Is about understanding the unconscious relationship of the Doctor … · The main purpose of a...

Amelia Lyons

23/10/[email protected] 1

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...Is about understanding the unconscious

relationship of the Doctor and patient, from

the counter transference of the Doctor.

Sklar 2017


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*The position of no emotional involvement is

unsustainable – emotions cannot be killed. To

ignore or suppress them makes people ill, so

we need to find out and talk about them.

Learn how to use our emotions like a surgeon

uses his knife.


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*The main purpose of a Balint Group is to

“examine the relationship between the Doctor

(Health professional) and the patient, to look

at feelings generated in the health

professional as possibly being part of the

patient’s world and then use this to help the

patient”. Balint 1964


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*Not awake or responding

*Done without realizing

*The part of the mind which is inaccessible to the conscious mind butwhich affects behavior and emotions

* the part of mental life that does not ordinarily enter theindividual's awareness yet may influence behaviour andperception or be revealed (as in slips of the tongue or in dreams)

* the part of the mind that a person is not aware of but that is oftena powerful force in controlling behaviour


Conscious

Communication

with patient

Personal material of Doctor/HP stimulated by the encounter

Taking on/’hooking into’ the transferential role that the patient has put you into

The HP/Doctor’s unconscious attempt to ‘counter’ the transference of the patient

Projected material of the patient that the HP/Doctor has taken in somatically, psychically or mentally

The Iceberg of

Counter

transference

Conscious

Barely Conscious

Unconscious

* The Doctor/HP consciously and unconsciously carries information about the patient – which gives insight but is sometimes outside of his/her/their awareness

* The group can help penetrate the unconscious by closely attending to their own experiences (as the Doctor/H Professional recounts the narrative), non judgmentally, free associating, dreamily – and feeding back, sharing these associations & feelings with the group

* This can unlock/free up/unhook the HP/Doctor’s unconscious and help to re establish the more objective but curious, empathic position


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Conscious

(Verbal)

Barely conscious

Unconscious

(non verbal & body language)

Conscious

(Verbal)

Barely conscious

Unconscious



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Presenter

Conscious

(Verbal)

Barely conscious

Unconscious


Conscious

(Verbal)

Barely conscious

Unconscious



*

Conscious

(Verbal)

Barely conscious

Unconscious


Conscious

(Verbal)

Barely conscious

Unconscious


Conscious

(Verbal)

Barely conscious

Unconscious


Group member

Group member

Group member

Group member


*GROUP COUNTER TRANSFERENCE*Group members focus on attending to their own experiences,

accept them non judgmentally, link to the here and now process of the relationship between hp/doctor and patient.

*All thoughts are welcomed no matter how crazy or wild

*Hunches, phantasies, feelings expressed without embarrassment in an ordinary way can lead to the group making more sense of the material

*Notice what we are avoiding mentioning (leaders in particular)

*No single person has privileged access to ideas

*Questions and advice are discouraged but participants are encourage to speculate and to imagine what is being expressed in the doctor –patient relationship


*The Leader’s task

*Enable an atmosphere in which free associations can be

developed and understood within the group – different

from other types of supervision/reflective practice

*Not do for the group what it can do for itself

*Tolerate and comment on resistance (eg offer the group

feedback on what it is ignoring or avoiding)

*Offer feedback constructively when the group becomes

stuck


*The Focus of the Balint group

*The purpose of the group is to improve the Professional’s

understanding of the patient & their problems rather than

find a solution.

*The centre of the clinical gaze is on the counter

transference of the professional Sklar 2017

*Discussion should be focussed on the H Professional –

patient relationship, and the Professional’s feelings about

the patient are at the centre of the work.

*Balint said that what a patient thinks about their illness is

less important than what the patient feels in the present

moment, in the room, with the Doctor.


*What is brought to the

group

The Case history might focus on

*Concern for the patient

* Inability to understand the interaction

*Sense of feeling stuck

*Sense of being pre occupied with a patient, cannot

let it go..


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*Clinical/scientific details are avoided and more

attention is given to the story of the encounter and the

emotions it arouses in the group..

with the goal of new ways understanding and gaining

insight into the physician- patient relationship.

(Kjeldmand 2008)


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*The HPs/Doctor’s reactions and assumptions about the client (both what is observed and said)

*Talking about feelings, thoughts, fantasies, images provoked by thinking about the encounter with the patient

*Thinking about who the patient reminds them/you of?

* In what ways could the patient be like this person?

*Thinking about how the current HP/Doctor - patient relationship…

*might be mirrored in the Balint group discussion (either in the process dynamic or in the content),

*might be mirrored in the patient’s life,

*might be mirrored in the patient’s relationships.


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*The HP/Doctor must first identify with the patient and

then withdraw/be ‘released’ from that identification to

resume their professional position.

*If the HP/Doctor has an increased understanding/a changed

state of mind at the end of the group, or afterwards, that

is a sign the group has worked

*The HP/Doctor may not need to say anything to the

patient, but a new atmosphere develops

*“the hearing, understanding Doctor, meets the patient in a

fresh light, a new beginning is enabled..”


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Patient

Immediate ailment

Early life & difficulties

Somatic illness

State of mind


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*Son of a GP. Trained Dr. Initially biochemist then analysis

*Analysed by Sandor Ferenczi in Hungary.

*Ferenczi – anticipated mutuality (empathic reciprocity), inter

subjectivity and the importance of the analysts counter

transference

*Refugee to UK in 1939, Wife died, Parents suicide 1944, Joined

Tavistock 1945

*Started groups in 1950s for GPs, travelled in Europe promoting

Balint groups


* Balint, M. (1964, reprinted 1986) The doctor, his patient and the

illness. London. Pitman Medical. 2nd edition Edinburgh:ChurchillLivingstone; 1957.

Balint, E., Courtenay, M., Elder, A., Hull, S., Julian, P. (1993) Thedoctor, the patient and the group: Balint revisited. London and NewYork: Routledge;.

Elder, A., Samuel, O. Eds. (1987) While I’m here, doctor: a studyof the doctor/patient relationship. London: Tavistock publications.

Kjeldmand, D., Holmström, I., Rosenqvist, U. (2004) Balint trainingmakes GPs thrive better in their job. Patient Educ Couns. 55(2):230-235.

Lakasing, E. (2005) Michael Balint — an outstanding medical life.BJGP.; 55 (518): 723-724.

Sklar, Jonathan (2017) Balint Matters : Psychosomatics and theArt of Assessment. Karnac USA

*BALINT METHOD : “the entirety of the work is

about understanding the unconscious relationship of the Doctor/HP and patient,

from the counter transference of the Doctor/HP” Sklar 2017

* Free association in a non judgemental environment

* Fostering unconscious to unconscious communication

* Not problem solving, trust in the professional to do that.

* The objective is – merely to share associations, images, thoughts, feelings, fantasies about what is going on. This process may help to unlock something in the HP’s unconscious.

* The focus is on the health professional and on the relationship they have with the patient

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