http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2014; 28(5): 466–470 ! 2014 Informa UK Ltd. DOI: 10.3109/13561820.2014.902369
ORIGINAL ARTICLE
Revisiting Balint’s innovation: enhancing capacity in collaborative mental health care Eunjung Lee1 and David Kealy2 1
Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada and 2Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada Abstract
Keywords
Interprofessional collaboration is increasingly recognized as a key response to the challenges associated with complex mental health issues in community primary-care settings. Relatively few practice models, however, provide an orientation and a structure that combines quality patient care, professional development, and the building of community capacity. A psychodynamic tradition of supervision and collaboration, an approach known as the Balint model, holds considerable potential to bring this orientation to collaborative primary care and mental health teams. As a consultation group, the Balint approach brings participants’ attention to subtle emotional–interpersonal phenomena such as the provider–patient relationship, the presentation of illness, and the experiences of patients and team members. We introduce and provide an overview of the Balint group model, including several concepts proposed by Balint to illuminate the emotional and relational complexities of providing mental health care in a collaborative primary-care setting. The context of our discussion is the implementation of a modified Balint group approach within a Canadian collaborative mental health Care (CMHC) program. We also discuss how an interprofessional application of this approach can enhance patient care, contribute to care providers’ professional development, and build community capacity.
Balint model, community capacity building, collaborative mental health care, interprofessional collaboration, psychodynamic approach
Introduction Mental health care has a long tradition of interprofessional teamwork in psychiatric service settings. However, a considerable amount of mental health care is provided in primary care, by solopractice family physicians (e.g. Miedema, Tatemichi, ThomasMacLean, & Stoppard, 2004; Norton et al., 2011). Recognition of the need for collaboration between these care systems has grown steadily, with recent trends toward integrating and sharing mental health care within primary care settings. Collaborative, shared mental health care initiatives can improve the detection and treatment of mental health issues by incorporating interprofessional mental health knowledge and resources into primarycare practice, where individuals may have frequent, consistent, and lasting contact with their family physicians across the life span (Kelly, Perkins, Fuller, & Parker, 2011). These initiatives, also referred to as ‘‘shared care’’ and ‘‘circle of care’’ programs, have been espoused as innovative means to enhance patient care, improve access to specialist care, and facilitate primary care physicians’ knowledge about mental health care (Cohen, 2000; Rockman, Salach, Gotlib, Cord, & Turner, 2004).
Correspondence: Eunjung Lee, Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, Ontario, Canada M5S 1A1. E-mail: [email protected]
History Received 24 March 2013 Revised 22 January 2014 Accepted 05 March 2014 Published online 1 April 2014
Interprofessional collaboration: mental health in primary care The trend toward mental health and primary-care integration is catching on internationally, having been supported by the World Health Organization ‘‘as a way of improving access to personcentred mental health care’’ (Kates et al., 2011, p. 2). In Canada, over the past 15 years, there has been a steady growth in interprofessional responses to the challenges of mental health service delivery. These collaborative responses have been driven by two major factors: (1) the heavy demands faced by family physicians in Canadian health care – most Canadians rely upon their family physician as a primary provider of mental health care (Kates, 2008); and (2) resource limitations – including a shortage of psychiatrists – have prompted Canadian mental health services to ‘‘find new ways to use their resources more efficiently and effectively, with a greater emphasis on a consultative role and support’’ (p. 467). The Canadian Psychiatric Association (CPA) and the College of Family Physicians of Canada (CFPC) accordingly developed a partnership for collaborative mental health care (CMHC) in 1996, seeking to integrate psychiatric care within primary care settings, and further established the Canadian Collaborative Mental Health Initiative (CCMHI) in 2004 (Kates, 2008). Despite the increasing trend of mental health and primary-care collaboration, and the benefits associated with it, there is relatively little literature on how interprofessional consultation models can be developed in order to build capacity across care systems. Existing models of collaborative care are mostly
DOI: 10.3109/13561820.2014.902369
centered around improving access to psychiatry for primary care patients who might not otherwise visit a mental health clinic, often operating on a case-by-case basis or as a form of expert-led knowledge translation that focuses on ‘‘solving a case.’’ Such programs typically embed a mental health professional (e.g. psychiatric nurse, social worker, or psychiatrist) within a primary care office where several family physicians practice, offering both direct care and case-based consultation. Although useful and beneficial, this kind of arrangement is limited in promoting care providers’ professional development and the expansion of community capacity. The present paper explores an alternative model of interprofessional consultation that in our view remains as innovative today as when first introduced more than 50 years ago. This model, based on the work of physician and psychoanalyst Michael Balint, also involves regular interprofessional contact, direct care, and consultation – but with a slightly different purpose. The target in the Balint model is not the identification of a particular syndrome or the amelioration of symptoms, but is instead the development of participants’ capacity to explore and contain the emotional vicissitudes associated with mental health practice. The Balint approach prioritizes the deepening of care providers’ emotional receptivity and understanding over the solving of a case or prescribing of an intervention. In turn, this focus brings an overall expansion of community capacity in mental health/ primary-care contexts through effecting changes in care providers themselves. Interestingly, many North American care providers, both in family practice and in mental health systems, are unfamiliar with this model – one that, in our opinion, deserves attention for its potential to advance interprofessional mental health-care capacity.
Building community capacity The development of enhanced community1 capacity is composed of three distinctive dimensions: problem-solving capability, the creation of sustainability, and infrastructure building. This involves service development not only to solve immediate problems but also to establish infrastructure for sustained and institutionalized problem solving (Russell-Mayhew, Arthur, & Ewashen, 2008). In order to achieve these elements of community capacity building, O’Hanlon and colleagues (2002) recommend concrete strategies such as continuing education, professional development and training opportunities for staff, and professional support or supervision. Through these strategies, they aim to achieve successful collaborative partnerships, indicated by ‘‘knowledge and attitude change, skill development, policy change, and service and environment change’’ (p. 31). We suggest that the Balint approach fosters these outcomes through its unique approach to mental health and primary-care collaboration. In our experience, a modified Balint approach can enhance mental health capacity by developing clinical competence and confidence among health-care providers. Below we will describe and discuss the use of the Balint model in the context of Canadian collaborative care.
The Balint model Michael Balint, a physician and psychoanalyst, developed a group method to collaboratively explore the nature of the 1
Here we limit our discussion of the ‘‘community’’ to care providers that include physicians in family medicine, psychiatrists, and other non-medical care providers (e.g. social workers, psychotherapists, nurses), in order to closely align with the Balint model. However, we acknowledge the broader care community includes patients’ families and other community service agencies (e.g. school, employment).
Revisiting Balint innovation
467
provider–patient relationship, to deepen interprofessional relations, and to enhance understanding of mental health concerns among general practitioners (GPs). Balint’s work at the Tavistock Clinic in England during the 1950s (Balint, 2000/1957) anticipated the contemporary collaborative care movement in primary care. Balint was interested in the psychological aspects of many of the complaints and illnesses presented to GPs, and the emotional undercurrents operating in the doctor–patient relationship. Balint suggested that physicians should view the patient as ‘‘proposing an illness to the doctor’’ (Balint, 2000/ 1957, p. 22). This ‘‘proposal’’ requires careful attention to its potential emotional and interpersonal meaning – beyond being simply a cluster of symptoms – and how the physician may respond to it (Kutter, 2002). Derived from a psychoanalytic supervision model, Balint groups were developed to explore primary-care cases involving either overt or suspected psychiatric distress or pathogenesis. Balint’s seminal book, The Doctor, his Patient and the Illness (2000/1957) introduced the model of these groups, and illustrated the ‘‘limited, though considerable, change’’ (p. 299) observed in participants’ capacity to work psychologically, and thus attend to their patients’ mental health issues. Consultation groups based on the Balint model are, by their very nature, interprofessional. Groups consist of a leader – usually a psychiatrist, psychoanalyst, or psychotherapist – and front-line clinicians such as GPs, nurses, occupation therapists, addiction counselors, psychologists, and social workers. Although initially developed to train family physicians, Balint groups have been emerging in ‘‘a variety of other fields where sensitivity to one’s reaction to those served is important’’ (Smith et al., 1993, p. 599). Using the Balint group, Smith and her colleagues (1993) describe how a weekly conference evolved into an interprofessional round-table educational and support program for nursing home staff including ‘‘nurses, aides, social workers, therapists, family practice residents, and physicians, in providing care to the geriatric patient’’ (p. 599). Balint was alert to potential unacknowledged stumbling blocks involved with specialist– generalist relations, and advocated that the strengths and unique perspectives of each contributor be respected. Indeed, he indicated that the gulf between mental health specialists and general practitioners amounted to a serious impediment to effective care, anticipating by several decades the current motivation toward collaborative care. Balint felt that a new kind of intermediary knowledge could be generated between the GP’s cradle-to-grave care, spread out as it was over short complaint-related visits, and the in-depth, searching interviews of mental health professionals. Balint refashioned three essential psychoanalytic principles in order to guide the consultation groups: The first is ‘‘the principle of free association’’ (Freud, 1963/1916, p. 106). The leader begins by openly asking a question, ‘‘Who would like to report on some issues around a particular case?’’ rather than dictating a theme to discuss. A participant in a Balint group reports ‘‘as freely as possible’’ about special concerns and impasses when dealing with a patient, and the other participants also react to what has been presented as freely as possible. Thus, each participant should have respect for both confidentiality and the ‘‘courage of one’s own stupidity’’ (Balint, 2000, p. 305). The second principle of ‘‘evenly suspended attention’’ (Freud, 1977/1912, p. 112) directs participants beyond the content of what is presented, toward the process by which the discussion occurs during the group sessions. In other words, the way in which the participant describes the case, including the tone of voice or the omission of certain information, is thought to hold potential significance for understanding the material. Balint’s third principle, the notion of internal force and drive, draws attention to ‘‘unusual features that occur at the emotional level in the relationships’’ among doctors,
468
E. Lee & D. Kealy
patients, and consultation group members. This includes attention to the latent message ‘‘behind manifest speech’’ (Kutter, 2002, p. 314). For example, group members may join in a discussion of a certain ‘‘type’’ of patient – someone who rejects clinical interventions yet who complains bitterly. The task of the group is to contemplate whether such dialogue reflects the group members’ anxiety about feeling helpless when patients present in this way. In this instance, the group’s deeper sense of helplessness could, if touched upon, spark some further reflection on how one manages such feelings in day-to-day work. In other words, the group must cast a wide net in considering communicative and interactive phenomena within the group as reflecting, at an unconscious level, aspects of either (or both) the patient’s and the participant’s psychology. As Forssell (2007) notes, these essential psychodynamic principles support the general aim of the Balint Group of making the participants more conscious and skillful; and to notice the processes and problems in the communication between oneself and the other’’ (Forssell, 2007, p. 184), in order to better understand their own work (even when somebody else is presenting a case), and what happens with themselves and their patients in practice. Integrating the Balint model in collaborative care Although the Balint group model has been recognized internationally for its value in family physician training (Salinsky, 2002), the application of this psychodynamically inspired process to building collaborative care capacity has received scant attention. Balint groups have traditionally consisted of a consultant leader and 10–12 GPs, but the model may be readily applied to smaller collaborative care programs. We write from the experience of integrating Balint’s approach into a CMHC team that consisted of one psychiatrist (the leader), one designated CMHC social worker, one social worker from the local community mental health centre, and three GPs in a mid-sized inner city in the western part of Canada. Meetings occurred biweekly, for 1 h each session, and were oriented around the discussion of patients whom the family physicians found challenging or considered in need of psychological support. Often these patients were discussed as referrals to the psychiatrist or social workers for assessment and direct treatment, typically involving psychotherapy. However, cases were also discussed in terms of understanding the patient’s psychological dynamics and psychosocial constraints, and how these were brought to bear on the doctor–patient relationship. A gradual, organic capacity building occurred as our collaborative process unfolded. We have identified three broad areas of enhanced capacity – identifying and addressing ‘‘deeper diagnosis’’, optimizing the doctor-patient relationship, and coordinating interprofessional responses – all of which were anticipated in The Doctor, His Patient, and the Illness (Balint, 2000/1957). Identifying and addressing ‘‘deeper diagnosis’’ Balint suggested that many patients ‘‘unconsciously’’ present psychiatric or psychosomatic symptoms as a kind of offering to the doctor. The patient who attends the primary-care clinic frequently for a chronic yet vaguely defined symptom may be presenting a covert wish to be taken care of, to have loneliness alleviated, or to be invited into an inquiry regarding difficult psychological issues. Although inferences about such underlying motives need not to be explicitly explained to the patient, they invariably shift the doctor’s focus toward psychosocial concerns that the patient can barely express. How the doctor responds to this offer is crucial in addressing the deeper, core issues at the heart of the ‘‘proposal’’ that the patient brings forth in their complaint. He noted that the doctor’s responses, conveyed via
J Interprof Care, 2014; 28(5): 466–470
empathic listening and inquiry, can help the patient feel that his proposal of the illness is accepted and understood. Part of this understanding involves the physician’s acceptance that the patient may not yet be able to consciously think about their issues in emotional terms. The patient may nonetheless experience relief at the depth of the physician’s responsiveness to an offering of illness. Balint’s notion of the ‘‘deeper diagnosis’’ involves ‘‘an understanding not only of the illness but also of the personality of the patient who has that illness, the interactions with the family, the social setting, the influence of the physician on these relationships, and an appreciation of the impact of the patient and the setting on the physician’’ (Balint & Shelton, 1996, p. 888). This deeper diagnosis – a consideration of the patient’s core issues, contextual factors, and the relationship with the physician – provides a more holistic perception of the patient’s needs both within their practice and from other care providers’ resources. Tuning into the deeper diagnosis and responding to it accordingly can directly increase community capacity. Physicians in general practice deal with a tremendous volume of mental health related complaints. A combination of time constraints, a bio-centric medical diagnostic model, and patients who are anxious for answers can lead to pressure for a swift ‘‘correct’’ diagnosis, often involving numerous specialist referrals and consultations. Aspects of a case that do not fit neatly into such a model – often where emotional difficulties are involved – tend to remain obscured by what Balint referred to as the ‘‘collusion of anonymity.’’ This refers to an obliviousness to the patient’s difficult emotional realities that become implicitly reinforced through specialist consultations and investigations. The limited and often vague results leave the patient feeling that the ‘‘offering’’ of illness has been rejected – that ‘‘nothing is wrong with you’’. The physician and other specialists may then react with surprise when, instead of a reduction of symptoms, the patient makes a more clamorous presentation of them. In the end, ‘‘everybody is trying hard, is expending his energies in a futile way, but nobody can be held responsible for the management – or mismanagement – of the case’’ (Balint, 2000/1957, p. 80). The patient’s proposal of an illness (to be distinguished from a purely medical problem) is largely an unconscious attempt to be heard for his or her emotional concerns, and for these to be taken seriously. Through prioritizing objective, syndrome-oriented findings over emotional phenomena, the collusion of anonymity can unwittingly ignore the ‘‘deeper diagnosis’’ and scuttle the professionals–patient relationship. An important aspect of the modified Balint group is to draw upon others’ perspectives, such as therapists and/or psychoanalytically oriented psychiatrists, in order to foster novel or alternative conceptualizations of the symptoms presented by patients. This interprofessional dialogue can help to ease the pressure to quickly identify an elusive syndrome, and assist with formulating the ‘‘deeper diagnosis’’ accompanying the patient’s ‘‘proposal’’ of symptoms. Optimizing the helping relationship between patients and professionals A lot of mental health work has been somewhat solitary – especially for GPs. Such treatment often consists primarily of trials and renewals of psychiatric medications, especially antidepressants. However, we believe that all mental health clinicians benefit from the contact with the larger group of profession. It was clear in our group that GPs had been providing much more than medication, valuable though that may be for some patients. Yet the doctors themselves had largely overlooked the
Revisiting Balint innovation
DOI: 10.3109/13561820.2014.902369
non-pharmaceutical help that they had been offering. It seemed to the non-GP members of our team that, in being taken for granted, this relational–emotional help was at risk of being disregarded or even devalued altogether. Interprofessional consultation thus shone a brighter light on the doctors’ and other professionals’ general helping relationship skills, emphasizing their robust contributions to patients’ improved outcomes, and seeking ways to maximize their impact. Balint (2000/1957) was well aware of the powerful yet unacknowledged therapeutic effects of GPs’ non-medicinal interventions. He proposed that the physician is a drug and proposed the concept of ‘‘the drug doctor’’ (Balint, 2000/1957, p. 5). Like any pharmaceutical agent, the clinician – or more accurately, aspects of the clinician-patient relationship – must be thought about carefully in terms of how to prescribe, the optimal dose for the patient, and the presence of any harmful effects. Psychotherapists are well aware of how to utilize the therapeutic relationship to ameliorate suffering. Physicians are taught this too – under the rubric of ‘‘bedside manner’’. Attention to the ways in which the doctor and patient relate to one another, particularly the physician’s therapeutic regulation of this relationship, is thus of paramount interest to the Balint consultation group. Mental health clinicians in our team benefited from close consultation with doctors, particularly with respect to the doctors’ longer term relationships with patients and their family members. These relationships provided insights around patients’ patterns of somatic symptoms, as well as their baseline demeanors and characteristics. Potential problems in the emotional undercurrents of primary and mental health-care relationships are also usefully explored in the Balint approach. Practitioners from each discipline come to appreciate that no one is immune to the influence of one’s own emotional responses in the clinical situation. The Balint model is particularly useful for elaborating and exploring clinicians’ emotional responses and beliefs at the level of direct patient involvement. Health-care providers are typically loath to acknowledge how aspects of their professional self might impede optimal clinical care. Psychoanalytic theory advises the necessity of therapists’ attention to such factors (i.e. counter transference). Balint paid special attention to the ways in which participants’ attitudes, emotional responses, and moral judgments could infiltrate clinical decision-making, interventions, and communications with patients. He coined the term ‘‘apostolic function’’ to refer to the tendency of professionals to handle patients’ problems according to the idiosyncrasies of their own motivations and personality characteristics. Balint observed that this tendency was often manifest in advice given to patients, particularly concerning social issues that reflects the clinician’s way of thinking about or handling a problem. Our group experienced this ‘‘apostolic’’ phenomenon when patients presented with distress over relationship difficulties. When a patient sobs over the awful way in which her partner treats her, there may be a strong temptation to say something like, ‘‘you just need to leave him – he’s causing you too much pain’’, or to offer an antidepressant medication. Other authors have since noted the complexity involved in managing counter-transference when prescribing (Gabbard, 2005). Part of the ‘‘apostolic function’’ includes the pressure to maintain the role of being a healer and a helper. Prescribing, repeating medical tests, and advice-giving may be relied upon to defensively instill the feeling that something helpful has been done in the face of confusion or futility. The interprofessional consultation group provides a forum for being able to identify, normalize, and reflect upon these dynamics. An atmosphere of acceptance and safety should prevail in order that issues of personal approach and style may be talked about and understood. This can be fostered by conveying the
469
attitude that all clinicians, regardless of discipline, role, or care setting, are subject to counter-transference forces and the potential enactments associated with them. Upon recognizing and accepting the presence of emotional reactions and belief systems in patient care, the group can attend to the work of exploring the potential meaning of their appearance in clinical work. A modified Balint group also addresses the aftermath of inevitable dilemmas, gaffes, and crises. Participants can increasingly develop ‘‘the experience that it is possible to confide in someone else when things are about to go wrong’’ (Forssell, 2007, p. 191). Reflectivity regarding one’s missteps – through the support of the group – empowers team members to remain curious, open, and tolerant of uncertainty. If this process goes well, its ultimate consequence is an expansion of human and organizational capacity (Nastasi, 2004). Coordinating interprofessional responses The attitudes and emotional responses of participants are not limited to reactions to direct patient contact. Beliefs regarding professional roles and systems of care can also have a profound and often unacknowledged effect on the care provided. The coming together of different professions is a fertile environment for reconsidering such beliefs and thinking collaboratively about their effects on patient care and professional capacity. At the inception of our team, for example, the physicians expressed a long-held belief that many of their patients would not be eligible for mental health services since they were ‘‘not ill enough’’. At the same time, they subscribed to the notion that the local system of care could be of little help, due to a protectionist stance regarding its scarce resources. These perceptions limited their referrals for specialist mental health service, and led to a sense of resignation that only minimal patient recovery could be expected in the absence of such care. As the interprofessional team developed, the process of getting to know one another helped to modify these beliefs; the physicians learned that, although the local mental health system was strained, opportunities existed for their patients to obtain help from interested and responsive clinicians. Similarly, given a current trend of a short-term treatment in mental health, clinicians in our team often felt that very limited work had been accomplished during their involvement with many patients; clinicians sometimes felt that their work had little impact on a patient’s quality of life. This cumulative sense of failure and ineffectiveness can injure the capacity of the participants. During the interprofessional consultation, however, the clinicians would be reminded by doctors that the changes clinicians instilled in treatment stayed with their patients, and often increased after the completion of mental health service.
Conclusion Although the CMHC movement has a policy and procedural presence in Canadian health care, it has been an ongoing challenge to achieve knowledge and attitude changes among practitioners. A potential impasse associated with implementing the Balint model is a perception that Balint groups take up too much valuable clinical time. This concern, however, is perhaps no different than any other obstacle in clinical practice: what may appear a hindrance can paradoxically represent an opportunity to change and transform one’s practice. While interprofessional consultation groups such as the Balint model may appear to be too time-intensive, we suggest that professionals who are willing to ‘‘take time to learn how to improve [their] psychological relationships with patients’’ (Luban-Plozza, 1995, p. 258) would achieve time savings in the long run. The emotional knowledge developed in these groups can prevent time-wasting activities such as the ordering of unnecessary investigative tests or a
470
E. Lee & D. Kealy
proliferation of referrals. Group consultation can thus reduce the ‘‘confusion of tongues’’ (p. 20) between patients’ offer of illness/ suffering and professionals’ acceptance of the illness. There are other systemic obstacles to the broader implementation of this approach. For example, the current reimbursement system in North American health care is based on the number of patients receiving services, with little systemic support in place to encourage GPs and psychiatrists to participate in ongoing interprofessional consultation groups. As well, there are limited human resources in terms of psychiatrists/psychotherapists who have the training and professional commitment to lead modified Balint groups. Nevertheless, positive reports on the Balint approach indicate that ‘‘Balint training produces more empathic doctors [and other professionals] who are also more cost effective’’ (Salinsky, 2002, p. 334). Our discussion of this model’s use in the context of Canadian collaborative mental health care adds to this finding. Applications of this model should also be subjected to scientific investigation regarding its efficacy and utility. Unfortunately, rigorous research on the Balint group has to date been lacking (Torppa, Makkonen, Ma˚rtenson, & Pitka¨la¨, 2008). With its emphasis on relationships, emotions, and the meanings of idiosyncratic reactions to clinical phenomena, the Balint process may appear at odds with knowledge derived from controlled trials. The crux of the model, however, rests not in the knowledge disseminated from mental health clinician to GP, but instead lies in the development of receptivity to complex and nuanced emotional phenomena, complementing medicine’s empirical knowledge base. How this approach would make changes in care providers’ increased empathy with patients’ emotional sufferings, their own professional development, and their institution’s and care community’s capacity building would be important questions to be addressed in future research. The discoveries that gradually emerge from the Balint process enrich the team’s responsiveness to patients and communities. At the same time, the process provides an intrinsic reward to participants: the expansion of emotional receptivity and inner capacity. As Luban-Plozza (1995) notes, the Balint method is ‘‘a note-worthy contribution towards a broader understanding of the complex relationships involved in health care and towards the adoption of a more human and holistic approach in treatment and prevention’’ (p. 258). Capacity is built within team members themselves, contributing to an overall readiness to tackle complicated emotional and mental health issues in community practice. Russell-Mayhew and his colleagues (2008) note that ‘‘capacity building involves building on strengths in the individual, but also making use of available resources to strengthen the community’’ (p. 230). Applying and expanding the Balint model to collaborative mental health care involves drawing upon the strengths of all involved care providers, in order that the whole may become greater than the sum of their parts. A new knowledge is created, somewhere in between the perspective of GP and psychotherapist. With this comes enhanced capacity, which itself brings another realization: that we have only just begun, and much more work awaits the interprofessional team.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the writing and content of this paper.
J Interprof Care, 2014; 28(5): 466–470
References Balint, J., & Shelton, W. (1996). Regaining the initiative: Forging a new model of the patient-physician relationship. JAMA: The Journal of the American Medical Association, 275, 887–891. Balint, M. (2000/1957). The doctor, his patient and the illness. London, UK: Churchill Livingstone. Cohen, J.J. (2000). Collaborative care: A new model for a new century. Academic Medicine, 75, 107–112. Forssell, J. (2007). Has anyone met a patient? Balint groups with young doctors in their foundation years at a country hospital in Sweden. Psychoanalytic Psychotherapy, 21, 181–191. Freud, S. (1963/1916). Further recommendations in the technique of psychoanalysis. Therapy and technique. New York: Collier Books, Inc. Freud, S. (1977/1912). Introductory lectures on psychoanalysis. New York, NY: Liveright Pub. Gabbard, G.O. (2005). Psychodynamic psychiatry in clinical practice. Arlington, VA, USA: American Psychiatric Publishing, Inc. Kates, N. (2008). Promoting collaborative care in Canada: The Canadian collaborative mental health initiative. Families, Systems, and Health, 26, 466–473. Kates, N., Mazowita, G., Lemire, F., Jayabarathan, A., Bland, R., Selby, P., & Audet, D. (2011). The evolution of collaborative mental health care in Canada: A shared vision for the future. Canadian Journal of Psychiatry, 56(5), 1–10. Kelly, B.J., Perkins, D.A., Fuller, J.D., & Parker, S.M. (2011). Shared care in mental illness: A rapid review to inform implementation. International Journal of Mental Health Systems, 5, 31. doi:10.1186/ 1752-4458-5-31. Kutter, P. (2002). From the Balint method toward professionrelated supervision. The American Journal of Psychoanalysis, 62, 313–325. Luban-Plozza, B. (1995). Empowerment techniques: From doctorcentered (Balint approach) to patient-centred discussion groups. Patient Education and Counseling, 26, 257–263. Miedema, B.B.O., Tatemichi, S., Thomas-MacLean, R., & Stoppard, J. (2004). Barriers to treating depression in the family physician’s office. Canadian Journal of Community Mental Health, 23, 37–46. Nastasi, B.K. (2004). Meeting the challenges of the future: Integrating public health and public education for mental health promotion. Journal of Educational and Psychological Consultation, 15, 295–312. Norton, J.L., Pommie´, C., Cogneau, J., Haddad, M., Ritchie, K.A., & Mann, A.H. (2011). Beliefs and attitudes of French family practitioners toward depression: The impact of training in mental health. The International Journal of Psychiatry in Medicine, 41, 107–122. O’Hanlon, A., Ratnaike, D., Parham, J., Kosky, R., & Martin, G. (2002). Building capacity for mental health: A two and a half year follow-up of the Auseinet reorientation of services projects. Adelaide: The Australian Network for Promotion, Prevention and Early Intervention for Mental Health (Auseinet). Rockman, P., Salach, L., Gotlib, D., Cord, M., & Turner, T. (2004). Shared mental health care model for supporting and mentoring family physicians. Canadian Family Physician, 50, 397–402. Russell-Mayhew, S., Arthur, N., & Ewashen, C. (2008). Community capacity-building in schools: Parents’ and teachers’ reflections from an eating disorder prevention program. Alberta Journal of Educational Research, 54, 227–241. Salinsky, J. (2002). The Balint movement worldwide: Present state and future outlook: A brief history of Balint around the world. The American Journal of Psychoanalysis, 62, 327–335. Smith, M.F., Litts, W.C., Robbiano, L., Hoin, J.J., Nathan, R.G., & Bont, E.M. (1993): Using a Balint-like group for geriatric education in a nursing home setting, Educational Gerontology, 19, 597–606. Torppa, M.A., Makkonen, E., Ma˚rtenson, C., & Pitka¨la¨, K.H. (2008). A qualitative analysis of student Balint groups in medical education: Contexts and triggers of case presentations and discussion themes. Patient Education and Counseling, 72, 5–11.
Copyright of Journal of Interprofessional Care is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
ORIGINAL ARTICLE
Revisiting Balint’s innovation: enhancing capacity in collaborative mental health care Eunjung Lee1 and David Kealy2 1
Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada and 2Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada Abstract
Keywords
Interprofessional collaboration is increasingly recognized as a key response to the challenges associated with complex mental health issues in community primary-care settings. Relatively few practice models, however, provide an orientation and a structure that combines quality patient care, professional development, and the building of community capacity. A psychodynamic tradition of supervision and collaboration, an approach known as the Balint model, holds considerable potential to bring this orientation to collaborative primary care and mental health teams. As a consultation group, the Balint approach brings participants’ attention to subtle emotional–interpersonal phenomena such as the provider–patient relationship, the presentation of illness, and the experiences of patients and team members. We introduce and provide an overview of the Balint group model, including several concepts proposed by Balint to illuminate the emotional and relational complexities of providing mental health care in a collaborative primary-care setting. The context of our discussion is the implementation of a modified Balint group approach within a Canadian collaborative mental health Care (CMHC) program. We also discuss how an interprofessional application of this approach can enhance patient care, contribute to care providers’ professional development, and build community capacity.
Balint model, community capacity building, collaborative mental health care, interprofessional collaboration, psychodynamic approach
Introduction Mental health care has a long tradition of interprofessional teamwork in psychiatric service settings. However, a considerable amount of mental health care is provided in primary care, by solopractice family physicians (e.g. Miedema, Tatemichi, ThomasMacLean, & Stoppard, 2004; Norton et al., 2011). Recognition of the need for collaboration between these care systems has grown steadily, with recent trends toward integrating and sharing mental health care within primary care settings. Collaborative, shared mental health care initiatives can improve the detection and treatment of mental health issues by incorporating interprofessional mental health knowledge and resources into primarycare practice, where individuals may have frequent, consistent, and lasting contact with their family physicians across the life span (Kelly, Perkins, Fuller, & Parker, 2011). These initiatives, also referred to as ‘‘shared care’’ and ‘‘circle of care’’ programs, have been espoused as innovative means to enhance patient care, improve access to specialist care, and facilitate primary care physicians’ knowledge about mental health care (Cohen, 2000; Rockman, Salach, Gotlib, Cord, & Turner, 2004).
Correspondence: Eunjung Lee, Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, Ontario, Canada M5S 1A1. E-mail: [email protected]
History Received 24 March 2013 Revised 22 January 2014 Accepted 05 March 2014 Published online 1 April 2014
Interprofessional collaboration: mental health in primary care The trend toward mental health and primary-care integration is catching on internationally, having been supported by the World Health Organization ‘‘as a way of improving access to personcentred mental health care’’ (Kates et al., 2011, p. 2). In Canada, over the past 15 years, there has been a steady growth in interprofessional responses to the challenges of mental health service delivery. These collaborative responses have been driven by two major factors: (1) the heavy demands faced by family physicians in Canadian health care – most Canadians rely upon their family physician as a primary provider of mental health care (Kates, 2008); and (2) resource limitations – including a shortage of psychiatrists – have prompted Canadian mental health services to ‘‘find new ways to use their resources more efficiently and effectively, with a greater emphasis on a consultative role and support’’ (p. 467). The Canadian Psychiatric Association (CPA) and the College of Family Physicians of Canada (CFPC) accordingly developed a partnership for collaborative mental health care (CMHC) in 1996, seeking to integrate psychiatric care within primary care settings, and further established the Canadian Collaborative Mental Health Initiative (CCMHI) in 2004 (Kates, 2008). Despite the increasing trend of mental health and primary-care collaboration, and the benefits associated with it, there is relatively little literature on how interprofessional consultation models can be developed in order to build capacity across care systems. Existing models of collaborative care are mostly
DOI: 10.3109/13561820.2014.902369
centered around improving access to psychiatry for primary care patients who might not otherwise visit a mental health clinic, often operating on a case-by-case basis or as a form of expert-led knowledge translation that focuses on ‘‘solving a case.’’ Such programs typically embed a mental health professional (e.g. psychiatric nurse, social worker, or psychiatrist) within a primary care office where several family physicians practice, offering both direct care and case-based consultation. Although useful and beneficial, this kind of arrangement is limited in promoting care providers’ professional development and the expansion of community capacity. The present paper explores an alternative model of interprofessional consultation that in our view remains as innovative today as when first introduced more than 50 years ago. This model, based on the work of physician and psychoanalyst Michael Balint, also involves regular interprofessional contact, direct care, and consultation – but with a slightly different purpose. The target in the Balint model is not the identification of a particular syndrome or the amelioration of symptoms, but is instead the development of participants’ capacity to explore and contain the emotional vicissitudes associated with mental health practice. The Balint approach prioritizes the deepening of care providers’ emotional receptivity and understanding over the solving of a case or prescribing of an intervention. In turn, this focus brings an overall expansion of community capacity in mental health/ primary-care contexts through effecting changes in care providers themselves. Interestingly, many North American care providers, both in family practice and in mental health systems, are unfamiliar with this model – one that, in our opinion, deserves attention for its potential to advance interprofessional mental health-care capacity.
Building community capacity The development of enhanced community1 capacity is composed of three distinctive dimensions: problem-solving capability, the creation of sustainability, and infrastructure building. This involves service development not only to solve immediate problems but also to establish infrastructure for sustained and institutionalized problem solving (Russell-Mayhew, Arthur, & Ewashen, 2008). In order to achieve these elements of community capacity building, O’Hanlon and colleagues (2002) recommend concrete strategies such as continuing education, professional development and training opportunities for staff, and professional support or supervision. Through these strategies, they aim to achieve successful collaborative partnerships, indicated by ‘‘knowledge and attitude change, skill development, policy change, and service and environment change’’ (p. 31). We suggest that the Balint approach fosters these outcomes through its unique approach to mental health and primary-care collaboration. In our experience, a modified Balint approach can enhance mental health capacity by developing clinical competence and confidence among health-care providers. Below we will describe and discuss the use of the Balint model in the context of Canadian collaborative care.
The Balint model Michael Balint, a physician and psychoanalyst, developed a group method to collaboratively explore the nature of the 1
Here we limit our discussion of the ‘‘community’’ to care providers that include physicians in family medicine, psychiatrists, and other non-medical care providers (e.g. social workers, psychotherapists, nurses), in order to closely align with the Balint model. However, we acknowledge the broader care community includes patients’ families and other community service agencies (e.g. school, employment).
Revisiting Balint innovation
467
provider–patient relationship, to deepen interprofessional relations, and to enhance understanding of mental health concerns among general practitioners (GPs). Balint’s work at the Tavistock Clinic in England during the 1950s (Balint, 2000/1957) anticipated the contemporary collaborative care movement in primary care. Balint was interested in the psychological aspects of many of the complaints and illnesses presented to GPs, and the emotional undercurrents operating in the doctor–patient relationship. Balint suggested that physicians should view the patient as ‘‘proposing an illness to the doctor’’ (Balint, 2000/ 1957, p. 22). This ‘‘proposal’’ requires careful attention to its potential emotional and interpersonal meaning – beyond being simply a cluster of symptoms – and how the physician may respond to it (Kutter, 2002). Derived from a psychoanalytic supervision model, Balint groups were developed to explore primary-care cases involving either overt or suspected psychiatric distress or pathogenesis. Balint’s seminal book, The Doctor, his Patient and the Illness (2000/1957) introduced the model of these groups, and illustrated the ‘‘limited, though considerable, change’’ (p. 299) observed in participants’ capacity to work psychologically, and thus attend to their patients’ mental health issues. Consultation groups based on the Balint model are, by their very nature, interprofessional. Groups consist of a leader – usually a psychiatrist, psychoanalyst, or psychotherapist – and front-line clinicians such as GPs, nurses, occupation therapists, addiction counselors, psychologists, and social workers. Although initially developed to train family physicians, Balint groups have been emerging in ‘‘a variety of other fields where sensitivity to one’s reaction to those served is important’’ (Smith et al., 1993, p. 599). Using the Balint group, Smith and her colleagues (1993) describe how a weekly conference evolved into an interprofessional round-table educational and support program for nursing home staff including ‘‘nurses, aides, social workers, therapists, family practice residents, and physicians, in providing care to the geriatric patient’’ (p. 599). Balint was alert to potential unacknowledged stumbling blocks involved with specialist– generalist relations, and advocated that the strengths and unique perspectives of each contributor be respected. Indeed, he indicated that the gulf between mental health specialists and general practitioners amounted to a serious impediment to effective care, anticipating by several decades the current motivation toward collaborative care. Balint felt that a new kind of intermediary knowledge could be generated between the GP’s cradle-to-grave care, spread out as it was over short complaint-related visits, and the in-depth, searching interviews of mental health professionals. Balint refashioned three essential psychoanalytic principles in order to guide the consultation groups: The first is ‘‘the principle of free association’’ (Freud, 1963/1916, p. 106). The leader begins by openly asking a question, ‘‘Who would like to report on some issues around a particular case?’’ rather than dictating a theme to discuss. A participant in a Balint group reports ‘‘as freely as possible’’ about special concerns and impasses when dealing with a patient, and the other participants also react to what has been presented as freely as possible. Thus, each participant should have respect for both confidentiality and the ‘‘courage of one’s own stupidity’’ (Balint, 2000, p. 305). The second principle of ‘‘evenly suspended attention’’ (Freud, 1977/1912, p. 112) directs participants beyond the content of what is presented, toward the process by which the discussion occurs during the group sessions. In other words, the way in which the participant describes the case, including the tone of voice or the omission of certain information, is thought to hold potential significance for understanding the material. Balint’s third principle, the notion of internal force and drive, draws attention to ‘‘unusual features that occur at the emotional level in the relationships’’ among doctors,
468
E. Lee & D. Kealy
patients, and consultation group members. This includes attention to the latent message ‘‘behind manifest speech’’ (Kutter, 2002, p. 314). For example, group members may join in a discussion of a certain ‘‘type’’ of patient – someone who rejects clinical interventions yet who complains bitterly. The task of the group is to contemplate whether such dialogue reflects the group members’ anxiety about feeling helpless when patients present in this way. In this instance, the group’s deeper sense of helplessness could, if touched upon, spark some further reflection on how one manages such feelings in day-to-day work. In other words, the group must cast a wide net in considering communicative and interactive phenomena within the group as reflecting, at an unconscious level, aspects of either (or both) the patient’s and the participant’s psychology. As Forssell (2007) notes, these essential psychodynamic principles support the general aim of the Balint Group of making the participants more conscious and skillful; and to notice the processes and problems in the communication between oneself and the other’’ (Forssell, 2007, p. 184), in order to better understand their own work (even when somebody else is presenting a case), and what happens with themselves and their patients in practice. Integrating the Balint model in collaborative care Although the Balint group model has been recognized internationally for its value in family physician training (Salinsky, 2002), the application of this psychodynamically inspired process to building collaborative care capacity has received scant attention. Balint groups have traditionally consisted of a consultant leader and 10–12 GPs, but the model may be readily applied to smaller collaborative care programs. We write from the experience of integrating Balint’s approach into a CMHC team that consisted of one psychiatrist (the leader), one designated CMHC social worker, one social worker from the local community mental health centre, and three GPs in a mid-sized inner city in the western part of Canada. Meetings occurred biweekly, for 1 h each session, and were oriented around the discussion of patients whom the family physicians found challenging or considered in need of psychological support. Often these patients were discussed as referrals to the psychiatrist or social workers for assessment and direct treatment, typically involving psychotherapy. However, cases were also discussed in terms of understanding the patient’s psychological dynamics and psychosocial constraints, and how these were brought to bear on the doctor–patient relationship. A gradual, organic capacity building occurred as our collaborative process unfolded. We have identified three broad areas of enhanced capacity – identifying and addressing ‘‘deeper diagnosis’’, optimizing the doctor-patient relationship, and coordinating interprofessional responses – all of which were anticipated in The Doctor, His Patient, and the Illness (Balint, 2000/1957). Identifying and addressing ‘‘deeper diagnosis’’ Balint suggested that many patients ‘‘unconsciously’’ present psychiatric or psychosomatic symptoms as a kind of offering to the doctor. The patient who attends the primary-care clinic frequently for a chronic yet vaguely defined symptom may be presenting a covert wish to be taken care of, to have loneliness alleviated, or to be invited into an inquiry regarding difficult psychological issues. Although inferences about such underlying motives need not to be explicitly explained to the patient, they invariably shift the doctor’s focus toward psychosocial concerns that the patient can barely express. How the doctor responds to this offer is crucial in addressing the deeper, core issues at the heart of the ‘‘proposal’’ that the patient brings forth in their complaint. He noted that the doctor’s responses, conveyed via
J Interprof Care, 2014; 28(5): 466–470
empathic listening and inquiry, can help the patient feel that his proposal of the illness is accepted and understood. Part of this understanding involves the physician’s acceptance that the patient may not yet be able to consciously think about their issues in emotional terms. The patient may nonetheless experience relief at the depth of the physician’s responsiveness to an offering of illness. Balint’s notion of the ‘‘deeper diagnosis’’ involves ‘‘an understanding not only of the illness but also of the personality of the patient who has that illness, the interactions with the family, the social setting, the influence of the physician on these relationships, and an appreciation of the impact of the patient and the setting on the physician’’ (Balint & Shelton, 1996, p. 888). This deeper diagnosis – a consideration of the patient’s core issues, contextual factors, and the relationship with the physician – provides a more holistic perception of the patient’s needs both within their practice and from other care providers’ resources. Tuning into the deeper diagnosis and responding to it accordingly can directly increase community capacity. Physicians in general practice deal with a tremendous volume of mental health related complaints. A combination of time constraints, a bio-centric medical diagnostic model, and patients who are anxious for answers can lead to pressure for a swift ‘‘correct’’ diagnosis, often involving numerous specialist referrals and consultations. Aspects of a case that do not fit neatly into such a model – often where emotional difficulties are involved – tend to remain obscured by what Balint referred to as the ‘‘collusion of anonymity.’’ This refers to an obliviousness to the patient’s difficult emotional realities that become implicitly reinforced through specialist consultations and investigations. The limited and often vague results leave the patient feeling that the ‘‘offering’’ of illness has been rejected – that ‘‘nothing is wrong with you’’. The physician and other specialists may then react with surprise when, instead of a reduction of symptoms, the patient makes a more clamorous presentation of them. In the end, ‘‘everybody is trying hard, is expending his energies in a futile way, but nobody can be held responsible for the management – or mismanagement – of the case’’ (Balint, 2000/1957, p. 80). The patient’s proposal of an illness (to be distinguished from a purely medical problem) is largely an unconscious attempt to be heard for his or her emotional concerns, and for these to be taken seriously. Through prioritizing objective, syndrome-oriented findings over emotional phenomena, the collusion of anonymity can unwittingly ignore the ‘‘deeper diagnosis’’ and scuttle the professionals–patient relationship. An important aspect of the modified Balint group is to draw upon others’ perspectives, such as therapists and/or psychoanalytically oriented psychiatrists, in order to foster novel or alternative conceptualizations of the symptoms presented by patients. This interprofessional dialogue can help to ease the pressure to quickly identify an elusive syndrome, and assist with formulating the ‘‘deeper diagnosis’’ accompanying the patient’s ‘‘proposal’’ of symptoms. Optimizing the helping relationship between patients and professionals A lot of mental health work has been somewhat solitary – especially for GPs. Such treatment often consists primarily of trials and renewals of psychiatric medications, especially antidepressants. However, we believe that all mental health clinicians benefit from the contact with the larger group of profession. It was clear in our group that GPs had been providing much more than medication, valuable though that may be for some patients. Yet the doctors themselves had largely overlooked the
Revisiting Balint innovation
DOI: 10.3109/13561820.2014.902369
non-pharmaceutical help that they had been offering. It seemed to the non-GP members of our team that, in being taken for granted, this relational–emotional help was at risk of being disregarded or even devalued altogether. Interprofessional consultation thus shone a brighter light on the doctors’ and other professionals’ general helping relationship skills, emphasizing their robust contributions to patients’ improved outcomes, and seeking ways to maximize their impact. Balint (2000/1957) was well aware of the powerful yet unacknowledged therapeutic effects of GPs’ non-medicinal interventions. He proposed that the physician is a drug and proposed the concept of ‘‘the drug doctor’’ (Balint, 2000/1957, p. 5). Like any pharmaceutical agent, the clinician – or more accurately, aspects of the clinician-patient relationship – must be thought about carefully in terms of how to prescribe, the optimal dose for the patient, and the presence of any harmful effects. Psychotherapists are well aware of how to utilize the therapeutic relationship to ameliorate suffering. Physicians are taught this too – under the rubric of ‘‘bedside manner’’. Attention to the ways in which the doctor and patient relate to one another, particularly the physician’s therapeutic regulation of this relationship, is thus of paramount interest to the Balint consultation group. Mental health clinicians in our team benefited from close consultation with doctors, particularly with respect to the doctors’ longer term relationships with patients and their family members. These relationships provided insights around patients’ patterns of somatic symptoms, as well as their baseline demeanors and characteristics. Potential problems in the emotional undercurrents of primary and mental health-care relationships are also usefully explored in the Balint approach. Practitioners from each discipline come to appreciate that no one is immune to the influence of one’s own emotional responses in the clinical situation. The Balint model is particularly useful for elaborating and exploring clinicians’ emotional responses and beliefs at the level of direct patient involvement. Health-care providers are typically loath to acknowledge how aspects of their professional self might impede optimal clinical care. Psychoanalytic theory advises the necessity of therapists’ attention to such factors (i.e. counter transference). Balint paid special attention to the ways in which participants’ attitudes, emotional responses, and moral judgments could infiltrate clinical decision-making, interventions, and communications with patients. He coined the term ‘‘apostolic function’’ to refer to the tendency of professionals to handle patients’ problems according to the idiosyncrasies of their own motivations and personality characteristics. Balint observed that this tendency was often manifest in advice given to patients, particularly concerning social issues that reflects the clinician’s way of thinking about or handling a problem. Our group experienced this ‘‘apostolic’’ phenomenon when patients presented with distress over relationship difficulties. When a patient sobs over the awful way in which her partner treats her, there may be a strong temptation to say something like, ‘‘you just need to leave him – he’s causing you too much pain’’, or to offer an antidepressant medication. Other authors have since noted the complexity involved in managing counter-transference when prescribing (Gabbard, 2005). Part of the ‘‘apostolic function’’ includes the pressure to maintain the role of being a healer and a helper. Prescribing, repeating medical tests, and advice-giving may be relied upon to defensively instill the feeling that something helpful has been done in the face of confusion or futility. The interprofessional consultation group provides a forum for being able to identify, normalize, and reflect upon these dynamics. An atmosphere of acceptance and safety should prevail in order that issues of personal approach and style may be talked about and understood. This can be fostered by conveying the
469
attitude that all clinicians, regardless of discipline, role, or care setting, are subject to counter-transference forces and the potential enactments associated with them. Upon recognizing and accepting the presence of emotional reactions and belief systems in patient care, the group can attend to the work of exploring the potential meaning of their appearance in clinical work. A modified Balint group also addresses the aftermath of inevitable dilemmas, gaffes, and crises. Participants can increasingly develop ‘‘the experience that it is possible to confide in someone else when things are about to go wrong’’ (Forssell, 2007, p. 191). Reflectivity regarding one’s missteps – through the support of the group – empowers team members to remain curious, open, and tolerant of uncertainty. If this process goes well, its ultimate consequence is an expansion of human and organizational capacity (Nastasi, 2004). Coordinating interprofessional responses The attitudes and emotional responses of participants are not limited to reactions to direct patient contact. Beliefs regarding professional roles and systems of care can also have a profound and often unacknowledged effect on the care provided. The coming together of different professions is a fertile environment for reconsidering such beliefs and thinking collaboratively about their effects on patient care and professional capacity. At the inception of our team, for example, the physicians expressed a long-held belief that many of their patients would not be eligible for mental health services since they were ‘‘not ill enough’’. At the same time, they subscribed to the notion that the local system of care could be of little help, due to a protectionist stance regarding its scarce resources. These perceptions limited their referrals for specialist mental health service, and led to a sense of resignation that only minimal patient recovery could be expected in the absence of such care. As the interprofessional team developed, the process of getting to know one another helped to modify these beliefs; the physicians learned that, although the local mental health system was strained, opportunities existed for their patients to obtain help from interested and responsive clinicians. Similarly, given a current trend of a short-term treatment in mental health, clinicians in our team often felt that very limited work had been accomplished during their involvement with many patients; clinicians sometimes felt that their work had little impact on a patient’s quality of life. This cumulative sense of failure and ineffectiveness can injure the capacity of the participants. During the interprofessional consultation, however, the clinicians would be reminded by doctors that the changes clinicians instilled in treatment stayed with their patients, and often increased after the completion of mental health service.
Conclusion Although the CMHC movement has a policy and procedural presence in Canadian health care, it has been an ongoing challenge to achieve knowledge and attitude changes among practitioners. A potential impasse associated with implementing the Balint model is a perception that Balint groups take up too much valuable clinical time. This concern, however, is perhaps no different than any other obstacle in clinical practice: what may appear a hindrance can paradoxically represent an opportunity to change and transform one’s practice. While interprofessional consultation groups such as the Balint model may appear to be too time-intensive, we suggest that professionals who are willing to ‘‘take time to learn how to improve [their] psychological relationships with patients’’ (Luban-Plozza, 1995, p. 258) would achieve time savings in the long run. The emotional knowledge developed in these groups can prevent time-wasting activities such as the ordering of unnecessary investigative tests or a
470
E. Lee & D. Kealy
proliferation of referrals. Group consultation can thus reduce the ‘‘confusion of tongues’’ (p. 20) between patients’ offer of illness/ suffering and professionals’ acceptance of the illness. There are other systemic obstacles to the broader implementation of this approach. For example, the current reimbursement system in North American health care is based on the number of patients receiving services, with little systemic support in place to encourage GPs and psychiatrists to participate in ongoing interprofessional consultation groups. As well, there are limited human resources in terms of psychiatrists/psychotherapists who have the training and professional commitment to lead modified Balint groups. Nevertheless, positive reports on the Balint approach indicate that ‘‘Balint training produces more empathic doctors [and other professionals] who are also more cost effective’’ (Salinsky, 2002, p. 334). Our discussion of this model’s use in the context of Canadian collaborative mental health care adds to this finding. Applications of this model should also be subjected to scientific investigation regarding its efficacy and utility. Unfortunately, rigorous research on the Balint group has to date been lacking (Torppa, Makkonen, Ma˚rtenson, & Pitka¨la¨, 2008). With its emphasis on relationships, emotions, and the meanings of idiosyncratic reactions to clinical phenomena, the Balint process may appear at odds with knowledge derived from controlled trials. The crux of the model, however, rests not in the knowledge disseminated from mental health clinician to GP, but instead lies in the development of receptivity to complex and nuanced emotional phenomena, complementing medicine’s empirical knowledge base. How this approach would make changes in care providers’ increased empathy with patients’ emotional sufferings, their own professional development, and their institution’s and care community’s capacity building would be important questions to be addressed in future research. The discoveries that gradually emerge from the Balint process enrich the team’s responsiveness to patients and communities. At the same time, the process provides an intrinsic reward to participants: the expansion of emotional receptivity and inner capacity. As Luban-Plozza (1995) notes, the Balint method is ‘‘a note-worthy contribution towards a broader understanding of the complex relationships involved in health care and towards the adoption of a more human and holistic approach in treatment and prevention’’ (p. 258). Capacity is built within team members themselves, contributing to an overall readiness to tackle complicated emotional and mental health issues in community practice. Russell-Mayhew and his colleagues (2008) note that ‘‘capacity building involves building on strengths in the individual, but also making use of available resources to strengthen the community’’ (p. 230). Applying and expanding the Balint model to collaborative mental health care involves drawing upon the strengths of all involved care providers, in order that the whole may become greater than the sum of their parts. A new knowledge is created, somewhere in between the perspective of GP and psychotherapist. With this comes enhanced capacity, which itself brings another realization: that we have only just begun, and much more work awaits the interprofessional team.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the writing and content of this paper.
J Interprof Care, 2014; 28(5): 466–470
References Balint, J., & Shelton, W. (1996). Regaining the initiative: Forging a new model of the patient-physician relationship. JAMA: The Journal of the American Medical Association, 275, 887–891. Balint, M. (2000/1957). The doctor, his patient and the illness. London, UK: Churchill Livingstone. Cohen, J.J. (2000). Collaborative care: A new model for a new century. Academic Medicine, 75, 107–112. Forssell, J. (2007). Has anyone met a patient? Balint groups with young doctors in their foundation years at a country hospital in Sweden. Psychoanalytic Psychotherapy, 21, 181–191. Freud, S. (1963/1916). Further recommendations in the technique of psychoanalysis. Therapy and technique. New York: Collier Books, Inc. Freud, S. (1977/1912). Introductory lectures on psychoanalysis. New York, NY: Liveright Pub. Gabbard, G.O. (2005). Psychodynamic psychiatry in clinical practice. Arlington, VA, USA: American Psychiatric Publishing, Inc. Kates, N. (2008). Promoting collaborative care in Canada: The Canadian collaborative mental health initiative. Families, Systems, and Health, 26, 466–473. Kates, N., Mazowita, G., Lemire, F., Jayabarathan, A., Bland, R., Selby, P., & Audet, D. (2011). The evolution of collaborative mental health care in Canada: A shared vision for the future. Canadian Journal of Psychiatry, 56(5), 1–10. Kelly, B.J., Perkins, D.A., Fuller, J.D., & Parker, S.M. (2011). Shared care in mental illness: A rapid review to inform implementation. International Journal of Mental Health Systems, 5, 31. doi:10.1186/ 1752-4458-5-31. Kutter, P. (2002). From the Balint method toward professionrelated supervision. The American Journal of Psychoanalysis, 62, 313–325. Luban-Plozza, B. (1995). Empowerment techniques: From doctorcentered (Balint approach) to patient-centred discussion groups. Patient Education and Counseling, 26, 257–263. Miedema, B.B.O., Tatemichi, S., Thomas-MacLean, R., & Stoppard, J. (2004). Barriers to treating depression in the family physician’s office. Canadian Journal of Community Mental Health, 23, 37–46. Nastasi, B.K. (2004). Meeting the challenges of the future: Integrating public health and public education for mental health promotion. Journal of Educational and Psychological Consultation, 15, 295–312. Norton, J.L., Pommie´, C., Cogneau, J., Haddad, M., Ritchie, K.A., & Mann, A.H. (2011). Beliefs and attitudes of French family practitioners toward depression: The impact of training in mental health. The International Journal of Psychiatry in Medicine, 41, 107–122. O’Hanlon, A., Ratnaike, D., Parham, J., Kosky, R., & Martin, G. (2002). Building capacity for mental health: A two and a half year follow-up of the Auseinet reorientation of services projects. Adelaide: The Australian Network for Promotion, Prevention and Early Intervention for Mental Health (Auseinet). Rockman, P., Salach, L., Gotlib, D., Cord, M., & Turner, T. (2004). Shared mental health care model for supporting and mentoring family physicians. Canadian Family Physician, 50, 397–402. Russell-Mayhew, S., Arthur, N., & Ewashen, C. (2008). Community capacity-building in schools: Parents’ and teachers’ reflections from an eating disorder prevention program. Alberta Journal of Educational Research, 54, 227–241. Salinsky, J. (2002). The Balint movement worldwide: Present state and future outlook: A brief history of Balint around the world. The American Journal of Psychoanalysis, 62, 327–335. Smith, M.F., Litts, W.C., Robbiano, L., Hoin, J.J., Nathan, R.G., & Bont, E.M. (1993): Using a Balint-like group for geriatric education in a nursing home setting, Educational Gerontology, 19, 597–606. Torppa, M.A., Makkonen, E., Ma˚rtenson, C., & Pitka¨la¨, K.H. (2008). A qualitative analysis of student Balint groups in medical education: Contexts and triggers of case presentations and discussion themes. Patient Education and Counseling, 72, 5–11.
Copyright of Journal of Interprofessional Care is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
