reflecting team processes in family therapy

Reflecting team processes in family therapy: a searchfor research

Sara Willotta, Terry Hattonb and Jan Oyebodec

Tom Andersen’s Reflecting Team approach is widely (and creatively)employed in family therapy. Despite continuing enthusiasm for the practice,however, there are few journal articles reporting empirical research andonly one (now dated) review of the literature. After defining reflecting teamprocesses through practices that are embedded in particular approaches toknowledge construction and theoretical interpretation, we offer an over-view of the empirical research found in our search of the literature. In thesecond half of this article we ask why there is so little existing research in thisarea. Various possible explanations are explored and future directionsproposed. We conclude that a dialogue around the complex interweavingof practice, theory and research (that is, praxis) would be a helpful overallstance to adopt in relation to future work in this area.

Keywords: reflecting; team; research.

Following the introduction of this approach in the late 1980s,reflecting team processes (RTPs) have had a profound effect on familytherapy (Perlesz et al., 1994; White, 1995). Hoffman (2007), forexample, refers to ‘the reflecting team’ and ‘witnessing’ (a practiceinherent in reflecting team working) as two of the three pillars ofwisdom that have guided her work. A recent survey of 130 systemicpractitioners in the UK found that 92 per cent of respondents usedteamwork for around a third of their therapy time, with RTPs beingthe most commonly used approach (Thorn, 2008). Despite continuedenthusiasm for the practice, however, there are few journal articles

Journal of Family Therapy (2010) ]]]: 1–24doi: 10.1111/j.1467-6427.2010.00511.x

Address for correspondence: Sara Willott, Primary Care Psychology and Family Therapyservice, 208 Monyhull Hall Road, Kings Norton, Birmingham, B30 3QJ. E-mail: [email protected]

a Clinical Psychologist working in a primary care psychology and family therapy serviceand a community mental health team. Birmingham and Solihull Mental Health FoundationTrust.

b Systemic Psychotherapist and Clinical Psychologist in a primary care psychology andfamily therapy service. Birmingham and Solihull Mental Health Foundation Trust.

c Consultant Clinical Psychologist, Older People’s Directorate, Birmingham andSolihull Mental Health Foundation Trust Course Director, Birmingham University.

r 2010 The Authors. Journal compilation r 2010 The Association for Family Therapy and SystemicPractice. Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 MainStreet, Malden, MA 02148, USA.

(2012) 34: 180–203

reporting empirical research (Moon et al., 1990; Smith, et al., 1994)and only one review of the literature by Kleist (1999).

After outlining what is unique about RTP in terms of approach to theconstruction of knowledge, theory and ethics, we offer an overview ofexisting research. Exploring why there is so little empirical work led usto propose several hypotheses in an effort to explain this relative lack.Despite framing this exploration around initiatives that are geographi-cally based in the UK (such as National Institute of Clinical Excellence[NICE]1 benchmarks for what constitutes gold standard research), wewould argue that the issues raised have wider relevance. Finally andbased on this exploration, we will propose some future directions forresearch into reflecting process practices in and outside teams.

Andersen’s RTP approach

Tom Andersen was a Norwegian family therapist who (alongsidecolleagues) introduced the reflecting team approach (1987), laterreferred to as ‘reflecting processes’ (1995) and ‘reflecting conversations’(Anderson and Hoffman, 2007). Hoffman (2007) noted that it wasGoolishian’s suggestion before he died that Andersen broaden the termout into phrases such as ‘reflecting conversations’ or ‘processes’ in orderto emancipate the approach from reification into a technique. Giventhat in this field, underlying approach, theory and practice are seen asinterwoven, we begin with an overview of the approach in relation totheory and technique before turning our attention to research.

From constructivism to social constructionism

Andersen tended to avoid situating himself squarely within particularapproaches to knowledge construction or aligning himself with onetheory over another. Others however, have traced the seminal influ-ences behind his RT conception to both second-order cybernetics(machine-like feedback systems) and constructivism (Hoger et al.,1994a) or social constructionism (Carr, 2000). Despite a commonrejection of positivism however, the differences between constructi-vism and social constructionism have important implications for re-flecting team processes in family therapy (Hoffman, 1990a). WhenAndersen first published work on RTs in the late 1980s, he drew

1 A UK Department of Health body whose aim is to recommend best practice based on allthe empirical evidence available.

2 Sara Willott et al.


A search for research in refl ecting team processes 181

heavily upon the work of theorists whom others (e.g. Hoffman, 1988)have labelled key influences in the emergence of second-ordercybernetics and constructivism. His later writing in the 1990s, how-ever, appears to demonstrate a growing interest in social construction-ism as well as acknowledging other, less tangible influences such asbody processes and ethics. As an example of how a new method,technique or approach can ripple out into changes in the other twoareas, Burnham (1992) discusses the way in which the RT methodcontextually influenced techniques as well as them having implica-tions for the therapeutic approach. It is possible therefore, that thissubsequent shift in approach resulted from the employment of RTs inpractice. We will also be arguing below that Andersen’s increasingemployment of social constructionist and critical practices corre-sponded with the prevailing zeitgeist in academic humanities and socialsciences, illustrated by a turn to language in the 1980s.

Andersen (1987) pointed to Bateson and Maturana’s conceptsaround multiple perspectives, ‘systems’ and ‘difference’ as theoreticaljustifications in the first article outlining the RT approach. Theprevailing positivist-realist view (Simon, 1992) in first-order familytherapy had been that we can have direct access to a world out there,the simplest causal explanations are preferred and the subjectivity orpower status of the therapist is irrelevant. By contrast, constructivistssuch as Bateson and Maturana argued that the world we perceive isuniquely different to the one anyone else experiences because ourintra-personal perceptual equipment means that we filter informationin a lens-like fashion. Bateson (1972) argued for multiple perspectives(reflected in Maturana’s ‘multiverse’) and questioned the degree towhich the observer could be objectively separate from the observed(Inger, 1993). Bateson reworked the original first-order cyberneticmetaphor of rigid systems and circular causality, to argue thatindividuals were situated in a relational context within which theproblems they presented were maintained. As a corollary, Maturuna’sradical constructivist concept that living systems were self-creating,circular and structurally determined from within (i.e., autopoietic),meant that a family therapist could not simply instruct a client systemto change from the outside (Maturana and Varela, 1980). In contrast,a family therapist should respect the way in which the system hasconstructed itself, interact with the system for a while (structuralcoupling), perturb it and wait for those in the system to decide what (ifany) changes they would like to make. The image of ‘perturbation’ issimilar to Bateson’s earlier ideas on the ‘difference that makes a

A search for research in reflecting team processes 3



difference’ (1972). Andersen translated this as meaning that the mosthelpful kind of difference for a stuck system is one that is large enoughto be noticed and yet not so big as to risk being ignored as alien orpotentially explosive. A key theme running through Andersen’s workis that sharing different versions of the world can result in a shiftwithin the other (system). The family therapy team in Milan drewheavily upon Bateson in their 1970s systemic practice, arguablyproviding a springboard for much of Andersen’s RTwork.

Andersen (perhaps using Bateson’s ideas as a catalyst) made increas-ing reference to social constructionist concepts and theories in the1990s. For constructivists, ‘reality’ is constructed in the mind. Con-structivism appears to assume (albeit implicitly) the existence of anontologically real world out there, even though we do not have accessto it. In contrast, social constructionists argue that social factors outsidethe mind provide resources for the construction of reality alongside theways in which all individuals reposition themselves in relation to thosesocial constraints. Gergen (1985), for example, argues that we constructand renegotiate our identity through language and other socialresources. Presumably Andersen (at least by 1992) considered theconstraints on a family system to be less tightly bound than they areperceived as being in a constructivist approach (see Simon, 1992), withwider cultural-linguistic factors playing a larger part than they werepreviously credited with. Influential in this dialogue were the post-Milan theorists and practitioners (e.g., Cecchin, 1992; Hoffman, 1993;Tomm, 1993) and other social constructionists such as Anderson andGoolishian (1992). According to Andersen (1992), Anderson andGoolishian brought these ideas into the clinical arena. By 1992,Andersen was also acknowledging the influence of narrative ideas inthe social construction of self and these concepts became evident in hiswriting on RTs (e.g. Moran et al., 1995). Over the last decade or so socialconstructionist ideas such as narrative have increasingly informedcontemporary family therapy practice (e.g. Anderson and Goolishian,1992; Carr, 2009a; Lax, 1995; Reed, 1993) as interest in postmodernideas and critical psychology have gained some purchase across thesocial scientific and psychotherapeutic communities.

Theoretically driven practices

Adopting a constructivist and then a social constructionist approachhave been integral in the development of practice as RTPs have beenshaped and reshaped over the last twenty years. If we look at theories




around the development of problems as well as theories aroundchange, the social constructionist assumptions that language is centraland there is no single unified truth have increasingly underpinnedpractice. Families2 are invited to attend RTP family therapy whenrelationship difficulties have resulted in a stand still (Andersen, 1990)or stuck (Lax, 1995) system. Arguably, getting stuck results fromfamily members viewing ‘the problem’ from a single perspective‘reality’ for long enough to dig themselves into a metaphorical grooveor rut. After digging for a while, all that can be seen are the bottomand sides of the groove (often relayed verbally to others as a problem-saturated narrative, to adopt narrative therapy language). The thera-pist who joins the family system adopts a not-knowing and curiousposition (Anderson and Goolishian, 1988) in order to explore thegroove alongside the family before opening up new ways of looking atthe issue. Reflecting teams are in a unique position to offer multipleperspectives, with different team members adopting different positionson the issue. This is a tangible demonstration of the polyvocality(multiple voices) (Gergen, 1999) inherent in social constructionism.Polyvocality is a technique that some other family therapy approaches(e.g. Cade, 1980) draw upon. What the RTP approach offers inaddition, however, is that the team reflect in front of the family, sothat the family witness the different perspectives at firsthand, ratherthan have the different voices relayed to them via the interviewtherapist. Accessible polyvocality is more than a useful technique tobe employed in particular situations: it is central to the whole approach.

Another way in which this practice of reflecting in front of thefamily is underpinned by social constructionist and critical ideas is thatunhelpful power relations can be undermined. This is done through (1) theco-construction of meanings (Anderson and Goolishian), with bothinterview therapist and family having access to a shared resource inthe reflecting team system, (2) demystifying a reflecting process thatusually takes place behind closed doors (Andersen, 1987; Hoffman,1990b; Miller and Lax, 1988; Singh, 1996; Smith et al., 1993) and (3)shifting the focus of the therapy session ‘gaze’ temporarily from theclient onto the RT, thus alleviating the clients’ feelings of being underconstant scrutiny. It is hoped that this also allows the family to step

2 We are defining family as any group of people in sustained relationship (e.g. Asen,2002). Another definition that resonates with our position is one used by the Association forFamily Therapy and Systemic Practice (2007) that a family is ‘any group of people who definethemselves as such, who care about and care for each other’.




back and see the groove rather than be in it. Once the groove ispictured as only one reality among other possible positions, theopportunity for second-order change is more available.

It is beyond the remit of this article to detail the family therapymodelsand practices that provided a springboard for the slowly emergingdecision to reflect in front of the family. Nor do we have the space to tracethe historical changes in the approach used by Andersen and hiscolleagues over the last two decades. This has been covered comprehen-sively by other authors (e.g. Haley, 2002; Hoffman, 1988, Lax, 1989;Mittelmeier and Friedman, 1991; Reed, 1993). Neither do we intend todetail the various and creative ways in which RTPs are currentlyemployed; again, this has been covered elsewhere (e.g. Anderson andJensen, 2007; Burnham, 1992; Jenkins, 1996; Reed, 1993).

What we do want to talk about now is research: what is out therecurrently, the relationship between research and theoretical approachand the implications of this relationship for practice. Once we excludeunpublished dissertations, non English-language papers and empiri-cal studies that do not directly and formally research RTPs, there are(to our knowledge) only two outcome studies, one survey and half adozen articles on RTPs. The latter is dominated by a single group ofresearchers publishing from the early-1990s to the mid-1990s. We willmake passing reference to the excluded studies only where relevant.The focus of this overview will examine the two outcome and sixempirical articles published that directly explore RTPs.

Existing research into RTPs

There is a growing body of evidence that systemic interventions areeffective for a wide range of mental health difficulties for both adultsand children (see recent reviews by Carr, 2009a, b). The only review ofresearch into RTPs to our knowledge however was published in 1999by Kleist. He offers a comprehensive list of each piece of researchpublished from 1992 to 1996, presented in date order. The moreconceptually based overview below refers to all the articles listed byKleist (apart from one examining the acquisition of skills in students).

Outcome studies

Griffith et al. (1992) carried out a small, partially controlled study withtwelve client families presenting with somatic symptoms; a client groupcommonly assumed to be less suitable for RTP work (Hoger et al.,




1994a). Using Structural Analysis of Social Behavior (SASB; a micro-analytic technique for examining complex social communications) theyfound that, following an RTapproach, clients communicated with moretrust, nurturance and interdependence and talked less in ways thatblamed, belittled, controlled and monitored other family members.

Hoger et al. (1994a) report on the results of two exploratory studiescarried out between 1987 and 1991 in Germany and Austria, selectingspecific symptoms and global relief as measures of effectiveness.Similar to other outcome studies in marital and family therapy (seereview by Gurman et al., 1986) two-thirds of these clients reportedsymptom improvement and around 80 per cent reported overallglobal satisfaction.

Other empirical work into efficacy that is either not published inEnglish (Hoger et al., 1994b) or not published in peer-reviewed journals(e.g. Rasmus, 2003; Stough, 2000) appears to be less encouraging.These studies do not support the contention that RTPs are a moreefficacious way of working with families in comparison with otherapproaches to family therapy, although McGovern (1996) found a slighttrend towards the effectiveness of RTs over strategic team models.

In an informal evaluation carried out by White (1995) into a narra-tive version of RTs (developed shortly after Andersen’s and labelled as‘definitional ceremonies’), clients estimated that they were equivalentto 4.7 sessions of ‘good therapy’. Before turning to ways in which RTsmight enable change, we briefly outline a study that indicates whichprocesses are being employed by clinicians.

A survey of practice

Using the Delphi technique (a questionnaire-based method of collect-ing information from a wide panel of ‘experts’), Jenkins (1996)carried out an international survey to ascertain which theoreticalconcepts and practical strategies were endorsed and employed bytwenty-one knowledgeable RT therapists. Of the techniques andinterventions endorsed, only 20 per cent were deemed to be suffi-ciently consensual by Jenkins to be included in the final profile. Mostof the theoretical assumptions and practices revolved around the twobroad assumptions that

1. Identity is socially constructed; there is not one single truth orperspective.

2. Unhelpful differences in power should be undermined.




There was recognition that, as long as techniques did not jar withthese assumptions, there was a lot of space for creativity. Additionalaspects of practice and principle that could not be easily predictedfrom these two broad theoretical premises but which achieved con-sensus were as follows:

1. shifting between talking and listening positions2. adopting a curious and neutral rather than a directive or inter-

pretive stance3. creating a process that invites and encourages self-reflection for

therapists4. ensuring that reflections are different, but not too different, from

the existing client position.5. ensuring that reflections are limited to less than 10 minutes.

Although multiple perspectives are helpful, too much talk mayoverload the family.

That the RTapproach is perceived to be a philosophy more than amethod could explain the relative lack of agreed techniques. Jenkinsdoes not, however, offer the reader any indication of the terrain of the80 per cent of practices or techniques that were not included in thefinal profile. He notes that there is a risk that the panel may not havebeen representative and we have no idea, despite their apparentpopularity, what proportion of family therapists actually employ RTprocesses (cf. Thorn, 2008).

Process studies

The half-dozen empirical articles reporting interview-based andlargely qualitative research by Smith and colleagues explicitly exploreonly the broad assumption around multiple perspectives and theprinciple of shifting between talking and listening positions fromJenkin’s survey outlined above.

Multiple perspectives: but how many is too many?. As noted above, offeringmultiple perspectives is a fundamental practice based on the socialconstructionist approach that there is no single truth or reality(Andersen, 1987, 1995; Mittelmeier and Friedman, 1991). In a seriesof qualitative, interview-based studies, Smith and colleagues com-bined aspects of ethnography and grounded theory to explore the RTexperiences of both clients and therapists. The first study wasanalysed thematically and written up as two articles; one describing




the clients’ experience and the other looking at the therapists’experience. They found that clients valued being offered more thanone credible explanation for the same event, particularly when thesediffered (Smith et al., 1993; see also Hoger et al., 1994a; Lytton, 1998;Sells et al., 1994). Likewise, therapists concluded that multiple realitieswere helpful to clients and that disagreement was positive, althoughchallenging and intense, for the interview therapist in particular(Smith et al., 1992). This particular finding about RTs is reflected ina study carried out by O’Connor et al. (2004) exploring the value ofnarrative therapy.Both clients and therapists in Smith et al. (1992) also noted,

however, that too much feedback or comments unrelated to thepreceding therapeutic conversation were unhelpful, as these steeredclients toward chaos rather than weighing alternatives around parti-cular dilemmas or events. This resonates with the final principle listedabove from Jenkins’s survey, as well as recommendations in theliterature on reducing the number of unrelated possibilities andincreasing meaning coherence (e.g. Andersen, 1987; Miller andLax, 1988; Perlesz et al., 1994). To this end, therapists in Smith et al.(1992) argued that it was useful when the interview therapist broughtreflections together after the team had left.

The ‘fly-on-the-wall’ experience. Jenkins describes a process of shiftingbetween talking and listening positions that involves the interviewtherapist-plus-client-family system pausing in their dialogue to listento the RT system. A conversational pause is crucial in order to reflecton process (Andersen, 1990). Whether this is accomplished by one-way mirrors or seating positions in the same therapy room, thesystems are separated from each other in space as well as in dialogue.The one system should not interrupt the other once it is their turn totake centre stage. The gaze shifts from one system to the other andback again once the RT has finished their discussion. According toethnographic, content-analytic research carried out by Smith et al.(1994), this ‘eavesdropping’ (Hoffman, 1990b) or ‘fly-on-the-wall’experience (Prest et al., 1990) promotes a meta level (second-order)reflection that, in turn, encourages clients to hear the multipleperspectives offered. The shift in gaze means that a response is notimmediately expected; the process is slowed down and clients canmentally step back. Clients also say that the spatial separationbetween the systems enables them to hear problems differently (Sellset al., 1994).




Differences in client and therapist experiences. In addition to practicesemployed by RT therapists, Smith and colleagues explored differ-ences in client and therapist experiences (Sells et al., 1994; Smith et al.,1995). Sells et al. found that clients were concerned with issues such asspatial proximity between themselves and therapists and with hearingproblems differently. Therapists, on the other hand, were morefocused on effectiveness and the different uses of RTs. Taking upthe last point, therapists assumed that a team was helpful only whenthe family were experiencing a major problem, such as therapeuticimpasse or a conflict between family members. Although this reso-nates with recommendations in the literature (e.g. Miller and Lax,1988), this view was not supported by the clients. The clients reportedthat the times when the RT was generally less effective were in theearly stages of therapy, as they built rapport with their interviewtherapist. In their most recent article, Smith and colleagues examinedclient and therapist dialogue in detail before, during and afterreflections. Using Interpersonal Process Recall, Smith et al. (1995)found that client and therapist experiences, not surprisingly, differedin all three phases, with couples focusing on process before reflectionsand therapists on expectations. During the reflections, the couplesfocused on the impact and the therapists on purpose. After them, theclients concentrated on value and the therapists on impact. They alsofound that the context prior to reflections was important in setting thestage, in order for the clients to be in a position to listen, and featuressuch as trusting the interview therapist and collaboration were seen tobe crucial.

Implications of these research findings for practice. Assuming that problemsarise for families in part because they are stuck in the view that there isonly one way to look at an issue, these studies imply that thehelpfulness of the RT revolves around offering families the opportu-nity to move away from this position. The research outlined abovesuggests specifically that teams should ideally select a limited numberof ideas central to the conversation they have just heard and interactwith each other in such a way that different positions on this smallnumber of issues are openly but respectfully talked about (Haley,2002). Hearing others talk about the groove you inhabit currentlyalongside other potential positions, when you are hovering above theconversation rather than being in the conversation, offers a uniquevantage point to see the groove as a position rather than the position.Coherence can then be maintained by the interview therapist once the




gaze switches back to the family-plus-interview therapist. Undermin-ing unhelpful power relations (by demystifying the process, therapistcuriosity and client choice from the ‘smorgasbord of ideas’ (Haley,2002, p.31) available presumably oils this process as it loosens up thepositions available to adopt. The use of RTPs offers an opportunity todeconstruct and question oppressive power relations while maintain-ing a curiosity about the multiverse of diverse positions inhabited byvarious family members in the context of that family. Much has alsobeen written about the usefulness of this approach for training others(e.g. Lebensohn-Chialvo et al., 2000), possibly serving as a furtherjustification for the resource rich expense of a team.

Why so little research? Exploring the issues

Interesting though these findings are, they constitute a very smallresearch base from which we can reflect on practice. In our explora-tion of why there is so little research, we start by asking whether this isa problem faced by all areas of psychotherapy. Then we turn ourattention to models underpinned by constructivist and particularlysocial constructionist approaches. Finally, we look at whether newtheoretical directions in the RTP literature offer further clues aboutwhat is arguably an increasing gap between theoretical approach andresearch.

Rhetoric and best practice: exploring why is there so little research. Training isprobably the most productive period of time for most psychothera-pists in terms of research. The numbers who continue to carry outresearch or even publish their doctoral theses is low, however,(Cooper and Turpin, 2007; Thomas et al., 2002). Within this generallack of research activity, some psychotherapeutic models are less wellresearched than others. To our knowledge there are no controlledoutcome studies of constructivist or social constructionist approachesto family therapy (Carr, 2000; cf. Jones and Asen, 2000 outlinedbelow). One contributory factor for this may be the nature of thecriteria used by NICE to judge the quality of research evidence. BothUK and USA health policy promote discourse on evidence-basedpractice (e.g. Carr, 2009a), which is reflected in clinical guidancethrough organizations such as NICE (2004).To relate this to the articles reviewed earlier, the two outcome

studies support the contention that RTPs as a practice are at least as




effective as other family therapy methods. However, given (1) thesmall sample sizes in both, (2) the lack of experimental control (e.g. nocontrol groups or psychometric testing of measures, [Hoger et al.,1994a]) and (3) problems with generalizability and comparison(Griffith et al., 1992), neither of the outcome studies would rate highlyusing NICE criteria. It could be argued, with some justification, thatthese findings do not provide firm support for a team approach over alone therapist. NICE criteria are ostensibly based on conventionalbenchmarks employed in reductionist and positivist methodologies(Carr, 2009a; Moon et al., 1990), however. These privilege a rando-mized controlled trial (RCT) design (Dixon-Woods et al., 2006) andmay therefore encourage a research–practice gap in family therapy(Sexton et al., 2008). Furthermore, it could be argued that theresearch questions about process asked in social constructionistapproaches to family therapy map even less neatly onto the qualitycriteria of quantitative research that are recognized by NICE (seeStratton, 2007 for a historical overview).

Where is research in the future of RTP literature?. An edited book (Ander-son and Jensen, 2007) show-cased recent thinking and developmentsin the field. One interesting direction that practice has taken is theincreasing acknowledgement of embodiment in therapeutic pro-cesses. It could be argued that this was an implicit feature of theapproach from the start, given the importance accorded to spatialseparation as well as Andersen’s claim that Gudrun Øvreberg and herteacher Aadel Bulow-Hansen brought theory alive through their workaround breathing and muscles (Andersen, 1990). It is only fairlyrecently, however, that embodiment has become explicitly discussedin the field. Shotter in particular (2005, see also Shotter and Katz,2007) has introduced the concept of ‘embodied knowing’ into thediscussion about RTPs. Acknowledging an indebtedness to Bateson’s‘creatura’, with its emphasis on non-verbal language (1972), Shottertalks about the importance of relational and dialogical communicationthat is not necessarily reliant on spoken language. In possibly the lastpublished words of Andersen (2007), he talked about the distinctionbetween verbal and non-verbal communication as spurious. As notedin the introduction to this article and evidenced by the numerouscontributions to the recent book on RTPs, enthusiasm for anddiscussion over these processes is demonstrably alive and strong.That there is virtually no reference to research in a book that outlinescurrent thinking and future directions, however, is worthy of com-




ment. This lack is particularly surprising, given the small amount of(now dated) empirical research available. While we celebrate theexplicit inclusion of embodiment (as well as other exciting ideas,such as Bakhtin’s concept of dialogical versus monological relatinginto everyday clinical practice), we wonder whether this move mightfurther explain the lack of research in this area, given that mostexisting research methods would find it a challenge to capture suchcomplex, contextualized and nuanced practices. Andersen increas-ingly positioned himself on the margins (Roberts, 2008) in order thatclient voices could take centre stage. It could be that although this‘innovative edge’ (Anderson and Hoffman, 2007, p.572) offers a fineperspective outside the norm, it places the field further from recog-nized research bench-marks.

Future directions (and harnessing the innovations)

Dialogues not monologues: is this a case of the frog slowly boiling in a lab containeror studying the cracks?. We are suggesting here that the Bakhtinianconcept of dialogical versus monological (Shotter, 1992; Willott, 1998)interchange (translated by Shotter, 2004) into the more everydaypsychotherapeutic practices of ‘withness’ versus ‘aboutness’ ways ofrelating could usefully be bought to bear in the discussion of thecentral question posed in this article.There are a number of wider questions that are we feel are relevant

to the specific enquiry we focus on in this article over why there is solittle research into RTPs. These include:

1. Why is there such a gap between the rhetoric around research-practitioners and resources allocated to support research forqualified psychotherapists?

2. Is psychotherapy training sufficient to equip newly qualifiedpractitioners to carry out independent research without furthersupport, such as mentoring schemes (Thomas et al., 2002)?

3. Is there a mismatch between existing research methods and(much) clinical practice (Dallos and Smith, 2008)?

4. Is the distinction between outcome and process spurious (Ander-sen, 1990) and possibly unhelpful (Burck, 2005)?

Despite the relevance of these background questions, we do not havethe space to discuss them here. Rather, we will focus more narrowlyon questions around particular approaches to knowledge and power.




Reflecting on why there is so little dialogue about the question of research in thisarea. First, dialogue can be side-stepped by those defining the norm.One notable example is the London Depression Intervention Trial, aproject designed to compare the effectiveness of antidepressants,individual cognitive-behavioural therapy (CBT) and systemic coupletherapy (Jones and Asen, 2000). The attrition rate of participantsallocated to the CBToption was such that this therapeutic model wasexcluded from the trial. What is particularly interesting, however, isthat an article published about the trial makes only passing referenceto deleting the CBToption because of the high drop-out rate (Leff etal., 2000); leaving little opportunity for dialogue. Alongside a discus-sion over why couple therapy was preferred by these participants,exploring why CBTwas even less acceptable than medication wouldhave been interesting. Secondly, given the relationship betweenknowledge and power, we wonder if a concern has built up amongpsychotherapists around whether such dialogue might be used bythose outside the psychotherapeutic community to undermine theprofessional and academic standing of psychotherapists. Thirdly, itcould be argued from the section above summarizing future direc-tions in the RTP literature, that there is an implicit idea that researchis unnecessary in the advancement of best practice; perhaps focusinginstead on the ‘artist practitioner’.

The multiverse of alternatives can be explored and negotiated once dialoguesaround these issues are entered into more widely. Alternatives include carry-ing out more RCTs, a discussion of value-based practice, valuingeffectiveness alongside efficacy, a common factors approach andjuxtaposing the artist practitioner alongside the scientist practitioner.If we were to reduce the practice-research gap by carrying out moreRCTs then a manualized approach might be useful for social con-structionist versions of family therapy (Carr, 2009b). Where this hasbeen attempted (e.g. the London Depression Trial [Pote et al., 2003]) itwould be interesting to discuss how such an enterprise fits with a socialconstructionist epistemology and ontology and the extent to whichclinical practice that is underpinned by non-positivist approaches canor should employ yardsticks that stem from a positivist perspective.If we distinguished between effectiveness and efficacy more clearly

and valued effectiveness (Seligman, 1995) more highly this mightundermine the privilege accorded to NICE criteria (which revolvesaround efficacy). NICE gold standards rest on efficacy but do notnecessarily tell practitioners what is most effective in the naturalistic




context of therapeutic practice. Addressing the increasing research–practice gap, Sexton et al. (2008) argue for a levels of evidenceapproach; from broad levels that have a bias toward efficacy to themore specific and nuanced methods for collecting evidence (such ascase studies) which tell practitioners more about effectiveness in messytherapeutic contexts. This attempt at a both/and perspective mighthave the potential to challenge the acceptance of RCTs as the goldstandard by which all other types of evidence are judged (and foundwanting) and lead practitioners to search for and use researchevidence already out there that adopts alternative criteria (Stratton,2007).A common factors approach (Norcross and Goldfried, 2005) ad-

vocates moving away from the comparison of different modelsaltogether in order to address the question; which practices (such astherapeutic alliance), rather than which models, are most useful. Thisendeavour is not only a helpful avenue for psychotherapy practice butserves to undermine the privilege of certain epistemological positions.Despite key areas of overlapping interest (such as therapeutic alliance)however, we wonder whether it would be premature to consider apan-theoretical integration for the RTP approach currently.Unless we discuss these issues openly, however, new initiatives led

by those already defining the norms may increasingly dictate practiceand continue to marginalize fine-grained, process-oriented qualitativeresearch. Just like a frog in water brought slowly to the boil, there is adanger that this insidious state of affairs might increasingly becomethe unnoticed backdrop to practice. Where there is hegemony,however, there are always points of resistance to witness (Foucault,1980) and Leonard Cohen reminds us lyrically that the light gets inthrough the cracks.

Shifting the goal posts: how can we study the frog in the pond?. We are notarguing here that outcome research under controlled conditions isnever useful or that qualitative research is synonymous either withexploring process or with one particular approach to knowledgeconstruction. Most research into RTPs has been qualitative in analytictechnique, however, and the underlying approach is social construc-tionist or at least postmodern (Hoffman, 2007). Given this, there is astrong argument to be made that the degree to which you can trustthe findings should be judged according to a different (albeit over-lapping) set of criteria from those that NICE and similar non-UKorganizations use to advocate best practice. This is an area of




continuing debate and many would argue that a definitive set ofcriteria is not only impossible (for quantitative as well as qualitativeresearch) but conflicts with an innovative and an anti-reductionistapproach (e.g. Parker, 2004). Elliott et al. (1999) therefore prefer thephrase ‘evolving guidelines’, which serves to promote dialogue ratherthan to present criteria as if they were set in stone.That there exist over one hundred quality checklists reflects the

proliferation of qualitative research over the last decade (Dixon-Woods et al., 2006). On one end of a continuum are those authorswho consider that traditional expectations of reliability and validityapplied to quantitative research should be the yardstick by which allempirical work is judged (e.g. Lincoln and Guba, 1985; Strauss andCorbin, 1990). According to Dixon-Woods et al. (2004), others adopt arelativist stance and claim that these criteria bear only some or norelation to qualitative research. Harre (2004) turns the debate aroundand argues that qualitative research is more scientific than quantitativeresearch (see also Harding, 1992), given that human beings arereflexive and their behaviour is meaningful and contextually specific.To fail to account for these components, he notes, undermines theveracity of our conclusions. Assuming that all research is inevitablysubjective and that meanings are socially constructed rather thanfixed, Parker (2004) formulated alternative criteria to judge thequality of research: (1) new research questions should be groundedin existing research and psychological theories where possible, (2) acoherent linear argument should be constructed unless there is a clearrationale for stepping outside that genre and (3) the work should be asaccessible as possible to the chosen audience.Using Seligman’s distinction and Parker’s criteria, the outcome

studies of RTPs by Smith and colleagues cited above provide soundpreliminary evidence for the effectiveness of clinical practice. Dialo-gue about what counts as good quality empirical work may encourageresearch into RTPs.

Specific research avenues for future research. Based on the overview ofempirical research outlined above, we have spotted several new areasof potential research that are either explicitly talked about by theauthors of existing research or represent avenues that we havewondered about, based on our reading.First, Smith and colleagues found some interesting differences

between client and therapist experiences. It is educational, althoughhardly surprising, to find that clients and therapists focus on different




aspects of the process at different points in the session. That clientsand therapists disagree as to when RTPs are most useful was lesspredictable, however. This finding runs counter to therapists’ assump-tions (Jenkins, 1996) as well as advice in the literature, and is worthyof further empirical examination.Second, there is some evidence (Smith et al., 1995) that the relation-

ship with, and context provided by, the interview therapist seems to bea significant factor in increasing the likelihood of clients being in aposition to take in the reflections offered by the team. In an earlierarticle, Smith et al. (1992) concluded that reflecting teams did notwork when a rapport was not established (see also Kleist, 1999; Sells etal., 1994). It seems possible that having an audience for the initialconsultation(s) may interfere with therapeutic alliance-building be-tween the interview therapist and family members. The epistemolo-gical shift toward embracing multiple realities can be difficult forclients to grasp, given that they may arrive with an expectation of whattherapy is, based on media constructions or their previous experienceof healthcare professionals; hoping perhaps for a unified piece of‘expert’ advice (cf. Silver, 1991). The gap between what is offered andwhat clients expect may be too large (or too unusual) to make sense.Being watched by three relatively faceless’practitioners for aroundtwo-thirds of the session, all of whommay well be perceived as expertsdespite any attempt to tackle disparities of power (Young et al., 1997),could well be overwhelming or intimidating (Smith et al., 1993).Young et al. raise some interesting questions on the degree to whichclient families (as well as new trainees) are aware of this unequalrelastionship but feel unable to voice their fears over unequal powerrelationships when faced with the RT approach. Young et al. call forformal research to be carried out into these questions. We couldexplore, for example, ways in which the interview therapistintroduces RTPs, as well as comparing the experiences of familieswho establish a therapeutic alliance with a primary therapist beforeworking with a team, as opposed to those who work with a teamthroughout.Third, asking research questions about the possibly taken-for-

granted and therefore less visible processes used by practitioners(see Jenkins, 1996) that have not yet received any research attentionshould be interesting. These include; (1) the extent to which practi-tioners adopt a Milan-derived ‘curious and neutral’ stance, and (2)whether engaging in RTPs increases self-reflection in team members.If RTPs are embedded in social constructionism then we might




expect, for example, that the more experience therapists have withthe process (as opposed to the technique), the more they will endorsea social constructionist approach. Further questions are (3) what itmeans to employ appropriately unusual reflections, and (4) examin-ing the guidelines suggested by Andersen around grounding reflec-tions within what is said in the room.Finally, if practitioners are beginning to incorporate embodied

knowing into their work, we need to develop ways of researchingthis that go beyond the linguistic analytic techniques currently avail-able. This is particularly so for clients who struggle to expressthemselves using verbal language (e.g. Booth and Booth, 1996).There are some innovative methods that have been developed toexplore visual data empirically (e.g. Gleeson et al., 2005). Perhaps alsothe social poetic methods described by Riessman (1993) wouldcapture Andersen’s social ‘poetic moments’ in dialogical exchanges(Shotter and Katz, 1998) and the ‘dance motions’ in withness practices(Shotter and Katz, 2007).3

Conclusion

The RTP approach is based in particular approaches to knowledgeconstruction. Like any theoretical practice, however, it is subject todynamic shifts and transformations. Existing outcome research ispromising but sparse and tends not to meet the quality criteria forbest clinical practice laid down by those who commission services.Qualitative research into processes supports the social constructionistidea around multiple perspectives as well as the way in which a shift ingaze or talking and listening positions promotes second-order change.Process research is, therefore, helpful but quite dated, as well as beingrelatively thin on the ground and leaving other questions (such asexplorations of power) in need of much more attention.

Empirical research into RTPs supports the often-cited observationthat research in family therapy tends to lag behind theory, enthusiasmand practice (Green and Herget, 1989; Jenkins, 1996; Lask, 1987;Nichols, 1984; Sells et al., 1994). The RTP approach, in particular, isincreasingly at odds with official yardsticks in evaluating best practice.This was never an easy relationship, given the mismatch between the

3 Any emerging methods would, however, need to distinguish those expressions that arebeyond or before language from those that are part of a participant’s inner dialogue andtherefore not available for analysis (see also Fredman et al., 2007).




underlying approaches of each. New theoretical directions in theRTPs literature, however, risks creating an even wider gap. ExtendingBurnham’s discussion around approach-method-technique, we arearguing that best practice also includes research (i.e. praxis). Praxisadvocates interweaving theory, research and action/practice (e.g.Stanley, 1990, cf. Lang et al., 1990). This both/and approach shouldavoid an overemphasis on either technique (e.g., Hoffman, 1993;Perlesz et al., 1994) or on theory and approach (Reed, 1993). Weargue that research potentially serves to increase dialogue betweenapproach, theory and practice. In addition, it could bridge the gapbetween interesting innovations in the field and clinical guidance overbest practice.

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