Title: Creating an innovative way for the Patient-Centered Medical Home to respond to patients with complex problems and dysfunctional styles of interaction
1Creating 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
2Forces impacting Primary Care
- Tension between population health and individual
responsibility - Government cost containment/New payment
structures - New roles and members of practices
3What about our patients?
- Increasing incidence of chronic disease
- Multimorbidity
- Fraying social structures eroding traditional
sources of support
4attachment 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
5Attachment Theory - basic concepts(John Bowlby
Mary Ainsworth)
6special needs (to feel secure.)
- Refugees
- Marginalised
- Damaged by early abuse/neglect
- Mothers (parents)
- Elderly
- Bereaved
- and
7PROFESSIONALS!
- Doctors!
- Nurses!
- Receptionistset al
8A Useful Concept for Primary Care
- The Practice as a Secure Base?
- What makes a Practice Secure/Insecure?
- For professionals?
- For patients?
- Understanding Patterns of Consultation?
9The Practice as a Secure BaseQuestions?
- 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 historystory of the
practice? - Role of MH professionals? In or out?
- Role of play/creativity
- How is change/loss (and trauma) managed?
10Mentalization
- 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
11Attachment Mentalization
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
12Mentalization Emotion
- When it works - Positive emotions increase
- When it fails - Negative emotions increase
- Negative emotions appear to impair mentalization
on FMRI scans
13- 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
14Balint 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
15Michael 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
16- At the center of medicine there is always a
human relationship between a patient and a
doctor. - -Michael Balint
17- 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
18Balint groups enhance Mentalization!
19What a Balint Group is not
- Psychotherapy Group
- Encounter Group
- Traditional Case Consultation Group
- MM Conference
- Topic Discussion Group
- Personal and Professional Development Group
- Not prescriptive, didactic, advice giving
20Characteristics 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
21Ground Rules
22The Group Convenes
23Calling for the Case
24Cases
- 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
25Group Process
26The Case Arrives
27Clarifying Questions
28The Presenter gets to Listen
29The Group Starts Working
30Imagining Patient and Doctor
31Group Exploration Continues
32Functions 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 ones own experience from
presenters - Further empathic understandings
33Functions 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
34Group time
35PCMH, Attachment, Mentalization and
BalintPutting them together
- Not only training
- Linking the twopowerful organisational impact
- Practice-based Balint Groups
- Primary Care Team (Tuesday) Meetings
- Making a House a Home
- Changing Models of Employment
36Attachment Mentalization
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
37Balint 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
38For further info...
- The American Balint Society
- americanbalintsociety.org
- Don Nease donald.nease_at_ucdenver.edu
- Frank Dornfest frank_at_dornfest.org