Abstract
This is a ‘millennium reprint’ of the second edition of this book published in 1963. Its reprint is timely; the joint report of the Royal Australian College of General Practitioners and the Royal Australian and New Zealand College of Psychiatrists on Psychiatry in Primary Care, published in 1998, emphasizes the need for a seamless continuing education in doctor–patient relationship issues for all doctors, and especially for general practitioners. The first edition of this book, published in 1957, was a landmark in the field. Others, such as George Engel, wrote about the patient–doctor relationship and illness behaviour, but Balint provided the evidence of what goes on in such relationships and also gave us a model, ‘the Balint Group’, which has been used widely ever since. He worked with groups of UK general practitioners over many years, in action research that led to the identification of important concepts, such as that of the ‘basic fault’ and the ‘deeper diagnosis’, which have become pivotal in working with doctors in understanding what they do. Other important concepts to emerge were those of the ‘apostolic function of the doctor’ and the ‘doctor as drug’. His work is an example of applied psychoanalysis. That is an anathema to the purists, but its application has led to the better understanding of how people function in organizations, and in particular how unconscious processes in groups determine how organizations function. More recently it has been applied to an understanding of the processes at work in secondary school teaching.
The book is divided into three parts. The first part, on diagnosis, presents 15 extended clinical vignettes produced by general practitioners during their group meetings with Balint. Many of the vignettes are examples of what we now call ‘somatization’. By facilitating the group's exploration of their free associations and feelings about the material presented, Balint was able to allow these general practitioners to see that their preoccupation with physical diagnosis and authoritative prescription was often a defensive reaction and did not meet the needs of their patients. One might think that it would not be necessary to demonstrate this 40 years later, but those who work with general practitioners in Balint groups report that little has changed. It seems that although modern medical education emphasizes the biopsychosocial approach, it requires something other than the didactic approach to allow doctors to understand the nature of the doctor-patient relationship. It is as if doctors require ongoing psychotherapy, that is, ongoing working through of issues that have to do with unconscious processes.
The second part of the book deals with psychotherapy by general practitioners. Psychoanalytic psychotherapy was in its infancy at the time, and it is fascinating to read the many extensive clinical vignettes presented by general practitioners as they try to apply psychotherapy within the extremely rigid medical model existing in the UK at that time. The issues raised are most pertinent to the struggle of general practitioners today. How can brief psychotherapy be applied in the peculiar setting of general practice where the doctor often has to do a physical examination on the same patient with whom he or she is trying to do psychotherapy? Which psychotherapy should be used? How will supervision for this be obtained?
The third part of this revised edition includes some fascinating follow-up reports on patients presented in earlier sections. It also expands on the concepts of illness behaviour which were later elaborated by Pilowsky and others. What a patient makes of his or her symptoms is what determines what they do about them, and about any advice given to them. Doctors learn this through bitter experience; Balint's techniques facilitate faster learning. In the introduction to this millennium edition, written by Michael Balint's son John, Professor of Medicine and Director of the Centre for Medical Ethics at Albany Medical College New York, the point is made that the ideas expressed by Balint and his research group are even more pertinent today. The rise in patient autonomy and the controls imposed on doctors by a market-driven philosophy have altered the doctor-patient relationship in a way that can be traumatic for both. As doctors are forced into partnerships with patients, there is an even greater need for them to understand the forces that work in shaping that relationship. Some doctors will continue to seek individual supervision for their work, but increasing numbers are finding that the group work which Balint pioneered provides enormous peer support and produces an environment in which they feel free to explore their emotional reactions, and begin to make changes in the way that they practise. Most psychiatrists will have read this book; I was grateful for the stimulus to re-read it. Psychiatry trainees should read it during their consultation-liaison psychiatry rotation. It ought to be required reading for any general practitioner undergoing continuing education.