A systematic review and meta- synthesis exploring client experience of reflecting teams in clinical practice

There is a dearth of readily available evidence on the impact of reflecting teams in family therapy. A synthesis of the literature was needed to provide clarity and insight into client experience of the process. A systematic search of the reflecting team literature was conducted and 11 papers using qualitative methodologies were identified. The findings of these studies were synthesised using meta- ethnography. Three themes were identified; ‘unu-sual and strange’; ‘unique conversations’ and ‘therapeutic environment’. The reflecting team process was unanticipated and unique, but it could be helpful where people were made to feel safe and understood. Reflecting teams, while initially received as an odd and unusual experience, are typically found to be an effective and helpful approach within family and couples therapy. Extra considerations should be taken to ensure that clients feel able to engage with the process, avoiding it becoming overwhelming and unhelpful. Practitioner points


Rachael Harris and Jon Crossley
There is a dearth of readily available evidence on the impact of reflecting teams in family therapy. A synthesis of the literature was needed to provide clarity and insight into client experience of the process. A systematic search of the reflecting team literature was conducted and 11 papers using qualitative methodologies were identified. The findings of these studies were synthesised using meta-ethnography. Three themes were identified; 'unusual and strange'; 'unique conversations' and 'therapeutic environment'. The reflecting team process was unanticipated and unique, but it could be helpful where people were made to feel safe and understood. Reflecting teams, while initially received as an odd and unusual experience, are typically found to be an effective and helpful approach within family and couples therapy. Extra considerations should be taken to ensure that clients feel able to engage with the process, avoiding it becoming overwhelming and unhelpful.
Practitioner points • Higher levels of self-awareness and uncertainty are present for the family when first presented with the reflecting team. • A strong rapport with the lead therapist can support family engagement with the team. • Reflecting teams were experienced as more effective when they represent a diverse group of professional, ethnic and cultural backgrounds. • Hope and validation are vital parts of creating a therapeutic space which is effective in introducing difference to a family.

Background
The current study aimed to synthesise research pertaining to the use of reflecting teams from a client's perspective, to guide understanding of the value of this method in clinical settings. The Milan systemic school (Selvini Palazzoli et al., 1979) is credited as the 'first generation' of the reflecting team approach. Within this model, the 'identified therapist' conducted a session with clients while the team of therapists listened behind a one-way mirror. The identified therapist would leave and hold a reflective conversation with the team away from the therapy space. The therapist would then make a choice about which parts of this discussion to bring back to clients. Tom Andersen was reportedly uncomfortable with the lack of collaboration with clients within this process, and with the 'expert' position of the identified therapist and those on the team (Haley, 2002). By bringing the team conversation into the therapy space, the family could hear the ideas for themselves. These new ideas allowed a family to consider alternative perspectives, becoming open to a different way of being together (Andersen, 1987). This method is commonly known today as a 'reflecting team' (Andersen, 1991). Including clients in discussions that would have previously been conducted away from them allowed for increased collaboration between clients and therapists (Andersen, 2007;Haley, 2002).
Reflecting teams have been used in a variety of clinical settings including family therapy (Jenkins, 1996), couple therapy (Allan et al., 2019), physical health settings (West et al., 2015), learning disability services (Anslow, 2013) and addiction services (Garrido-Fernandez et al., 2017). Despite its widespread use in family therapy, there is limited literature regarding the reflecting team process (Willot et al., 2012). The literature available highlights that the impact on clients can be diverse. Kleist (1999) found that the reflecting team process could improve the therapeutic alliance, thereby expediting therapeutic outcomes. Brownlee et al. (2009), however, found that the team was not always considered a positive intervention, even though most clients appreciated aspects of the experience. Tseliou and colleagues (2020a, 2020b) conducted a meta-synthesis exploring the change process within systemic therapy. They found reflecting teams could be a hindrance due to them being an unfamiliar practice, but the team was considered a positive experience overall (Tseliou et al., 2020b).
Given the sparse and diverse literature available, it has been argued that further research is required to understand how reflecting teams work (Heatherington, Friedlander & Greenberg, 2005), across different client groups and methodologies (Kleist, 1999). To guide and inform this research effectively, reviews are needed to gather together and synthesise the disparate findings.
Previous literature reviews have offered a descriptive outline of the available research without a systematic search of the literature or critical analysis of the reviewed studies. This systematic review therefore synthesises and evaluates the recent qualitative research, to improve understanding of the client experience of the reflecting team process. This review focuses solely on research that has utilised a qualitative approach for two primary reasons. Firstly, drawing on a single methodology has provided greater consistency for analysing the data, allowing clearer and more coherent conclusions to be drawn. Secondly the underlying philosophies of constructionism and phenomenology within the reflecting team approach (Jenkins, 1996) lend themselves to exploration using qualitative data.

Search strategy
Initial scoping searches explored the literature available and aided the generation of relevant key words. PROSPERO was checked for any previously established reviews, but none was identified. The terms 'reflecting team' and 'reflecting process' were both used by Andersen when describing the approach (Roberts, 2009) and were therefore both included in the current review to capture as many relevant papers as possible.
Broader search terms were also used owing to the paucity of literature and to ensure all relevant research was captured within the current review. Dixon-Woods et al. (2006) suggest that broad search strategies can be beneficial when synthesising constructs to develop new meaning for the chosen review question. The search strategy is presented in Table 1. The databases PsychINFO, Web of Science, Medline and Scopus were searched using the keywords, as these represented a wide range of sources. A grey literature search using Google Scholar and hand searching of relevant articles did not elicit any further articles. These searches were completed between November 2019 and January 2020. Papers were screened by one author, but the process was supervised by and discussed with the second author.

Inclusion criteria
It was decided that searching for papers published within the last 20 years would elicit a suitable range of appropriate studies. Initial scoping searches found a comprehensive review completed by Kleist in 1999. It was therefore concluded that reviewing literature from the last 20 years would include as much research as possible, without duplicating previous work.
Client experience was framed as the perspective of a single service user, and/or their partner or family member. The reflecting team was operationalised as a team of therapists and/or healthcare staff who were witness to a therapy session and shared their reflections with either the therapist directly, or attendees and the therapist. They were either in the same room as the therapy session, or in a separate room but still experiencing the session live. This provided the scope for the widest possible range of iterations of the approach to be included.
Qualitative research was understood as any methodology that explored and analysed rich descriptive data. This might have been through retrospective accounts of client experience or via dialogue within session. It was decided that it would be helpful to draw within session and retrospective experience together despite their different epistemological positions, given the limited literature available and to gain the broadest possible understanding of the reflecting team process.
Further inclusion and exclusion criteria are outlined in Table 2. Figure 1 outlines the search process using a PRISMA flow diagram (Moher et al., 2009), and the list of reasons for exclusion. The remaining twelve papers were subject to a quality appraisal process.

Quality appraisal
Appraising the standard of diverse qualitative research necessitates a broad approach to fully evaluate the different ways that the range of methods were used. The framework by Caldwell et al. (2011) was understood to provide a suitable scope and was therefore drawn on and adapted to support the quality assessment of the remaining papers. Questions pertaining to qualitative research only were retained, and articles were rated according to whether they met the specified criteria. They were scored as either meeting the criteria entirely (rated 2), to some degree (rated 1), or not at all (rated 0). Any papers with a rating of 0 on any questions were excluded from the analysis ( Table 3). The total scores for each paper were used to assess each paper's contribution to the synthesis. Some studies lacked clarity regarding the methodology and details of data analysis, which were outlined as important quality markers in Caldwell et al.'s (2011) framework and received lower ratings accordingly. Lower scores for the conclusion were allocated where the descriptive details of the results were prioritised over a rich discussion of the implications, or where discussions of limitations or suggestions for future research were missing or vague. One paper was excluded from the analysis (Lever & Gmeiner, 2000) as it did not refer to ethical considerations in any capacity, which was one criterion within the framework. Two papers scored relatively lowly in comparison with the others (Egali et al., 2014a;Williams & Auburn, 2016). These scores were deemed to indicate a good enough standard to contribute to the synthesis but had less influence within the analysis.

Study characteristics
The results represent the views of more than 120 people. Reported ages of participants ranged from 2 to 66 years. Five studies reported the ethnicity of participants. All thirty-five participants whose ethnicity was reported were described as white British or Caucasian. The studies were carried out in traditionally Western settings, such as in the UK (n = 3), USA (n = 2), Canada (n = 4) and Australia (n = 2). All eleven studies were carried out in the context of community mental health care, including deaf services (Munro et al., 2008), Williams and Auburn (2016) 11 Is the context of the study outlined?  community learning disability services (Anslow, 2013), family and couple's counselling services (Egeli et al., 2014a(Egeli et al., , 2014b(Egeli et al., , 2014cMitchell et al., 2014;Parker & O'Reilly, 2013;Pender & Stinchfield, 2014;Williams & Auburn, 2016) and physical health settings (West et al., 2015). Seven of the eleven papers referred to members of the reflecting team who were currently in training (Allan et al., 2019;Egeli et al., 2014aEgeli et al., , 2014bEgeli et al., , 2014cMunro et al., 2008;Pender & Stinchfield, 2014;West et al., 2015). The characteristics of each study are outlined in Table 4. Eight papers focused on direct reports of client experience (Allan et al., 2019;Anslow, 2013;Egeli et al., 2014aEgeli et al., , 2014bEgeli et al., , 2014cMitchell et al., 2014;Munro et al., 2008;Pender & Stinchfield, 2014), and three focused on the interaction of both clients and therapists (Parker & O'Reilly, 2013;West et al., 2015;Williams & Auburn, 2016). Six participants' data were used across three studies (Egeli et al., 2014a(Egeli et al., , 2014b(Egeli et al., , 2014c. All but one of the studies collected their data through an interview process with participants. Williams and Auburn (2016) used conversation analysis of transcriptions of video-recorded family therapy to explore interactions between clients and therapists.

Meta-synthesis
A synthesis of qualitative data can provide explanations that might not be possible from individual studies (Paterson, 2012). Previous reviews have been aggregative in nature, and it was felt that an integrative synthesis could bring these experiences together to revise the current understanding of how reflecting teams may be optimally used.
Meta-ethnography (Noblit & Hare, 1988) translates the findings of each paper onto the others, generating overarching themes and concepts. Meta-ethnography allowed for these diverse papers to be drawn together and translated onto one another while also allowing for refutations across papers. The results section of each selected paper was subject to detailed coding, which led to descriptive themes representative of the initial paper. The primary focus of the analysis was on client quotations, but author interpretations were also considered, as these had been integral to the selection of the individual quotations. As each additional paper was analysed, further concepts were elicited and synthesised into overarching interpretative themes which went beyond the individual papers' analyses.

Summary of findings
Three core conceptual themes were identified: the perception of the reflecting team as 'unusual and strange', the 'unique conversations' experienced in therapy with a team and the recognition of the 'therapeutic environment' created through the use of the reflecting team.
Unusual and strange. Two subthemes were identified within this overarching narrative. The first related to feeling watched and becoming more self-aware when there was a team listening to the session. The second subtheme related to reflecting teams resonating differently with alternative approaches.
'Somebody watching you'. An uncomfortable feeling arose for some in relation to either the one-way mirror or the direct awareness of a team observing the session. Some clients reported that the unusual experience of a reflecting team was related to feeling exposed, on display to people they had not met before and were sharing intimate details with.
'I felt like a circus person, there were people just watching you. ' (13-year-old male client, Mitchell et al., 2014, p. 244) About a third of the papers identified that there was something uncomfortable in hearing the reflections, knowing that these were based on observations of the family discussions. There was a sense from participants that they were receiving comments on their personal lives and not able, at that point, to say anything.
'I think it was kind of uncomfortable with them on the other side when we were having our session. And Yes! Like an out of body experience, being on the other side. People talking like we weren't even there'. (Adult female client, Allan et al., 2019, p. 393) Despite a high level of self-awareness, people were able to engage in the session to some degree. As time passed in the initial session, participants felt that they were able to talk more freely and became immersed in the content of the meeting.
'Somebody's watching you and you know they're watching you, but you really don't see them, so you kind of forget they're watching you.' (Adult female client, Allan et al., 2019, p. 393) Resonating differently with alternative approaches. This subtheme reflects how different ways of using a reflecting team were experienced by clients. In most papers, the reflecting team was present in the room behind a one-

© 2021 The Authors. Journal of Family Therapy published by John Wiley & Sons Ltd on behalf of Association for Family Therapy and Systemic Practice in the UK.
way mirror listening to the session. In one paper, the team was silently listening while in the same room as the family (Anslow, 2013). Only one paper used a reflecting team whose reflections were only heard by the lead therapist (Parker & O'Reilly, 2013). Another paper compared both reflections being heard and not heard by those attending therapy (Mitchell et al., 2014).
Listening to the reflecting team directly gave families the opportunity to witness the ideas being generated and the consensus of that discussion, as long as they were able to focus on what was said. The amount of information generated was at times experienced as confusing and overwhelming when clients listened to the reflections directly. This was particularly pertinent where there were other distractions in the room. Mitchell et al., 2014, p. 249).

'I thought, "you know I don't remember half of that…" I was in the room; I was trying to keep the kids quiet so that I could hear what was going on' (Adult male client,
The presence of a one-way mirror particularly strengthened the perception that those in the therapy room were the ones in the spotlight and more exposed. 'It felt like "Bones"…they interrogate people and they sit in the other room and watch and they go "do this, do that, do that"' (12-year-old female client, Mitchell et al., 2014, p. 244) One paper suggested that the use of a therapeutic letter gave clients something tangible to take away with them to remind them of the conversations held in therapy.
'If it's in black and white then Jackie can keep reading it over and over again, and not look at the negative part so much […] because you have to look a bit harder for the positives'. (Adult female client, Mitchell et al., 2014, p. 249) 'Unique conversations'. This theme is represented by two subthemes, one which explores how talk is used to generate new ideas and meanings, and another which considers the impact of multiple perspectives in the therapy space.
Transforming talk. At times, the focus of team reflections was on certain individuals, and sometimes on specific parts or the whole of the family system. The authors of one paper suggested that clients noticed when reflecting teams privileged some elements of the therapeutic conversations but not others. For one participant who had a learning disability, this provided a voice and empowerment to their views, which had not been previously possible: 'there was one thing about getting my dad to treat me as an adult and let me make my own decisions because I'm old enough now…Felt right, it was.' (Adult female client, Anslow, 2013, p. 241) New perspectives offered by the team were generally well received as they allowed for new ideas to emerge and the process of looking for solutions to start.
'they kind of put it on the table and it was a different perspective to look at it from that side so we could kind of get the gist of how it was going so we could tweak it, which was nice'. (Adult female client, Allan et al., 2019, p. 390) Benefit and weight of multiple voices. Families found that having more professionals listening and thinking about them gave access to more ideas and potential solutions. These alternative ways of thinking were generally seen as beneficial. Multiple therapists sharing similar thoughts about a situation also helped to validate those perspectives.
'The more people working on certain problems, maybe a solution will come around easier…yeah, because they might have ideas that the two counsellors don't have, and I definitely don't have the answers'. (Adult male client, Pender & Stinchfield, 2014, p. 278) 'they were different ideas, some I'd agree with some I didn't agree with, sometimes they weren't perhaps the ideas that I would come up with but they were good ideas'. (Adult female client, Munro et al., 2008, p. 317) Participants were also aware of the different professional groups involved, including trainee and qualified therapists, psychologists, psychiatrists and nurses. This appeared to impact the credibility of the feedback and how it was interpreted by clients.
'I was probably going to take the most stock into what [the instructor] had to say. I remember thinking, here's the important one.' (Adult female client, Egeli et al., 2014c, p. 98) Participants reflected on considerations of people's age, gender, sexuality, culture and ethnicity on the reflecting team. Hearing from people with a different background to their own was validating for some but raised concerns for others about the ability of the team to appreciate what life might be like for those from another culture. 'To me it was really positive in the way I felt like they perceived our relationship. But it would be really interesting to see how it would be different if it was women of colour.' (Adult female client, Allan et al., 2019, p. 393) Therapeutic environment. This theme had two subthemes, one which described the atmosphere of safety created in therapy, and the other which represented the positive regard and hope offered by the team, beyond the conversations taking place.
Creating safety. This subtheme described the feeling in the room that allowed (or disallowed) the therapeutic conversations to take place. When clients felt safe, they were able to have more difficult conversations in therapy, which they might not have been able to have elsewhere. Uncertainty about the process resulted in one client feeling unable to respond to his partner.
'I started getting uncomfortable, […] Yeah, I'm trying to figure out the room. I was vulnerable. I needed somebody to lead me. I didn't know what to do so I ended up not doing anything. ' (Adult male client, Egalie et al., 2014b, p. 28) Clients that met the team before the session stated that seeing the faces of reflecting team members increased their ability to talk openly, and enhanced feelings of being part of a collaborative process. Feeling safe and being able to trust those on the team was an important part of being able to use the reflecting team.
'The first session was sort of strange, but once they introduced themselves and stuff it made it easier to talk freely and openly'. (Adult male client, Pender & Stinchfield, 2014, p. 278) There was an appreciation of the use of simple language delivered in a warm and understanding way. The team being professional, nonjudgmental and discreet reassured participants and helped them to continue with therapy using the reflecting team.  Munro et al., 2008, pp. 316) 'Reflection of Hope'. Participants appreciated the reflecting team's professional approach and the delivery of reflections which focused on personal strengths, positivity and validation. The professional attitude from the reflecting team and therapists, as well as feeling that the team were working collaboratively, helped participants feel hopeful for change.
'I think having that reflection of hope back at you. Especially, I think, if you're in a difficult relationship or having a difficult time, that would really bring out some positivity that a lot of couples would need'. (Adult female client, Allan et al., 2019, p. 389) Participants talked about the impact of a focus on their strengths as individuals, and within their relationships. This was more likely to be experienced as validating when the reflections were presented alongside comments that were normalising and demonstrated the team had understood the client's perspective.
'They seemed very careful not to form extreme conclusions about what they were seeing (…) if I had come in and people had been very cold and very well "why didn't you do it that way", you know I probably would have busted out crying.' (Adult female client, Pender & Stinchfield, 2014, p. 278) Participants within the studies by Egeli et al. (2014aEgeli et al. ( , 2014b identified how focusing on strengths could be invalidating, as clients typically come to therapy expecting to talk through certain difficulties. Some clients were concerned that the reflecting team had not fully heard or appreciated what they had brought to the session. 'I didn't feel like I was doing as much as she [the RT member] was giving me credit for. So in a sense there I [had] a bit of that vulnerability, because I saw her seeing me as higher up than I see myself. She saw me as doing more than I see myself doing and that kind of made me feel like maybe I'm not doing enough'. (Adult female client, Egali et al., 2014b, p. 31)

Discussion
This meta-synthesis of eleven papers resulted in three main themes relating to the 'unusual and strange' experience of reflecting teams, the 'unique conversations' held in the therapy space and the 'therapeutic environment' that was created by the therapist and the team.
The reflecting team was described as an unusual experience, and for some this resulted in feeling anxious or vulnerable. Tseliou et al. (2020b) suggested that the unfamiliar experience of the reflecting team can be a hindrance to the therapeutic process. Anxiety related to the use of a reflecting team, particularly with a one-way mirror, has previously been found to inhibit engagement in therapy (Young et al., 1997). Over time, this feeling faded and allowed for clients to experience a different way of communicating within their relationships. Andersen (1987) argued that by encouraging clients to hear 'unusual' ideas from the team, clients were able to move away from their 'usual' patterns of relating to each other to facilitate change, but if the experience was too unusual, it could cause clients to stop engaging with the process entirely (Andersen, 1991). This position was generally supported by the research within this review.
Clients who did not hear the reflections directly found it helpful as it gave them a break from the session while the team spoke to the lead therapist. Hearing a lot of information directly from the team was identified as confusing, due to the format and the amount of evidence generated. This is consistent with previous findings, that the reflecting team can be unhelpful if too much is shared (Griffith et al., 1992), or if there is information which does not feel relevant to the family (Lax, 1995).
Clients noted that their words and meanings were typically taken by the team and reflected back in a considered and thoughtful way. This privileged the view of certain family members and allowed distance from ongoing difficulties to create new ways of looking at them. Clients also appeared to appreciate multiple perspectives, either due to more people validating a single idea or the family hearing several different ideas to consider. Families have previously reported benefitting from hearing conflicting ideas from team members, which has allowed them to select the ideas which particularly resonate (Cox et al., 2003). Multiple ideas have been found to allow families to recognise that there can be various solutions (Smith et al., 1992). Family members' different ideas may cause conflict at times, but the therapist's role in both holding and moving forward different narratives has been found to be experienced as beneficial (Tseliou et al., 2020a).
Participants also found it helpful when the team comprised a diverse group of people in terms of professional background, age, gender and culture. Panya and Herlihy (2009) suggested that creating safety in the therapeutic space may be more important than matching the reflecting team to clients with respect to ethnic and cultural backgrounds. The findings from the current review highlight the importance of both safety and a representation of diversity on the reflecting team. Having a diverse group of people on the reflecting team potentially creates the context for a richer discussion between the multiple perspectives (Smith et al., 1993).
The findings from this review suggest that participants need to feel safe to talk openly, but the presence of the team might initially become a barrier. Cox et al. (2003) highlighted the potential for the reflecting team to create a supportive atmosphere where clients feel respected and understood. Not having an atmosphere of safety has been found to inhibit a client's desire to share their story (Lever & Gmeiner, 2000). The use of positive language and a collaborative stance, as well as reflecting hope towards the family, supported family members to feel more optimistic for changes in the future. Snyder et al. (2002) highlighted that change process research has identified hope as a common factor for change across various models of psychotherapy. Young et al. (1997) identified that a reflecting team reframing ideas as possibilities allowed family members to hear positive reflections, as well as suggestions for change. The findings from the current review advocate for the use of positive connotation when working as a reflecting team. A focus on clients' strengths is understood be validating and empowering (Smith et al., 1995). Caution is advised, however, as this review identified that it may also cause people to feel that their difficulties have not been well represented, or that there is not a full understanding of the issues brought to therapy. A both/and position is needed, of being responsive to the family's position including the challenges, and not focusing too much on problems which may risk the family losing hope (Lax, 1995).

Strengths and limitations
The current review brought together a range of qualitative studies examining the experience of using a reflecting team over the last 20 years. Data from three of the papers (Egeli et al., 2014a(Egeli et al., , 2014b(Egeli et al., , 2014c) came from the same study, but each paper emphasised a different focus. All papers represented a valuable element within the literature review, but their contribution to each theme was also considered carefully throughout in terms of the quality appraisal. It is difficult to use a singular framework to appraise such a variety of qualitative methodologies. However, it was understood that the quality appraisal used was sufficient to help distinguish between papers which were, and those which were not, of an acceptable quality.
The small number of studies which reported ethnicity identified representations from white, Western backgrounds. It would be beneficial for future research to address this lack of representation with inclusion of participants from wider social, cultural and ethnic backgrounds. It would be hard to separate the impact of the reflecting team process from other processes happening within the therapeutic space. Tseliou et al. (2020aTseliou et al. ( , 2020b identified themes similar to those of the current review within their examination of systemic therapy discourse, both with and without a reflecting team. These included the benefits of acknowledging multiple perspectives, of deconstruction and then reconstruction of new meanings, and of moving away from blaming narratives.

Implications
Therapy with a reflecting team can provide a context for new conversations and behaviours to occur. The current review suggests that this, at least in part, is due to multiple perspectives being shared in a safe environment. It is important to bear in mind how much information and how many perspectives are helpful for the family, as too much may be confusing or overwhelming. Reflecting teams may be experienced as more effective when the team is representative of a diverse group of professional, social, ethnic and cultural backgrounds. A feeling of safety needs to be created by the team for participants to engage. Hope, identification of strengths, and validation are all necessary parts of building and maintaining a therapeutic space which is effective in introducing difference.