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

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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

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Forces impacting Primary Care

• Tension between population health and individual
  responsibility
• Government cost containment/New payment
  structures
• New roles and members of practices

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What about our patients?

• Increasing incidence of chronic disease
• Multimorbidity
• Fraying social structures eroding traditional
  sources of support

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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

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Attachment Theory - basic concepts(John Bowlby
Mary Ainsworth)
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special needs (to feel secure.)

• Refugees
• Marginalised
• Damaged by early abuse/neglect
• Mothers (parents)
• Elderly
• Bereaved
• and

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PROFESSIONALS!

• Doctors!
• Nurses!
• Receptionistset al

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A 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?

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The 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?

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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

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Attachment 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
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Mentalization Emotion

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

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• 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

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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

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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

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

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• 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
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Balint groups enhance Mentalization!
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What 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

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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

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Ground Rules
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The Group Convenes
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Calling for the Case
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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

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Group Process
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The Case Arrives
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Clarifying Questions
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The Presenter gets to Listen
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The Group Starts Working
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Imagining Patient and Doctor
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Group Exploration Continues
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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 ones own experience from
  presenters
• Further empathic understandings

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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

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Group time
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PCMH, 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

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Attachment 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
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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

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For further info...

• The American Balint Society
• americanbalintsociety.org
• Don Nease donald.nease_at_ucdenver.edu
• Frank Dornfest frank_at_dornfest.org