Nurturing attachments group: A virtual group intervention for adults caring for traumatised children in the context of COVID-19.

Background: Evidence indicates that the more traditional and behavioural parenting strategies are ineffective when parenting a child who has experienced developmental trauma. Recognising the need to parent with an attachment focus, the current paper evaluates the effectiveness of running the [Enfys] Nurturing Attachments Group, virtually, within the context of the COVID-19 pandemic. Method: A pilot feasibility study evaluated eight bespoke groups. Consenting professionals and co-professionals completed the Brief Parental Self-Efficacy Scale (BFSS), Care Questionnaire (CQ) and the Parental Reflective Functioning Questionnaire (PRFQ).
Results: One hundred forty individuals attended the groups, with 51 (36%) completing both pre-and post-measures. The results provide evidence that professionals and co-professionals reported statistically significant positive increases on both the BPSS (d = .55) and CQ (d = .62). For the PRFQ, the results showed a statistically significant decrease on the Pre-mentalising sub scale, a non-significant mid-range score for Certainty about Mental States and a non-significant increase for Parental Interest and Curiosity in Mental States.
Conclusion: The study has demonstrated initial viability of effectively facilitating the [Enfys] Nurturing Attachments Group, virtually. Importantly, it has also shown that the group can be run with professionals alongside co-professionals.

Introduction

Following the seminal work of Bowlby (1951) and Ainsworth (1967), the clinical and academic understanding of attachment theory has grown (Bowlby, 2008; Krumwiede, 2014). Whilst the provision of ‘good enough’ care can facilitate the development of a secure attachment, and subsequently a child who is more likely to develop a more adaptive internal working model, encompassing their view of themselves, others and the world (Silver, 2013). The Adverse Child Experiences (ACEs; Foege, 1998) research confirmed that early adverse and traumatic experiences or major emotional neglect can lead to varying levels of security versus insecurity or disorganised attachment styles that can lead to characteristic features of neurobiological dysregulation (Lahousen et al., 2019). Presentations of this nature more recently have been framed as complex trauma or developmental trauma (Schmid et al., 2013), with the rapid increasing numbers being described as a silent epidemic (Kaffman, 2009).

Herman (1992) introduced the concept of ‘Complex Trauma’, which she differentiated from Post-Traumatic Stress Disorder due to its multiplicity of traumatic events, combined with the immediate and long-term impact. When complex trauma befalls in childhood, within their caregiving relationship it has become known as developmental trauma. These traumas might include neglect, abuse and maltreatment towards the child, most likely from their parent or primary carer (Lyons et al., 2020). The term developmental trauma also incorporates looking at the damaging effects of trauma on various aspects of development, for example, physical, emotional, sensory, social and brain development (D’Andrea et al., 2012; Van der Kolk, 2005). Children who have experienced developmental trauma typically have difficulty forming attachments and regulating their emotions (Cook et al., 2005), with long-term consequences for a child’s learning, relationships and emotional and physical well-being (Golding, 2014).

When providing care to a developmentally traumatised child, one of the greatest challenges facing caregivers is managing high levels of complex behaviour (Sinclair et al., 2004). Mary Main and her colleagues have been credited with documenting links between a mother’s (or primary caregiver’s) ability and capacity to hold their baby’s (child(ren)) state(s) of mind and the subsequent attachment (Main et al., 1985). Fonagy et al. (1991) are credited with defining reflective functioning or maternal reflective functioning, capturing the ability of an individual to imagine the mental state(s) of their self and others. Reflective functioning is a particularly important concept when thinking about those individuals who may have experienced developmental trauma, given the complex presentations often observed and a need to consider the underlying communication, mental states and possible intentions (Slade et al., 2005).

Due to the challenges faced by developmentally traumatised individuals in regulating themselves, it is often the role of adults to hold this responsibility. Furnivall and Grant (2014) reported that adults who engage with this population group can either add to their difficulties or be a part of their recovery pathway. Whilst it is acknowledged that any child can experience developmental trauma, it is widely acknowledged that children in care/looked after children account for a significant proportion (Bazalgette et al., 2015; Luke et al., 2014). Rahilly and Hendry (2014) reported that whilst children can have positive experiences of the care system, they often experience repeated placement moves and movement between biological family and the care system (i.e. children’s services, foster carers, residential placements), which can exacerbate/compound their early trauma. It is important that the professionals supporting those adults providing care appropriately scaffold understanding, skills and confidence to respond, meet and ultimately care for these children (Golding, 2014).

Behavioural programmes, for example, The Incredible Years, which focuses on parenting children who have not experienced developmental trauma, have proven an effective intervention for children and young people demonstrating behaviours that challenge (Puckering et al., 1994). Conversely, more recent evidence indicates that the traditional and behavioural parenting strategies are ineffective with a developmental trauma population group (Havighurst et al., 2020).

To facilitate an increased understand alongside the development of the skills required to support the complex needs of traumatised children, an approach which considers a child’s needs more globally (e.g. attachment, emotional, sensory, developmentally, socially etc.,) was required (Rork & McNeil, 2011). Dyadic Developmental Psychotherapy (DDP; Hughes, 2006, 2014) provides a framework for meeting the expressed and hidden needs and supporting children to recover from developmental trauma. Built on theories of attachment and intersubjectivity, DDP aims to support a family and the system around them to feel ‘safe and connected through the development of healthy patterns of relating and communication’ (Casewell et al., 2014, pp. 1) Whilst DDP is an integrative approach based on several evidence-based therapeutic approaches, methods and techniques (Becker-Weidman & Hughes, 2008), and is argued to meet the basic principles for the effective treatment of complex trauma (Cook et al., 2005), there have also been strong criticisms that DDP specifically as a therapeutic approach has an insufficient evidence-base (Chaffin et al., 2006; Craven & Lee, 2006; Mercer, 2014, 2015). Anecdotally, there are numerous reports that DDP appears to be an effective intervention for developmentally traumatised children (Casswell et al., 2014); however, there is a clear lack of highly robust evidence and a need for large-scale randomised control trials (Hughes et al., 2015; Staines et al., 2019; Wingfield & Gurney-Smith, 2019).

With a recognition that traditional therapies do not effectively meet the holistic needs of a traumatised child (Howe, 2005), there was a need to develop an approach that could support using a bottom-up methodology (Perry, 2006). The Nurturing Attachments Groupwork Programme or Nurturing Attachments Group is an 18-session programme developed by Kim Golding to meet this need. It was designed to support caregivers of traumatised children who have attachment-related difficulties. The programme, informed by the DDP model, includes three core modules: ‘understanding challenges of parenting’, ‘therapeutic parenting’ and ‘looking after self’. A core component of DDP is the therapeutic parenting approach, PACE, which includes Playfulness, Acceptance, Curiosity and Empathy. The group content includes psychoeducation, activities and discussions, supported by hand-outs, and helps caregivers understand parenting children with developmental trauma (Golding, 2017). Selwyn et al. (2016) stated that the aims of the Nurturing Attachments Group are to increase support, understanding and confidence in adults who care for children with developmental trauma.

Downes et al. (2019) examined the efficacy of Kim Golding’s Nurturing Attachments Group with adoptive parents, concluding the intervention increased parents’ understanding of their children’s behaviour and their confidence in managing behaviour that challenged. Furthermore, Gibbons et al. (2019) reported foster carers improved their ability to reflect on both their own behaviour and their children’s. This research provides evidence that caregivers can adapt their parenting styles to meet the child’s emotional and developmental needs and have a better understanding of the child’s perspective of the relationship. Hewitt et al. (2018) took a qualitative approach to analysing adoptive parents’ experiences of the Nurturing Attachments group using Interpretive Phenomenological Analysis. They found that parents felt empowered by the skills that they had learnt and felt hopeful that they could meet the challenging needs of children who have experienced developmental trauma. Wingfield and Gurney-Smith (2019) looked at adoptive parents’ experiences of DDP and found that one of the twelve families that took part in the study felt they did not see the progress they had hoped for and that DDP was not suitable to their needs, highlighting that there continues to be some uncertainty around who is most suitable for DDP (Turner-Halliday et al., 2014) and that one size does not fit all (Roth & Fonagy, 2013). Furthermore, it has been suggested that research regarding the Nurturing Attachments Group should use larger sample sizes and discussed the need for DDP-informed parenting/carer groups to be subjected to a randomised control trial and/or quasi-experimental methodologies (Selwyn et al., 2019).

Unfortunately, the COVID-19 pandemic in 2020 (COVID-19; Gov.uk, n.d.), had a significant impact on the provision of therapeutic interventions, most notably, face-to-face/direct therapeutic work. In the context of parenting children with developmental trauma it has meant significant complexity and brought additional challenges, most significantly an increased numbers entering the care system (Local Government Association, 2020). This has highlighted the need to ensure system support for caregivers has remained available, even within the context of a political and health landscape, which has and continues to change (Cluver et al., 2020; Humphreys et al., 2020).

Research has concluded that online/virtual therapeutic groups have proved successful in generating feelings of empowerment and independence (Barak et al., 2008), and therapeutic relationships can be easily built (Weinberg, 2020). Strong evidence continues to emerge regarding virtual delivery of therapeutic groups, for example, the provision of cognitive behavioural therapy (CBT) groups for common mental health problems (Gratzer & Khalid-Khan, 2016; Health Quality Ontario, 2019) such as anxiety and depression.

To date, there are no outcome data for including professionals within the Nurturing Attachments group. However, Bronfebrenner (1979) Ecological Model identifies the importance of the wider system on any individual. In addition, there are no published findings concerning the effectiveness of Nurturing Attachments groups when delivered virtually. The intention of this paper is to firstly to share outcomes of a novel, virtual delivery of the Nurturing Attachments group within a small NHS service catering to the needs of developmentally traumatised children, and to provide some practice-based evidence. Secondly, this paper aims to share outcomes of the Nurturing Attachments group programme involving the participation of professionals alongside carers. Modification of this intervention was developed during a time of crisis and therefore does carry several methodological flaws.

Due to this study a piece of practice-based evidence, the authors acknowledge there are several limitations with the design, for example, it has not been possible to delineate the influence of bespoke group format. In-line with our aims, we hypothesise that the outcome data from our study, overall, will continue to indicate that the Nurturing Attachments group is effective when delivered virtually (inclusive of a variety of formats).

Our primary hypothesis is:

1. An increase in parental reflective functioning, measured using the Parental Reflective Functioning Questionnaire (PRFQ), from the beginning to the end of the group.

Previous Nurturing Attachment Programmes have also included the following two scales. There is no validation data for these scales and therefore their inclusion is to provide a cross reference to previous research. Our secondary hypotheses are:

2. An increase in parental self-efficacy, measured using the Brief Parental Self-Efficacy Scale (BPSS), from the beginning to the end of the group.

3. An increase in carer understanding (of their child), confidence (in caring for their child) and perceived reward (in caring for their child), measured using the Carer Questionnaire (CQ), from the beginning to the end of the group.

Method

Design and ethics

A feasibility pilot study was conducted of a 12-hour, bespoke, virtual-group intervention aimed at introducing and increasing the understanding of developmental trauma; alongside introducing attachment informed approaches for parenting those children who have experienced developmental trauma. The local university health board research department was consulted and approved the service evaluation alongside the Clinical Lead.

Service context

The service is an NHS service for children who are looked after, children on the edge of care and adopted children. The service invites a range of caregivers to attend an adapted version of Kim Golding’s Nurturing Attachments Group. For the purpose of this service evaluation, those invited were separated into either professionals or co-professionals. The distinction being a co-professional being an individual who has regular daily contact covering extended periods across the whole day (e.g. foster carers, kinship carers, adoptive parents, special guardianship order carers and residential carers) and professionals being those who have more limited contact, weekly, monthly or which is predefined, that is, school hours (e.g. those from the educational, health and social sectors).

Enfys nurturing attachments group

A series of virtual Enfys Nurturing Attachments Groups based on Kim Golding’s programme were facilitated by Enfys. The groups included 12-hours of content. The group content was delivered in several bespoke formats to meet the needs of those attending. For example, some groups followed a six two-hour session plan (based upon Kim Golding’s group), whilst others the content was delivered in two six-hour sessions. In total, eight groups were facilitated from June 2020 to December 2020.

The content of the Nurturing Attachments group included psychoeducation about developmental trauma and the impact it has on children and young people. This included topics and concepts such as: connection before correction; blocked trust; intersubjectivity; the attunement-break-repair cycle; survival modes; attachment styles; toxic shame; shield of shame.

Following this, the Nurturing Attachments Group looked at ways in which individuals can use DDP principles to parent traumatised children therapeutically. These principles included: remaining open and engaged; being mind-minded; using PACE; understanding the importance of using natural and logical consequences. Finally, the group covers concepts such as blocked care and the importance of self-care when parenting children displaying behaviours that challenge.

Due to the COVID-19 Pandemic, all eight groups were delivered online via Zoom. Adaptations were made to account for meeting virtually. These included: more frequent breaks; offering additional technical support for those requiring it; using virtual breakout rooms for small group discussions; using a range of modalities to deliver group content such as YouTube video clips and Canva slides.

The training materials and hand-outs were designed by Enfys, based on the resources developed by Golding (2014), and were emailed out to participants before each session. The group was facilitated by members of Enfys, usually 2–3 facilitators including a mix of clinical psychologists, trainee clinical psychologists and graduate mental health workers.

Participants

In total, there were n = 140 participants, with 60% completing >75% of the content/sessions. The groups consisted of 84 co-professionals, 31 professionals and 25 participants did not report their professional group. All the participants supported or cared for children and young people who had been exposed to developmental trauma, most of whom were looked after. Co-professionals had a named social worker from the local government children’s social services department. Professionals self-referred. The group has a wide eligibility criterion, whereby the only exclusion criteria are biological parents are not eligible and those missing two or more sessions are not permitted to continue.

Data collection

Of the n = 140 participants who attended the groups, 58 completed pre-measures only, 31 completed post-measures only and 51 completed both pre- and post-measures (32 co-professionals, 14 professionals and 5 participant’s profession not stated). Data were discarded if participants had only completed either pre- or post-measures (n = 89). The included data represents 36% of the total participants (n = 51). Participants completed the following measures pre- and post-group:

Brief parental self-efficacy scale

The BPSS is a 5-item scale that asks parents how much they agree or disagree with five statements on a Likert scale (Woolgar et al., 2012). An example statement is, ‘Even though I may not always manage it, I know what I need to do with my child’. The scale had a high level of internal consistency, as determined by a Cronbach’s alpha of 0.752.

The carer questionnaire

The CQ (Golding & Picken, 2004) was used to evaluate the impact of the group. The original questionnaire involved scaling questions (‘a little’, ‘somewhat’, ‘a lot’, ‘not at all’) and were used to elicit participants’ views on the impact of the group on parent’s knowledge, level of confidence, parent and child functioning and on overall atmosphere in the family home. The reliability of combining these ratings is 0.74 (Cronbach Alpha reliability analysis). We used a modified version of the Carer Questionnaire which involved 12 statements using a 10-point Likert scale.

Parental reflective functioning questionnaire

The PRFQ is designed to assess parental reflective functioning and asks parents the extent to which they agree with a set of 18 statements on a 7-point Likert scale(Luyten, Mayes, et al., 2017)(Luyten et al., 2017). The measure is made up of a three-factor structure, each with six corresponding items and produces an individual score for each factor.

Procedure and data analysis

The measures were given to carers and professionals prior to or during the first session and immediately following the final session. Measures were emailed to participants and either completed via Google Forms, or using Microsoft Word, with each participant provided with code a unique code to ensure data was collected anonymously. Participants were informed at the start of the group that their data may be used for service development and research purposes. Participants had the opportunity to withdraw their data if they were not comfortable with this. Analyses were conducted in SPSS.

Descriptive statistics were calculated for the pre- and post-scores on the PRFQ, BPSS and CQ, both for the overall sample and for each professional grouping. To test our primary hypothesis and determine whether there was an overall improvement in PRFQ scores, paired samples t-tests were computed on the total PRFQ scores for the overall sample and separately for each professional grouping. Similarly, to test hypotheses 2 and 3, paired samples t-tests were computed on the total BPSS (parental self-efficacy) and CQ (carer understanding) scores again for the overall sample and separately for each professional grouping.

Results

Overall, 51 individuals completed both pre- and post-measures (46 Female; 90%). Descriptive statistics were explored for the PRFQ, BPSS and CQ scores at the beginning and end of the Enfys Nurturing Attachments Groups, for the overall sample and by professional grouping (Table 1). For the overall sample, the data indicate an improvement in PRFQ, BPSS and CQ scores in-line with all hypotheses. These improvements were statistically significant when examining hypotheses for the overall sample, and when exploring these data by professional grouping, some remained statistically significant.

Table 1.

Descriptive statistics for the pre- and post-scores for the PRFQ, BPSS and CQ.

	Overall sample		Co-Professionals		Professionals
Pre-measure scores	M	SD	M	SD	M	SD
PRFQ total	67.53	65.65	68.7	47.48	63.63	104.91
BPSS total	18.71	3.14	19.28	3.12	17.42	3.34
CQ total	86.98	14.06	88.33	14.33	84	13.67
Post-measure scores
PRFQ total	70.93	48.1	70.75	50.51	71.84	35.08
BPSS total	20.56	2.66	20.59	2.92	20.77	.49
CQ total	95.04	14.77	95.28	14.87	94.23	19.59

N.B. PRFQ = Parental Reflective Functioning Questionnaire; BPSS = Brief Parental Self-efficacy Scale; CQ = Carer Questionnaire.

For the hypothesis 1, there was a mean positive change (increase in score) of 3.4 points in the total PRFQ scores for the overall sample, which when computing a paired-samples t-test was found to be statistically significant, t (46) = −2.85, p = .003. This remained significant when applying bootstrapping (1000 samples), p = .012 (d = .45). When examining the change in total PRFQ scores for the professionals group, there was a mean positive change (increase in score) of 8.21 points in the total PRFQ scores, which was also statistically significant when computing a paired-samples t-test, t (10) = −3.46, p = .003. This remained significant when applying bootstrapping (1000 samples), p = .016. When examining the change in total PRFQ scores for the co-professionals group, there was a mean positive change (increase in score) of 2.05 points in the total scores, which was not statistically significance when computing a paired-samples t-test, t (37) = −1.66, p = .052.

For hypothesis 2, there was a mean positive change (increase in score) of 1.85 points in the BPSS scores for the overall sample, which when computing a paired-samples t-test was found to be a statistically significant improvement, t (41) = −3.69, p = .001, and remained significant when applying bootstrapping (1000 samples), p = .001 (d = .55). When examining the change in BPSS scores for the professionals group, there was a mean positive change (increase in score) of 3.85 points in the total BPSS scores, which when computing a paired-samples t-test was found to be a statistically significant improvement, t (10) = −2.641, p = .025, and remained significant when applying bootstrapping (1000 samples), p = .043. For the co-professionals group, there was a mean positive change (increase in score) of 1.31 points in the total BPSS scores, which when computing a paired-samples t-test was found to be a statistically significant improvement, t (29) = −.063, p = .039, and remained significant when applying bootstrapping (1000 samples), p = .04.

For hypothesis 3, there was a mean positive change (increase in score) of 8.06 points in the CQ scores, which was statistically significant, t (41) = −4.44, p = <.001, and remained significant when applying bootstrapping (1000 samples), p = .001 (d = .62). When examining the change in CQ scores for the professionals group, there was a mean positive change (increase in score) of 10.23 points in the CQ scores; however, this was not statistically significant, t (10) = −2.010, p = .072. For the co-professionals group, there was also a mean positive change (increase in score) of 6.95 points in the total CQ scores which was statistically significant, t (29) = −2.941, p = .006, and remained significant when applying bootstrapping (1000 samples), p = .006.

Discussion

This pilot feasibility study reports on the therapeutic outcomes for professionals and co-professionals following completion of a virtually facilitated Enfys Nurturing Attachments Group. The service evaluation represents several firsts and is contextualised by the COVID-19 pandemic. For the first time, this study reports Nurturing Attachments Group outcomes for: 1) virtually facilitated groups, 2) groups containing professionals and co-professionals (i.e. other than adoptive parents) and 3) combined professionals and co-professionals groups. The facilitated Enfys Nurturing Attachments Group used a range of bespoke group formats; however, due to the methodological limitations, whilst this was a first, this aspect was not evaluated so conclusions cannot be drawn.

The service evaluation found that the provision of a bespoke virtually facilitated Enfys Nurturing Attachments Groups is feasible, viable and provides early statistical support to consider further investigation. These results are important in the context of COVID-19, and in providing early indication to support a therapeutic group-level intervention that combines professionals and co-professionals. With respect to the DDP-informed evidence base, this evaluation provides an insight into the potential benefits for its effectiveness in indirectly supporting traumatised children through directly supporting those involved in the system (professionals and co-professionals) caring for them.

The primary hypothesis stated that on completion of the Enfys Nurturing Attachments Group, individuals would indicate higher total scores for the Parental Reflective Functioning Questionnaire (PRFQ). Our secondary hypotheses stated that individuals would record higher total scores for the Brief Parental Self-Efficacy Scale (BFSS) and Carer Questionnaire (CQ). The results showed the three-hypothesis changed in a positive statistical direction.

The PRFQ overall sample observed a statistically significant increase. With respect to the professionals and co-professionals, the professionals observed a statistically significant increase, whereas the co-professionals observed a positive non-statistical change. This outcome suggests that both groups perceived that following their attendance that they were better able to hold their young person(s) internal state, in their mind (i.e. feelings, desires, wishes, goals and attitudes). This outcome is important given the well-established findings that children who have experienced developmental trauma are increasingly likely to develop complex behavioural and emotional difficulties that can lead to them isolating those caring for them (Bammens et al., 2015). In addition to the potential (indirect) benefits for the young person, there are perceived benefits for those in the caring role. In England, there are >80,000 children in care, 72% of whom are in foster care placements (CoramBAAF, 2020). Hughes and Baylin (2012) reference the concept of blocked care, which has also been referred to as ‘compassion fatigue’. Hannah and Woolgar (2018) discuss the significant impact of these concepts and the associated increased risk of repeated placement changes for this population group (Rahilly & Hendry, 2014). An intervention that increases a carer’s reflective functioning ability and capacity could potentially prevent blocked care and reduce placement breakdowns.

Importantly, these results are in line with previous research (Selwyn et al., 2016) and support the premise that the group content facilitates an increased ability for individuals (professionals and co-professionals) to be better able to support, ‘parent’ (Golding, 2015) and care for traumatised children. The findings for the PRFQ do however require a contextual perspective as this is the first study to use the PRFQ for professionals and co-professionals following completion of the Nurturing Attachments Group.

In considering our secondary hypothesis, both groups reported statistically significant positive increases on both the BFSS and CQ. As highlighted previously, the inclusion of these measures was premised around the Adoption Plus Summary Report (Selwyn et al., 2016). This report included the BFSS scale following its recommendation by the Child Outcome Research Consortium (www.corc.uk) for use in the evaluation of parent training, and the CQ due to its factor structure mapping closely to the core elements of DDP. When comparing our results with this report, the results were both comparable. This is a valuable additional finding as it shows that despite: 1) a different population group (i.e. co-professionals and professionals) and 2) bespoke formats the outcomes are maintained.

Strengths and limitations

The outcome of this study provides some early positive results, and the authors acknowledge that these must be contextualised within the significant limitations. This study evolved from a need to provide an accessible intervention during a time of crisis and therefore suffers from several methodological flaws. For example, a lack of control group/fidelity measure alongside a lack of ability to draw statistical information about the differing bespoke formats. In addition, the lack of diversity and limited demographic data makes generalisability very difficult, alongside the fact that only 36% of the individuals completed both pre- and post-measures. However, it is important to reflect that this was more a methodological flaw in ensuring robustness around post-measure data collection as opposed to a reflection of completed sessions (60% completing >75% of the content/sessions).

There are also strengths within this study. Most notably, the ability to provide an ongoing therapeutic intervention, in a time of unprecedented uncertainty, to support professionals and co-professionals caring for traumatised young people. The ability to adapt the length of the group meaning the service was adaptable to meeting the pressures on professionals and co-professionals. This was particularly true for the full lockdown, when restrictions were at their greatest. We also ensured that facilitators rotated through groups and worked in different pairings to ensure parity in the content delivery.

Implications for clinical practice

The current restrictions imposed by COVID-19 have forced the use of virtually facilitated therapeutic interventions. The data from this study have provided early information that the virtually facilitated Enfys Nurturing Attachments Group provides benefits for both professionals and co-professionals caring for traumatised children. Whilst it is believed that COVID-19 restrictions will be lifted, this study delivers evidence about the potential benefits and viability of delivering the content of the Nurturing Attachments Group virtually; and therefore, expands on the options to engage professionals and co-professionals in future interventions.

Directions for future research

The current study explored the viability and therapeutic effectiveness of a virtually facilitated group-level intervention for professionals and co-professionals caring for traumatised children; but did so with significant methodological flaws. A future study is required to address these methodological errors, to inform whether statistical evidence exists to support the virtual Enfys Nurturing Attachment Group as a viable intervention within this population.

It is the view of the authors that it would be important to consider burnout, as this is an issue within this population, both for professionals (Huby et al., 2009) and co-professionals (Bridger et al., 2020). The incorporation of a validated measure of burnout may provide important information on whether a correlation exists between burnout and reflective function.

Conclusion

The study has provided early insight to the viability of effectively facilitating the Enfys Nurturing Attachments Group, virtually. The study has provided several firsts, most noticeably the facilitation of joint professional and co-professional groups. Whilst there are several noted limitations, it is hoped that this study will provide the springboard for further investigation and research that can provide the necessary methodology to draw robust recommendations and conclusions.