Journal of Psychiatric and Mental Health Nursing, 2010, 17, 583–593

Using systemic reflective practice to treat couples

and families with alcohol problems jpm_1574 583..593

B . F LY N N r g n r m n d i p c p n d i p a c c m a
Specialist Nurse Therapist, Couple/Family Therapy team coordinator, UKCP Registered Systemic Psychotherapist,
Nursing Council on Alcohol committee member, Member of the Association for Family Therapy, Kent and
Medway Community Alcohol Service, Mt Zeehan Unit, St Martins Hospital, Canterbury, UK

Keywords: alcohol treatment, couple Accessible summary

and family therapy, nursing practice,
reflective practice, systemic • Alcohol services in the UK generally treat clients from an individual medical and
psychiatric perspective. Carers, partners, children and other family members are
Correspondence:
infrequently actively involved in the clients’ care process.
B. Flynn
Kent and Medway Community Alcohol • A reflective family-based approach was introduced in an attempt to improve treat-
Service
ment engagement with drinkers with relatives. Favourable findings from several
Mt Zeehan Unit self-reporting research and evaluation studies are provided and analysed.
St Martins Hospital • The use of this intervention was found to be effective in facilitating change in
Littlebourne Road drinking and relationships. Family members when involved in the care management
Canterbury proved to be influential in the behaviour change process.
Kent • Family group reflecting interventions should be used more extensively and involve-
CT1 1TD ment of partners and family members in care programmes should be promoted.
England Implications for the extended use of the intervention both in addiction settings and
UK wider health and social care practice are discussed.
E-mail: brendan.flynn@nhs.net;
bssrflynn@aol.com
Abstract
Accepted for publication: 5 March 2010
In the UK, an adult with a drinking problem is generally treated from an individual
doi: 10.1111/j.1365-2850.2010.01574.x perspective with minimal involvement of carers and relatives. In response to this gap in
service provision, a systemic reflecting intervention was introduced to assist couples
and families experiencing alcohol-related difficulties. The article documents the back-
ground and development of this initiative. Findings from evaluation and clinical
outcome studies are reviewed and demonstrate how the use of the approach proved to
be effective in facilitating positive change both in drinking and family behaviour. In
conclusion, the paper explores the implications of how systemic reflective practice with
family groups may be extended and be usefully used in wider addiction, diverse mental
and general health-care settings.

attention to the needs of children and families of drinkers

Introduction
Before the introduction of a interrelational systemic reflec-
tive modality, treatment options available to couples and
families with an adult member drinking excessively in the
UK were fragmented, highly specialized and difficult to
access (Orford & Velleman 2003), leaving non-drinking
relatives, carers and children marginalized. Alcohol treat-
ment provision, according to Murray (2006), pays scant
nationally.
In response to this identified unmet clinical need, a
multidisciplinary team implemented and developed a
collaborative systemic intervention to assist couples
and families experiencing problems with an individuals
alcohol use within a national adult alcohol treatment
service. The paper highlights some hypotheses for this
inconsistent and disjointed situation and offers an

© 2010 Blackwell Publishing 583

B. Flynn
overview of the resulting irregular treatment service
provision.
A review of the interventions development as well as
the encouraging clinical impact the initiative had on the
clients drinking behaviour and their interactional func-
tioning is detailed. The approach relied heavily on the
postmodernist use of reflecting teams and practice, the
employment and principles of systemic reflective tech-
niques are also examined.
The main conclusions from three sets of evaluation
studies of the interventions activities are compared and
contrasted to relevant evidenced sources generally from
non-systemic family therapy modalities. The findings indi-
cate that therapy engagement rates improve both for the
drinker and relatives using the intervention, also problem-
atic drinking and associated behaviour lessened and fre-
quency of relapse episodes decreased.
Curative dynamics and factors that contribute towards
the interventions’ effectiveness are reviewed and discussed.
Implications for future treatment service development
and research also emerged from the findings, which are
explored finally.
Background
An estimated 920 000 children in the UK are currently
living in a home where one or both parents misuse alcohol,
additionally 6.2% of adults have grown up in a family
where one or both parents drank problematically (Alcohol
Concern 2008), also in 2006, 9% of men and 6% of
women were reported to be drinking in a chronic and
dependent manner (DoH 2008).
Historically, alcohol treatment organizations have been
dominated by individual-based medical and psychiatric
interventions (Heather & Robertson 1997) during the early
stages of treatment, frequently moving towards group-
based interventions during the rehabilitation stage (Jarvis
et al. 1995).
In recent years, a treatment paradox was emerging in
that there was a growing reluctance within alcohol treat-
ment agencies across the UK to provide couple- and family-
based clinical interventions. This attitude continued to
prevail even though evidence-based research was increas-
ingly supporting the use of interactional systemic
approaches to address an individual’s drinking (Copello
2003).
Reasons for resistance in implementing family-based
services in North America are explored by Fals-Stewart &
Birchler (2001) and O’Farrell (1992) and in the UK by
Copello & Orford (2002). First, these authors claim two
commonly reported factors for this inconsistency are that
couple/family treatment modality was seen as ‘too inten-
584
sive’ and not typically used in a complementary way with
other services but rather as ‘a stand-alone intervention’. It
was also noted that frequently there was a commonly held
notion among service providers, that family members
are ‘adjuncts’ and are not central to addiction treatment
services.
The influence of the language (Copello 2003) used by
commissioning agencies, service providers and associated
professionals in describing worried or concerned relatives
and friends as ‘significant others’ and ‘third parties’ is very
telling. This attitude indicates a less important and margin-
alized role in the care process of drinking problems. The
neglect of family members and relatives of drinkers has also
been attributed to a ‘consequence of the lack of a family
orientation in professional training and practice, plus the
existence of a number of dated and unhelpful models that
cast the family in negative light’ (Copello et al. 2005).
The use of addiction-focused family-based psychosocial
interventions is gaining recognition according to the
growing research evidence (Asen 2002, Copello & Orford
2002, Sprenkle 2002, Stratton 2005, DoH 2006, Raistrick
et al. 2006, Carr 2009), which is welcomed but is over-
shadowed by the inadequate service provision.
In order to contextualize the intervention and appreci-
ate the sparse clinical provision of interrelational based
modalities and programmes, a service evaluation of
partner- and family-based interventions used elsewhere
was undertaken. A summary highlighted that in the UK,
Social Behaviour Network Therapy (Copello et al. 2002)
has been the only significant intervention recently devel-
oped specifically to support family groups experiencing
addiction problems. Social Behaviour Network Therapy
was reviewed in the UKATT, United Kingdom Alcohol
Treatment Trial (2005) project, the results were promising
but service implementation nationally has been unhurried.
Cognitive Behavioural Marital Therapy is used in some
addiction agencies in the UK, although in an arbitrary
fashion. Cognitive Behavioural Marital Therapy is more
of a psycho-educational method that effectively involves
partners only in the treatment process (McCrady et al.
1986, Raistrick et al. 2006). Behavioural Couples Therapy
(BCT) that again focuses on eliminating the reinforcement
of addictive behaviours and promotes reinforcement of
behaviour conducive to change in substance use behaviour,
is clinically effective claim O’Farrell & Fals-Stewart
(2006). Despite strong empirical research support (Fals-
Stewart et al. 2009), BCT is not widely used in community
alcohol services. Interestingly, in the UK, the National
Institute of Clinical Excellence (NICE 2007) has recom-
mended that BCT is used in national drug treatment agen-
cies, an allied discipline with similar objectives to alcohol
treatment services.
© 2010 Blackwell Publishing

Elsewhere, in the US programmes like Community
Reinforcement Approach (Miller et al. 1999) employs
positive behavioural reinforcement approaches with family
members. Where adolescents or young adults experience
addiction problems the family can be offered Multiple-
systemic therapy (Henggeler et al. 1999). These interven-
tions the authors claim are effective both in treatment
engagement and positive treatment outcomes.
It was in the context of a lack of partner- and relative-
based interventions across the UK and a growing but influ-
ential recognition of the need for this service that the
intervention was established. The initiative received further
encouragement from the findings of Edwards & Steinglass
(1995) in the US, in which the involvement of relatives
increased engagement and positive outcome of treatment,
Vetere & Henley (2001) had also effectively introduced
a systemic therapy modality into an alcohol service in
the UK.
Method
Objective
A guiding objective for this initiative was to provide a
couple- and family-based treatment modality, which
appeared to be underrepresented in current alcohol service
provision. When involving partners and family members in
treatment activities with the individual drinker, it was
anticipated that this unmet need could be addressed in a
more accessible and beneficial manner for service users.
The purpose of the intervention was primarily to help
family groups in systemically understanding that excessive
drinking is chosen behaviour and the responsibility of the
individual, but it always occurs in a relationship context
and can be influenced by family of origin dynamics or as a
part of a restricted communication process within a current
relationship (Ary et al. 1993). Therefore, a further objec-
tive was to utilize reflective systemic therapy in order to
facilitate couples and families to alter, adapt or introduce
new attitudes, beliefs, behaviours and communications into
their interactional context that supports and maintains
change in interrelational drinking conduct (Vimpani &
Spooner 2003).
By involving partners and family members in an indi-
vidual’s treatment and applying systemic clinical principles,
it was also anticipated that the dynamics of the therapeutic
engagement and change in alcohol-related behaviour may
be different compared with traditional treatment interven-
tions. An understanding and quantification of the impact
this change could potentially have on current alcohol treat-
ment outcomes and future clinical developments was an
additional organizing objective for this initiative.
© 2010 Blackwell Publishing
Using systemic reflective practice
Procedure
Family groups are internally referred to the team by the
alcohol service key workers. The identified adult drinker
will have received help to limit their consumption or
abstain from drinking before referral.
Adult couples are invited to the first session with the
referring key worker and other professional carers in order
to explore reasons for referral and treatments used to date.
Relatives, children and others then join future meetings
as agreed. The family’s rate of attendance depends on
progress made and clinical need, sessions can take place
every 2–4 weeks and duration of therapy can be from 2–6
months, the frequency and duration of meetings are
decided in collaborative reviews.
Couples and families wishing to receive help without
the presence of the reflecting team are offered alternative
arrangements in accordance with service protocols. If
drinkers, partners or family members express feeling vul-
nerable and/or experience difficulties with the treatment
process, or where drinking or related damaging or harmful
behaviour escalates, review meetings will be convened with
clients, key workers and other professionals involved in
care management attending. Clinical protocols indicate
that potential risks and concerns will be collaboratively
explored and shared decisions made about whether therapy
should be continued, deferred or concluded and whether
alternative individual care should be provided to the
drinker and relatives concerned.
The identified drinker and relatives are often involved
in other complementary support activities like AA,
AL-ANON or generic counselling services. The interven-
tion is only available currently on one afternoon weekly;
this is due to organizational constraints. A diverse range of
age, ethnic, culture and gender context is represented in the
service user population.
Family configurations share intimate beliefs, behaviours
and relationships that can influence individual functioning
and inadvertently maintain problems. Working within this
interactional context can reduce the problem behaviour
and locate strengths and resources in family relationships
(Gorell Barnes 1998, Street 1994), which individual and
group approaches can not so readily achieve. Family
involvement and support can be extended beyond the clini-
cal setting into social, domestic and cultural domains cre-
ating a continuous therapeutic consequence.
The three evaluation and research studies cited in this
article were all submitted to the appropriate local health
service research and ethics committees. Approval was
granted for all with the recommendation that participants
of the projects were informed of the findings and anonym-
ity was maintained throughout to protect all drinking
585
B. Flynn
individuals, partners and family members. Consent was
obtained from service users to use quotes from outcome
and evaluation projects in this paper. The team’s clinical
activities, research and service user observations and expe-
riences since 2005 are documented.
Team
The family therapy team is multidisciplinary, with a
maximum of six members at any one time. The team is led
by a specialist nurse therapist, the author, with a principle
psychotherapist who is an approved supervisor and school
liaison officer forming the core membership; all three are
experienced and trained as systemic psychotherapists. The
remainder of the team is made up with health and social
care professionals and ex-service users on supervised train-
ing placements. Membership of the team reflects a mixed
professional, age, gender, cultural and ethnic background.
The team use a ‘live reflecting supervision’ arrangement, in
which observers and therapists collectively explore the
meetings contents, process and dynamics before, during
and immediately after sessions.
Reflecting practice
Systemic therapy uses a range of therapeutic interventions
(Carr 2000), one of which is the reflecting team and process
(Lax 1985, Andersen 1991, 1993, Jenkins 1996).
Bateson (1972) points out that we learn about ourselves
and our relation to others through comparative reflections.
As we compare what we know against a background of
other possibilities, the comparison allows us to make dis-
tinctions. One of the ways of doing this is for team
members to share their views, stories, perspectives with the
clients as a template for comparison; the team members’
reflections may become a background for the creation of
clients’ new reflection and understanding.
The practice attracts some criticism as it is promoted as
a therapeutic stance but in advance of an underpinning and
coherent theoretical body of knowledge (Donovan 2007)
so inviting comments that is a transient clinical fad. Argu-
ably, reflective approaches originate from a practice-based
theory position, Jenkins (1996) and Stratton (2009) add
that meaningful research-based practice development may
be difficult to employ unless there is agreement on the
assumptions and concepts that comprise its theory base.
The activity provides an unusual collaborative and egali-
tarian space in which clients listen without having to
justify, defend, explain or set the record straight, where
new ideas can surface and a different kind of listening and
in-deutero learning takes place (Boscolo & Bertrando
1996). However, clients can only participate in conversa-
586
tions that their range of interactions and ideas allow, new
information offered must be congruous and within the
family members comprehension (Lax 1989).
Application
When the therapists meet clients, the reflecting team
observe the interview from behind a one-way screen in an
adjacent room. The reflecting team observers (max 3) are
invited into the room when the therapist and clients agree
they would like feedback. The team reflect among them-
selves for a few minutes clearly so the clients hear what is
said and then leave. Clients are invited by the therapists to
comment on the teams reflections or to have a ‘dialogue
about the dialogue’ (Andersen 1991).
Modus operandi
Reflections and observations delivered by the team can
include: assisting family groups to identify problem-
creating communication as well as facilitating problem-
dissolving discourse, reflections can also present
speculative explanations for the problem and advance
alternative explanations. Reflective dialogue can include
exploring hypothetical future scenarios or ways in which
family members have constructed views of the problem.
Encouraging the exploration of family explanations for the
problem picture and commenting on ways in which family
members might construct new or alternative solutions can
be helpful in providing new perspectives. Framing and
connoting narrative and behaviour positively plus empha-
sizing ‘both-and’ rather than ‘either-or’ stories when intro-
duced by the team, can stimulate family members into new
interactional thinking.
Findings
Research
In 2005, an experienced team member supervised by the
Institute of Family Therapy undertook a research project to
record the family groups experience of reflecting tech-
niques. Semi-structured questionnaires (Smith 1995) were
completed by 24 family groups, both drinkers and family
members attending meetings were individually consulted,
the author concluded:
The overall finding from the questionnaires regarding
clients’ experience of the Reflecting Team was consid-
ered to be between very helpful and helpful. Overall the
scores show a significant positive outcome for all of the
couples/families. . . . (D. Stikker, 2005, unpubl. MSc
dissertation).
© 2010 Blackwell Publishing

Clients also made the following comments that as a
result of the treatment with a reflecting team:
. . . we feel more confident in managing other problems
. . . we talk more about different things
. . . it helped us that our problems were understood
from different angles
The comments in this study suggests that the non-
judgemental interactional manner of the reflecting teams
approach assists clients to understand their problems as
located in communication and relational systems (Ander-
son & Goolishian 1988, Hoffman 1992, 2007), where
problems can be resolved through the use of language with
the assistance of the team’s reflections, discourse and par-
ticipation in co-construction of alternative meanings and
solutions.
This stance promotes a different and pluralistic under-
standing of behaviour experience and management of
problems. According to Boscolo & Bertrando (1996), dif-
ferent perspectives can be then recursively reintroduced
to the therapy process through further reflecting activities
with service users, a collaborative learning process.
Research comments seem to reflect a positive forward-
looking attitude. Statements frequently included ‘us’, ‘our’
and ‘we’ suggesting a shift towards a collective relational
view of themselves and a joint belief about managing the
future. It is likely that the intervention helps client groups
to avoid focusing on pathology as in the past and places
attention on recognizing competencies and abilities
(Morgan 2000). Families appear to be learning how to
avoid similar problems and maintain a problem-solving
attitude, a principle from the Solution Focused Therapy
school (Berg & Miller 1992, Carpenter 1997).
Evaluation
An independent evaluation project was commissioned in
2006 to report on service user’s experience of the overall
treatment process. An external researcher, a psychology
postgraduate under the supervision of a local university,
interviewed 14 family groups using questionnaires after the
2nd meeting (C. Chan, 2006, unpubl. MSc dissertation).
The interview format used followed the ‘funnel structure’
in accordance with the conventions of semi-structured
interviewing (Smith 1995).
The findings showed that 12 out of 14 (approx 86%) of
the all identified drinkers referred with family members,
made significant change in their drinking behaviour as a
result of this intervention. Reduction in drinking or absti-
nence from alcohol is recorded by self-reporting and
completion of the Severity of Alcohol Dependence Ques-
tionnaire (Stockwell et al. 1994). Additionally, changes are
often corroborated by relatives especially children. This
© 2010 Blackwell Publishing
Using systemic reflective practice
finding is supported by Epstein & McCrady (1998) who
maintain that family involvement in addiction treatment
can significantly improve treatment outcomes for the user.
An additional finding was that 10 (approx 72%) of all
family groups who engaged reported both in meetings and
questionnaires that this general style of family interactional
work helped in promoting better problem resolution,
understanding and communication between individuals.
Paying attention to the relational and social context, as the
intervention does, rather than the symptom appears to be a
contributory factor in the effectiveness of the practice, this
is corroborated in research by Miller & Wilbourne (2002)
in the US and findings in the UK Alcohol Treatment
trial (UKATT, United Kingdom Alcohol Treatment Trial
(2005)).
In this study, 9 (approx 67%) of clients with a drinking
problem reported when consulted that it was beneficial and
supportive to have their non-drinking partner present at
meetings, results also found in the US by McCrady et al.
(1986) and O’Farrell et al. (1985). An interesting point
given that this challenges the prevailing assumption within
treatment agencies that drinkers do not want their family
or relatives involved in their care.
Finally, 86% or 12 of non-drinking relatives including
children expressed positive comments in meetings and
questionnaires about feeling involved and included in the
general treatment process, reflecting the unmet need and
importance of carers to receive support and be actively
involved in care management (Meyers et al. 2002). This
may also verify the current lack of service provision and
confirm the importance of helping this inadequately served
family group both in the UK (Alcohol Concern 2003,
Wooster 2003) and internationally (Klingemann 2001).
Treatment outcome
End of treatment outcomes from the 2007/2008 period
using a mixture of both open and closed questions com-
pleted by all service users are also analysed. In 2007, 19
referrals were made to the team 14 family groups com-
pleted outcome questionnaires and in 2008, 21 were
referred and 16 interviewed. (Fig. 1)
Engagement rates of all family groups who continued to
return after the first meeting were 73% in 2007 and 76%
in 2008, which are consistent and significant. This may be
understood in the context of the therapeutic alliance that is
formed between the service users, therapists and reflecting
teams. According to Bing-Hall (1995, 2008), families and
couples who experience distress, trouble and upset often
see the threat, danger and problems coming from within
the relationship or family, not from outside. Therefore, it
can be considered that the reflecting process encourages a
587
B. Flynn
Couple & Family Therapy Outcomes
20
14
73%
15
REFERALS
10
4
3
19% 2 2
5 15%
1 1
10%
5%
0
DNA'd 1st Dropped out Engaged in 2 or Positive change
meeting after 1st meeting more meetings
Figure 1
End of Couple & Family Therapy outcome results 2007/2008
more secure emotional base for couples and families, with
its emphasis on a trusting, non-judgemental and accepting
environment. Further co-exploration (Bertrando & Arcel-
loni 2006), illumination and reprocessing of participants
emotions and experiences can then occur with the support
and validation of the therapist and team (Vetere & Dallos
2008).
Figure 1 shows a correlation between numbers reporting
positive change in drinking as well as positive change in
relationships, a finding which is supported by the systemic
principle of circularity (Cecchin 1987, Selvini-Palazzoli
et al. 1980). When there is a change in one element or part
of the system, the result will be in a change in another part
of the same system so that functioning is maintained in a
positive feedback loop.
The summaries of the ‘Soothsayers’ (reflecting team)
were full of helpful insight, and thorough in their con-
tinuity. We both/all experienced a sense of growth
towards mutual understanding. (Family B 2008)
. . . an important part of the therapy moved us forward
and led to lasting changes in our relationship. The use of
‘third party’ (reflecting team) observers was an extraor-
dinarily powerful tool that permitted us to see ourselves
as others might see us but in a non-confrontational way.
(Family D 2008)
The above quotes from the outcome study are typical in
that they demonstrate that the intervention seems to facili-
tate members of family groups to reconstruct a collective
intersubjective awareness of themselves and their world,
using new information from the team and each other (Burr
1995).
Client’s experiences of the reflecting narratives in this
study appear to be important. It seems from the feedback
588
2007 (19 referals) 2008 (21 referals)
16
15
76% 14
13 74% 13
66%
68% 68%
1 1
9%
5% 4% 5%
No change in Positive changes No change in
in drinking drinking in relationships relationships
that reflecting processes or ‘outsider witnessing’, as Fox
et al. (2003) in New Zealand describe it, are sensed as a
practice of ‘acknowledgement’ (White 2004) where the
team’s respectful, speculative ‘as if’ (Anderson 2007) dis-
course allows families to make space for alternative stories
(Roberts 2000) and perspectives to emerge.
Non-attendance of family groups for initial meetings or
disengaging after the first meeting is of concern, 25% in
2007 and 24% in 2008. Reasons for this could be reluc-
tance of non-drinking members to participate in the
helping process, regarding the drinker as the primary
problem and not their responsibility or role to assist.
Non-drinking relatives may avoid attending as they fear
they will be partially blamed for the drinking problem, as
outdated and counterproductive family therapy models
have implied, i.e. ‘scapegoating’, ‘enabling’ (Copello et al.
2005).
Family groups who become engaged in therapy and
report no change in drinking 5% in 2007 and 4% in 2008,
or in relationships, 5% in 2007 and 9% in 2008, are of
interest. It is possible the drinker and family members
may not be sufficiently motivated to address the alcohol
problem at that time and/or that the team have inaccurately
gauged the family situation. Procheska et al. (1992)
emphasize the need to assess the stage of readiness for
change and tailor the intervention or reflection accordingly.
Additionally, anecdotal feedback from referring key
workers of couples and families who fail to attend or
disengage prematurely suggests the use of the reflecting
team and observation equipment creates anxiety for some
and acts as a deterrent to attending for others. Further
reports claim some service user groups regard drinking as
an individual problem that non-drinking family members
© 2010 Blackwell Publishing

should be protected from by professional services, and they
should not be immersed further into the problem in family
meetings. Individuals in some families informally report
also that they view the cause of drinking problems as
located in the drinker and don’t regard the problem as
interactional in nature and lack a ‘reciprocal causality’
understanding (Fals-Stewart et al. 2009), therefore involve-
ment of the non-drinking members in the treatment process
is seen as pointless.
Research into reasons for non-attendance or premature
disengagement may confirm the above observations or
highlight further reasons; changes can be then made to
clinical practice, structure and protocols in order to facili-
tate improved engagement and enhance care provision.
Discussion
Clinicians often refer family groups claiming they are
‘defended’, ‘relapsed’, ‘codependent’ and ‘dysfunctional’.
These family and professional descriptions are ‘thin’
according to Morgan (2000) and the discourse claims Fou-
cault (Danaher et al. 2000) can become dominant and sub-
jugative, disempowering service users and elevating
professionals to an authoritative and prevailing position.
Reflecting practice avoids using these self-limiting and
pejorative phrases and offers new and liberating descrip-
tions of behaviour, a ‘thicker’ and richer account of them-
selves (Freedman & Combs 1996). The absence of
professional jargon in the questionnaire responses suggests
that this process may be happening with families within
our study.
Feedback from professional referrers frequently reports
past service users functioning well with minimal relapse
experiences. Maistro et al. (1995) and Walitzer & Dermen
(2004) found that engaging with family groups lessened
chances of relapse in addictive behaviours. In view of this,
there may be a case to argue for the integration of interac-
tional reflective techniques with the involvement of rela-
tives into current addiction relapse prevention programmes
based on Marlatt & Gordon’s (1985) seminal work. This
family-based prevention proposal is supported by Velleman
et al. (2005) and Cuijpers (2003). On a similar theme,
Steinglass (2009) has suggested combining systemic prac-
tice, which could include a reflective element, with conven-
tional and proven motivational interviewing techniques
(Miller & Rollnick 2002).
The collaborative and egalitarian nature of the meetings
may be creating an environment of ‘withness’ or ‘dialogi-
cal’ thinking. Shotter (2004) claims that these concepts
describe a dynamic form of reflective interaction that
involves coming into contact with another’s living being,
utterances, bodily expressions, words and their works,
© 2010 Blackwell Publishing
Using systemic reflective practice
where the role of expert is less important, this reflective
process shows some parallels with the collaborative ‘open
dialogue’ practice developed by Seikkula and colleagues in
Finland (Seikkula & Olsen 2003, Seikkula et al. 2006).
The teams activities appear to help clients to discover
new meanings and descriptions, not necessarily with
scientific therapeutic tools and approaches but with an
understanding and deciphering through a collaborative
hermeneutic method, the process used by the team and
family groups is an applied back-and-forth movement
(Shotter 2008) of shared exploration and decontextualized
learning (Geertz 1983). The response of service users to the
team’s activities as noted is constructive and positive.
Myerhoff (1992) from an anthropological perspective
described this type of reflective encounter as a ‘definitional
ceremony’. When an audience is added to an interview this
strongly reinforces the participant’s experience of a more
valuable identity.
The findings have also identified some limitations and
gaps in the data collection methodology. All three sets of
data relied on the use of pre-structured questionnaires.
These were quantitative in nature with the intention of
producing objective and reliable information about the
effectiveness of the intervention; however, the findings are
essentially subjective originating from self reports. The
analysis therefore is more difficult to quantify, but content
analysis obtained from the studies has offered some inter-
esting points, the findings contribute to an emerging and
needed theory-based practice tradition in addiction treat-
ment (Emmelkamp & Vedel 2006, O’Farrell & Fals-
Stewart 2006).
Naturalistic inquiry (Creswell 1998) would assist in
developing an understanding that explores the service
user’s social, human experience and interpretation of the
interactional reflecting process more fully. Orford et al.
(2006) points out that this is needed as there is to date no
established tradition of combining treatment outcome
research with qualitative study of the experiences of addic-
tion service users. Perspectives of clients of addiction ser-
vices should not be regarded in a passive way as in the past
but be included in therapy research more routinely and
vigorously (Townend & Braithwaite 2002).
The three sets of evaluation and outcome studies did not
make adequate reference to control groups or comparisons
to other prevailing individual or group clinical modalities.
The improvement in drinking may have occurred sponta-
neously (Sobell et al. 1996) without the reflecting interven-
tion or clients might responded just as well to individual or
group approaches. A study to contrast individual and
group therapy outcomes to reflective family intervention
findings would be useful and will need to include control
group study. A wider focus in future would also need to be
589
B. Flynn
given to the influence of gender, age, ethnic and cultural
dimensions in the treatment outcomes as well as how these
factors influence the team reflections.
The use of systemic reflecting teams in adult alcohol
treatment services with couples and families has received
criticism as being uneconomical and demanding on staff
resources. Involving family members, particularly adoles-
cents and children, in therapy may reduce the chances of
reassigning drinking problems and related treatment needs
(Velleman & Templeton 2007) to the next generation, so
creating a long-term harm reduction and cost-saving
benefit. According to Crane (2008) and Meads et al.
(2007), in addition to the therapeutic benefit couple/family
therapy provides, there does not seem to be any increase in
health-care cost and policy makers should begin to offer
this form of care to couples and families who need it.
Additionally, Godfrey (2006) found in the UKATT project
that incorporating social and familial support networks
into addiction treatment programmes, is as equally cost-
effective as using conventional individual Motivational
Enhancement Therapy approaches (Miller 1994).
The couple/family therapy team, because of the con-
straints of the alcohol organizations service provision
structure, engaged with approximately 1.5% (14 in 2007
and 16 in 2008) of the organizations 1000 drinkers with
families. This leaves a vast number of service users, part-
ners and relatives unable to access this service, highlighting
a very significant unmet need locally and a more serious
concern if the findings are extrapolated across national
agencies. The paucity of service provision for family groups
becomes more disconcerting if considered within the
context that according to Velleman & Templeton (2007)
up to 8 million family members (spouses, partners, chil-
dren, parents, siblings) nationally are living with the nega-
tive consequences of somebody else’s drinking or drug
misuse.
The final discussion point details how data-base
searches and general enquiries nationally highlight an
absence of any research or clinical evidence of a formal
manualized methodology that underpins systemic reflective
practice. Future development of a reflecting practice model
may provide confidence and encouragement for other treat-
ment services to consider implementing a similar approach.
However, the teams experience backed by evaluation find-
ings and anecdotal reports shows that the service users
respond positively to the team’s unstructured spontaneous,
creative and alternative contributions, which shapes the
information that becomes ‘the difference that makes the
difference’ (Bateson 1972). So ironically, with less emphasis
placed on a programmed delivery the service users appear
to experience the intervention as a more natural and
genuine form of care and humane encounter.
590
Clinical implications
Based on the team’s experience and findings, the use of
reflecting teams and practice would be of significant
benefit within the mainstream care programmes in
national alcohol treatment services. The team also advo-
cate that the use of family-based interventions with a
reflective practice element should be considered in other
adult mental health-care settings as part of multi-modal
approaches, where behaviour is an identifiable problem
and prone to relapsing episodes. Behavioural conditions
that may benefit from this clinical modality and where
some theory-based support exists, include drug misuse
(Williams & Chan 2000, Liddle 2004), schizophrenia
(Kuipers 2006), depression (Jones & Essen 2000, Leff
et al. 2000), bipolar disorder (Benyon et al. 2008) and
domestic violence (Stith & Rosen 2003).
Anderson & Jensen (2007) explore further health and
social care implications when employing this type of inter-
vention in more diverse non-mental health treatment care
settings, where the approach may provide further clinical
benefit. Martire et al. (2004) and Hilscher et al. (2005) for
example, claim that clients and carers affected by chronic
physical conditions like dementia, cancer, heart disease,
intractable pain and stroke can be effectively supported in
this manner.
The findings contain some limitations, but clearly dem-
onstrate that the intervention appears to support the
growing idea that familial interactive approaches can play
an important role in addiction treatment engagement and
positively influence treatment outcomes (Copello et al.
2005, 2006, Orford et al. 2006) and assist in the manage-
ment of non-addiction behavioural ailments (Stratton
2005, Carr 2009). More robust research needs to follow
where a focus can be placed on treatment process, qualita-
tive evaluation and cost-effectiveness analysis in order to
assist with future clinical and provision development.
Conclusion
The overall review of the interrelational reflective interven-
tion suggests that the inclusion of partners, children, rela-
tives and friends can positively influence the therapeutic
engagement and outcome of treatment interventions. Use
of systemic reflecting approaches proved to be therapeuti-
cally effective with favourable treatment outcomes and dis-
tinct health and social care benefits in an area where there
is a significant unmet treatment need. The intervention
should be considered as a complementary modality along-
side individual and group interventions in the mainstream
treatment of drinking and related health-care difficulties in
services across the UK.
© 2010 Blackwell Publishing

Finally, the use of systemic reflective practice is hope-
fully stimulating fresh postmodern thinking, narrative and
clinical activities within the prevailing clinical dogma in
addiction treatment agencies nationally.
Acknowledgments
Thanks to John Hills, Lesley Middleditch, current and past
team members for their support over the years, also to
Arlene Vetere for comments on this paper. Consent was
obtained to use the following study findings in this paper:
MSc Family and Systemic Psychotherapy
A Quantitative Research-based dissertation
Investigating Couples/Families experiences of the Reflect-
ing Team within an Alcohol Treatment Agency Setting.
Unpublished work, Institute of Family Therapy, London,
Dirk Stikker, 2005
Couple Therapy Evaluation
Psychology Department, University of Kent. Unpublished
work. C. Chan, 2006.
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