Creating an innovative way for the PatientCentered Medical Home to respond to patients
with complex problems and dysfunctional styles
of interaction
Donald Nease and Frank Dornfest
Forces impacting
Primary Care
•Tension between
population health and
individual
responsibility
•Government cost
containment/New
payment structures
•New roles and
members of practices
What about our
patients?
•Increasing
incidence of
chronic disease
•Multimorbidity
•Fraying social
structures eroding
traditional sources
of support
attachment theory
• proposed by Bowlby as a way to
understand why and how people form
varying attachments to others
• formation of a secure attachment style
depends on the existence of a “secure
base” in early life
Attachment Theory - basic concepts
(John Bowlby & Mary Ainsworth)
…special needs (to feel
secure….)
• Refugees…
• Marginalised…
• Damaged by early abuse/neglect
• Mothers (parents)…
• Elderly…
• Bereaved…
• and…
PROFESSIONALS!
• Doctors…!
• Nurses…!
• Receptionists…et al
A Useful Concept for Primary
• The Practice asCare
a Secure Base?
• What makes a Practice
Secure/Insecure?
• For professionals?
• For patients?
• Understanding Patterns of
Consultation?
The Practice as a Secure Base
Questions?
•
•
•
•
•
•
•
What does a practice feel like for those who work
there?
How is the boundary function managed?
How does the practice express its capacity to be
reflective? Mentalisation – self and other?
Narrative competence? Shared history…story of the
practice?
Role of MH professionals? In or out?
Role of play/creativity
How is change/loss (and trauma) managed?
Mentalization
• “the mental process by which an
individual implicitly and explicitly
interprets the actions of himself and
others as meaningful on the basis of
intentional mental states such as
personal desires, needs, feelings,
beliefs and reasons”
Bateman and
Fonagy 2004
Attachment
Mentalization
Lack of secure emotional
connection to parent Lack of a “secure base”
Impaired capacity to read
emotional content of
interactions
Difficulty establishing a
trusting relationship
Mistrust and
misunderstanding of
medical context
Patients that interact with
us inappropriately
“They must be trying to
abuse me or the system”
Mentalization &
Emotion
• When it works - Positive emotions
increase
• When it fails - Negative emotions
increase
• Negative emotions appear to impair
mentalization on FMRI scans
•
•
•
•
•
•
420 recorded visits to UK
primary care with MUS
Discussions analyzed
utterance by utterance
Physical intervention
proposed more by docs
than patients
Few docs showed empathy
Was there a failure of
mentalization?
Ring, et. al, The somatising effect of clinical
consultation: what patients and doctors say
and do not say when patients present
medically unexplained physical symptoms,
Soc Sci Med 2005 vol. 61 (7) pp. 1505-1515
Balint groups
First established in the
UK by Michael and
Enid Balint
Utilize a case
presentation/discussion
format in a small group
Purpose is to
reflectively explore
specific "troubling"
patients and the
relationship
Michael Balint




Born in 1896 in Budapest, son
of a GP
Psychoanalytic training in
Berlin and Budapest,
emigrated to London, worked
at the Tavistock Clinic
He and his 3rd wife, Enid,
began the training/research
seminars for GPs after WW II
1957 “The Doctor, his Patient
and the Illness” published
“At the center of medicine
there is always a human
relationship between a
patient and a doctor.”
-Michael Balint
“In contrast to didactics or reading,
the Balint process reaches past the
rational system to influence intuitive
functioning. It does so by engaging
the intuitive system through
encouraging nonjudgmental
speculation, while at the same time
monitoring rationally by juxtaposing
the doctor and patient's views.”
“One of the strengths of Balint work
is that the group can take a problem
and introspect out loud with the
presenter, who is free to incorporate
or reject new understandings.”
Lichtenstein and Lustig, Integrating intuition and reasoning--how Balint groups
can help medical decision making, Australian family physician 2006 vol. 35
(12) pp. 987-989
Balint groups
enhance
Mentalization!







What a Balint Group
is not
Psychotherapy Group
Encounter Group
Traditional Case Consultation Group
M&M Conference
Topic Discussion Group
Personal and Professional Development
Group
Not prescriptive, didactic, advice giving
Characteristics of a
Balint Group
•
•
•
•
•
•
Ideally fixed membership
•
Closed Group
Ideally two co-leaders
Focus on doctor-patient relationship
Power of the group
Preference for an ongoing case
Less conscious aspects of relationship
Ground Rules
Confidentiality
Avoid Advice
Respect, Turn Taking
Ownership
The Group Convenes
Leader
Leader
Calling for the Case
Leader
Who’s got a
case?
Leader
Cases
• Presentations are spontaneous
• Patients we have ongoing relationships
with
• Patients who we feel conflicted or
strongly about (stuck)
• Patients that leave us feeling
unfinished, who we lose sleep over
• Patients who we “take home” with us
• Patients that bubble up in the moment
Group Process
Leader
I do.
Leader
The Case Arrives
Leader
Angela is a 79 yr
old blind woman….
Leader
Presenter
Clarifying
Questions
Leader
Are there any clarifying
questions?
Leader
Presenter
The Presenter gets to Listen
Leader
Why don’t we let the
presenter just listen
while we work the
case
Leader
The Group Starts
Working
Leader
I imagine Angela
to be…
Leader
Presenter
Imagining Patient
and Doctor
Leader
If I were the doctor,
I might feel…
Leader
Presenter
Group Exploration Continues
Leader
This image just popped
into my mind of a…
Leader
Presenter
Functions of Group
Members
• Explore doctor-patient relationship
• Look inward, be imaginative, creative, look
for less conscious aspects
• Attend to and share thoughts, images,
fantasies, associations, hypotheses
• Differentiate one’s own experience from
presenter’s
• Further empathic understandings
Functions of Balint
Leaders
• Create and maintain a safe space
• Structure and hold the group over time
• Protect presenter and group members
• Encourage reflection, empathy and
compassion
• Attend to group development
• Debrief with co-leader after each group
Group time
PCMH, Attachment, Mentalization
and Balint:
Putting them together
• Not only training…
• Linking the two…powerful organisational impact
• Practice-based Balint Groups
• Primary Care Team (Tuesday) Meetings
• Making a House a Home
• Changing Models of Employment
Attachment
Mentalization
Lack of secure emotional
connection to parent Lack of a “secure base”
Impaired capacity to read
emotional content of
interactions
Difficulty establishing a
trusting relationship
Mistrust and
misunderstanding of
medical context
Patients that interact with
us inappropriately
“They must be trying to
abuse me or the system”
A PCMH with a Balint
Group - A secure base for
patients
Patients with impaired
attachment can be better
understood and cared for
Balint catalyzing formation
of a secure base
• Provides a safe environment for clinical staff to bring
their difficult interactions with patients
• Multiple perspectives encouraged
• Playful speculation a plus
• Difficult emotions are surfaced and detoxified
• If successful the practice becomes a secure base for
staff and patients
For further info...
• The American Balint Society
• americanbalintsociety.org
• Don Nease:
donald.nease@ucdenver.edu
• Frank Dornfest: frank@dornfest.org