by Dr Andrew Elder, 25 September 2020
Michael Balint was a dominant figure in that particularly productive era of the Tavistock’s history just after the Second World War. He was born into a middle-class Jewish family in Budapest, the son of a GP. After qualifying in medicine in 1918, he became interested in psychoanalysis and studied in Berlin before returning to Budapest to start analysis with Sandor Ferenczi. It was in Budapest that he began to experiment with seminars focussing on the everyday work of general practitioners.
Michael and Alice Balint in the mid-1930s
In 1939, Michael Balint and his family left Hungary to escape the Nazis and came to the UK. Initially he settled in Manchester where his first wife, Alice, suddenly died. In 1948, at the age of 52, with considerable life experience behind him, he joined the staff of the Tavistock Clinic where he worked until his retirement in 1961. It was during this comparatively short period at the Tavistock that his most creative work was done and for which he is now widely remembered.
Balint had an incisive intellect and soon collected around him a group of colleagues who found him both stimulating and exasperating. Bob Gosling wrote, ‘with Balint around the frontiers of knowledge were forever being pushed back’ (Stewart, 1996). Under Balint’s editorship numerous publications appeared as a series of Mind and Medicine Monographs published by Tavistock Publications; twenty-three titles, nearly all concerned with a detailed exploration and research of the interface between mind and medicine. His influence was profound and felt in many different areas of practice: in brief (focal) psychotherapy and its research evaluation (Malan); in the training of family planning doctors in psychosexual medicine (Main); in the use of small groups in professional training (Gosling); in investigating the role of a psychotherapist within a general practice (Brook); and on opportunistic listening to health visitors and others in primary care (Daws). Balint combined an acute analytical and theoretical mind with a down-to-earth pragmatism. He remined very much ‘a doctor’.
Balint’s great masterpiece for GPs is The Doctor, His Patient and the Illness, published in 1957 and based on the work of the first GP research group which he recruited at the Tavistock in 1951. By placing the detailed exploration of individual doctor-patient relationships at the centre of his enquiry, he initiated a radical challenge to conventional medical practice. As he put it, by far the most frequently prescribed drug in general practice is the doctor himself: what do we know of its pharmacology? This challenge led to a sustained and detailed examination of the therapeutic aspects of doctor-patient relationships which continued for over forty years in a series of five research groups, all of which published their findings. Balint also laid out his understanding of a new role for GPs who he said, ‘will have to shoulder the privilege of undivided responsibility for people’s health and well-being.’ His conception of this new role was profoundly influential on the (then) newly founded College of GPs.
Publications from the early research groups (and from the College) led to a growth of GPs wanting to attend groups. The Tavi ran a programme of weekly training groups for GPs for many years; at its height, training up to sixty or seventy doctors at any one time. The GP and Allied Professionals’ Workshop which examined the leadership of these groups continued for many years after Balint’s retirement and provided a forum for the training of future leaders.
The essence of Balint groups has remained the same – no teaching, no case notes, mutual exploration of professional work within a clear framework to facilitate free association and observation of shifts in feeling – a profoundly psychoanalytic structure. It had its origins in part from Michael’s experience of the Hungarian tradition of psychoanalytic training with its emphasis on analysing the counter-transference of candidates in supervision, and in part on Enid Balint’s experience with social workers treating clients with marital difficulties in the Family Discussion Bureaux which they had founded at the Tavistock in 1948. Our aim, says Balint, is to help the doctors to become more sensitive to what is going on, consciously or unconsciously, in the patient’s mind when doctor and patient are together’.
Michael and Enid Balint
So, what can we say about the BALINT legacy in 2020 – fifty years after Michael’s death? First, an area of encouraging development in the last ten years or so. More and more medical students are being introduced to Balint groups. Twenty-two of the UK’s medical schools now have some sort of Student Balint Group scheme. This would surely have pleased Michael Balint who started running groups for students at UCH after he retired from the Tavistock.
Michael and Enid Balint
In addition to a growing number of GP groups, there has been increased interest in joining groups from nurses and hospital doctors particularly in oncology and the care of the dying and from psychiatrists for whom participation in a Balint group is now a mandatory part of training. In the present Health Service, a ‘good-enough’ Balint group provides a much-needed space for medical teams to think together and take note of their feelings. In the last few months, during the pandemic, the Balint Society and faculty leads of the Royal College of GPs have received numerous requests for the provision of more Balint-type groups. The first report of an on-line Balint group (linking young hospital doctors across different countries) was published only five years ago. Now, of course, all groups world-wide are held on-line.
The Balints travelled widely and developed an extensive network of colleagues interested in their ideas. An International Federation (IBF) of Balint Societies was formed in 1975 and now has twenty-eight affiliated countries, some in Asia and the most recent being Brazil.
It is striking to note how resilient the basic structure of a Balint group has been across many different countries and cultures. But also, important to note that the Balint approach remains peripheral to mainstream medical culture.
Unlike nearly all other approaches to improving doctor-patient communication, the Balints’ approach involves a change in the doctor, and therefore brings the potential for a genuinely new kind of doctor into being; one more able to be self-aware and to attend to the emotions involved in a clinical encounter.
From his early years as a psychoanalyst, Michael Balint was a keen exponent of the value of applying psychoanalytic principles and insights to other fields of practice. In the encouraging and creative atmosphere at the Tavistock in the post-war period, Michael Balint’s energy and creativity was able to flourish and he produced a body of work and an approach to professional training which continues to spread and influence new generations worldwide.
*Dr Andrew Elder FRCGP DEd (Hon). Andrew was a GP for 36 years in inner London and retired from his practice at Paddington Green in 2008. In addition to full-time clinical work as a GP, he was involved in postgraduate and undergraduate teaching throughout his career. He joined his first Balint Group in 1972 at the Tavistock Clinic in London. He worked with Enid Balint from 1977 until her death in 1994 and contributed to two books which arose out of research groups with her While I’m Here, Doctor (Elder & Samuel, 1987) and The Doctor, the Patient and the Group. He co-edited Mental Health in Primary Care with Jeremy Holmes (2002). He was a consultant in the Adult Department at the Tavistock Centre from 1995 to 2000 and President of the UK Balint Society.
Andrew’s chapter on Michael Balint is published in The Tavistock Century: 2020 Vision, Phoenix Publishing House, 2020.