556 September 2000 Family Medicine

Residency Education

The Reflecting Team: An Innovative Approach for

Teaching Clinical Skills to Family Practice Residents

Patricia Lebensohn-Chialvo, MD; Marjorie Crago, PhD; Catherine M. Shisslak, PhD

Background and Objectives: This paper provides a description and evaluation of the reflecting team
approach as a teaching method for family practice residents. We have used the reflecting team ap-
proach in our longitudinal behavioral health program for 6 years. Our purpose in using this ap-
proach is to 1) teach listening and interviewing skills, 2) teach systems-oriented psychosocial inter-
ventions, and 3) provide behavioral health consultations for patients. Methods: A five-item, self-
administered, open-ended questionnaire evaluating the reflecting team approach was administered
to a sample of family practice residents. Results: Completed questionnaires were received from 18 of
the 22 family practice residents participating in the longitudinal behavioral health program (a re-
sponse rate of 82%). Responses to the questionnaire items indicated that the residents understood the
purpose of the reflecting team approach and felt that they had acquired a variety of clinical skills
from the approach, including listening and interviewing skills, positive reframing of patients’ prob-
lems, how to give positive feedback to promote behavioral change, and increased knowledge of psy-
chosocial assessment procedures and treatment methods. Conclusions: The residents’ responses to
the questionnaire items indicated that they perceived the reflecting team approach to be a practical
and useful method for learning a variety of clinical skills.

(Fam Med 2000;32(8):556-60.)

The reflecting team approach was developed by Tom
Andersen, a Norwegian psychiatrist.1-3 The purpose of
the reflecting team approach is to offer individuals,
couples, or families new perspectives on their problems
or predicaments. Reflecting team sessions usually last
about an hour and consist of the following segments:
1) the patient/family is interviewed by a member of the
team for approximately 30 minutes while the rest of
the team listens, either in the same room or from be-
hind a one-way mirror, 2) the patient/family and inter-
viewer listen while the other team members discuss with
each other their reactions to what they heard during the
interview, eg, their impressions, ideas, questions, specu-
lations (approximately 15 minutes), and 3) the patient/
From the Department of Family and Community Medicine (Dr Lebensohn-
Chialvo) and the Arizona Prevention Center (Drs Crago and Shisslak),
University of Arizona.
family then discuss with the interviewer their reactions
to what the reflecting team members said, while the
reflecting team listens (approximately 15 minutes).
Andersen1-3 provided the following guidelines for
conducting reflecting team sessions: 1) comments by
team members should focus only on what was commu-
nicated during the interview (either verbally or
nonverbally), 2) the language used by the team mem-
bers should be positive, respectful, and nonaccusatory,
and 3) suggestions regarding possible strategies for
change should be presented as tentative rather than
definite.
The reflecting team approach has been used with a
number of different groups, including patients in a
managed health care setting,4 patients characterized as
“somatizers,”5 school children with emotional or be-
havioral problems,6 adolescents with gang-related or
substance abuse problems,7 and abusive or neglectful
parents.8 This approach has also been widely used in
the training of counselors, psychologists, and marital
and family therapists.9-12
Residency Education
The effectiveness of the reflecting team approach has
been evaluated in a variety of studies. A recurrent theme
in the evaluation of this approach by patients or clients
is the value they attribute to being presented with dif-
ferent opinions, perspectives, and alternatives as they
listen to the reflecting team’s comments.13-15 In a study
of 35 families who were contacted an average of 15
months after termination of treatment using the reflect-
ing team approach, 66% of the families reported symp-
tom improvement, and 80% reported being very satis-
fied with treatment.16 Evaluations by supervisors and
trainees indicate that this is an effective and efficient
training tool that allows trainees to develop relation-
ship skills and feel more comfortable before working
with families for the first time.17-19 Trainees report feel-
ing less defensive and more open to receiving feedback
than in more-traditional supervision models, primarily
because the egalitarian context feels “safer” and en-
courages the sharing of different perspectives and ex-
periences.20
To our knowledge, there has been no published re-
port on the use of the reflecting team approach for teach-
ing family practice residents. However, at a recent con-
ference of family medicine educators, Arthur Frank21
recommended this approach as the best one for teach-
ing listening skills to family practice residents. The
present study evaluated the usefulness of the reflecting
team approach in teaching family practice residents a
variety of clinical skills.
We conducted an evaluation aimed at eliciting open-
ended responses from a group of family practice resi-
dents who had been exposed to the reflecting team ap-
proach for 1 year as part of their training in behavioral
health assessment and treatment. This study was not
designed to evaluate patient outcomes or to collect lon-
gitudinal data. Instead, it was decided that the first step
in evaluating this approach as a teaching method for
family practice residents was to ask the residents them-
selves if they had gained anything from their experi-
ence with this approach and, in addition, if they thought
patients had benefited from this approach.
Description of the Approach
We piloted the use of the reflecting team approach
in our family practice residency program in 1994 and
continue to use this approach for teaching family prac-
tice residents about listening and interviewing skills and
the implementation of psychosocial interventions. We
use the reflecting team approach for individual and fam-
ily psychosocial consultations that we provide for our
patients as part of a longitudinal behavioral health pro-
gram. (Training in behavioral health in our residency
has a longitudinal format instead of a block rotation.
Family practice residents, divided into small groups by
graduate year, meet once a month throughout the 3 years
of residency.)
Vol. 32, No. 8 557
The longitudinal behavioral health program includes
1) a Balint session in which residents can discuss rela-
tional problems they are having with their patients,
peers, supervisors, or staff, 2) case presentations, 3)
presentations on various clinical topics, and 4) psycho-
social consultations with patients where we use the re-
flecting team approach. Residents meet in groups based
on their postgraduate year. They bring their individual
patients or patient families for a behavioral health con-
sultation on an as-needed basis. They present the pos-
sibility of the behavioral health consultation to those
patients and their families who they think might ben-
efit from the approach. Patients who are referred for
these consultations have diverse complaints, including
problems with children and adolescents, marital con-
flicts, issues with chronic illness or death and dying,
noncompliance, substance abuse, and chronic pain.
The reflecting team consists of the family practice
residents, a clinical psychologist, a family physician
trained in family systems, and a doctor of pharmacy.
The referring physician, who is considered part of the
consulting (family) system, presents a brief summary
of the patient’s problem in a pre-session meeting and
states what he/she would like to gain from the consul-
tation. Resident members of the reflecting team are re-
minded to comment only on what they observe or hear
during the interview and frame their reflections in a
positive manner. They are instructed not to talk directly
to the patient or family members, and if they cannot
frame their observations into a positive reflection, they
are to remain silent.
The psychologist or family physician then conducts
a standard information-gathering interview about the
presenting problem, including family history, while the
rest of the team listens (on occasion, a senior resident
may volunteer to do the interview). Then the inter-
viewer, patient, and referring resident/physician listen
to the rest of the team reflecting about what they heard
and observed during the session. The other faculty
member acts as a facilitator during the reflection pro-
cess. The reflections are presented in a respectful and
positive manner, emphasizing the strengths that the in-
dividual or family has, as well as possible ways of
implementing change. Then the patient/family reflects
on what they heard during the discussion by the re-
flecting team. At the conclusion of the session, the in-
terviewer usually provides an intervention incorporat-
ing the comments of the reflecting team, establishes a
follow-up procedure, and thanks the patient/family for
their participation. After the patient/family leaves, there
is a brief post session to review how each participant
felt about the interview and the reflection process.
For the first year and a half, we worked in a facility
that had a one-way mirror, and this was used by having
the reflecting team and the patient/family change places
during the reflection process. When that facility was
558 September 2000 Family Medicine

no longer available, we moved to a larger room and The major themes in the residents’ responses to the
placed the furniture for the patient/referring physician/ five items on the questionnaire are presented in Table
interviewer at one end of the room, while the reflecting 1. When asked about the purpose of the reflecting team
team sat at the other end. Everyone was told to pretend approach, 72% of the residents indicated that the pur-
that there was a wall or mirror in between the two sides pose was to share different points of view with patients
of the room. and peers, which is consistent with the purpose set forth
by Andersen,1-3 who developed this approach. The resi-
Methods dents’ responses to item 2 of the questionnaire, regard-
We developed a 5-item, open-ended, self-report ques- ing skills acquired from using this approach, indicated
tionnaire evaluating residents’ perceptions of the reflect- that the residents felt that they had acquired a variety
ing team approach. The five items on the questionnaire of clinical skills, such as positive reframing (11%); in-
were 1) What do you understand to be the purpose of creased listening skills (33%); how to give positive feed-
the reflecting team approach in patient consultations? back (28%); and increased knowledge of interviewing
2) Based on your experience with the reflecting team techniques, psychosocial assessment procedures, and
approach and the longitudinal behavioral health pro- treatment methods (50%). On item 3, half of the re-
gram, what skills did you acquire? 3) Which of the skills spondents reported acquiring interviewing skills that
that you learned from the reflecting team approach can could be applied to their own practice. Other skills
be applied to your own practice? 4) What do you think
the patients who participated in the consultations got
from the reflecting team approach? (5) Do you have
any suggestions for changing the reflecting team ap- Table 1
proach in the future?
The questionnaire was administered to family prac- Major Themes in Family Practice Residents’
tice residents (divided by postgraduate year) at the be- Perceptions of the Reflecting Team (RT) Approach
ginning of a monthly longitudinal behavioral health
teaching and supervisory session. Attendance at these Items and Themes Total (%)
sessions was required. The only excused absences from Item 1: Purpose of the RT approach
the sessions were for residents who were on vacation Improvement in interviewing skills 6 33
Insight into patients’ problems 3 17
or who had scheduled time off after being on call. There Sharing different points of view with patients and peers 13 72
were a total of 30 sessions conducted per year, 10 ses- Increase skills in patient evaluation and management 7 39
sions for each of the three groups of residents (PGY-1,
Item 2: Skills acquired from RT approach
PGY-2, and PGY-3). At each session, residents partici- Increased listening skills 6 33
pated either by presenting one of their patients for a Positive reframing of patients’ problems 2 11
consultation or by being a member of the reflecting How to give positive feedback to promote
behavioral change 5 28
team. More knowledge about different interviewing techniques,
The residents were asked not to put their names on assessment procedures, and treatment methods 9 50
the questionnaires. The residents’ responses to the ques-
Item 3: Skills that can be applied to one’s own practice
tionnaire were reviewed independently by the three Active listening 6 33
authors, and major themes were extracted. The three Positive reframing 3 17
authors then met to discuss each of the residents’ re- Increased understanding of psychosocial issues
and psychopharmacology 5 28
sponses and achieve consensus about the themes rep- Interviewing skills 9 50
resented by each response. Data analysis consisted of Giving positive feedback 4 22
calculating the frequency and percentage of each of
Item 4: What patients acquired from RT approach
these themes. Encouragement/empowerment/reassurance 9 50
Multiple perspectives on their problems 15 83
Results Positive feedback 5 28
Eighteen of the 22 residents (82%) participating in Item 5: Suggestions for changes in RT approach
the longitudinal behavioral health program completed No suggestions 13 72
questionnaires. Four residents were absent when the Use a one-way mirror 1 5
Observe more interviewers 1 5
questionnaire was administered due to vacation time More interviews by residents 1 5
or post-call status. The residents ranged in age from 28 More time with patients 1 5
to 49. Seventy-two percent of the residents were fe- More updates on past patients 1 5
males, and 28% were males. Six residents were PGY-
1, seven were PGY-2, and five were PGY-3. Thirty- Because residents could give any number of responses to each item, the
nine percent of the residents were minorities, includ- percentages per item do not equal 100%.
ing African-American, Native American, Asian-Ameri-
can, Hispanic, and East Indian.
Residency Education
acquired that were applicable to practice are shown in
Table 1.
When asked what they thought the patients had ac-
quired from this approach, the majority of the residents
(83%) indicated that they thought patients had gained
multiple perspectives on their problems, in accordance
with the purpose of this approach outlined by Ander-
sen.1-3 In response to the final item on the question-
naire asking for suggestions about changing the use of
the reflecting team approach in the future, only five
residents suggested changes; these are listed in
Table 1.
Discussion
This study was designed to evaluate the effective-
ness of the reflecting team approach as a teaching
method for family practice residents by eliciting resi-
dents’ perceptions of this approach. Andersen1-3 con-
tends that this method, first and foremost, allows indi-
viduals, couples, and families to gain new perspectives
on their problems. In accordance with this contention,
83% of our trainees believed that the patients who par-
ticipated in this approach did indeed gain multiple per-
spectives on their problems. The second most-positive
benefit residents believed the patients had gained was
encouragement, empowerment, and reassurance. Fur-
ther, our evaluation indicates that many of the residents
believed that their knowledge of interpersonal skills had
increased as a result of using this method.
The theoretical purpose of the reflecting team ap-
proach was clearly understood by the residents; 72%
stated that they realized the purpose of this approach
involved sharing different points of view with patients
and peers. Overall, based on the residents’ responses to
the questionnaire that was administered, we believe that
application of this clinical technique in patient assess-
ment and intervention is also a beneficial method for
teaching clinical skills to family practice residents. This
experimental teaching approach encourages residents
to participate in a nonthreatening setting with their pa-
tients. Resident participation in this setting facilitates
the process of acquiring interviewing and intervention
skills by observing these skills being modeled by ex-
perienced clinicians.
The major strength of this study is that it describes
and evaluates an innovative teaching method whose use
with family practice residents has not, to our knowl-
edge, been reported previously. This study thus repre-
sents a first step in the evaluation of the reflecting team
approach with family practice residents.
Since the study has several limitations (eg, small
sample size, lack of longitudinal and outcome data),
we are currently in the process of designing three addi-
tional studies to address these limitations. Study 1 will
involve administering a questionnaire similar to the one
Vol. 32, No. 8 559
used in the present study to groups of family practice
residents each year for 5 consecutive years. We will
thereby be able to determine if the perceptions of fu-
ture residents are similar to those of the sample of resi-
dents evaluated in the present study.
Study 2 will involve contacting former residents who
participated in the reflecting team approach as part of
their training. They will be asked whether any of the
skills they learned by being exposed to this approach
have proven helpful to them in their medical practice.
Study 3 will focus on an evaluation of satisfaction
and outcome among a sample of patients who were the
recipients of a consultation based on this approach. Pre-
vious research studies that evaluated the reflecting team
approach from the point of view of the patient indicate
that patients generally find this approach both helpful
and effective in alleviating symptoms.13-16 These pro-
posed studies will help overcome some of the limita-
tions of the present study.
Conclusions
The reflecting team approach described in this pa-
per has been used to teach and supervise trainees in
various other disciplines (eg, marital and family therapy,
counseling, and psychology), but this is the first report
of the use of this method for teaching clinical skills to
family practice residents. Data obtained from an evalu-
ation of this approach in a sample of family practice
residents indicated that the majority of the residents
perceived this approach to be of benefit to them in de-
veloping such skills as improvement in interviewing
techniques, active listening, positive reframing of pa-
tients’ problems, and giving positive feedback to pro-
mote behavioral change. These results suggest that the
reflecting team approach is a useful and beneficial
method for teaching a variety of clinical skills to fam-
ily practice residents.
Corresponding Author: Address correspondence to Dr Lebensohn-Chialvo,
University of Arizona, Department of Family and Community Medicine,
College of Medicine, Tucson, AZ 85719. 520-694-1610. Fax: 520-694-1640.
E-mail: plebenso@u.arizona.edu
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