From the outset, it was a difficult piece of work. After the senior partner left a message outlining what had happened, he was hard to get hold of. We played phone tag for several days before we eventually spoke. Before committing to my working with the team, he wanted to meet me alone. Again, it was tricky to pin down a date. I felt his resistance. The push-pull of engaging with me. He was hesitant. Reluctant. I knew it was something he wanted to avoid. It was understandable. And on the afternoon of our meeting, when I get off the train, I too am full of a cold sense of dread.
The GP practice is housed in an enormous converted Victorian house on the outskirts of London. We meet in Richard’s consulting room. It’s a large, light room with big bay windows. When I comment on the room, he is quick to tell me: ‘all the rooms are like this’. Perhaps he wants me to know that he doesn’t have special privileges as senior partner? That everyone is treated equally? That it’s a good place to work?
As he organises some tea for us, I sit for a moment and wonder what it must have been like for him to discover his colleague slumped downstairs at his desk - a salaried GP in his thirties, who had taken his own life after working with the practice for the past three years.
The senior partner spends much of our meeting with his head in his hands. He is distraught. Confused. And, understandably, still in shock. He alternates between berating himself for ‘not being able to see it coming’, and worrying about the team: ‘how will they get over this?’ He wants advice. ‘What should I do? How can I pull them together?’ He feels he should lead them out of this. He tells me he cancelled a scheduled team meeting, ‘I didn’t know what to say…’ and his voice breaks with emotion.
What is reflective practice?
In the face of tragedy, the pull towards getting through to some indefinable place ‘on the other side’ is not uncommon. Feelings of grief and sorrow and trauma are uncomfortable. We want to erase or bypass them. The work I do with teams offers a place to process these feelings. I offer this ‘reflective practice’ with some teams on a regular basis. I also take on work like this; crisis intervention following a traumatic event, where the initial offer is usually three sessions with the whole team over a number of weeks.
On the day of the first meeting, people are reluctant to come into the room. The avoidance of the painful event is palpable. Staff distract themselves with a search for chairs, making tea, opening biscuits, idle chit chat and phone scrolling. Anything to delay focusing on the reason we have gathered together.
Suicide evokes extremely difficult and complex feelings. Obviously for family and close friends, but also, in this instance, for work colleagues. We spend an inordinate amount of time with people at work. We can work alongside them day after day, and in the aftermath of such an event, people can feel that this volume of hours should have translated into some clue as to their state of mind. But, as many relatives will attest, the emotional turmoil of a loved one can often be hidden or unavailable.
Reflective practice is underpinned by different theoretical models. My own approach is drawn from the work of Wilfred Bion, who applied psychanalytic theory to his work on groups and leadership, most notably with traumatised soldiers in World War II. Bion’s container-contained theory was developed from Melanie Klein’s work on the mother-child bond, where it is the role of the mother to bear and absorb her infant’s difficult emotional state, by holding and transforming them. The mother is, in effect, an emotional instructor to her child, essentially making an unbearable state more bearable.
Applied to a group, my role is to listen, absorb and bear witness to the difficult feelings. My role is not to give advice, accentuate the positive or jolly the team out of their feelings, however strong the pull might be towards either, or all of these things. At times, this process can involve interpreting what’s said in the room, as well as what’s being avoided – a crude example might be a long and detailed conversation about a broken chair that might really be saying something about a system that’s irreparable.
Expressing complex emotions
Over a six-week period, I meet with the team three times. The sessions are not easy. Full of avoidance, and pain, and a feeling that everyone in the room would rather be anywhere but there. It is my job to hold the space. But over the course of the sessions, the GPs and members of the wider primary care team are able to articulate that in a job where the ‘primary task’ is to try and make people better, they had lost a colleague. They felt they had failed. While knowing little about his life outside work, they were beset with the idea that as healthcare professionals, they should have known. As a group, they grappled with the agonising ‘what if? question that’s left in the wake of a suicide. Between them, they were also able to express the full range of complex emotions: sadness, grief, shock, guilt, denial and also anger.
What also happened gradually, was that the senior partner was able to express his feelings of guilt and responsibility. And given it was my role to facilitate, he was able to relinquish his role as leader who needed to save and rescue his staff. Instead, he was there as a participant, sharing his own complex feelings. His ability to be vulnerable and open meant that he felt less alone, and, as a consequence, the team members were able to move out of their fragmented and individualised shock, to a shared experience of grief, that allowed conflicting feelings to be expressed.
In my novel, The Family Retreat, the main character is a GP, on a restorative break with her family after a difficult work incident. Overwhelmed by the demands of a busy home and work life, she made an error with a patient. It’s not a terrible mistake but the incident has a domino effect, leading to a downward emotional spiral. For a woman who has always gone above and beyond for her patients, the incident leaves her racked with shame. She feels a failure. Whatever has held her together up until that point, collapses. Burnt out and stressed, she’s signed off sick. Then away on holiday, haunted by her previous mistake, she throws herself into a situation that will come to shatter their rural idyll.
In an NHS already stretched to capacity, mistakes do happen. Sometimes, as we know, there are devastating consequences for patients – but the emotional fallout for the professional can also be profound and life-altering. What might arise from a systemic breakdown can be experienced as a deeply personal failing. And with pressure on GPs and other staff exacerbated by Covid, the ongoing staff sickness and difficulties with retention, shows there is little sign of let up.
Reflective groups as essential interventions
The use of reflective practice groups is growing across NHS Trusts and, in a similar vein, the Balint Society has long since offered reflective and safe spaces for GPs to explore feelings about their patients and the complexities of the work. And, while universally seen to be an excellent model to prevent staff burnout, anecdotal evidence suggests many primary care teams are simply too busy to schedule these groups on a regular basis.
While reflective groups might seem a slight offer in the face of an over-stretched system, when I take my chair in one of the many ongoing groups I facilitate, I am repeatedly reminded of the power of words. The significance of a safe, nonjudgmental space. A meeting without an agenda. A time when a team can come together to reflect on their patients and how they are coping as a team. Above all, it is a place to feel in a system that is predominantly task-focused, and by doing so, staff are better able to ‘contain’ the emotional demands of the job, and work more effectively with their patients.
For Richard and his team, the crisis sessions were essential in helping them on their journey of reparation following such a terrible tragedy. Afterwards, members of the group expressed initial reservations about the process, but all concluded that, however painful, it was extremely helpful to come together as a group. I strongly believe all teams undergoing any traumatic event should be offered this kind of an intervention as part of their personal and team recovery. And as a facilitator who has seen the transformative power of these groups when offered on a regular basis, I would argue they should be an essential fixture in the diary, rather than a luxury ‘add-on’ when time and resources permit.
Bev Thomas worked for many years as a clinical psychologist in primary care in east London. Her work now focuses on supporting teams and organisations in the NHS. Her second novel, The Family Retreat is published by Faber.
This case study is an amalgam of several real cases to protect confidentiality.