The Psychoanalyst and the Clinic. A Balint Group for Psychiatrists
Freud’s prediction that the large scale application of psychoanalysis must force us to alloy the pure gold of psychoanalysis with the copper of suggestion was followed by the comment that “whatever form this psychotherapy for the people may take, whatever the elements out of which it is compounded, its most effective and important ingredients will assuredly remain those borrowed from strict and untendentious psycho-analysis” (Freud, 1919, p.168). How is the psychoanalyst to behave in the complex world beyond the comfort of his analytic consulting room?
The psychoanalyst as Consultant Psychotherapist is invited to train staff as psychotherapists as well as to help them in the acquisition of psychodynamic skills in order that they are more psychologically competent in their particular fields. This is to enable junior psychiatrists to learn to acquire psychodynamic psychiatric skills and be more competent psychiatrists. The same may be true for social workers, occupational therapists, nurses, general practitioners and psychologists – those members of the helping professions who gravitate to the psychotherapist in the mental hospital. The role for the Consultant is to help these professionals be better at their own jobs, with all the clinical interpersonal human relationships involved, rather than to train them as specialist psychotherapists or psychoanalysts.
The problem is how to train staff who deal with patients’ psychological problems to be aware of and sensitive to unconscious processes without offering them the well-proven method of having personal analysis. In fact, the dilemma is more so as training is not the substitute for therapy for staff, although there is more often a pressure in that direction for covert personal therapy.
A person’s awareness of the unconscious is altered little by lectures, seminars or even supervision of case material other than in an intellectual and usually highly defended modality (unless, of course, this goes with a psychotherapeutic experience). What is usually missing is an inner experience of conviction of the unconscious. The pressure to teach in this intellectual way is usually very great. The institution (psychiatric establishment) expects lectures, the trainees expect supervision and seminars, and all of this can be (unconsciously) designed to neutralise the psychoanalyst in his setting in the NHS.
Arguably as long as the psychoanalyst is mainly addressing these institutional “needs” and pressures he is directed into being the psychotherapist only and as a consequence can become a castrated psychoanalyst. For the psychiatric establishment it may be proper for the psychotherapist to provide knowledge on various topics. As long as it stays in the form of lectures and seminars it may be safe, neutralised, reasonably harmless and certainly away from the vicissitudes of the clinical relationship.
The various techniques of psychotherapy offer the developing therapist a variety of defensive possibilities, partial solutions to his own unconscious conflicts or an efficient repository of narcissistic supplies. The trainee may gain a great deal being an active and magically omnipotent therapist. However the possibility of that student working through his conflicts within his own treatment usually does not occur. Should the trainee then be satisfied with the making use of various psychotherapeutic techniques, which may both help patients and himself but which are often external, tacked on skills and even perhaps a type of character armor or is there a possibility that the Psychoanalyst is able to effect an internal change in the student, which will then be the driving force for the capacity in his acquiring psychodynamic skill.
It is very difficult to maintain an analytic stance in the NHS as one is likely to be seen by one’s non-analytic colleagues (psychotherapists and psychiatrists) as being awkward and perhaps not fitting in with the process of departmental life. Of course, this is true and as one would no more encourage a patient to neutralise analytic work, why evade responsibility in a similar position as a Consultant in the institution? It is not the fault of colleagues that they too have unconscious processes which gives them a capacity for resistance. It is this factor however that needs to be constantly thought about so that the psychoanalyst can develop an analytic relation to the NHS as an institution, which can often become a battle regarding the necessity for a psychoanalytic way of thought. Such matters can range from the psychoanalyst being expected to be on call for hospital emergencies throughout the day, thus disrupting his clinical sessions, or to being expected to present psychodynamics and complexities of the mind in the same brief way that behavioral techniques are taught. Another attack would be an invitation to supervise psychotherapy trainees once monthly on patients seen once every two weeks The analyst must construct his boundaries with care, oppose such onslaughts on his professional life yet also attempt to take his colleagues along with his strange analytic behavior. The alternative, of course, is to submit to the pressure and there resides, I would argue, the demise of the analyst in the institution.
One way to give a psychiatric resident trainee real inside experience of the analytic relationship is to establish an analytic stance with him oneself, yet keeping to a boundary of not being his analyst. The Consultant Psychoanalyst can create an analytic setting in which one can take in, to a certain extent, how analysts behave; talk and more importantly become acquainted with their ways of thinking. A quiet atmosphere maintained, listening with a free-floating mind and tolerating and even at times welcoming silences. Time is given to find out what is being thought and for ideas to develop and expand. Boundaries of starting and ending the supervision without being interrupted are essential. Such work is not about discussion whilst walking along a corridor in between other tasks.
Some of the theoretical ideas about training mental health professionals are derived from Enid and Michael Balint’s training in groups and G.P. seminars, as well as from the Hungarian system of analysis. The British system of analytic training followed that described in Berlin with the tripartite model i.e. personal analysis, theoretical courses and protracted analytic clinical work under supervision, which are kept separate from one another. In the Berlin system when the countertransference of the candidate to his patient comes up, by tacit agreement, it is not dealt with in supervision but is left to be worked through in the personal analysis. Thus the emphasis in supervision is focused on the understanding of the particulars of the patient’s psychodynamics and is usually taken from the stance of “what does the patient try to convey to his analyst?” The Hungarian analytic training added the idea that the training analyst should carry out one the supervisions of the candidates’ cases.
To quote Michael Balint: “In the Hungarian system the inter-relation of the transference of the patient and the counter-transference of his analyst is the focus of attention from the start and remains there. What is studied is the interaction of these two transferences, that is, how they influence and modify each other.” (Balint, 1952, pp. 231-232).
Balint, using this experience of the Hungarian system of supervision, went on to develop a training based chiefly on the close study by group methods of the worker’s counter-transference. He initially worked with General Practitioners and founded a group methodology, together with Enid, that came to be called “The Balint Group”.
Shelaigh Davies and I started the first Balint Group for psychiatrists in training, at the Royal Free Hospital in 1980, when we applied this methodology. Soon after I established such groups outside London, where I was appointed Consultant Psychotherapist. Certain conditions are required in order that psychiatrists can show their counter-transference as freely as possible. In the group the clinical presenter speaks freely on his or her clinical experiences about a psychiatric case. Notes are discouraged in order to permit all the subjective distortions, omissions and second thoughts. These, as well as the criticisms and comments of the listening group, are evaluated as a kind of free associative interaction. The real proof of the correctness or otherwise of the construction of what happened in the clinical relationship is contained in the subsequent interviews, in the same way as proof of a dream interpretation is often confirmed in the subsequent dream.
The doctor-group leader relationship is used very sparingly, if at all. Discussion of a personal and intimate nature is avoided in order to discourage the group developing into a therapy group. There is usually a more or less constant pull in this direction that the leader must note but not act out. In the relationship between the doctor and his peers, the individual’s way of treating patients in comparison to those of his colleagues in the seminar can be seen and often experienced. Each doctor will bring his own character to bear. The group setting is used to demonstrate that any form of therapy entails a specific kind of interaction between the patient, the doctor and the institution, the nature of which can be understood and the future development of which (and with it the efficacy of treatment) can often be predicted. The group associates to the clinical material and, in particular the doctor-patient relationship with the leader staying in the background until everyone has had a say. The leader’s interventions can then be at the interface, such as pointing out something which had been left out or is not being faced, rather than being critical to the doctor’s actual presentation. In other words the leader promotes an analytic stance in freeing communications and making conscious the unconscious.
The group will endeavor to lead the material away from an unconscious core, which is painful and instead allow the vacuum to be filled with some other matter such as teaching .The effect of this, in time, is to deaden the seminar and take it away from its interactive edge, away from “the fire in the belly of the seminar” to paraphrase Klauber. This is the edge where the difference between being a therapist and analyst may lie. It is also the difference between the Balint Group and case supervision For instance the group may attempt to not think or feel for themselves by involving the leader to give his “clever” thoughts and even more insidiously his “clever teaching of concepts”. At once there is a slippage away from the emotional importance of the counter-transference and all the emotions and issues that it raises and instead the group happily basks in a backwater of intellectual conceptualisation.
The aim for Balint in his G.P. groups was to develop in the doctors a sensitivity to the patient’s emotional problems to enable them to understand these problems more safely and in greater depth and then to help them acquire skills and to use this understanding for the goal of therapeutic effect.
A pre-condition for ‘the acquisition of psychotherapeutic skills does not consist only of learning something new: it inevitably also entails a limited, though considerable, change in the doctor’s personality’. (Balint 1937 p. 299).
He must be able to notice and to tolerate emotional factors active in his patients that he rejected or ignored before and he must learn to accept them as worthy of his attention.
These seem noteworthy ideas in relation to training general practitioners to be more skilled in their communicative interactions, yet mental hospitals and the staff working in them is different. The task is to improve the training of professionals in their own profession rather creating new psychotherapists. Psychiatric trainees can be given an attenuated form of psychoanalysis that can make them think, “yes why didn’t I think of this or why did I rush on by and leave such and such out? Or why did I not have the courage to take my strange thoughts about the clinical interaction more seriously.” Then there is a chance that a few may realise that there is something in the system of work called analysis and wish to further develop themselves by having a personal analysis. The use of counter-transference and analytic understanding can reveal a paradox, lacuna, a presence or an absence. This in itself can be realised as being highly unusual by those trainees whose expectation of a system is one which is sole interest is in labels, diagnoses and which tablets to prescribe.
Moreover there is often something in the doctor himself that is deriving support from the psychiatric way of working. If this can be glimpsed by the doctor, then his embracing of the organic and the known may not be so powerful and he can direct attention to the fearful, the unknown, the paradoxical and the fragments in the course of his work with his patients but also in so doing, himself.
Yet this is idealistic as only occasionally can one have such an impact on a doctor. One is usually working with doctors and nurses with high levels of scepticism and resistance and occasionally ill colleagues. I wonder if sometimes the awfulness of what a colleague is doing to a patient, for example the living out of the doctor’s illness by projection onto the ill patient, is too much for the insightful colleague. This is a subject that often patients are well aware of such that they do not say more of their predicaments if they think that the doctor cannot bear it. It is well known that in the profession of psychiatrist there can be a high repository of mentally ill or character logically disturbed colleagues who prefer to maintain the illusion that the illness is to be found in the patient, rather than with themselves. After all Shreber was a senior judge despite having, at times, severe psychopathology. Being a psychiatrist can operate as a convenient way of hiding from oneself for some. Possibly the Balint seminar can be supportive to the ill doctor and relieve the patient of having to carry the burden. One may ease the doctor into analysis. But if this does not occur, one has to suffer the pain of being impotent in such circumstances and have to be the voyeur of poor practice. This is a painful problem for the trainer. There may be many indications that a colleague seems to continue in a rigid, defensive psychiatry, projecting pathological parts of himself into the patient container. Ideally within an institution the analyst may act to hold more of the pathological projections and relieve the patient of such burdens. Often the other psychiatrists in the Balint group can speak up both helpfully and supportively to an ill colleague.
In the seminar with junior psychiatrists, the trainees do not bring along psychotherapy cases but their everyday work. The task is not some general supervision but specifically centered on the problem that the doctor has with his patient. This is to enable the participants to feel the emotional impact of their everyday clinical relationships, as well as making sense of the interactive processes in terms of theory. However, an experience can often be solely about “learning to do what the supervisor does”. Then one can see the development of tacked on skills, mimesis rather than a real inner learning experience alive with conviction. After some time many doctors attending the seminar begin to obtain a feeling for the present day material of their patients in terms of the patient’s past life and experiences. I do not mean this in a flat unemotional, ‘correct’, history, but by being able to experience the past relationships of the patient within the presenting illness, as well as the “here and now” transference of the patient-doctor relationship. Here it can be an alive transferential relationship and the doctor, once he has begun to experience such feelings in himself about his work with his patient, has been able to shift inside of himself and how he functions as a psychiatrist.
Clinical Case 1
After several months, two of the doctors attending the Balint group became responsible for the in-patient group of anorexic patients in the hospital. One session was described when all the patients complained about how precisely a correct amount of potato must be placed on the plate at mealtimes. The discussion developed into how precisely the words that the staff used had to be. “The staff should use neither too many nor too few words in communicating with the anorexic patients, but just sufficient.” As an example of the obvious sense of control being demanded , the staff were told that they should have should be given lists of words that should or should not be said, as the staff said upsetting things such as “Now you are looking better”. There are links which can easily be seen between behaviour and language (words) and thinking. In this group of anorexics the same mental mechanisms are involved. The seminar became silent for a moment and then quite excited as external behavior became translated for them into a real experience into thought and fantasy that the doctors could think about. This was far different from an earlier sense that patient’s talk is irrelevant, as they have brain pathology that makes listening superfluous. The doctors could begin to recognise a pattern between the pathology of anorexia and pattern of eating and then find the same pattern in their relationships with the hospital staff. This could be understood and used by the doctor in his treatment by relating to his patients in a new way and by realizing the value of listening. Now the dynamics of someone being in control , whilst others were being dominated could be felt by the psychiatrists. This was not really about the surface phenomena of a food regime but more deeply about patterns of control of behaviour that had been laid down in childhood as a defensive structure against something that might now become an object of analytic enquiry.
Clinical Case 2
A young woman who had taken a severe overdose told everyone around her that everything was now all right. Soon after she took another overdose and was brought into hospital against her wish under a section of the Mental Health Act due to her suicidal state. She continued to persuade anyone who listened in the hospital that she was really well and was precipitously discharged, overdosed and was again brought back to hospital. Sometime later the patient was discharged and the junior doctor who was seeing her in the outpatient department presented her in the seminar. He did not know what he could do. He referred her for a psychotherapy consultation but she did not attend. “She is so cut off”, he said.
One of the group then remembered that the previous time the doctor had presented this patient was when she had been an in-patient. He had then brought the problem of what to do with an importuning patient. She continually tugged on his sleeve when she spied him in the corridor, asking if she could leave, as she was now fine. She would wear a provocative nightgown, expressly denying being depressed or even ill. What he had been describing seemed to have been felt by him as an attack by his patient, to the extent that it severely curtailed his movements on the ward due to his fear of being overwhelmed by her demands. What was extraordinary was the doctor’s total denial of this memory, even though it was clear to the other seminar members. He wanted to quickly pass on, giving the impression of some irritability with us that we were wasting time with irrelevant things. He wanted to deny the patient her madness as well as its impact on him.
Rather than quickly passing on to other matters he was instead invited to look at his apparent memory loss. After a few moments pause he re-found the memory. He said it was true, he had forgotten how provocative she had been towards him. On thinking more he was able to realize the strangeness of his memory lapse as at the time it had had a very powerful effect on him. I then said: “the patient does not acknowledge a state of mind such as depression and suicidalness and is cut off from it. Perhaps her doctor was in identification with his patient so that he cannot remember the ill part of her, attacking him (or revealing itself to him). This would be in order to make it apparently easier for the doctor to see his patient in the out-patient department and say, “‘it’s all OK.” The group was very struck by this and for a moment there was a realisation of how much the powerful patient was taking over the doctor’s thinking. Now the doctor could encompass the material and with some freedom to think restored to him was able to work in a new way with his patient.
This doctor had a capacity to think and to feel which were, to a certain extent helpful.
He talked carefully and thoughtfully about the omnipotence of doctors, the medical hierarchy and organic psychiatry. He had discussed psychotherapy training with several colleagues and yet he felt quite lost. Yet in this proper state of being lost he had the capacity to present his work honestly and accept the seminar’s thoughts. The seminar was a point in his development where both thinking and feeling could be connected for him in his general psychiatric work.
Clinical Case 3
One member of the Balint group had missed the group the week before, as she had had to deal with the aftermath of a suicide of one of her in-patients. At the next meeting she began to talk about the young male patient who had killed himself by jumping in front of a train. She wondered anxiously what could have been done to stop it and went on to decide that the patient should have had electro-convulsive treatment. Apparently other patients on the ward knew of his intentions and he had tried to kill himself earlier when on a walk away from the ward. It was the other patients who had managed to dissuade him at that time from harming himself. The presenting doctor also thought the patient had not been on special observaion, with an individual nurse, as there was an acute shortage of nurses on the ward.
The nurses on the ward, when they heard the news of the death of a patient, had suggested to the doctor that there ought to be a community ward meeting to break the news to the other patients. The doctor was most reluctant and only agreed with much trepidation. She acknowledged her fantasy that if told, the other patients would follow suit and kill themselves. She could only give a fragmentary history of her patient. He had been admitted because of problems with his job. He was an agricultural graduate who, apparently, had felt unwanted in his present job. His mother had recently married for a second time to an electrician. Furthermore his intended move away from home had collapsed. The doctor had diagnosed the patient as having a “situational crisis”. On questioning for more details by the group it emerged that following his mother’s new marriage he had been invited to leave mother’s house, his home.
The group then learnt that the patient’s father had killed himself by wrapping wire around himself and electrocuting himself when the patient was fifteen years old. This vital fact was provided in a desultory way, as though it was hardly worthy of even a mention. The young man had been given a diagnosis of mania, which was “obvious” according to his doctor. “What else could be done?” she said. There followed a silence and I asked about the community meeting as it had been mentioned but not discussed. She said it had gone well enough. The patients had supported the staff and told them that they were not to blame. Of course, we were told, that only happened after the psychotic woman patient had been removed. The group smiled but was not curious. It was as if the utterances of patients, especially mad patients were irrelevant to understanding and need not be even listened to. I asked why someone had to be removed in order for the meeting to seem to work. In my mind I was wondering what was the thing that had to be repudiated, and even banished from the room. We were told that the psychotic patient had three sets of “ravings”:
- She said that lots of the others in the room would follow this death. This was just the unacceptable thought that the doctor herself had had and which demanded being shut out of her own mind.
- The patient said that she was the Angel of Death.
- She then said that she would have wished to push the patient in front of the train herself. Nurses then removed the patient, apparently in order to allow the community meeting to be supportive to the staff.
Nobody in the group wanted to make anything of these interesting statements and the conversation in the group turned back to organic methods of treatment and the value of electroconvulsive treatment in endogenous depression. After a while I said that every suicide might be seen to contain a murder and the woman who even suggests murder, by pushing the patient herself into a train had then to be excluded from everyone else. At once the presenting psychiatrist remembered that the patient had killed himself on his mother’s birthday. A great sigh of knowingness then went round the group. Now sense could begin to be made of the fragmented history. The patient’s rage and hatred for mother, recently remarried emerged as the birthday present he gave to her. Her remarrying had certainly led to his exclusion. He could now be seen as the sacrifice to atone for his own omnipotent Oedipal phantasies and for his unconscious guilt for murdering his father. Also mother’s new husband was an electrician who perhaps, in her son’s unconscious phantasy, electrocuted his father. The question was then asked whether the psychiatrist was in an unconscious state of mind re-enacting this drama with the potential offer of electrical treatment for her patient.
A shaft of light was thrown on the story. It is not just about the organic constitution of a patient. The treatment possibility of ECT is just a means to shut out this awful Oedipal drama and the diagnosis of a situational crisis just trivializes everything. Do the doctor and the group want to know about the horrid stuff of murder, hatred, revenge and sacrifice? The group was able to follow and make sense because of an analytic line of enquiry, which began with the comment “Someone is being excluded” (for speaking an unconscious truth). The doctor was very surprised at the connections and may have been helped to move from a vigorous protection of the organic basis of psychiatry. The group was able to know about mental mechanism of repression, which they had all experienced in the session by also excluding psychological truth in their discussion of ECT and organic treatments, in the same way that the doctor had done to the excluded patient.
Clinical Case 4
Dr. D. presented a case of a 22-year-old single woman whose father had died in the last year or so. She had recently taken an overdose and was referred to psychiatric outpatients with a diagnosis of depression. The patient was catholic and the doctor was shocked to find that his patient had become pregnant for the third time in the last two years, and was presently so. He had realised with some horror that she conceived around the time of her first appointment with him, when he had decided see her weekly for about four or five months to help her sort out, as he saw it, her grieving reactions.
He thought that she was a nice, pretty, diminutive young woman in need of help! However, he also described her as having two states of mind: the poor innocent young victim, but also a cold, callous, hurtful woman, who would not do anything in order to make her life and her doctors’ life easier. She had an Asian boyfriend, several years older. The patient was adamant that he must not know that she was pregnant as he would be upset or even devastated.
The young psychiatrist was feeling quite out of his depth and did not know what to say to his patient. The doctors in the Balint Group discussed whether the patient knew about contraception and eventually a view prevailed that she did. Someone suggested that pregnancy could be thought about from the position of an attack. The group was then able to look at the possibility of attack as being an unconscious motif on the boyfriend, on the patient herself, and also on the doctor. The psychiatrist felt stuck -what should he do? He had said that she was attacking herself, by taking the overdose, in relation to her father’s death, but whatever he said to her seemed to have no impact.
The group was then able to look at the mechanisms of being stuck as well as aggression. One doctor spoke about regarding the idea that patient might be full of sadism and masochism; hurting herself maybe was a response to the recent loss of her father. Some of her history now emerged. The patient had grown up feeling she was without any emotional stability in her family. If she thought something at home was stable she was made to regret such a feeling. For instance her mother had recently telephoned to say “please come home we need to see each other”. When she did visit she found her mother in a drunken state. She felt her father similarly was uncaring and unloving. The patient described what seemed an unhappy and even perverse family atmosphere.
I was now able to say that perhaps the patient felt herself to be both abused and also abusing. She could be in both states of mind towards herself, her pregnancies and the doctor. Now the psychiatrist was able to understand how she felt, as a victim. He had thought that he might then rescue her but he could now wonder if he was becoming, in the transference, her victim. This would function in a similar way as a baby being a device to apparently heal the adult, by functioning in a messianic way. Both she and a baby, can be seen as being abused. Terminations contain feelings that move unconsciously towards death, in connection with her father’s death as an expression of a form of enacted mourning.
The presenting doctor then made the analogy that it was like he had operated on some small lesion and then, to his surprise found a massive cancer. He felt that his finger was inside the cancer and he wanted to get out and close the wound up as quickly as possible. His phantasy continued as he described what it might feel like if he removed his finger, such that stuff would pour out all over him. He felt quite frightened. At this point, I said that as well as the two positions in the psychology of sado-masochism, of being victim and abuser, there was the third possibility of being the voyeur. Sometimes the only role, at a certain moment, is for the doctor to watch and have to see and feel the pain without being able to magic it away suddenly. At this point the seminar became quiet. One doctor remarked on how difficult a patient with sado-masochistic structures could be. I said that to be a psychiatrist, it would help to thoroughly know about such mental mechanisms, but to do so could also be full of pain, as their quietness was showing. They became sadly animated, at the pain that became both revealed and felt by the presenting psychiatrist and the group. Somebody said that feeling pain was not of much use and maybe one should stick to the positive things only. Yet for most of the others, there was a sense that although knowledge may not necessarily help the patient at a particular moment, it certainly does help the doctor locate what is going on. If one know more about unconscious states of mind, including affect, one, might at least feel more stable in order to bear horror.
The doctor who presented the case now seemed to have much more of awareness, but he still did not know what to do. Somebody said “well you still have three months to look at these issues with her”. There was a debate then about whether one should finish treatment when one says one is going to finish or carry on. The general consensus was that the doctor should not be seduced into carrying on seeing the patient indefinitely; being the whipping boy of a patient who keeps bringing sado-masochistic pathology and having to swallow it. Instead he had the opportunity of showing her an ending different from a termination. I then said that he might be able to prepare her for a process called “psychotherapy”, that if she is able to end treatment with him and maybe come back in six months time, without having had another pregnancy, that if she wanted to investigate her mind, she could then be referred to the psychotherapy department. However, there may be a phantasy that the psychotherapy department can do magic things with vast cancers. The doctors then had a dialogue about the expectations for outpatient psychotherapy as sometimes equivalent to having a heart transplant. In other words some appreciation of how large an operation may be required, in view of the patient’s sense of an unmitigated awful upbringing. For a moment, these junior psychiatrists were able to see that they did not have to cure everybody. Some psychiatric patients might be intolerably ill or maybe even incurable at that time in the same ways that it is well recognised in general medicine. Something had begun to be understood. It was not the doctor’s task to cure all his patients but to help them tolerate their lives.
Clinical Case 5
The first case presented by a new colleague, in the Balint group is sometimes an unconscious self-representation. A young doctor presented a case soon after beginning his psychiatric training. He was on call and suddenly found that he became alarmed for no apparent reason about a particular patient on his admission ward. He feared for his safety. He rang the ward, to be told that all was well. His concern was undiminished, so he rushed over to the ward. His anxiety led the nurses to search for the patient, who could not be found. The doctor searched frantically around the ward, discovered the patient hanging in a bathroom and was in time to cut him down and resuscitate him. This was an impressive example of a sixth sense that some claim can be a vital element for the medical practitioner.
His colleagues congratulated the young psychiatrist. The group was not able to process further the anxiety of the doctor in his concern for his patient and the case was left. A few months later, out of the blue, this young doctor hanged himself and was also found and resuscitated. What may have been happening in such a shocking identification of the mental state in the doctor with his patient? The idea of the patient hanging, which the doctor was in time to rescue, was an experience left inside the doctor, not decathected, and left available for the doctor to identify with as the ill patient. The young psychiatrist had his own silent and private history, unknown until the enactment. And what of the treatment of the young psychiatrist? The doctor was sent to another hospital, this time as a patient and treated, by the Consultant Psychiatrist for manic-depressive illness with ECT!
The effect on the rest of his junior colleagues was profound. Suddenly there was a sense in the group of trainees, that the sharp demarcation between doctors and patients, healthy and ill, was not available. To compound this story, when a junior psychiatric colleague visited that ill psychiatrist on the admission ward, he discovered his friend hanging again. He too was made to recreate the scenario, which the doctor initially discovered by saving his hanging patient on the ward from death.
We as doctors are vulnerable. The doctors in the group expressed and shared the opinion that the job of psychiatrist, at times, is very, very stressful, with the thought that perhaps mental illness was catching, like an infectious disease. This group of trainees was then able to acknowledge the usual defensive poise of being off sick, for forty-eight hours, having flu (spelt flew), as a device to have a break from the mental intensity of the work, rather than a breakdown. That the car crash of a psychiatric colleague may mean more than just “one of those things” and may well represent a concealed suicide attempt. Many of the doctors began to realise that knowing more about themselves might be a sensible direction to go in, in the face of such a terrible enactment by one of their colleagues.
Of course, there may be an institutional temptation to give the ill doctor a glowing reference, so that he can be transferred to work in a distant part of the country, out of sight, out of mind. Whether it is good for the doctor’s patients, or the doctor himself, can be a very hot issue to handle. How do we, as trainers, bear to face trainees with their unsuitability for psychiatry in terms of their character, the use they want to make of their patients, or their mental illness? Yet it is essential to do so.
Clinical Case 6
The doctors in the group began with the theme of an old Professor leaving and a new one arriving. Previously the old Professor had finished a lecture whilst at the same time the doctors had been meeting separately in an anteroom and everyone leaving the lecture interrupted their meeting by passing through their room, all except the Professor. One of the doctors had seen through a crack in the door, left ajar that the Professor, alone now in the lecture hall, was looking at a celebratory picture of himself that had recently been hung on the wall. After some minutes he also passed through the doctors’ meeting, interrupting it, and talking to one or two people. There was another theme from the group about parties. The Professor was having a leaving party and there was also a party for a junior psychiatrist, who had just left. One doctor offered to discuss a certain case, but a colleague exclaimed he must not.
A new psychiatrist arrived at the group. She was initially ignored as the group began to talk about why they were meeting. A joke then followed about how there was going to be a grand college leaving party for the old Professor and that the new one would be meeting the junior psychiatrists for cheese and rolls the following week. I commented that the new doctor must be wondering what food she was going to be eating here in the group. There was a desultory silence. I remarked that it had already been mentioned that a clinical case can often help the group out, when it is stuck, and one had been offered, but it seemed that we must not hear about it. There were only twenty minutes to go when Dr. B. presented a case of an exceedingly damaged woman who was a self-mutilator. In the past she had managed to cut off both her ears in bits. A few days before at her birthday party on the ward she disappeared to the toilet, cut her tongue in half and flushed it away. Dr. C., who had not wanted to hear the case earlier, had been on call as the attending doctor at the ensuing bloody emergency.
There was only a brief space to talk about the case and the psychiatrists wondered about the diagnosis of autism or not. It seemed that the patient’s mother was schizophrenic and he daughter had been brought up totally without concern and care, apparently treated as if she was a cat and often locked in the attic. Someone suggested that she obtained relief from cutting herself. Another of the doctors suggested that the behaviour was highly sexualized, but the most salient feature was that she seemed very content with what she had done, as with blood pouring out of her mouth, she was smiling and laughing on her return to the ward. Dr. C. was then invited to say what it had been like seeing her as an emergency. She said that she did not have any equipment readily available to clamp the tongue. The nurses had held tightly onto gauze. She immediately sent the patient off to the main emergency department at the local hospital. Later, the surgeon rang up very angry about how the patient could have been allowed to do such a thing, as if it was the doctor’s fault. Another doctor in the group spoke of a new Consultant who, within a week of arriving, had to deal with a patient killing herself and he attends the inquest on her death. There was a fear being expressed in the group of things being out of control, especially when there was new staff around.
We were very near the end of the seminar. I intervened to say that we had been talking about parties; that beneath the parties that linked the patient and the Professor’s leaving, there was the shock and horror of those of us who were left. It was difficult to adjust to a complicated and horrific case in such a short time, but the telling of it made sense of the beginning of our meeting, with the jocularity and celebration of endings. Maybe there was a sense that those colleagues who were having their parties and going are well out of it, leaving the rest of us to bear witness. This had been expressed in the sadistic material of the patient, with everybody on the ward and now in the Balint group having to look at what she had done. One of the doctors then added the important idea that perhaps the Professor represented all of us, looking in the mirror to ascertain what price he had paid for staying so long. What parts were missing and what does being a psychiatrist mean in terms of having to put up with a great deal of trauma to oneself – in other words, what price do we pay?
In this vignette, one was privileged to obtain sight of the internal drama of a group of psychiatrists, faced with being on the receiving end of the most horrific assault by a patient. The cutting off of a tongue at a birthday party and experiencing the horror of that patient’s mind projected into the staff by the smiling attacker, then becomes a template for seeing the party for the professor as a kind of cannibalistic feast. It is unbearable yet has to be borne. If the psychiatrist is able to cover over such material, it may well be left to become part of a pathological structure to be evacuated by the doctor in not understanding what is going on in the psychiatric ward and in the mental hospital. Instead such horror of what patients/people are capable of doing can be drowned in alcohol, or expiated in suicide by the psychiatrist. This is a serious arena for the future psychiatrist to think about rather than brush aside.
T.S. Eliot provides a vision of the effect of treatment in the clinical situation:
Sudden in a shaft of sunlight
Even while the dust moves
There rises the hidden laughter
Of children in the foliage
Quick now, here, now, always-
Ridiculous the waste sad time
Stretching before and after.
(Eliot, 1935, p.176)
Such work needs a thorough experiential training. During psychiatric training, the psychiatrist who begins to understand unconscious process and who has had an internal experience to not have his capacity for thinking assaulted will be better placed to withstand the shock of the impact. Although the case vignettes have some shocking aspects, they are also part of the ordinary contents of severe mental illness in mental hospitals that go on week to week. It is gratifying to know that the Balint Group is an enshrined part of the education of junior psychiatrists. There are even some groups established for Consultants. I have some concern however when I hear seminars being called ‘Balint-type’ as I wonder what part is missing from the mix. From the examples offered above progress often follows from the simple observation that something has been mentioned but not spoken about, so I have concern for the fate of some of such groups that are like but different from the model I have been describing. Finally it is the patient who leads the psychiatrist in the direction of knowledge by describing his symptoms, myths and stories for elucidation and to do this well the psychiatrist needs to know about his own personal history as part of the process of being a psychiatrist
Freud, S. (1919). Lines of Advance in Psycho-Analytic Therapy. S.E., 17.
Balint, M. (1952). Primary Love and Psychoanalytic Technique. 1952 Tavistock
Balint, M. (1957) The Doctor His Patient and the Illness. IUP New York
Eliot, T.S. (1935) Burnt Norton, Four Quartets, The Completer Poems and Plays. Faber and Faber 1969.
This article is published in Balint Matters: Psychosomatics and the Art of Assesment. London: Karnac.