Trauma, health, and «illness» – Constellations can provide clarity

How intention constellations can bring clarity

Franz Ruppert

Abstract

Instead of using the abstract term "state of health," it is better to speak about "being healthy." As a psychotherapist, you can ask yourself: How does it show that a person is mentally healthy? What promotes health and what hinders it? Illness is a construct that can lead to only the symptoms being treated. This simplified approach often obscures the underlying cause of the symptoms, which goes much deeper. Many symptoms are the result of trauma. They can be a direct expression of trauma, or they can stem from attempts to suppress the trauma. "Traumatized love" and "traumatized sexuality" are forms of trauma that have a profound impact on people's lives. This can lead to many kinds of illness symptoms, both physical, psychological, and social. Intention constellations is a method developed by the author. This method utilizes fundamental knowledge from multigenerational psychotraumatology and helps clients achieve mental health and stabilize their healthy state.

Being mentally healthy

It has long been known that good health is not simply the absence of disease (Fröschl 2000). Good health also does not automatically appear just because disease symptoms are removed. Regardless, it is much clearer to talk about being healthy. It reflects the way you live your life, rather than being an abstract description.

We psychotherapists also need our own theoretical concept that defines what it means to be mentally healthy. Relying on categories like DSM or ICD is not enough to work therapeutically with people in a way that truly helps them heal and stay well. On the contrary, categorizing mental disorders often makes people psychologically sicker than they were before. A diagnosis such as schizophrenia or borderline syndrome (emotionally unstable personality disorder, alternative definition according to the ICD-10 manual) can be a violation of a person's self-esteem, and such diagnoses can foster a desire to give up, causing people to stop trying to return to a healthy life.

The foundation of my psychotherapeutic work is a concept of mental health that includes ideas from Dan Siegel, among others. All mental functions, which involve registering reality in a meaningful way, selecting relevant information, and processing it further, must fit well together. The energy that drives the mental programs to process the information must flow freely. The information must form a meaningful whole. According to Dan Siegel, a healthy mind is full of energy, and it is stable, integrated, coherent, and complexly organized. It is neither too rigid nor too flexible, remaining maximally open to new things without descending into chaos (Siegel 2010, p. 352 f.).

Trauma is the root cause of many physical and mental symptoms

Generally, I assume that psychological disorders are the consequences of psychological trauma, especially when the conditions are chronic. This means that in order to recover psychologically, a person must integrate traumatic life experiences into their psyche, and individuals living in traumatizing environments must distance themselves from them.

The knowledge and insight I have gained through 20 years of practice as a psychotherapist have developed into a theory of multi-generational psychotraumatology. The foundation of this concept has been presented in my earlier books (Ruppert 2001, 2002, 2005, 2007, 2010, 2012, 2014).

According to this theory, there are principally three states a living organism can be in:

1. A healthy state of well-being. The person does not feel threatened and can therefore remain open to their surroundings while also setting healthy boundaries for themselves.
2. A stressed state. The individual is threatened by danger. The entire organism is activated and focused on preventing harmful impacts. These are stress reactions.
3. A traumatizing condition. The human being (or other organisms) is exposed to threats from the outside world. These are too intense to protect oneself against with a stress reaction; doing so would only worsen the situation. The chance of survival increases if the highly activated stress reaction is calmed down. For this to happen, essential mental functions must be blocked: sensations must be turned off, feelings must be frozen, thoughts must be stopped, and action must be prevented. When this happens, inner wholeness and coherence—psychological integration—are destroyed.

Ongoing stress, having a sense of constant threat, is one of the main sources of physical and mental symptoms. This has major social consequences. Stressed individuals struggle in relationships and easily provoke conflicts with others.

According to my model, ongoing stress is primarily a consequence of the psyche splitting after a traumatic experience, making it a direct result of trauma. A person with trauma experiences is also at a higher risk of acting in ways that lead to new traumas. This happens partly because suppressing these experiences can make them unable to see reality, and partly because they create illusions that they mistake for reality, which can ultimately harm them.

After experiencing trauma, a person has three different active programs in their psyche (see figure 1):

1. Programs that still represent the trauma situation, despite external circumstances having changed (traumatized parts)
2. Programs intended to keep the split-off, traumatized parts out of awareness (survival strategies)
3. Programs that, despite trauma experience, remain healthy (healthy parts)

The fragmentation of a living organism's structure after experiencing trauma

After many years of psychotherapy experience, a healthy psyche has the following characteristics for me:

1. The sensations are open to reality.
2. The emotions are aligned with the outer and inner reality, meaning they can be regulated from within.
3. Thoughts are oriented towards truth and clarity.
4. Our own identity is clear and well-defined.
5. One remembers important experiences.
6. Personal opportunities are assessed realistically.
7. Relationships with others are constructive and are ended if they become destructive.

In addition to their healthy parts, people with trauma experiences have two other psychological structures:

1. An emotional spark, meaning the psychological experience of the trauma.
2. A firefighter trying to put out the fire, or at least trying to prevent it from starting again.

I call these the survival parts.
According to my theory, these two mental structures contain everything that can manifest as symptoms.

When the traumatized structures are activated, a person may experience panic through symptoms such as palpitations, irregular heartbeat, diarrhea, abnormal sweating, digestive problems, uncontrolled aggression, or bottomless grief and despair.

The survival strategies, which are in a permanent state of stress to keep the traumatized parts under control, themselves produce countless symptoms:

• They contribute to pain and confusion that cause distraction.
• They contribute to the use of medication and substances to numb oneself even further.
• They contribute to physical overexertion that causes premature wear and tear on the body, as well as mental and physical overexertion leading to burnout.

There is a whole catalog of symptoms classified as illnesses in the diagnostic tool DSM-5. For the most part, these symptoms are nothing more than a list of the many different survival strategies people use to keep their traumatized structures under control. A smaller portion of the diagnoses in the DSM-5 point directly to traumatized parts (such as panic anxiety).

In my experience, symptoms stemming from traumatized structures and survival strategies are shaped by the specific type of trauma involved. In my theory, I distinguish between different forms of trauma.
There are two main types

1. shock trauma, i.e., a sudden trauma
2. early trauma

We experience shock trauma, for example, during a car accident or when someone we love dies suddenly. Developmental trauma, on the other hand, is long-lasting, such as within a romantic relationship or a parent-child relationship.

Another categorization in my theory distinguishes between four traumas

• existential trauma
• loss trauma
• symbiotic trauma
• attachment system trauma

Existential and loss traumas usually trigger states of shock. I have already mentioned a few examples of existential and loss traumas.

Symbiotic and attachment system traumas are different forms of relational trauma that often burden people throughout their lives. Symbiotic trauma occurs when a child fails to secure a vital, safe attachment to their mother and a stable, supportive attachment to their father. No matter how hard the child tries, all attempts fail because the parents are traumatised. They are unable to establish the emotional connection the child needs for stable psychological development.

I focus particularly on the connection between mother and child, because the mother is the first person the child bonds with. This happens even before birth. All other bonds come after that. This also applies to the bond between father and child. It can be very emotional, but it is always subordinate to the influence of the quality of the bond between mother and child. This remains true even if the father connects with the child during pregnancy. The mother's special role must also find its expression in theory. Psychotherapy experiences show that many more people struggle with a complicated relationship with their mother than with their father, even though the relationship with the father can also be traumatic.

In a bonding trauma, the relationship with the parents is turned upside down. The child worries about the mother's well-being and uses all its energy to stabilize its traumatized parents. The child does everything possible to connect with them. It even identifies with the parents' split-off trauma parts and copies their survival parts.

An important consequence of early trauma is that the child attaches to other people as a substitute for the mother when a secure attachment cannot be found with her. It can also happen that the child tries to meet its bonding needs with the father instead of the mother. If the father can meet these bonding needs, it is a great help to the child. However, because traumatized mothers most often find traumatized partners, a child seeking secure attachment often goes from bad to worse.

Recently, I have also begun to distinguish between different forms of traumatic violence we may be exposed to (see image 2)

• traumatization caused by natural forces
• traumatization caused by human violence
• traumatized love
• traumatized sexuality

Traumatized love corresponds to the concept of symbiotic trauma. The term love was introduced to clarify that this involves the traumatization of the very core of our human existence and our fundamental needs. When we are unable to love, or perhaps have never learned what healthy love is, we lack the foundation for healthy attachment and healthy interpersonal relationships. This deeply affects our joy of life and all our efforts to live in relationships, whether as couples, within families, or in work environments. When love is traumatized, our connection with other people is fundamentally disrupted: we either distance ourselves too much, retreating extremely and avoiding contact, or we cross boundaries, disrespect the limits of others, and enter into an unhealthy symbiosis with them.

Often, traumatized love is the foundation for traumatized sexuality. When a child does not receive the important and necessary physical contact and emotional care from their mother, and also lacks protection, the child becomes an easy target for people with sexual interests in children. Sexual abuse is often the result, and this has terrible consequences for the child. Previously, I have mentioned that specific physical symptoms can be linked to specific traumas. Anorexia is a possible consequence of sexual abuse, meaning traumatized sexuality. In my experience, the symptom of anorexia often occurs in those who have been subjected to sexual abuse.

• because the child wants to make their body less attractive to the abuser
• because the child wants to gain control over bodily reactions so that the body does not react with pleasure when it is
• forced sexual stimulation
• because the child believes they can live without their body
• because the child cannot talk about the sexual abuse, but still looks for recognition from the emotionally distant mother through achievements and success

Illness as a construct

Headaches, high blood pressure, cancer, fibromyalgia, rheumatism, anxiety, depression, dementia. The list of all physical and mental symptoms that we label as illness is almost endless. And it continues to grow: the new edition of the Diagnostic and Statistical Manual of Mental Disorders, DSM-V, is more comprehensive than its predecessor. For example, it now includes a condition known as disproportionate anger.

We are all used to thinking in terms of illness categories, and it seems like a given, which is why it is also important to critically question the artificial construct of "illness." In many cases, logically speaking, it is simply an unnecessary repetition using new terms. A phenomenon, such as severe headaches, is given a disease label. This often happens with the help of Latin or Greek names, such as migraine. What stands before and after the equals sign looks different (severe headaches = migraine), but the words have the same meaning. The tautological equating of a symptom with an illness has several practical consequences:

1. No questions are asked about the cause of the symptom.
2. The symptom is recognized as an illness and is therefore socially accepted.
3. This recognition grants the right to receive medical treatment for the symptom.
4. One receives publicly funded medical treatment.

None of this is inherently objectionable, but the approach has one major and significant drawback: Symptoms are classified as the disease itself, and treatment is therefore based entirely on the symptoms. The physician or psychotherapist treating the illness aims through their interventions to completely eliminate the symptom, or at least reduce it to the point where it is no longer disruptive.

When a young woman, for example, stops eating and is diagnosed with an eating disorder (anorexia nervosa), treatment begins by motivating her to eat again or by forcibly nourishing her body. Even though the young woman may gain weight this way, it does not change her fundamental attitude toward herself. She still rejects her body. Nor does the treatment change anything regarding the symbiotic entanglements within the family system, which are in all likelihood the cause of her symptoms.

Regardless, when it comes to constructed diseases, the focus is not on the sick person, but on the symptoms. When we, as doctors, therapists, or workers in the healthcare system, use the concept of disease, we must ask ourselves a different question: What are the causes of the symptoms a person is suffering from?
Why can one person have the same symptoms as another, yet not experience it as suffering? What potential functions do the symptoms serve? What would be present if the symptoms were no longer there? Would that person then be considered healthy?

The illness symptoms that follow from symbiotic entanglements

In my experience, symbiotic entanglements resulting from trauma fuel many of the symptoms we see. In cases of love trauma, a child will attach to their traumatized mother through the symptom. Even though the child suffers because of the symptom, they cannot let it go, as doing so would mean giving up contact with their mother.

After a sexual trauma, a person often finds themselves trapped in the victim-abuser dynamic. They may suffer from many symptoms, but will avoid looking closely at where these symptoms stem from. This may be because doing so would force them to confront the full extent of their victimhood. Often, a person who has suffered abuse still maintains a relationship with the abuser—a relationship that should have ended. In such cases, it is easier to escape into symptoms or into the role of being sick. The hope is that this will prevent further abuse while allowing them to stay in the destructive relationship.

In an attachment system trauma, it becomes most apparent why the theory of psychotraumatology must be multi-generational. Some children are born into families steeped in victim/perpetrator dynamics. To survive in such a system, a child has no other choice than to become a victim and/or perpetrator themselves. Such children therefore develop victim and perpetrator attitudes as a survival strategy. Only when a person steps out of such a relational system can they be free from the victim/perpetrator split within themselves. Only then can they aim for a life free from victim and perpetrator attitudes.

Intention constellations

In 1994, I was introduced to family constellations through Bert Hellinger. He made the topic well-known through books and public events (Weber 1995). For a while, I copied Hellinger's way of working, but gradually I realized that this type of family constellation risked feeding into the illusion of a happy, perfect family without facing the reality of how people truly relate to one another. This is why I believe it is essential to look closely at the underlying theories behind any constellation work that is done.

Since 1998, I have developed my own theory step by step as the basis for the constellation method. It relies on attachment theory (Bowlby 2006 a, b, c, Brisch 2014) and trauma theory (Fischer und Riedesser 1998, Levine 1998, 2011, Herman 2003, Huber 2003, 2013, Putnam 2003). As I develop my theoretical knowledge, the way I use constellations also changes. I still view constellations as an outstanding method for making the psyche visible in a structured way and for shedding light on unconscious, very early, and split-off events. Through representatives, the client can see many layers within themselves that can lead to fundamental changes.

I no longer call the approach "family constellations" or "systemic constellations" but "trauma constellations." This is because the main focus is always on the traumas that lie behind the client's symptoms, regardless of whether they are of a physical, psychological, or social nature.

Since 2009, I have been working with a method I call *«intention constellations». The reason is that I have concluded that a successful constellation requires the client to formulate their own intention. The intention shows the person's starting point, what moves them, what they have access to within themselves, what they want to open up to, and what they do not want to approach. With this method, the intention can be formulated based on the healthy parts of the psyche or from survival strategies. For example, if someone wants a symptom to disappear, this depends on whether the person is also open to looking at the cause and function of the symptom. When that is the case, the intention comes from the healthy parts. If, on the other hand, the client is not interested in what messages the symptom can provide, this is a sign that the client is still holding on to a survival strategy.

In an intention constellation, the client first chooses a representative for their intention and positions themselves together with the representative. The dialogue and interaction between the representative of the intention and the client make clear what the issue is about and what potential for change the constellation offers the client. There are three general variations:

• The intention, which initially acts as a survival strategy, transforms into a healthy part toward the end of the constellation—meaning the client experiences their healthy structures growing while the survival parts lose their power.
• With the help of an intention originating from the client's healthy parts, access to a traumatized part of the client's psyche becomes possible.
• The intention can help stabilize a healthy state that has already been established following a previous encounter with the traumatized part.

Based on my splitting model, I have also developed a model of change (figure 3).

Integration of the split after a trauma

• opening the gateway to trauma feelings
• reducing illusions
• supporting stabilization and greater autonomy
• strengthening the healthy parts

Intention constellations and salutogenesis

Meaningful, comprehensible, and manageable are the core concepts of the Salutogenic Model (a theory on what promotes good health) by Aaron Antonovsky (Antonovsky 1997). All three dimensions are also present in my model of healthy psychological structures. Only when the psyche fulfills its actual function and gives us access to external and internal reality are we operating from the healthy parts of our psyche. Conversely, when we are driven by our trauma or survival parts, reality is largely muted, which increases the risk of further traumatization.

Our experiences are particularly significant when they are tied to our emotions. If we are separated from our feelings, much of life loses its meaning, and we experience an inner emptiness. From this inner emptiness, we may also do things that harm us without even realizing it. Traumatic survival parts may try to fill this emptiness with substances, such as drugs, which in turn leads to further trauma and more health symptoms.

When we talk about understanding something cognitively, it is also clear that only a healthy psyche can truly grasp what is happening. The traumatized parts, on the other hand, try not to understand what is going on (at times very purposefully) in order to protect themselves from anxiety and pain. Instead, they create a dream world in which they try to live. They accept the loss of reality to avoid being confronted with memories of the trauma. It is also the trauma-survival parts that feel relieved when the symptoms they themselves create are not examined for root causes, but are instead labeled as illness. In this way, responsibility for one's own health is handed over to experts, and one can slip into the role of a victim regarding one's own illnesses.

Manageability is the practical side of a healthy psyche. We see the opportunities available for concrete actions. These actions are targeted and solve problems where possible. Only the healthy part is able to handle the reality of trauma. At this level, too, the trauma survival parts follow a different logic: they see opportunities for action where none exist, and they overlook existing opportunities to solve problems. They are either overly optimistic or overly pessimistic. Nor do they see the opportunities to heal from the trauma or to prevent new traumas from occurring. They are convinced that the trauma does not exist, at least not within themselves.

Through the constellation method, psychological structures can be seen in all their complexity. Therefore, it is also possible to examine in detail whether the measures being implemented are helpful, or whether they push a person even deeper into psychological fragmentation. It has often been shown in constellations that what clients previously thought was health-promoting was just another survival strategy to better endure the effects of trauma or to compensate for them.

All past experience with therapy shows that the greatest health-promoting potential lies in reintegrating split-off psychological parts. In this way, a traumatized person's thoughts and emotions can stop conflicting with one another and instead complement each other in a meaningful way.

The main reason why clients seek out my psychotherapeutic practice is that they have been exposed to trauma. Often these experiences go back a long way in their biography, often even going back to the time before their birth. Here I use the term "early trauma" (Ruppert 2014). Striking physical and psychological features (symptoms) are therefore not an independent illness. It is another indication that this person has experiences in life that have not been processed in a good way. If, for example, a child has symptoms, it is not necessarily the case that there is something wrong with the child. It may just as well be that the child lives in unhealthy relationships. It often turns out that when the mother or father works on their own traumas, the symptoms of illness in the child will also disappear.

Good health therefore cannot be defined as the absence of symptoms. In my view, good health is based on healthy structures within a living organism. It is the result of what we eat, physical activity, and, above all, the mental programs we use to shape and experience our interpersonal relationships. Denying and repressing does not promote salutogenesis. Working purposefully, consistently, and continuously through past trauma and leaving traumatizing relationships, on the other hand, promotes health.

If we humans could also stop traumatizing each other (for example through wars, domestic violence, or in parent-child relationships), that would be the greatest contribution we could make to human health.

*The methodology within the "intention constellations" method has changed since Ruppert wrote this article, and the new methodology will be presented at the Trauma Conference.