The Balint SocietyThe website of the Balint Society

Why Balint?

Michael Courtenay

Keynote address at the Northumberland Balint weekend held at Longhirst Hall, 19-21 June 2009

I am very pleased to have been invited to give this introductory talk to a Balint-work weekend in glorious Northumberland, where I spent a memorable holiday some forty years ago, but only hope I am not such a dinosaur as to be of no relevance to your work. I entered general practice in London in 1952. Entry into a practice at that time was difficult, as elderly GPs were postponing retirement in order to get a good pension, which meant having to work for 10 years in the NHS. Being married with two children and virtually broke, when I was offered a partnership it was an offer I couldn’t refuse, in spite of having done insufficient postgraduate training. I was very keen to get started, having spent four and a half years in the army, where I had seen men maimed and killed, and later at the concentration camp at Bergen-Belsen in April 1945, where I saw horrors which live with me still. NHS general practice was in a parlous state. The number of patients to see every day was never less than sixty per doctor, and the only investigation available without referring the patient to hospital outpatients was a chest X-ray!  We did do simple tests on blood and urine, but that was all. That was bad enough, but what was worse was that what my patients complained of rarely seemed to have been described in the textbooks I had studied as a medical student. There was almost a sense of relief when a urine sample tested positive for glucose! I did twig that many patients had an emotional problem, and a funny little book on anxiety symptoms by a Dr Ross became my vade mecum, but only filled a pothole in a bumpy road. It also became clear that many specialists could not put a diagnostic label on my undiagnosed patients either, so that referring them to one specialist after another only produced a fat-folder of notes and no light at all.

I struggled for five long years before reading Balints’ The Doctor, his Patient and the Illness. You may be amused to hear that I read it while hospitalized for epididymitis! I wrote immediately to the Tavistock Clinic to enquire whether I could join a group. I was summoned for an interview by Michael Balint, which was the most searching one I have ever had, though I cannot explain to you quite why. Having told him in response to a question that I had four children, he said, ‘You’re not afraid of responsibility then’. Shortly afterwards he wrote to say I could join his group in September. That was 1957.

The group met at Michael and Enid Balints’ house in Park Square West. The imposing front door was up a few steps, and the hall was rather dark. Stairs led up to the first floor which consisted of a large L-shaped drawing room The deep sash windows looked out onto the trees in the square, and above the mantelpiece there was placed a long medieval carving. We met in the larger part of the room, but my curiosity drew me to peep in the lesser part, where there was a caricature of Michael Balint adorned with horns! Enid was there as she was to co-lead the group with Michael, and there were eight of us to constitute the group, six men and two women. All but one of us were practising in or close to London, the exception came from rural Gloucestershire. He was obviously an innovator, as he told us he had a radio in the boot of his car so he could receive and transmit messages on his rounds. (There were no transistors then!) He had to take a whole day off to attend the group, which he did regularly for three years. He was a very calm and thoughtful doctor and presented cases regularly. Although many of his patients lived and worked on farms, their complaints seemed to differ little from the urban ones of the rest of us. Then there was the Superior Doctor. He was not slow to tell the rest of us what to do! Later he left general practice to run a drug-dependency clinic, which was new aspect of life in those days. Next came a rather motherly woman who presented cases mainly involving family problems. Then there was a young doctor who had joined a practice just outside London in which the other partners were a father and son. He was very likeable, but I think the rest of us thought he was bullied and exploited by his partners, who were also relatives. Next was an older man who practised to the west of London and seemed less disorientated than most in the new setting. Then there was me, practising in south London and totally bewildered. I found it quite testing to take the tube to Regent’s Park Station on the underground to be there by two p.m. and get back for evening surgery at five. The other woman was young and dynamic, married with young children, with a loud voice. At first I found this disconcerting. I offer you as evidence that Balint-work does what it says on the tin that we later became good friends. And then there was the Pole. He told us his name and where he worked, and those were the only words I heard him utter before he left the group at Christmas time. He never presented a case.

In those days group members were expected to have a case ready every week, and to have seen the patient for one or more long interviews, as the initial idea was to turn us all into quasi-psychotherapists. Michael Balint was active and forceful in his leadership, and not afraid to inject little paragraphs of teaching. Enid was relaxed and quiet and would intervene to protect a group member who was being pressured by her husband. I slowly began to see what we were being asked to do, but even when the Pole had left, things were far from clear. Gradually I began to see forward, the focus on the doctor-patient relationship opened a door to understanding patients whose problems had previously been intractable. At the same time I think my family found me less of a pain.

But I do not wish to depress you before you start, things have changed! It is because of the past experience that the Balint Society has introduced such weekend workshops in which we are now engaged. John Salinsky’s short introduction proves it.

As a psychoanalyst Balint was used to seeing patients five times a week, and time constraints were rather ignored. For instance, once in my first group Michael Balint suggested we put the spotlight on the sex-life of every patient we saw during a single surgery. The surgery I chose became very long, even though I had tried to choose a quiet day! I still remember that one patient, who had come for a final certificate to return to work, remarked, ‘And I thought I should be out of the surgery in no time’. I think that Michael Balint had been prompted to give us this task as in 1960 the Family Planning Association approached him because there had been a lot of feedback from the doctors working in birth control clinics that showed that many of the patients coming had sex problems, sometimes cryptic, sometimes overt. This led to the formation of a group to study the nature and treatment of common sexual problems, the first one studied being non-consummation in marriage. Later groups attempted to use brief psychotherapy for sexual problems. While considerable success was achieved, it became clear that some patients were not being treated with adequate skill by semi-trained ‘psychotherapeutic’ doctors.

Michael Balint came to realize this was also relevant to the way the GP groups operated, and the product of another group, of which I was a member, was the book Six Minutes for the Patient. The focus of this group was the exploration of what was possible in the average GP consultation, and I believe that this still continues to be the case in most groups today.

Interestingly in view of the fact we are enjoying a weekend Balint meeting, the tide turned for the new approach at a similar weekend in Aberdeen, having been invited there by a local psychiatrist, who wished to observe the Balint approach. For the first time ‘ordinary’ cases in general practice were presented, and it proved a breakthrough for the group. However, I would like to say that, initially, this change was not readily accepted by some of the doctors who had been members of the very first group.  For instance, Philip Hopkins, the man responsible for the birth of the Balint Society, its first President and editor of the Balint Society Journal for 25 years, was one such, and had even altered his mode of working by seeing four patients for long interviews in the afternoon for four days a week, so maintaining a caseload of 16 patients at a time. But he was altogether an exceptional man.

So what is the relevance of doing Balint-work in general practice as it is today? One of the insights that emerged from Balint’s first group was his concept of what he called ‘the drug doctor’, the idea that each doctor has a personal therapeutic potential for his/her patients. The consultation could no longer be seen as an objective process where the doctor listens to the patient’s story, brings his/her intellect to bear on it and then tells the patient the diagnosis and outlines the treatment. The consultation is thus transformed into a subjective experience for both doctor and patient, which then goes beyond the classical medical history, taking everything relevant from the personalities of each of them into account. The reflections by the doctor on what appears to be happening between him/herself and the patient then stand side by side with both the way the complaint is presented and its impact on what the doctor feels as a result. Recently, neuroscientists have made us aware that thought and feeling are inseparably bound in our consciousness, and that the idea of rigorous objectivity is probably a mythical state.

Balint noticed that the doctor presenting a case in the group often appeared to be acting out aspects of a patient’s story, apparently unconsciously, and that often gave a clue as to how the patient viewed the world. At the same time the doctor’s attitude seemed to stem from hidden factor in the doctor’s make-up, being a personal response to the patient as a person. This idea led to another of Balint’s concepts, that of the ‘apostolic function’.  It seemed to him that every doctor had a clear, though unconscious, view as to how a patient should properly behave vis-à-vis the doctor. Does this have echoes for you? And I do not exclude my colleagues or myself even after many years of Balint-work; for I have observed that we all tend to develop alterations to our apostolic function, rather than lay it to rest!  Evidence for this may be found in the book What are you feeling, doctor? which was an attempt to understand which factors in a doctor’s personality might have a bearing on his/her clinical work. Another of Balint’s ideas was the need to develop ‘a third ear’. By this he meant that we should develop a sensitivity towards matters in the process of communication between patient and doctor beyond ordinary verbal exchange. The image of the patient with his hand on the handle of the door as he is on the point of leaving the consulting room, who then says ‘By the way, doctor’, is an iconic example. Beyond that Balint always stressed that what the patient didn’t say was often more important than what he did. If there is an area of life which could be presumed to be relevant, but about which the patient remains silent, that may point the way for the doctor’s further line of enquiry.

But I will (in the words of business-speak), push the envelope; I think the aim of Balint-work is also to provide the doctor with a ‘third eye’. By this I mean, when  you feel entirely at a loss with the patient in front of you, either because the diagnostic process seems to lead nowhere, or because the patient pisses you off by his attitude or consulting pattern, perhaps it is time to figuratively take a deep breath and imagine that you are now somewhere up near the ceiling (an image akin to some reported near-death experiences), looking down on  the patient and yourself getting precisely nowhere and from this imaginary increased over-arching distance in the consultation process, try to take a detached view of how you got there. It is a way of ‘earthing’ one’s emotional overload to mobilize a new perception on what has been going on between you and the patient. Try it; you may be surprised!

Turning from questions of personality to the milieu of general practice as it is today, though I am only a grateful patient of my splendid GP, in talking to her and reading the BMJ I sense that some of the stresses I experienced in 1952 have re-surfaced in a different guise. I note the difficulty in getting a partnership, the demands of new generations of patients whose expectations are now much more sophisticated, and who have access to a lot of information on the internet, much of it of dubious validity. The Balint group provides a little space and time without the day-to-day pressures of modern life, encouraging the sharing of problems by allowing a number of other perspectives to be set beside your own, as well as the freedom to share flights of imagination however wild, to be used or rejected by the presenting doctor. This is a healthy exercise, it is freedom to speak one’s mind about important things without fear of being bullied or belittled. It is way of getting unstuck.

In my first draft for this introductory talk my mind turned towards thinking of an illustrative case, in spite of the fact that I have not seen a patient for 20 years. But while illustrative cases have been the bedrock of writing about Balint work, I think it would be wrong to introduce one now, even though several unreported cases still lie bright in my memory. The essence of Balint-work is experiential, and you have already tasted the process yesterday evening. Anyway to talk about a case here would be worse than useless, in that any single case would bear too heavy a burden of importance at the beginning of this weekend which is designed to be a door into a new way of learning.  So I will urge you to take a deep breath and walk out into a new landscape of medical practice, where the air is bright with the brainstorming of your own feelings. Take courage! Although you do not yet know your fellow group members and the animateurs of your group, be bold to trust their goodwill towards you, seeing that all of us are vulnerable human beings who need all the help we can get. Let your gut feelings fly and do not be afraid to look stupid. We are all stupid some of the time, and Balint urges us to ‘have the courage of our stupidity.’

If we have reached a point where understanding the patient seems beyond us, we must try a different path towards that understanding, by letting our imagination rip. Visualize yourself with the patient and observe your interaction up to the point you have reached, with the thought that there is something on your side of the interaction that is somehow interfering with your wish to reach the goal of understanding the suffering person who sits in the other chair. He/she may appear difficult, demanding or downright impossible. What is it about the patient that makes that true?  Especially to you!