Journal of the Royal Society of Medicine Volume 72 June 1979
469
turn to provide her with the psychological container that she so desperately needed. It was this discovery that he could tolerate her and hold her together that stopped the deteriorating downward spiral. As stated earlier, one of our major dilemmas is how to care for our patients while simultaneously having to cope not only with the patients' anxieties but also those they rouse in us. When the anxieties are of the intensity experienced and projected by this patient it is difficult for any doctor, particularly if not specifically trained to do so, to cope alone. Discussion of the kind described can provide the support he needs. This is one of the tasks of a psychotherapist in helping to increase the psychotherapeutic resources of general practice.
References Bion W R (1970) Attention and Interpretation. Tavistock Publications, London Brook A (1978) Health Trends 10, 37 Brook A & Temperley J (1976) Journal of the Royal College of General Practitioners 26, 86
The Balint group approach
Enid Balint BSC Member, Institute ofPsychoanalysis 63 New Cavendish Street, London WI
This short paper will describe the contribution that psychoanalysts and psychiatrists can make in the field of general practice, and also how useful the general practitioner can be to the psychiatrist and the psychoanalyst. For the last quarter of a century, I, a nonmedical psychoanalyst, along with other psychoanalysts who have been medically qualified, have worked with groups of mature general practitioners, both in London and in Europe. More recently I have worked with groups of trainee general practitioners in London, and with young physicians in a hospital setting on general medical and surgical wards in the United States. I have therefore clearly seen the difference between what we mean when we talk about psychiatry in general practice (or the way that psychiatry can influence general practice) as compared with the way psychiatry can be used in any other setting. I shall be using the word psychiatry in a very wide sense: not only to describe psychiatric disorders as such, i.e. nameable illnesses, but also for emotional disturbances not associated with organized, nameable illness. In general practice, the questions the general practitioner has to ask himself are not only what illness is this patient suffering from, but also what (if anything) is wrong with him at this moment, other than his diagnosable illness and symptoms; what is he showing to me, or what is he trying to convey to me here and now; and, finally, how can I help him? I shall use the word psychiatry to cover all emotional problems, even feelings of sadness and misery; upsets, remorse and so on which occur during the lives of our patients, and which are presented to the general practitioner sometimes with some diagnosable illness, sometimes when no diagnosable illness is present. Patients in hospital have, of course, the same kind of illnesses. There too, they can be observed by the doctors on the wards, but the treatment that the hospital doctor can offer them must be different from the treatment the GP can offer, since the period of observation is usually shorter. Methods I have already introduced the ways in which I have worked with groups of general practitioners for the last quarter of a century and also with groups of physicians in a hospital setting. I must now describe briefly the kind of groups to which I am referring. So-called Balint groups are formed when about 10-12 general practitioners, or other 01 41-0768/79/060469-03/$O 1.00/0
,."
1979 The Royal Society of Medicine
470
Journal of the Royal Society of Medicine Volume 72 June 1979
physicians, decide to meet together with one or two psychiatrists or psychoanalysts (or sometimes with general practitioners who have had training in this kind of work) to discuss patients. The meetings are usually planned to take place once a week over a period of two or more years and last for I 2 hours each. At the meetings the physicians are asked to talk about any patient they are currently treating, preferably not those with quite obviously neurotic or psychotic disturbances, but patients who puzzle them, or who do not seem to be cured by obvious remedies. After one doctor has given a report about a patient, the other doctors are asked to comment; not only to ask the presenting doctor questions, but also to ask themselves questions and try to answer them; to use their imagination, their knowledge and observations. The leader encourages the doctors to expand their usual ways of thinking and to rethink the meaning of what are often interesting inconsistencies in the asides given by the reporting doctor. This kind of work can be done over a long period, when not only rethinking but skills are learned; or it can be done quite briefly at extended weekend conferences, though with less chance of gaining skills. Observations stemming from this method of work One of the differences between psychiatry as practised by the general practitioner and psychiatry as practised by the physician in the hospital setting is that in a hospital setting the doctors work in a team. They are not isolated and they may not have final responsibility for the decisions that they take. They also have nurses and various kinds of aides around them. Each patient is looked after by a number of different people and if the doctor is puzzled by various inconsistencies in a patient's behaviour or illness, he does not have to puzzle so hard on his own, and tends to think of his patient as an ill person in the traditional sense; the psychiatry he offers him is more likely to be geared to illnesses, e.g. depression, psychotic disorders. This may not help the doctor observe what the patient is really like on the ward at that moment, or what he (the doctor) is like when he is with his patient. General practitioners, however, even if they are still under the supervision of a trainer general practitioner, are on their own when they are with their patients. Even though they discuss their patients with their supervisors or in groups, they feel intensely responsible for their patients and, when they are seeing them, they are completely alone and are the only ones who actually hear what the patient says and sees how he looks when he says it. This seeing and listening is the kind of psychiatry I am interested in, and if seen in this light it can contribute to general practice. The general practitioners themselves have to make decisions about what to say, what to treat, what to ignore, what to observe, what to reflect about and what to turn their backs on. They are already trained to take seriously and observe certain phenomena and to treat them in a traditional manner; but if they are trained in groups to observe and take seriously other matters, other phenomena which are not taken seriously in hospitals, this could form the basis of psychiatry in general practice. We must remember that the majority of patients never visit psychiatrists (i.e. doctors trained to treat psychiatric disorders), and are never labelled as neurotic or psychotic. In America I was asked to work in a new unit in the general hospital. The service I worked in was a consultative service, staffed by psychiatrists available to help doctors on any of the wards in the hospital. I was asked to lead a seminar to discuss this work, to which psychiatrists, nurses, aides and other doctors were invited. Though I was first asked to interview the patients we soon decided that it would be better if together we tried to make sense of what the various doctors and nurses told us and whether, when we worked together, something new about the patient that had not been observed before, or had been thought irrelevant, might help the treatment. We soon found that this was so; the doctors began to think again and to reflect together and to work as a group. In Balint groups it is our main aim to help physicians rethink their findings, see their patients from a different angle, understand their relationships with them and see what happens when they discuss their thoughts in the presence of their colleagues, with a leader whose aim is to help work proceed. The group work enables them to talk together in a manner somewhat different from their usual one; to think carefully, to talk freely and to examine what they say. Our findings suggest that the leader (psychiatrist/psychoanalyst) and physicians learn a great deal from one another. They begin to ask each other different kinds of
Journal of the Royal Society of Medicine Volume 72 June 1979
471
questions about their patients and themselves and to observe quite different kinds of phenomena. I am sure you know how narrow our usual field of vision is and, if we broaden it, we are likely to be aware of what might help our patients better. I have spent many years working with experienced doctors who have been in practice for some years; it is often difficult for these doctors to broaden their vision. They may respect the psychiatrist leader and his views very highly and try to copy him, but it is difficult to do this and usually fairly useless because each individual doctor and patient is different. We have even found that it is not very useful to try to apply psychoanalytical or psychiatric theory in general practice. The patient can be fitted into such theories, but the value of this exercise is limited. In trainee groups this hazard seems less pressing. The doctors have only recently left hospital where they have learnt traditional medicine and quite properly value it highly. They can therefore afford to be much more openly critical of the new psychiatric leader; but in spite of this they seem to be willing to look at and to think and reflect about what the leader says, or what their colleagues say, without agreeing easily but without rejecting entirely what is offered to them. They do not swallow things whole but they will ponder upon what comes up during the discussion and use it or reject it according to their own knowledge, personalities and to the relevance of what is discussed. This observation seems to be a very good omen for the future of psychiatry in general practice; for if doctors are willing to look critically at previously unobserved phenomena and accept or reject them on the basis of their sound medical training, psychiatrists and psychoanalysts will also be able to reflect about its relevance with their patients when the need occurs. In all Balint groups, but perhaps mostly in trainee groups, the doctors seem to be willing to look inwards at their own responses and reflect about themselves as well as their patients. They do not seem to need to keep up a good front but show that they are thinking. This makes the leader able to continue with his thinking and realize his own limitations as well. Bibliography Balint M (1957) The Doctor, his Patient and the Illness. Pitman, London Balint M & Balint E (1961) Psychotherapy Techniques in Medicine. Tavistock Publications, London Balint E & Norell J S ed (1973) Six Minutes for the Patient. Tavistock Publications, London Brown D & Pedder J (1979) Introduction to Psychotherapy: An Outline of Psychodynamic Principles and Practice. Tavistock Publications, London Malan D H (1963) Study of Brief Psychotherapy. Tavistock Publications, London
469
turn to provide her with the psychological container that she so desperately needed. It was this discovery that he could tolerate her and hold her together that stopped the deteriorating downward spiral. As stated earlier, one of our major dilemmas is how to care for our patients while simultaneously having to cope not only with the patients' anxieties but also those they rouse in us. When the anxieties are of the intensity experienced and projected by this patient it is difficult for any doctor, particularly if not specifically trained to do so, to cope alone. Discussion of the kind described can provide the support he needs. This is one of the tasks of a psychotherapist in helping to increase the psychotherapeutic resources of general practice.
References Bion W R (1970) Attention and Interpretation. Tavistock Publications, London Brook A (1978) Health Trends 10, 37 Brook A & Temperley J (1976) Journal of the Royal College of General Practitioners 26, 86
The Balint group approach
Enid Balint BSC Member, Institute ofPsychoanalysis 63 New Cavendish Street, London WI
This short paper will describe the contribution that psychoanalysts and psychiatrists can make in the field of general practice, and also how useful the general practitioner can be to the psychiatrist and the psychoanalyst. For the last quarter of a century, I, a nonmedical psychoanalyst, along with other psychoanalysts who have been medically qualified, have worked with groups of mature general practitioners, both in London and in Europe. More recently I have worked with groups of trainee general practitioners in London, and with young physicians in a hospital setting on general medical and surgical wards in the United States. I have therefore clearly seen the difference between what we mean when we talk about psychiatry in general practice (or the way that psychiatry can influence general practice) as compared with the way psychiatry can be used in any other setting. I shall be using the word psychiatry in a very wide sense: not only to describe psychiatric disorders as such, i.e. nameable illnesses, but also for emotional disturbances not associated with organized, nameable illness. In general practice, the questions the general practitioner has to ask himself are not only what illness is this patient suffering from, but also what (if anything) is wrong with him at this moment, other than his diagnosable illness and symptoms; what is he showing to me, or what is he trying to convey to me here and now; and, finally, how can I help him? I shall use the word psychiatry to cover all emotional problems, even feelings of sadness and misery; upsets, remorse and so on which occur during the lives of our patients, and which are presented to the general practitioner sometimes with some diagnosable illness, sometimes when no diagnosable illness is present. Patients in hospital have, of course, the same kind of illnesses. There too, they can be observed by the doctors on the wards, but the treatment that the hospital doctor can offer them must be different from the treatment the GP can offer, since the period of observation is usually shorter. Methods I have already introduced the ways in which I have worked with groups of general practitioners for the last quarter of a century and also with groups of physicians in a hospital setting. I must now describe briefly the kind of groups to which I am referring. So-called Balint groups are formed when about 10-12 general practitioners, or other 01 41-0768/79/060469-03/$O 1.00/0
,."
1979 The Royal Society of Medicine
470
Journal of the Royal Society of Medicine Volume 72 June 1979
physicians, decide to meet together with one or two psychiatrists or psychoanalysts (or sometimes with general practitioners who have had training in this kind of work) to discuss patients. The meetings are usually planned to take place once a week over a period of two or more years and last for I 2 hours each. At the meetings the physicians are asked to talk about any patient they are currently treating, preferably not those with quite obviously neurotic or psychotic disturbances, but patients who puzzle them, or who do not seem to be cured by obvious remedies. After one doctor has given a report about a patient, the other doctors are asked to comment; not only to ask the presenting doctor questions, but also to ask themselves questions and try to answer them; to use their imagination, their knowledge and observations. The leader encourages the doctors to expand their usual ways of thinking and to rethink the meaning of what are often interesting inconsistencies in the asides given by the reporting doctor. This kind of work can be done over a long period, when not only rethinking but skills are learned; or it can be done quite briefly at extended weekend conferences, though with less chance of gaining skills. Observations stemming from this method of work One of the differences between psychiatry as practised by the general practitioner and psychiatry as practised by the physician in the hospital setting is that in a hospital setting the doctors work in a team. They are not isolated and they may not have final responsibility for the decisions that they take. They also have nurses and various kinds of aides around them. Each patient is looked after by a number of different people and if the doctor is puzzled by various inconsistencies in a patient's behaviour or illness, he does not have to puzzle so hard on his own, and tends to think of his patient as an ill person in the traditional sense; the psychiatry he offers him is more likely to be geared to illnesses, e.g. depression, psychotic disorders. This may not help the doctor observe what the patient is really like on the ward at that moment, or what he (the doctor) is like when he is with his patient. General practitioners, however, even if they are still under the supervision of a trainer general practitioner, are on their own when they are with their patients. Even though they discuss their patients with their supervisors or in groups, they feel intensely responsible for their patients and, when they are seeing them, they are completely alone and are the only ones who actually hear what the patient says and sees how he looks when he says it. This seeing and listening is the kind of psychiatry I am interested in, and if seen in this light it can contribute to general practice. The general practitioners themselves have to make decisions about what to say, what to treat, what to ignore, what to observe, what to reflect about and what to turn their backs on. They are already trained to take seriously and observe certain phenomena and to treat them in a traditional manner; but if they are trained in groups to observe and take seriously other matters, other phenomena which are not taken seriously in hospitals, this could form the basis of psychiatry in general practice. We must remember that the majority of patients never visit psychiatrists (i.e. doctors trained to treat psychiatric disorders), and are never labelled as neurotic or psychotic. In America I was asked to work in a new unit in the general hospital. The service I worked in was a consultative service, staffed by psychiatrists available to help doctors on any of the wards in the hospital. I was asked to lead a seminar to discuss this work, to which psychiatrists, nurses, aides and other doctors were invited. Though I was first asked to interview the patients we soon decided that it would be better if together we tried to make sense of what the various doctors and nurses told us and whether, when we worked together, something new about the patient that had not been observed before, or had been thought irrelevant, might help the treatment. We soon found that this was so; the doctors began to think again and to reflect together and to work as a group. In Balint groups it is our main aim to help physicians rethink their findings, see their patients from a different angle, understand their relationships with them and see what happens when they discuss their thoughts in the presence of their colleagues, with a leader whose aim is to help work proceed. The group work enables them to talk together in a manner somewhat different from their usual one; to think carefully, to talk freely and to examine what they say. Our findings suggest that the leader (psychiatrist/psychoanalyst) and physicians learn a great deal from one another. They begin to ask each other different kinds of
Journal of the Royal Society of Medicine Volume 72 June 1979
471
questions about their patients and themselves and to observe quite different kinds of phenomena. I am sure you know how narrow our usual field of vision is and, if we broaden it, we are likely to be aware of what might help our patients better. I have spent many years working with experienced doctors who have been in practice for some years; it is often difficult for these doctors to broaden their vision. They may respect the psychiatrist leader and his views very highly and try to copy him, but it is difficult to do this and usually fairly useless because each individual doctor and patient is different. We have even found that it is not very useful to try to apply psychoanalytical or psychiatric theory in general practice. The patient can be fitted into such theories, but the value of this exercise is limited. In trainee groups this hazard seems less pressing. The doctors have only recently left hospital where they have learnt traditional medicine and quite properly value it highly. They can therefore afford to be much more openly critical of the new psychiatric leader; but in spite of this they seem to be willing to look at and to think and reflect about what the leader says, or what their colleagues say, without agreeing easily but without rejecting entirely what is offered to them. They do not swallow things whole but they will ponder upon what comes up during the discussion and use it or reject it according to their own knowledge, personalities and to the relevance of what is discussed. This observation seems to be a very good omen for the future of psychiatry in general practice; for if doctors are willing to look critically at previously unobserved phenomena and accept or reject them on the basis of their sound medical training, psychiatrists and psychoanalysts will also be able to reflect about its relevance with their patients when the need occurs. In all Balint groups, but perhaps mostly in trainee groups, the doctors seem to be willing to look inwards at their own responses and reflect about themselves as well as their patients. They do not seem to need to keep up a good front but show that they are thinking. This makes the leader able to continue with his thinking and realize his own limitations as well. Bibliography Balint M (1957) The Doctor, his Patient and the Illness. Pitman, London Balint M & Balint E (1961) Psychotherapy Techniques in Medicine. Tavistock Publications, London Balint E & Norell J S ed (1973) Six Minutes for the Patient. Tavistock Publications, London Brown D & Pedder J (1979) Introduction to Psychotherapy: An Outline of Psychodynamic Principles and Practice. Tavistock Publications, London Malan D H (1963) Study of Brief Psychotherapy. Tavistock Publications, London
