The Balint approach: the therapeutic relationship as a reflection of unconscious and irrational forces

Balint was a Hungarian psychoanalyst whose approach was derived from the work of Freud.7 14 Psychoanalysis takes as its starting point that unconscious and often irrational motives drive much of our behaviour. In applying psychoanalytic principles to the relationship between patient and family practitioner, Balint made three critical observations:

• General practice includes a high prevalence of neurotic illness—that is, with symptoms that can be traced back to desires or fears repressed into the unconscious.

• Trivial and ‘inexplicable’ complaints are the main vehicle through which this type of illness presents to the practitioner.

• The key to healing in neurotic illness is the persona of the practitioner—that is, such patients need, more than anything else, a dose of what Balint memorably called ‘the doctor as the drug’.7

Balint encouraged general practitioners to reflect in groups on clinical cases in order to reveal the hidden meaning of the emotions they had felt and how they and the patient had behaved. Balint considered objectivity to be an over-rated virtue, inherently impossible to achieve. Rather, he argued, the doctor's subjectivity (and particularly, reflexive attention to his or her own emotional responses in the consultation) is the key to both making the diagnosis and defining an appropriate treatment. The clinical interaction in general practice, Balint believed, is a complex dialogue held over time and in an atmosphere of trust, which will reveal insights into the nature of neurotic illness and offer scope for its cure.

Balint's influential work built on the earlier work of Carl Rogers, who challenged the widespread assumption of the day that the therapist's behaviour was the essential element in healing.8 Rogers argued that the relationship conditions offered by the therapist (empathy, congruence and unconditional positive regard) were in and of themselves therapeutic. This suggestion has since been confirmed empirically and underpins a large body of work on psychotherapeutic approaches to the clinical encounter.15 16 The evidence summarised in these reviews has consistently shown that ‘objective’ measures of the quality of the relationship are less good predictors of outcome than subjective ones such as mutual warmth.

Narrative approaches: the therapeutic relationship as co-construction of a story by teller and listener

All stories have four things in common: characters, setting, trouble and plot.17 In the illness narrative, trouble is disease, disability, disfigurement and so on—plus the accompanying loss of social status and independence.18 Coping with illness and minimising its impact requires perseverance and forbearance. Every ill person faces different day-to-day challenges, a different family context, different constraints of work or neighbourhood and different moral choices. Constructing an illness narrative in the therapeutic encounter allows us to make sense of our trouble and develop plans for coping with it in the context of our lives.9

Bakhtin argued that all stories are a dialogue.19 The role of the listener is not merely to absorb a story passively, but to provide an engaged and critical audience for it.10 Drawing on Bakhtin, Frank takes issue with conventional biomedical perspectives which encourage doctors to use listening as a ‘tool’ for extracting information that can contribute to a problem solving sequence. In such an approach, ‘the [patient] remains the object of the professional's privileged subjectivity: there is no relationship in the sense of reciprocated feeling for one another’.10

The clinician, suggests Frank, provides the subjective ‘otherness’ for an interactional narrative in which the patient will construct, and make sense of, his or her illness narrative. The accumulation of (often brief and disjointed) clinician–patient encounters over time constitutes above all else ‘just listening’ to an unfolding narrative of restitution (the illness gets better), tragedy (the illness gets worse) or quest (the illness gets worse but the sufferer finds fulfillment in facing and coping with it).20

The clinical encounter has a significant ethical dimension which emerges from the particularities of the story. This stance draws on a number of philosophers (eg, Buber, Heidegger) broadly classified as existentialists, who emphasised not merely the ability to connect with the patient but the need to be fully present and open to being changed by the patient's unfolding story.21 22 What Buber referred to as the ‘I-thou’ relationship (intersubjective, mutually constitutive, ethical, fundamentally different from any ‘I-it’ relationship) has close parallels to what Rita Charon calls narrative competence (the ability to acknowledge, absorb, interpret and act on the stories and plights of others9). This is, perhaps, the essence of what will be missed if the therapeutic relationship is assessed solely in terms of the objectively measurable.23

Critical consultation analysis: the therapeutic relationship as an unequal power struggle

Medical sociologists have studied the consultation from the perspective of socio-linguistics, in which researchers ask why particular utterances were made in particular ways at particular times. This critical analysis extends beyond the consultation and considers the social context and power relationships within which talk gains a particular, contextual meaning.24

Habermas distinguished between the discourses of ‘system’ (economy and state) and ‘lifeworld’ (family and household).25 The ‘micro’ of interpersonal relationships links with the ‘macro’ of society and state such that any particular doctor–patient encounter is a product of the roles of ‘doctor’ and ‘patient’ in wider society and is influenced by wider political and economic forces.26 27

Using a socio-linguistic technique called conversation analysis28 to analyse consultation transcripts, Mishler demonstrated that the patient's lifeworld is colonised by the ‘voice of medicine’ (an example of encroachment by the state into the personal world).29 Subsequent empirical studies have confirmed and refined Mishler's original model.30 31 For example, Barry et al revealed the subtle ways in which the doctor imposes the ‘voice of medicine’ on what is said:…the [apparently] unremarkable interview, while appearing coherent and fluent on the surface, fragments meaning by means of frequent interruption, lack of acknowledgement of responses and shifts of topic with no reason given. The doctor is in control as both first and last speaker in each exchange. Only the doctor is involved in developing the topic of talk, by asking a series of seemingly (to the patient) disconnected questions. … [T]he cost is a loss of context in terms of how the problem developed (the history and course) and the effects on the patient's life.30

A key theme in this critical literature is trust—especially ‘hegemonic trust’—when the system has colonised the individual's lifeworld so effectively that he or she ceases to question an oppressive situation (eg, when disempowered patients believe that the doctor is very important and should never be challenged or interrupted).32

Socio-technical approaches: the therapeutic relationship as part of a wider care network

An important question about the therapeutic relationship is ‘what is its underpinning logic?’ Philosopher Annemarie Mol has written a seminal book called The Logic of Care, based on a detailed ethnographic study of patient–doctor and patient–nurse encounters in diabetes.13 She argues that healthcare is often driven by an underlying logic of choice—especially informing and supporting the decisions and choices of an ‘empowered’ patient.33

Important though choice is, Mol argues that it is secondary to the core business of clinical care, especially in chronic illness. The logic of care differs in important respects from the logic of choice, not least that it is continuous rather than episodic, affective rather than objective, and sees the clinician and patient as on the same ‘side’ rather than polarised into (say) ‘patient centred’ or ‘doctor/nurse centred’. Whereas in the logic of choice, the focus is on particular decisions made by a rational patient at particular time points, the logic of care emphasises the ongoing, never-ending work from both patient and clinician that goes into the complex task of living with an illness. It also accommodates the irrational, inconsistent and even self-destructive impulses that drive all of us sometimes when we are sick or confused, and lets the patient shift between active and passive as appropriate to their illness and needs.

Mol writes (broadly) from the perspective of actor-network theory—an imaginative philosophical approach which sees people and technologies as linked in complex, ever-changing and inherently unstable networks.34 This conceptual lens, which has some affinity with critical consultation analysis described above (especially, the focus on questioning taken-for-granted assumptions about social relationships), allows the analysis of quality in the therapeutic relationship to move into a more contemporary era—for example, by placing less emphasis on the doctor–patient relationship as the sole focus of care and more on how the wider network of doctors, nurses, receptionists, lay carers and the patient themselves can work flexibly to identify and meet a changing set of needs.