What an Auschwitz survivor taught NHS safeguarding leads about resilience

Tony is a 46-year-old paediatrician and safeguarding lead for a large NHS Trust. He is married and has an eight-year-old daughter called Sophie. Tony is a smart, affable down-to-earth character – he's the sort of doctor who wears a tweed jacket in preference to a dark blue suite.

Until recently, he would have described himself as being tough-minded – he had to be, given the nature of his work. Early this year, he was sat at his kitchen table, at 3am, and he began to sob uncontrollably. His wife, understandably alarmed came down to find Tony with his head in his hands, crying. Next to him was an empty bottle of Pinot Grigio and his laptop, open at a report, which told the story of the mistreatment of a four-year old child.

The work of a safeguarding lead

NHS Safeguarding leads are responsible for overseeing services that protect the most vulnerable in society – children, those with learning difficulties and vulnerable adults. It's a tough and emotionally demanding job. Two factors interact to make the role particularly tough:

External – safeguarding leads usually have an additional senior clinician role which involves, amongst other tasks, managing the impact of structural changes in the NHS and the workload of staff. In other words, providing more with fewer resources. 

Internal – the psychological and emotional impact of the work. By the very nature of their work, safeguarding professionals are exposed to highly emotionally distressing material. For example, reviewing material relating to serious crimes against children or vulnerable adults; including the case management of child sexual abuse, significant abuse, the death of children, young people or adults. Exposure to such material takes a psychological and emotional toll on the professional.

Compassion fatigue, vicarious trauma, burnout

Safeguarding leads are at increased risk of developing secondary traumatic stress (also called vicarious stress, compassion fatigue, or burnout. This can manifest in the person experiencing a freeze–flight–fight response, where the person feels helpless or overwhelmed, starts to avoid situations that make them anxious, or conversely becomes irritable and aggressive. Other symptoms of secondary trauma include:

• feelings of hopelessness and burnout,
• inability to embrace complexity
• inability to listen
• anger and cynicism
• insomnia
• chronic exhaustion,
• anxiety
• physical ailments
• guilt

The steady and relentless 'drip, drip, drip' effect of seeing this traumatic material day in and day out, can cause demoralisation, pessimism and apathy. In turn, this can have serious consequences for the person's  physical and mental wellbeing; increasing the risk of burnout, mental health related sickness absence. This can ultimately result in valued and highly trained staff leaving the service altogether.

How do you build resilience in already resilient, seasoned professionals, who have seen it all before?

Most safeguarding leads are senior doctors or nurses and tend to be resilient, experienced professionals who have been around the block a few times. Because of their clinical backgrounds, most of them are also familiar with the standard stress anxiety models and techniques.

As a group, they tend to be scientist practitioners who expect sophisticated, intellectually robust, evidence-based methodologies and often need to be eased carefully into new, different and creative ways of overcoming problems. Safeguarding leads often have a background in mental health services and are already familiar with  the fundamentals of managing stress and anxiety.

For NHS England, the problem was; how do you help this group of tough, experienced professionals protect themselves from the risk of secondary trauma?

The Personal Resilience Programme was born from a partnership between NHS England and a independent consultancy firm. The programme was innovative in both its content and method of delivery.

The content combined an existential approach to psychological trauma, drawing on Viktor Frankl's work about his experience surviving Auschwitz [i]. This was combined with elements from cognitive behaviour therapy ('the stories we tell ourselves') and Nicholas Naseem Taleb's theory of Antifragile [ii]. In addition, the course included information on secondary trauma [iii].

Finding meaning in unbearable situations

On a chilly Autumn day in September 1942, Viktor Frankl [self-caricature, drawn around 1990, above], a Jewish psychiatrist, his wife and his parents, were arrested in Vienna, and transported to a Auschwitz. By 1945 his family, including his wife, had perished. Frankl managed somehow to survive. The following year he wrote one of the most profound books to be written about the holocaust and the human condition, Man's Search for Meaning, about his experiences in the camps.

In the book, Frankl concluded that the overwhelming difference between those who survived the camps and those did not, was the person's ability to find meaning and purpose in even in the most hopeless circumstances. Frankl wrote "Everything can be taken from a man but one thing, the last of the human freedoms – to choose one's attitude in any given set of circumstances, to choose one's own way."

For all its stress and trauma, the one thing that safeguarding work doesn't lack, is meaning and purpose. Unfortunately, the form filling box-ticking beaurocracy of the NHS often puts a barrier between the practitioner and the meaning inherent in the work [iv].

Our aim was to strengthen resilience in the group by helping them to strengthen their connection to the very real meaning and purpose in their work. Safeguarding work is hard – nothing will take away the stress – but connecting with the meaning and importance of the role will make almost any amount of stress, bearable.

Naseem Nicholas Taleb and Antifragile

Nassim Nicholas Taleb, in his book Antifragile, writes that most of us think that the opposite of fragile, is resilience. Taleb argues that this is wrong, suggesting that the real opposite of fragile is, in fact, antifragile. Antifragile is very different from resilience, because people, objects and systems that are antifragile actually get stronger when exposed to external stress; whereas, resilient things remain the same. 

Most things in nature are antifragile. The best example is your own body. Expose yourself to stress by exercising, you will get stronger.  Expose yourself to stress by taking a vaccine, your immune system becomes stronger. 

Taleb writes that in an environment that is too comfortable, people can develop a sense of entitlement where their ability and enthusiasm waste away. Just like the overprotective parent who goes on to produce a weak and fragile child, too little pressure destroys performance at work.  

A principle of Antifragile is that stress is only good when it is acute. In other words, when you have short bursts of stress, followed by periods of rest. It's like exercise: if you run three times a week you will get fitter, but if you run every day, without a rest period, you are likely to get injured.

Stress in safeguarding work (or indeed any type of work) is only bad when it is unrelenting – one thing after another, without any recovery time. This was the second theme of the course: resilience is a function of recovery time.

The delivery: How we used theatre techniques in the NHS

Traditionally, doctors and nurses get a lot of technical training involving lectures and death by PowerPoint. In contrast, this training was about feelings, and helping them to manage difficult feelings. The content and delivery of the course needed to reflect this.

Two facilitators delivered the programme: an experienced clinical psychologist and a specialist in drama-based learning. The delivery was interactive and immersive, using techniques from theatre including: storytelling, the use of theatrical masks, forum theatre and mime.

Drama is a very powerful tool in enabling people to examine their own attitudes, psychological processes and behaviour. All of us find it easier to look at someone else with an objective eye and offer words of wisdom, than to reflect on ourselves. This is especially so when the issues involved are difficult and sometimes painful as they often were for the safeguarding leads who participated in the programme.  Many had developed well-practiced coping strategies, which often became barriers to developing fresh approaches to dealing with trauma.

In the acted scenarios we used a real stage mask as a metaphor for the coping strategies that the safeguarding leads might have developed to deal with exposure to traumatic and difficult events. This is the 'front' they use to others and, sometimes, to themselves – "I'm fine!". Accepting that the mask can be useful and necessary, we sought to identify how it could also be problematic.

The group worked together with the character to 'lift the mask', to understand what was underneath it, when and why it comes down and what is necessary to reduce its destructive use. This simple metaphor was a useful tool for the participants to begin to understand and manage their own emotions and coping strategies.

Was it effective?

We delivered 11 full day events to 117 safeguarding leads and evaluated the effectiveness of the programme using pre- and post-measures of understanding of secondary trauma and its effects, awareness of personal triggers and confidence in one's ability to cope. We analysed the data using standard statistical measures.

The outcomes were impressive. Participants' understanding of key concepts, awareness of personal triggers and confidence in coping skills all improved, as a result of the training. There were significant differences between pre- and post-course ratings of understanding of key concepts such as 'burnout', 'secondary trauma' and 'vicarious trauma'; in ratings of awareness of personal triggers; and in ratings of confidence in personal coping strategies, in order to navigate the difficult work content, whilst looking after their own well-being.

The significant change in the latter two questions are particularly important, as they demonstrate the participants' ability to apply the knowledge to their own personal circumstances and understand how to make a difference for themselves.

We also gathered comments from the participants. The themes of this feedback were very interesting. There were many comments about how enjoyable the day had been; some saying that it was the best training day they had attended. People liked the drama-based approach and said that it was thought provoking and promoted discussion and reflection. People also commented on the practical outcomes and benefits; one person describing the programme as being 'life changing'. Another later reported that they had significantly altered their work-related behaviour as a result of the programme, in order to better protect their wellbeing.

Helpful for other professions?

Perhaps this cohort of professionals are generally adept at coping with work related stress and distress. However, the feedback on the experience and impact of the programme would suggest that this is not wholly a coping profession; therefore, we feel that this programme was relevant, important and necessary for this group.

We also felt that this approach to resilience may be helpful for other professions and organisations, both within the wider NHS and other sectors with senior people struggling with stress and burnout. The feedback also suggested that some people felt it would be beneficial for whole teams to receive this type of training as a work group. This would require more individualised consideration of context, systemic dynamics and team, rather than individual resilience. Others suggested the benefit of one-to-one sessions, and clinical supervision; this reflects a possible need for more person-centred, individual and ongoing support for work-related resilience. 

- Dr Mike Drayton is Clinical Psychologist and Director at Opus Performance Ltd 
[email protected]

- Ms Jessica Memarzia is a Trainee Clinical Psychologist with the University of East Anglia

- Dr Sarah Robinson is Patient Experience and Quality Manager, Nursing Directorate, NHS England - Midlands and East (East)  

Further reading

[i] Frankl, V. E. (1984). Man's search for meaning: An introduction to logotherapy. New York: Simon & Schuster

[ii] Taleb, N. (2012). Antifragile: Things that gain from disorder. New York: Random House.

[iii] Figley, C.R. (1995). Compassion fatigue as secondary traumatic stress disorder: An overview. In C.R. Figley (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York, NY: Brunner/Mazel. 


[iv] Menzies, I.E. (1959). 'The functioning of social systems as a defence against anxiety' in Containing Anxiety in Institutions : selected essays by Isabel Menzies-Lyth. London : Free Association Books (1988) pp. 43-88

See also our recent news report on the mental health of UK doctors