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 BaseQuestions?

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. 1505-1515

Balint groupsFirst 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 3rd 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. 987-989

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 Advice Ownership

Respect, Turn Taking

Ground Rules

Leader

Leader

The Group Convenes

Leader

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

Leader

Group Process

I do.I do.

Leader

Leader

Presenter

The Case Arrives

Angela is a 79 yr old blind woman….

Leader

Leader

Presenter

Clarifying Questions

Are there any clarifying questions?

Leader

Leader

The Presenter gets to Listen

Why don’t we let the presenter just listen while we work the

case

Leader

Leader

Presenter

The Group Starts Working

I imagine Angela to be…

Leader

Leader

Presenter

Imagining Patient and

Doctor

If I were the doctor, I might

feel…

Leader

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: donald.nease@ucdenver.edu

•Frank Dornfest: frank@dornfest.org