The Function of Balint’s Levels of Mind
in Balint Groups
Introduction
This article comes out of a larger project that traces the evolution of Balint groups from Michael Balint’s original writings through those who have added to the understanding of Balint groups over the years. A sabbatical provided the time to travel to read the original notes and correspondence of Michael and Enid Balint as well as interview experienced Balint group leaders in the United Kingdom and the United States. Early on in this project, the role of fantasy and creative speculation in finding new solutions to problematic doctor-patient relationships emerged as a particularly fascinating area for consideration, and is the focus of this article.
A study by Johnson (2004) and his colleagues to determine how Balint groups differ from support groups found that one distinguishing feature of Balint groups is that they facilitated creative speculation. Indeed, this function of Balint groups was initially proposed by Balint as an essential factor of the group in The Doctor, His Patient and the Illness. Others, including Courtenay (1977), Enid Balint and colleagues (1993), Brock (1999), Salinsky (2003), Elder (2007), have described how Balint leaders establish boundaries, promote safety, facilitate cohesion, and set a frame that allows for creative speculation to promote learning and change in the group. This article looks at creative speculation through another lens, that of Balint’s three levels of mind and how they might operate within the group. This perspective in no way contradicts the established literature on Balint groups. Rather, it suggests another dimension that could be helpful to Balint leaders in setting the frame, understanding what is happening within the group and helping to resolve the suffering and frustration common to a mismatched or problematic doctor-patient relationship.
Each of Balint’s levels of mind is an expression of a type of relationship. Balint, as with many theorists of the object relations school of psychoanalysis, believed that human relationships were not secondary to biological drives but were motivational forces in their own right. Balint believed that all human illness and suffering, biological and psychological, could be understood only within the context of relationships. This paper examines his relationally-based levels of mind as a potential resource in understanding: 1) the purpose of fantasy and creative speculation in the group; 2) how patient suffering is empathically understood and processed by the group; and 3) how the initial frustrations presented by the doctor become the bases for patient healing and new beginnings. The goal is to deepen our understanding of the Balint group experience by incorporating these levels of mind. Although these levels of experience have been discussed in the psychoanalytic literature (e.g. Ornstein, 2002; Bonomi, 2003), they have not been a major topic in the literature on Balint groups.
The Levels of Mind
Balint (1992) proposed three levels of mind, each occurring within the context of a different type of interpersonal relationship. The first is the Oedipal level, which Balint suggests is the level of mind that operates within a triangular relationship of three or more people, and has the essential characteristic of conflict. It originates within the family as the child learns to cognitively regulate competitive affects and channel them into more cooperative, rational, and socially acceptable expressions. This, then, becomes the prototype for future adult relationships. Balint suggests that this is the level of mind that typifies most adult-to-adult communications. It is the level of conventional language in which competition and psychic conflict are active but modulated in the striving for rational thought.
The second level of mind is more complex to describe because it originates at a pre-Oedipal level of development before language is fully developed. Balint described this level of experience as a basic illness or basic fault in the biological structure of the patient. He theorized that both physical illness, especially chronic and psychosomatic illnesses, as well as psychological disorders existed as expressions of this basic fault. Balint distinguished this level of mind from the Oedipal level as existing only in a two-person relationship because its origin is in the two-person bonding between the infant and primary caretaker.
The third level of mind is the area of creation, which, according to Balint (1992), is the least understood. Although it happens all the time, it is difficult to observe and study as it occurs within a one-person relationship, that is, within the individual. It does not involve another human being, even though others may be present, silently observing. It is a moment of personal insight or an ah-ha experience that leads to new solutions.
The Oedipal Level
As mentioned above, the Oedipal level of mind always involves a more than two-person relationship and is typified by the adult language and communication that attempts to find rational solutions to problems. It also always involves emotional and intellectual conflict. Most adult problem solving strategies occur at this level of mind. Residency training typically functions at this level via challenging questions and competition among residents.
Within the Balint group, the Oedipal level of mind has two expressions, which Balint understood as two different types of relationships, or transference-countertransference phenomena. The first is the transference and countertransference dynamic between the group members and the group leader. According to Balint (1963), this type of interaction, what he calls the primal-father transference, should be avoided in the Balint group least it become a therapy group. Accordingly, the Balint leader typically redirects the group away from examining the relationship between the group leader and individual group members. In an update of Balint’s types of relationships expressed in the group, Elder (p. 15, 2007) reframes the group-leader-to-group-member relationship as the relationship between the group leader and the work of the group. This is a useful revision because it sets the context for the leader to make group-level interpretations and avoids focusing on Oedipal-type transferences and conflicts from group members to the leader.
The second type of transference and countertransference dynamic that occurs at the Oedipal level of mind is not between group members and the group leader but among the group members themselves. Balint (1963) referred to this as the brother-hoard transference, which he viewed as more productive for the group than the primal-father transference discussed above. The norms for expressing this type of transference in Balint groups, as set by group leaders, have evolved. Initially, Balint encouraged a more confrontational approach among group members, although he did note the importance of maintaining a balance between sheer aggressiveness and sugar-coated constructiveness. Over time the level of confrontation promoted among members was mitigated by Enid Balint and has been modulated even more in most Balint groups as a more supportive, protective and less confrontational frame has evolved.
Oedipal-level dynamics are common in the early stages of a group and may go on for some time in highly competitive groups. It is often what group leaders struggle with and attempt to control by establishing clear boundaries and modeling caring, supportive, and non-critical norms. Both primal-father and brother-hoard transferences can emerge during the case presentation before the group takes the case from the presenter. For example the presenter may attempt to get approval or create frustration in the leader (primal-father transference) by the way the case is presented. Similarly, clarifying questions from group members may have a critical tone or implication for the presenter (brother-hoard transference). Again, group leaders tend to redirect member-to-leader transference dynamics via group level interventions while encouraging a supportive environment to minimize member-to-member transferences. Typically, Oedipal-level dynamics diminish the longer the group exists and the more cohesion develops. As a result, residents in their second year of Balint often display fewer Oedipal-level transactions than those in their first year. Those who have been in Balint groups over many years typically engage in even fewer Oedipal-level exchanges as they are more likely to want to get to a deeper level of functioning, which brings us to our next level of mind.
The Basic Fault Level
Balint’s second level of mind, the basic fault, is active in what he called the two-person relationship and is perhaps the most useful in understanding how Balint groups produce change in the doctor-patient relationship. Balint initially proposed this idea in the 1930s while treating patients in traditional psychoanalysis, expanded the idea in The Doctor, His Patient and the Illness, and eventually dedicated an entire book to it, The Basic Fault. It was central to his thinking over most of his career and is a unifying principle in his work on the doctor-patient relationship. To understand how this level of mind is expressed in Balint groups, we need to understand the dynamics and motivational force of the basic fault.
Balint (1992) identified four characteristics of the basic fault that distinguish it from the Oedipal level of functioning: 1) it exists only in a two-person relationship (caregiver-child, doctor-patient); 2) it is a special two-person relationship that is focused primarily on the needs of just one person who must be attended to, while the other is seen as powerful and capable of either gratifying or frustrating the needs of the primary partner; 3) as a solution is approached, the dynamic force between the individuals is conflict free, although conflict may have been experienced earlier in the relationship; and 4) adult language is often useless or misleading in describing events at this level, as it simulates pre-Oedipal functioning.
The term basic fault is itself revealing. Balint used the adjective basic to imply that there is nothing deeper or beneath it in the psyche; it is a deficiency in the personality’s foundation whose influence extends widely, probably over the whole psychobiological structure of the individual, involving in varying degrees both his mind and his body (Balint 1992, p. 22). The term fault was chosen because it is the word many of Balint’s patients used to describe this phenomenon, often expressing a sense that a fault within them needed to be put right. Balint elaborated on the term by explaining that it is analogous to a geological fissure, a deficiency in the organism that is vulnerable to biological and psychological stress. The term was never intended to be pejorative.
Balint believed that the fault originated in infancy or very early childhood for various reasons, including genetic vulnerabilities and failure of the primary caregiver to meet the infant’s biological and psychological needs. The range of ways the infant’s needs might not be adequately met is quite extensive, including anxious, depressed, inattentive, over-protective, rigid, inconsistent, over-exciting, or indifferent caregivers. In fact, the list of possible genetic and environmental failures in care giving is so extensive, that it is likely that few leave early childhood without a basic fault. However, it is the extent of the fault that is important in the later expression of biological and psychological disorders. A more extensive fault could result in a lifetime of symptomatic expression in response to the stresses of life. Balint also suggests that even a minor basic fault could produce biological and psychological symptoms under sufficient stress.
If the basic fault is significant, the life-long result of this early failure is an individual’s feeling that something is wrong within, which in turn generates a great deal of anxiety that can be expressed biologically or psychologically. Although the most obvious example of this can be seen in psychosomatic illnesses, Balint (1992, p. 22) believed, based on his research and experience, that the basic fault was also a factor in a great number of ordinary clinical illnesses. He also believed that under the influence of emotional stress, including medical treatment, a biological illness could give way to a psychological disorder and vise-versa. In doing this, Balint suggested that the basic fault provides a theoretical foundation for the mind-body connection, the high co-morbidity rates of biological and psychological disorders seen by the general practitioner, as well as the co-morbidity of depression with heart disease and numerous other chronic physical disorders.
Elsewhere, Balint (1969) clarified the basic fault by distinguishing between Class I pathologies which are localized, easily diagnosed and external in origin, and Class II pathologies which are internal in origin, meaning that the patient has no localizable illness but is himself ill. Balint suggested that Class I pathologies require “illness-oriented” treatment and Class II pathologies require patient-oriented treatment. Class II illnesses revolve around the basic fault and require a deepening of the doctor-patient relationship as part of successful treatment. Later, Balint (1992), suggested that even localized illnesses with external origins could stress the basic fault and produce additional symptoms not normally associated with the illness.
With his concept of the basic fault, Balint introduced an innovative psychobiological construct into traditional psychoanalytic theory, one that functions as a dynamic motivational force throughout life as the individual seeks to put together the ingredients that will heal it. He distinguishes the basic fault from Freud’s motivational forces of instinctual drives (which can be gratified) and psychic conflicts (which can be resolved) by proposing that the basic fault can only, in the best-case scenario, be healed with a defect metaphorically similar to scar tissue. More typically, however, the basic fault goes unhealed, or only partially repaired, as it is difficult to find the right mix of ingredients to promote the healing. Here Balint is clearly suggesting that the resolution has to come in the form of a significant relationship with a trained healer to provide what is missing. Given that the basic fault is expressed in both psychological and biological disorders, Balint believed that the general or family practitioner was best placed to provide this healing. This led him to the idea of training general practitioners in psychotherapy via the early Balint groups. Although the idea of the family doctor as psychotherapist was abandoned, the value of sensitizing the doctor to the psychological and relational needs of the patient has continued as a primary function of the Balint group.
Moreover, the basic fault is at the center of Balint’s thinking about the doctor-patient relationship. Many of the clinical issues he wrote about in The Doctor, His Patient, and the Illness are based on the idea of the basic fault and are still significant in understanding the work of a Balint group. Five of these are particularly helpful in understanding how the concept of the basic fault influences Balint groups: the patient’s proposed illness, the drug doctor in response to the patient’s proposed illness, a deeper diagnosis, the apostolic function, and the collusion of anonymity.
Balint suggests that the patient and the doctor are involved in a negotiation to identify the real illness that needs to be treated, particularly in what he called Class II illnesses, which require patient-centered medicine. The position of this paper is that the real illness in these cases is the basic illness or basic fault discussed above. The patient proposes an illness in the form of a symptomatic picture to which the doctor responds. This response includes relational qualities of the doctor that have a healing potential, which Balint refers to as the drug doctor. He writes that we need to understand the pharmacology of this drug doctor in order to evaluate if it is the right drug and dosage for the deeper illness underlying the patient’s symptoms. Balint believed that a deepening of the diagnosis through empathic listening and a better understanding of the patient can further the healing qualities of the doctor-patient relationship. According to Balint (1963, 1969), this requires a level of listening so different than the listening skills typically used by doctors that, once acquired, results in a considerable though limited change in the doctor’s personality.
This deeper level of listening is often hindered by what Balint identified as the doctor’s apostolic function, which consists of his or her conditioned beliefs about what the patient needs based on years of medical training. The apostolic function can block the doctor from hearing the patient correctly, leading to frustration in the doctor and the patient. The resulting range of negative emotions in the doctor sometimes motivates the doctor to inappropriately refer to specialists, which Balint called the collusion of anonymity. In summary, the patient initiates a process of negotiating with the doctor about an illness, a treatment and a type of relationship necessary for healing. This article suggests that the patient is actually asking for a healing of the basic fault and that the Balint group can take the doctor to this level of mind to explore his or her relationship with the patient in a new, more meaningful way that challenges the doctor’s apostolic function.
All of these dynamics, processes and clinical dilemmas are part of the cases presented in a Balint group. The initial case presentation usually includes all the phenomena just described: the patient’s offer of an illness, the doctor’s diagnosis and treatment response to the patient, and the physician’s frustration when the patient does not seem to respond to what the drug called doctor is offering. The doctor’s apostolic function has been challenged leaving the doctor feeling frustrated, angry, helpless or confused. Sometimes referrals to specialists have been made with little positive outcome. Other group members ask clarifying questions and, as mentioned earlier, it is during this time that Oedipal-level-of-mind conflicts are likely to occur among group members.
When the case is turned over to the group there is a shift in the frame. This shift occurs when the leader signals an end to clarifying questions and invites the group to take the case. It is likely that at this point a well-functioning Balint group enters a mild state of what Balint (1963) called benign regression. Balint was careful to distinguish between malignant regression and benign regression. The former is a pathological need for the gratification of narcissistic needs, and the latter is an essential part of what he called new beginnings, which are creative solutions to problems--exactly what the Balint group is attempting to achieve. For Balint, benign regression is a prerequisite to approaching the basic fault level of mind in the group because it frees unconscious affects that are necessary for insight and change.
In recent years, the giving of the case to the group is often punctuated by the pushback, in which the presenter moves his or her chair slightly back from the circle to signal a shift to reflective listening as the group holds the case. This ritual may be helpful in facilitating benign regression in both the presenter and the rest of the group. Of course, this can only be successful after the group leader has set protective boundaries and an empathic frame that promotes safety and cohesion. Otherwise, the group could not process the case without producing conflict, which would keep it at an Oedipal level of mind. If the group feels safe enough to allow the benign regression to occur, it moves toward a basic fault level of mind and conflict is minimized. At the basic fault level, the group can provide a holding environment for the two-person, doctor-patient relationship to be explored, understood and deepened. This is a process that takes time and is unlikely to occur early in the life of a group.
When the group takes the case from the presenter, members begin to examine the relationship between the presenting doctor and the patient, which is Balint’s third type of transference-countertransference dynamic in the group (the first two occurring during the Oedipal level of functioning discussed earlier). The group is encouraged to use fantasy and creative speculation to examine this two-person relationship. Although there are more than two people present, via fantasy the group encloses the doctor-patient relationship into a protective space where it can be examined and understood affectively. Each group member can imagine himself or herself in this encapsulated dyad, both as the doctor and the patient. This is a psychological state that approaches the basic fault level of mind, previously held out of conscious awareness. The rational language of the Oedipal level of mind is replaced by visual images, metaphors, and affectively based stories. This is similar to the surfacing of previously unconscious information through collective dreaming Johnson (2007) describes, which allows group members to assimilate new insights. During this time group members can experience themselves in both the needy and care-giving roles unique to the basic fault level of experience without being distracted by conflict. Through creative speculation, all four characteristics of Balint’s basic fault are actualized via fantasy, if not experienced directly. This is the foundation of true empathy and over time can result in what Balint called a considerable though limited change in the doctor’s personality. Perhaps most important, according to Balint (1963), it is at this level of understanding that we can identify what treatment is really needed, or what dosage of the drug doctor is required to help the patient heal.
The Area of Creation
Balint’s third level of mind, the area of creation, is the most speculative. Because it is a one-person relationship—an internal relationship with oneself—observers can only get a glimpse of it as a person enters and exits this level of experience, which typically occurs in moments of silence. Balint (1992, pp. 26-27) writes:
True, we cannot be with him during the actual work of creation, but we can be with him in the moment just before and immediately after, and in addition, we can watch him from the outside during his actual work. Perhaps, if we can change our own approach from that of considering the silence as a symptom of resistance to studying it as a possible source of information, we may learn something about this area of the mind.
Notice that here he also acknowledges the importance of silence in the group, not as a resistance, but as a space for new ideas to emerge.
Balint believed that the area of creation is where all artistic, philosophical and scientific innovation begins. It is not a place of rational thinking, which would be the Oedipal-level of mind. Instead, this level is reached when the fantasies, images, and creative speculation of the basic fault level lead to what Balint (1992) called new beginnings, which are experienced as flashes of insight, and sometimes epiphanies. According to Balint, a person may be at this level of mind for only a few seconds, while others seem to remain at this level for longer periods of time. In terms of the Balint group, it is likely that experiencing the basic fault level of mind, even symbolically through creative speculation, creates a series of brief but fertile moments in which areas of creation, or new beginnings can emerge into consciousness.
Summary and Conclusion
Balint’s three levels of mind are basic to his thinking about how change occurs at the deepest level of human functioning. They provide a template for understanding the types of relating that can either inhibit or promote change in the Balint group. At the Oedipal level, the group is operating out of the rational apostolic function doctors are trained to use to process clinical information. Balint (1969) suggested that doctors need to learn the limitations of their apostolic beliefs by being confronted by the limitations of these beliefs. This work, and the resistance to it, occurs at the Oedipal level of experience.
The basic fault is a rich concept that is foundational to many of Balint’s ideas including the patient’s proposal of an illness (which may not be the real problem), the deepening of the diagnosis to understand the real illness, and the pharmacology of the drug “doctor” to accurately meet the patient’s needs. Within the Balint group, reaching the basic fault level of experience through fantasy and metaphor helps the doctor learn a new way of understanding the patient and develop self-knowledge. It is the basis of true empathy that can result in a deeper understanding of the patient and the doctor.
The area of creation may occur only in brief moments in Balint groups. These are unpredictable events that emerge from the group as it reaches the deeper understandings of the basic fault level. These may be experienced as “ah ha” moments, peak experiences, or epiphanies, great and small. It is from these experiences that new beginnings arise and the doctor-patient relationship is transformed.
References
Balint, E., Courteny, M., Elder, A., Hull, S., & Julian, P. (1993) The Doctor, the patient and the group: Balint revisited. London: Routledge.
Balint, M. (1963). The doctor, his patient, and the illness (2nd ed, Millennium reprint, 2000). London: Churchill Livingstone.
Balint, M. (1969). The Structure of the Training-cum-research-seminars: Its implications for medicine. Journal of the Royal College of General Practitioners, 17(81), 201–211.
Balint, M. (1992). The basic fault. Evanston, IL: Northwestern University Press.
Bonomi, C. (2003). Breaking the solid ground of common sense: Undoing “structure” with Michael Balint. The American Journal of Psychoanalysis, 63(3), 219-238.
Brock, C.D. & Johnson, A.H. (1999). Balint group observations: The white knight and other heroic physician roles. Family Medicine, 31(6), 404-408.
Courtenay, M. (1977). The leaders, the doctors, and their patients. Journal of the Balint Society, 5, 19-24.
Elder, A. (2007). The role of the Balint group leader. Journal of the Balint Society, 35, 15-17.
Johnson, A.H., Nease, D.E., Jr, Milberg, L.C., & Addison, R.B. (2004). Essential characteristics of effective Balint group leadership. Family Medicine, 36(4), 253-259.
Johnson, A.H. (2007). Restructuring the unconscious in Balint group work. Journal of the Balint Society, 35, 11-13.
Ornstein, P.H. (2002). Michael Balint then and now: A contemporary appraisal. The American Journal of Psychoanalysis, 62(1), 25-35.
Salinsky, J. (2003, rev. 2005). Balint groups and the Balint method. Course syllabus, Balint leaders intensive training, March 15-18, 2007. Santa Rosa, CA.
Return
|
