When the mind hides behind physical ills

New book examines methods of late British dpctor Michael Balint in integrating psychotherapy in general practice.

Doctors perform surgery (generic) R 370 (photo credit: REUTERS/Swoan Parker)
Doctors perform surgery (generic) R 370
(photo credit: REUTERS/Swoan Parker)
According to international studies, between 30 and 40 percent of patients who repeatedly go to the family doctor with aches, pains and other physical complaints have concealed psychological problems. But with general practitioners’ offices full of waiting patients and the average Israeli getting less than 10 minutes of attention, how many primary physicians can really discover what underlies the physical symptoms? It is nearly impossible.
It was Dr. Michael Balint – a Jewish- and Hungarianborn psychiatrist and psychoanalyst and convert to Unitarian Christianity – who studied the doctorpatient relationship and founded “Balint groups” of GPs and specialists, including psychologists and psychiatrists to analyze patient cases and advise and support the primary physician. Living most of his life in England, Balint (born Mihaly Maurice Bergmann to a Budapest physician and his wife) in 1957 published a landmark book, The Doctor, His Patient and the Illness that even now continues to have an impact on Western medicine.
Offering descriptions of dozens of patients he personally encountered, Balint analyzed treatment relationships with them, explained how to understand cases with underlying emotional problems and offered advice on coping with them.
With his future third wife Enid, he led discussion sessions with psychologists and social workers at London’s Tavistock Institute of Human Relations with a group of social workers and psychologists and developed what is now called the “Balint group,” that eventually included MDs. The Balint Society was founded in 1969, a year before his death, followed by an International Balint Federation to coordinate group activities around the world. Balint groups meet in a variety of Israeli medical settings even today.
Prof. Benjamin Maoz, an emeritus professor of psychiatry, founder and first director of the School of Psychotherapy at the Ben-Gurion University of the Negev and Balint group pioneer in Israel, teamed up with family physician Dr. Nili Ben Zvi to write a new Hebrew-language book on Balint. Published by Probook, the 191-page volume is called Be’ikvot Balint: kriya modernit besifro... (In the Footsteps of Michael Balint: A contemporary view of his book...).
The preface was written by Dr. Andre Matalon, head of the family medicine department at the Rabin Medical Center-Beilinson Campus in Petah Tikva, who noted that Balint’s longtime textbook for medical students remains relevant.
Maoz and Ben Zvi not only translated the original volume into Hebrew for the first time but also added to each of the 21 chapters what they think about Balint’s ideas.
They also presented case studies of contemporary Israeli patients they personally encountered and how analyzing their emotional and even psychiatric problems could help diagnose and treat them. The book is certainly not an easy read for the layman, and it may not be even for some physicians.
“I have no doubt that [this book] will quickly turn into a mandatory text, not only for residents in family medicine, every family medicine specialist in the country, every general practitioner and every doctor in general who reads Hebrew but also for any person who has a treatment connection with another person – because he touches the essence of contacts that bring about recovery,” Matalon wrote.
Balint and his group participants often encountered patients who were very difficult to treat because they sent them repeatedly for medical tests but nothing was discovered to explain their physical complaints. Balint wrote that at least “some of the people – who for some reason or other, find it difficult to cope with the problems of their lives – resort to becoming ill.”
He referred to physicians themselves as a “drug” because by their talking to the patient and discovering hidden problems, influenced how they coped with illness and responded to treatment.
Medical schools teach students how to reach a diagnosis by assessing their findings from a physical examination and various medical tests and eliminating diagnoses that don’t fit. But in many cases, all the results come back without an explanation for the physical complaints, so such patients are often sent to specialists to find the answer. But when they too send the patient back without an explanation, Balint wrote, the person may need psychological help – not necessarily from a psychiatrist or psychologist but from the family doctor himself.
Maoz and Ben Zvi note that today’s GPs have the advantage over Balint that there is video and other technological means of recording group discussions of patient cases so they can be analyzed.
Among the cases the book authors discuss was of one a 55-year-old North African woman, married with a number of children. She described difficulties in her aliya to Israel and her absorption as a new immigrant.
She had been forced by her family to marry a man she didn’t love, and he didn’t make a decent living. One of their children suffered from a mental disability who, as a teen, acted strangely and was said to need institutionalization.
But the mother insisted on taking care of the child on her own.
The mother’s own physical condition declined, but, they write, the National Insurance Institute threatened to discontinue her monthly support payments. At an NII session to “prove her daughter’s disability,” she felt she was being accused by the investigators of lying and cheating. Her physical symptoms continued to decline.
But her doctor made the decision to send her to a psychiatrist who encouraged her to talk about her life and problems. As a result, many of her symptoms eased.
The psychiatrist wrote a letter to her family physician, keeping her in the picture on how psychological stress affected her physical health.
“One must of course be careful not to hurt [the general practitioner]” in such a letter, making it seem as if he were telling the GP that if he had gotten to know her better, her life suffering would have been much different, Maoz and Ben Zvi write.
They continue that patients today want to know a name for the condition from which they suffer. With the Internet full of medical information – not all of it correct – and many patients investigate the names of diseases.
But when their GP tells them he didn’t find any medical problem or that everything is normal, because they still feel unwell they are angry and frustrated by being unable to find a diagnosis to look up online.
Another case described by Maoz and Ben Zvi was a young family that moved from a kibbutz to the city. It included parents and three children aged 10, seven and four. The father was a contractor for renovations, while the mother worked long hours in a computer company, thus requiring her own mother to take care of the children.
The seven-year-old complained of stomach pains and headaches, which were looked into by the family doctor who even sent him to a neurologist, but no medical problems were found. Such complaints disappeared and then reappeared over several years as the boy grew up – pains, weakness and the like, but all the medical tests showed nothing.
But the GP finally sat down to speak to father and son separately, then together, and discovered that the boy’s grandfather with whom he had been very close had died. This death was found to be the source of all the physical complaints. Five years later, the father went to the same family physician with a request to send him for blood tests. During the visit, he revealed that he and his wife had serious problems in their marriage and that they were going to be divorced. The boy’s physical complaints had disappeared. The physician and the father finally discovered together that besides the difficulties suffered by the boy as a result of his grandfather’s passing, the marital strife in the home were also responsible for the child’s repeated physical complaints.
The authors write that modern medicine differentiates between disease and illness. Disease is an objective medical syndrome or condition from which a patient suffers, while illness expresses the subjective suffering of the patient. The disease does not always explain the patient’s illness, they write, thus a look at his medical chart can be very misleading. It is up to the general practitioner using Balint group discussions with psychologists and other professionals to breach the gap between the two, they continue.
Balint, in his own, book, bemoans the situation he called “Collusion of Anonymity” in which no healthcare professional takes general responsibility for the patient. As a result, the patient feels he’s being “thrown” like a ball from one doctor to another. Who ensures that the patient is followed up when a problem is found? What happens when the experts make their recommendations? The GP should be, as the patient’s “medical gatekeeper,” but in fact, many often he or she is too busy with red tape and other patients’ urgent complaints. Balint mentions that sometimes, the patient himself is to blame for getting interested in his condition and actively looking for authoritative help.
He also advises the patient to read medical notes written by specialists to the family practitioner, even if they are usually written in difficult technical language, to collect information that they neglect to tell them.
Balint also discusses the problem of patient’s delay, in which the ill person waits months or even years to go to his doctor with his problem. They always find an excuse not to go for diagnosis and treatment. Maoz and Ben Zvi suggest in this chapter that such delaying tactics often some from habits they learned as children; they waiting to take them to the doctor due to lack of time or money. But the delay may also result from the adult’s denial that he has a serious medical problem.
“The more one learns about the problems of general medicine, the more we see the tremendous value of psychotherapy,” the British psychiatrist wrote in his 1957 volume. In his time, only those with financial means were able to pay for psychotherapy, and under the British National Health Service at that time, very little was available. Many psychiatrists were opposed to psychotherapy either openly or subliminally; the psychiatrists of that era preferred to give or refer to electroconvulsive shock therapy, medications, brain surgery and other treatments. Balint preferred that GPs trained in psychotherapy give the treatment to their patients themselves rather than psychiatrists not trained in psychotherapy. He noted that most psychiatrists of his day were so hostile to psychotherapy that they couldn’t be regarded as the address for help. Balint concludes that he hopes GPs will be more open to psychotherapy and ready not only to rule out causes of irrelevant diseases so they can diagnose the one affecting the patient but also to look beyond into the mind if nothing comes up.
“Of course, the situation has changed since the 1950s in Britain. Communications with patients and the biopsychosocial approach are well known, even if not enough,” concluded Maoz and Ben Zvi. In both Britain and Israel, most psychiatrists don’t use psychotherapy as Balint did, and most psychotherapy curricula in medical school do not accept general practitioners or family medicine specialists. There are medical social workers who do learn some of this, they write, but Germany is more advanced as it allows GPs to study psychotherapy to provide integrated treatment for their patients.
It would be helpful if psychiatrists visit primary care clinics in Israel to advise GPs, pediatricians and gynecologists on problematic patients, they write. It would also help patients who have to cope with the increasing number of chronic disorders such as asthma, kidney disease and diabetes and suffer psychological problems as a result, they conclude.