So far this series has talked a lot about the impact of traumatic experiences on us as individuals. But working in healthcare usually means working in teams and experiencing distressing events as part of a team.

In this episode, Paula speaks with Dr Sadie Thomas-Unsworth, consultant clinical psychologist and lead for staff support and palliative care, about the guidelines she and colleagues have written entitled Group Psychological ‘Debriefs’ - Practice guidance for post-event team reflection following distressing events at work. Published by the Association of Clinical Psychologists and authored by Sadie, Dr Harriet Conniff, Dr Joanna Farrington-Exley, Dr Zoe Berger and Dr Julie Highfield.

Sadie’s links:

Group Psychological Debriefs (acpuk.org.uk)

Other links:

ACP-UK

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SPEAKERS

Sadie Thomas-Unsworth, Paula Redmond

Hi, I'm Dr. Paula Redmond, a clinical psychologist, and you're listening to the When Work Hurts podcast. On this show, I want to explore the stories behind the statistics of the mental health crisis faced by health professionals today and provide hope for a way out through compassion, connection and creativity. This season is brought to you by the Association of Clinical Psychologists, the representative professional body for clinical psychologists in the UK. Join me as I talk to inspiring clinical psychologists about their work in this field, and learn how we can support ourselves and each other when work hurts. So far in this series, we've talked a lot about the impact of traumatic experiences on us as individuals. But working in healthcare usually means working in teams and experiencing distressing events as part of a team. For this episode, I spoke with Dr Sadie Thomas Unsworth, consultant clinical psychologist and lead staff support and palliative care about the guidelines she and colleagues have written entitled Group Psychological ‘Debriefs’ - Practice guidance for post event team reflection following distressing events at work. Published by the Association of Clinical Psychologists and authored by Sadie, Dr Harriet Conniff, Dr Joanna Farrington-Exley, Dr Zoe Berger and Dr Julie Highfield. Psychological debriefs have been a somewhat controversial area. So I started by asking Sadie to give us a sense of some of the context around this.

So the controversy around debriefs really dates back to the 2005 NICE guidance. So in 2005, NICE produced some guidance around the prevention and treatment of post traumatic stress disorder. And in that guidance, it recommended against the use of single session debriefing for the treatment or prevention of PTSD. And it did that based on an earlier Cochrane Review, which found that the use of single session debriefing was ineffective in preventing post traumatic stress disorder and in fact, in two studies had been indicated to potentially be harmful. Now, this was particularly tricky because by at this time, debriefing was already in pretty common use in many first responder services and health care providers, following a paper in 1983, published by Mitchell, which outlined a model called critical incident stress debriefing, which had been designed to support first responders and emergency services after they'd been involved in potentially traumatic events. And so the practice was already pretty widespread, and then the NICE guidance came out, it's recommending against it, which I think caused a real challenge for a lot of psychologists and mental health professionals.

Yeah, it's really interesting, actually, because I was thinking about, I know it's a different context, but I grew up in Johannesburg in the 80s, and 90s and there was huge levels of violent crime. And, you know, one of the standard kind of protocol was to have a debrief, a single session debrief, whether that was with families or individuals, and unfortunately, had to experience that myself. And then, when I came of age as a psychologist, which was post, around 2005, I guess, realising this wasn't the thing, you know, that there was a danger around it, where it you know, it had been, yeah, really like standard practice.

Absolutely. And it's one of the very few interventions, like it's one of the very few psychological interventions that's been associated with causing harm. If you think about it, that's not something, that's not something that as psychologists we've had to experience very much of, so I think it has been particularly problematic, but but actually, when you start to look at the evidence base in some more detail, it becomes apparent that the picture is probably a lot more complicated than that headline suggests. And in fairness, the the NICE guidance doesn't step, it is clear about what, why it makes its recommendations on the evidence, but I think a lot of people perhaps haven't haven't necessarily always read the full NICE guidance, they've only read the headlines, or they certainly probably haven't looked at the Cochrane review itself. And so there's developed I think, a concern about the practice, which I think is justified, I think we should be very cautious. So for some, given the fact that I do a lot of it and I've obviously been an author on the guidelines, I actually advocate for a very cautious approach to creating these spaces for staff after difficult events, but but if you look at the evidence base, then well, first, first and foremost, it's about debriefing for the purpose of preventing Post Traumatic Stress Disorder or treating Post Traumatic Stress Disorder. And that's understandable that they looked at it for that purpose, because that's actually what most of the literature, early literature was exploring. But in reality, I think most psychologists aren't, aren't debriefing for the purpose of trying to prevent Post Traumatic Stress Disorder, that's usually not even on their thinking, actually, I think often we're using this kind of model or this space for quite different purpose. So the evidence base doesn't really relate to the purpose of which we would use it. But the other thing is actually, most of the studies that were included in the Cochrane Review, including the two where some evidence of harm was shown, we're using debriefing with primary victims. So a bit like what you were describing, perhaps, when you were younger, but actually, the model that's had the most attention, which is critical incident stress debriefing, wasn't designed to be used with primary victims, it was designed to be used with, with or in organisational settings with, you know, healthcare staff or first responders. So the application of that model to that client group, it essentially means they weren't using it for its intended purpose. So they weren't using it for its intended purpose and they weren't using it with its intended group. What the NICE guidance and the Cochrane Review showed that single session debriefing, particularly with individuals who were the primary victims of trauma might be problematic and there was some evidence to suggest that. But that's clearly quite a different thing to using, using debriefing with a team who were, who are, by definition, a secondary victim or you know, experiencing vicarious trauma.

Yeah. And my understanding around the harm that came out of those studies was about re-traumatising people through the process. Is that right? And that, you know, being too detailed about that picture was not helpful.

No, exactly. So there was, and there was something about the conditions of which those people were invited, you know, how much choice they had about participating in the space. And, again, this speaks to intention, so debriefing in that purpose was around preventing trauma. So often the mechanism used was this idea of like reprocessing. So y'know, which, as therapists, many of us will be familiar with, kind of maybe in their kind of trauma focused CBT space, where you would intentionally create a space for somebody to work through a traumatic event. But of course, in the context of debrief, single session debriefing that's happening without any of this protect, you know, without any of the mechanisms we would normally put in place in terms of ensuring that people are ready to be able to do that work and have the ability to ground themselves, etc, none of that, none of that happens. So it's, it's probably not that shocking, actually, that if you mandate somebody to come, particularly in a group setting, to talk about a highly traumatic event, and then, and then make them talk about it in detail, I suspect for you know, for most practitioner psychologists, we wouldn't be surprised to find out that that wasn't a good idea. That's quite different to the processes that have been, that we've been talking about in terms of supporting staff after difficult events.

So how would you define, or how do the guidelines define debriefing in this context of staff support?

So for me debriefing in staff support is best understood as a post event reflective space. And that's why we actually made the choice to call the guidelines, Post Event Team Reflections, or PETRs, how we refer to it, because we felt describing it as a reflective space was a much more accurate description of actually what we're aiming to do in that space. So in a staff support context, typically when we create those reflective spaces for staff after distressing or potentially traumatic events, it's not for the purpose of processing trauma. But, but simply actually to create a space for, for the staff to develop a shared understanding of what happened and a shared story of what they've been through together. And then to have the opportunity to ask any questions and address any sort of misunderstandings or concerns about, about the event. And then, the really key thing is to create a space for them to, to build upon that shared story to get a sense of cohesion, connection with colleagues, collective efficacy, so individual, an individual sense of self efficacy, but also a collective sense of self efficacy, a collective community efficacy, and, and hopefully, draw a sense of meaning and connection with their values through this reflective conversation. So I hope what we're doing in that space is validating the humanity of their experience of taking, taking a moment to pause and acknowledge that this group of people have been through something, something that mattered to them. And so the aims in that context are hopefully really quite different to the aims of kind of some of the other models of debriefing.

And could you talk us through what this process looks like, what the model is, what a session would look like?

Yeah, absolutely. So, firstly, the process of post event team reflections begins before the room. So the really, the really important thing is in the preparation phase, and probably the most, most important element of this thing, this whole thing is the preparation. So for us in our organisation that starts with a request coming from a clinical team, so I work in a physical health setting. So a clinical team would put a request into staff support for somebody to come and facilitate a space. And we would arrange a consultation with that requester. And when we did that consultation, we'd be trying to do a number of things. So we'd be doing essentially a bit, a piece of assessment. So we're really formulating, so why, why the request at this time for this team about this event. And drawing up a bit, an initial psychological understanding of what it might be that's leading to this request at this time. So we're doing a bit of assessment work. But we're and we're starting to hypothesise at what the psychological function of a reflective space might need to be, like, what would it be? What would the purpose of it be? What would we be hoping to achieve? And also we're talking through and looking for any factors that might make us think that debrief wouldn't be appropriate. So for example, if the team was in really, y'know like really difficult relationships, and was not really, you know, perhaps struggling, not functioning well at the time, and then they had a distressing event, we would certainly pause and think about whether it was going to be useful and appropriate to bring that team together to talk about what is in addition to their baseline level of difficulty to then talk about something that was difficult. On top of that, we might suggest that one to one support would be more appropriate. And then there's other factors that we would consider around things that might suggest that we shouldn't do a debrief. So we'd be, we'd be considering that with the requester. But also then letting the requester know what it's going to look like, know what we expect from them. So this is really important, again, anyone who's been involved in debrief will probably be able to relate to this. It's the amount of times if you don't do that prep, right, the person that requests it comes in, usually because they're trying to help, sort of tries to lead the process or sort of interjects and does stuff that you think oh, it's not, it was kind of a reason I hadn't done that, actually, and I was intentionally leaving silence and, and so being really having an upfront conversation and saying, this is how we're going to do it, and this is why, it really helps to set up, set up the meeting. And then finally, it's a chance to identify whether there's any people that we should be particularly concerned about, that there's you know, that they know about that we should think about whether they come or whether you know whether we just need to touch base with them. So there's the preparation phase, then there's the reflective space itself, which relative to the preparation phase, in some ways is straightforward. And that, this looks a little bit like some other models at the surface, but actually what we're trying to achieve through the conversation is quite different. So typically, we do ground rules, and explain the purpose, explain the purpose of the session, and then we would do a period of storytelling, so an invitation to tell the story of the event. But we would be explaining to them at the beginning, that we are not looking to elicit kind of sensory descriptions, we are not trying to paint a picture of the event, we're trying to get a high level description, what happened when, for the purpose of putting the jigsaw together and we often will use that metaphor for other people that are attended. If we've already identified it was likely to be a very traumatic event, then we may skip the storytelling stage altogether. So we'll, there's a judgement call, it's usually made before about whether you're going to engage in storytelling, but if you, if we think it would be appropriate and helpful for the team to do that, then we'll do it. So we do the storytelling and the team contribute to that, and we our job just really is to elicit openly contributions, so we don't put anyone on the spot. I think that's really key. So there's no and X, can you can you tell me about this or why, how did you feel when that happened? I mean, there's no how did you feel when that happened as wel This is when we're retelling the story, we're not eliciting thoughts and feelings, this is just high level 'and then this happened and then this happened'. Once we've done the storytelling we, we come on to the come on to the section where we start to think about how we've been since. So what's the impact of, impact of this event on you. And that's when we may then start to ask a few open questions about how people have been feeling and thinking since the event. But again, taking real care to avoid putting anyone on the spot, so we tend to ask these questions in an open way to the whole group. So people can chip in if they feel comfortable, they can step out if they don't, I mean, they can literally step out, but also they can kind of mentally step out, and part of the ground rules is to talk about that, about the ability to just mentally step out of the space as well as physically. Then once we've done that stage, we're going to start thinking about meaning making, and fostering connection and cohesion, and listening, and hopefully we'll have be doing this the whole way through, but listening for threads of hope. So one of the kind of ideas that we're using that sits underneath this process, this reflective processes is the principles of psychological first aid. So that self efficacy, that community efficacy, connectedness, sense of calm, and really critically hope. And that's where someone with skill, I think comes with real skill comes in, in listening for the hope, and hearing, hearing the threads of it and being able to reflect that back. Some of that's about kind of using ideas that we might use in I don't know, ACT, or CFT, where we're perhaps we're thinking about three phrases of compassion, for example, but also thinking about values and intention. So when you woke up, when you woke up on that, in that morning, and you left your house to come to work, what was your best hope for the day? I think even when things have been extremely difficult, even when care did not go the way the staff team hoped that invariably their intentions were good. And helping people to reconnect with that, their intentions can be extraordinarily helpful for when a team have been involved in an episode of care that perhaps felt, perhaps felt like it didn't go as it should, which I think is one of the trickiest situations to bring a team together for. We then do a bit, can do a bit of psychoeducation. Now, you might do that before the meaning making or after it really is a flexible model, so it depends on when it feels helpful. The purpose of psychoeducation would be really around normalising staff responses. This is the big thing about this space really is about, is about normalising and getting people to realise that they're not on their own with however they're feeling. But it's also then also about potentially signposting people on, so letting people know when they might want to go and consider other access to support if they feel they need it. And it, the final stage would be the signposting and the agreeing any actions or next steps. Because we're not debriefing for the purpose of learning, we're, that isn't the primary function, but it's obviously not banned. So if as you're doing this, as we're facilitating the space, if some learning shows up, and it feels like that would be helpful, then we would normally contract in the you know, in the moment whether everyone in the room is happy for that to be shared and who that will be shared with, and who that will be shared by. I think as a facilitator, you need to be quite careful about not getting too embedded in that process. You know I think sometimes we can be tempted to offer to do the sharing on behalf, and sometimes we have to because there isn't an obvious other person. But I actually tend to view that as a barrier to communication, you're adding a barrier of communication between the team and wherever they need to communicate by putting ourselves in the middle of it. So I'd much rather use that space to help them think about how they'll do it. Otherwise, I think it's not as helpful as we intended some times. And that's the process and then there should be a follow up. So I guess the thing to say about the PETR model, and this isn't y'know true of I think a lot of the guidance now is that it's we're not proposing that this should be a single session, single offer. So I think this reflective space should be part of a menu of choices for staff after, it shouldn't be this or nothing. It's clearly not, I guess that's the other thing I haven't said actually, although I've alluded to, this is optional, it is absolutely optional. People should only come to these spaces if they feel like that fits with their preferred way of coping. So talk as, people know, usually, if they're a talker, they're going to find it helpful versus somebody who prefers not to do that. So, so they should only come if they want to, but of course, they can only make that choice in an informed way, if they've been fully briefed on what, on what to expect, before and after. And ideally, they can only make an informed choice if there is a choice. So there has to be something else. So really, we should be putting it alongside the provision of some support, some sort of one to one offer, whether that's something like TRIM or another, you know, one to one slots with psychology or other suitable services. And similarly, a follow up. So in the PETR model, we don't have any, we suggest that you should follow up and somebody should touch base with the team. There's not sort of a formal, a formal process. But it is really important that we shouldn't parachute in, do it and then disappear, and then never know whether it was helpful or not. So something about evaluation, I think is really important. But there's also something about some ongoing communication with that team to check that we met the needs, that we had identified collaboratively with them and whether there's anything else we should be doing. So that's three stages. So prepare, meet and follow up.

Yeah, brilliant. Thank you. And I guess just one thought I had was about how, and I don't know if this is a silly question, but how do we define what kind of event would indicate a debrief?

I don't think it's a silly question at all, and again, I don't think because, it's because it's so not a silly question, I don't think there's actually a straightforward answer. Because I think it's dependent on a lot of different factors. I think it can be really varied. I think we've created these reflective spaces, I've certainly been involved in creating reflect spaces after a really large array of trigger scenarios, or precipitating events. I think it's, for me, it's any event where a group, team have gone through, where I feel they might benefit from participating in, in a space for the purpose of reflection. And when I say event, the thing about the PETR model is it's been designed to be able to be used after like an episode of time, you know, after an episode of care or a period of time. So it's not the model doesn't require a single event at all, actually, because as hopefully I've just described, this is much less, this isn't, this isn't about processing a specific unit of time, this is about sharing the story of an experience. So that could be a year, year long piece of, episode of care with a client, for example, you could do a PETR after that. The storytelling would tell the story of the year. The reflections and the meaning making would be this, how did it how, how have you felt since this came to an end? What's been showing up for you? The process works equally well actually, for big things and small things. So I think it could work after a single event, I think it can work after a period of time. That so, practical examples, that might be the death of a patient, and that might be the death of a really well regarded patient, you know, a patient that was that the team knew very well and really cared about. That might be the death of a patient where the team had struggled to find a way of relating to them, and they struggled to find one, that brings a very different psychological burden, I think. Or it might be, it might be a sudden and difficult, a difficult death. So I think when you do them it can be hugely varied. But I think there are some scenarios where we have to be very careful about whether you do them or not. Would it be helpful to talk about that?

Yeah. Say more about that, yeah.

So, so, we differentiate between distressing and traumatic events effectively. So, a distressing event, the well loved patient that dies and expected death. And actually, the primary psychological need or experience is one of grief and loss and sadness. Creating a reflective space to acknowledge that, to acknowledge the impact that client or patient had on you as an individual and as a team, to remember them and to, to honour their relation, their memory and their relationship with you can be a beautiful, a beautiful reason to come together and create a reflective space. You could contrast that with a unexpected, highly distressing, visually distressing perhaps, you know, someone might use the word horrific, horrific death where perhaps is accompanied by sites that were, would be extraordinarily distressing to see and I guess crucially, out of the normal for that team. Now, in that case, perhaps where they were confronted by something that is not there every day, so for them, maybe experienced as traumatic, perhaps it's particularly horrific what they had to see, I'd want to be very cautious about bringing that group together. Now, it's not to say we can't do it, but I think you need to be very cautious about it and want to have a very careful conversation with that clinical, whoever was requesting it, to think about it, I'd want to be very careful about who was attending. So they need to be a homogenous group in relation to the experience. So give you a practical example. Say it's a, say it's a physical health setting, for example, say a patient dies in a mass bleed. And I'm not going to describe it too much, but say that it was quite visual. Now, five clinicians are in the room at the time trying to manage it, they all had the same exposure to the event, they saw the same things. So if they make an informed choice, to come and talk about the event, in any, we're not gonna talk about in detail anyway, but if they make an informed choice to come and talk about it at some level, they know what it is they're coming to talk about. They were there. We're not adding new imagery, we're not adding new information, they were there the first time, they saw it. In that context, I want to be very careful about whether the reception, ward receptionist comes. Now quite typically, I think, teams that people do debriefs, and they do allow the whole team to, you know, and the ward receptionist might come, and I guess our feeling is that we just need to be really thoughtful about that, actually, is it helpful for that receptionist, to now hear that stuff. Because that wasn't, that wasn't in their experience, they didn't have that experience. So think about those, so again, so one of the options there might be to not, would be a) to carefully control who comes in, offer more than one space. So that's how we usually would do that. If there's multiple teams or multiple individuals involved, who might have quite different perspectives, then we might offer more than one space. Or you might skip the storytelling phase. So we might say, we're not going to, we're not going to go, we're not going to go through the pieces, what we're going to do is we're gonna ask one person to provide a brief overview. And then, you know, and we prep them for that. So usually two to five minutes, high level stuff, we've explained to them why we're keeping it at this high level, no descriptions, space, and then we go straight into the kind of later phase of the PETA, which is around how have you been since? So we pick the start of this up with how have you been since? So I think it's, I think events like that, the other one is, you know, the key one, actually, if it's not traumatic because we're worried about the sort of horror of the event then the, then the other reason would be because of personal threat. So very careful about bringing a group together when, if a member of staff, for example, has been experienced some sort of violence and aggression or assault. And again, it's not to say you can't do it, but you need to be very cautious and thoughtful about how that's going to feel for them to hear other people describe that because they are a primary, because the you know, that then speaks to this issue about being a primary victim, they actually are a primary victim. So that would be the one we'd be the least likely to bring the group together and would really only do it if we'd had some reasonably extensive conversations with the person that was the primary victim. And even then, to be honest, I can't think of a time we've done that in recent, in recent times.

Okay. Yeah, that's really helpful. And I'm wondering about timing. How do you decide when, how far after the event or the end of the episode to hold the debrief?

So this is really tricky, because I guess, you know, what we're talking about is that we're operating in a space, I just think we need to be really open and honest about this. We're operating in a space where there isn't a good evidence base in favour of, in favour of this work and, and so I think, I mean, if anyone has a definite idea, I'd be, I'd be surprised, I'd be curious as to how they have it, I certainly don't, because there isn't any, there isn't anything from any empirical literature to really support doing them at any given time. I think some of the models go quite, so some of the models err towards sort of earlier. So critical incident strategy briefing, for example, tends to be a little bit earlier. I think some psychologists err towards being a bit later. There is actually a, I've been involved in a study that's just looked at psychologists perspectives on debriefing, and one of the, one of the outcomes of that wasn't a psychologist concern about not going too soon. So there was much more concern around being too soon then too late. We tend to think you tend to go for around a week or two weeks. Again, I think the key thing is that you want to match your timing up with what you understand to be the primary need. So what I mean by that is, if when you're doing that assessment, if you think, actually probably, you know, from during the consultation, you think I think there's just a sense that people need to understand what happened here. Because people have got a lot of questions, they don't really understand how we went from A to B to C. I would say if the issue is primarily one of getting questions answered, you probably want to go a bit, you probably want to go a bit quicker, because those are the things that are waking people up at night. Y'know, these are the two in the morning, 'did I do the right thing?' causing distress. And actually, if you can get that addressed, then actually can reduce a lot of anxiety. I think if you when you do the consultation, you think like this is absolutely this primarily about making, making meaning and connecting of our sense of values or connecting with each other. For example, I don't know perhaps if it was an event where you thought there was probably a lot of moral distress and so you really wanted to help people connect with their kind of sense of purpose and values and foster team cohesion, then I think there's some merit in perhaps having a bit more of a pause and breathing space to allow people to occupy that really, really reflective headspace. So, ideally, I think we should match timing with our assessed needs. But it is I think, y'know I don't think it's a clear answer and there's a real, real need for further research to address that, and I think that's one of many questions that need addressing.

And another question about timing, how long is the session?

So they vary, so I think usually say about 90 minutes. We quite often have to do them in 60, just because the teams that we're working with can't find a way of doing them in 90. But I've got to say 60 is a struggle, like in, in practice, it's really hard to get it done that quickly. And sometimes you want two, you know, sometimes you do want two hours, I think there's something about tire, not tiring people out. Like we have to remember, our stamina might not be the same as theirs. And, and you know, for us, obviously, it's not resonating in the way that it is for them. So I think 90 is probably ideal. But again, this is operating in the absence of any solid evidence base. So I think this is about clinical judgement, effectively.

And I'm just thinking about some of the practicalities around that, just thinking about staff having an experience like that, and then going back on the wards.

Absolutely.

How do you...?

How do you manage it? Yeah, it's really difficult. So I think one of the, so one of the things that we do is we try and make sure that the psychologist is got longer than the debrief time, so that we can just stay in the room where, and just hang around, and we say to, so especially if it's face to face, and we do quite a lot remotely now, but if it's face to face, just to say, well, we actually I'm just going to sit here for another 10-15 minutes, please pop back in. And actually my experience is that stuff often do pop back. So they all leave because I guess it's only quite visible about not leaving, and then you'll get a certain number that sort of double back and just want to, usually just want to say a couple of things that following on from it. That final stage is about, which I probably didn't talk about, so the process for the final stage of the PETR is the very final bit is about helping them to think about how they reenter the next bit of their day. So often that might look like so, we've come to the end of the space, the space today, and I've heard you talk about X Y Z, I'm wondering now how you can help yourself to move from this space here with the team into wherever it is you're gonna go next, what are you going to do to help yourself? And even just asking that question, I think gets people, I think it does a couple of things. Most important, it gets them to acknowledge that they're moving space. I think that's part of the thing often because we often don't recognise that do we? We're so busy, we just sort of fall between things, like we're just like free-falling from one space to another. So I think it's about just getting them to mark it in their mind that oh, yeah, that's ended, I'm going there. Somebody's obviously cueing them to think about what they need, is in itself helpful, and they'll often say, I'm gonna go grab a drink, or I'm going to, I'll make sure I just take a couple of breaths. On occasion I've been known, I've been known to invite people to do a grounding exercise at the beginning and or end of reflective spaces. I don't always do it at all actually, it's depends on context, but I think it can be, it can be really helpful. And you know, just something like the five senses or gives them their feet in the ground or something like that, something very basic, can be really helpful. But I think it's a really important consideration, a really important consideration in terms of that moving. The thing that's nice about a team is they're usually going to move into the next space together. So most of the time, they'll probably go in they'll leave this space and go to the next one together. And actually what you see then is them chatting as they leave. Often actually, often when quite lovely way, because they're often feeling very connected and you know, there's a whole, you've fostered cohesion in them, so you sort of watch that as they walk out. It's a challenge online, particularly if you've got staff joining from home, which I think is probably quite I mean, that's certainly common for us. They might choose to work from home because they know that they'll have peace and quiet to join the space. And I think that often, you know that I think that feels really hard knowing, especially if it was hard, and you don't manage you, it doesn't end kind of that hopefully. And we are always trying to thread hope, but obviously we have to, we have to honour the experience that they've had, so we can't just be shoehorning hope and positivity where it isn't there, that obviously wouldn't be helpful. So I think that that can feel a bit tricky. Really, ideally, as part of your kind of working up that prep process, there's some thought around that. So and again, this does depend on your asking, is there anyone you're particularly worried about to the person that's requesting it. They usually know. So one of the things we're saying is, well, would it be okay, if we feel worried, would you be okay to check in with them afterwards? Could you give them a quick call? And again, part of the ground rules, certainly, certainly the pattern that I use, includes if you know if at any time you feel distressed and you need to leave or if, you know, if we observed that we think you might need some support, we might just, we might just get in contact, we might ask X to just touch base with you. But it's just to check if you're okay. To hopefully really wrap people up in a sense of being thought about and cared about.

Any other considerations for doing it online?

Yeah, I mean, so when I first did it, I was really frightened. So the first time I did one online was really early, actually into COVID, and I was really nervous, and there was practical things, so there's practically it's like, knowing people's names, because sometimes they're on the screen, but sometimes it's not, and sometimes you have things like des, you know, if you're in a teams call and it just says like 578, and you think well, I don't want to call you 578 halfway through, you know. So it's little things like that, like taking the time to write things down that I would not necessarily have to do if I was face to face there. There's absolutely about the mopping up at the end. Think about agreeing the rules over if you know if your connection drops out, come in, please do just rejoin. Checking that you know everyone, so one of the important questions to ask on an online one is does, is everyone here? How do we phrase it? So I usually say something along the lines of can I just check, is everyone here who were expecting to be here? And that way, because there's a confi... you know, I mean, the link, obviously, you would hope wouldn't have been shared. But I think it is prudent to be a bit thoughtful about just checking that somebody hasn't sort of dropped into his meetings that would never happen physically, everyone would notice if there was somebody there., but online, it can be a bit trickier. I think numbers are tricky. So I think I mean, I'm reasonably comfortable facilitating reflective spaces with reasonably large groups face to face, and I don't, that feels okay. I think online, it's a different thing. So I'd prefer to have less people. I think the real one is, we've got mixed, so online and face to face in the same, which is pretty common. What, what we've learned is that, that we find is that the best thing to do is to try and facilitate in the same mode as the majority of your attendees. So, so if you've got 14 people attending and 10 are going to be online and 4 are going to be in a room, you be online as a facilitator. If the other of the opposite is true, and 10 people are in the room, and four people are online, be in the room. So I just, you know, there just seems to be slightly easier to hold the space. I think if you're doing, we always do them in twos. So it's worth saying that actually, you know, not everywhere, I think some psychologists have different thoughts about that. And the guidelines, we suggest that two would be optimum. We do that, really, so there's somebody to... well there's a couple of functions, one of which is that somebody can follow up if anyone's distressed, because if you're trying to hold that space, and it's so like, it's really hard work actually, really, I'm really concentrating. Actually, I you know, I'm not confident that on my own, especially with a bigger group, particularly if it's complex, that I can hold the process and keep a really good eye on the emotional temperature of the space, so for me a second facilitators job is to be really keeping an eye on the emotional temperature of the room and join my attention to anything if I need to, I don't mean signalling somebody out, but you know, pausing me and just asking an open question that might help me to realise and or to realise afterwards to say, oh, actually, I was a bit worried about that person there. It's probably worth just going and seeing if we could check on them or it's worth asking the manager to just double, y'know just to go and check and say Hi and check they're doing okay. Now obviously online that's much more difficult, but I think more important to have a second person because they can do that. And if you've got mixed attendees, then what we tend to do, well, then obviously, we've got two people, you put one in one in one. So you'd have one online, one in the room. And if you can't do that, for any reason, have one with specific responsibility for one aspect. So have your second facilitator and say, your job is to monitor the online room. I'm physically in the room, so can you keep an eye on all the online people? Or vice versa. I think that really helps.

And cameras on or off?

So cameras on, cameras on but... so yeah, so when I did this very first one that I did online, it was really, it was actually quite big. And, and it was mixed. So it was a roomful of people plus about 10 people joining online. And they took, they turned their cameras off at random stages during the, during the space and I was so really stressed actually, because I was really worried that they were okay, is it I've done something terrible, I'm doing a terrible job. Actually, I sent out an evaluation form after it. And they talked about how brilliant it was to join online and to have the option of turning their camera off when they felt too distressed, and that it felt really safe and helpful for them. And so I you know, I've held that in mind, actually, I thought, okay, so that's reassuring, isn't it? So I see to turn your camera off is the equivalent to stepping out the room. We encourage people, if they're physically in the room, we would we encourage and we do everything we can to make it as comfortable as possible for somebody to step out if they need to. Turning your cameras off, I think it's got the same function, so we probably should encourage it as much. I actually think that's one of the few really great things about doing them online is that I do think it makes it that much easier for people to step out of the space if they want to. Because with have the best will in the world, it's clearly hard for somebody to physically leave a room. And that's again, why I think that preparation phase is so important. Because we really need to try not get those people in the room, that we really don't want people in the room that it's not a good space for them, because it's very hard for them to get back out of. With that in mind, one of the things that I try and hold in mind when I'm facilitating a reflective space is, I try as best I can to facilitate for the person that I think is the most vulnerable in the room. And so part of that's based on the assessment information. So for example, if there was, I don't know, maybe somebody, maybe the manager or whoever's requested it has flagged that member staff was particularly, has been particularly distressed or worried about the event, then that I'll be, I'll be holding that in mind. And when I'm facilitating I'll be a keeping a particular eye on them or asking the second facilitator to, but given what I know about their, their experience and their story, and we may have also spoken to them if we were really worried as well, just to check that they want to come and that it's the right space, etc. And I'll be thinking, if I asked, you know, you get these points, and you think, Oh, I just desperately want to ask this question. You know, somebody says something you think I'm just so interested in what like, what maybe they were thinking at that point, never in this storytelling bit, in the phase after, you might really want to ask, well, what, what did that mean to them? Or? And I think we have to try and do is think well, why do I want to ask that? Is that about me satisfying my curiosity, which you know, it's particularly for practitioners, psychologists, obviously, is a skill that we've spent years cultivating intentionally. So is this me kind of just really wanting to understand because it's interesting and because I'm used to constantly assessing and formulating? Or is this going to perform a psychological function for that person if I ask that question? And then because it's a group setting, you have to take an extra step. So okay, maybe that will perform this function for you. But how is it going to feel for them? You know, so if I ask you this, but that person's already alluded to, maybe I don't know, experiencing guilt, and I asked you this, what's that gonna look like for you. So holding in mind, that person, the person or the persons that you've identified is perhaps carrying a bit more vulnerability in relation to this experience, and keeping it pitched for them. And what that means is, it means that these spaces aren't always, they're not that, they're often not that sort of, psychologically sparkle, you know, they there's often not these great epiphanies or magical moments where everyone has these kind of sense of ah, kind of know who I am and what I'm about now, because actually, we need to be really careful. We just need to be really careful. And I'd rather have a, create a space that doesn't have any psychology glitter, but it's okay. It's just okay and it's helpful. It's not amazingly helpful, it's just helpful. So I think holding that in mind is really, is really key.

And how, on the back of that, how do you evaluate the effectiveness of the sessions?

Yeah, so I, so again, I think this is a real like it's an issue. We're not really, we're evaluating the acceptability of the intervention. So we're, we're looking at staff experience. So we, every attendee of every one of our reflective spaces gets sent a form. Well, you know, unless something untoward happens with an email or whatever, but they should do, that's our process. And it's an anonymised form, asking about their experience. And we ask questions like, you know, did you feel, did you understand what was, what the space was for? Did you know what to expect for we came? What else did we ask? Did you feel safe to raise difficult thoughts and feelings? Did the facilitator style fit, kind of fit your needs? Those sorts of things. Would you recommend this space, was the space useful for you? So we asked those sorts of, we asked those experience questions, and we asked them after every one and we monitor them. But I think it's important to recognise that that's, you know, effectively, we're measuring acceptability of the intervention, which is not the same as measuring efficacy. And I, I think that's the case for most people and again, I think a problem. So I think it's a real challenge to measure effectiveness, actually. I think we should measure acceptability, I don't, I think it's easy to discount acceptability, actually, this is all about their experience, so their experience does matter, actually, if they you know, if they say that's a helpful experience, then I think they deserve to be listened to. And similarly, if they say that isn't a helpful experience, they definitely need to be listened to. But I think we do need to remember that that is not the end story here and we do need to be thinking about efficacy. I think efficacy has been hard to think about because of this issue over purpose of debriefs. So I think there's been a lack of clarity for a lot of practitioners around why they're doing it, there's, you know, there's almost a sense of like, oh, something's happened, so you do a debrief. And not really a pause of well, okay, well, but what is the purpose of that debrief at that time? I think the more we can start to refine and be clear about our purpose, the more that will shine a light on what, what it is we're trying to make a difference on and will help us think about efficacy. So I hope that with regard to the model, PETR model, will start to think about, we'll start to think about connectedness and cohesion, looking at outcomes around that, we'll start to think about hope and efficacy, because I, my, my hope is that is the psychological elements that we're working on in that space. So that's what I think we should be looking to measure. But it's yeah, it's a work in progress.

And what, what would you say that because you've written the guidelines for practitioners, psychologists, published by the Association of Clinical Psychologists, what do you think clinical psychologists specifically bring to this process?

Yeah. So, so what I would say is, I'm not sure it is specific to clinical psychologists. I mean, I would certainly probably consider counselling psychologists and probably health psychologists as well, actually, so I think it's more practitioner psychologists. We wrote the guidelines with clinical psychologists in mind, because it was for the Association of Clinical Psychologists, and we were all clinical psychologists, so that felt most appropriate, but I do, I think they think about practitioner psychologist and what they can bring to this space. Thinking though, about clinical psychologists, for me, a PETR is not a manualized intervention, it's not designed to be a manualized intervention. This is a, this is a guide, you know, it's a guidance document, for a framework that you can use your clinical judgement, to apply when working with teams. And so the key there is clinical judgement. And I think that clinical judgement requires, or actually requires quite a lot of depth of knowledge, I think we are, we are expecting you to have a knowledge of mental health, a knowledge of trauma, a knowledge of risk assessment and risk management, a knowledge of group processes, and it's not a group therapy, but you do clearly need to have a reasonable understanding of group processes, and then a knowledge of of a range of psychological approaches, as I've already kind of alluded to, so drawing upon things from ACT, CFT, CBT. And I think that ability to use all of that different knowledge bases is I guess, one of the, one of the things that clinical psychologists bring to the party, I think, as clinical psychologists, I don't know about you Paula, but I've always, I always struggle with feeling like a jack of all trades. I'll be like I know a little bit about quite a lot of stuff and I've really struggled, I feel nervous, and I don't have the depth of knowledge in any particular area. I think in this context, if ever there was a context where that's good is this, because you absolutely want that breath. You want to be thinking systemically whilst you're in this space with people, but you also need to be understanding the individual factors that might be at play for people. So, so for me, I think the clinical cycle is the ability to use judgement. And the ability to draw upon a breadth of psychological theory, as well as an understanding of mental health, which makes them, makes it really important I think, that these spaces are facilitated by practitioner psychologists, certainly and often clinical psychologists within that. I think this came up actually, recently, I was asked this question because I know that a number of organisations facilitate debriefs, I think probably tends to be critical incident stress debriefs, actually, with non psychologists, and that is, that's an accepted way of doing it within that model. I think, I think the key thing is that the PETR has not been designed to be a manualised, and y'know it's not there, I don't know how it could be, we've got no evidence base yet, you know, we're extracting from one evidence, for example, the literature around psychological first aid or the literature around peer support, we're extracting from that and using it to help inform how to create these spaces. I think in the absence of really robust efficacy studies, we need to ensure a higher level of expertise from the facilitators, because they, because they ask us that they're using clinical judgement. And that, and that's why I think that feels really important. But I can, you know, it's not impossible to imagine that might change. I think, if we learned more about what the critical elements of these respective spaces were, then I think we'd be able to work out who, who had the right skills to facilitate them with more confidence,

And I'm curious about how you find doing this work? What's it like, from your point of view,

So, so it's pretty much the hardest thing I do, clinically, I would say. I mean, not always. So occasionally they're, they're like, really straightforward. Like, just really straightforward. They sort of do everything themselves, you know, you set it up, you do a hopefully, you obviously do the prep stuff, and then you do the ground rules and the expectations, you set it all up really nicely, and then it's almost like, it's almost like set a ball down a hill, and it just does its thing and it gets to the bottom of the hill, and it kind of comes, and then you stand there and you sort of gently mop it up, but it slows itself down actually. Sometimes it's so beautiful, takes the ball goes down that hill by itself, naturally loses pace towards the end, and all you have to do is put the gentlest of touches on it to bring it to a stop. So it can be incredibly straight, like really quite straightforward and kind of easy and beautiful and lovely. Often, though, I think it's significantly harder than that, you know, these are as complex... complexity upon complexity, as complex as multiple people experiencing this event in multiple ways, and you're trying to look out for all of, y'know, you're trying to look out for all of them, you're trying to guide them through a process and hopefully, you're really aware of the stuff that we've already talked about, you're really aware of the kind of areas that would be probably unhelpful to occupy. And so you're trying to guide them through that process and not, and not fall into any of these traps. And then you've got all the group dynamics stuff that can show up. So it's actually, it's extraordinarily difficult. So I find them really tiring. I have to use, or genuinely have to concentrate so hard. So I joke actually, because I'm terrible to have a second facilitator, it's awful second facilitating with me because I create no space for the second facilitator. I just do it, I sort of do the show by myself, and they do just end up bearing witness. But it's not, it's not because I don't want, it's not because I don't want to more actively involve them. But to be honest, it's because I'm working so hard, I'm concentrating so hard, but I can't actually process them as well if you see what I..., like, oh, would that be a good time to bring them in? Genuinely, I just don't usually have the mental space to consider that because I'm just scanning, thinking, judging, so much. So I find, so I find them really difficult and I get very nervous. And I mean, obviously I've done like, hundreds upon hundreds, I get very nervous before them still. Because, because they're a huge responsibility, actually. Because I really, I really care. Like, it kind of sounds naff, but I really, really do really genuinely care about our colleagues and about creating a space that's useful to them. And there's as I said, there's no manual in regards to this type of space. So you know, you've got to use a lot of judgement. I think I talked about this kind of glitter thing. So what I, my hope before I go into any debrief is I hope I'm going to create a space of like psychology glitter, and people are going to say these that, you know, I'm going to ask, I'm gonna such an insightful question that somebody is gonna say something that makes them like have this like epiphany moment, and they feel at one with the world and each other in the healthcare context and stuff. And that's what I hope is gonna happen. And, and every now and again, like it does, like every now and again, you do sort of have that and people will say stuff like, I once did one where people spontaneously clapped at the end, like not me, and they weren't clapping at me, they were just clapping at each other. Because there was just this sense that, you know, they really did get this sense of like, we all, we all came together, and we tried so hard. So they can have this, they can have this amazing beauty and deep, and I feel a deep sense of gratitude. Like that, I mean, that's the pervasive feeling I usually have at the end is a sense of gratitude, because actually, what you bear witness to is staff doing, it's doing extraordinary things through extraordinary challenge. And, and I sit there, and I think, gosh, we are so lucky to have you, we're just so lucky to have you. But most of the time, they're not glitter. Occasionally, they're, they're very far from glitter. Occasionally, they're like crowd control, you know, and actually, you're thinking, I've just got to get everyone through this space. And I just need to make sure we don't accidentally fall into talking about that. And like, we don't let that poor person end up feeling the focus of all the attention for the whole time. And so sometimes they're actually really hard. And they're just hard. And your outcome is just hope that it's useful, but you're very far away from glitter. And most of the time they're somewhere in between the two. So you know, your aim is it to be, to be helpful and useful, but probably won't have any psychological epiphanies. I find them emotional. So I guess that's the other thing is that because like I said, for me, usually it's gratitude, like and that makes me want to cry. But there is also something about obviously there's something about the sadness, I think there is think about and it's really worth thinking about actually, I think witnessing in that kind of, creating that reflective space, so you really open yourself and you are listening with your every fibre of your being listening to their story, obviously means you are opening yourself up to all of the pain and sadness and fear and whatever of guilt feelings that are coming out. And that clearly takes that clearly takes a toll. So I'm certainly much more disciplined now about what I have afterwards. So for the first few years, I would sort of do them and I wouldn't necessarily think a lot about creating space for myself afterwards. And I, you know, I mean, I probably wouldn't usually run straight into anything else, but I would potentially go into something quite quickly. And I really try to avoid doing that now and I know my colleagues do too, because I think they are hard work and you need to acknowledge that they're really hard, they're hard work.

Anything else that you feel is important to have in place for you to do this work or other colleagues?

Yeah. So. So I do think. So I think there is something about training, actually. And that's a tricky one, because there isn't an obvious training route at the minute. But I, but I think, so we train in our department, we train the staff, and I think the feedback we've had is that that is enormously useful to work through, to work through very specific scenarios. So hope, you know, I've talked a lot about hope and I really think it's important. It's actually obviously incredibly nuanced and skillful, to hear hope at times when there, where it feels very far away, you know, when a team are feeling really unhappy with how something went, to listen and hear the threads of hope, and find a way of reflecting that back that doesn't un-validate the pervasive feeling is actually an incredibly skillful, skillful thing. And I think practising and learning that through more working with more experienced facilitators is really, really helpful. So I think training's key. And having, having reflective spaces to reflect on the reflection as only psychologists can do. But I do think it's really important, actually. Because we're making, we're making judgments all the time. And I guess that's the other thing. This is broader than just the debriefs, I think this is about staff support. But one of things I often think about about staff support is how visible it is. So y'know, as clinical psychologists, for example, most of our work is decidedly not visible is it? It goes on in quiet, confidential cubes, where nobody sees them. And other than maybe getting some outcome data or evaluation data, effectively, what we do is really unseen. And so we're not, we're not exposed to scrutiny in our, in our work. When you do staff support, and particularly if you're doing anything with groups or teams, it's the opposite to that, it is really visible. And not only is it really visible, it is visible often by your peers, because you're usually creating these spaces in the culture that you work. And I think that's important because it allows you to make much clearer informed judgments about what would be appropriate and not, but it, I think it changes the psychological experience as a facilitator and it definitely it means that you've run the risk of your, your ego, talking rather a lot to you, and possibly allowed. And, and I think we need to be thinking about y'know, I think we need to be thinking about that. I think it's brave, I think is really brave to create these spaces and personally exposing, so there's something about how much experience you've got as a psychologist and what you know, so we don't, we only let, only certain people in our department would lead the facilitation, they would have undergone our training programme in the PETR model, and they would have seen, usually at least one but usually two, and actually what we actually say is, if you're not going to facilitate them regularly, ideally, at least once a month, you probably shouldn't be leading them because the skills required, I think it's very hard to maintain your skills if you leave too big a gap between them. So yeah, I guess those things and then the space and time, and I guess just watching how many you're doing. So you don't want to do too little, because I think it's hard to maintain your skills. But similarly, I think has to be very careful about doing too many, given the amount of sadness and pain you're going to be absorbing in that space.

And is there anything else Sadie, that's, that is important to you maybe on a, on a personal kind of level that helps support you and holding all of this for others?

Yeah. I don't. So I mean, for me, it's probably peer... like it's having the team. So when I started in the trust, I was the palliative care psychologist. That's how I came to this, really, that's how it came to staff support actually. And so it was pretty, initially it was actually just me doing them. And then and then some one of the other psychologists started doing them with me and, and I look back now and I think that, was actually really lonely. Like, and actually I don't, I'm so grateful now because we, because we y'know, there's a team of us that do them and you can go and catch somebody afterwards and say, I'm really struggling, I'm really worried I messed it up or I'm really worried I wasn't as helpful as I can be. And they can help you unpick that and talk about that. So I think having peers that you can feel vulnerable with and you can be really open and honest with is for me, is really critical.

Thank you for listening. If you've enjoyed this episode, please support the podcast by sharing it with others, posting about it on social media, or leaving a rating or review. I'd love to connect with you, so do come find me on LinkedIn or at my website. And do check out ACP-UK and everything it has to offer. All the links are in the show notes. Thanks again and until next time, take good care.