Reflections on a Support Group for Doctors Recovering from Long Covid

In October 2020 I was invited by Dr Clare Gerada, in her capacity as Chair of the charity Doctors in Distress (DiD), to facilitate an on-line support group for medical doctors experiencing symptoms of Long Covid. The group was free, through the charity, to doctors at any stage of their career working in the UK.

Structure and recruitment process

The structure of the support group[i] was 10 weekly sessions of 1 hour and 15 minutes. The first session was a webinar where doctors interested in such a group could attend to hear what was to be offered and ask any initial questions, followed by 8 facilitated sessions and ending with a further webinar. The final webinar was the closing session and an opportunity for facilitators and doctors to give feedback to all involved in the experience. About 70 doctors registered and attended the initial webinar and subsequently 3 on-line support groups were set up running alongside each other in break-out rooms. Two groups were conducted by group analysts (one a retired doctor) and one by an NHS GP who also works for NHS Practitioner Health (www.practitionerhealth.nhs.uk). The three facilitators met online with Clare Gerada and the DiD coordinator, Marie Searles, before and after each session for a few minutes pre- and post-check-in.

The support groups, in group-analytic terms, were homogeneous in that they were offered to individuals with a specific identity, medical doctor, attending with a particular issue, Long Covid.

It was agreed that the first two sessions of the groups were open so that new members could join if they had only heard about the group at short notice. Thereafter, sessions 3 through 8 were closed.

Some challenges

A support group, and one so brief, has its own technical difficulties in terms of achieving the balance between depth of emotional focus and practical educational/psycho-educational dissemination of information. One clear distinction in this group was that all members were very experienced, and in the main, senior doctors and I, as a non-medical group analyst had little knowledge of the medical terms used or conditions described. The physical medical focus was initially a new language for me, despite working in NHS mental health services for many years.

This was the first online group I had facilitated. Thankfully, during the time of the pandemic I have been a member of a number of online groups through the Group Analytic Society international (GASi) and the Institute of Group Analysis UK, so I had some sense of what to expect on the screen, including the use of the chat facility. I’m so glad of these experiences, and especially participating in larger groups with up to 49 heads and shoulders in boxes on my screen, attempting to read facial language and movements and also to connect simultaneously with chat. In earlier sessions of the Long Covid support group the use of chat came fast and furious. It was tricky to pay attention simultaneously to the individuals, the group as a whole and the chat, as well as my own internal process.

The experience of those entering my group

These doctors were experiencing great distress due to the immense uncertainty and fear around their physical symptoms and the impact these had on their whole life, not just their professional roles.

“Having a new, poorly understood disease has made the transition from professional to patient harder and many doctors have struggled with the vulnerability of being ‘on the other side’.” (Burns, Warren; 2020)

Some of the doctors had never received a positive Covid test as they caught the virus early in the pandemic when testing was only carried out in hospital settings. Early in the pandemic, acknowledging and recognising symptoms in previously healthy adults was important, even without the positive result, as no-one really knew what was happening except that patients were coming into hospital very sick and were dying. Hospital doctors and GP’s, as with other front-line health and social care workers were affected due to lack of knowledge about the virus and inadequate appropriate personal protective equipment (PPE) such as masks, visors and clothing.

I read the comment below in a brief article, “What Your Patient is Thinking”, in the British Medical Journal (BMJ) when I began to write about the support group.

“I was told to stay at home unless I thought I was dying . . . I was left on my own to manage shortness of breath, chest pain, fever, intermittently low oxygen, tachycardia, dizziness, brain fog, headache, sore throat, rash, back pain, and a myriad of other. . . . It wasn’t the lack of treatment options or information that troubled me most . . . .  It was the lack of empathy. I never felt heard.” (Jensen; 2020).

It wasn’t clear whether the author was a doctor, but the article was written from a patient perspective. Similar experiences were often described by all the members of my group.

One aspect of working in a group with individuals who were physically unwell was that some members were too ill to attend or had hospital appointments at the time of the session. On occasion, as many as two or three individuals were unable to attend. There were times when a member chose to attend but felt so unwell or exhausted that they connected into the group from their bed. This seemed to represent something very powerful and often unspoken in the group. That someone would literally arrive in their sick bed, so to speak, at the same time as expressing their need to remain emotionally connected to the support group. This felt like new territory to me as a Group Analyst.

The first 2 sessions were filled with medical conversations. Group members described their physical symptoms using medical terminology and got nods of recognition from others. They shared their experience of these physical symptoms and how they were seeking help for a variety of seriously debilitating effects of the virus and post viral illness. Most of the doctors were signed off sick, some were working very part-time and under close supervision because of concern about cognitive deficits caused by the neurological impact of the virus. For nearly every member this was the first time they had been sick, and certainly none of them had a pre-existing long-term medical condition that caused them to take months away from work.

Many experienced being judged negatively, often with a sense that the doctor they were consulting thought their symptoms were purely psychological and that they couldn’t be physically ill. This corroborates what Clare Gerada states,

“. . . doctors being guilty, feeling privileged, driven, not being able to be patients.” (Gerada; 2019)

I found it hard to imagine anyone suffering with the physical symptoms they described not feeling emotionally and psychologically distressed. There seemed to be a particular sense that the female doctors were treated with the most negative discrimination and often with condescension.

Reflecting on my own experience of running the groups

I noticed my own experience of countertransference and emotional resonance as one of rage, shame and shock, listening week after week to the experiences of these doctors. Sometimes, I would find myself just listening to the long discussions about their medical procedures that had no certain outcome. All I found myself able to ask was how this left them feeling. As the weeks progressed, and a safety between us developed, members became more able to connect with and share their emotional response to the trauma they were going through. This was deeply affecting for everyone and on occasion left the group quiet and thoughtful while members resonated in an emotionally meaningful way with what had just been expressed.

My stomach is churned up while I am writing this. I am unsure what it’s about – probably anxiety, perhaps excitement, but it’s uncomfortable. It is the first time I have attempted to write something for publication. It made me think about cows chewing the cud and the need for them to have a few stomachs to digest grass. I decided to look this up and discovered that cows have only one stomach but with four sections for the different stages of digestion and assimilation. I found listening and connecting online to the experiences and suffering these doctors were going through collectively really hard to digest and assimilate. Perhaps this is partly due to my own sense of being a patient and expecting them to be there for me when I am physically unwell and vulnerable. Connecting with, and acknowledging their vulnerability changed an aspect of the power dynamic that many of us are used to in the doctor-patient relationship. We were experiencing together as a group the global impact of the Covid pandemic and its multi-layered sufferings that for many have been fatal, and for others have been unbearable in personal and socio-political ways. There was also something intersectional, the interconnectedness between race, class and gender and how this creates discrimination and disadvantage. The loss of sense of power and privilege whilst seriously unwell that linked to how some felt they were treated by “the system” because they were female and/or of colour.

I think the indigestible nature of the content of sessions transferred to my experience of writing about the work. It connects me with a deep wailing, a mourning inside me for all people around the world who have lost their lives during the pandemic, and in the Long Covid group, seeing how much needs to be mourned by these doctors.

A thought I had about being with experienced doctors was, “What am I doing here? I have nothing to offer these extremely bright, knowledgeable and articulate professionals”, whom I feared would see me as someone not equipped to deal with their suffering. They initially wanted to just discuss their physical symptoms and what was or wasn’t being done by their contact as patients with their local medical specialists and GP’s. They began to experience a sense of otherness, as if they didn’t count as a patient other than just like anybody else and were not as special or privileged because they were doctors. I wondered with them if they were treated negatively because they were doctors who dared to break the rule that they should never be ill or vulnerable. Clare Gerada speaks about the medical matrix with its own goals and patterns of communication and power structures. This medical matrix determines the way doctors behave, even to the extreme of never showing their own vulnerabilities, yet at their graduations having to commit to the Geneva Declaration they

“. . . dedicate themselves to the service of humanity.” (Gerada; 2019)

but not including themselves. 

Some group members would give long monologues about how they had received help through various legal and union channels and would put contact information on the chat. It was often difficult for me to intervene at these points to suggest we focus on the emotional aspects as this information was also helpful for the other group members. I often needed to remind myself of the aims of the group – a space to share and support each other, not a therapy group but clearly therapeutic. Comments were often both defensive against touching their trauma and at the same time informative for everyone from the point of their “medical selves”. It was the interplay in my mind of these powerful emotions, the pandemic situation for all of us, alongside the first experience of an online client group that sometimes left me in a trance-like state on occasion, unable to find my voice as if waiting for someone to shake me. The hypnotic effect of watching a therapy group being played out on a monitor, a screen, in the Zoom, not in the room. I also reflected on the fact that we don’t use equipment as therapists. We are our own reflective monitors, and we are all in this hypnotic trance-like real-yet-unreal state because of Covid pandemic. The only sense of control I seemed certain about was my responsibility for holding the beginning and end of each session. Even this “dynamic administration” was regularly challenged by technical issues. It was a parallel process to the depths of personal uncertainty that each member was going through in relation to their health and as a consequence many aspects of their lives.

My internal responses to comments about being ignored or misinterpreted by their own GP’s and hospital doctors they consulted with due to their symptoms at some points came to the fore for me. I had recently been discounted by my own GP for an ailment I consulted him about, only to discover later when my symptoms became worse that it was a serious condition that needed treatment. I even recall saying to myself in one group, “So now you know how it feels to be a patient”. I was aware of a heartlessness about this inner thought and sensed that it linked closely to the shame they experienced now they were ill and had been previously healthy, privileged medical professionals. Over time the taboo of illness and ordinary humanity and compassion for themselves as a patient became more able to be explored. As Behr (2020) suggests, they began to,

“. . .realise they are no longer alone in what they have been through and rapidly go on to build a matrix out of their common ground.” (Behr; 2020) 

Much of the discussion of the physical symptoms highlighted the uncertainty, the not knowing and the lack of a solution that felt so hard for them to bear. As doctors they were often used to, especially the GP’s, of working with uncertainty with their own patients, but it was difficult for them to experience it for themselves as none of them had experienced serious physical illness previously.

Curiously I spoke about my desire to write this article with a German colleague. She was reminded that in German literature Foulkes described 5 levels in the group – current, transference, projective, body and primordial. The body level of the group is often left out in English translation. (personal communication, Regina Klein). The bodily emphasis in this work was clearly important as a way into the more disturbing aspects of their experiences as well as how they connected to the social in terms of a global pandemic.

As the group developed, some members openly questioned their identities and began to speak about what is the “me” that came from their professional identity as doctors; being challenged, as parents, friends, colleagues and now patients and wondering where “me” now is. Some who came as migrants to this country spoke about how they had been affected by lockdown and their physical persona – hair, dress, and the make-up that they had previously put on every day to feel accepted and had now suddenly been stripped away by the pandemic and the national restrictions. They no longer had these protective possibilities. This added to their vulnerability as they could now be seen behind the mask, when previously they had wanted to blend in professionally. This reminded me of Fanon and the title of one of his books, “Black Skin, White Masks”. Uncertainty about position and privilege was more openly discussed, especially as there was a predominance of women in my group, some of whom were migrants.

A number of the doctors were struggling with their human resources departments to receive sick pay or be given reasonable consideration for their difficulties to enable some to return to work with reduced workloads. For all these doctors experiencing Long Covid, their foundation “medical” matrix had shattered, and they were in some way trying to recreate a firm core. The

“. . . internalised stigma of being sick.” (Gerada, Griffiths; 2019)

 left them feeling isolated and judged by their colleagues.

“Hardly surprising as doctors as a group are altruistic, responsible and conscientious – anything less is deemed by peers as unacceptable. These traits, while necessary for a career in medicine, reinforce the illusion of invincibility when left unchecked.” (Gerada, Griffiths 2019).

The power of sharing in a safe and open reflective group space enabled them to begin to find emotional strength to develop compassion for each other and potentially heal and recreate a more compassionate medical matrix for themselves.

“The group-analytic group . . . with a guarantee of an open, protected thinking space, is the appropriate way to help doctors work maturely with the system and to achieve a healthier life-work balance.” (Wilke; 2005)

Postscript

Doctors in Distress, a registered charity, continues to offer on-line support groups for doctors experiencing the symptoms of Long Covid. The work has now been extended to offering similar on-line support groups to other professional groups in the NHS. Many of these groups are now facilitated by experienced group analysts.

Doctors in Distress aims to support all health and care professionals through the provision of groups. This allows staff to gain and give support to each other. The Charity’s over-arching aim is to reduce suicide amongst all health care staff.

Notes

[i] To protect the anonymity of participants, this paper describes a composite of the experience of two groups.

References

Burns S, Warren, S (2021) Learning from Doctors with Long Covid. British Medical Journal. February 26^th 2021

Behr H (2020) Commentary on “Groups for the Dead” by Clare Gerada and Frances Griffiths. Group Analysis. Vol. 53(3): 380-385

Fanon F (2021/1952) Black Skin, White Masks. Translator Richard Philcox. Penguin Modern Classics

Gerada C (2019) The Making of a Doctor; the Matrix and Self. Group Analysis. Vol. 52(3): 350-361

Gerada C, Griffiths F (2020) Groups for the Dead. Group Analysis. Vol. 53(3): 297 – 308

Jensen L (2020) What Your Patient is Thinking. British Medical Journal. November 2020

Wilke G (2005) Beyond Balint: A Group Analytic Support Model for Traumatised Doctors. Group Analysis. Vol. 38 (2): 265 – 280

Vivienne Harte
vivharte@btinternet.com