Balint Matters

Psychosomatics and the Art of Assessment

Jonathan Sklar

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429911194
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

This book explores the life and theories of Michael Balint, who kept alive Ferenczi's analytic traditions in Budapest and brought them to London, where they became a vital part of the Independent Group's theory and practice. Balint's theoretical understanding of regression, 'new beginnings', 'basic fault', as well as his profound impact on medicine, are all described. The work in the Balint groups by general practitioners, psychiatrists, and physicians are explored. Whole person and psychosomatic medicine, championed by Balint, is contrasted with today's more compartmentalised approach to medicine, including the increasing separation of the GP from the family. In the second part of the book Dr Sklar reflects on the complex tasks involved in psychodynamic assessment. Vignettes illustrate the importance of understanding the forces in family dynamics, the value of an early memory and a dream, and the sexual life of the patient. The author argues that Balint's ideas are of particular significance to us today, in our world of quick fixes and the overspecialisation of medicine.

Part I
An Overview of Michael Balint's Work

Chapter One
Regression and new beginnings: Michael, Alice, and Enid Balint, and the circulation of ideas

Who is crazy, we or the patients? (the children or the adults?)

—Sándor Ferenczi, The Clinical Diary (1932, p. 92)

Michael Balint was born Bergmann Mihály in Hungary on 3 December 1896 to a general-practitioner father. In 1920, he changed his name to Michael Balint, against his father’s will, and converted to the Unitarian Religion, thus avoiding some sanctions imposed on Jews. Whilst studying medicine during the First World War he was called up for army service, during which he received a severe injury to his thumb that led to a claw-like deformity. In 1917 he was given Freud’s Totem and Taboo by a young colleague, Alice Szekely-Kovacs, who had been a university classmate, together with Margaret Mahler (all would later become analytic colleagues). In 1918, Ferenczi was appointed to the first Chair of Psychoanalysis, and the young Balint attended the inaugural lecture series in 1919, just before the overthrow of Bela Kuhn’s Communist Republic. Michael and Alice, now married a year later in 1920, fled the counter-revolution to Berlin, where Michael worked in the biochemical laboratory of Otto Warburg. By 1922 the couple had both started analytic training with Hanns Sachs in Berlin. Balint regarded Sachs as too didactic an analyst—one who would nevertheless interrupt sessions by answering the phone (Stewart, 1996, p. 2). Two years later they then returned to Budapest, both commencing an analysis with Ferenczi, remaining with him for a further two years until he left Hungary for an eight-month lecture tour of the US. It was in Ferenczi’s waiting room that Balint first came into contact with Melanie Klein. From 1925 he began publishing papers on psychoanalysis and assumed a leading role within the Hungarian psychoanalytic movement. By 1935, two years after Ferenczi’s death, Balint became director of the Budapest Psychoanalytic Institute. Following the Anschluss of Austria in 1938, he and Alice made arrangements to flee to Britain with their son. They were aided by Ernest Jones, who in 1939 helped them to settle, not in London as desired, but in Manchester. Within a few months of their arrival, however, Alice suddenly died of a ruptured aneurysm—a condition under whose shadow they had lived for several years. In 1945, Balint’s parents, who had remained in Hungary, committed suicide to avoid being arrested by the Nazis. That year, Balint made the decision to move to London, where he obtained a Master of Science in psychology with a thesis entitled “Individual Differences in Early Infancy”. If we consider this brief early history from a Ferenczian perspective, one is able to trace elements of Balint’s traumatic landscape: a hand deformed by war, forsaking his father’s name, twice escaping from home and country, and the sudden death of his wife and both parents within a few short years. Such traumata involving the self, the other, and the environment would become profound topics of debate in his subsequent writings, which were developed amidst the growing influence of notions of early object relationships.

Alongside this personal and geographic history, it is useful to give an initial summary of Balint’s prominent relationship with the tradition of psychoanalysis that preceded him. Balint became Ferenczi’s literary executor, and when travelling to England brought with him, amongst many documents and papers, the original manuscript of The Clinical Diary, which covered the last year of Ferenczi’s life and his private thoughts on the clinical and theoretical gap that had opened up between him and Freud from late 1932. Balint transcribed and translated this valuable record into English. He also had possession of Freud’s letters to Ferenczi, a collection forming half of that extraordinary correspondence. Devoting considerable effort to keeping the flame of Hungarian psychoanalytic thought alive, Balint strongly desired to publish the correspondence along with The Clinical Diary. Together they contained the core of the Budapest Psychoanalytical School and its historical development in association with Freud. Due to consideration for those individuals still living, however, including Anna Freud—who refused the publication of her father’s half of the correspondence—Balint was unable to publish them in his lifetime. To touch on one central topic of this crucial set of correspondence, Freud had, in his later career, become cautious about the therapeutic efficacy of psychoanalysis (Ferenczi, 1932, p. 93). In contrast, Ferenczi was well-known for his enthusiasm for clinical work. Balint was to continue Ferenczi’s research into themes such as the analytic setting, character analysis, and, in particular, the role of the analyst in the analytic environment, culminating in his final and most important book on regression, The Basic Fault: Therapeutic Aspects of Regression (1968). The other major strand of Balint’s corpus— relating to his and Ferenczi’s trust in clinical work—was the application of psychoanalytic thinking to the study of doctors and their interaction with patients. This resulted in his book The Doctor, his Patient and the Illness (1957), which he described in the introduction as “researchcum-training” (p. 3), and which became well-known amongst medical practitioners. What I am seeking to offer in this opening chapter is not merely an account of Balint’s trajectory, but an examination of a moment in the history of the conceptualisation of psychoanalytic training and technique—and the controversies that have subsequently arisen.

The analytic pair

In terms of the understanding of psychoanalytic technique, one of Balint’s particular contributions was to examine the process and the role of the analyst in establishing the character, range, and depth of the project of the analytic pair. As Jacques Lacan noted, Balint focused on understanding the fundamental object-relation, which he calls “primary love, namely the relations between mother and infant” (Lacan, 1975, p. 209). For Lacan, a key element in this understanding was provided by Alice Balint’s paper “Love for the Mother and Mother Love” (1939), in which, theoretically, the mother satisfies all the needs of the infant. This complex scenario of real and imagined experience is the structural crucible on which all that follows is based. Alice Balint heroically demonstrates “that maternal need displays exactly the same limits as every vital need, namely that when one no longer has anything to give, well one takes … [I]n any given so-called primitive society … when there is nothing left to eat, you eat your child” (Lacan, 1975, p. 210, italics in original). His reading pays tribute to Alice Balint for recognising the negative component of this relation. Using this model as his template, while remaining perhaps more conventionally within its terms, Michael Balint based his account of primary love on the mother–infant relationship, in which the maternal object corresponds to the satisfaction of a need.

Masud Khan’s shrewdly if cacophonously entitled essay “On the Clinical Provision of Frustrations, Recognitions, and Failures in the Analytic Situation: An Essay on Dr. Michael Balint’s Researches on the Theory of Psychoanalytic Technique” (1969) draws a connection with Ferenczi’s last controversial paper, “Confusion of Tongues Between Adults and the Child” (1933), and makes clear that Balint is the true heir of that Budapest strand of technique and theory. Central to Balint’s conceptualisation is the idea of the “basic fault”, a term used to describe the relatively common experience in early two-person relationships that something is wrong or missing, and that this has been carried over into the oedipal period (from two to five years old). In Balint’s theory, resolution of the “basic fault” takes place through regression within the analytic setting. This is a subject that divides the analytic world today, with many colleagues regarding regression as antithetical or even dangerous to an analysis. For Balint, however:

The analyst must accept the regression. This means that he must create an environment, a climate, in which he and his patient can tolerate the regression as a mutual experience … What the analyst must provide—and, if at all possible, during the regular sessions only—is sufficient time free from extrinsic temptations, stimuli, and demands, including those originating from himself (the analyst). The aim is that the patient should be able to find himself, to accept himself, and to get on with himself, knowing all the time that there is a scar in himself, his basic fault, which cannot be “analysed” out of existence; moreover, he must be allowed to discover his way to the world of objects—and not be shown the “right” way by some profound or correct interpretation … To provide this sort of object or environment is certainly an important part of the therapeutic task. Clearly, it is only a part, not the whole of the task. Apart from being a “need-recognizing” and perhaps even a “need-satisfying” object, the analyst must be also a “need-understanding” object, who in addition must be able to communicate his understanding to his patient.

(M. Balint, 1968, pp. 177–181)

Balint is signalling a radical adaptation in technique in order to attempt to reach those patients who are unable to speak their distress in a language other than regression—an adaptation that will include enactment as well as psychosomatic defences as means of attempting to communicate beyond words. Rather than being fearful of the demands it might make on the analysis, and of not knowing where such a path may lead, Balint directs attention to the essential means of such communication as a furtherance, rather than a hindrance, to the analytic process.

New beginnings

To understand this, we need to go back to Balint’s earliest ideas— specifically, to the concept of the “new beginning”. He introduced this concept surprisingly early, at the 1932 Wiesbaden conference in which Ferenczi gave his last paper, the badly understood and poorly received “Confusion of the Tongues between Adults and the Child”—I have written much on Freud and Ferenczi’s misunderstandings of each other’s positions (Sklar, 2011, pp. 2, 40, & 69). From a historical perspective, Balint was already drawing attention to the clinical development of Ferenczi’s analytical descriptions of the therapeutic dyad in arrested development. For some patients, in the childhood situation a complementary factor was that the child’s trust had been betrayed. When the patient repeats this in analysis the analyst’s passive unobtrusiveness alone can help the patient drop his self-protective character structure. For Balint, this constituted the experience of the “new beginning”. Such patients, due to earlier loss or traumatic environments, give expression to the need for that which was felt to be missing—more particularly, a missing form of being. This missing state is the precondition for object-relating, meaning that achieving it will enable the patient to be in a condition to both offer and receive object-love, very often for the first time in their life.

For Ferenczi, particular levels of tension, described with a metaphor of elasticity, were sometimes essential for the development of the analytic process (Ferenczi, 1928, pp. 87–101). Freud agreed with the idea of elasticity as a description of the analyst’s tact (ibid., p. 99). Evolving this theme, Balint continued to write about this necessary elasticity in technique (M. Balint, 1950, pp. 117–124). In relation to such flexibility and sensitivity, in his contribution to honour Melanie Klein on her seventieth birthday in an issue of the International Journal of Psychoanalysis, he described new beginnings that occur near the end of analysis as: “reactions which can be observed and recognized only with difficulty, as the level of pleasure amounts only to a tranquil quiet sense of well-being” (M. Balint, 1952, p. 215, italics in original). For more ill patients it is likely that such an atmosphere was rarely available in the early stages of their life, if at all. For Balint, analytic work can enable a new chapter of life and relationships to be available to the analysand, who, whilst fully cognisant of prior defences against early traumatic impingements, can nonetheless move away from the grip of these past fixities and expectations. In Balint’s own summation,

new beginning means the capacity for an unsuspicious, trusting, self-abandoned and relaxed object-relation. There are two clinically necessary conditions without which a proper phase of new beginning cannot develop. These are: (a) the relinquishing of the paranoid attitude, the realization that the paranoid anxieties were unfounded or at least grossly exaggerated; (b) the acceptance, without undue anxiety, of a certain amount of depression as an inevitable condition of life.

(M. Balint, 1952, p. 220)

Here we find the roots of Balint’s exposition of primary love as a form of love that is earlier than and free of the Kleinian death drive, postulated as early aggression, and envy by the baby of the breast. In relation to such negative early experience, Balint took issue with previous notions of developmental chronology, arguing that particular defensive structures are acquired in relation to early environmental impingements and traumas. For Klein, “the first phase of the human mind is dominated by paranoid anxieties and mechanisms and … this is followed by the depressive position” (M. Balint, 1952, p. 221). In this paper, Balint characterised these arguments about early development in a to-and-fro discourse that remains theoretically open rather being entrenched in politics—those of either a particular psychoanalytic theory or a particular analytic group. He does not idealise theory but sets out how complicated it can become. Whilst he praised Klein for her valuable contributions about working with children, he did not agree with her view of the death drive as an early given and as a bedrock of the mind. He believed that clinical techniques should evolve through the challenge of the patient’s history and through the dynamics between archaic object-love and the early environment—dynamics to be exposed within the analytic process.

For Balint, in contrast to Klein, pathological narcissism was always secondary to trauma, and he disagreed with the formulation of early object relations as starting with the death drive, seeing this as an instinctual reductionism. Klein’s destructive force, residing in each individual and tending towards the annihilation of life, was represented by greed, destructive envy, and omnipotent denial of dependence—all of which, for her school, coexist from uterine life. Balint thought that archaic object-love was only underdeveloped, such that the analytic task was to assist its growth. Remarking on complexity well beyond a Kleinian split of the object into just good and bad, he described “unsuspicious, naïve, archaic object-love” as “the first post-natal phase in the development of the human mind; it is a centre or nodal point from which all later developments radiate” (M. Balint, 1952, p. 223). One development from this primary stage would then be narcissism, as developing according to the environmental provision—meaning the amount of trauma that may have occurred, due, say, to the mother’s impingements. Eventually, he argues, “the depressive position must be considered more fundamental, more primitive, than the paranoid” (ibid., p. 224).

A digression on the death instinct

Before ending this section, I would like to introduce Paula Heimann, who qualified as an analyst in Berlin in 1933 with a classical Freudian training, after which she immediately had to flee to London. There she soon became interested in Klein’s work and underwent further training with her. In time, she became one of Klein’s closest associates, and her early papers are clear expositions of Kleinian concepts: sublimation and creativity (1942), the internal object (1949), and the early stages of the oedipal complex (1952). But from around 1949 she began to move away from Klein, becoming critical of the theory of the death drive and of early aggression. Eventually, as outlined by Margret Tonnesman, Heimann

viewed severe pathological states, like psychotic depressions, as regressions to early death-like somatic traumata with lack of differentiation of self and object and extreme cruelty operative in the patient’s inner world. In her … paper, “Notes on the anal stage”, she suggested re-naming the anal-sadistic phase of development the anal-locomotor phase, as sadism and cruelty point to failure in the environmental facilitation during this phase of development.

(Tonnesmann, 1989, p. 19)

In this paper, Heimann relates to both Donald Winnicott’s and Balint’s views of the environment as provision that either holds or fails to hold. In a later paper, she goes on to illuminate the difference between Freud’s theories of the life and death instincts. The natural position of human beings is to generally wish to survive, and to go on living.

What, then, is the death instinct? There are many situations in which our patients tell us and show us that they want to be dead. I believe that it is more correct to say that they want to be dead than to say that they want to die; indeed, analysis reveals that the wish in question concerns a state that is painless, while the fact of dying is usually strongly invested with phantasies of pain. Behind the wish to be dead what one really finds is the wish to be free of pain, whether physical, or psychical, such as shame, guilt, intolerable fears, anxiety, depression, confusion, despair, and so on, or we find phantasy wishes to be revenged upon or to kill an object with which the patient has unconsciously identified. A fairly typical revenge phantasy, which is often pre-conscious, consists of imagining one’s parents in a state of terrible guilt, suffering from remorse, accusing each other over their child’s grave: here an Oedipal wish is concealed behind the wish to be dead.

(Heimann, 1969, p. 253)

Here, Heimann is developing an understanding of death, away from a fundamental wish to return to an inanimate state, as described by Freud. Rather, the idea of being inanimate is primarily an expression of negativism, indifference, contempt for pain, and lack of self-interest. These are states of mind of an opposite formation to that of a creative life, fragments of dissociative mind—as found in psychosis, severe manic-depressive states, and perversion—which can start as intrusions of bad parenting in early infancy. Heimann eventually states: “Personally, what I no longer find convincing is the relation between the hypothetical death instinct and the primary destructive drive” (ibid., p. 255). The importance of this later work lies in its descriptions of her giving up the seductive pull of inertia and primary destructiveness. Kleinians regard the latter as a central concept, and see an analysis without such introspective theoretical discussion as superficial. I would argue that such a position distances the Kleinian analyst by diminishing the historical findings of the various intrusions into the bodies and minds of babies, children, and adolescents, discovered through the transference, as well as being a radically different theory of primary love championed by Balint. For the Balints, these intrusions constitute the traumatic substrate that can be found in the centre of the environment that is analysis and, when understood, can be overcome by the patient that discovers the possibility of a new beginning.

The basic fault

In his final book, The Basic Fault (1968), Balint examines the above dynamics in the regressed patient and their analyst. Here the word “fault” is used in a geographic sense, as in a fault line that may connect or disjoin underlying tectonic plates. The term functions as a metaphor for splits in the ego and for their subsequent development, including that within analytical treatment.

Let us start by examining Balint’s text from the perspective of hi...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• PATIENTS WHO APPEAR MORE THAN ONCE
• ACKNOWLEDGMENTS
• ABOUT THE AUTHOR
• INTRODUCTION
• PART I: AN OVERVIEW OF MICHAEL BALINT'S WORK
• PART II: BALINT GROUPS
• PART III: ASSESSMENT
• REFERENCES
• INDEX