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Donald Nease and Frank Dornfest

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

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Donald Nease and Frank Dornfest

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  1. 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

  2. Forces impacting Primary Care • Tension between population health and individual responsibility • Government cost containment/New payment structures • New roles and members of practices

  3. What about our patients? • Increasing incidence of chronic disease • Multimorbidity • Fraying social structures eroding traditional sources of support

  4. 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

  5. Attachment Theory - basic concepts(John Bowlby & Mary Ainsworth)

  6. …special needs (to feel secure….) • Refugees… • Marginalised… • Damaged by early abuse/neglect • Mothers (parents)… • Elderly… • Bereaved… • and…

  7. PROFESSIONALS! • Doctors…! • Nurses…! • Receptionists…et al

  8. 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?

  9. 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 history…story of the practice? • Role of MH professionals? In or out? • Role of play/creativity • How is change/loss (and trauma) managed?

  10. 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

  11. Attachment Mentalization

  12. Mentalization & 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

  14. 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

  15. 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

  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

  18. Balint groups enhance Mentalization!

  19. 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

  20. 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

  21. Ownership Avoid Advice Confidentiality Respect, Turn Taking Ground Rules

  22. The Group Convenes Leader Leader

  23. Who’s got a case? Leader Leader Calling for the Case

  24. 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

  25. I do. I do. Leader Leader Group Process

  26. Presenter Leader Leader Angela is a 79 yr old blind woman…. The Case Arrives

  27. Presenter Leader Leader Are there any clarifying questions? Clarifying Questions

  28. Why don’t we let the presenter just listen while we work the case Leader Leader The Presenter gets to Listen

  29. I imagine Angela to be… Presenter Leader Leader The Group Starts Working

  30. Leader Presenter Leader If I were the doctor, I might feel… Imagining Patient and Doctor

  31. Presenter Leader Leader This image just popped into my mind of a… Group Exploration Continues

  32. 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

  33. 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

  34. Group time

  35. PCMH, Attachment, Mentalization and Balint:Putting them together • 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

  36. Attachment Mentalization

  37. 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

  38. For further info... • The American Balint Society • americanbalintsociety.org • Don Nease: donald.nease@ucdenver.edu • Frank Dornfest: frank@dornfest.org

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