Creating an innovative way for the Patient- Centered Medical Home to respond to patients with complex problems and dysfunctional styles of interaction Donald Nease and Frank Dornfest

Forces impacting Primary Care Tension between population health and individual responsibility Government cost containment/New payment structures New roles and members of practices

What about our patients? Increasing incidence of chronic disease Multimorbidity Fraying social structures eroding traditional sources of support

attachment theory proposed by Bowlby as a way to understand why and how people form varying attachments to others formation of a secure attachment style depends on the existence of a “secure base” in early life

Attachment Theory - basic concepts ( John Bowlby & Mary Ainsworth)

Refugees… Marginalised… Damaged by early abuse/neglect Mothers (parents)… Elderly… Bereaved… and… …special needs (to feel secure….)

Doctors…! Nurses…! Receptionists…et al PROFESSIONALS!

The Practice as a Secure Base? What makes a Practice Secure/Insecure? For professionals? For patients? Understanding Patterns of Consultation? A Useful Concept for Primary Care

What does a practice feel like for those who work there? How is the boundary function managed? How does the practice express its capacity to be reflective? Mentalisation – self and other? Narrative competence? Shared history…story of the practice? Role of MH professionals? In or out? Role of play/creativity How is change/loss (and trauma) managed? The Practice as a Secure Base Questions?

Mentalization “the mental process by which an individual implicitly and explicitly interprets the actions of himself and others as meaningful on the basis of intentional mental states such as personal desires, needs, feelings, beliefs and reasons” Bateman and Fonagy 2004

Lack of secure emotional connection to parent - Lack of a “secure base” Impaired capacity to read emotional content of interactions Difficulty establishing a trusting relationship Mistrust and misunderstanding of medical context Patients that interact with us inappropriately “They must be trying to abuse me or the system” Attachment Mentalization

Mentalization & Emotion When it works - Positive emotions increase When it fails - Negative emotions increase Negative emotions appear to impair mentalization on FMRI scans

420 recorded visits to UK primary care with MUS Discussions analyzed utterance by utterance Physical intervention proposed more by docs than patients Few docs showed empathy Was there a failure of mentalization? Ring, et. al, The somatising effect of clinical consultation: what patients and doctors say and do not say when patients present medically unexplained physical symptoms, Soc Sci Med 2005 vol. 61 (7) pp

Balint groups First established in the UK by Michael and Enid Balint Utilize a case presentation/discussion format in a small group Purpose is to reflectively explore specific "troubling" patients and the relationship

Michael Balint  Born in 1896 in Budapest, son of a GP  Psychoanalytic training in Berlin and Budapest, emigrated to London, worked at the Tavistock Clinic  He and his 3 rd wife, Enid, began the training/research seminars for GPs after WW II  1957 “The Doctor, his Patient and the Illness” published

“At the center of medicine there is always a human relationship between a patient and a doctor.” -Michael Balint

“In contrast to didactics or reading, the Balint process reaches past the rational system to influence intuitive functioning. It does so by engaging the intuitive system through encouraging nonjudgmental speculation, while at the same time monitoring rationally by juxtaposing the doctor and patient's views.” “One of the strengths of Balint work is that the group can take a problem and introspect out loud with the presenter, who is free to incorporate or reject new understandings. ” Lichtenstein and Lustig, Integrating intuition and reasoning--how Balint groups can help medical decision making, Australian family physician 2006 vol. 35 (12) pp

Balint groups enhance Mentalization!

What a Balint Group is not  Psychotherapy Group  Encounter Group  Traditional Case Consultation Group  M&M Conference  Topic Discussion Group  Personal and Professional Development Group  Not prescriptive, didactic, advice giving

Characteristics of a Balint Group Ideally fixed membership Closed Group Ideally two co-leaders Focus on doctor-patient relationship Power of the group Preference for an ongoing case Less conscious aspects of relationship

Confidentiality Avoid AdviceOwnership Respect, Turn Taking Ground Rules

Leader The Group Convenes

Leader Calling for the Case Who’s got a case?

Cases Presentations are spontaneous Patients we have ongoing relationships with Patients who we feel conflicted or strongly about (stuck) Patients that leave us feeling unfinished, who we lose sleep over Patients who we “take home” with us Patients that bubble up in the moment

Leader Group Process I do.

Leader Presenter The Case Arrives Angela is a 79 yr old blind woman….

Leader Presenter Clarifying Questions Are there any clarifying questions?

Leader The Presenter gets to Listen Why don’t we let the presenter just listen while we work the case

Leader Presenter The Group Starts Working I imagine Angela to be…

Leader Presenter Imagining Patient and Doctor If I were the doctor, I might feel…

Leader Presenter Group Exploration Continues This image just popped into my mind of a…

Functions of Group Members Explore doctor-patient relationship Look inward, be imaginative, creative, look for less conscious aspects Attend to and share thoughts, images, fantasies, associations, hypotheses Differentiate one’s own experience from presenter’s Further empathic understandings

Functions of Balint Leaders Create and maintain a safe space Structure and hold the group over time Protect presenter and group members Encourage reflection, empathy and compassion Attend to group development Debrief with co-leader after each group

Group time

Not only training… Linking the two…powerful organisational impact Practice-based Balint Groups Primary Care Team (Tuesday) Meetings Making a House a Home Changing Models of Employment PCMH, Attachment, Mentalization and Balint: Putting them together

Lack of secure emotional connection to parent - Lack of a “secure base” Impaired capacity to read emotional content of interactions Difficulty establishing a trusting relationship Mistrust and misunderstanding of medical context Patients that interact with us inappropriately “They must be trying to abuse me or the system” A PCMH with a Balint Group - A secure base for patients Patients with impaired attachment can be better understood and cared for Attachment Mentalization

Balint catalyzing formation of a secure base Provides a safe environment for clinical staff to bring their difficult interactions with patients Multiple perspectives encouraged Playful speculation a plus Difficult emotions are surfaced and detoxified If successful the practice becomes a secure base for staff and patients

For further info... The American Balint Society americanbalintsociety.org Don Nease: Frank Dornfest: