A. Descriptive statistics 

The majority of respondents (7 of 19) were Clinical Psychologists. The remainder came from other professions including different therapy modalities, a psychiatrist, an assistant psychologist, an administrator and a librarian. As regards levels of familiarity with CAT, there was 1 CAT supervisor, 8 CAT practitioners, and the remainder had either a non- specialist general awareness, or no awareness, of CAT. 11 were from mental health NHS trusts, 5 from acute NHS trusts, 2 from non-NHS organisations and 1 unstated. Most received the CSL indirectly from colleagues or via social media or the internet, with Twitter the most common route of access. All respondents from outside the local area were CAT practitioners or supervisors and found the CSL through social media.

B. Thematic Analysis

The six themes emerging from the analysis are described below.

1. I see me; I feel seen

One of the most striking elements of the feedback is the near universal resonance of the CSL to how the respondents themselves felt at the time, both personally and professionally. In seeing this named, it helped them to feel ‘seen’, validating and normalising their feelings and experiences during the early stages of the pandemic. It also enabled them to realise these were widely shared:

‘OMG, that’s me! Exhausted and jaded, wanting to hide away.’ (P3)

‘It was most helpful to have a list making the common struggles easily accessible and helping me to think and make things I was already thinking but hadn’t really named.’ (P10)

‘it was incredibly normalising to read the range of responses.’(P19)

Explicit recognition of the personal resonance of the CSL was most common amongst those with senior roles and those who were CAT qualified. This resonance appeared to be the impetus to share the CSL and to use it with colleagues and teams. It contributed to the ‘removal of “other” status’, and was ‘a tool for all.’ (P11)

2. Widely applicable and accessible

The CSL had been used in a wide variety of ways. Some respondents explicitly mentioned its influence on their own thinking and practice, in helping them reflect personally and professionally. A number had used it with clients. Most had used it as a tool to start discussions with staff: in reflective practice sessions, in team meetings and in individual meetings, as well as distributing it by email. Two had not shared it further.

The range of settings and staff the CSL had been used in and with is notable in its breadth. Settings included: in acute and urgent care, the Frontline19 support service for NHS staff, an administrative team, a community brain injury team and adult social care. Those it was shared and discussed with were: Nurses, healthcare support workers, Occupational Therapists, Doctors, Community Psychiatric Nurses, Managers, Clinical Psychologists, Psychiatrists, a Benefits Advisor, Fundraiser, shielding staff, staff who had been redeployed, housekeeping staff and schools. Its accessibility to non-psychologists was seen as a strength:

‘I was slightly apprehensive about sharing it with a ward team (not psychologists) because of the level of self-reflection needed, however everyone was able to use and relate to it.’ (P12)

A number of respondents mentioned that being located remotely from team members hindered their ability both to use the CSL more pro-actively and to gauge others’ response to it. There were other limits to its usefulness for some:

‘Others [colleagues] either weren’t bothered, had their own ideas in place or just didn’t want to admit that there were problems with themselves or the workplace.’ (P1)

‘We were all just trying to adjust to offering therapy remotely and incredibly busy. Conversations (when they happened) tended to be kept light and focused on practical problems.’ (P19)

3. Collective validation

The CSL helped to validate and normalise teams’ and colleagues’ feelings and experiences. Seeing these written down and named had been powerful:

‘I used it to present to my team as a CPD session during lockdown. It was extremely helpful and resonated with a lot of people in the team. It helped us make sense of our experiences.’ (P12)

In many places the CSL had been a conduit for people sharing feelings, difficulties and experiences with each other, and to make collective sense of these, allowing for both similarity and difference:

‘Feedback was. . . it was good to be able to talk through their experiences and that the struggles list made sense of a lot of what they had been feeling.’ (P10)

Perceptions of the impact included staff feeling: less angry and anxious, more listened to, energised and connected with and under- standing of each other, and able to open up conversations that carried on after the session:

‘It has helped them think about how they work with their teams, re-charged their batteries to an extent.’ (P4)

‘Received very positive feedback on the sessions, some people in the team said it almost felt like therapy and created a safe space for us to think/ reflect and share experiences/ thoughts /feelings.’ (P12)

‘Tools like this normalise distress and help people share connections with each other.’ (P10)

4. Permission to talk, and to feel

The CSL normalised the unprecedented personal and professional struggles of staff during the pandemic:

‘Staff found it humanising and it gave permission for staff to voice previously unvoiced feelings.’ (P1)

‘I remember people being more forthcoming in sharing examples about not feeling like a hero and it was really validating.’ (P8)

It enabled conversations to happen that may have been difficult or avoided, at a time of uncertainty and pressure:

‘It helped open discussion about the way difficult team dynamics had emerged.’ (P7)

‘It was a way to scaffold a conversation in teams where talking about feelings are seen as a weakness (prison setting).’ (P14)

It provided a structure for reflection, a ‘tool to invite conversations’ (P11), that was unthreatening, easily accessible, reflected difference and resonated emotionally:

‘Knowing what’s normal makes things that feel shameful, embarrassing or unspeakable, possible to talk about.’ (P10)

5. Opening up possibilities

The CSL was intentionally non-directive, giving ideas to explore not instructions.

‘They present different possibilities – thus enable exploration of difference – not everyone thinks or feels like me. They give ideas, points for discussion – not rights or wrongs.’ (P4)

‘It was not at all patronising. It did not make grand claims but gave practical, uncomplicated ideas to try as suggestions only. It did not tell us what to do, which I always appreciate.’ (P20)

Conversations based around the CSL had been a springboard to changes in ways of working: setting up a ‘wobble room’, instigating a team check in at the end of the week, and thinking about Covid’s effect on the service, its clients and the team:

‘We then made our own document of neurorehabilitation struggles to share within the team, tracking how Covid affected our population and some of the barriers we faced. This was not in a CAT style, but it was a space for reflection and documenting what was happening at the time and how we felt about it.’ (P8)

Through collective use of the CSL, new and shared understandings emerged:

‘I used it with a team of nurses who had been redeployed. It provoked lots of really helpful discussion and a sharing of feelings and experiences. Particularly helpful was the ‘hero’ pattern. None felt they were frontline staff and that the ‘others’ were heroes. All members of the team had been ill with Covid. This discussion helped them see that there were no heroes but that they were all heroes.’ (P10)

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6. Developing psychological skills

The tool supported staff to develop psychological skills such as reflection, acceptance, problem solving and flexibility. It also helped to develop this capacity within teams, helping them to stop and reflect collectively:

‘Lots of people identifying with the themes, individuals feeling empowered to reflect on their professional and personal journeys in relation to COVID, greater willingness to accept the situation/ look for positives.’ (P5)

‘It helped them observe what was happening without being pulled into it to the same extent.’ (P7)

For those respondents less experienced in CAT, their resonance with the CSL and the validation it provided that their own experiences were shared, seemed to give them the confidence to share the CSL more widely and with enthusiasm. A librarian, for example, shared it with their family who then shared it with colleagues. An Assistant Psychologist used it to facilitate a discussion within their own team:

‘It was validating and also gave me more courage to discuss this with colleagues!’ (P8)

The CSL’s accessibility was described in its being ‘of the moment’, as well as short, simple and clear. Suggestions to make it more accessible included use of visuals such as maps, more simple language and updates to reflect the changing situation as the pandemic progressed.