermediate conclusions. The effectiveness of the last placement was evaluated on a 10-point scale, where 0 points corresponds to the absence of changes in the stated problem, 10 points means a complete solution to the problem. The clients were also given the opportunity to use the "-1" rating in the case when the problem situation worsened after the placement.

           Some of the clients could not decide on the rating and indicated their answer in a numerical interval, for example, "8-9". Considering the rounding of the obtained numbers in one direction or another incorrect, it was decided to use fractional estimates, for example, "8.5". Also, one client insisted on a rating of "9.9", arguing "so as not to jinx it." Thus, estimates appeared in the study "5,5", "6,5", "8,5", "9,5" and "9.9". 

            Out of 49 clients, 9 people gave the maximum score of 10 points, which corresponds to . 18%.

10 points – 8 people + 1 (18.7 %)

9.9 points – 1 person (2.0 %)

9.5 points – (+1) (2.0 %)

9 points – 1 (2.0 %)

8.5 points – 1 (2.0 %)

8 points – 3+1(8.2%)

7 points – 2 (4.1 %)

6.5 points – 2 (4.1 %)

6 points – 4+1 (10.2 %)

5.5 points – 1 (2.0 %)

5 points – 2+1+1+1 (10.2 %)

4 points – 0+1 (2.0%)

3 points – 3 (6.1%)

2 points – (+1) (2.0 %)

1 point – 1 (2.0 %)

0 points – 10 people (20.4 %)

-1 point – 1 person (2.0 %)

            The median assessment of the effectiveness of the placement method in the studied cohort was 6.0 points, which indicates that half of the respondents rated the effectiveness above 6.0 points ^[10]. In general, the analysis of the data allows us to conclude about the diversity of opinions in the surveyed group. There is a significant range of estimates, which may be an interesting object for a deeper study and analysis of the factors influencing the perception of effectiveness.

            Once again, I want to note that the assessment of the arrangements was subjective, not always shared by me. For example, the assessment of a young man who contacted us with a problem of job instability. He did not stay at any place of work for more than two or three months, all the time there was a conflict with the head, after which he was fired. When I turned to this young man for an assessment of the effectiveness of the last placement, he was just fired from his next job. At the same time, he gave an 8.5 rating, fervently convincing that this time the situation is 85% different. In fairness, it should be noted that currently this client has been working in one place for a year and even got a promotion, became the head of the department. Another curious assessment came from a 40-year-old woman who could not get pregnant, there was not a single pregnancy throughout her life. She's a happy mom now. At the same time, she puts an assessment of the effectiveness of the past arrangement 5. She believes that not only the arrangement helped in the achieved result, but also the Holy Matron, to whose relics the client made a pilgrimage. 

            In order to expand the understanding of the data used in the study, I present below a description of one arrangement, followed by a detailed assessment of the client.

Case Description

            A girl came to the arrangement. Her problem of being late is always late and everywhere (according to her). Confirms that so far there have been no serious negative consequences of her behavior. So what's the problem then? She recently got a good job, they are unlikely to tolerate her tardiness... But my suggestion to put a figure of this work is rejected. She wants to deal specifically with delays in all areas of her life. I propose to put three figures: the CLIENT's deputy, the figure of her LIFE and the figure of LATENESS - to see how much lateness interferes with life. That's where we start.

O – the figure of TARDINESS

W is the figure of the client's LIFE

K is the CLIENT'S deputy

            The figure of LIFE stands next to the CLIENT's deputy, on her right side. The figure of the LATECOMERS stands in front of them, at a considerable distance. She says she feels bad, anxious, her attention is focused on the figure of life, she does not notice the client's deputy. For the client's deputy, the figure of lateness is also not important, it does not matter. She relies on the figure of life, says that it is a man. Usually, in the arrangements on the right hand of the figure of a woman is the figure of her husband. It is also known that in the placement space, adult family members can be arranged in a semicircle, starting with the eldest.The client is not married, is not in a long-term relationship with a man, lives with her parents. I assume that this man is the father. To check, I enter the client's deputy dad in the field. The figure of life gives way to him, she retreats to the corner of the hall.

O – the figure of TARDINESS

W is the figure of the client's LIFE

K is the client's deputy

P – the figure of the client's DAD

            The deputy POPE looks intently at the figure of LATENESS, does not notice other figures. He says that the figure of LATENESS seems familiar to him, looks like some familiar woman. It looks like the father is projecting some kind of story of his daughter's lateness, possibly related to a woman he knows. To test this assumption, I introduce a new figure - the deputy of a familiar woman of the pope. This new figure stands in front of the pope. At the same time, the figure of the LATECOMERS and the CLIENT's deputy disperse to the far corners of the hall.

O – the figure of TARDINESS

W is the figure of the client's LIFE

K is the CLIENT'S deputy

P – the figure of the client's DAD

Z – the figure of a FAMILIAR woman

            DAD looks at the figure of a friend, says that she is much older than him and generally unpleasant. A friend says she wants to sit down - I put a blanket on her floor. She sits down on the blanket, looks at DAD and says that she knows him - just a boy who has no meaning for her. Then she lies down on the blanket. In the arrangements, the figures lying on the floor more often indicate the premature death of a person.

            I am contacting the client for clarification. It turns out that when her dad was a child, he and his family lived in Dushanbe, caught the military action taking place there then. As a test, I introduce the figure of military operations in Dushanbe into the arrangement. This figure stands next to a lying ACQUAINTANCE. The deputy POPE nods. "Yes, that's how it was," he says, "although she wasn't pleasant, I still feel sorry for her." His expression and tone raise questions for me. I ask the deputy if he is to blame for the death of this woman. "No, no," he answers too hastily, "No! and he adds almost in a whisper, "no..." I add a substitute for the part of the POPE's personality that considers him guilty of the death of a woman friend. We need to find out if there is such a part of the personality. DAD turns away from her, and part of the personality utters several accusatory phrases against him. DAD covers his face with his hands.

O – the figure of TARDINESS

W is the figure of the client's LIFE

K is the client's deputy

P – the figure of the client's DAD

Z is a FAMILIAR figure

CHL is a part of the pope's personality (which considers the POPE to be responsible for the death of a WOMAN friend)

            I ask MY FRIEND to get up from the floor. (I have already removed the deputy of military operations in Dushanbe from the lineup, he was just a test figure). I ask my FRIEND to repeat the permissive phrase after me - You are not to blame for my death, you are just a child, you could not change my fate. DAD turns to her and asks her to repeat the phrase. He listens attentively, then goes to his accusing part of himself and hugs her. I ask the figures in the center to take a few steps back (an ACQUAINTANCE, DAD and his part of the personality). The client's deputy and the figure of her life come to the center. I turn to the figure of LATENESS, if she wants to join them. LATECOMERS say that they rather want to stand next to a FRIEND. At the same time, LATENESS feels good, nothing bothers them – this deputy stands next to the figure of a FRIEND.

O – the figure of TARDINESS

W is the figure of the client's LIFE

K is the client's deputy

P – the figure of the client's DAD

Z – the figure of a FAMILIAR woman

CHL is part of the pope's personality

            The CLIENT's deputy looks at the figure of his LIFE, they smile at each other. Behind them is the figure of the POPE with his attitude towards lateness. Perhaps his ideas will no longer interfere with his daughter's life? The deputies of the ACQUAINTANCE and the LATENESS are also behind the client's back – where the past should be. The order of the generic system has been restored, the arrangement is complete.

            There is nothing particularly remarkable about this story. There are such events and such reactions. A letter that I received the next day from a client is noteworthy: "During, I remembered a story that my dad told me about how they were taken hostage at school, grade seven. But for some reason I didn't say. There was a civil war in Tajikistan. Dad said that he saw the military, managed to warn the class, they ran to the fence, the boys climbed over, but the teacher could not (she was small and fat), said something like "boys, help", but they could not or did not. Maybe the teacher is the woman we saw in the arrangement. Of course, he tells all this with laughter and jokes, but it is clear that everything that happened could be very traumatic." The accuracy of the substitutes is amazing. After all, even the figure of lateness stood next to a FRIEND. In this story, it was a familiar woman, a teacher at school, who was late.

            Six months later, I turned to the client for an assessment of the effectiveness of the last placement. Here is her answer: "I give a grade of 5 points. Now there are periods of lateness, the more important the day, the longer the time of lateness, there are periods when there are none at all. Well, the delay time has been reduced: now it's mostly 1-10 minutes, and before 40-60. I also want to add that my anxiety has gone away for 9 out of 10 when I'm going somewhere. Before the placement, I was terribly nervous when I went to work, even if I arrived on time, I was like a squeezed lemon from worries. And now I'm able to maintain inner peace and self-confidence even when I'm late. This is very important to me. I have had this problem since childhood and I have tried to solve it using various methods, here I really noticed the effect. Thank you!"

            Often, the client does not realize the full depth of the problem in the initial request. As can be seen from the client's feedback, significant positive changes have occurred in her condition, the problem with which she did not mention at the beginning. At the same time, she gave an average assessment of the effectiveness of the arrangement. As mentioned above, the client's assessment of psychotherapy is subjective and sometimes very specific. But at the same time, it is she who is the most informative when it comes to paid services to the public.

            The results showed that 50% of the respondents (25 people) rate the effectiveness of this method above 6.0 points on a 10-point scale. The data obtained allow us to conclude that the use of the system placement method allows us to obtain positive results from most customers. The conducted research is of practical importance and allows us to recommend a method of systemic arrangements for providing psychological assistance to the population. In the future, it is planned to analyze customer requests in order to find out in which cases the use of arrangements is most effective.