After a historical introduction, illustrated by a couple of case histories, an outline is given of the purpose and working method of Balint groups operating in the Netherlands at the moment.
Next, the role of the Dutch Balint Association is described. The purpose of the Dutch Balint Association is to increase GPs' knowledge of Balint group. In such a group, the aim is to enhance the GP's approach, as an alternative option to an accredited refresher course.
Almost 45 years ago, Judith Van Lidth de Jeude (1), at the time GP in Zeist, was the first person in the Netherlands to draw attention to the work of the English psychoanayst Michael Balint, whose book 'The Doctor, his Patient and the Illness'(2), has by now become a classic for General Practitioners. It has been distributed all over the world and translated into several languages and is regularly quoted from. In the Netherlands too, the book has drawn a lot of attention. In the sixties, countless GPs took part in seminars, generally led by a GP and a psychiatrist-advisor. Veldhuyzen van Zanten and Gelly have described in detail the procedure of the so-called Balint method (3,4). Balint's work was published at a moment when GPs had serious doubts about their approach to their patients. In the book, GPs could read that in the field of medicine their aid was indispensable. They had much to offer, and specialistscould also learn something from them: a sense of the patient's well-being. Balint also encroached on the traditional pupil-teacher relationship with medical specialists. To him, the GP was the person par excellence to further develop integrated medical science.
In those days, GPs could readily recognize themselves in the description given by Balint in his books. At the time, their one-sided aim was to determine somatic causes for diseases. The patient's phychological make-up was only taken into consideration later, sometimes very much later. Fear of failing to diagnose a serious somatic ailment still plays a considerable role in the GP's approach. For a GP, physical examination, after the recording of the anamnesis, is an important instrument. If in spite of careful physical examination, the GP fails to find a disorder, this ought not to be seen as a disappointment, but rather as a challenge. A challenge which the GP should be able to tackle, armed with psychological know-how and skills. The essence here is, that the GP should listen to the patient in a specific way.
This sort of listening is not to be confused with the traditional way of doing so, for example when recording the anamnesis. As Balint says: 'The ability to listen is a new skill, necessitating a considerable though limited change in the doctor's personality'.
In other words, listening does not only apply to the verbal message, it also involves perceiving facial expressions and gestures, sensing a mood etc. The point is to learn to recognize not only the complaint, but also the 'complaint beneath the complaint'. In this context, Trijsburg c.s (5) pointed out the instrumental relevance of empathy. Understanding the patient without losing professional distance is essential for a GP's work. The doctor's own, subjective, reaction often helps to clarify what the patient is trying to explain. (6) In the relationship between doctor and patient, the ability to recognize one's own feelings, such as irritation, helplessness, fear and anger, is very important for the handling of the relationship. Thus, Balint's prime focus is on a study of the medicine 'Doctor': the doctor as medicine. A normal GP must get to know himself as a medicine.
Balint not only focused on the role of listening, the empathic attitude, he also described how doctor and patient tend to negotiate. Van Lidth de Jeude calls it 'haggling' (8). This process of negotiation leads to an agreement between doctor and patient, making it possible for the latter to organize (2) his complaint, or in many cases, to somatize it (9). The doctor's role in the haggling process is crucial: 'one of the most important side effects if not the main effect of the drug doctor is his response to the patient's offer'. The doctor's reaction determines the form in which the patient moulds his relationship with the GP and consequently his complaint. The GP ought to be aware of his own contribution to this somatic fixation. A common difficulty, for example, is that for the patient's benefit it's better to be clear than kind. Many GPs find it hard to let go of the image of the kind, understanding doctor. They tend to stick to this image, even when confronted with a patient who tries to manipulate them - for example into an unnecessary referral, hospital admission or special medication - and wrongly give in to the patient's wish.
Enid Balint, Michael Balint's wife, discussed research, changes and developments in Balint groups. Her observations about the changes in objectives are remarkable. At first it was assumed that it was the doctor's task to track down the patient's real problem ñ the cause of the ailment. The result of this assumption was that GPs had long conversations with relatively few patients which could hardly be combined with the daily work load. (10) Nowadays, however, we do not deem it necessary to start by tracing the cause of the problem, there might even be objections to doing so. Enid Balint writes: 'In general practice work the patient's feelings in the present, and the changes in them, seem more important and more reliable'. By trying to place himself in the patient's condition, the doctor is able to identify with his feelings. Furthermore, he must be capable of distancing himself and being an objective professional observer.
Samuel discussed the aims of a Balint group accordingly
- to improve the doctors' perception and understanding of their patients' communication
- to allow doctors to become aware of the 'blind spots' in their interactions with patients and
- to encourage doctors to value their interpersonal skills. (11)
Samuel emphasizes that the group is not meant to be therapeutical: 'So it does not examine the doctor's emotional state except in so far as it affects his professional relationship with a patient.'
Similar views are expressed by Scheingold. (12)
A result of the adaptation of aims is that it is easier for GPs participating in Balint groups to fit their treatment into their daily practice. Now, for example, the point at issue is not what the patient's motives are, but what the emotional implications are of the current visit to the GP. On this level, the doctor is supposed to understand on an emotional level what the patient means and the latter should feel understood. This often gives considerable relief. For a GP, understanding often involves a flash of insight: the various bits of information fall into place like pieces of a puzzle.
These flashes of insight often play an important part in clarifying the patient's request for help. In the modern GP's surgery, the first question is what caused the patient to come. This may not necessarily be inconvenience or pain, it might also be fear of the cause of the pain.
In the Basic Skills Guide of the Dutch College of General Practitioners, a lot of attention is paid to techniques for assessing a patient's request. If it is clear why the patient has come to see the doctor, and both doctor and patient agree on the purpose of the visit, this decreases the risk of iatrogenous damage. The GP uses himself as an instrument. He is capable of doing so mainly thanks to continuity in his relationship with the patient, and often also the patient's relatives. Understanding the instrument, oneself, is essential to the GP. One must rely on one's empathy, particularly when one needs to sense the patient's emotions and moods. A GP must be able to enter into his patient's feelings, while simultaneously maintaining enough distance to be able to work objectively. This is important, because doctors can damage their patients in several areas of medical science if they do not 'administer themselves as an adequate medicine', which, unfortunately, often occurs. For example: a GP with private problems of his own might more readily prescribe tranquilisers to a patient.
Members of Balint groups work in line with with Balint's principles. The aim is definitely not to change the doctor's personality. A group generallys convene once every 2 to 3 weeks, for 1,5 hours. Some groups choose to convene once a month for 3 hours.
The case history under discussion is not sent to the group members beforehand, but is introduced by means of written notes. A subject for discussion could be a problem with a patient which bothers the GP, and which he would like to discuss.
The group generally consists of 8 to 10 GP's. At the first meeting, the members introduce themselves to each other.
The following questions are discussed:
- Who are you? What made you decide to be a GP?
- What do you expect of the Balint group?
- Why did you decide to take part now?
- What do you hope to learn?
Then the Balint method is outlined:
- A GP introduces a problem, he explains the situation, his relationship with the patient concerned, and his own opinion
- The other group members ask questions, which might result in recognition. The tell about similar cases that occurred to them and explain their own approach.
- In the next round, they try to assess the root of the problem, the part that is shared and the ensuing suggestions.
- The final round is focused on the GP who introduced the problem. Has it been of any help to him? Does he recognize points raised in the discussion and will he be able to handle the problem in practice?
The group session
The (GP) chairman opens the meeting by asking whether somone wishes to start with an acute case: something the GP has experienced and which bothers him, or a case he cannot solve satisfactorily. A GP could also plan a visit to a difficult patient prior to the group session, with a view to asking the group's advice. Generally, it has been agreed beforehand that one or two group members would introduce a case.
During the session, GP M. describes an 86-year-old patient whom he met while working as a substitute. On an earlier occasion, the patient had struck him as being a woman with a theatrical attitude. A nurse phones to say that the lady has suffered from diarrhoea during the night, that she has turned a bit blue round the mouth, and that she complains of a pain in her shoulder. As pain killer, she has been given NSAIDs, which made her feel unwell. The GP's advice is to stop medication. During the medical examination, the patient's complexion improves, she still complains of an aching shoulder, but the diarrhoea without blood has stopped. Late in the afternoon, the patient has a heavy discharge and starts to perspire. The GP has her admitted to hospital, where she dies, diagnosed as mesenterial thrombosis.
The GP still feels uncomfortable about this case and wonders: 'Should I have dealt with this patient differently? Must I reproach myself for doing something wrong?' During the discussion, it turns out that his colleagues know him as an excellent GP, in their eyes he treated the patient considerately and well. He continues by telling how he lost another patient because of a bleeding aneurism. He still feels he took too long to decide and regrets not having listened to his intuition, and had the patient hospitalized. Now he realizes what is bothering him, he can cope with the case. He decides to contact his colleague, the patient's GP and ask him whether her relatives would appreciate an explanation of the course of events.
Colleague B's last visit of the day is to an eight-week old baby whose mother suspects it is suffering from whooping-cough. There has been a serious case of whooping cough in the family. She uses an inhalator, to no avail. Blood tests have also been carried out. The results are not known yet, the child is moderately ill. The mother is at home alone, her husband is at work, she hardly speaks Dutch. She wants the child to be referred to hospital. On consultation, the paediatrician reacts dismissively: 'You haven't promised to send the child to hospital, have you?' The GP feels in a fix between the mother and the paediatrician, which irritates her. What must she do now? The group reacts: why does their colleague feel in a fix, what role does the father play, what relationship does the GP have with the family, what risks does she dare to take? They know she is very demanding for herself, isn't she too much so? One of the colleagues is worried about her work ethic. Colleague B acknowledges the reactions, she knows she demands 200% of herself, or else it's not worth while. She is also influenced by the role of her partner, who works in the hospital. She wants to be taken seriously by him. If she refers a patient to the hospital, she first has to tackle the colleague whom she is referring the patient to, then her husband, and finally herself.
As described above, a GP introduces a case. Then his or her professional approach to the case is discussed in the group. Special attention is paid to the aspect of transfer. Which ëemotional problems' does the GP encounter in his relationship with the patient? What feelings does this evoke in him or her? Naturally, the group members vouch for each others' privacy. The GP who introduces a certain case can count on the other members' restricting the information to the group. It is of the utmost importance that each subject can be dealt with in a safe and familiar atmosphere. Whoever brings in a case must feel secure!
The psychotherapist's role is to draw attention to all kinds of psychological phenomena. He does so by asking questions during the sessions, by making remarks and by elucidating. At the end, he generally gives a concluding explanatory commentary.
Group members are not expected to broach their own personal problems. The aim is to enhance understanding, thereby benefitting the GP's work, the aim is not to change the GP's personality. In other words: the group should not be characterized as therapeutical, but is intended to gain experience in tackling psychosocial problems that arise in a GP's profession. Personal problems could rather be discussed with another psychotherapist.
Summarising, Balint groups have the following aims:
- To draw attention to what happens in a psychological sense in the contact between GP and patient
- To find a style of one's own in the communication with patients. Here especially, discovering one's potential and limitations is decisive.
- To elucidate the specific position of the GP in the field of mental health care.
- To enhance psychological understanding or else knowledge of the participants, for the sake of GP work in general.
If you would like to become a member of a Balint group, the work group requests that you should meet the following criteria:
- You have worked as a GP for a few years
- You do not see the group as a possible form of psychotherapy.
- You prefer not to participate in a group of which your partner or another member of the HAGRO is also a member.
For writing this introduction, we are grateful to use H.J. Dokter and F. Verhage, De dokter als medicijn. Utrecht: NHG,1991.
International Balint Federation: The Dutch Balint Association is connected to the International Balint Federation, for information see www.balintinternational.com.