Co-therapy and reflecting teams in couples and family therapy: a mixed methods systematic review
We carried out a mixed methods systematic review of the effects and experiences of using two or more therapists in couples or family therapy.
Many couples and families need help from family counselling services to strengthen relationships, resolve conflicts and improve cooperation. The presence of more than one therapist in family and couples therapy is recommended in some cases, but there is a lack of knowledge about when and why more than one therapist should be used. We therefore carried out a mixed methods systematic review of the effects and experiences of using two or more therapists in couples or family therapy.
We carried out systematic searches in databases and for gray literature. We identified no studies of effect. We thematically synthesized 13 qualitative studies, five on co-therapy (participation of two therapists in the therapy) and eight on reflective teams (several therapists observe the therapy). We then assessed our confidence in the findings with the GRADE CERQual approach.
Co-therapy could contribute to personal and professional development for therapists, better care of the clients (especially in complex family cases and cases with children) and increased feelings of safety for therapists. A prerequisite for cooperation between therapists was having a safe relationship and respect for different professional points of view. It was advantageous to introduce the involved therapists to clients early in the process. The health system was often not set up to accommodate the use of two therapists on one case. We have moderate confidence in these findings.
Factors that could positively impact reflective teams were a positive focus on the therapy, an appropriate combination of therapists, feedback given in clear language, concrete advice and tools, as well as an early introduction of the team to the clients. It could be overwhelming to be met and observed by several therapists, while at the same time it could sharpen clients’ focus. We have low confidence in these findings, and they should be interpreted with caution.
Many couples and families need help and assistance from family counselling services to strengthen relationships, resolve conflicts and improve cooperation. Having more than one therapist is a recommended way of working in some cases. Therapy with the presence of several therapists can be carried out in different ways, either by two therapists working together (we refer to it as co-therapy) or by using a main therapist and a reflective team. There is a lack of knowledge about when and why more than one therapist should be used. The Norwegian Institute of Public Health (NIPH) was therefore commissioned in November 2021 by the Directorate for Children, Youth and Families to prepare a systematic review of the effects of and experiences with co-therapy and reflective teams in work with couples or family matters. The aim of this systematic review is to provide a base for further development on mediation in family counselling services.
We aimed to answer two research questions: 1) What are the effects of using co-therapy or reflective teams compared to one therapist in therapy/mediation with couples or families? and 2) What experiences do couples/families and therapists have with co-therapy or reflective teams in couples and family therapy?
We carried out a systematic review using the Norwegian Institute of Public Health's methods manual for systematic reviews and the Cochrane Handbook. To identify relevant studies, a librarian searched seven international literature databases. Furthermore, we did an extensive search of grey literature and checked reference lists of the included studies. We assessed the title, abstract and relevant full texts against the inclusion criteria. Next, we assessed the methodological limitations in the included studies using a design-specific checklist, and thematically synthesized the extracted data. Finally, we assessed our confidence in the findings using the GRADE CERQual approach. This assessment reflects our confidence in the likelihood that the review finding is a reasonable representation of the topic of interest. The assessment is based on four components: methodological limitations of the included studies, coherence, adequacy and the relevance of the included studies.
We identified no studies on the effects of co-therapy or reflective teams. We included 13 studies (described in 17 publications), published between 2001-2021, that explored therapists' and clients' experiences of co-therapy or reflective teams. Five studies explored co-therapy and eight studies explored reflective teams. The studies were carried out in Norway, Sweden, the USA, Great Britain, Australia, Canada and Hong Kong.
Main findings from the synthesis of studies exploring co-therapy
Some therapists experienced that co-therapy could contribute to personal and professional development. A prerequisite for good cooperation between therapists was having a safe relationship and respect for different professional points of view. Factors that could negatively impact this cooperation were very different professional points of view, different levels of experience, a lack of communication and interaction, and competition to be the most competent therapist. Some therapists found it advantageous to introduce the involved therapists to clients early in the process, because it could be difficult to become involved later and build relationships with the clients. Several therapists felt that co-therapy could contribute to better safeguarding of all family members, including children. This particularly applied in cases with many children, children with large age differences and more complex family cases, because it was easier to maintain focus and overview. In some situations, therapists felt it was safer to have two therapists due to safety concerns (threatening behaviour from clients, fear of violence, etc.). Several therapists found that the system was not set up to use two therapists on a case, often there were no therapists available, and they had to have strong professional arguments to obtain approval of co-therapy.
We have moderate confidence in the findings about co-therapy. This means that we think it is likely that the review finding is a reasonable representation of the topic of interest.
Main findings from the synthesis of studies exploring reflective teams
Many clients valued the positive focus of the therapists' feedback, use of clear language and concrete advice and tools on how to deal with the problems and the client’s own feelings. However, some clients highlighted that the reflective team process made them feel uncomfortable and more self-conscious. At the same time, being observed by a team could sharpen the clients’ focus and make them more aware of their own behaviour and use of words. Some clients felt that it was important to be introduced to the team, preferably early in the process. Some clients felt they lacked people in the team who could identify with their situation, especially regarding gender, ethnicity and sexual orientation.
We have low confidence in the findings about reflective teams. This means that we think it is possible that the review finding is a reasonable representation of the phenomenon of interest. These findings should therefore be interpreted with caution.
The results from this systematic review provide a description of experiences and perspectives on co-therapy, which are most likely transferable to a Norwegian context. However, we have low or very low confidence in the findings about reflective teams. This means that we believe that it is possible or unclear whether the findings are a reasonable representation of the topic of interest. The comparability to a Norwegian context for many of the studies is uncertain. This is because many of the studies had several methodological limitations and the setting and form of therapy appeared to be different from Norwegian family counselling services. Different ways of conducting therapy, cultural perspectives as well as norms and values can have influenced the participants’ experiences and the topics they choose to address in an interview.
In some cases, it was challenging to assess the studies' relevance, because some studies had unclear descriptions of setting, form of therapy and populations. If it did not appear in the title or abstract that there was more than one therapist present, the study was excluded. This may have contributed to us missing studies that some would consider relevant to the research question. Regarding experiences with co-therapy, there was only one study that dealt with the clients' own experiences, and we cannot say much about how co-therapy is experienced from the clients' perspective. How it is experienced by the therapists does not necessarily reflect what the clients experience.
The lack of studies that investigate effect was a prominent finding of this review. We identified no studies comparing co-therapy or reflective teams with the use of a single therapist in family or couples’ therapy. Our findings also indicate that few studies explore co-therapy in couples or family therapy. For reflective teams, we identified more studies, that mainly interviewed the clients. Even though co-therapy and reflective teams share the use of more than one therapist, the results are not directly comparable, given that there are large differences in their execution.
We identified no studies about the effect of co-therapy or reflective teams compared to the use of one therapist, and therefore cannot answer the research question about the effect of these forms of therapy. We identified some qualitative research that explored clients’ and therapists’ experiences with co-therapy and reflective teams in couples and family counselling. These studies indicate that co-therapy and reflective teams may have several advantages for therapists and clients, but some findings are uncertain. For organizations that consider offering therapy with two or more therapists there is limited conclusive evidence to rely on, but existing studies indicate that co-therapy and reflective teams have advantages for therapists and clients. It would be useful with studies that investigate the effect of using several therapists and clients’ and therapists’ experiences with co-therapy and reflective teams.