Some Reflections on the GASi Online Large Group Experience During the COVID-19 Pandemic

It is Monday 24 July 1983[1], a day which begins as usual for me in my home city of Colombo, Sri Lanka. There has been tension in the air and rumours of potential ethnic violence, but my brother has gone to work as normal, and I am revising for my final medical examinations. Around 10am, I become conscious of shouting and banging in our street, and a mob appears. My mother’s first instinct is to lock us into our home, but I tell her to collect what little jewellery and money she has: we will go to our Sinhalese neighbours’ house. We leave via a back gate and our neighbours bravely let us. We take refuge in their toilet; from its window, I shortly see black smoke and realise that our house has been set alight. What was going to happen to us? How could we survive the anti-Tamil mob? Would I be able to take my final exams? My world was crashing in. I was confronting a large group turning on the minority group with which it had previously lived in relative peace.

Fast forward exactly 37 years: 24 July 2020, safe in my adoptive UK, a senior doctor in the NHS and member of GASi, I am reflecting on our 12-week large group experience held online. I must begin these reflections with an account of my personal background and some formative events, which reveal the ongoing role of group processes – a phenomenon I believe to be universal.

I was born and bought up in Colombo, Sri Lanka (then Ceylon) in a middle-class family, and as part of the minority Tamil community. My grandparents had left their native Tamil-speaking area in the north of the island to settle in the capital. Despite growing up in a multi-ethnic, cosmopolitan area, I experienced minor and moderate incidents of racial discrimination and conflict during my schooldays.

Ceylon had become an independent dominion of the British Empire in 1948, and English was the main language of administration and education. Growing up, I was aware that in 1956 a senior, Oxford-educated, politician, who had sent his children to be schooled abroad, had hypocritically led a party preaching nationalism, which would divide the country along linguistic lines. Not surprisingly, the party came to power. Soon after this, school classes were linguistically differentiated (Sinhalese, Tamil and English), based on ethnicity.

In 1972, when Ceylon became the republic of Sri Lanka, there was further ethnic discrimination against Tamils, restricting their opportunities for work and study. There had been outbreaks of discrimination and ethnic violence in 1958, and these were repeated in 1977, 1981 and 1983, the latter being the riots I describe above. Many educated Tamil people left the country in what has been called a diaspora, whilst others began to form groups of resistance and demanded an independent Tamil state. One of these groups would prevail, becoming the Tamil Tigers (LTTE).

During my A-levels, I was both fascinated and horrified by the events in Jonestown, Guyana[2] as well as by a local incident involving a priest who was convicted of murder by poisoning[3]. At the same time, I was dealing with the sudden loss of my father and the uncertainties this brought. These personal experiences and international events sparked my interest in the power of groups, destructive as well as creative, and of their leaders.

Despite political events, I succeeded in entering Medical School in Colombo. By this time, the LTTE were assuming greater control of local areas in the north and east. This resulted in tension in the university itself. Some of my fellow Tamils, especially those living in a shared hostel, were subjected to discrimination and acts of humiliation in the build-up to the riots of July 1983.

I had early on realised that, in order to cope with the theoretical and practical demands of medical studies, we needed to share the burden through study groups. I attribute my success in achieving an Honours degree to the mutual support we gained from this group. As I recall in the first paragraph above, just before my finals were due in 1983, there was major, nation-wide ethnic violence, well-orchestrated by a few hard-core politicians. Our Sinhalese neighbours gave my mother and me refuge for the first couple of weeks, after which I moved to stay with a medical school friend and his family.

Similarly, whilst living with my friend’s family, we studied together. This and our other study groups became more that academic: they were providing affective and practical support, since we were planning to leave Sri Lanka after graduation, due to the personal and professional circumstances we, as Tamils, would have to face. Soon after completing my degree, I had the opportunity to do an internship abroad but, for professional/administrative reasons, I, like all but one of the members of my study group, stayed in Sri Lanka and completed our internships there, enduring the uncertainties we all faced. However, within a year of completing our internships, every one of our study group had left Sri Lanka.

In 1985, I came to the UK to pursue postgraduate studies in psychiatry and have remained here ever since. 37 years on from our studies, my study/peer group and I remain in close contact and hold regular get-togethers in different countries. Indeed, during the pandemic, we have had lengthy Zoom meetings each weekend, irrespective of the difficulties imposed by our living in extreme time zones from the USA eastwards to Australia. It is only recently, through these Zoom meetings, that we have been able to speak candidly about our own experiences during that critical period of our lives. All but one of my study/peer group have specialised in fields of medicine other than psychiatry but they have now begun to appreciate the value of this group experience in coping with the anxieties provoked by the Covid-19 pandemic, which is affecting all medical specialities.

I began my postgraduate training in psychiatry at a time when there was a major ideological shift: the old asylum model (large group) was seen as dehumanising and was being rapidly replaced by so-called ‘care in the community’[4]. This was based on the naïve belief that we now had the medications and quasi evidence-based treatments to support a successful transition. I, too, was initially persuaded but I soon realised, as I became more experienced, that most of the time, we were treating symptoms rather than causes. A seminal experience for me was when, as part of my training, I assisted a Jungian analyst (who subsequently became a Consultant Psychotherapist) as a co-therapist for a period of three years. Although he was not a group analyst, on reflection, the group he ran was based on the principles of the Median Group. I saw the long-term benefits it brought for patients who had been given different diagnostic labels, but was unable to comprehend the processes that had achieved these results. This experience also taught me the cost-effectiveness of such interventions in an over-subscribed NHS.

Inspired by this, I enrolled on the 1-year introductory course at the IGA in 1994. The training highlighted the benefits and challenges of small and large group experiences: for me, the small group captured the essence of family dynamics, and the pre-Oedipal and Oedipal stages of emotional development. The large group was initially quite daunting and overwhelming, capturing the sense of loss one feels outside the safety of the small group (‘family’). The reactions of some fellow-trainees (emotional and behavioural outbursts) revealed the struggle we were all experiencing. Both the large and small group experiences captured the essence of the therapeutic benefits described by Yalom[5] and Foulkes[6] as well as the destructive processes identified by Bion[7] (Basic Assumptions). As we were trying to work through the ending of our training, I found myself addressing my own journey of fleeing from my homeland and building a new life where I had to negotiate uncertainties, both personal and professional.

I wanted to pursue further group training, and I felt myself most drawn towards the 2-year Median Group[8] training available at the time. It was there that I first met Pat de Maré and a few other GASi members. The theory and group experience of this training, and the struggle to have meaningful dialogue whilst negotiating very uncomfortable emotions such as hate, rage, frustration and loss, galvanised my appreciation of the healing/therapeutic processes of median/large groups. It helped answer some of the questions raised during my earlier training as a co-therapist. The confidence I gained through this training, prepared me to take on a consultant psychiatrist post in 1996, at a time when the honeymoon period of care in the community was overshadowed by some notorious incidents (‘Community Scare’4) which prompted further revamping of Mental Health legislation.

Since that time, mental health services in the community have been in turmoil, under constant redesign and fragmentation (‘Community Chaos’ followed by ‘Community Scarce’4); professionals and managers became psychotically anxious and were acting defensively, undermining the very essence of continuity of care. It led to further personal and professional challenges for me, such as investigation of my practice. Despite this hostile environment, I have managed to survive and continue my professional practice, using every opportunity to set up groups for patients, trainees and colleagues; between 2010 and 2017, whilst I was the Royal College Tutor for Wessex Deanery, I facilitated a Balint group for psychiatrists and trainee GPs, with very positive results and feedback.

After leaving that post for professional and personal reasons, and moving back to my London home, I felt a sense of loss and sadness but was able to return to attending the 3-monthly GASi members group. When these group meetings were cancelled due to the pandemic, I again felt a sense of loss. I therefore welcomed the opportunity to take part in an alternative, the on-line group.

Like any new experience, not everything went smoothly with the group at first: there were teething problems with the technology, for example, with some people (including myself) losing connectivity, or being unable to see or hear participants. We were a very large group (100+), participating in diverse countries and time zones, and bringing together different professional and personal experiences. There was helplessness, frustration, hate, anger and loss, yet most people came back each week indicating the benefits and containing nature of this group. We were coming to terms with a novel experience: the old rules were inapplicable, and sometimes our discussions did not flow as expected. The uncertainty of the Covid-19 world was being reflected in the group, something we addressed explicitly when we compared how our respective governments and leaders were dealing with the pandemic. It reminded me of the small and large experiences of my group training, 25 years ago.

While the main group was struggling to engage in a dialogue, the new technology offered a chat room facility which some members began to communicate in, in parallel to the oral discussion. This further contributed to the ambivalence of this whole new experience.

As we began to develop as a group, Black Lives Matter[9] (BLM) became a global issue. The racist abuse by police officers in the USA brought out deep-seated prejudices, not merely those of Black vs White, but others such as the value of youth vs elderly. Competing expectations and values were exposed. Some people began to share their dreams, and one member of the group recounted a highly symbolic one that she had had. A white woman beyond child-bearing age, she had dreamt that she had given birth to a child of a different colour. We shared views on this dream and I interpreted it as symbolising our group experience: the conventions of our traditional group were no longer valid in this changing world. The child that had been born was our new, on-line group, which was disrupting our old values and forcing us to create new ways of maintaining our equilibrium.

The twelve-week group experience highlighted for me the importance of adaptation to survive in an ever-changing world, where the changes are beyond our control. One of the things I was able to share in the group was the fact that I left my home country under extremely unpleasant circumstances and loss, but had had the strength to return in February 2020 to celebrate the 150th anniversary of Colombo Medical School, where I gave two presentations. Moreover, I had been invited to talk at the University[10] on the theme of radicalisation, building on my previous work on confronting stigma and discrimination[11]/[12]. Our on-line group meetings have enabled me to reflect more and discuss openly my evolving group understanding.

Darwinian theory talks of survival of the fittest but this is only possible through evolution over several generations. When it comes to mental health matters, survival is the individual’s ability to adapt within one’s own lifetime. In sum, this large group experience has demonstrated to me the importance of ‘impersonal fellowship’, pioneered by Pat de Maré and other group analysts. By confronting idiosyncratic views, and through a process of constructive dialogue, we can address overt and covert stigma, discrimination and other destructive group processes, contributing to adaptation within one’s lifetime. This has become even more significant as we all face the uncertainties of the post-Covid-19 era.

“To be truly mindful of others, we have to reach a state of no mind.”[13]

References

[1] ‘Black July’ see e.g. https://www.bbc.co.uk/news/world-asia-23402727

[2] See e.g. https://www.youtube.com/watch?v=VWqACvTknls

[3] See e.g. https://letterboxd.com/film/according-to-matthew/

[4] Willis, J. & Yoganathan, N. (2013) ‘The Madness of Psychiatry in 21st century UK’ downloadable from https://www.academia.edu/4404365/THE_MADNESS_OF_PSYCHIATRY

[5] Yalom, I. (2005) Theory and Practice of Psychotherapy. Karnac Books, London.

[6] Foulkes, S.H. (1990) Selected Papers: Psychoanalysis and Group Analysis. Karnac Books, London.

[7] Bion, W.R. (1961) Experiences in Groups. Tavistock, London.

[8] de Maré, P. (ed.) (1991) Koinonia: From Hate, through Dialogue, to Culture in the Larger Group. Karnac Books, London.

[9] https://blacklivesmatter.com/

[10] Yoganathan, N. & Willis J. (2020) Discussion of Radicalisation and Stigma. See https://iouc.cmb.ac.lk/discussion-radicalization-stigma

[11] Yoganathan, N. et al. http://careif.wordsofcolour.co.uk/wp-content/uploads/2017/09/Careif-Position-Statement-STIGMA.pdf

[12] https://www.careif.org/2017/10/04/careif-global-position-statement-stigma-mental-illness-diversity/

[13] Yoganathan, N. (2009) ‘Dialogue: From Socrates to Darwin and Beyond’. World Federation for Mental Health Conference, Athens, Greece.

Dr N Yoganathan
24 July 2020
drnynathan@blueyonder.co.uk