Are we all Balintians now?

An invitation to the Balint Society’s annual dinner provided a welcome opportunity to revisit and review the enduring legacy of Michael Balint on British general practice and psychiatry.

I was one of the smallish band of “Balint boys” (and girls) who were lucky enough to be in his seminars for medical students at University College Hospital, London, which ran for a couple of years in the mid-1960s. Several of us ended up as psychiatrists. I remember that first electrifying seminar well. He instantly reminded me of my maternal grandfather, a powerful influence in my life: stocky, bull necked, with thin, swept back hair, myopic, intriguingly deformed hands, and a bossy yet an acute listener. In retrospect, the resemblance was probably only superficial, but Balint, like all charismatic people, had the ability to evoke strong transference reactions. One could not help projecting onto him significant aspects or figures from one’s life: the father one wanted to please, the feared critic, the Goliath figure one would have to slay to find one’s manhood, the encyclopaedic polymath that one admired and envied, the attentive and protective lover. As for the last: an acquaintance who had been a patient of his always referred to him as “my darling Balint.” She was still seeing him at the time of his premature death and, like many others, was not given time to resolve her positive transference.

His skill with medical students was to persuade us that we—role-less nothings in the medical hierarchy then prevailing in hospital medicine, even in a liberal institution like UCH—were the “experts” on our patients. Only we, not the consultants and other gods, had the time, he insisted, to sit and talk with our patients, to hear their fears and hopes. He taught us how to take a psychological “history”—the real histories of people’s lives, their attachments, losses, traumas, dreams, and disappointments—to complement and illuminate the medical histories we were being groomed to extract and regurgitate on ward rounds. This subversively seductive message was manna to the subset of our year who became Balint devotees. Not only did it make us feel special: its “down-power” view chimed with the zeitgeist; this was the 1960s, after all.

Once we told our stories in the seminar, Balint’s facilitative dogmatism opened up new vistas. Incredibly, he seemed to want to know what we felt about our patients and had the ability to get us to talk without embarrassment about our reactions in a group of peers. He had a master narrative to help make sense of our patients’ (not to mention our own) lives. The child is father to the man. We have to separate from our mothers; find, fight, and love our fathers; discover our sexuality; identify and dis-identify with our heroes; adjust to the realities of life without compromising our desires. Illness can be an escape route from these vicissitudes. Our patients were regressing to earlier stages as they stepped off the developmental train, by choice or necessity. (Balint, who had diabetes and was a GP’s son, knew all about illness.)

Part of Balint’s magic was his insider-outsider role. At the same time he was clearly drawn to and respectful of British values and the democratic traditions embodied in the NHS. He had perfect command of English (his third language, after Hungarian and German), yet used it in that creatively idiosyncratic way that only non-native master stylists can (think of Conrad or Nabokov). Phrases such as “interpenetrating harmonious mix-up” (mother-baby intimacy), “the drug doctor” (positive transference and the placebo effect), and “the basic fault” (the deep pain of disturbed and traumatised “pre-oedipal” patients) have a vividness and unforgettability that is uniquely Balintian. As an antidote perhaps to his exceptional verbal facility, Balint was also an advocate of the healing powers of silence in psychotherapy.

Another aspect to Balint’s appeal was that, despite his psychoanalytic mystique, he remained very much a doctor. He combined an acute analytical and theoretical mind with down to earth pragmatism. “If it works, use it” is intrinsic to his attitude. He is famous in the psychoanalytic world for “the somersault” episode.1 A patient had complained on his couch for years of her fear of physical exertion: “I’ve always wanted to do a somersault but never had the courage,” she bemoaned. “Why not do one right now?” asks Balint. Up she gets, twirls on his consulting room carpet, and never looks back. Or so the story goes.

This is often cited as example of psychotherapeutic integrationism, combining psychoanalytic and behavioural techniques in one session. Balint earned opprobrium among some psychoanalysts for that sort of thing; it is exactly what makes him so appealing to GPs and psychotherapeutic eclectics like myself. It is also part of the legacy of his own analyst, Ferenczi, also Hungarian, who pioneered “active techniques” and maintained that, in the end, it is the analyst’s love that cures the patient.

The somersault paradigm also illustrates another Balintian insight: that psychic change rarely proceeds in a simple linear fashion. Balint’s concept of “the flash” captures these moments of spontaneous insight shared by doctor and patient: “Oh my goodness, perhaps my tummy ache is all about how furious I am with my step-dad and the things he did to me.” This quasi-paradoxical approach calls for courage and confidence on the part of the therapist. Balint used to encourage us as students to take risks, such as when delving into our patients’ sex lives, reminding us that the way to ski safely was, counterintuitively, to lean down the slope rather than away from it.

It is easy to forget what an innovator Balint was. He was one of the few psychoanalysts to take epidemiology seriously. He realised that psychoanalysis could never be available for the masses. The Balint movement was a response to that insight: because most people consult their GP several times a year, equipping GPs with psychological mindedness is a way of touching those parts of the psyche that conventional medicine can’t reach and of reaching people to whom the ivory couches of Hampstead are inaccessible.

He was also a world pioneer in psychotherapy process-outcome research. David Malan’s Tavistock Clinic brief therapy studies were instigated under the tutelage of Balint. Here too he was trying to find ways to abbreviate psychoanalytic work and thus to widen its applicability. The concept of focality in therapy—that at any given moment in therapy the themes of a session centre around one pivotal psychic point—is another Balint coinage, today taken for granted. He was a relational psychoanalyst before its time. He insisted on a “two person” psychology to understand the analyst-patient relationship, abhorred analytical omniscience, did not eschew limited and judicious personal revelation in therapy, and saw the therapeutic relationship as a more important curative factor than any specific technique or interpretation.

What would Balint make of today’s scene in general practice? With counsellors and cognitive behaviour therapists embedded in most practices, and group experience firmly embedded in GP training and continuing professional development, is the “job done”? Are we all Balintians now? I think he might have demurred. Psychological mindedness is always hard won. The mind and its institutions have myriad ways of avoiding pain and failing to face the truth. Social fragmentation, neglect and trauma, and population mobility (Balint knew what is was like to be an immigrant) take their toll in ways that have an impact on the GP surgery. A recent joint document by the Royal College of General Practice and the Royal College of Psychiatry acknowledges this and makes useful suggestions about training in psychological therapies for GPs and psychiatrists (including Balint groups).2 Deprofessionalisation, abdication of leadership, the retreat of whole person medicine, and lack of continuity of care are endemic among doctors, breeding cynicism and self servingness.

Redressing these tendencies and bringing out the full potential in medical workers is never easy, but the basic Balintian principles remain as true today as they did 40 years ago:

• A fundamental belief in the primacy and healing potential of relationship, including the doctor-patient relationship

• Valuing the potential of groups within which to explore feelings and the power of many minds when they set to work on an “impossible” problem

• The importance of moral courage and the ability to risk anxiety as one seizes the moment, including the therapeutic moment when it arises

• Trusting the “butterfly effect,” the small change that makes a big difference, whether this be in brief therapy or the small but significant change in personality that a Balint group can induce in its members

• Acknowledging the ubiquity (including in the consulting room) of the demands of sex and aggression and, if unmitigated, of their possible destructive consequences

• Valuing the constructive potential of secure attachment and creativity.