In diagnosing psychotic illnesses theorists confine themselves to studying specific symptoms such as disorganised behaviour, hallucinations and delusions. Common forms of behavioural disorders are extreme retreat from normal activities and duties, in some people combined with all signs of depression and in others connected with an extremely high level of activity. Common for both the depressive and the manic form of psychoses is a high arousal of all kinds of feelings, that affect negatively the perception and the thinking of a person. Hallucinations which we call a type of false perception can affect all sensory channels, for example: seeing phantoms, hearing voices, smelling corpses, feeling spiders on your skin. The most important forms of delusion are: delusions of grandeur, love delusions, delusions of jealousy, persecutory delusions, body related delusions. (Sass, Wittchen, Zaudig, 1998). The narrowest definition of psychosis confines itself to delusional fantasies and elaborate hallucinations whereby the patient does not have insight into their pathological nature. A slightly less narrow definition includes within it hallucinations which the sufferer recognises as a hallucinatory experience. The diagnosis ‘psychosis’ is often equated with schizophrenia. (ICD – 10, 1993, p.103ff.) and an alteration of the whole personality a patient.

Common for both the depressive and the manic form of psychoses is a high arousal of all kinds of feelings, that affect negatively the perception and the thinking of a person.

Medical Psychiatry – In the opinion of medical orientated psychiatry, psychosis and other related illnesses are disorders of the neurological metabolism, a problem of the human hardware, so to speak. For psychiatrists persecutory ideas and hallucinations do not seem to have any basis in the life context of a psychotic patient. In the search for the physiological origins of psychosis a multitude of explanations has been put forward over the last hundred years such as ‘bad blood’, defective genes, metabolic disturbances in the brain and most recently even viruses. But in spite of enormous research activitiy for none of these theories has conclusive proof been produced. (Breggin 1996, Rufer, 2001).

An arbitrary linking of psychosocial to biological factors is in my opinion also not sufficient to explain the emergence of psychosis. The so called ‘Vulnerability Stress Model’ cannot satisfactorily explain the phenomenon of schizophrenia. The problem with this model is that both factors – vulnerability and stress – are defined in a circular fashion through each other. That a person is vulnerable i.e. that his information processing ability is disturbed and that he must have been under some inner or exogenous psychosis inducing stress, can only be assumed retrospectively, that is, after he has become psychotic. It is neither possible to specifically define the degree of vulnerability in a person nor to quantify it. Likewise it is not possible to produce a listing of stress factors that can be reliably linked to the origin of psychotic illnesses or reliably used as an indicator for predicting the onset of psychosis.

Psychodynamic theories of Psychosis – Psychodynamic e.g. psychoanalytical psychosis theories (Mentzos 1992) point towards a breakdown of ego function in psychosis because of early childhood trauma or aggressive or sexual instinctual impulses that the person was unable to cope with or to integrate into her personality structure. Psychosis then serves the function of overcoming the inability of the ego to cope with aggressive and sexual impulses (Lempa 1992). However this model does not explain the fact that psychotic patients are also able to behave normally over extended periods of their lives and even in between psychotic episodes and do not fundamentally lose their ability to think reasonably and to feel appropriately.

Communications- and Family Systems Explanations – This type of explanation transcends the narrowness of those previously cited where the focus is solely on the patient, his brain or his ego. Parents who don’t communicate meaningfully (‘double-bind-theory’) (Bateson, Jackson, Haley and Weakland, 1956), mothers who give confusing messages (‘schizophrenia inducing mother’), or a family atmosphere in which ‘over protectiveness’ or excessive control were the rule are discussed in the literature as causes of psychosis or at least as significant factors. It is not made clear, however, what the cause of the parents’ behaviour might be, or why a psychosis inducing atmosphere is created and where such confusing communication within the family comes from.

This article cannot provide a discussion that does justice to all the specific features of the different scientific disciplines, theories and schools of thought that attempt to reach a better understanding of psychosis and schizophrenia. Likewise the current state of empirical research cannot be thoroughly examined. My practical therapeutic experiences with people who have become psychotic, however, have shown me that none of the explanations of psychosis and schizophrenia offered so far have solved the riddles of these enormous breakdowns of a human existence satisfactorily.

In the opinion of medical orientated psychiatry, psychosis and other related illnesses are disorders of the neurological metabolism, a problem of the human hardware, so to speak. For psychiatrists persecutory ideas and hallucinations do not seem to have any basis in the life context of a psychotic patient. In the search for the physiological origins of psychosis a multitude of explanations has been put forward over the last hundred years such as ‘bad blood’, defective genes, metabolic disturbances in the brain and most recently even viruses. But in spite of enormous research activitiy for none of these theories has conclusive proof been produced.

I have been using Family Constellation, after Hellinger’s method (Hellinger, Weber, Beaumont, 1998; Hellinger, 2001), in my psychotherapeutic work, for eight years. Over time I have observed, how in constellations representatives of psychotic patients suddenly get shaky legs, or feel as if they are about to float off the ground, or that they are overcome by massive attacks of rage. Some representatives feel as though they are in a fog, so that they don’t know what is really happening around them or as though their body is torn into pieces. Psychoses seem to engender specific symptoms in the representatives. It is this fact which makes them relatively easy to diagnose within the context of a constellation.

I have given several family constellation seminars especially for people who have experienced psychosis and for family members of psychotic persons. As a result of the experience gained by working with about 50 such clients in groups and individual therapy, I have recently formulated hypotheses which may describe the specific family dynamics inherent in psychoses and offer a fundamental explanation how psychosis and schizophrenia come into existence within the bonding system of families (Ruppert, 2002). In the following I will first describe a case study of my work with a young man who suddenly for no apparent reason became psychotic and then sum up some of my insights what kind of schizophrenic situations in families lead over two, three or even four generations to psychoses.

...how in constellations representatives of psychotic patients suddenly get shaky legs, or feel as if they are about to float off the ground, or that they are overcome by massive attacks of rage.

Initial situation – Mr. P., about 30 years of age, came for his first appointment in February 1999. He seemed calm and composed. The only striking thing was his stilted way of speaking. He used hackneyed expressions in almost every sentence, such as ‘so to speak’, ‘in a certain way’, ‘so to say’. When I inquired further what might be the meaning of these expressions he told me that he was using them in order not to say too much.

He told me that lately he had kept himself isolated and wasn’t going out much. He had felt insecure since his aunt had died one year ago in a car accident. She was the older sister of his father. The reason why he wanted psychotherapy was to learn how to become more self-confident in public. Often he felt others were disapproving of him, with that blood would rush to his head and he would feel shame.

In a telephone conversation a few days later with the psychiatrist, who had prescribed him with antidepressant and a neuroleptic drugs and who had referred him for therapy with me, I learnt that Mr. P. had been suffering from paranoid delusions since the beginning of the year. He felt persecuted, thought he was under surveillance and had the idea that others were plotting against him.

Life history – Mr. P. was the first child of his parents. He had one sister who was seven years younger than him. The patient couldn’t remember having had any childhood illnesses. He seemed healthy and said he felt strong and physically fit. He had no problems at school, and passed the equivalent of A-levels with good grades. He said that in order to impress his paternal grandmother he had tried particularly hard in primary school as a little boy.

After A-levels he began his law studies. He then lived in a flat-share situation with a friend. For one year he had a girlfriend who was a student and the same age as himself. He had never been suicidal. He failed his first degree after which his psychological problems increased. He then moved back to live with his parents. At the beginning of therapy his aim was to re-sit his examinations.

Persecution Mania – In my next meeting with Mr. P he presented me with all his delusory ideas: he was convinced that he had done something for which he was going to be punished. He already felt persecuted via radio and TV. When I asked him what he had done he said that he didn’t know for sure, but his thoughts were that he had jumped the traffic lights on his bicycle and as a result had caused a traffic accident behind him. He was now mistrustful of all people, even his parents and his friends. They all probably judged him and disapproved of him. An escape from the situation was unlikely now and on the one hand he had better give himself up and confess his guilt. On the other hand, if he was not guilty he felt that a big injustice was being done in that even his intimate thoughts were observed by the people close to him, especially his family.

First attempts with constellations – When I asked him about traumatic events in his family the patient said that he did not know of any special occurrences in his family, apart from his aunt’s car accident. When I then took him to a constellation group for the first time, he set up his family in a way, that all representatives (father, mother, sister and himself) stood very close together. None of the representatives felt good. When I added a woman to the constellation, based on my hypothesis that there was someone missing in the system, she immediately fell to the ground, crying loudly. And all the other members of the family looked at her with deep sorrow but no one seemed to be able to make any movement towards her. The father’s representative, especially, was very affected by the strange woman but didn’t know what it meant. I broke off the constellation at this point. By the end of the day Mr. P. had developed increased paranoid hallucinations and I felt that I must give him an opportunity to talk about his thoughts and feelings to prevent a psychotic breakdown. After the workshop he still came to individual sessions, but the psychotherapy stagnated.

Family Secrets – The turning point in his therapy came after separately conducted interviews with the patient’s parents. Both father and mother singled out taboo events in each other’s families:

— The father remembered a serious car accident in the family of his wife. His mother in law’s first husband was hit by a car on the 31.12.1945 and died a few days later in hospital.

— The patient’s mother told me that her mother in law, the mother of her husband, had confided to her on her deathbed that she had had a love affair with the brother of her husband. Nine months later the first child, a daughter, was born. This daughter was possibly the child of the mother’s brother in law (the patient’s great-uncle) and not her husband’s. This child was the aunt of Mr. P. who had recently died in a car accident, and whose death had left Mr. P. feeling so insecure.

After further investigations with the mother my suspicion was confirmed that there were confusing, traumatic and schizophrenia inducing events in the families of origin of both parents:

a) Regarding the death of the patient’s maternal grandmother’s first husband: it became evident that the fatal accident caused by a car had not been pursued or cleared up either by the police or the courts of law. Apparently there had been witnesses who had declared the car driver at fault. Furthermore it seemed likely that the driver of the car that had killed this man was a highly regarded citizen of the town. As the grandmother’s first husband was a refugee, i.e. an outsider one can’t help thinking that, in view of the circumstances at the end of the war, the accident had been covered up in order to protect a local person of high standing.

The grandmother had come to this small town from Berlin together with her one-year–oldson in order to meet up with her husband who was returning from the war. After his death she remarried a local man and stayed in that town. She had another five children by him, the first of which was the patient’s mother. Something else that was striking in the mother’s system was the fact that the mother’s younger brother suddenly stopped working in his mid-thirties and went into early retirement for psychological reasons. His first name was the same as that of the grandmother’s first husband.

b) In the father’s family system there were confusing views regarding his mother’s sexual relationships. It became obvious that the father’s sister was always quarrelling with her mother and was reproaching her for something. It seemed that she was suspicious and insisting that her mother tell her, who her father was. But her mother always refused to be drawn. The patient’s father refused to believe that his sister could be the child of his uncle even after his wife had told him his mother’s deathbed confession.

Recurring unsavoury ‘dirty’ thoughts – In the following period the patient increasingly worked himself up into what he called his ‘recurring thoughts’. They centred on words and phrases which took hold of his mind and which he regarded as ‘bad’ and ‘dirty’, such as: ‘you dirty pig’, ‘atomic war’, ‘Aids’, ‘gassing of Jews’, ‘whore’, ‘scapegoat’, ‘child molester’. His condition deteriorated to such an extent that his father wanted to admit him into the clinic for further investigation. I managed to persuade the father to wait and see whether the coming to light of any family secrets would help towards improvement in his son’s condition.

Matters were compounded by the fact that the patient complained increasingly about being tired and that he slept a great deal. To try and re-sit his examinations under these conditions seemed increasingly hopeless. The patient became more and more inactive and put on a lot of weight. Whether or not the antidepressants contributed to his weight gain is hard to judge, but cannot be ruled out. To advise him to discontinue the medication would not have met with success, as he himself assumed an organic cause for his illness. To stop medication under these circumstances would probably have increased the likelihood of him being admitted to a psychiatric ward.

Setting up of the father’s family of origin – During an individual session I then let the patient set up himself and his father with cushions. In my individual therapeutic sessions the use of simple cushions as representatives of people and feelings has proved for me a very helpful method for working with the patients’ family system and corresponding feelings. Mr. P. put both cushions very close together. Father and son stood facing each other closely. When I stood in the place of the father, I had the spontaneous impulse to continually turn around in circles, with no sense of this movement ever ending.

In a subsequent family constellations group I suggested the patient set up himself and his father’s system based on his recurring thoughts. Immediately the representatives for the father, grandfather, grandmother, aunt and great-uncle were in a heated discussion, which the patient’s representative watched with great interest from the outside. This dispute could have gone on forever. I could not find any interventions which might point towards a good solution. I then sent the grandfather, grandmother, aunt and great-uncle out of the room, where they continued with their heated discussions. The father’s representative who remained did not feel any better, but his son looked at him and seemed a little more relaxed.

This constellation showed me that the patient was connected in his soul with the family secret in his father’s family and that the confusion and insecurity he feels are transferred from there. The amoral and especially sexual connotations in his recurring thoughts seemed to fit very well into the triangle-relation of grandmother-grandfather-great-uncle.

Work with the maternal family system – In the following individual sessions I concentrated on trying to better understand the patient’s entanglements in his mother’s system. He felt emotionally upset after talking to his mother about the fact that his grandmother’s first husband had died in a car accident. He also told me that his phobic thoughts about being criminally persecuted had begun on New Year’s Eve 1998, the anniversary of the car accident 23 years ago.

Together with Mr P. I tried to reconstruct the details of the accident and thereby made clear to him that his fears of being persecuted could have a parallel in the thoughts and feelings of the driver of the car who had caused the accident in which his grandmother’s first husband died. This man had neither faced his guilt nor his responsibility and was therefore bound to have lived in fear of being discovered and of being called to account for what he had done. I then let the client bow before the fate of his grandmother and her first husband as an attempt towards a solution to the entanglement of his soul in that trauma. This ritual had a very calming effect on the client.

Growing stabilisation – In the following weeks the patient’s revolving thoughts were getting less intense and he now was able to clearly identify these thoughts as alien to his ego - “I know that these thoughts are entirely irrational” - even though he kept insisting on having experienced thought transmissions (i.e. he predicted what someone was about to say or how he was going to react).

The war trauma – Further significant therapeutic progress was made with this patient when both parents agreed to take part in a family constellation seminar with me. Because of this upcoming event the mother had sounded out her relatives. She found out that her mother had been raped by a Russian soldier in Berlin at the end of the war. Unfortunately the father did not come to the second day of the constellation seminar. I therefore asked the mother to set up her current family (father, mother, patient/son, daughter) and to add the important people from her family of origin. This constellation clearly showed the trauma of the patient’s grandmother and how her daughter is still entangled with this trauma. Therefore I asked the patient’s mother to bow before the fate of her mother. and then asked her to stand in front of her mother facing her son saying to him: “I will protect you from what is behind me. You are free.” The representative of the patient felt good about that.

Finding inner peace – The patient himself was not present at the above mentioned seminar. He reported at our next meeting that his mother had told him about her constellation in great detail. But she had not mentioned to him what I considered to be the crucial part for the solution: her bowing before the fate of her mother, the patient’s grandmother. I therefore asked the patient to bow before two cushion representing the fate of his grandmother and mother. He did this with real seriousness and dignity.

He came to his next session having clearly changed. He said that he was much more confident and less tired. He had decided not to take his exams but to start an apprenticeship as a trader in a publishing company. And step by step he was then able to disentangle himself from the emotional confusions in the soul of his father and his mother which have so much undermined his own emotional stability and his ability to think clearly.

After three years of therapy his compulsive thoughts have not altogether disappeared and I think there is a slight risk that they remain in existence so long as the father shows no signs of contributing to the clearing up of the confusion and uncertainty resulting from his family system. He still refuses to believe in the confession his mother made on her deathbed. Accepting it as true, that his sister has a different father to himself would confront him with the possibility, that his sister’s car accident was connected with the conflict between her and her mother. It is known, that his sister parted in distress from her mother after a particularly bad argument and then soon after died in a car accident. The schizophrenic situation for his son, Mr. P, is that on the one hand he loves his father deeply and on the other hand he cannot really trust him.

It is clearly decisive in my opinion that a space is now created that allows the client insight into what has confused his soul. The injustice and rape in the family of origin of his mother are never going to be resolved or expiated. The confusion o f whether or not the aunt in the system of the father is the child of the grandfather or of the great uncle is also not going to be resolved. However, Mr. P. now has the possibility of making peace with the ghosts of the past in his mind. He can now look at the events in the family systems of his parents knowing that he is innocent and that he is neither accountable nor can he atone for the guilt of others, regardless of what really happened. He will no longer need to feel shame for what others have done.

Psychoses originates in bonding systems through family conscience – In my attempt to better understand the roots of psychotic symptoms the causes for mental confusions are not seen by me to lie in an illness of the brain, nor in a malfunction of perception, nor in information processing, nor in a disturbance of the development of the sexual or aggressive drives. The main factor in my opinion is the family of origin, where family members are intimately related and bonded together through their feelings and where they share something that we could call “a common soul”. John Bowlby had already pointed out 50 years ago the existence and enormous relevance of the human bonding system (Bowlby, 1980, 1995) Only now are his findings really being used to better explain psychic illnesses (Brisch, 1999). Through Bert Hellinger’s findings of the trans-generational effects of a family conscience (Hellinger, Weber & Beaumont, 1998) we have many more possibilities for understanding strange psychic symptoms and human behaviours as logical consequences of the interpersonal exchange of feelings and even thoughts in bonding systems.

Traumatic events transfix mental states – Interpersonal relations leave positive as well as negative emotional traces in the soul of family members. Traumatic events which cause the family to break apart leave all the members in a confused state of mind with no relief from feelings of anxiety, guilt and shame, as long as the confusing and destructive relationships remain and take effect. These feelings become more and more fixed the more one tries to repress them. They survive and can consequently take possession of those who come later.

Mental states taken over from others – Children and even grandchildren are receptive of and touched in their soul by repressed feelings and thought fragments of unresolved traumatic events from their parents and grandparents. They take them into their own psyche. Those feelings and thoughts which the parents have been unable to integrate are internalised by the children and grandchildren and felt in their souls as if they were their own. These feelings and thoughts become mixed up with their own experiences. Like a virus in software they occupy the “ego-program” of descendants once they are made vivid by a triggering event.

Interpretation of psychotic phenomena based on trauma theory – According to trauma theory (Fischer & Riedesser, 1999) one can look at psychoses as a bursting forth of the repressed memories of traumatising events in a family system. They are like nightmares, which do not torment those immediately concerned with the real events but rather those later generations when the psychological defence system has become more fragile, which allows repressed memories to intrude into the psyche of someone in a later generation.

Parallel events trigger the traumas – Psychoses often break out unexpectedly. We do not yet have any conclusive explanation for this. We may find certain clues if we look at psychoses as an event which takes place beyond consciousness on the level of the family soul. Psychoses break out when something repeats itself in a later generation which resembles the original confusing event. If someone finds themselves in a parallel situation reflecting the original event, thoughts and feelings from that event then infiltrate and confuse his thinking and feeling. Triggering events can be the death of a person, a separation from parents or lover, a love engagement, a wedding, the birth of a child or the anniversary of the original event.

Three-generational systems – A three-, sometimes four-generational sequence often occurs in relations to psychotic illnesses (grandparents-parents-children). The grandparents do something which creates a traumatic, confusing and schizophrenic situation in their family. The children suspect that something is the matter with their parents, but thinking or talking about the confusing events is kept as a taboo in order not to weaken the parents and endanger the continuity of the family system. If they did it would be too dangerous for everyone and the feelings of anxiety, grief, guilt and shame would grow out of control. A fog is therefore created in the family system around the traumatic events.

The children of these parents learn themselves to repress things perfectly. They have no idea that they are repressing anything and need to remain unaware of this in order to protect themselves and their parents. What remains is a nameless, incomprehensible yet deep-seated insecurity in the whole bonding system.

The insecurity encroaches on the children of the parents’ generation. That which is repressed, nebulous and taboo reaches the generation of the grandchildren as dissociated feelings and thoughts. This generation, unlike that of their parents does not even have an inkling that there are events in the family system that mustn’t be thought about.

The truth in hallucinations, paranoid delusions, and delusional systems – What we call hallucination is the certainty of a child in the next generation after the traumatic event that there is more in their field of perception than their parents would like them to believe. And equally that is their attempt to unearth something hidden. What we call a delusional system is the logical elaboration of their suspicion, that there is something wrong with the feelings in their family and hidden in the dark. The powerful force of these “dark secrets” (Bradshaw, 1995) is shaping their fate. If we bring the delusion down to earth the secret can be recognised as something human. The psychotic patient can be brought out of his delusion when that which has been kept in the dark across generations is allowed to be brought into the light

Interpersonal relations leave positive as well as negative emotional traces in the soul of family members. Traumatic events which cause the family to break apart leave all the members in a confused state of mind with no relief from feelings of anxiety, guilt and shame, as long as the confusing and destructive relationships remain and take effect. These feelings become more and more fixed the more one tries to repress them. They survive and can consequently take possession of those who come later.

From my experience with psychotic patients I can see two clusters of schizophrenic situations in families out of which psychoses develop over two, three or four generations. The first concerns children who are not allowed to know the identity of their father, the second concerns mysterious death in the family system.

Secrets about fathers – There are several causes that raise confusion about the real father of a child:

• Incestuous love affairs between fathers and daughters, brothers and sisters, uncles and nieces, a stepfather and a daughter of his wife,
• love affairs between a woman and a man before her marriage to another man,
• love affairs between a woman and another man although she is already married,
• love affairs between a man from high social class and a woman from a low one.
  (historically a marriage then seldom was accepted by the man’s parents)

Sometimes the woman is already pregnant by her lover. She then quickly marries another man and pretends to her unsuspecting husband that the child is his. As she has sexual relations with her husband, it isn’t outwardly obvious who the father of the child is. As a rule the woman knows. She, however, keeps it a secret and all the others who know keep quiet. Often her husband has his suspicions, perhaps the child doesn’t look anything like him - , but he isn’t keen to admitting this as he would then be seen to be cuckolded.

Sometimes the woman continues the relationship with the man she really loves and wants to marry after her marriage to her husband and then becomes pregnant by her lover. That may be made easier by prolonged absences of her husband, for instance, when he is away as soldier in a war. As she continues to have sexual relations with her husband when he is on leave from the front and her lover, only she knows who the father of the child is. In order not to threaten her marriage or her reputation she lies about the truth. If the truth was known it would threaten the cohesion of the family. The woman therefore must try to erase all trace. She can, for example, deflect attention away from her indiscretion through exaggerated piousness. Torn between her love for the father of the child and the pressure not to admit to it publicly, she tries to repress her loving feelings. She becomes hard and shut off and emotionally unavailable to her husband and her children.

Mysterious deaths or murders in the family system – A second category of family dynamics, which in my observation can lead to psychotic illness,, deals with mysterious deaths and sometimes even murder in the family system:

There are some specific scenarios that confuse feelings about dead family members:

• Uncertainty as to whether the death of a family member was an accident, a suicide or a murder or at least was supported by actions of other family members,
• Uncertainty as to whether parents did enough and fulfilled their responsibility in trying to save the life of a child who was ill or endangered.

It represents a particular burden for a family system if someone who belongs to that system has actively brought about the death of a person, within that family, for instance, if a man kills his first wife in order to marry his second wife. Abortions in a late state of pregnancy are also experienced like a murder.

In Germany, with a certain regularity we come across situations in constellations where grandchildren begin to shake as soon as their grandparents, who lived their lives during the Nazi-regime, are put up in a system. In such cases it can be assumed that the grandparents were deeply entangled with the Hitler-dictatorship , were, for example, members of the SS and took part in unjustifiable actions which the family conscience cannot tolerate and accept as actions of self-defence. They most probably have committed acts which, even under the circumstances of war with its altered moral values, must be looked upon as arbitrary murders, committed against totally innocent and defenceless people. Sometimes the children of these murderers protect their parents and there is a taboo against knowing which function the father really might have had in the party or the army. Often the parent’s generation deny murders that have been committed directly or indirectly, e.g. by judges, prosecutors, doctors or psychiatrists under the Hitler dictatorship. The grandchildren however still feel the threat emanating from a grandfather who was responsible for the deaths of many innocent people in his function as judge or district administrator. He remains frightening and causes panic in the soul of his descendants.

A big source of confusion in a family, also in the Nazi-context, is the fact that some people have betrayed Jewish relatives and so delivered them up to death in concentration camps. Here, too, only the revelation of the truth can help, if, for example, one of the grandchildren disappears into the darkness of a psychosis and behaves as if he too lives in a concentration camp like the victims of his grandfather or mother and as if he too is doomed to death like them.

A murder that is not cleared up and punished by the law may under some circumstances also have the consequence that a later born family member comes into contact with the trauma-feelings associated with this crime and unconsciously repeats a murder or a criminal act in his state of a psychosis.

Mania and Paranoia – The symptoms of “Mania” and “Paranoia” seem to be distributed distinctly over two basic patterns as follows: A manic compulsion to act or speak and to have many love affairs as symptoms of a psychosis points in my experience to suppressed feelings of great love in the family system. Whereas paranoid feelings of tremendous anxiety, guilt and shame are probably the symptomatic expression of denied guilt and responsibility for a death or even a murder in the bonding system of a family.

Sometimes the woman is already pregnant by her lover. She then quickly marries another man and pretends to her unsuspecting husband that the child is his. As she has sexual relations with her husband, it isn’t outwardly obvious who the father of the child is. As a rule the woman knows. She, however, keeps it a secret and all the others who know keep quiet. Often her husband has his suspicions, perhaps the child doesn’t look anything like him - , but he isn’t keen to admitting this as he would then be seen to be cuckolded.

Including the parents – From the above it follows that therapeutic work with psychotic patients cannot remain limited by focusing solely on the patients themselves or their physiology or neurology. The patients themselves are only the symptom bearers. Meaningful therapy must include their parents and all those who may be able to name the confusing and taboo-ridden events in the family system. The fact that one cannot bank on the cooperation of parents is clear from the context of the above mentioned case study. The parents, the patient and other relatives may prefer to hold onto their cover up or denied guilt, albeit unconscious, in order not to threaten their inner stability which is maintained with great difficulty. Psychiatric or medical explanations for the illness of their children, and purely medicinal treatments fit more comfortably with their wish for forgetting and denial.

Without the cooperation of the parents it is much harder to get to the root causes of the psychotic illness. Even if the parents, for their own psychological survival, have learned to repress completely what may be the cause of the psychosis in their children, one should, nevertheless, try and win them over to participate in the therapeutic process for their children’s sake. One has to admire all the more those parents who face the situation and the risk of a family constellation in order to help their psychotic child find a way out of his entanglement.

Including the siblings – If the patient has siblings, these, too, are as a rule, under the influence of the same family secrets. Often they are heavily burdened and show symptoms of psychosomatic illness. When the psychotic patient recovers there is a risk that one of his siblings may take over the role of bringing to light the confusion, injustice, guilt, shame etc. in the family soul. So it is important not only to treat the symptom bearer but also to look at the changes in the whole family system. Often it is the firstborn in the family who carries in his soul the dissociated energies of confused feelings in the system. Should it happen that the firstborn is released from his plight to, for example he has the wrong sex to repeat the original trauma, the second or third children are at risk of becoming psychotic and carrying in their soul the burden of the confusion.

The psychotic symptoms lead to the original confusing events – The psychotic symptoms are the trail, which a traumatic and confusing event leaves in a family system. When we follow this trail, refusing to be distracted by anything superficial, we reach the goal. The psychotic symptoms gives a clue to the family secret or taboo as at the same time it shields it from being discovered.

The role of family constellations – I do not think that without any knowledge of the confusing events mirrored in the psychosis, family constellations alone can help. However, family constellations can act as trigger progress in psychotherapy and so present a chance for secret events to come to light. But it does not make much sense to let the patients set up family constellations when the constellation-facilitator has little knowledge of the family history and has generally no idea what could possibly lead to psychotic breakdowns.

If in a constellation something strange is brought to the surface of consciousness for which there is no explanation in the family system, we have to leave it at that and hope that what has been brought to light will go on working in the patient’s soul towards a good resolution. I have quite often experienced that this is the case. Further speculations tend to increase the confusion rather than limit it.

Confronting the confusion – The understanding of psychoses presented here gives a plausible explanation for why these severe mental disturbances are so difficultto comprehend as meaningful psychic processes. It also demonstrates why the patients themselves cannot contribute to the uncovering of the cause of their illness and why they are at the mercy of the psychic confusion. It also becomes easier to understand why the parents are often faced with a complete riddle when their child suddenly, from one day to the next, becomes restless and develops psychotic symptoms.

With this insight into the real causes of psychotic symptoms the tendency of lay people as well as experts to suppose that the origin of psychoses lies in the patients themselves or in obvious external conditions like puberty or consummation of drugs and not in the wider family system becomes more understandable. Many members of medical and psycho-social professions seem to be allied with the taboo against recovering the memory of a trauma and exposing family secrets. Professional helpers are often reluctant to mention family details that can bring about enormous feelings of anxiety, guilt and shame and massive resistance in their clients.

The family dynamics of psychoses confront me as a psychotherapist with the limits of my competence. The feelings of bonding within a family system are at least as powerful as instincts and drives in the individual, as postulated by psycho-analytic theory. Sometimes a child will sacrifice his happiness and his life so that his family can continue to exist. Sometimes his parents sacrifice him as a compensation for their own guilt. Sometimes whole families will sacrifice themselves rather than face the truth or expose their secrets. In cases such as these we must withdraw and accept what is. For others who want to find a good resolution to the threatening past in the history of their family system we can be of help in ending the cancerous process of confusion.

If in a constellation something strange is brought to the surface of consciousness for which there is no explanation in the family system, we have to leave it at that and hope that what has been brought to light will go on working in the patient’s soul towards a good resolution. I have quite often experienced that this is the case. Further speculations tend to increase the confusion rather than limit it.

BREADSHAW, J. (1995). Family Secrets. What You Don’t Know Can Hurt You. New York: Bantam Books.

HELLINGER, B. (2001). Love’s Own Truths. London: Zeig, Tucker & Theisen.

HELLINGER, B., WEBER, G. & BEAUMONT, H. (1998). Love’s Hidden Symmetry. London: Zeig, Tucker & Theisen.

RUFER, M. (2001). "Psychopharmaka – fragwürdige Mittel zur Behandlung von fiktiven Störungen". In M. WOLLSCHLÄGER (ed.), Sozialpsychiatrie (S. 225-68). Tübingen: dgvt-Verlag.

RUPPERT, F. (2002). Verwirrte Seelen. Der verborgene Sinn von Psychosen. Grundzüge einer systemischen Psychotraumatologie. München: Kösel.

References