The paper was written for the presentation at the HESTAFTA Symposium on: “Therapeutic Interventions with Families in Public Child and Adolescent Mental Health Services” at the 13__th Panhellenic Congress of Child and Adolescent Psychiatry, Athens, 3-5/11/23.
Abstract
Reflecting Teams (RT) are used in family therapy as a way of introducing multiple perspectives and providing feedback to the families. The reflections provided by the members of the reflecting team can have a positive influence on the family members as they go through the process of change. By promoting learning, self-reflection, collaborative problem solving, and interdisciplinary collaboration these groups contribute to the support, training and professional development of the therapists. The purpose of the current presentation is to further our understanding on the usefulness of reflecting groups in family therapy, suggesting that they can be beneficial to families as a means of effective therapeutic intervention and that they can also serve as a useful resource for the therapists’ professional development. The results are analyzed and the reflections on the limitations, benefits, and challenges, from the clinical experience of a reflective group within a community-based child and adolescent mental health setting (K.K.E.P.P.E. Nea Smyrni) in Greece, are also presented.
Introduction
Children and adolescents’ mental health community centers play a key role in providing mental health services to children, adolescents, and their families in Greece. Their contribution is particularly important given the prolonged and multi-factorial crisis, as well as the severe psychological consequences the Greek family has suffered over the last decade.
In these particular agencies, the operation of family clinics contributes to the support of the entire family, as well as the improvement of children’s and adolescents’ mental health. It is through challenges, mainly concerning the nature of the requests and the context in which the center operates, that the importance and the effectiveness of systemic therapy in the context of a community mental health agency for children and adolescents is highlighted.
In systemic family therapy, the reflecting team serves as a useful resource for therapists, by offering opportunities for continuous education, self-reflection and collaborative problem-solving. This paper aims to explore the role of family therapy, and understand the function of reflecting groups in enhancing therapeutic practice and improving therapeutic outcomes for children, adolescents and families within mental health community settings. Clinical examples will be utilised in order to present the positive outcomes and the challenges that the reflective process poses on therapists as well as the clients of the Mental Health Community Center in Nea Smirni (Athens).
Family Therapy in Community-based Mental Health Facilities for Children and Adolescents
As a consequence of the alternating consecutive crises during the past decade in Greece, there has been a significant increase in requests for mental health services for children and adolescents. Child and adolescent mental health centers - like other public services - face unique challenges in addressing the complex needs of children and their families, while remaining understaffed and underfunded.
It seems that the matrix of multipolar crises that the Greek society has been facing for more than a decade now - the most recent being the health crisis - has negatively impacted the everyday life of families, such as the habits of the family members, the nature and quality of their interactions as well as the family system’s ability to cope with stresses, leading to the destabilization of the family functioning.
A mental health community agency for children and adolescents, such as the Child and Adolescent’s Mental Health Community Center of Nea Smyrni, receives a plethora of requests and referrals from parents, community schools or other services (e.g. municipal social services, institutions, juvenile prosecution) on a daily basis. Empirically, most requests concern the diagnosis and therapy of complex difficulties that children and adolescents face, such as difficulties in social interactions, manifestations of delinquent behavior, internet addiction, alienation, conflictual intra-family relations and family breakdowns.
Children’s mental health is inextricably linked to their family’s environment, including the dynamics, the communication patterns and the relationships within the family system. Family therapy plays a critical role by providing comprehensive support and interventions for children and adolescents facing mental health challenges.
Unlike individual therapy, which focuses solely on the individual’s experiences, family therapy recognizes that a child’s mental health is influenced by their family environment, relations and communication patterns. By including the whole family in the therapeutic process, family therapy aims to foster greater levels of understanding, communication and cooperation between the family members, in order to support the child’s well-being.
The implementation of family therapy in mental health community centers for children and adolescents, stresses the importance of cooperation and holistic care. Family therapists work closely with their multidisciplinary team, which consists of child psychiatrists, speech therapists and occupational therapists, to ensure that the child’s treatment is comprehensive and holistic. This multidisciplinary approach allows for a more thorough assessment of the child’s needs, and also allows for a coordinated effort in addressing both individual and family concerns.
In addition, systemic family therapy with children and adolescents in a community setting often extends beyond the consulting room to include community agencies and services. Therapists may work with schools, social services, etc., to create a supporting network around the family and the child. This holistic approach recognizes that a child’s mental health is affected by multiple factors within their environment, and seeks to address these factors systemically.
In conclusion, systemic family therapy plays a vital role in mental health community centers for children and adolescents, by offering comprehensive support and interventions to children and adolescents facing mental health issues. Systemic family therapy promotes understanding, communication and resilience in families, children and adolescents by involving the entire family in the therapeutic process.
Understanding the Reflecting Team in Systemic Family Therapy
Since the late 1980s, the Reflecting Team (RT) has been used in family therapy as a way of introducing multiple perspectives and providing the “difference that will make a difference” in the family (Andersen, 1987). It consists of therapists who observe the therapeutic process and the dynamics in a family session, providing feedback and alternative perspectives to the primary therapists as well as the family members. Additionally, the reflecting team’s main purpose is to provide a second level of analysis through the reflective process, improve the therapeutic outcomes provided to families, promote professional development and enhance the therapists’ clinical skills.
In Andersen’s reflective group model, families are invited to construct their own meanings by listening to the different perspectives of the reflective group members. The discussions among members are based on their own observations of the family, offering tentative speculations on how family members relate to the problem, as well as internal sensations or images pertaining to the problem. The purpose of these discussions is to introduce new possibilities for the family and allow them to decide which one best fits their experiences. The “and/together” approach rather than the “or/alternatively” one allows for the coexistence of different perspectives between and among the group members (Andersen, 1987). The generation of multiple perspectives and responses to a problem is considered an integral part of this model, allowing clients to be present in the "doubt and ambiguity" within a group (Haley, 2002). Andersen reported that the facilitative conversations were those in which different versions or perspectives of the same problem could lead to a change in the family system.
The basic principle for the effectiveness of reflecting groups is based on Bateson’s (1972) idea of diversity. The different perspectives that family members have on life situations often cause disagreements within the family over which perspective is “right”. The discussions of a reflecting group create dilemmas and an imbalance to the notion of “universal truth”, while promoting the possibility of change and movement among the members of a family system (Roberts et al., 1999).
In the most basic form of the reflective process, Andersen (1987, 1991) brings the reflecting team, which is located behind the one-way mirror, into the therapy room, so that the family members can eventually see and hear the reflections. Specifically, the reflecting team observes the family therapy session behind a one-way mirror. The two groups (therapists/family and reflecting team), then switch positions so that the therapists and the family listen to the reflecting group’s discussion. These experiences last between 2 and 15 minutes (Andersen, 1987). Andersen (1987) suggested that the reflecting group’s comments should be assumptions rather than interpretations or announcements. After the reflecting team has completed its discussion, the family and therapists return to the therapy room to discuss the comments made by the reflecting team.
Reflecting teams can be implemented in different forms, each one offering benefits and improving therapeutic practice, depending on the nature of each family’s needs. Based on the review of the literature, the following main approaches are encountered:
a. “Live Observation and Feedback”. Team-members observe the family therapy sessions behind the one-way mirror. After the session, they provide direct feedback to the main therapists, highlighting dynamics and areas to be examined (Harris, et al., 2021).
b. “Reflection Process”. Members focus on what is happening in the therapeutic process rather than the case’s information. They discuss the key issues of the session, such as challenges, positive outcomes, the therapist’s style, biases, and countertransference reactions with the family members and the therapists (Andersen, 1987, 1991). This approach promotes self-awareness and continuous professional development for therapists.
c. “Case Consultation”. The reflecting team reviews case presentations or taped sessions. They then move on to structured discussions, through which they analyze the case, examine different cases and provide suggestions for therapeutic interventions or further exploration (McCollum, 1995; Lax, 1989).
d. “Supervision”. Reflecting teams can act as a form of supervision by providing support and guidance to less experienced therapists. In this particular approach, members can review specific cases, provide consultation, and support other therapists in handling complex therapeutic dynamics (Burck et al., 2019).
e. “Peers’ Supervision”. In this approach, reflecting teams consist of therapists of the same level of clinical experience - without including supervisors or more experienced therapists. Team-members meet in order to share their clinical experiences, seek help and learn through a collaborative and supportive system (Haggerty et al., 2011; Ziminski, 2019).
In conclusion, reflecting teams offer an important platform of support and a means of continuous education and professional development for family therapists. By adopting interdisciplinary collaboration, embracing different systemic perspectives and attempting to discover new meanings, reflecting teams can offer families high quality therapy. However, reflecting teams might present challenges relating to issues of confidentiality, group dynamics and planning, which require careful consideration and proper management. Overall, reflecting groups can serve as a foundation for effective and ethical family therapy practice, facilitating the development and transformation of families and therapists alike.
The Therapists’ Experience of Participating in A Reflective Team at the KO.KE.PSY.PE. of Nea Smyrni.
The family clinic was reopened in 2017 and included three trainees in family therapy under the supervision and coordination of a psychologist/systemic therapist.
From the initial phase of the reflecting team’s formation to the present day, several fermentations have taken place, which in turn have cultivated a culture of systemic thinking and reflection. The group consists of a number of basic elements such as complementarity, freedom of expression, co-evolution, contribution to the reflective process based on the individual identity of each therapist, and the undiminished interest of all in family therapy.
From our experience as therapists, our participation in the reflecting team has provided the following contributions:
a. Education and Professional Development
The enhancement of the therapeutic practice through continuous learning and professional development was considered to be one of the primary benefits of the reflecting team. By observing therapy sessions and participating in reflective discussions, therapists have the opportunity to obtain knowledge that is beneficial to their own practice, identify areas for professional development and learn from the clinical experiences of their colleagues (Landis & Young, 1994; Shurts et al., 2015). This reflective process fosters a culture of continuous improvement and ensures that therapists remain abreast of emerging research and optimal practice.
b. Self-reflection and Self-knowledge
Participation in a reflecting team provides a supportive environment for therapists to engage in self-reflection and increase the awareness of their own beliefs, biases and reactions during their therapy sessions. Through the process of receiving feedback and exploring alternative perspectives, therapists can gain deeper insights into their therapeutic style, interpersonal dynamics, and the impact of their interventions on families (Hillerbrand, 1989). This increased self-awareness is essential for protecting the therapeutic boundaries, managing countertransference reactions, and fostering positive therapeutic alliances with clients, particularly in the sensitive context of children’s and adolescents’ mental health.
c. Collaborative Problem Solving
The reflecting team facilitates collaborative problem solving and decision-making. The team can collectively develop strategies, address challenges and develop innovative approaches to effectively address complex clinical cases (Hoger et al., 1994). This collaborative process fosters a sense of companionship, cohesiveness and mutual support among the team members, which transfers into family therapy sessions ultimately benefiting the children, adolescents, and families assisted.
d. Improving the Quality of Treatment for Families, Adolescents and Children
It was noticed that the reflecting team contributed to positive changes in family functioning, communication and resilience of all family members, by improving the quality of treatment services, promoting evidence-based practice and addressing systemic factors that affect mental health. This leads to a lower financial burden on the Greek NHS and an increase in the number of people receiving therapeutic services from a community agency.
Families' Experiences of a Reflecting Group
Through clinical experience, it was observed that families may have different thoughts and perceptions about working with a reflecting team within a community health setting for children and adolescents. Initially, the reflective process is perceived by families as a strange and unusual experience, but they subsequently accept it as an effective and useful approach to treatment.
Reactions and perceptions may vary depending on the family, personal experiences, and expectations. Some common thoughts include:
· Privacy Concerns: Several families are concerned about the disclosure of sensitive issues discussed during treatment and about ensuring the privacy of the treatment process.
· Hopes for Improvement: Many families engage in the reflective process hoping to improve communication, relationships and their overall well-being.
· Concerns about Reflection: A number of families may fear that they will be criticized by the members of the reflecting group, or that the reflection will stir up painful emotions because of the reference to personal experiences.
· Hopes for Cooperation and Support: Other families are positively disposed towards the cooperation and support offered by the reflective process.
More specifically, the following points emerged, through reports on how parents, children and adolescents evaluate their cooperation with the center's reflecting team (benefits and limitations):
(the sense that someone is watching)
"The family clinic played, and still plays, an important role in the management of our family's minor difficulties... I felt like I was talking to the people present without being influenced by the "presence" of the people behind the mirror...And even if at times, after answering a question, I "thought" someone was watching me...I was still "relieved" by my answer".
mother, 39 years old
(concern over the evaluation)
"The conversation taking place in the room is quite comfortable and we usually get absorbed in it forgetting that there are other people behind the mirror assessing us".
father, 51 years old
(trust - objectivity - focus - cooperative problem solving)
"I feel quite good knowing that there is someone watching behind the mirror, as I believe that a third person is objective and can witness everyone's expressions and body movements, and can also grasp things that the people we talk to in the room cannot perceive"
mother, 42 years old
"I think the visit (to the family clinic) helps us a lot because it is a way of having unbiased and uninvolved experts (in front of and behind the mirror) listening to us and focusing on things that we, perhaps, do not pay much attention to. Overall, I think the reflecting team has been very helpful for us".
father, 48 years old
"I think the team is working well, everything they have suggested to work on as a family so far, has been of great help to us”.
mother, 43 years old
(ignorance)
“I haven’t thought about those behind the mirror, but I think they also express their opinion”.
adolescent, 13 years old
(a strange sensation_)_
"it's weird to have a strange lady behind the glass, and when I come here things get better"
boy, 7 years old
"I like that we try to solve our problems with the help of 3 other people and that we discuss with psychologists about how to improve our daily lives. I believe we are getting a bit better… (I like that there is a strange lady behind the mirror)".
girl, 10 years old
Overall, parents, children and adolescents outlined that their experience with the reflective process may have initially seemed like an unusual experience to them, and some members may have felt anxious - especially when using the one-way mirror. Later on, the negative feelings let up in favor of a different way of communication within the family and the creation of a therapeutic environment.
Possible obstacles…
Despite the benefits of reflecting groups in systemic family therapy, there is a number of potential obstacles that might arise in a community-based mental health setting for children and adolescents within the wider public sector.
a. In a number of instances, the cooperation and the presence of the members of a reflecting group are essential for results to be obtained. The obstacles that might arise relate to communication problems, absences, staff relocations, opinion discrepancies or conflicts. Any lack of cooperation between the team-members or between one member and the coordinator can serve as a disruptive factor for the reflective process.
b. The lack of adequate training and experience of the members in family therapy can also lead to serious dysfunction of the reflective process.
c. Setting up and running reflecting teams takes time, resources and energy. The underfunding and understaffing of the wider healthcare sector in Greece often leads to a general under-functioning of mental health services, which can constitute an obstacle to the proper functioning of the reflecting groups.
d. Managing a reflecting group can be a strenuous process for a mental health professional in the public mental health sector, who on top of his/her responsibilities has been assigned the role of the coordinator, as this requires handling difficult and sensitive issues such as conflict management, problem solving and time management. External supervision in the form of a formal and continuous training in systemic family therapy is not adequately supported in all public mental health settings in Greece.
Discussion
In conclusion, reflecting groups in family therapy within mental health community centers for children and adolescents serve as critical components of an integrated mental health care system for children, adolescents, and their families. By promoting continuous learning, self-reflection, collaborative problem-solving, and interdisciplinary cooperation, these groups enhance therapeutic practice and contribute to positive therapeutic outcomes. As the demand for child and adolescent mental health services continues to grow, the role of reflecting groups is increasingly essential in supporting therapists and improving the quality of care provided to families through mental health community settings.
However, reflecting groups pose a number of challenges that need to be addressed. One challenge concerns the management of the members' relationships within the reflecting groups. To mitigate this challenge, reflecting groups need to foster an environment of mutual respect, transparency and collaboration, where all group members feel valued and empowered to contribute with their knowledge. In addition, reflecting teams should encourage reflection and self-awareness among therapists, allowing them to acknowledge and challenge their own biases and assumptions. Furthermore, reflecting groups may face difficulties in scheduling meetings and coordinating the participation of multiple group members, especially within busy clinical settings.
Overall, the development and integration of reflecting groups into public mental health services requires dedication, professionalism and collaboration from the mental health professionals involved, if high quality services are to be provided in such mental health community centers for children and adolescents.
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