Case 1 – ‘The dismissed shock absorber’
In response to the animator’s routine question as to who would like to present a case, one female GP was keen to present a situation. She reminded the group that she had wanted to present this case in the previous meeting and stated: “Well, and I still have this situation, with new developments because I am dismissed.” It should be mentioned that it was only later in the discussion that the meaning of this statement became clear to the other group members (i.e. the patient had ‘dismissed’ the GP). The group immediately agreed to hear more about this case, and the presenter went ahead:
“The first time I saw this lady, completely accidentally, she called me saying that she needed a doctor because she didn’t feel well. So, I arrive [at her place], she’s lying on a mattress in a room in a working-class house, and she’s obviously suffering from an anxiety attack. And so, I talk to her for a while and then, well, apparently, she thinks that she’ll have me as her doctor. You should know that this lady lived in that house, I mean apartment, that the apartment was rented by her companion of the moment, and that at that moment, there were three or two children in the apartment which had only two rooms....”.
These introductory phrases provide a good sketch of the presenter’s initial report of the case, which proves to be highly anecdotal and strongly focused on the patient’s complex and chaotic situation. This initial presentation illustrates how this GP was somewhat stuck in a restricted perception of the situation. On the one hand, her discourse predominantly focused on the patient and, in particular, the patient’s way of living; her ideas and questions on the role she played (i.e., the presenter’s difficulties and feelings) were, by contrast, left almost unmentioned. On the other hand, the abundance of details and anecdotal information contrasts with the scarcity of meta-reflection on the situation. The presenter frequently used passive formulations (e.g. “I am dismissed”; “she’ll have me as her doctor”), which reflect well her feelings of being overwhelmed by the situation.
After a while, one animator intervened by inviting the presenter to talk about her own position in the situation she just presented. Indeed, the presenter had not elucidated the reason (s) for presenting this case, nor had she formulated some kind of question towards the group. Clarifying this was found to be commonplace in most of the Balint group meetings that we observed. The focus of such elucidation or question (e.g. whether on the patient’s problem or on the presenter’s own difficulty) can provide a first impression of the presenter’s perspective and acknowledgement of his or her subjective implication in the situation. In this presentation, such clarification was not spontaneously offered by the presenter. Moreover, she proved to have difficulties to react to the animator’s intervention, providing more anecdotal information about the patient instead. Throughout the discussion, group members made numerous attempts to encourage the presenter to express her reasons for presenting this case, either through direct questioning (e.g. “And how are you yourself situated in this story?”; “What is bothering you?”) or suggestions (e.g. “I don't know what your question is, but I want to say, I have some difficulties with therapeutic ruptures”; “Maybe this [feeling of it being a tough situation] is the reason why she presented the case”). The presenter’s reactions to these questions and suggestions further illustrates how she is somewhat absorbed in the situation and has difficulties verbalising her subjective position (e.g. “it has always been a complex situation”, “it really deteriorated”, “I wanted to know whether you can provide me with some ideas about how I could have avoided being taken in by that inextricable situation”).
The group members’ interventions consisted of a mix of questions and invitations for reflection on the one hand, and of ideas and suggestions that open up additional perspectives on the case on the other hand. Some interventions, for instance, aimed to stimulate the presenter’s reflection on the doctor-patient interaction. For example, when a group member posited that they must have had some kind of bond during all those years, the presenter reported how she had been communicating with the patient by means of a notebook for some time, and the difficulties this eventually evoked for the patient. Later in the discussion, one group member asked: “I was wondering how you relate to each other, like a woman accomplice to a woman, like a sister (…)? Well, in fact [this comes down to] how you imagine your relationship [with this patient] functions for her. Like a mother? Or like what?” Interestingly, these suggestions triggered a recollection in the presenter about the patient calling her a friend. She referred to a situation where this patient had asked her for money “as a friend.” Here, the presenter herself did not spontaneously explore the role the patient had attributed to her, yet the group picked-up on this, guiding and inviting the presenter to occupy a different position.
Other group interventions addressed the presenter’s tendency towards rationalisation as well as the scarcity of affective references. On the one hand, the group challenged the presenter’s propensity to rationalise situations by questioning the assumptions underlying her rationalisations. For instance, the presenter’s conviction that a medical centre is more structured than a private practice was repeatedly put into question by several group members. On the other hand, the group actively engaged in the affective dimension. By verbalising their own affective states, either in relation to the situation (e.g. “It's an impossible situation”; “It's lost from the beginning”), in relation to the patient (e.g. “I like her, I find her dynamic”), or in relation to the presenter (“I think you’ve come a long way with her”), the group actively introduced a supplementary range of subject positions. Some of these comments prompted the presenter to verbalise fragments of her own affective implication in the situation. For example, one group member’s comment that “she [the presenter] has done a lot for her [the patient]” makes the presenter claim “it’s true, I’m sure,” adding “too much” and “I didn’t protect myself enough.” This remark possibly indicates a subtle change in the presenter’s perception of the doctor-patient relationship: the presenter finally appears as someone who does not merely endure a situation, but as someone who actually has a choice with regard to how she can react to the situation.
The interactions outlined above reflect how members of this Balint group jointly created different perspectives on the situation that was presented: group members helped the presenter to transcend her immediate way of perceiving the situation and to explore it from other subject positions. For instance, this became apparent through a remarkable re-definition of the doctor-patient relationship. Whereas in talking about the doctor-patient relationship, the presenter repeatedly used expressions reflecting an employer-employee context (e.g. “I am dismissed”; “she’ll have me as her doctor”; “she fired me”; “she imposed a timetable”), one group member’s remark concerning the position a GP can occupy in such complicated cases led the presenter to reframe her position: “Maybe I was too much of a shock absorber.” The shift to a different semantic frame as well as the presenter’s active formulation of her own position may indicate her subjective position had been affected. However, other opportunities to articulate new subject positions were not taken up by the presenter. For example, when a group member commented on the fact that she had lent money to this patient, defining this as a boundary he would never cross, the presenter emphasized that she only did so with this patient. This statement prompted an animator to ask “But what does she evoke? What has she evoked that makes you say I only did this with her? (…) It is something very strong, isn’t it?”. While this reaction invited the presenter to elaborate on the way she is affected by this patient, she did not follow the animator’s prompt, but merely referred to what the patient needed the money for. This illustrates how the presenter only partly engaged in the acknowledgement of her subjective position in relation to the patient.
Apart from immediate alterations in the presenter’s discourse, another indication of the change that the group discussion evoked can be found in the case follow-up, which usually takes place during the next Balint group meeting. Although the presenter had no subsequent professional contact with the patient (the patient had ‘dismissed’ the GP), there had been a brief encounter which the presenter discussed with the group. On the one hand, she continued to engage in a rather unaffected and passive mode of storytelling. She commented upon a moment when she had seen the patient in the street, using phrases such as “I thought I was immune”, “One would like to have some news” and “I say to myself, well, she hasn’t contacted me yet.” On the other hand, she also attempted to verbalise how she felt when she met the patient in the street: “But I made the reflection…, I can’t explain exactly what the feeling was like, but it was not a pleasant one. Whereas I thought I was immune, I wasn’t. (…) Seeing her like that, I had a strange…, a malaise, I don’t know, really a malaise.” Moreover, referring to the fact that she is not in the position to solicit information about the patient from other professionals, she defined herself in more active terms (“I have detached myself from it”). Her hesitant search for a suitable expression (showing ambivalence and indeterminacy) and the additional focus on her own emotions indicate that the discussion had had an effect on the presenter’s perspective, helping her to transcend the imaginary mode of relating to the patient, in which she appeared to have been the passive victim of the other.
Case 2 – ‘The escaping approacher’
Following an animator’s question as to whether anybody had a case to present, the group remained silent for a while. Finally one female GP stated: “I have a case.” After checking whether anybody else wanted to present a case, the animator passed the floor to this GP. She began with a brief description of the patient (an 80-year old widow living in a nursing home), followed by an account of their first meeting:
“And so, I go and meet her for the first time, and our first interaction was rather peculiar. I introduce myself, and immediately, things are complicated: I called her by her maiden name [upon which she objects:] ‘No, no, no (screaming), that’s not how I’m addressed, I’m called Mrs Blah Blah Blah.’ Moreover, it’s a long and hyper-complicated name. I say to her: ‘Alright, ok.’ [She goes on]: ‘For 40 years I’m Mrs Blah Blah Blah, and so, you should address me that way.’ Ok, alright. ‘Because, you know, I’m the daughter of a statesman, Mr Blah Blah Blah.’ Actually, she’s a patient from (country), who has been living here since she was married, so for a really long time. She was married to a statesman, or something like that, all of her grandchildren are politicians. Well, so I say to myself, it’s rather peculiar to talk to me like that, but, well, maybe she is somewhat confused. So then we started talking, but I thought it was peculiar because I found her a real snob, a real snob. Appearances are hyper-important [to her], she told me 40 times she was the daughter of a statesman.”
This fragment illustrates well this GP’s general style of reporting during her initial case presentation. Unlike the previously discussed case presentation, this one is clearly marked by affectivity. The presenter’s sense of irritation is tangible through the examples she used to describe the patient (e.g. the patient’s insistence on being called by her marital name), through her tone of voice as she mimicked the patient’s way of speaking, and through the feelings she expressed about the patient (e.g. “she irritates me”, “it’s unbearable”). In a number of the presenter’s comments, the seeds for conflict escalation within a predominantly imaginary mode of relating to the patient are apparent: her focus on the patient’s aggressive behaviour functions as a mirror in which her own irritation is reflected. However, the presenter also outlined various attempts to try to understand the patient’s behaviour (e.g. “Well, so I say to myself, it is rather peculiar to talk to me like that, but, well, maybe she is somewhat confused”). At first, these reflections all seem to revolve around her decision as to whether or not the patient suffers from ‘cognitive problems’ without taking into account other possible interpretations. The case presentation ended with the presenter narrating her attempts to go beyond the patient’s hostility by trying to engage her in different topics of conversation, attempts which proved to be vain. She concluded: “I have trouble relating to this patient,” “I don’t know what she is looking for” and “I can’t develop a rapport with her.”
One animator picked-up on these comments to open up the group discussion. A simple informative question (inquiring about the size of the patient’s room) led the presenter to state from a more reflective perspective that indeed the patient’s discourse did not tally with some of the actual facts (e.g. her family’s social standing versus the small room she’s living in). This incongruity was further elaborated by the group, portraying the patient’s situation as “past glory” and “a nineteenth century lady addressing her domestics” and suggesting the possibility that this patient might have been ‘fleeced’ by her children.
By explicitly designating the patient’s behaviour as a role she is taking up, one group member opened up further reflection on the meaning of this behaviour. Several dynamics were suggested: perhaps the patient feels humiliated and that is why she humiliates others; perhaps she is suffering and unable to admit it; the patient might be uprooted; “piquing” might keep her vivid; her behaviour might reflect resistance (against getting old, against her family that put her in the nursing home). In this part of the discussion, new perspectives were jointly constructed: several group members provided alternative ideas for understanding the patient, which were then commented upon by the presenter. One animator denominated these attempts to understand the patient as “a movement of compassion passing through the group.” The presenter then stated, with a notably softer voice: “I would like to approach her, but I have the impression that she won’t let me.” At this point in the discussion, the initial feelings of irritation towards the patient appeared to have been replaced by feelings of ‘compassion.’ On the one hand, this shift might be understood as transgressing the fixity of feelings of irritation; on the other hand, the shift was quite radical and possibly induced another fixed image with a different content. What stands to the fore is the presenter’s image of the other, which clearly determines her subjective position. Further suggestions supplied by the group (e.g. to compliment the patient; to invite her to speak about her dead husband; to encourage her to be more active in rebuilding a new life) served as cues for the presenter to deepen her understanding of the patient.
However, this changed perspective (from irritation to compassion) did not acknowledge the presenter’s more complex and ambivalent feelings about the situation. When an animator suggested to the presenter to share her concerns with the patient, this ambivalence particularly came to the fore. A renewed flow of irritation was triggered in the presenter, which indicates that her shift in perspective did not address the dimension of symbolic functioning. She reported “not knowing how much she wanted to share with her [the patient],” “not wanting to invest in that person,” and eventually remarked that “she [the patient] just seriously pissed her off.” She resolutely concluded that there are only two options: “either their relationship must end, or something must change.” One animator’s further elaboration on positive aspects of this doctor-patient relationship (e.g. the fact that they are creating a bond; that the GP is adopting the right technique by playing the waiting game; that she might be the patient’s ‘antidepressant’) appeared to actually enhance the presenter’s ambivalent feelings. As she searched for words to verbalise this incongruity, the presenter re-counted her last meeting with the patient, adding a salient detail. Apparently, when the patient had gestured for further interaction (“Are you already leaving?”), the presenter had been thinking that she “just wanted one thing: to escape.” Since the presenter seemed to be unaware of her ambivalence, an animator reflects back the presenter’s comment by stating: “she finally acknowledged you and then you wanted to escape.” The presenter’s initial difficulty to notice the ambivalence she had just expressed might indicate that she was surprised by her own words. At this point, the presenter appeared to be confronted with the otherness in herself, with forces that determine the situation on an unconscious level, or put differently: with her subjective dividedness. By acknowledging her tendency to escape from the patient, the presenter articulated her subjective implication in (the difficulties that characterise) the situation. This acknowledgement of the ambivalence she is confronted with (wanting to approach the patient, while also wanting to escape from her) contrasts sharply with her previous conscious conviction of wanting to develop a bond with the patient.
As this multiplicity of subjective positions was articulated, the presenter took up a more reflective stance, and gained a different perspective on the position she had been occupying in relation to the patient. The group discussion carried on for a little while. In response to one group member’s recapitulation of the discussion, criticizing the lack of exploration of the patient’s actual suffering, one animator emphasized having been impressed by the presenter’s sensitivity to the patient’s affectivity. With this intervention, she redefined the GP’s role as the carrier of a wide range of the patient’s emotions. The final minutes of the discussion were devoted to one group member’s suggestion to introduce some humour into their relationship and to be more playful with the patient.
The case follow-up one month later underscored the presenter’s altered subjective position, which impacted upon the doctor-patient interaction: “I saw her again and in fact, it was weird because the consultation was completely different. Normally it’s quite tense and we don’t succeed in having a real exchange. (…) Now, we’ve been able to have some sort of exchange and, in the end, it was interesting. It was the only time we had a real exchange; for once, it was pleasant. I think the dynamic has changed a little bit, so that’s good, she opened her heart to me, and well, that’s nice.” This follow-up was distinctively positive (e.g. “interesting,” “pleasant,” “nice”). The presenter’s discourse focused on their bond (e.g. “the consultation,” “the dynamic,” “we”) and also included reflective elements on the situation (e.g. referring to the “dynamic” of the interaction, making a comparison with their previous interactions). Remarkably, the presenter appeared to interpret the situation as if the patient had changed (e.g., “she spoke to me about her husband,” “she opened her heart”), which indicates that she is not entirely aware of her own altered position.