Contrasting Team and Co-Therapy Approaches to a Walk-In Family Therapy Program
Funding: This work was supported by School of Psychology and Public Health, La Trobe University.
ABSTRACT
Policy calls for family-inclusive, single-session approaches to mental health challenges are growing. In response, an online, single-session family therapy approach, Walk-In Together (WIT), was successfully piloted in a small team format in a specialist setting. For wider implementation, including in mental health services, use of a team for WIT sessions was a clear resource barrier. This small qualitative study examined the viability of a co-therapy approach to WIT sessions. For a 4-month period, families were allocated to one of two WIT program formats. Ten completed the two-therapist format, and six the team format. Sixteen family members participated in semi-structured individual interviews, exploring their experiences of the WIT service. Four therapists participated in a focus group about working in the differently sized co-therapy models. Descriptive qualitative analyses consider similarity and difference in the experiences of these two ways of working. For family members, strong similarity of session experience, essential change elements and nature of impact was evident between the two formats. In contrast, therapists showed some preference for the team format, particularly with complex presentations and training contexts, yet fully endorsed a two-therapist format in resource limited contexts. From family and therapist perspectives, essential change was equally achieved in the team and co-therapy formats. The benefit of a WIT session for family members appears to lie more with timely response, transparent engagement and well-contained process and less with the number of therapists providing these functions. We describe ways in which the current study may inform research and support implementation.
Summary
- The Walk-in Together (WIT) service was described by members of 16 families as equally helpful and accessible as an online family therapy service, regardless of the number of therapists involved.
- While a small team model is supportive for therapists working with complex presentations, work within a two-therapist dyad was equally possible for therapists and efficacious for families.
- The impact of the WIT intervention lies less with the number of therapists, and more with a rapidly available session, and well contained and transparent processes of engagement with the family.
1 Introduction
‘Walk- in’ mental health services are designed to provide support to clients at or very near the time of their first request for help, avoiding obstacles to appointment scheduling and reducing the need for complex intake assessments and waitlists. As the name implies, in the traditional model, clients can ‘walk in’ without an appointment or immediately access support at a clinic at the time they elect. Walk-in mental health services for individuals have demonstrated efficacy (Horton et al. 2012; Slive and Bobele 2011; Slive et al. 2008; Stalker et al. 2012; Young et al. 2008), yet remain untested in family contexts, in digital or in-person modalities.
In response to this gap, our team began a series of studies toward an effective, brief, online family intervention in the context of mental health challenges. The first step was to progress research into the effectiveness of family therapy telehealth and establish evidence-based guidelines for responding to acute need for accessible service during the COVID-19 lockdown period (McLean et al. 2021). The second was to develop and pilot the first specialist ‘Walk-in Together’ (WIT) program, offering online, ‘walk-in’ family therapy, in a single session frame (Hartley et al. 2023; Hoyt et al. 2021; Moore et al. 2025).
1.1 The Original ‘Walk-In Together’ Service Model
The session, originally offered on the same day of calling during the COVID-19 lockdown, is now provided within a week or two of the families' first contact. This allows the family time to coordinate work and school schedules—a more complex task than it was in lockdown. Little background intake information is collected prior to a session. A follow-up phone called is provided 2 weeks later.
At the time of the current study, the WIT clinic was an optional entry point to the service, offered to all families eligible for the service (presenting with a serious mental health and/or alcohol/drug, or trauma-related challenge). Families could also elect to be allocated to a waitlist for multi-session family therapy. Once screened for eligibility, families are allocated the next available, suitable appointment time. The clinic is staffed by a rostered team of qualified and experienced clinical family therapists.
The original model of WIT, as examined in the current paper, was established in 2021. WIT family therapy sessions are 75–90 min in duration, offered online. The session adheres to a single-session thinking (SST) session road-map, adapted to a single family session (Rycroft and Young 2021).
The therapists encourage the family to work ‘as if’ this may be the only conversation the family has with them about their challenge. Therapists help the family to scope their shared hope for the session, and create a realistic goal and a focus for achieving this within a single session. Multiple family therapy questioning and positioning techniques help the family members connect over priority setting, identify and allow differing perspectives, and stay on track to address relational impacts of the presenting issue and map a collective way forward.
In the original small team model, three or more therapists attend each session. Two therapists worked with the family live on screen, and the third/fourth/fifth therapists were ‘off screen’ recording notes but re-appearing to conduct a reflecting team conversation while the family members listen before sharing their responses to the therapists' reflections. Therapists enable each family member to identify their key takeaways from the session and to document next steps together. The session notes summarise the family's conversation, take-aways and plans. These are shared onscreen with the family toward the end of the session and edited according to family member feedback. A final session summary is later emailed to the family. The process is identical for the two-therapist model, other than the second therapist takes a less active role in the session, offers a reflection, note takes and finalises these notes after the session. See Table 1 for an overview of these steps.
| WIT procedure | Practice principle |
|---|---|
| (1) Pre-session Single Session Thinking questionnaire emailed to each family member for completion before the FT session. Therapists review the questionnaires | Family setting the agenda and leading the discussion |
|
(2) Online session with the family co-facilitated by 2 therapists or a small team (50 min) |
Relational questioning specific to the family's main challenge, focus for the session, relational safety and connection |
|
(3) Therapists' reflection to the family (10–15 min) Focused therapeutic reflection with acknowledgment of the family's difficulties, perspectives strengths/resources and potential next steps (family mute their audio and listen to the therapists' conversation) |
Open and transparent therapist conversation & witnessing to the family, with multiple perspectives shared. Strengths/resources focused |
|
(4) Family response to the therapists' reflection (10 min) Focused reflection on what caught their attention most and how it relates to the purpose/hope for the session |
Family reflecting together, scaffolding new shared insights or learnings about their family |
|
(5) Shared screen session summary notes to the family (5 min) Summary is read out aloud by the ‘behind screen’ therapist. Family invited to edit to ensure the summary is accurate |
Collaborate on a therapeutic document |
|
(6) End of session take aways (5–10 min) Each family member is invited to share what they will take away (learnings, insights or actions) from the session. Family is reminded they are welcome to ‘walk back again’ into the WIT-FT service in the future, after an interval (5–10 min) |
End of session, noting change in the family's relationship to the problem and their new focus |
| (7) Session summary notes sent to the family within 48 h | Shared document to reinforce the family's learnings and next steps |
1.2 Further Development
In a first step toward proof of concept, a pilot study explored the acceptability and utility of the WIT service from the perspectives of family members and therapists (Hartley et al. 2023). Pilot findings from 44 family members (from 22 families) offered first evidence of utility and efficacy. Families found WIT was straightforward, accessible and impactful with respect to the presenting challenge. Key elements of change from the family perspective included rapid access to help, within days of contacting the Centre, collaborative focus on the ‘most important thing’ to be discussed, the team's reflections to the family and shared drafting of the outcomes of the session. WIT therapists also perceived the timeliness of the service to be a key element of change, endorsing the approach for families from diverse backgrounds and constellations, presenting with various mental health concerns, including those in crisis situations (Hartley et al. 2023).
The WIT clinic was first established around a small team approach of three to five co-therapists. This approach was chosen to support quality, intentional systemic family therapy practice, reflecting team processes and a therapeutic approach to session documentation. It was thought to enable more impactful session outcomes and greater efficiency in follow-up administrative work.
Therapists were clear on the benefits of the small team approach: decreasing front-end paperwork and intake hurdles, managing risk in-session, gathering live referral information and having at least one therapist with topic expertise present. The team reflection component of the session was thought to be a key change mechanism (Hartley et al. 2023).
1.3 Study Aims and Approach
In its first 2 years, approximately 200 families were seen in this pilot frame. The small team therapist approach had clear value and was accepted as best practice in the specialist service context. It has gone on to inform the design of an internship model of training.
- Do family members' experiences of engagement, support and impact from the WIT intervention differ, according to the number of therapists involved in its delivery?
- Do therapists conducting WIT sessions experience their work and its viability and benefit differently, according to the number of therapists involved in its delivery?
2 Methods
2.1 Study Design
A two-therapist WIT format was developed and trialled alongside the team format between July and October 2023. Families were randomly allocated to either the team or the two-therapist WIT clinic, dependent on the day of their appointment. All WIT sessions involved two or more members of a family or people in close caregiving relationships.
Referral process and the protocol for the conduct of the WIT sessions remained standardised across both dyad and team conditions, with the following exceptions. In the two-therapist model, the session was led by the first therapist and the second therapist remained live on screen, listening, offering occasional input, recording the session notes and participating in the end of session reflection. This differs from the team model, two therapists remain live on screen and the third/fourth/fifth therapists are ‘off screen’ for the majority of the session, recording notes and re-appearing to join the end of session reflection and share notes. Ethics approval for this study was obtained via the La Trobe University Human Research Ethics Committee (HREC21191).
2.2 Participants
2.2.1 Part 1: Family Member Experience
Family members over the age of 12 participating in a WIT session between July and October 2023 were recruited prior to the session via an emailed request to be contacted about a qualitative interview at a follow-up timepoint. They were provided with a participant information and consent form (PICF, online), and once returned, offered an interview. Thirty-one families were seen in total. A response rate of 50% was achieved (15 of 31 families seen during this time were represented in the study by at least one member, with 16 individuals in total). Reasons for non-participation were not collected.
2.2.2 Part 2: WIT Family Therapists
Eight therapists who had facilitated multiple sessions in the WIT clinic, in both team and dyad models were approached via email to participate, with a description of the study, a PICF and consent form. Scheduling permitted four therapists available on the day to participate in the focus group. Therapist participants were all employed at The Bouverie Centre, three female, two male, with post-qualification experience as family therapists ranging from 12 to 39 years. All had worked in the WIT clinic for 2 years. All therapists identified as Caucasian, three as second-generation migrant. One was an endorsed co-therapist in First Nations family therapy programs in prison and mental health contexts.
2.3 Procedure
2.3.1 Part 1. Family Members
Family members were offered a follow-up interview for this study, 3–4 weeks post their WIT session. Family member interviews were arranged for a time convenient to the participant and lasted between 20 and 30 min (mean = 24 min). All interviews occurred online, were audio recorded via Zoom and later transcribed. Remuneration of $50 was provided for their time. Family interviews were conducted by a female researcher (EH, Research Fellow). The researcher did not have a relationship with family members before the interviews. Family members were provided with the opportunity to ask questions before the interview, and consent was verbally re-confirmed. No repeat interviews were necessary.
The automated Zoom transcripts of interviews were accessed, and all identifiable information removed to ensure participants' confidentiality. Transcripts were then reviewed and edited by an administrative worker to search and correct errors in Zoom transcription. Interview data were tabulated into standardised qualitative analysis tables. Transcripts were analysed in their original form (i.e., not returned to the participants for comment or correction).
2.3.2 Part 2. WIT Family Therapists
A 90-min therapist focus group was also conducted by EH (Research Fellow). The researcher was known to the therapists, having completed prior research together. No remuneration was offered. Therapists were given the chance to ask questions about the research prior to beginning the session. Consent was verbally re-confirmed by the researcher. Four WIT therapists participated in the focus group, which was conducted online, audio recorded and transcribed via Zoom. One provided comments outside this group due to scheduling on the day. Transcripts were analysed in their original form (i.e., not returned to the participants for comment or correction).
2.4 Information Collected
2.4.1 Part 1. Family Member Experience
2.4.1.1 Demographic Information
Family members' demographic information was routinely collected as part of service registration and used with consent in the current study. This included age, gender, role in the family (e.g., mother, father and daughter), presenting problem and number of attending family members. Noting ethnicity/country of origin was not collected in this study.
2.4.1.2 Qualitative Interviews
A qualitative interview format was structured with nine questions, revelatory of three pre-determined themes: (1) perception of WIT session accessibility and process, (2) perceived session outcomes and therapeutic components contributing to change and (3) experience of two-and team formats, actual and speculated. Interviews contained nine questions (with additional sub questions and elaboration when necessary) to elicit responses around each theme. The questions addressed: the accessibility of the walk-in service; the most useful elements of the service; experience of reflective process at the end of the session; anything that changed in the family as the result of the WIT session; anything particularly useful that therapists did or said to that end; anything the participant wished the therapists had done or said differently; having two therapists or a small team of therapists working with your family, views about the likely experience of the opposite condition and other comments about the experience of the WIT service.
2.4.2 Part 2. Therapist Experience
2.4.2.1 Focus Group
The focus group included seven main questions (with additional sub questions and elaboration when necessary) that explored therapists' perceptions of working in a co-therapy dyad, or a small team. Reflections focused on differences in 2 vs. team formats, regarding (1) the sustainability of the models and considerations for implementation in other services contexts; (2) the nature of the co-therapeutic relationship; (3) therapist roles within the session; (4) the end of session reflection between therapists to the family; (5) complex family presentations; (6) session length and pragmatics and (7) other comments/perspectives regarding the co-therapy model vs. the team model.
2.5 Analyses
We note here that in a small, non-experimental study, it is clearly not possible to offer definitive analyses of group differences. Rather, the attempt was to rigorously describe the core experiences of all participants, and to offer the best ‘sense check’ and meaning making possible with regard to any group differences. To this end, we followed some commonly held principles in qualitative methodology, to ensure a systematic approach to description of and making meaning from these valuable data.
We applied a systematic approach to describing individual participant experiences, ensuring rigour within the examination of reports and avoidance of confirmation bias. Given the three pre-determined categories of enquiry, sub-theme development was necessarily deductive. One researcher generated sub-themes for all cases within the three pre-determined categories of enquiry by grouping related codes within conditions (i.e., for the 10 participants in the two-therapist condition, and then for the six participants in the team condition). A second coder (ZC) double coded five cases, and the two researchers compared these sub-themes, refining descriptors to achieve consistency. Minor discrepancies such as labelling of sub-themes and re-grouping of themes were resolved between the coders through discussion. Finally, a third researcher (JM) reviewed 100% of raw transcripts and the derived sub-themes to corroborate or challenge commonality and divergence of content within and across the two groups, and for further sense making of the findings. At the level of description, the third coder ensured coding of meaning units was revelatory of full nuance and context, and that any evident difference or similarity between responses of the two treatment groups was fully explicated.
Final themes were decided upon collaboratively and findings were summarised and reported. Our reporting follows simple critical/realist principles, namely via the documentation of assumed realities evident in the data. While the subjective experience of the third researcher was ‘tabled’ and implicit meanings were considered and explicated in places, our analytic approach to this small study fits best to a descriptive rather than inductive narrative frame. Given this approach, the consolidated Criteria for Reporting Qualitative Research 32-item checklist (Tong et al. 2007) were adequate for the reporting of our results and were utilised.
With the therapist data, our approach to the practitioner focus group sub-themes was similar, with summative descriptive reporting of content, simply organised by question order in the group discussion. Given all therapists had experience of working in both treatment conditions, and were asked explicitly about those conditions, we did not examine implicit differences, as we did with the family data. The final transcript was reviewed by a third researcher (JM) with a focus on capturing essential variation between therapist participants views, and also consensus.
3 Results
3.1 Part 1: Family Members
3.1.1 Demographic and Family Information
The demographic and family information for participating family members is presented in Table 2. Family members involved in the research were, on average, 51.4 years old, most likely to be mothers and most attended the WIT session with one other family member. Of the 16 family members who participated in the qualitative interviews, 15 consented for their demographic information to be accessed and reported. Of the 15 families, 9 participated in the co-therapist WIT model and 6 in the small team model. As per the service's eligibility criteria (as a tertiary mental health service), all families presented because of a challenge with a member's serious mental illness, and/or alcohol/drug misuse, and/or another form of serious trauma, for which prior individual counselling/therapy had been attempted. Primary presenting concerns by child and adult are indicated in the table below.
| Two-therapist model (9 families) | Team model (6 families) | Total (15 families) | |
|---|---|---|---|
| Age | |||
| Age range | 32–67 years | 34–63 years | |
| Mean age (years) | 52 years | 50.5 years | 51.4 years |
| Gender | |||
| Female | 5 | 3 | 8 |
| Male | 4 | 3 | 7 |
| Role in family | |||
| Mother | 4 | 2 | 6 |
| Father | 2 | 2 | 4 |
| Son | 2 | 1 | 3 |
| Daughter | 1 | 1 | 2 |
| No. family members attending | |||
| Two attendees | 5 | 3 | 8 |
| Three attendees | 3 | 1 | 4 |
| Four attendees | 1 | 2 | 3 |
| Child or adult presenting concern | |||
| Child | 2 | 2 | 4 |
| Adult | 7 | 4 | 11 |
| Nature of concern | |||
| Mental ill health | 3 | 3 | 6 |
| Trauma | 1 | 2 | 3 |
| Estrangement/conflict | 5 | 1 | 6 |
Below we describe the content sub-themes emerging from the interviews, illustrated with comments from participants (P1–16) and any evident similarity and difference between the two treatment groups.
3.1.2 Perception of WIT Accessibility, Use of Single Session, Reflecting Process and Notes
3.1.2.1 Online Rapid Accessibility
The responsiveness was really good. We were in crisis that day, and we got support that day. (P4, two-therapist model)
In contrast, four participants across both conditions had a preference to book sessions ahead:I thought it would be months, but there it was perfect, so good. So the day that I called up, we got a session that afternoon. (P6, two-therapist model)
I would say [the same day booking] is a little bit less than ideal because it's hard to plan your day when you don't know when your appointment is going to be, especially when you've got children. You need to figure out like, if somebody needs to take time off work to attend. I think if you could book a time a week ahead that would help. (P2, team model)
Reflections on the experience of a single session were again strikingly uniform across the interviews. Dominant themes were gratitude for the rapid response, and acceptance that the limited offering had made enough of a difference to either hold a situation or mobilise family resources toward novel solutions. Tinged with this was a suggestion that more might also be more:Just even having the family therapy session is kind of stressful enough. But then the logistics of actually getting one of those sessions was kind of like doubling the stress of it. (P5, team model)
I think it's a brilliant service. I mean, it would also be great if it was possible to do it in person, but I think the Zoom thing for us worked out simpler… I understand that there's funding, and there's all sorts of things. In an ideal world, yeah, you would be able to book in a follow up in a week and they would just say, how did you go with that practice? (P9, two-therapist model)
3.1.2.2 Use of a Single Session
Uniformly, family participants reported value in the skills and techniques used by the therapists, or attributes of the therapists themselves, irrespective of the number of therapists present. Themes and content pertaining to change and agents or helpful aspects of the session did not differ in kind or emphasis between the two groups. Dominant and consistent emphasis across all participants was given to the skilled nature of family therapy practices. While all participants noted the benefit of more than one therapist, implicit difference in skills according to number of therapists was not evident:If … maybe we could get those therapists again, then maybe we'd schedule it in again. (P10, two-therapist model)
It was really good to be able to hear each other's perspectives that they drew out through the type of flow of the interview. Normally, we would have just talked about the issue itself rather than talking about how each of us was coping within the crisis. I can't think of the word, but it was really collaborative in a way, and I'm gonna say, honest. (P4, two-therapist model)
3.1.2.3 Reflecting Team Process
The reflecting team conversation between therapists was a core component of all WIT sessions. Without exception, this part of the session was experienced by all family participants in both conditions as a helpful, novel therapeutic process that prompted ‘a new way of thinking’ about the issue. This was often reported as the ‘main benefit’ of the session in each format.
… Some things they were saying were things I have thought about and hearing it from a different person kind of reassured me that I wasn't like thinking the wrong things, so you know there's always a reassurance you get when somebody else agrees with you. (P8, team model).
Of value, one family participant in the two-therapist model had experienced the team approach the previous year. This participant was not certain that a team provided an additional contribution that may not have been available with two therapists:What we found really helpful was when we turned our mics off and we were actually able to listen in on them discussing us, and I thought that was really insightful … I thought that was so brilliant. (P9, two-therapist model).
Useful insights about problems in the reflective process were evident in both conditions. Those seemingly unrelated to the number of therapists present included statements such as ‘showed understanding, but did not go beyond to helping … like I wanted to be challenged a bit for me and my dad, you know, to do some homework’. Another questioned if the therapists were ‘holding back’ in reflections: ‘If I just really wanted some validation and affirmation, then what they were giving was really, really great so I definitely don't want to take that away, but I think a part of me was also looking for an added layer of like a challenge’. In the team format, limitations pertaining to the team's size were noted by two participants, feeling that listening to a small team of people was ‘time consuming’, and that it was ‘redundant’ to have several therapists all sharing similar reflections.[In both formats], reflections between them were quite extraordinary. So, whether there's opportunity for better reflections and discussions between a team, I don't know. As in additional perspectives in that regard may well be beneficial … It's like, “okay, there are more people in the room who are providing their undivided attention for a long period of time”. It felt like time was no issue. (P9, two-therapist model).
3.1.2.4 Session Summary Notes
Many reported that the summary could be useful to prompt further reflection or therapeutic progress after the session:There is a summary provided, like a verbal summary, that's read or extracted from the notes … I thought that was a highly skilled task that was performed, and then efficient whereby they were emailed not long after the session. (P3, two-therapist model).
Only one participant found the notes less than useful:Oh, it's very useful, because one of my children couldn't get to the session, couldn't participate. But she read the notes later. There are a couple of things that we now all say to each other “Look, remember, we said that we would do this when we come to situations where we're having that difficulty in listening?” (P6, two-therapist model)
Like, I guess there was a purpose for them, and like, that was fine, but it almost felt like a little bit of a waste of time, re-clarifying things that we'd already gone through. I was more interested in talking about things that we had been waiting a long time to talk about. (P5, team model)
3.1.3 Perceived Session Outcomes and Therapeutic Components Contributing to Change
Not that anything is solved. But there's movement. (P11, team model)
Evident in all protocols was a sense of the WIT session being a safe space to talk with family members, providing ‘new’ ways of talking and listening beyond the session, The ‘new’ talking had flow on effects for improving understanding, compassion or empathy within the family. A sense of shared safety gave an opportunity to try some new ways to address their issues:I think they made me aware of the strong bonds we have in our family to support this person, who is going through enormous difficulties in their life. It put the onus back on us to actually look after our own mental health, to be able to continue to support this person. (P4, two-therapist model)
I think the [children] now understand that they can talk about, you know, anything … they, at some point, felt that keeping quiet means protecting me from, you know, whatever horrors was going on in their mind. But being able to see me talk freely, and I think it helped give them that release that they could, you know, talk to me. (P8, team model)
This session gave us the opportunity to reconnect, to have compassion for each other and kind of push the refresh button. We were able to be more compassionate to each other and I guess for our specific situation, we had a big issue. Like an ongoing issue that like had a big explosion I guess. (P10, two-therapist model)
For one family, the WIT session explicitly created safety during the wait for more intensive services. It was as a starting point as a helpful holding space, prior to engaging in further therapeutic support:Change? Oh, dramatically, oh, fantastic! Yeah. My big concern was the other members of the family didn't understand the depth of trauma that their sibling had experienced, because there had been previous difficulties and conflict. Now I think within that conflict I can see that it's different. It's not taking it to heart as much now, and also a lot of empathy for their sibling. So we got empathy. We lowered the expectations and there is less impact when something does happen that has hurt them. I think that having that understanding coming from therapists who are bringing in their perspectives, helped. (P1, team model)
I mean it's definitely been great to do those sessions and feel like we're getting the ball rolling. I guess we did them while we were on the wait list for the ongoing therapy … So we felt like we did that walk in session to kind of tide us over until we got in [to an ongoing service]. (P8, team model)
3.1.4 The Change Elements Within Therapist Attributes and Techniques
Responses about the nature of interventions that best addressed the presenting issue or helpfully managed interactions between family members clustered around the following themes: conveying empathy, balanced engagement with all family members, holding space for family members not present, checking in with everyone present, strategies for managing the problem and psychoeducation:It was really good to actually be able to hear each other's perspectives that they drew out through the type of flow of the interview. Normally, we would have just talked about the issue itself rather than talking about how each of us was coping within the crisis. I can't think of the word, but it was really collaborative in a way, and I'm gonna say, honest. (P4, two-therapist model)
Strongest emphasis across both treatment groups was given to validation of the family's experience and harnessing their existing strengths:We talked about one of our family members having sort of anger management problems and that they needed time to self-regulate. They said, “Yes, that's true, but sometimes people aren't able to self-regulate. They need help. So sometimes you might want to consider just helping them to helping them to self-regulate, not trying to resolve things, but just helping them to breathe and just calm down”. So that was a new one for us. (P 9, two-therapist model)
I think they also possibly made me aware of the strong bonds that we have in our family to support this person, who is going through enormous difficulties in their life and I guess, put the onus back on us to actually look after our own mental health, to be able to continue to provide support to this person … “put your own oxygen mask on first”. (P4, two therapist model)
Most family participants noted the impacts of qualities of the therapists, describing them as thoughtful, experienced, knowledgeable, professional and impartial, ‘devoted’ to supporting the family's situation and holding ‘genuine concern’ for the family. Many noted the skill of the therapists in managing dynamics between the family members present, including reluctance to participate, and keeping the session on track, and linked this to the presence of two therapists working with them. Listening was noted by the majority of participants:The one or two strategies we came up with ourselves … that made the difference. We came up with them. All we had the therapists for, I think, was a sounding board. (P6, two-therapist model)
I thought the service was really good, because, having two [therapists] there, that was great … if one of us was perhaps getting off track or not sticking to the point, we were sort of guided back to the issue, or what was being discussed. They were very good. (P13, two-therapist model)
Even just the way they ran the session, the way they were aligned with each other. Just a real sense that they were very knowledgeable and experienced. Yeah, just had lots of strategies and ideas. (P 9, two-therapist model)
Some also noted personal attributes such as therapist gender. Three mentioned the therapist/s had usefully shared they were parents, which helped them to connect, feel understood and make further use of the therapist's interventions:They were devoted to listening to us. You know the deep, active listing they engaged in. It just leaves an impressionable mark of the whole experience as a positive one. (P3, two-therapist model)
I found that particularly helpful where they could share some information that connected to our situation which caused us to kind of reflect and implement some strategies that would directly relate to that. (P5, two-therapist model)
3.1.5 Experience of Two and Team Formats
In varying degrees, without exception, all participants noted that multiple therapists allowed for both alignment on the major issues and also different perspectives about the family's situation, offering the family diverse expertise. All family participants reported benefit from listening to the dialogue between the therapists, and a sense of alignment within this experience. Implicit is a role-modelling function:Usually, traditional therapy is with one therapist … So, if there are two, it doubles whatever observations that are being carried out. (P8, team model)
It was really good. I think the fact they could bounce off each other and each bring their own take on things, we all thought that was better than just having a single therapist. It reinforced things. (P9, two-therapist model)
Given all but one participant experienced either the two therapist or team format, any clear or implicit difference in content or emphasis was examined by the researchers. Of note, all participants reported perceived benefit in having therapists who played somewhat different roles. In the team format, three of six participants made specific reference to the helpfulness of an observing therapist who could ‘just listen’ and didn't take an active part in leading the session. Implicit was a sense of having insurance that important content would not be missed, as someone was always ‘keeping an eye’ on verbal content and also non-verbal cues of family members:Three therapists when there's four family members kind of balanced things out. (P1, team model)
I felt that I could get a more rounded … resource. With them being a small team, what it meant was that if one person were to have missed something, the others would catch it. (P8, team model)
Contribution is doubled. So you kind of quite literally get double the input and they also feed off each other, too. That feeling of being held it's strengthened by having the two, and it was not at all uncomfortable. (P3, two-therapy model)
Yet the number of therapists present did not guarantee a supportive experience:They did have different roles. One of them was more inquiring about the situation and offering support, the other was really listening in the background, sort of like an observer, almost yes, but also had an opinion at the end of a session. (P4, two-therapist model)
In contrast, one participant in the team format reflected that the number of therapists likely made a lesser contribution to positive outcomes for their family than did the net sum of expertise of the therapists, and their way of working with each other:I was aware the third person who came in at the end was, like, playing a separate, a different role to the other two … having three human beings, kind of make an attempt to absorb and reflect on and feed something back, I found it extremely helpful. … Still they missed some things, like a hurtful statement said by [family member] was not responded to, I think was not good. (P2, team model)
One participant experienced a session in the two-therapist condition recently and in the team format the previous year. They reflected each session was helpful and the number of therapists had not made a difference to the outcomes of each session, feeling it was the same 'net result' (P3, two-therapist model).I don't know if the number of therapists present makes the difference as much as the experience those therapists have, and like, whether they complement each other or they have the same skillset. I think the blend [of therapists] is more important than the number. (P14, team model)
Five participants in the small team condition predicted that their session would have been equally helpful if conducted by two therapists, given the availability of ‘more than one set of eyes and ears’ for observations and reflections:I think it still would have been great. Any two of those therapists would have been great. But because each of them brought such unique perspectives, professional and personal … the missing therapist, it would have lacked that richness, definitely. (P1, team model)
You need to make sure you're observing everything that needs to be observed. So, I suppose two therapists or three could do the job. (P8, team model)
3.2 Part 2: WIT Therapist Experience
This section summarises findings from the interviews about therapist experiences of the viability and benefit of the two WIT formats and implementation considerations, illustrated with comments.
3.2.1 Relative Benefits of a Two-Person Versus Team Approach
Therapists noted that working in teams was particularly beneficial in situations where risk or complexity arose during the sessions. As limited background information was available, addressing these issues within a single session context was seen by two participants as more challenging without the additional resource of a third therapist:… the real advantage of the third person, as I am thinking is that, as co-therapist you've got another resource in the room that you don't have otherwise … you just know that they're going to come in with the goods at a certain moment in their reflecting. And they're also doing the documentation. So, there's more resources and it this could make for a better experience for the family. (Therapist 3)
These therapists believed that families in complex situations benefit more from a team-therapist model, as the additional resource available off camera supported the work of those facilitating the session, addressing complexity without compromising the ‘fullness of the experience offered’. One therapist highlighted how the presence of the third therapist could benefit both therapists and families:Particularly where there are more complex issues in the room … it becomes harder to hold … as a walk-in single-session. We're not operating with established relationships. We're not operating with background information. We are responding very much in the moment … We are trying to be interventive and this can feel harder to do with two people. (Therapist 2)
The benefit of sharing the session notes with the family was uniformly unquestioned, with therapists reporting that the additional resource of a third therapist could be focussed on observing the session, and to record more detailed notes than might otherwise be possible. Views were somewhat divided though about the need for a team to achieve useful notes. One therapist felt the notes could be shared in a ‘good draft form’ at the end of the session whereas when working with two co-therapists, the notes taken tend to be less detailed, and less ‘baked’:I believe that the families we see increasingly are extremely complex with traumatic experiences, and having a third person “behind the screen” [camera turned off] provides containment for the therapists and for the work. It means that people are working more effectively and efficiently because they've got somebody else who is there as a resource to turn to. (Therapist 1)
This concern was not shared by the other therapists, who questioned whether family members were impacted by different level of detail in the notes:In a two-person [session], not only are notes brief, but they are a bit more of a … literal representation of different comments. There is an intent to … write that session summary with a narrative philosophy … where it's seen as an intervention. There is a reframing and a phrasing of the session summary in such a way to have a positive impact for the family … and I find that's harder to do after the session, and it's harder to do in a 2-person model. (Therapist 2)
Hidden benefits of a smaller team included more focused preparation, ease of coordinating each person's role and navigating this in session. These functions were seen by some to be more complex when working in teams:The benefit of a team model versus two is still for me, a question. And so, part of this is what is the benefit of the notes being shared and being sent within 24 h in the team format, versus being sent 1–2 days later in the two-therapist model. How does that differentially benefit the family and outcomes? We just don't know what effect that actually has, if any. And we don't know whether less is more in relation to notes, or any other part of the intervention. (Therapist 3)
Participants reflected on the dynamics of working together in co-therapy, or teams, with some describing a well-functioning, collaborative dynamic as ‘the co-therapy dance’. They discussed the ways that having two or more therapists involved affected the ease of establishing this ‘dance’ together. All observed that it could be easier to get to know each other's styles and work well together in pairs, whereas when more therapists worked together in teams, this could require more ‘improvising’:It's always pretty straightforward [with] two people because it's just you having a conversation with the other person, whereas when there's three or more people, making sure you're all on the same page, how you're going to work together, who's doing what – it's more complex. (Therapist 4)
Two felt that working in teams provided an important additional sense of support with the presence of a separate therapist who was not directly engaging in session facilitation:I did find, over time, that two therapists was a bit easier… particularly when it was the same therapist over time. You build a sense of coherence with that person … your sense of their language, their tone, interests, style, and their direction, and where they go in that regard. In a small team, the dance is slightly different and involves improvising in that moment more. (Therapist 3)
I prefer the small team model … It means that you can get on with the dance of the two-person [model], but you know there's a backstop, and particularly with cases which are very difficult. You can talk to each other “in front” of the screen/camera, but you also know there's a third person who will reflect on what you both have said, as a safety net. (Therapist 1)
The phrase that comes to mind is having more space. So, the small team model in my experience leaves the two therapists in the room to be more fully engaged in a more even distribution of managing the session. That is challenging when it's a two-person model, because one person is attending to the notes, and so it's harder to be as active in the space. (Therapist 2)
3.2.2 Viability and Implementation in Other Contexts
Therapists reflected on limited family therapy resources available within other mental health service contexts, where a rapid response, single-session therapeutic approach to family inclusion was indicated. Given universal support by these therapists for the utility of the WIT approach for other services, all reported that in such contexts, a co-therapy, rather than team approach, was possible and preferable:The small-team model is good for when we have new trainees who are coming into WIT. They get to sit behind [the screen/camera]. They see us work … observe us in action. This is such a good process for them, and for any work they might do subsequently. (Therapist 1)
The focus group identified other forms of implementation that could take pressure off service resources, including a partnership model, for example with sessions conducted by the treating mental health clinician paired with a clinical family therapist.I think what has a currency is less about the number of staff in a particular session and about achieving containment that permits an effective intervention with complex families. (Therapist 2)
4 Discussion
The WIT service began as a single-session intervention in which sessions were led by a small team of family therapists. Its early successful outcomes generated interest in wider implementation, including in service systems not resourced with trained family therapy teams. The aim of this small study was to explore any obvious differences for families or therapists in the acceptability and viability of a two-therapist approach to the WIT family therapy service, to progress implementation plans in light of possible limitations of either approach.
Three outcomes emerged from qualitative accounts of family members and therapists. First, from the family perspective, no clear differences in experience, engagement and impact were evident between the two treatment groups. Positive outcomes were reported in both conditions, and negative outcomes were not evident in either group. The benefit of being seen by more than one therapist was central to the experiences of change described in both groups. Beyond this, the number of co-therapists involved was not a focus in accounts of what made a difference to outcomes, in either condition. Some reservation was expressed by family members about a team approach being potentially overwhelming. Third, family therapist views were divided about the relative benefit to ease of the therapeutic process. Some expressed a preference for teamwork with complex presentations citing the benefit of greater collegial support and a lighter administrative load during and after sessions. Some found a two-person model easier to coordinate and equally efficacious, with results often achieved in shorter session times. We consider these findings in turn.
4.1 Family Member Experiences of the Two WIT Models
No significant concerns were raised by family members about the number of therapists in their session, in either two-therapist or team-therapist models, nor aspects of the WIT model that they felt were compromised by the number of attending therapists. This suggests the quality of the family member experience of WIT was neither negatively impacted nor augmented by the number of therapists facilitating their session.
Family participants experienced the therapists' genuine care and validation as one of the most helpful aspects of these session. All participants mentioned the centrality of having more than one perspective on the family's situation, to both leverage and amplify the value of differing views, aligning with findings that co-therapy allows a ‘deeper, more reflected way, accompanying the clients in broadening their own perspectives’ (Hornova 2020). Family members valued connecting with differing experiences or attributes of therapists, for example, therapists' gender or parent status. As with prior findings, the relatability of therapist characteristics may have increased therapeutic efficacy (Del Re et al. 2021; Schöttke et al. 2017).
4.2 Family Therapist Experiences of the Two WIT Models
The therapists interviewed were divided on several issues, showing a qualified preference for some aspects of the small-team model as the optimal service-delivery mode, if unconstrained by resources. Elsewhere, the literature on the co-therapy model supports the notion of reduced therapist burnout and anxiety and increased therapeutic resources in the room. Elements that risked being compromised by a two-therapist model included ease of completing session notes and the richness of reflection at the end of the session. The presence of a small team aligned with the use of reflecting team approaches long used in family therapy (Sidis et al. 2022). The relationship between therapists, enacted via the ‘co-therapy dance’ was seen as key to the quality of the session, as found elsewhere (Xia and Ma 2020). In this, familiarity with colleagues' styles created a form of security as the direction of each session was navigated, and for most, it was easier to achieve with one other co-therapist rather than a team. Clearly, a small-team model is somewhat of a luxury in the current economic climate. While some therapists reflected wistfully on a bygone era, others found hidden efficiency in a small team session, with clear attendant economic viability.
In short, the merits of a team or co-therapy approach reflected to some extent the subjective experience of therapists and their varied preferences and working styles. Some practice implications for any service considering this way of working are nonetheless clear. For example, routinely working with the same co-therapists builds familiarity, and enables the co-therapy ‘dance’. Role satisfaction should be considered carefully, within context. Given research is just beginning to articulate the nuanced requirements of an online family therapy service model (Mclean et al. 2021), the finer points of effective reflecting team-work require further elaboration.
4.3 Synergy and Difference in Family and Therapist Perspectives
Given the divide in therapist views, could the family data settle the debate? Perhaps. Of note, families were somewhat more conservative about the merits of a team approach than were therapists. Five of six participants in the team therapist condition predicted that their session would have been equally helpful if conducted by two therapists, and 7/10 in the two-therapist model expressed concern that a team might be ‘too much’, ‘time consuming’ or ‘redundant’, and risking taking time away from the family's ‘talking time’. The value of the therapeutic reflection did not differ according to the number of therapists involved. The value in these diverse findings is clear. Implementation by a team may well be best reserved for complexity, and for training and primary consultation contexts. Regardless of context, leveraging the available diversity of perspectives and holding awareness of not crowding the family space with repetition remain key clinical skills.
4.4 Limitations
This was a small qualitative enquiry seeking to explore synergy and difference in the experiences of family and therapists of the two WIT model formats. It is major limitation of course pertains to the limits of narrative enquiry for this purpose. Participating family members did not experience both the two-therapist and small team models (except for one family member) and direct comparisons of each model of the service could not be made. Next, funding terms dictated a short project period in which we were only able to recruit small family participant samples, and in which longer term follow-up was not possible. The uneven number of small team sessions conducted reflected difficulty staffing that model during the project period and therefore only 11 such sessions were conducted, compared with 21 sessions facilitated by two therapists. That said, a recruitment rate above 50% was a strength of the study. We note finally the relatively senior age of family participants (see Table 2). Future research would optimally engage youth for their perspective on brief family interventions.
4.5 Future Research and Clinical Directions
Further research into walk-in single-session online family therapy is underway. Currently, a Medibank PHD program of research will conclude in 2026, exploring over 1 year the comparative outcomes and health economic benefits of walk-in family therapy against multi-session family work. Amidst this research, the team is working to articulate theory of change for brief, rapid response family work. In the field, a study of the viability and utility of WIT in both child and adult mental health settings is also underway, together with placement of the intervention in an early autism diagnosis program. Optimally, ongoing research beyond these settings will deepen our understanding of when, and for whom the WIT process enables families facing serious mental illness challenges to better manage, and indeed when it may prevent escalation of distress and attendant costs and service pressures. Finally, this work may attract a call to answer the question, ‘But can this work be done by one therapist?’. While systemic psychotherapists may pale at the idea, the question may attract future research, enabling future consumers to make an informed choice about single therapist versus co-therapy and team approaches.
This small study has informed our service model in multiple ways. The Rapid Access Family Therapy Service commences with a two-therapist led WIT session, supported by staff rostering and training that enhances an effective ‘co-therapy dance’. External implementation projects to assist the translation of WIT into public child and adult mental health services are now supported through internships into the team-based WIT teaching clinic. Ultimately, we hold that a ‘gold standard’ for the work lies less with the number of therapists, and more with well contained and transparent processes of engagement with the family, in a short space of time.
5 Conclusion
Findings here provide early evidence that a WIT family therapy service is perceived as an innovative, helpful and accessible service, regardless of co-therapy or team mode of delivery. Small steps such as these are important for services facing resource constraints, and for judicious investment of future research resources. Frameworks of response such as that offered in the WIT program have the potential to complement and extend the impact and reach of the mental health system's current capacity, supporting an individual's mental ill health recovery within their family and community context.1 In the context of repeated nation-wide calls for improved, family-inclusive practices in mental health care for people of all ages,2 this study suggests that building accessible, effective and resource-efficient family practices is possible and makes a difference.
Acknowledgements
Open access publishing facilitated by La Trobe University, as part of the Wiley - La Trobe University agreement via the Council of Australian University Librarians.
Conflicts of Interest
The authors declare no conflicts of interest.
