The Theory and Practice of Balint Group Work

Analyzing Professional Relationships

Heide Otten

• Publisher: Routledge
• Year: 2017
• Topic: Psychology
• eBook ISBN:
  9781351377829
• Subtopic: Education in Psychology
• Index: Psychology

Michael Balint's work grew out of a desire to analyze the doctor-patient relationship and improve diagnosis and treatment, and is now known and implemented internationally. In The Theory and Practice of Balint Group Work Heide Otten presents a practical guide to Balint groups and their relevance to clinicians in the modern world of internet diagnoses, distant patients and teams of specialists.

The book begins with a history of the therapeutic relationship and its influence on the development of Balint's work. Otten demonstrates how the sessions work, and goes on to look at the practical aspects of Balint group work with various professional and student groups, with participants of different cultural backgrounds and nationalities, and internationally. The requirements for leading a Balint group are then explored, and the book concludes with research findings and a look at how the practice can be extended to other professional groups. Case material from the author's own work is included throughout, and suggestions for additional creative elements such as sculpting, role play and psychodrama are also featured.

The Theory and Practice of Balint Group Work is an essential guide for psychoanalysts, psychoanalytic psychotherapists, counsellors and medical practitioners and theorists coming to group work for the first time or utilising Balint's ideas in their day to day practice. It will also appeal to others working in the helping professions seeking to strengthen the therapeutic relationship.

Chapter 1

Introduction

There are two main consequences of our age of communication, computers, networking and fast-paced information technology. On the one hand the disparity between experts and lay people may have lessened. On the other hand however, the new trend has produced super specialists who know ever more about so very little.

We depend on networking and teamwork. Professional relationships consequently take on a new quality in a modern cultural context. Not that long ago, primary medical care was shaped through an intimate, trusting relationship between someone looking for care and help and a caregiver, let us say a family doctor. Today we rely on the interconnected relationships of helper teams. The patient in his system of friends, family and the internet is faced with a group of specialists taking care of his problem.

Those helping caregivers are possibly knowledgeable and competent but contribute to “the collusion of responsibility”, as Balint calls it (Balint 1957). Who takes responsibility for the far-reaching vital decisions made by the collection of specialists? What are the relevant communication channels? Where is the place of the emotions and the importance of the role that they play?

The relationships between the professionals in the team also play a considerable role and affect the interface of patient and primary care doctor in everyday practice.

Modern medicine declares the creed of “shared decision making”, which is often contrary to the wishes, needs and – mostly inaccessible – feelings of the patient, who wants to be looked after, held and relieved from responsibility.

This leads to an ambivalence on both sides and unconsciously influences the therapeutic alliance and the relationship. Significant conflicts may be the result.

These unconscious processes call for analysis of the psychodynamics underlying the relationship. Questions need to be asked: do I understand the underlying conflict of the person who is looking for help? Do I see what is behind the symptom, behind resistance and defense? What influence has my own attitude on this relationship?

And what have been the influences of the relevant social systems – family, work place, hospital, health care system, society as a whole – on the functioning of the doctor and patient as the core unit of health seeking?

In the 1950s Michael Balint (1896–1970) – medical doctor, biochemist and psychoanalyst – developed a method of group work, together with NHS general medical practitioners. The aim was and still is today to recognize problems in the relationship between a patient and a doctor and to find a better understanding of what illness really means.

He called the first group “a training cum research group” and therefore emphasized the duality of the underlying purpose. One aim was the further education and training of the helper, the doctor; the other aim was to research the effect of the helper on the help-seeker (“the doctor as a drug”).

Balint approached his work with a scientific attitude: open in principle, capable of critique, permanently testing, correcting and changing the results. He demonstrated that knowledge and hypotheses about the patient and his illness are in constant need to be challenged, giving them a provisional and impermanent character. That has not changed in our groups today. We see the analytic group work as a method, that results in a combination of structure and spontaneity, with sense and sensibility making equal contributions, that always reveal something new and unexpected.

Today, the Balint method is also used in other social professions, to understand problematic relationships, to clarify context and to influence inner and outer reality. Teachers especially have gained benefit from understanding better and improving their relationship with students and their parents in a deeper way. The aim however is not to level out all disharmony, nor to equalize positions nor to remove intense feelings of anger, envy and impotence, but to bring them into conscious awareness and then use them to promote reflection, felt emotion and deeper awareness.

After all, what has been made conscious will be hard to push back underground again and can be openly worked with.

In this book I would like to introduce Balint’s thoughts and make his concepts available. I believe it is necessary to start with a short excursion into the history of medicine to bring alive the historic changes of the doctor–patient relationship, to make the work and passion of Balint become clear and enable us to understand how we have reached the positions where we are today.

Initially, the influence which the healer, doctor or caregiver exercised on the patient was the greater, the less scientific knowledge was available. The importance of faith, magic, mystical hold, religion, spirituality and naturalistic perceptions was paramount to medical knowledge and its application in those earlier days of healing. The development and introduction of researched science and its application to medicine then redefined the meaning of the whole person in his context and totality quite dramatically. Nevertheless, we experience that interpersonal contact still plays a major role for human beings, who are, after all, social beings in a cultural environment, especially in the relation to the person, who is helping.

In Balint’s words this translates as follows:

The discussion quickly revealed – certainly not for the first time in the history of medicine – that by far the most frequently used drug in general practice was the doctor himself … Still more disquieting is the lack of any literature on the possible hazards of this kind of medication, on the various allergic conditions met in individual patients which ought to be watched carefully, or on the undesirable side-effects of the drug.

(Balint 1957, p. 1)

Patient-centered, trustworthy, empathic and well informed: that is how patients wish their doctor to be. Open, full of trust and understanding: that is how doctors wish their patients to be.

Working in an atmosphere with these respective attributes in the partnership, the patient can receive full benefits. Diagnostic and therapeutic interventions can be implemented, the doctor’s skills, energy and knowledge can be maximized and harvested. The patient is allowed to receive attention and nurturing. The course of the illness is more likely to take a positive and productive development: “The doctor’s personality and subjective interests may have a decisive influence on what he notices and records about his patient” (Balint 1957, p. 53).

Reality however does not always lend itself to dealing with each other in beneficial ways. We are lacking time and lacking patience and we are distracted by perceived necessities. Consulting rooms do not automatically facilitate understanding in the meetings of two human beings: too many inside and outside variables have their effect upon us. And often there is not even the chance to become aware of these shortcomings. What feelings actually influence and maybe determine the meeting? Can I utilize them, or are they in the way? Do I bring anger, anxiety, frustration and prejudice from other sources into the relationship? And what feelings are brought to me by my counterpart in the therapeutic alliance? What effect do all these emotions have if they are hidden and cannot be verbalized or at least felt?

There is much to be gained from exploring these questions.

And not only in terms of the doctor–patient relationship. Any professional relationship involving caregivers, clients, helpers and seekers of help, in any shape or form can become extremely difficult. Others too, for example teachers and students, solicitors and clients, pastors and congregation members, social workers, nurses, psychologists and their patients, all know how burdensome human interaction can be.

Burdensome relationships are stressful for everyone involved; to analyze and understand the difficulties can lighten the everyday load and help to prevent burn-out. Introspection is necessary: what are my parts, why do I find it difficult to connect with the person in front of me? If I can ask and maybe answer these questions, I will be privileged to learn a lot about myself. On the other hand, I will be encouraged to change perspective. What might influence or move the other person, what situation is she in? What might be expected of me?

We all know from experience that unsatisfactory interactions with our patients weigh heavily on us and take their toll in frustration, exhaustion, mental suffering and illness. To prevent these consequences serves what we call “Balint work” – named after its inventor.

Dankwart Mattke called Balint work “the most robust form ever of applied Psychoanalysis” (Mattke et al. 2009, pp. 83–86).

This book aims to convey my passionate belief, that it is worthwhile to travel this path and undertake this process of trying to clarify and modify our day to day encounter with others.

Group work is the trusted method of relationship analysis. Every group member brings their own attitudes to the presented relationship and helps to depict the perspective of the doctor and his interactions, as well as the patient’s perceptions in his network of support, encouragement or distraction. All of a sudden or very slowly, a different picture of the situation is allowed to emerge.

This type of group work is practiced successfully in many countries and continents and it can be valuable to all professionals needing to reflect and explore and to find meaning in what is actually going on in their encounters with clients or patients.

Michael Balint published his book The Doctor, His Patient and the Illness more than fifty years ago. The literature on the subject is plentiful and I will give just some hints and references. My aim is to give practical examples and explanations to make the reader want to try this method, to read more about it, to join a group or experience it at a conference. More than anything else, I wish the reader to become a seeker of sorts, to ask their own questions and undergo their own personal experiences.

If I refer to the gender of a person, I will use a neutral form. If I refer to “he”, I also mean “she” and thus follow the traditional convention.

Part I

History and basics

Chapter 2

The doctor–patient relationship in history

Illness and health have always been central themes for mankind. This is well reflected in our written history, in the arts and in literature.

The less scientific knowledge was available, the greater was the impact of faith, mysticism, religion, philosophy and naturalistic thinking.

The healer was believed to have magical powers and nature was said to be healing.

2.1The classical era

“Medicus curat, natura sanat” – the doctor treats and nature heals, wrote Hippocrates (460–370 BC). He viewed the doctor as a supportive companion. It is not the doctor who wins over the illness, but the patient, the patient’s own healing powers and those of nature. The doctor makes his knowledge and experience available. The course of illness takes time. To disregard this brings more damage than benefit. A good doctor takes that into account and encourages his patient to do the same. He accompanies and serves the patient with his healing art. Philosophy and Science are the basics of ancient medicine. Harmony is viewed as the most essential prerequisite for health. Illness develops from disharmony of the humors. The doctor helps to rebalance the humors towards the correct mix and thus harmony can be restored. The art of healing is to perform the right action at the right time.

The human being inhabits a lifelong position between illness and health; the doctor is the agent who helps the human being to hold the balance: total health is unachievable, total illness means to die. When the doctor can no longer help or heal and when death nears, he turns away and leaves the dying person in the care of the priest. The limits of the healing art are very clearly defined and respected.

Doctors in the ancient era valued psychological factors as a relevant factor in the course of illness and the healing process. Psychological factors are well considered in medical treatment. The temples served as sanatoria: patients stayed there overnight. Dreams and conversations played an essential role in therapy. Most probably the psychosomatic illnesses were treated in this way at the time.

We learn from classical literature that the basis of healing art lies in the loving and open approach and the honest desire to help.

The Hippocratic oath reveals:

I will use all therapeutic interventions to the benefit of the patient and will do so to the best of my ability and judgment. I vow to never use them to the patient’s detriment or in any wrongful manner. … Pure and pious will I preserve my own life and healing ability …

The Declaration of Geneva (latest edition 1994) states: “On entering the medical profession I vow unreservedly to use my life for the purpose of duty towards humanity … The health of my patients will be the utmost priority of my actions…”

An important part of the rules and guidelines was aimed at the physician himself: there are prescriptions, which regulated the life of a healer: “The essential duty of the doctor is to heal his own mind and help himself, before he endeavors to help anyone else” (Epitaph, Athenian doctor during the classical period/Häfner 2007, p. xiii).

We know of a dress code and a code of conduct. The latter commanded the doctor not to harm his patient, to maintain confidentiality, not to perform sexual acts with patients and not to practice euthanasia. Surgical procedures were not performed by doctors: “I will to incise, not even patients suffering from Lithiasis, but I will leave this to the men, who perform that craft” (Hippocratic Oath).

2.2Old Testament

The...

Table of contents

• Cover
• Endorsement
• Half Title
• Title Page
• Copyright Page
• Contents
• Foreword by E.R. Petzold
• Foreword by John Salinsky
• Foreword by Donald E. Nease, Jr, MD
• Acknowledgments
• Chapter 1 Introduction
• Part I History and basics
• Part II Practical aspects of Balint work
• Part III Requirements for leading a Balint group
• Part IV Results and opportunities
• Bibliography
• Index