Creating space for reflection in dialogical family therapy: Exploring therapist practices and client responses in Reflecting Teams

The practice of reflecting teams, developed by Tom Andersen and first described in 1987, paved the way for a significant shift in family therapy practice. The choice to invite family members to observe the discussion between professionals symbolised a movement from observed to observing. This allowed family members to notice what resonated for them, and to decide what should be explored further. Beyond simply switching places, this approach also meant considering ways in which the family’s concern could be viewed from different perspectives and the voices of all in the meeting could be heard. Within the past 20 years innovative family and network-based models incorporating reflecting teams, such as Open Dialogue, have emerged showing great promise in crisis and severe mental health treatment settings. These collaborative and dialogical approaches have been appreciated by both professionals and family members, with largely naturalistic studies exploring alliance, helpfulness, and reductions in duration of untreated psychosis and ongoing disability. Despite growing literature in reflecting team and dialogical therapies, very few studies have focused on essential practice elements and psychotherapy process. This project aimed to explore processes in reflecting team dialogues from an intersubjective standpoint and to consider reflection as mutual transformation occurring between members of the network meeting.Study 1 is a qualitative study that explored the implementation of Open Dialogue into an Australian Child and Adolescent mental health service. Interpretative Phenomenological analysis (IPA) of 16 semi-structured interviews with professionals and family members was completed. Emergent themes indicated that staff appreciated authenticity and flexibility, and service users valued transparency and openness. One young person noted that the conversation between the reflecting team “made me think about it [what her mother had said] in another way, kind of..rethink what she meant” (see Chapter 3). Drawing on this reflecting process as a focus, this thesis sought to contribute to the understanding of how approaches with a reflecting team support both professionals and family members to reflect on the experiences of themselves and others. Study 2 explored the way in which dialogical therapists conceptualise and create reflective conversations in network meetings. This study involved interviews with twelve Open Dialogue therapists who were asked to describe the practices through which they facilitate relational reflection (Chapter 4). Using IPA again, themes centred on the value therapists placed on family members expertise, noticing their own responses in the meetings, and how they chose what to share in team reflections. They also noted relationally responsive practices, curiosity and the intention of opening space for further talk. This study offered insights into Open Dialogue therapists’ practices and experiences during reflecting team conversations. To understand further how reflective processes unfold between network meeting participants, gathering data ‘in-situ’ during reflecting team meetings was considered essential. Prior to collecting in-session data, methodological and theoretical aspects of psychotherapy process research relating to reflection required exploration.Study 3 involved a scoping review (Chapter 5) that critically reviewed the variety of constructs associated with reflection in psychotherapy process research. This review illuminated the differences between systemic understandings of reflective processes as intersubjective, and the more dominant individualist paradigm which emphasises reflection as an individual ability (e.g. mentalization, metacognition). Many of the studies reviewed did not report expected findings using individualist frameworks and critiques of client reflection as individualised were noted. Studies in this review that took an intersubjective or systemic lens tended to adopt qualitative or linguistic methods to capture reflective processes. In Study 4, theoretical aspects of understanding psychotherapy process as dialogical and interconnected were described (Chapter 6). The work of Henri Bergson, a philosopher of science who saw change as continuing interpenetrative moments rather than fixed states, was drawn upon to consider an appropriate theoretical perspective and methodology for observing reflection in psychotherapy process research.One of these methodologies is Systemic Functional Linguistics (SFL). SFL is a social semiotic theory of language that was chosen as the method for reviewing transcripts of reflecting team conversations in the final two studies. In study 5 (chapter 7) SFL was applied to transcripts from a 6-session family therapist reflective team supervision group involving six family therapists. SFL analysis of expressions from reflecting team members and supervisees found the use of epistemic modality and heterogloss supported a collaborative stance in the dialogue. Further, supervisees often responded by reflecting on their own position in relation to the problem and being curious about others’ positions. Study 6 developed and tested a refined SFL method to explore reflecting team dialogues and family members’ responses during Open Dialogue meetings. Ten families participated in this study with 14 hours of sessions time transcribed. SFL analysis was conducted on segments of text during and immediately following the team reflection. This study identified the use of physical, spatial, or landscape related metaphors for reflective or relational aspects of experience. For participants of reflecting teams, this appeared to support a fresh view on the problem and a sense of agency or power over it.While there are limitations to the qualitative, small sample size studies included in this process-oriented thesis, this work contributes to the literature on the dialogical and reflecting team therapies by providing insights into effectiveness, and an exploration of therapist practices and family member responses. These process- level insights may inform future outcome studies and training resources and provide support for professionals training in models such as Open Dialogue.