Volumul XIII, Nr. 49 cuprins 49.pdfdin România şi din străinătate, de orice fel de terapie de...

Buletinul AsociAţiei BAlint

Martie, 2011, Volumul XIII, Nr. 49

Periodic trimestrial, apare în ultima

decadă a lunii a treia din trimestru.

Fondat: 1999

Redactor şef: Albert VERESS M.D. Sc.D.

Lector: Almoş Bela TRIF M.D., Sc.D., J.D., M.A.

Tehnoredactor, coperta: Botond Miklós FORRÓ

Editat de: Asociaţia Balint din România

Tipărit la: Tipografia Alutus, Miercurea-Ciuc

Adresa redacţiei:530.111 - MIERCUREA CIUC,

str. Gábor Áron 10, tel./fax 0266-371.136;

0744-812.900

E-mail: [email protected]

[email protected]

Comitetul de redacţie:Tünde BAKA

Doina COZMANDan Lucian DUMITRAŞCU

Evelyn FARKASLiana FODORANU

Ioan-Bradu IAMANDESCUCristian KERNETZKY (D)

Mircea LĂZĂRESCUHolger Ortwin LUX

Dragoş MARINESCUIoana MICLUŢIA

Csilla MOLDOVANAurel NIREŞTEAN,

Iuliu OLTEANGheorghe PAINA

Ovidiu POPA-VELEAAlmos Bela TRIF (USA)

Ionel ŢUBUCANUÉva VERESS

Nicolae VLAD

cuprins

Manuscrisele sunt lecturate de un comitet de referenţi, care primeşte manuscrisele cu parolă, fără să cunoască numele autorilor şi propune eventualele modificări care sunt apoi transmise autorului prin intermediul redacţiei. Decizia lor este necontestabilă. Toate drepturile de multiplicare sau reeditare, chiar şi numai a unor părţi din materiale aparţin Asociaţiei Balint.

Plata abonamentului şi a cotizaţiei se face în cont CEC Miercurea Ciuc, nr. RO26CECEHR0143RON0029733, titular Asociaţia Balint, cod fiscal: 5023579 (virament) sau 25.11.01.03.19.19 (depunere în numerar)Preţul unui număr la vânzare liberă este de 2 EURO/număr la cursul BNR din ziua respectivă. Abonamentele pentru ţările occidentale costă 50 EURO/an, incluzând taxele poştale şi comisionul de ridicare a sumei din bancă. INDEX: ISSN - 1454-6051

prOBLEME ETicE DiFiciLE ALE cErcETĂrii MEDicALE cOnTEMpOrAnE- Almoş Bela Trif, MD, PhD, JD, U.S.A 3

MOViEs’ psYcHOLOGicAL iMpAcT On THE AuDiEncE – WiTH spEciAL rEGArD TO DALDrY’s THE HOurs - Baka Dorottya, esthete of art and literature, Budapest, Hungary 5

BALinT GrOups WiTH HOspiTAL pHYsiciAns- JKjell Reichenberg The Nordic School of Public Health, Göteborg, Sweden 7

EsTABLisHinG A BALinT GrOup FOr MEnTAL HEALTH WOrKErs – THE inALA cOMMuniTY MEnTAL HEALTH EXpEriEncE- Andrew Leggett - Princess Alexandra Hospital, Brisbane, Australia 11

THE MEDicAL cOnVErsATiOn, cOnVErsATiOnAL TEcHniQuEs AnD THE HAnDLinG OF EMOTiOns - C. Höfner, A. Koschier, HP. Edlhaimb, A. Leitner - Danube-University Krems 16

DEscriEri DE cAZuri- Ovidiu Popa-Velea, Bucureşti 26

DEscriEri DE cAZuri- Psih. Irina de Hillerin 27

www.asociatiabalint.ro

2 Buletinul AsociAţiei BAlint, vol. xiii., nr. 49, MArtie 2011

Buletinul AsociAţiei BAlint

Se primesc articole cu tematică le-gată de activitatea grupurilor Balint din România şi din străinătate, de orice fel de terapie de grup, de psiho-terapie, de psihologie aplicată şi de alte abordări de ordin psihologic al relaţi-ei medic - pacient (medicină socială, responsabilitate medicală, bioetică, psihosomatică, tanatologie). Materia-lele scrise la solicitarea redacţiei vor fi remunerate. Buletinul este creditat de către CMR ca prestator de EMC, deci orice articol publicat se creditează cu 25 de credite EMC. Abonamentul la Buletin se creditează cu 5 credite. Re-dactorul şef şi / sau lectorul au dreptul de a face cuvenitele corecturi de formă, iar în cazul neconcordanţelor de fond vor retrimite articolele autorilor cu su-gestiile pentru corectare.

Deoarece revista se difuzează şi în alte ţări, articolele care nu se limitează doar la descrierea evenimentelor ba-lintiene, trebuie să aibă un rezumat în limba română şi engleză, de maximum 10 rânduri dactilografi ate. Lectorul îşi impune responsabilitatea de a face la nevoie corectura rezumatului

Pentru rigoarea ştiinţifi că apreciem menţionarea bibliografi ei cât mai com-plet şi mai corect, conform normelor Vancouver, atât pentru articolele din periodice cât şi pentru monografi i (ci-tarea în text se notează cu cifre în pa-ranteză, iar în bibliografi e se înşiră au-torii în ordinea citării nu cea alfabetică şi doar acei autori care au fost citaţi în lucrare).

Recenziile cărţilor trebuie să cu-prindă datele de identifi care a cărţii în cauză - autorii, titlul, toate subti-tlurile, anul apariţiei, editura, oraşul, numărul de pagini şi ISBN-ul. Se tri-

mite în fi şier separat imaginea scanată a copertei. Se primesc doar materiale trimise pe diskete fl oppy de 3,5”, CD room, memory-stick sau prin e-mail ca fi şier ataşat. Se vor folosi numai caractere româneşti din fontul Times New Roman, culese la mărimea 12, în WORD 6.0 sau 7.0 din WINDOWS.

Imaginile - fotografi i, desene, cari-caturi, grafi ce - vor fi trimise ca fi şiere separate, cu specifi carea locului unde trebuie inserate în text pentru justa lor lectură. Pentru grafi ce este important să se specifi ce programul în care au fost realizate.

Articolele trimise vor fi însoţite de numele autorului, cu precizarea gra-dului ştiinţifi c, a funcţiei şi a adresei de contact, pentru a li se putea solicita exrase. Autorii vor scana o fotografi e tip paşaport sau eseu pe care o vor tri-mite ca fi şier ataşat, sau pe o disketă la adresa redacţiei.

Michael BALINT: Psihanalist

englez de origine maghiară

Data înfi inţării: 25 iulie 1993

Grupul BALINT: Grup specifi c alcă-tuit din cei care se ocupă de bolnavi şi care se reunesc sub conducerea a unui sau doi lideri, având ca obiect de stu-diu relaţia medic-bolnav prin analiza transferului şi contra-transferului în-tre subiecţi.

Specifi cul Asociaţiei: apolitică, ne-religioasă, inter-universitară, multi-disciplinară, de formaţie polivalentă.

Obiective: Formarea psihologică continuă a participanţilor. Încercarea

de a îmbunătăţi prin cuvânt calitatea relaţiei terapeutice medic-pacient şi a comunicării dintre membrii diferitelor categorii profesionale. Rol de “punte” între etnii, confesiuni, categorii socia-le, regiuni, ţări.

Activitatea Asociaţiei:• grupuri Balint,• editarea Buletinului,• formarea şi supervizarea liderilor,• colaborare la scară internaţională.

Cotizaţia se achită până la 31 martie a.c. Cvantumul ei se hotărăşte anu-al de către Biroul Asociaţiei. În cazul când ambii soţi dintr-o familie sunt membrii Asociaţiei, unul din ei poate cere scutirea de la plata abonamentu-lui la Buletinul Asociaţiei, al cărui cost

se stabileşte anual. Cei care nu achită cotizaţia până la data de 31 martie a anului în curs nu vor mai primi Bule-tinul din luna iunie, iar cei care nu vor plăti cotizaţia nici până la data de 31 martie a anului următor vor fi penali-zaţi cu o majorare de 50%!!! Cei cu o restanţă de doi ani vor fi excluşi disci-plinar din Asociaţie.Studenţii şi pensionarii sunt scutiţi de plata cotizaţiei, fi ind necesară doar abonarea la Buletinul Asociaţiei. Co-tizaţia pentru anul 2011 este de 20 EURO (la cursul ofi cial BNR din ziua în care se face plata), în care se include şi abonamentul la Buletin. Taxa de în-scriere în Asociaţie este de 20 EURO (nu se face reducere nici unei categorii socio-profesionale). Abonamentul costă 6 EURO.

BIROUL ASOCIAŢIEI:Preşedinte: Tünde BAKA – [email protected]şedinte: István VÁRADI – [email protected]: Csilla VAJDA-HEGYI – [email protected]: Albert VERESS – [email protected] Membri: Rita-Lenke FERENCZ, Holger Ortwin LUX, Attila MUNZLINGER, Ovidiu POPA-VELEA, Éva VERESS.

cĂTrE AuTOri

prEZEnTArEA AsOciAŢiEi BALinT Din rOMÂniA

RefeRAte

3Buletinul AsociAţiei BAlint, vol. xiii., nr. 49, MArtie 2011

prOBLEME ETicE DiFiciLE ALE cErcETĂrii MEDicALE cOnTEMpOrAnE - Almoş Bela Trif - MD, PhD, JD, U.S.A

Cum anul trecut am fost plagiat de un medic legist din Piteşti, dar am lăsat baltă urmărirea individului, am citit o sumedenie de articole despre frauda ştiinţifică. Unul dintre ele mi-a atras în mod special atenţia (1), iar de aceea m-am hotarât să scriu despre acest fenomen nociv, ce parazitează cercetarea ştiinţifică de pretutindeni.

Ce poate fi mai rău în ştiinţă decât o retragere a unei afirmaţii ştiinţifice care a fost deja preluată şi citată în literatura de specialitate, iar cercetători din lumea întreagă îşi bazează deja raţionamentul ştiinţific şi ipotezele pe date false sau parţial false? Vă recomand cu căldură să parcurgeti listele citate, ca să puteţi înţelege exact la ce nivel se situează frauda ştiinţifică şi unde începe pseudo-ştiinţa.

Numai in ultimul an, 2010, au trebuit retrase aserţiunile false despre: mecanismul semnalizării estrogenilor; cancerizarea celulelor stem; autismul generat de vaccinări; reactomul proteinelor; factorul de întinerire transferabil al celulelor stem de la şoarecii tineri la cei bătrâni, iar lista nu se opreşte aici. (2)

Poate nu întâmplător, cele mai senzaţionale descoperiri au fost intens mediatizate, iar cohorte de amatori, care nu au nimic în comun cu ştiinţa, au diseminat la nesfârşit prin E-mailuri repetate ad nauseum unele din descoperirile care s-au dovedit a fi false, de parcă dumnealor ar fi îndeplinit o datorie de onoare. Din nefericire, unele dintre aceste date false au ajuns să fie prezentate pe diverse bloguri de pe net ca elemente inerent secrete ale cercetării, care vor fi aduse în practică pe viitor, doar pentru beneficiul elitelor.

Se pune întrebarea legitimă: Ce îi face pe oamenii de

rând să accepte cu frenezie gogomăniile pseudo-ştiinţifice şi să dea apă la moară falselor descoperiri?

Un răspuns coerent la această întrebare este dat de Ben Goldacre, tânăr psihiatru britanic, educat la Oxford şi Londra, în cartea lui Ştiinţa greşită şi pe website-ul sau www.badscience.net. El face referiri extrem de detaliate la efectul placebo, la trialurile de medicamente unde cazurile care nu răspund bine sunt eliminate din statistică şi, nu în ultimul rând, la statisticele aşa zis „trase din condei”, unde - la o analiză mai atentă - se poate decela tendinţa de a înşela, pentru ca studiul respectiv să dovedească neapărat, cu orice preţ, Quod erat demonstrandum. (3)

O a doua întrebare ce se impune ar fi: Ce îi face pe cercetători să scoată la iveală asemenea minciuni ştiinţifice!? Voi încerca să vă prezint în continuare nişte răspunsuri aparţinând unor autori care au publicat în acest incomod şi delicat domeniu al eticii cercetării ştiinţifice. Consultând nişte lucrări mai vechi de-ale mele din domeniul bioeticii şi al eticii cercetării ştiinţifice medicale şi pe animale (4); (5), am găsit o minunată referinţă unde se defineşte frauda ştiinţifică (scientific misconduct) ca “orice fabricare sau falsificare de date, plagiat sau orice deviere gravă de la practicile ştiinţifice acceptate, survenită în procesul de a propune, a conduce sau a raporta o cercetare”. (7)

Există un text recent publicat de David Goodstein, profesor de fizică la Institutul Tehnologic din California, care a devenit extrem de repede clasic, fiind citat şi răscitat, mai ales pe Internet (ironic nu-i aşa?) – Despre faptă şi fraudă: Poveşti cu tâlc despre linia întâi a ştiinţei. Autorul

Abstract: Despite the effervescent scientific atmosphere dominating today’s medical world, some flaws

tend to ruin the good intentions of the majority of researchers and academics, working in the most ad-

vanced medical schools, and the most prestigious medical research institutions. The article makes refe-

rence to research misconduct, duplicate publication, and sloppy data analysis, generating data rushed

to publication, followed by the needed public retractions of the untruthful data, published because of a

thirst of glory.

Key words: ethics in medical research, bad science, defining scientific misconduct, scientific retracti-

ons, prevention of scientific misconduct

Rezumat: În ciuda atmosferei de fervoare ştiinţifică care domină lumea medicală de astăzi, câteva racile tind să ruineze bunele intenţii

ale majorităţii cercetătorilor şi profesorilor de medicină, care lucrează la cele mai avansate scoli medicale şi mai prestigioase institute

de cercetare ştiinţifică medicală. Articolul se referă la noţiunile de „research misconduct”, „duplicate publication”, „sloppy data analysis”

(fraudă de cercetare ştiinţifică, publicări redundante, analiză statistică a datelor făcută neglijent şi superficial), care generează publica-

rea pripită a unor date, urmată de necesara retragere publică a neadevărurilor ştiinţifice publicate din setea de glorie.

Cuvinte cheie: etica cercetării medicale, ştiinţă greşită, definiţia fraudei în cercetare, retragerea aserţiunilor ştiinţifice, prevenirea

fraudei în cercetarea ştiinţifică.

4

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Buletinul AsociAţiei BAlint, vol. xiii., nr. 49, MArtie 2011

se referă la lipsa de integritate ştiinţifică, la epidemia de greşeli ştiinţifice trecute cu vederea din neglijenţa sau nepăsarea cercetătorului – insulte directe la însăşi noţiunea de CERCETARE ŞTIINŢIFICĂ, după definiţia ei din dicţionar. Se pleacă de la premiza că integritatea ştiinţifică este elementul de bază a adevăratei ştiinţe, fie că e vorba de o cercetare de laborator, de un trial al unui medicament nou sau de observaţiile unui psiholog - etolog, care studiază comportamentul animalelor. (6)

David Goodstein prezintă cazul lui Marc Hauser, doctor în ştiinţe psihologice, cercetător de frunte în domeniul cogniţiei la oameni şi animale la Universitatea Harvard, care a publicat în 2002 o carte intitulată Moral Minds: How Nature designed our universal sense of right and wrong (Minţile morale: Cum a proiectat Natura simţul nostru universal de bine şi rău). Tot în anul 2002 Hauser a publicat în revista “Cognition” un studiu despre nişte primate (tamarinul Saguinus oedipus), un fel de maimuţici cu faţa şi spatele negre, dar cu o coamă albă ciufulită şi picioarele şi burtica albe. Hauser a stârnit interesul lumii ştiinţifice mondiale, afirmând că acestea animale plăcute la înfăţişare sunt capabile să creeze tipare generale în procesul de cogniţie - cunoaştere, asemenea copiilor mici. În decursul anilor el a fost citat de 38 de ori, dar în august 2010, consiliul ştiinţific al Universităţii Harvard l-a găsit vinovat de opt cazuri de omisiune în cercetare şi fraudă ştiinţifică. În mod necesar a urmat retragerea publică a concluziilor studiului publicat în 2002. (6)

D. Goodstein întrevede trei motive aparente ca răspuns la cea de a doua întrebare:

Mai întâi există presiune generată de carieră – orice cercetător e obligat prin natura muncii lui să publice ceva din cercetarea personală, ca să îşi justifice existenţa. (6) Toată lumea medicală murmură astăzi “PUBLISH-OR-PERISH” – adagio pe care l-am auzit prima oară de la neuitatul Profesor de Fiziologie Ioan Hăulică de la Universitatea de Medicină şi Farmacie din Iaşi – minunat Alma Mater pentru generaţii întregi de medici, profesori de medicină şi cercetători ştiinţifici.

În al doilea rând vine o anumită trăsătură de caracter ce se poate vedea doar la unii cercetători – acei mai ambiţioşi sau cu un surplus de încredere în sine – care cred că ştiu dinainte răspunsul la unele probleme, iar dacă ar sta să demonstreze cu migală ceea ce este de demonstrat, ar pierde timp preţios în cercetare. Ei nu sunt de loc leneşi sau înceţi, ba dimpotrivă, sunt extrem de vioi ca minte, iar de aceea sar peste etapele necesare demonstraţiei, dintr-o necesitate teleologică, de a termina cercetarea cât mai curând. (6)

O a treia explicaţie a lui Goodstein – cea mai dură după părerea mea – a fi că cercetătorii ce lucrează cu experimente greu de reprodus sunt tentaţi – prin însăşi natura muncii lor - să “aducă din condei” datele sau in extremis chiar să le fabrice pe loc. El citează un alt caz extrem, unde un fizician în tehnologia semi-conductorilor organici, aflat în culmea carierei, publica frenetic aşa-zise noi descoperiri, aproape

de la o săptamână la alta. Întreaga comunitate de biofizicieni şi bioingineri care sorbea cu nesaţ cele publicate au fost cutremuraţi şi jenaţi la sfârşit, deoarece nu numai că nu era vorba de nici o descoperire, dar nici vreun experiment nu fusese făcut. (6)

Acum s-ar întrevedea o a treia întrebare: Cât de scump plăteşte comunitatea de cercetare ştiinţifică pentru fraudele ştiinţifice şi cum pot fi prevenite aceste fraude?!

Toţi autorii pe care i-am consultat, nu numai cei pe care i-am citat, afirmă că este greu de imaginat - cu resursele actuale - cât de rău a făcut în lumea ştiinţifică frauda în cercetare. Există însă texte referitoare la prevenirea fraudei ştiinţifice, unde se face clară diferenţa între eroarea ştiinţifică ne-intenţionată şi frauda comisă prin nepăsare sau introducerea intenţionată de date fabricate sau complet false. (7) Metodele de prevenţie ale oricărui forme de abuz în cercetarea ştiinţifică medicală includ ceea ce s-ar putea denumi prevenţie primară – identificarea şi îndepărtarea cauzelor care duc la publicarea prematură de date, la prelucrare incompletă de date sau la publicarea excesivă - redundantă a aceloraşi date. (8)

Prevenţia secundară a fraudelor în cercetare se referă la doua lucruri – pe de o parte la o posibilitate crescută de a descoperi eventuala fraudă, folosind o alternative la statistica iniţială, iar pe de altă parte la aplicare unor sancţiuni acelor care sunt dovediţi că au comis una din faptele listate în definiţia fraudei ştiinţifice. (8)

Bibliografie:

1. R Grant Steen - Retractions in the scientific literature: is

the incidence of research fraud increasing?; J Med Ethics

doi:10.1136/jme.2010.040923; Published Online First 15

November 2010

2. Jef Akst - Top retractions of 2010: A list of the biggest papers

-- and scientists -- involved in retractions in the last year;

Published 16th December 2010 01:12 PM GMT

3. Ben Goldacre - Bad Science, published by HarperCollins

Publishers, Fourth Estate in 2009, 370 pages

4. Trif, A. B. - Ideas and controversies about the role of Bioethics

in passing laws; the consensus conferences, Clinica, vol. II,

nr.5, 1997, p. 43-44.

5. Trif, A. B. - Experiments on Animals – contradictions and

incertitude, Clinica, vol. III, nr.3, 1998, p.46-49.

6. David Goodstein – On fact and fraud; Cautionary tales from

the frontlines of science, Princeton, NJ; Princeton University

Press; 2010

7. Douglas L. Weed, MD, PhD - Preventing Scientific Misconduct;

Health Law and Ethics; American Journal of Public Health,

1998; 88 (1): 125-129

8. Patrick Hardigan, PhD – Scientific misconduct; Focus on

research – NSU – HPD, vol. 4; n. 4, December 2010

RefeRAte


It is common after watching an immersive movie that spectators profess: “It was such a realistic experience!” However, we almost never ask ourselves the question: what could be the reason for the audience living through a visual illusion, a prefabricated semblance, a work of art that is obviously an untruthful picture of reality? The answer does not come as a surprise: identification is the process that makes a psychological empathy appears and a lifelike experience of the story come about in the audience.

To begin from the very beginning, dear reader, think about Your first years when You contacted the world of visual arts, television and movies. Unless Your parents had time to read out fairy tales before going to bed, they played cartoons that made You calm, sleep well and have sweet dreams. Naive, inexperienced, unprejudiced children are even more able to identify with the main characters of the tales they hear or see, and parents purposefully use these means to have the desired optimal psychological impact on them. Moreover, I believe every single person can declare that these early visual experiences had a great impact on their adult lives as well.

As a next and higher stepping stone we have to consider the more developed phase of our lives when our literacy in and attitude towards visual culture became much broader

and much more conscious. Think broadly of the movies you can recall, that had the greatest impact on you. I assume, what’s more, I am certain that to a large degree these movies had an open ending. This constitutes a further method to expand the illusion of the prefabricated story transforming into a personal experience, and, as a consequence, the depth of psychological impact as well.

In addition, commercials constitute a constant participant through our cinematographic perception. It is unquestioned their intentional psychological effect that makes even the non-conscious audience an unconsciously influenced potential consumer. Commercials present Your basic needs in familiar, everyday situations and engaging ways of satisfying these needs. These fundamental aspects of commercials make powerful identification possible and this identification generates feelings and impressions that create the illusion of personal concern.

Finally, I would like to present an example that confirms the psychological creative power of visual fantasy. It has been tested and scientifically proved that when mentally visualizing the process of running the same muscles are stimulated as when going through the physical process of running. This test has also proved the intensified psychological impact of

MOViEs’ psYcHOLOGicAL iMpAcT On THE AuDiEncE – WiTH spEciAL rEGArD TO DALDrY’s THE HOurs * - Baka Dorottya - esthete of art and literature, Budapest, Hungary

Abstract: It happens frequently after having seen an immersive movie that we feel it has offered us a real

experience. This experience points at the basic effect of this genre of visual arts: the identification. Our minds

visualize the generated thoughts, which do also generate feelings in us. The extent of identification depends on

the realism, proximity of the visually represented sphere, and on the level of verisimilitude. The natural flow

of our thoughts received its greatest fulfillment in the stream of consciousness method of writing, whose main

representative in English literature has been Virginia Woolf and her work entitled Mrs. Dalloway. Daldry’s

creation constitutes the visual reconstruction of this flow-like method, revolutionizing the relationship

between viewer and creation, receiver and creator to an extent that completes identification, and the movie’s

atmosphere pervades the audience’s psychological dimensions.

Keywords: Stephen Daldry, The Hours, identification, stream of consciousness

Rezumat: Ni se întâmplă des ca după vizionarea unui film artistic reuşit să avem sentimentul că am avut parte de o reală experienţă.

Experienţa pune în evidenţă acest efect fundamental al acestui gen de artă vizuală: identificarea. Mintea noastră vizualizează gândurile

care s-au generat, iar acestea la rândul lor dau naştere la sentimente. Măsura identificării depinde de realismul, proximitatea sferei

reprezntate vizual, şi de nivelul verosimilităţii acesteia. Fluxul natural al gândurilor noastre s-a împlinit cel mai din plin în stilul de

scriere numit „stream of consciousness”, al cărui reprezentant principal a fost scriitoarea engleză Virginia Wolf cu opera sa intitulată

Mrs. Dalloway. Reconstrucţia vizuală a acestei metode scris flow-like, este opera lui Stephen Daldry, care revoluţionează relaţia

dintre spectator şi creaţie, receptor şi creator până ce identificarea devine completă şi dimensiunile psihologice ale spectatorului se

impregnează în totalitate cu atmosfera filmului.

Cuvinte cheie: Stephen Daldry, The Hours, identificare, stream of consciousness

6

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movies considering the fact that in their case the visualization is facilitated by the ready-made visual material that the viewers adapt to their own imaginative sphere.

So we have affirmed that psychological impact depends on the possibility of identification. Furthermore, identification depends on whether the viewer’s mental sphere and the movie’s audiovisual dimensions and its epic thread share some common features. As a consequence, the extent of identification is defined by the forcefulness of these overlaps between the personal and the visually represented worlds.

We have reached the point when You could ask me: why Daldry and why The Hours? My argument’s roots go back even to the early 20th century modernist literary stream in English literature. The main representative of this period was Virginia Woolf with her stream of consciousness method of writing. This method imitates the natural flow of thoughts occurring randomly in the human mind, and creates their almost mechanic documentation. Mrs. Dalloway is the novel that wonderfully exemplifies this revolutionary way of expression, and Stephen Daldry’s The Hours constitutes the adaptation that proves to be capable of adapting the stream of consciousness method onto a totally different medium, of creating a natural visual flow of Woolf’s mental processes. This later ability results in the viewer’s revolutionary position: Daldry invites the audience to take an active part in the process of creation of the central literary work, of Mrs. Dalloway itself.

As a further point You could ask me to justify the later assumption, and I will gladly do it for you. Henceforward I am going to present You the main items that confirm the permanent presence of the stream of consciousness method throughout Daldry’s visual work – getting closer to the viewer’s natural flow of thoughts, presenting them the process of a creation instead of the ready-made work, stimulating them to adapt the visual sphere to their own mental dimensions, think together, and receive as if the mental process took place in their own minds. These will also

lead You to the conclusion that the movie provides us with the possibility of an unexpectedly high level of identification and thus of a great degree of psychological impact.

First and foremost we have to consider the authentic biographical aspects of Daldry’s work. I suppose the audience has the basic background information about Virginia Woolf’s mental illness, her homosexual preferences, her remarkable contribution to English literature, and her final, tragic suicide. In addition, the audience is also supposed to be aware of the basic plot of Mrs. Dalloway. The main character, Woolf, and the basic epic line is familiar thus, and it facilitates the deepened reception.

Secondly, the plot is also familiar: an ordinary day in an ordinary housewife’s life. All of us go sometimes to buy flowers, cook, make the preparations for a party, love, and feel loved. In this way Daldry does also facilitate the mental visualization for the viewer, and presents him/her a situation that he/she does not have to interpret, reconstruct and adapt, but only to evoke, to pick out from a bracket of the mind.

Leonard Woolf tells Virginia:”Work then!”, and at this moment he does also make a call to the audience: identify with the omnipotent author and create the work, create the story, make the decisions, choose the characters, choose between alternatives, create the movie itself! Be part of it and create it Yourself!

In order the active audience to perceive its omnipotent position to a higher degree, Daldry does also provide them with a subjective perspective: when Virginia’s perspective is presented, we see the happenings from a higher angle. All of the characters live on the ground floor, together with their family, while the artist, the creator, and at the same time the audience as well live on the first floor, from where they can glance down, follow the happenings, the storyline from an outsider’s position, make the decisions, shape the epic span, see everything, know everything, and feel the omnipotence of a narrator’s point of view. Characters move in their own sphere, and actions happen in a random way, illogical changes are made that are not characteristic of a traditional plot. On the contrary, they are sudden decisions of a narrator whose thoughts are in a constant flow. The viewer experiences the visual work from Woolf’s position, and her creative mental process becomes adapted to the viewer’s own mental sphere. Identification happens, and we suddenly find ourselves in the body of an all-mighty author. We are creating the work, and we do also feel every single feeling occurring in Virginia’s psyche. We see, we feel, we create. The position of the traditional passive receiver gets transformed into an active initiation and identification.

The authenticity to become fulfilled the end of the movie provides us with a mythical sacrifice: Woolf commits suicide, so she has to sacrifice her alter ego, the poet, the visionary as well. She makes a decision: the poet has to die, Richard, in order each and every connection to be confirmed.

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BALinT GrOups WiTH HOspiTAL pHYsiciAns* - Kjell Reichenberg - The Nordic School of Public Health, Göteborg, Sweden

Abstract: The paper describes a study with 132 hospital physicians participating in Balint groups, lasting

from ½ to 4½ years. The physicians were senior registrars and junior consultants in non-psychiatric

department at a large university hospital. 5-8 physicians in 19 groups met for 90 minutes every other week.

Participants were invited to reflect upon how their personal situation affected their professional duties as

doctors and, conversely, how their professional duties touched upon personal issues. Key words: doctors’

professional duty, doctor’s personal issues, mutual interference between professional and personal life

Rezumat: Articolul descrie un studiu pe 132 de medici de spital care participau deja la grupuri Balint, cu

vechime de la 6 luni până la 4 ani şi 6 luni. Medicii aveau diverse poziţii la unele departamente ale spitalului

separate de departamantul de pshihiatrie. Participanţii au fost rugaţi să descrie cum situaţiile lor personale influenţează datoria lor

profesională ca medici, iar apoi cum activitatea lor profesională afectează viaţa lor personală.

Cuvinte cheie: datoria profesinaă a medicilor, situţiile personale ale medicilor, interferenţa reciprocă între viaţa profesională şi cea

personală

The development from a newly graduated doctor into a hospital specialist consists not only of improvement within one's own subject and enhancement of practical skills. The individual doctor becomes responsible for representing her or his own speciality at other clinics. Organisational changes mean doctors must also represent the medical profession in discussions about leadership and in disputes with other professions and they must learn to exchange views with the hospital administration.

In many cases, their period of clinical training coincides with research education and, later, responsibility for leading independent research projects. The process of becoming

a self-reliant hospital doctor often occurs at a stage of life when marriage and other changes in family situation are also taking place.

The object of this paper is to contribute to the understanding of how hospital physicians together reflect upon issues arising in their clinical encounters and upon challenges in their roles as members of staff in the hospital and clinical teams.

MethodsThis paper analyses a project with 132 hospital

physicians participating in Balint groups, lasting from ½

The protagonist dies, her alter ego is sacrificed, and – considering the total identification -, the audience becomes able to experience the catharsis, see the death, feel the death, experience the death, then rise above the tragedy, exit the scene, and become purified by the transcendental power of a tragedy experienced directly by identification, but at the same time being aware of the receiver’s position, the constant ability to move apart and regain the initial conditions.*This is an extract of the Thesis paper entitled: ”Mrs. Dalloway and The Hours”

References:

1. Abel, Elizabeth: Virginia Woolf and the Fictions of

Psychoanalysis, Chicago: The University of Chicago Press, 1989

2. Adoptációk: Film és irodalom egymásra hatása, Szerk. Gács,

Anna & Gelencsér, Gábor, Budapest: Kijárat Kiadó, 2000

3. Bennett, Joan: Virginia Woolf: her art as a novelist,

Cambridge: Cambridge University Press, 1964

4. Cunningham, Michael: Az Órák, Ford. Tótisz András, Budapest:

Ulpius-ház Könyvkiadó, 2002

5. Guiguet, Jean: Virginia Woolf and her Works, London: The

Hogarth Press, 1965

6. Kovács, András Bálint: A film szerint a világ, Budapest:

Palatinus, 2002

7. McFarlane, Brian: Novel to Film. An Introduction to the Theory

of Adaptation, Oxford: Clarendon Press, 1996

8. Woolf, Virginia: Mrs. Dalloway, Ford. Tandori Dezső,

Budapest: Magyar Helikon, 1971

9. Zsigmond, Adél: „A filmes adaptáció, mint értelmezői művelet”,

in: Látó, 2010. Február. Net. 2010.10.19.

Filmography: The Hours. Dir. Stephen Daldry. Perf. Meryl

Streep, Julianne Moore, Nicole Kidman. Miramax International &

Paramount Pictures, 2002. DVD.

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to 4½ years. The physicians were senior registrars and junior consultants in non-psychiatric department at a large university hospital. 5-8 physicians in 19 groups met for 90 minutes every other week. Participants were invited to reflect upon how their personal situation affected their professional duties as doctors and, conversely, how their professional duties touched upon personal issues and development. Balint leaders were psychologists or physicians with training in psychotherapy.

There are two main sources of analysis. The first one is notes from 150 instances when 2-4 Balint group leaders, together with an outside supervisor, met to consider the developments within the Balint groups some 10 groups. The second one is the author’s own field notes from 171 sessions in 5 Balint groups who met from 18 to 65 times. The author is a paediatrician who has training in psychodynamic and systemic therapy with experience of counselling ill children and their families and of conducting research in families that are coping with chronic illness.

The analysis started following a qualitative methods tradition with the aim of finding concepts useful for describing how hospital specialists reflected on becoming and being a hospital specialist. Coding was performed using everyday terms denoting feelings, reactions, thoughts, relations and ideas such as "anger", "pride", "undoing", "loyalty towards colleagues" and "justice". The code words were combined into concepts. Early in the stage of analysis, the concepts of contexts of cases, triggering incidents for the cases presented and main themes in group discussions were found in a report from medical student Balint groups [1]. These concepts were found useful in making sense of the material and were used as three headings in the analysis.

Time process, being a recurrent theme in the supervision of the Balint leaders, were used as the fourth heading. Groupings among main themes in group discussions were formed inductively. An iterative approach was used, comparisons between previous theory, such as that of transference and counter-transference, were used alternately with reading of the field notes and forming new groupings of concepts and conducting discussions with research colleagues. An aim is to use terms as defined in the fourth edition of Diagnostic and statistical manual of mental disorders from the American Psychiatric Association, DSM-IV-TR [2].

ResultsThe context of the professional situation of the hospital

physicians, as told by members in the groups, is described. Then I tell how triggering incidents and aspects of cases that the Balint group members reflect upon in the groups can be related to the professional context, then how themes of the group discussions can be connected to triggers of the specific professional context and, lastly, how the temporal process

as to presenting cases and reflecting upon organizational matters in the groups can be understood.

Contexts of casesThe contexts of the presented material were: limited

freedom to decide and take responsibility in critical matters of patient care, downsizing of hospital staff due to economic decline, the tribulations of struggling with members of the hospital team, physicians losing initiative to other professional groups in both biomedical research as well as health research with a qualitative approach and working hours well beyond what is considered normal.

Triggering incidents for the cases presentedEvents that triggered presenting cases – episodes from

professional life or private experience were: appreciation of the varied experiences of patients and their families, personal reactions in clinical encounters that were difficult to understand, being disregarded by superiors, being tasked with acknowledging non-physician staff's abilities and demands from family members to participate in family life.

Main themes in group discussionsThemes grouped according to content were demands

of being competent and constantly available to patients and colleagues, building professional identity, hospital physicians’ being trained to always being able to present an action as response to a clinical challenge or dilemma, getting tired of patients with a chronic illness, the death of young patients, the discovery that elder colleagues not necessarily express maturity but rather lack of independent thinking and shallow emotional reactions, patients demanding more and more of expensive and unnecessary diagnostic procedures, the pain of acknowledging that there are patients who prefer another doctor, envy towards colleagues with a happy appearance who seem to be able to combine clinical excellence, research originality and a rich personal life.

Temporal processWith time, four processes were seen in the groups.

Firstly, the members of the group moved from training and organisational matters to questions of personal reactions and contributions in the clinical encounter. Secondly, it became more possible for the Balint group leader to use the terms transference and counter-transference, or their every-day language equivalents. Thirdly, group members became increasingly aware of the opportunity to understand their reactions in patient encounters as defence mechanisms against emotional involvement, mechanisms such as isolation, intellectualization, rationalization, humour and suppression. Fourthly, the members of the groups developed their ability to use each other for guidance, relief and comfort.

Factors rendering it difficult for a group to move from organisational matters to case-oriented reflections were members missing sessions, especially unannounced absence, groups where members happened to share responsibility for the same patient, a member being promoted to a superior

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in the hierarchical hospital system and groups leaking information to outsiders, or raised suspicions of this being the case.

Discussion and conclusionThe analysis yields results similar to those reported from

a resident training programme, participants moving from a wish to discuss optimal training chances to reflecting on, in psychoanalytical terminology, transference and counter-transference [3].

What are the differences between the ways in which hospital physicians reflect in a Balint group setting to that of general practitioners? How can these differences be explained?

While general practitioners are prepared to utilize the Balint case approach, hospital physicians seem to require a number of initial sessions for discussing what constitutes good clinical training and organisational obstacles to good clinical practice. They need to discuss their own situation of being subordinates and being given roles to support the professional demands of other groups before being able to reflect upon their own and the group members' personal reactions in clinical encounters. A similar process is reported from a group of residents training to become general practitioners [4]. Hospitals are hierarchically organized and physicians have simultaneous duties as both medical specialists and team-workers with other professionals. This situation, together with feelings of limited influence over leadership, conveys attention in the Balint groups to areas of transference and counter-transference in the working group and the organization rather than upon these phenomena in interactions with patients and their relatives.

Hospital physicians lack the general practitioner’s tradition with its attention to one’s own personal importance in interaction with patients. Thus far there has been no movement equivalent to that of general practitioners’ new professionalism [5]. This new professionalism comprises "nice work", which is characterized by a toning down of vocational training, putting to rest the idea of the role of doctor as a calling and an ability to enter into dialogue with patients in a less paternalistic manner than before.

*This paper was presented at the 16th International Balint Congress, Poiana-Braşov, România

References

1. Torppa MA, Makkonen E, Mårtenson C, Pitkälä KH. A

qualitative analysis of student Balint groups in medical

education: contexts and triggers of case presentations and

discussion themes. Patient Education and Counselling 2008;

72: 5-11.

2. Diagnostic and statistical manual of mental disorders: DSM-

IV-TR. Washington, DC: American Psychiatric Association,

2000.

3. Smith M, Anandarajah G. Mutiny on the Balint: balancing

resident developmental needs with the Balint process. Family

Medicine 2007; 39: 495-7.

4. Merenstein JH, Chillag, K. Balint seminar leaders: what do

they do? Family Medicine 1999; 31:182-6.

5. Jones L, Green J. Shifting discourses of professionalism: a

case study of general practitioners in the United Kingdom.

Sociology of Health and Illness 2006; 28: 927-50.

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BETWEEn riTuALs AnD pLAY: OrGAniZinG AnD LEADinG BALinT GrOups in A GEnErAL HOspiTAL* - Yuval Shorer - Israel

Rezumat: Articolul e un eseu ce işi are originile în practica de zi cu zi. El abordează denominarea instrumentelor de lucru şi grijile

leaderului de grup în practica Balint. Se face o paralelă cu situaţia în care medicii delegă surorile medicale să invite afară din secţie

familiile bolnavilor, înainte de inceperea vizitei medicilor, în loc să o facă ei înşişi. Autorul susţine că grupurile “de tip Balint”, deşi

oarecum diferite, sunt croite dupa aceaşi paradigmă Balintiană. El crede că este posibil să se onoreze regulile organizaţionale pe de o

parte şi să se uzeze de creativitate, în acelaşi timp. El vede aceasta posibilitate prin eliberarea de regulile ierarhiei prestabilite, în aşa fel

încât să existe un grad de libertate de mişcare în sistemul total de reguli.

Cuvinte cheie: ritual, grup Balint, medici, surori medicale, vizitatori, familia pacientului

Abstract: This article is an essay rooted in everyday’s practice. It treats about the names of instruments of work and leaders’ procedural

concerns in the practice of Balint group. There is a parallel made with doctors delegating to the nurses some of the most inconvenient

gestures toward patient’s families. The author maintains that the “Balint-like groups” are somewhat different, yet similar to the Balint

paradigm. He things that it is possible to bridge the gap between honoring organizational rules on the one hand, and expressing

creativity on the other hand, by trying to free ourselves from the hierarchical rules, so we can find our way to freely play within the

constrictions of the system.

Key words: ritual, Balint group, doctors, nurse, visitors, patient’s family

The consulting psychiatrist is received by the hospital team with ambivalent feelings: on the one hand the team assumes that he-she can solve all the psychological problems of patients, while on the other hand, he-she is considered to be a stranger to the ward. "What are your tools?" they often ask, "Can you help us, the staff, too?" are two "ritual questions" welcoming the consulting mental health professional. As far as "globalization and the creative freedom" is concerned, the feelings of the mental health worker as he-she consults with the wards is like moving out of the provinciality of mental health where there is legitimization for both the expressive enterprises and the expression of feelings, to the huge "Globus"- the pulsating world of the general hospital. Here there are different, more confined and often restrictive rules. So how can one change this professional milieu into a playground for creative expression? Perhaps one way is forming a Balint group, which is to play without threatening the unwritten directives.

Rituals are behaviors that people or groups need emotionally. In rituals, there is both the covert as well as the overt public messages, such as in confirmation or Barmitzvah ceremonies. Then there are also personal rituals (like in OCD) or group rituals that may be hidden. We, as Balint leaders, have our rituals too: abiding by the strict rules of the organization, defining the place of our groups and the time frame in which the groups are held. Then we carefully select the members of our groups, seeing that they do not work together in the same system, without the boss, carefully differentiating between informative questions in the group and taking careful note of the emotional involvement of the group members. We also confine and avoid exposure of too

much or too deep personal/family dynamics, although we may not have explicitly requested this from the group.

I ask: what is the interplay between Balint leader's rituals and staff/ system rituals in group forming and conducting groups in a hospital setting?

This question arises after our experience in leading Balint groups for nurses and paramedical professionals in a general hospital in the south of Israel over the past five years.

Rituals involved in building a team in the general hospital:We try and identify health professionals from the various

sectors who want help, often during informal meetings in the" corridors of the hospital". These professionals, together with us, serve as catalysts for change. Through them, we attempt to seek the blessings of senior management, when we try and adapt our needs to theirs, for example where the group will be held and its time frame.

The ritual of "choosing the name" and the "working tools" expressed in a Balint group in the general hospital:

Our colleagues in the system are interested and inquisitive about our "working tools." They may therefore seek ways to help them cope with difficult families and patients. This leads us to redefine the group in this setting: “Me and the family at work” (double significance) is a broad subject in one of our groups which led members to talk both about their patients' families, as well as about their own. For example, a nurse told us of a family that was not satisfied with the room that the patient was allocated, blaming the nurse: "You would not behave that way towards your own father". She felt offended and hurt, and the discussion followed in the CBT and family therapy modes of how this criticism affected her so personally: her absolute need to be perfectly OK and to

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satisfy everyone, all the time, on one hand, and the family messages she received from her father before she chose her profession on the other hand. In this case, the utilization of role-playing helped to illustrate the problem. The use of a wide range of psychotherapeutic approaches help openness and experiential learning within the group and also tones down the exclusivity of the psychodynamic approach on which Balint groups were founded.

Rituals that are seen within the Balint group itself: Implicit rituals in the ward. The nurse mentions the ritual of the doctors’ ward round. “Every morning the doctors ask us to discharge families from the ward. This is not my job! Why does he take advantage of us?" We looked at the doctors' ward round as a permanent ritual, which has both overt and covert messages. The doctors, from their part, want calmness during the round. They claim that families may interfere with the process. Yet can this practice not be broken? Perhaps one member of the family can be present during this almost "holy ritual" and provide relevant information to the team? In the

group discussion, different ways of breaking this inbuilt ritual are discussed.

The nurses frequently complain of task over- load which lead to discussion about over responsibility they take, both at work and at home. This" ritual –complaining" towards "the system" was playfully, softened, when we read to them an imaginary letter from their "invisible group partner"- the doctor. Here the imaginary physician praises their dedication, but asks to discuss, as work partners, issues with them. In this way, the narratives enriched the group work.

In summary: These changes made our "Balint- like groups" somewhat different, yet similar to the Balint paradigm. I maintain that it is possible to bridge the gap between honoring organizational rules on the one hand, and expressing creativity on the other hand, by trying to free ourselves from the hierarchical rules, so we can find our way to freely play within the constrictions of the system.


Inala Community Mental Health services a population of approximately 200 000 people in the southwest of Brisbane, a subtropical east coast Australian city of 1.75 million people, most of whom live in detached timber or brick houses in suburbs that sprawl out on either side of a wide meandering river that opens on to Morton Bay, separated from the Pacific Ocean by the world’s largest sand islands. Inala, prior to settlement by ten pound British immigrants in the 1960s, had a substantial indigenous population. From that time, the name of the suburb, which was isolated in a semirural setting some 25km from the CBD, with poor access to public

transport, came to be despised and associated with social disadvantage.

Since the 1960s, successive waves of immigrants have settled there in low cost housing, and a community of pensioners and unemployed people have come to populate the public housing projects and privately owned caravan parks that have proliferated in the area. The largest buildings are a shopping complex known as Inala Civic Centre, Centrelink (the Australian government’s social welfare agency) and the Inala Community Health Centre, the ground floor of which is shared by the Community Mental Health

EsTABLisHinG A BALinT GrOup FOr MEnTAL HEALTH WOrKErs – THE inALA cOMMuniTY MEnTAL HEALTH EXpEriEncE* - Andrew Leggett - Senior Lecturer in Psychiatry, University of Queensland

School of Medicine, , Senior Staff Specialist Psychiatrist, Princess Alexandra Hospital, Brisbane, Australia

Abstract: The paper describes the context in which a new Balint group for mental health workers arises in a suburban Australian

community clinic, the process of the formation of the group and the evolution of the first five group meetings. The author expresses his hope

that the group might serve to ameliorate the tendency to demoralisation of mental health workers engaging with their clients in a setting

of socioeconomic disadvantage and cultural diversity.

Key words: immigrants, English as a second language, multiculturalism, sensitivity to cultural differences, taking offences

RRezumat: Articolul descrie contextul în care un nou grup Balint pentru personalul de sănătate mintală ia fiinţă într-o comunitate

suburbană din Australia, procesul de formare al grupului şi cum s-au desfăşurat primele cinci şedinţe de grup. Autorul speră că grupul

poate fi folosit la ameliorarea tendinţei de demoralizare a personalului de sănătate mintală care lucrează cu pacienţii lor aflaţi în condiţii

socio-economice dezavantajoase şi aparţinând la medii culturale diferite.

Cuvinte cheie: imigranţi, limba engleză învăţată ca o a doua limbă, medii culturale diverse, înţelegere pentru deosebirile de cultură, ase simţi jicnit

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Service, the Indigenous Health Service and the Alcohol, Tobacco and Other Drugs Service. Upstairs is the University Of Queensland School Of Medicine’s general practice clinic, established in the 1970s by the Whitlam Labor government as a research centre for socialised family medicine.

Other legacies that reformist government gifted to the Australian people included free tertiary education and universal health insurance, gradually eroded by subsequent governments into generously subsidised user-pays systems. The reforms still prevailed when I entered medical school, and contributed to the culture of hope and generosity within which I was taught primary care medicine as an undergraduate at the Inala Community Health Centre.

While Balint groups were not a part of our undergraduate program, Michael Balint’s emphasis on psychological medicine and the doctor-patient relationship were taught and practised, and The Doctor, His Patient and the Illness and The Fifteen Minute Hour were textbooks supporting our curriculum

Twenty-four years after completing my undergraduate final rotation in Community Practice, and after 16 years in private practice as a consultant psychiatrist and psychotherapist with postgraduate trainings in psychiatry, psychoanalytic psychotherapy and creative writing, I returned to public sector practice in order to increase my involvement in teaching and training, obtaining a permanent appointment as Senior Staff Specialist at Inala Community Mental Health.

I found that in spite of those waves of poor migrants, Inala remained a long way from the ocean; that Michael Balint had been forgotten; that the second hand clothing shops at the Civic Centre had been replaced by rows of Vietnamese greengrocers; that one of the many forensic patients in my outpatient practice had attempted to burn down Centrelink and the Civic Centre; that the only place to park my car was at the roadside next to the park in which a young woman had been recently murdered and from which a drug-crazed man wielding a samurai sword had been taken to the hospital to which my patients are admitted; and that patients discharged from other services were prone to attend demanding attention by drawing their machetes.

I found myself working with a team of idealistic mental health workers bearing the appellation of ‘case managers’ – nurses, psychologists, social workers and occupational therapists, struggling to sustain hope in their capacity to benefit their clients in spite of their heavy caseloads, but mostly espousing devotion to a highly medicalised model of intervention. When I was not involved in direct clinical assessments, which were always performed jointly with the case managers, I found them to be hungry for support and advice, especially that which facilitated psychological insight into their clients’ problems, and that which left room for explanations of the failure of medical treatment other than for the wrong psychiatric diagnosis, medication dose reductions,

the patients’ perversity or the case managers’ incompetence. Initially I found myself rerolled, deskilled and regarded with suspicion as though I either must be joining them because I was too gormless to make a go of private practice, or else I might be sent there as the sinister agent-messenger of the corporate Big Other.

In spite of this, I found myself constantly mobbed for advice, with consultations often sought in the corridors and tremendous pressure exerted to provide solutions without prior knowledge and outside of the context of the careful development of a therapeutic alliance. One day I found myself hunting for a patient file at the back of a large compactus in the administration area. Two of the case mangers blocked the exit and simultaneously began their agitated narrations of their clients’ woeful situations. I had a panic attack. In its aftermath, and that of my first Balint group leadership training workshop, I resolved to offer the case managers the opportunity to receive a kind of supportive intervention very different to that which they were accustomed – the possibility of receiving regular peer supervision and support focussed on consideration of the direct experience of the clinician-client relationship in the context of Balint group.

I broached the idea with our team leader, a nurse manager with extensive prior experience as a clinician in emergency psychiatry, a woman whom I had observed to have considerable capacity for emotional containment, and for approaching stressful situations in a calm and thoughtful manner. She was curious to know what the leadership workshop that I had recently attended might be about, and listened attentively to my explanation of the Balint group process and its historical relationship to the ideology that had sustained the Inala Community Health Service in its earlier years. She agreed that I should offer the possibility of forming a Balint group to the case managers at our next team meeting, and responded positively to my request that she join me as a co-leader for the group, initially by time keeping and debriefing with me after each session.

I suggested that I would welcome her more active support and intervention as she gradually became accustomed to the process. At the team meeting, there was considerable interest in the idea, and six or so of the case managers expressed their intention to join the group, with a few others expressing ambivalence. One raised the potential problems arising out of clinicians with different trainings and expertise, and potentially antagonistic ideologies attempting to join in supervision as peers. Others seemed to view the plan as potentially subversive of existing vertical hierarchies within the corporate culture of the health service. I could say nothing to allay this latter anxiety.

I suggested that we should meet fortnightly for an hour-long presentation and discussion of a single case, focussing on the psychological aspects of the case, especially on the case manager-client relationship. The first three meetings were arranged to immediately follow the team meeting on

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Wednesday mornings, in a timeslot usually set aside for staff development and training. The first meeting was well attended, but there was a long silence before one of the participants offered to present a case. In this meeting and the next, I noticed reluctance on the part of the presenters to talk about their own feelings, with some cautious testing of the consequences of expressions of frustration related to disempowerment.

I attempted interventions that encouraged imaginative discussion of the feelings and thoughts of those the case managers believed were powerful in relation to them and their clients, usually the senior medical staff, among whom I was numbered. I found some of the defensive responses painful, including those to the effect that whatever our clinical director might have to say about the situation, it would be right. The case manager’s fear of saying something that might be construed as subversive or disrespectful awakened in me wishes to transgress in just such a fashion, wishes that I attempted to consciously acknowledge but to refrain from overtly enacting. There were moments when I had to remind myself of the potential benefits of neutrality and restraint in leadership, traits that I admired in my co-leader, new as she was to the Balint process.

The third Balint group meeting fell outside of the intended fortnightly sequence, due to me being required to participate in a corporate orientation process that followed my appointment to permanency. Only one of the case managers attended. The team leader and I offered her a joint supervision of the case that was troubling her. It is impossible to conduct a Balint group with only one participant. I found this experience quite demoralising, but after debriefing with my co-leader, I raised the issue again at the team meeting, where most of the case managers expressed their continuing interest, but raised various concerns about the timing of the meetings, and their difficulties attending when pressed by other commitments. I empathised with these difficulties, and announced the need for a change in the timeslot for the group, as much due to changes in my schedule as due to the problems with theirs.

We settled on an early Tuesday morning time as the alternative and agreed to meet fortnightly. My clinical director, although he was not familiar with the Balint process, supported it by publicly announcing to the team that the Balint group was to be considered a compulsory part of the professional development program. I had previously emphasised the voluntary nature of the commitment, but I appreciated this expression of support, and I was relieved to find that the first meeting at the new time was well attended, and that the presenter, a nurse in his thirties whom I had noticed as having a capacity for calm and sound clinical judgement in emergencies, began his presentation by acknowledging his feelings of demoralisation and frustration in relation to the patient whose care he was discussing, a 22

year old man born in New Zealand (from whence one in six residents of Brisbane have originated) to Polynesian parents who had migrated there from Pacific Islands further to the north.

The presenter told us that he had been called to advise and assist the previous day after the patient’s parents had called the police to pick up their son from the park where he had spent the morning lying out in the sun sniffing petrol, across the road from the family home, within eyeshot of his mother, who became too distressed to be able to bear to watch him any longer. The patient had a four year history of schizophrenia in which the onset of positive symptoms including command hallucinations, disorganised thinking and behaviour had followed a period of gradual deterioration involving increased impulsivity, massive weight gain, lethargy and turpitude, punctuated by outbreaks of petty crime and the progressively relentless abuse of psychoactive substances including alcohol, cannabis, amphetamines and inhalants. The patient had no interest in his case manager’s efforts to involve him in social and rehabilitative groups and to refer him to the drug and alcohol service. When the patient had been hospitalised, his condition had considerably improved with antipsychotic medication and enforced abstinence from substance abuse, but he rapidly relapsed each time he was discharged from hospital, in spite of his compliance with medication being ensured by fortnightly depot intramuscular injections.

When asked by another member of the group about what he thought motivated the patient’s petrol sniffing, the case manager responded that he thought that it was the pursuit of pleasure to the exclusion of all other goals, that his patient seemed oblivious to the mental anguish that his actions caused his mother, the impotent rage that they aroused in his father and the feelings of frustration, helplessness and futility experienced by his case manager.

After the presenter told the group about the case and a period of factual questions from the group followed, I invited him to push back and observe the process in silence until invited to rejoin the group for the last ten minutes. The patients we work with are a culturally diverse group, as are the clinicians who make up our team. Case managers of indigenous Australian, Chinese, Vietnamese, Persian, and Anglo-Celtic Australian backgrounds have participated in the Inala Balint group, including several for whom English is a second language. Sensitivity to cultural difference is one of the team’s strengths. The discussion did not go far before the issue of the difficulty of making a culturally attuned response to the problems the patient presented to his family, his case manager were raised, as was the marginal position he had taken up with respect to the community within which he lived. A lot of sympathy was expressed for the patient’s mother, and the cultural meaning of eating and growing big was speculated upon. The intervention I offered in response

16

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to this was to ask the group to imagine what the patient’s father might want to say to the group about the problem. When the case manager rejoined the group, he was able to express more of his frustration and demoralisation, and to put words to his sense of being entirely at a loss as to how intervene helpfully.

After the group, I had half an hour to debrief with the team leader and address other administrative issues before seeing my first patient for the day – the patient who had been presented to the group and whom I was meeting for the first time today, jointly with his case manager, for the purpose of making an assessment and preparing a report regarding the relationship of his illness to his recent offending by driving without a license. Two days later the case manager approached me and told me about the fresh approach he had taken in dealing with the patient’s family – asking them how the patient’s problem would have been dealt with had it arisen in a traditional village setting on the island they had come from. This resulted in a family decision to take the patient back to that island for a holiday and seek the advice and assistance of community elders.

Between the fourth and the fifth meetings of our new Balint group, a malfunction in the air condition caused water to leak into the ceiling of our clinic, which collapsed into one of our consulting rooms. Somehow the emergency

repairs were negotiated without the presentation of a formal business case, in spite of Christmas coming. At the fifth meeting today, I noticed that the presenter launched readily into talking about how he had been touched emotionally by the response of a schizophrenic patient with a history of violent sexual offences when the case manager had passed on to the patient a Christmas gift donated by a charitable organisation. A discussion of the emotional difficulties case managers encountered in dealing with the many patients we manage who have a history of violent offending. When I began my clinic after the group this morning, I found that once again my first patient was the one chosen for discussion in the group, and the presenter and I were working together with the patient as a treating team, both of us having to negotiate a rapid switch in roles. The possibility occurs to me that a pattern is emerging, but two fish do not constitute a school, and I will endeavour to keep my mind open to the possibility of something different all together coming out of our next Balint group meeting, trusting that while the ceiling of the clinic may cave in, the sky will not fall on us. We will continue with our work, and not be crushed.


THE MEDicAL cOnVErsATiOn, cOnVErsATiOnAL TEcHniQuEs AnD THE HAnDLinG OF EMOTiOns* - C. Höfner, A. Koschier, HP. Edlhaimb, A. Leitner - Danube-University Krems; Department for

Psychosocial Medicine and Psychotherapy; Krems; Austria

Abstract: Medical Treatment from a holistic point of view, in terms of psychosocial and psychosomatic intervention, always consists of

inter-subjective processes between doctor and patient. This is consistent with Balint’s idea that by far the most frequently used drug in

general practice is the doctor himself. Therefore, it is a primary goal of the advanced training in psychosocial and psychosomatic medicine

to enable the doctors to perceive, understand and treat their patients in a more complex way than only from a somatic perspective. A

considerable instrument to achieve this goal is a communication, which allows the patients to bring in their own points of view, their lively

experience and their feelings as completely as possible. We investigated the doctor-patient interaction within a controlled intervention

study before and after the practitioners attended an advanced training course in Psychosocial Medicine (Psy1) and Psychosomatic

Medicine (Psy2) in order to find out if there is an increase in the their communication skills with patients. The analysis was made in

accordance with the criteria of a system called RIAS (Roter Interaction Analysis System, www.rias.org) where we specifically considered

the changes in interventional competencies. The results of the present study show that this goal was achieved with respect to communication

and intervention techniques. Improvement through intervention in the categories Naming Emotions and Understanding Emotions can

be documented, particularly in the handling of emotions (NURS-model; advanced training within the courses Psy1 and Psy2 /Austrian

Medical Chamber).

Keywords: Psychosocial medicine, psychosomatic medicine, Balint-work, doctor-patient interaction, Roter Interaction Analysis System (RIAS)


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Rezumat: Tratamentul medical holistic, ca intervenţie psiho-socială şi psiho-somatică constă în interacţiunile subiective dintre medic

şi pacient. Această afirmaţie stă alături de idea lui Balint că cel mai folosit medicament în medicina generală este însuşi medicul. În

consecinţă, educarea şi formarea în medicina psiho-socială şi psiho-somatică au ca scop principal crearea unor medici capabili să perceapă,

să înţeleagă şi să-şi trateze pacienţii întro manieră mai complexă decât prin simpla abordare somatică. Comunicarea între pacient şi

medic este un instrument de valoare în îndeplinirea acestui scop, permiţând pacienţilor să-şi exprime punctele de vedere, experienţa lor de

viaţă şi sentimentele pe deplin. Echipa noastră a investigat relaţia medic – pacient în cadrul unui studiu de intervenţie controlată făcut

înainte şi după un curs avansat de Medicină psiho-socială (Psy1) şi de Medicină Psiho-somatică (Psy2) cu scopul de a afla dacă există o

îmbunătăţire a capacităţii de comunicare cu pacienţii. Analiza s-a făcut cu ajutorul sistemului RIAS (vezi adresa website-ului), unde noi

am luat în consideraţie schimbările specifice în capacităţile de intervenţie. Rezultatele studiului demonstrează că scopul a fost atins în ceea

ce priveşte comunicarea şi tehnicile de intervenţie. Ameliorarea prin intervenţie la categoriile Denumirea Stării de spirit şi Înţelegere a

stării de spirit poate fi dovedită, mai ales în ceea ce priveşte controlul stării de spirit (Modelul NURS; formarea avansată prin cursurile

Psy1 şi Psy2 / Camera medicală a Austriei).

Cuvinte cheie: medicină psiho-socială, medicină psiho-somatică, activitate Balint, relaţia medic – pacient, Sistemul Roter de analiză

a interacţiunii (RIAS)

1. Theoretical BackgroundIn the last few decades, the medical system has

sometimes unfortunately turned away from the human beings, according to Fiedler (2002[2]). In his opinion, we have all become captured in a cycle of rapid scientific improvements, technical advances, and pharmacological innovations. Recently we have also become trapped in health care politics and strategies. We cannot escape from this environment of brand-new surgery methods, medications, equipment, and exceedingly higher administration efforts, as a result of which, the disease comes to the fore instead of the patient.

Fortunately, there are also other movements and forces that focus on the individual and inter-subjective level. Communication between doctors and their patients has become a more prominent topic in the last years (Angelelli 2008[3], Menz et al. 2008[4], Charon 2006[5], Greenhalgh 2005[6]). The objective of improved communication is a better relationship between doctor and patient, as Balint in the early fifties of the last century claimed, which finally leads to a superior understanding and therapy. An important element in the context of the training and inter-subjective communication are Balint groups, which facilitate the daily work of GP’s and all other clinical specialists in handling patients with chronic, psychosocial and psychosomatic illness.

A primary part of communication within the interaction of doctors and patients is the mutual process of getting to know each other’s subjective perception of realities (Langewitz 2002[7]). Patients cannot develop an idea of their disease without an adequate understanding of their health problems and a comprehensible explanation from their doctor. If physicians or specialists cannot identify the patient’s point of view and fail to explain somatic as well as psychic aspects of the health problem, this leads to uncertainty and fear. As a further consequence, coping strategies in biological,

emotional, mental and social concerns diminish and become rigid and insufficient. The individual patient is no longer capable of finding a solution that is as satisfying as possible.

The health-promoting inner and outer spheres of life become more and more constrained by a negative spiral of disease (Dieter/ Edlhaimb 2001[8]). Against this background, the medical fraternity itself designed the advanced training of Psychosocial Medicine (Psy1) and Psychosomatic Medicine (Psy2) in Austria.

Trainees in these curricula must have a total of 120 hours reflective work in Balint groups, and those who have completed this advanced training see this part of the curriculum as a central and effective core of their training. On the one hand, doctors generally are highly qualified in scientific medicine and evidence-based medicine; but, on the other hand, there is limited time and space for patients’ narratives in traditional medicine and a regrettable shortcoming in the communication skills of doctors. Especially in the field of chronic, psychosocial and psychosomatic illness, the transversal and inter-subjective movements through the patients’ narratives are the only way to get close to solutions to stop the disastrous spiral of diseases. However, the Balint group is a legitimate forum enabling doctors to engage unconditionally in discussing patients' stories within a safe environment. Patients with “multiple unexplained symptoms” are characterized by their complaint of symptoms for which no cause can be found or for which there are only insufficient biomedical explanations. They are probably one of the largest groups of patients for doctors in polyclinics in hospitals (Smith et al. 2007[9]).

So we had the ambitious goal of training GPs and other specialists in inter-subjective communication, and especially in learning to understand the doctor-patient relationship in the manner developed by Michael Balint.


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2. Research QuestionsIn this study we investigated the abilities that doctors

acquired in the advanced training of Psy1 and Psy2 in order to be able to make sophisticated psychosocial and psychosomatic interventions. The training consists of:1) 11 weekends per 20 teaching units2) the acquisition of stress relieving techniques3) 120 units of Balint groups over a period of 2 years4) 300 confirmed psychosocial and psychosomatic medical

visits and a written thesis.The main research questions are:

1.) Do the communication skills of physicians and specialists in the medical interview increase after the advanced training?

2.) Do the abilities and skills of doctors to intervene in the medical interview increase after the advanced training?

Furthermore, we wanted to find out if there is a change in communication and intervention techniques in the following the following categories:• Creating a good atmosphere and structuring • Addressing the psycho-social characteristics of the

patient• Permitting the patient to speak• Augmentation of the “adaptation phase”, the dynamic

and creative matching of the doctor’s and the patient’s realities, within the course of inter-subjective communication.

• Conversational techniques (Langewitz 2002[7], Langewitz et al. 2003[10]) such as (a) Waiting, (b) Echoing, (c) Mirroring, (d) Summarising (WEMS)

• Handling of emotions (Langewitz 2002[7], Langewitz et al. 2003[10]) such as (a) Naming, (b) Understanding, (c) Respecting, (d) Supporting (NURS)

One-waymirror:layperson=>live-rating+questionnaire

One-waymirror:professional=>live-rating+questionnaire

Physician=>questionnaire

Patient(Actor)=>questionnaire

UsabilityLab=>interactionbetweenphysiciansandpatients

Degreeofconcordancebetweenprofessionalsandlaypersons

Degreeofconcordancebetweenphysiciansandlaypersons

experimentalgroup+controlgroup

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2patientsperphysician

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3. MethodsWe conducted a controlled intervention study to

investigate the processes of interaction between doctors and patients during a medical visit. The objective of the advanced training Psy1 and Psy2 is to enhance the abilities of medical doctors to create a comfortable atmosphere, to interact clearly and in a structured manner, to address psychosocial characteristics of the patient, to permit the patient to speak and to improve their communication skills in terms of patient-centred conversation.

Before the physicians and specialists started their first

lecture, they conducted two medical visits in the usability lab of the Danube-University Krems that lasted approximately 20 minutes each. Two years later, after the end of the advanced training, the same procedure was repeated. Parallel to this experimental group, we observed doctors who did not plan to graduate in Psy1 and Psy2 in order to control the variable of experience over time.

Each doctor had to “examine” and “treat” two different patients – one with a severe diagnosis [HIV or cancer (Hodgkin lymphoma)] and one with a harmless illness (abdominal pain or asthma). Due to ethical concerns, the patients were


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adequately trained and well instructed actors and actresses, who practiced their scripts in a special preparation course to assure that they acted as authentically as possible.

The medical visits were recorded by video. For our data analysis we chose the Roter Interaction Analysis System (RIAS) invented by Debra Roter et al. (2002[11]; German translation: Langewitz et al. 2003[10]), which is a computerised method of coding doctor-patient interaction during the medical visit. The identification and classification of verbal expressions are coded directly from videotapes and not from transcripts. Therefore, assessment is possible of the tonal qualities, which transmit the emotional context of the visit beyond the significance of the words spoken. The communication units are defined as "utterances", which are the smallest discriminable speech segments for classification and which may vary in length. The rating is based upon their general affective impression of both the patient and the doctor and on global affective parameters, such as anger, anxiety, dominance, friendliness and interest. All videos were analysed by the same Balint group-Leader to avoid the problem of inter-rater inconsistency.

4. ResultsThe analysis of the experimental and the control group

is based upon 156 interviews with a total amount of 23,510 utterances. 120 videos were made with the experimental group and 36 interviews with the control group. 52% of the 23,510 utterances were made by the doctors and 48% by the patients. 4.1. Sample

At the time of the first data collection, our sample consisted of 65 doctors (43 female, 22 male). Two years later at the time of the second data acquisition, 39 (23 female, 16 male) of those 65 doctors participated in the study. The reduced number of probands was due to the fact that not all of the surveyed persons completed the postgraduate training of Psychosomatic Medicine (Psy2) after Psychosocial Medicine (Psy1).

The experimental group consisted of 56 doctors (39 female, 17 male) and the control group was composed of only 9 doctors (4 female, 5 male). 73% of the doctors worked

predominantly in a hospital and 27% worked in their own doctor’s office. 19% were medical specialists, 35% were general practitioners and 48% were still in medical training (multiple answers were permitted).

5 actors played the different patients. 42 videos were made with a male patient and 114 with a female patient.4.2. Most frequent statements of doctors

Typical clinical visits generally follow a specific pattern of (1) opening, (2) anamnesis, (3) physical examination, (4) counselling and (5) closing. Those segments are typically characterised by certain categories, although any category may occur within any segment of the interaction. The most frequent statements of the doctors were (see Figure 2):

(1) Back-channelling (1,469 utterances; 6.2% of all statements) as an invitation for the patient to continue talking and indicate sustained interest or attentive listening (Roter 2006[12]).

(2) Asking closed-ended questions – medical condition showed totally 1,431 questions (6.1% of all statements).

(3) Giving information – medical condition (1,277 utterances; 5.4% of all statements) includes statements of facts or opinions which relate to the medical condition, symptoms, diagnosis, prognosis, past tests and their results, medical background, personal and family medical histories, practices and allergies, as well as a basic identification of information or vital statistics as part of the medical record (Roter 2006[12]).

(4) Summarising (1,173 utterances; 5.0% of all statements) means to give a resume of the patient’s statements in own words (Roter 2006[12]).

(5) Transition words (661 utterances; 2.8% of all statements) are sentence fragments that indicate a movement to another topic or area of discussion or a train of thought or action. Many of those statements or fragments are place-holders (Roter 2006[12]).

(6) Waiting (791 utterances; 3.4% of all statements) is an essential part of patient-centred conversation and comprises a time period longer than 3 seconds, in which the awareness and attention is directed to the patient, who is invited to speak (Roter 2006[12]).

Most frequent statements of doctors

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791

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0 200 400 600 800 1000 1200 1400 1600

Back-channeling

Asking closed-ended questions - medical condition

Giving information - medical condition

Summarising

Transition words

Waiting

utterances

Figure 2: Most frequent statements of doctors (absolute frequencies of utterances)


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4.3. Most frequent statements of patientsThe most frequent utterances of the patients were (see Figure 3): (1) Giving information – medical condition (3,330 utterances; 14.2% of all statements) was the most frequent RIAS

category of all. Compared to the doctor’s utterances of this kind, it is almost three times higher.(2) Showing agreement or understanding (1,198 utterances; 5.1% of all statements) includes all signs of agreement

(phrased positively and negatively) or understanding (Roter 2006[12]).(3) Giving information – lifestyle (1,192 utterances; 5.1% of all statements).(4) Giving information – psychosocial (1,110 utterances; 4.7% of all statements).(5) Back-channelling (1,053 utterances; 4.5% of all statements).(6) Worry or concern (844 utterances; 3.6% of all statements) are non-verbal expressions which show that a condition

or an event is rather serious, distressing, worrisome or deserving special attention like comforting or another special consideration. (Roter 2006[12]).

(7) Transition words (757 utterances; 3.2% of all statements) is almost ex aequo with those of the doctors.

Most frequent statements of patients

3330

1198

1192

1110

1053

844

757

0 500 1000 1500 2000 2500 3000 3500

Giving information - medical condition

Showing agreement or understanding

Giving information - lifestyle

Giving information - psychosocial

Back-channeling

Worry or concern

Transition words

utterances

Figure 3: Most frequent statements of patients (absolute frequencies of utterances)

4.4. Interventions in interpersonal communication

The videos were analysed with regard to all utterances that dealt with communication techniques.

Orientation statements tell the other person what is about to happen and what is expected during the medical visit, to direct the other’s behaviour and to facilitate the process of the visit. They serve to orient the patient to the major topics of conversation. This technique helps the patient to cooperate. Instruction statements however include directive statements relating to the examination, including those in imperative form. They are often used to facilitate progress through the medical visit and include statements referring to procedural or administrative aspects (Roter 2006[12]) (see Table 1).

A very essential part of patient-centred conversation is Waiting, Echoing, Mirroring and Summarising (WEMS). Waiting comprises a time period longer than 3 seconds is not an ignorant “doing nothing”. It is an important intervention and the advertence and attention is addressed to the patient, who is invited to speak. In the study at hand, 661 interventions classified as waiting could be registered,

which represent 2.8% of all interventions and utterances. 575 of these utterances came from physicians and specialists of the experimental group (4.2% of all utterances from this group). 86 statements were done by doctors of the control group (0.9% of all utterances from this group, see Table 1).

Another crucial communication technique is echoing. Hereby the physician or specialist repeats the phrases used by the patient, like an echo, in order to encourage the patient to continue the narrative. There are also mechanisms for requesting repetition of the patient’s previous statement. Such requests are used when words have not been clearly heard (Roter 2006[12]). The surveyed doctors echoed 178 times, which represents 0.8% of all utterances. Doctors made 154 statements before and after their training (1.1% of all statements from this group) and the rest of 24 utterances by those without training (0.2% of all utterances of the control group). The patients echoed the words of the doctor 13 times (0.1%, see Table 1).

In mirroring, the doctor re-states the information given by the patient for the purpose of confirming a shared understanding of the facts being discussed. 93 utterances could be classified as mirroring feedback to emotional


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utterances of the patients. This includes communication techniques by which the doctor reflects back contextual or emotional information, which he or she has just been told by the patient. The purpose is to check the accuracy of the information (Roter 2006[12]). Mirroring represents only 0.4% of all utterances of the doctors. 80 statements came from the experimental group before and after training (0.6% of all utterances from the experimental group) and 13 from the control group (0% of all their utterances, see Table 1).

Doctors made many summarising utterances with a total amount of 1,173 (5%), whereas patients made 62 summarising comments (0.3%). The major part (891 statements, 6.5% of all their utterances) came from the experimental group, whereas the control group only summarised 282 times (2.9% of all their statements, see Table 1). This category means giving a resume of the patient’s statements in one’s own words or making statements that are shorter than the patient’s statements but strongly referring to them. The aim is to feed back the essence of a verbal message. Besides paraphrases or repetitions, the doctors also ascertain that they have a correct understanding of the meaning. The utterances can be in either question or statement form, but the function is to clarify or to ask for clarification of the other’s communication (Roter 2006[12]).

Prosodic interventions are non-verbal expressions and almost inaudible “under-talk” that accompanies the patient’s words. They are not meant to be responses to the patient’s questions, but an invitation to continue the conversation.

They indicate a sustained interest and attentive listening or encouragement emitted by the doctor when he or she does not hold the speaking floor. They do not serve to take the floor from the speaker. The right to speak remains with the patient (Roter 2006[12]). The doctors made 1,469 utterances of this kind (6.2%), whereas the patients showed 1,053 (4.5%) utterances of this category, also called back-channel responses. 1,159 statements came from the Psy1 and Psy2 doctors (8.4% of all their utterances) and 310 (3.2%) came from the control group (see Table 1)In all the videotaped medical visits the doctors undertook a total of 2,105 interventions of (WEMS) waiting, echoing, mirroring and summarising, which represents 9% of all communication. If we include also interventions like giving orientation and back-channel responses, this amount climbs up to 16.7% (3,924 utterances). The amount of WEMS was three times higher in the group of Psy1 and Psy2 doctors (12.3% of all their utterances before and after the training) than in the control group (4.2% of all their utterances within two years, see Table 1). The difference between the two groups is smaller, if we also take giving orientation and back channelling into account (22.8% of the experimental group and 8.1% of the control group). This reduction is due to the large part of back channelling compared to the other categories of the doctors without training (3.2%). Both differences are highly significant (p=0.000).

InterventionFrequency of Utterances (total)

Frequency of Utterances (Experimental Group)

Frequency of Utterances (Control Group)

Giving orientation 350 1,5% 278 2,0% 72 0,7%Waiting 661 2,8% 575 4,2% 86 0,9%Echoing 178 0,8% 154 1,1% 24 0,2%Mirroring 93 0,4% 80 0,6% 13 0,0%Summarising 1,173 5,0% 981 6,5% 282 2,9%Back Channel 1,469 6,2% 1,159 8,4% 310 3,2%WEMS 2,105 9,0% 1,700 12,3% 405 4,2%WEMS incl. orientation + back-channel 3,924 16,7% 3,137 22,8% 787 8,1%All statements (doc + pat) 23,510 100,0% 13,774 100,0% 9,736 100,0%

Table 1: Interventions of the Doctors

4.5. Effects of advanced training on the interpersonal communicationIt is noteworthy that the medical conversation at the second time of survey two years after the first one becomes slower.

Although the medical visits last longer (9 minutes 39 seconds on average), they contain fewer utterances, and the identified change of the right to speak declines. After the advanced training of Psy1 and Psy2, the patients show slightly more utterances (see Figure 4).


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159150

89,976,4

48 49

0

20

40

60

80

100

120

140

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Utterancesofthephysician

Permittingthepatienttospeak

Utterancesofpatient

first survey secondsurvey

WEMS – Doctors

CategoryExp. Group - First Survey

Exp. Group - Second Survey

Cont. Group - First Survey

Cont. Group - Second Survey

Total

107 Waiting 192 (2.0%) 383 (4.3%) 63 (2.3%) 23 (1.0%) 661 (2.8%)108 Echoing 61 (0.6%) 93 (1.0%) 16 (0.6%) 8 (0.4%) 178 (0.8%)109 Mirroring 16 (0.2%) 64 (0.7%) 3 (0.1%) 10 (0.4%) 93 (0.4%)110 Summarising 503 (5.3%) 388 (4.3%) 177 (6.5%) 105 (4.7%) 1.173 (5.0%)

All statements 9.554 (100%) 9.005 (100%) 2.705 (100%) 2.246 (100%9 23.510 (100%)

If we focus on all interactions between doctors and patients, which are important for person-centred communication, such as waiting, echoing, mirroring and summarising (WEMS), the following development over time emerges.

Professional waiting increases from 2.0% to 4.3% after the advanced training, while the control group declines within the two years from 2.3% to only 1.0%. The percentage refers to all utterances within one group (experimental group or control group) (see Table 2 & Figure 5).

All in all, echoing occurs relatively scarcely, but ascends from 0.6% to 1.0% after the training of Psy1 and Psy2. The doctors without training decrease from 0.6% to 0.4% (see Table 2 & Figure 5).

Also the technique of mirroring, which occurs very seldom, rises from 0.2% to 0.7% after the training, whereas the control group rises from 0.1% to 0.4% (which are 3 and 10 utterances, respectively) (see Table 2 & Figure 5).

Summarising declines in both groups – in the experimental group from 5.3% to 4.3% after the advanced training and in the control group from 6.5% to 4.7%. This result may be explained by the fact that different diseases were presented at the two different times of survey, and the second illnesses did not require as much information from the patients as the first (see Table 2 & Figure 5).

Figure 4: Comparison of First and Second Survey (absolute frequencies per visit)

Table 2: Combination: Time and Group Variables


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There is a highly significant increase in the use of the relevant intervention techniques of WEMS (waiting, echoing, mirroring and summarising) in the second survey (p<0.001). While the frequencies of these interventions of the experimental group increases over time, it decreases for doctors who did not do the training (see Figure 6).

2

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Comparison of WEMS

firstsurvey secondsurvey

Figure 5: Comparison of Conversation Techniques (percentage of all utterances)

Effect of Interaction WEMS

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firstsurvey secondsurvey

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Figure 6: Effects of Training

Regarding the utterances of the patients, they certainly reflect the content of the script, i.e. their role as actors and actresses. But even more relevantly, they reflect as well how much doctors are capable to open up the time and space for special utterances of the patients. It is important to impress upon the doctors that important information not only is the product of questioning and answering but also emerges from the interplay of questioning and answering and is offered unexpectedly and spontaneously by the patient. Therefore, we investigated how far patients of the experimental group get the chance to bring in interrelated chains of utterances in the medical conversation. The analysis of verbal fluency is based upon 23,510 individual utterances altogether. After excluding the back-channel utterances with which the doctors tried not to take the floor from the speaking patient and to encourage the patient to continue the conversation, there remained 18,679 utterances for our analysis to determine the trend to longer chains of uninterrupted patient narrations after the training of Psy1 and Psy2. The average amount of uninterrupted patient narrations increased from 1.37% to 1.83% in the experimental group of trained doctors, whereas it declined from 1.31% to 1.1% in the control group. This correlation is highly significant and implies that the advanced training produced the desired effects (see Figure 7).


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Table 3: Interventions of the Doctors

Figure 7: Speaking Right of the Patient (percentage)

1,37

1,83

1,311,11

00,20,40,60,81

1,21,41,61,82

uninterruptedreactions(experimentalgroup)

uninterruptedreactions(controlgroup)

first survey secondsurvey

4.6. NURS - The handling of emotionsThere are 4 main categories of dealing with the patient’s emotions that are crucial for a successful intervention: (1) Naming emotions (2) Understanding emotions, (3) Respecting emotions and (4) Supporting emotionsNaming emotions means empathy statements that paraphrase, interpret, name or recognize the emotional state of the

patient during the visit (Roter 2006[12]). Understanding emotions includes statements that indicate that the patient’s emotional situation, actions or thoughts

are understandable and normal. The purpose is to normalise the patient’s emotions, actions and thoughts by making them universal (Roter 2006[12]).

Respecting emotions implies statements that express a regardful handling with the patient’s emotions. Supporting emotions could not be found in the study at hand.

InterventionFrequency of Utterances (total)

Frequency of Utterances (Experimental Group)

Frequency of Utterances (Control Group)

Naming Emotions 85 (0.4%) 71 (0.5%) 14 (0.1%)Understanding E. 92 (0.4%) 70 (0.5%) 22 (0.2%)Respecting E. 24 (0.1%) 20 (0.1%) 4 (0.0%)Supporting E. 3 (0%) 2 (0.0%) 1 (0.0%)All statements (doc + pat) 23.510 (100%) 13.774 (100%) 9.736 (100%)

4.7. Effects of advanced training on the handling of emotions

The described technique NURS (naming, understanding, respecting and supporting emotions) was part of the advanced training in Psy1 / Psy2 and was reflected in the containing Balint groups within at least two years. Comparing the experimental group of trained doctors with the control group of untrained doctors, we found the following differences (see Table 4 and and figure 8).

Furthermore there were several sub-categories such as approval, disapproval, reassurance, and worry or concern, which we do not want to continue reporting in this context.


RefeRAte

Table 4: Frequencies of the RIAS-Categories 107-114

Figure 8: Handling with Emotions (percentage) – Utterances of the Doctors

Handling of disclosed and hidden Emotions - Doctors

CategoryExp. Group - First Survey

Exp. Group - Second Survey

Cont. Group - First Survey

Cont. Group - Second Survey

Total

107 Naming Emotions 28 (0.3%) 43 (0.5%) 6 (0.2%) 8 (0.4%) 85 (0.4%)

108 Understanding E. 15 (0.2%) 55 (0.6%) 5 (0.2%) 17 (0.8%) 92 (0.4%)109 Respecting E. 4 (0.0%) 16 (0.2%) 1 (0.0%) 3 (0.1%) 24 (0.1%)110 Supporting E. 2 (0.0%) 0 (0.0%) 0 (0.0%) 1 (0.0%) 3 (0%)111 Approval 5 (0.1%) 11 (0.1%) 1 (0.0%) 7 (0.3%) 24 (0.1%)112 Disapproval 3 (0.0%) 29 (0.3%) 0 (0.0%) 3 (0.1%) 35 (0.1%)113 Reassurance 49 (0.5%) 184 (2.0%) 10 (0.4%) 85 (3.8%) 328 (1.4%)114 Worry or Concern 11 (0.1%) 14 (0.2%) 0 (0.0%) 2 (0.1%) 27 (0.1%)

All statements 9.554 (100%) 9.005 (100%) 2.705 (100%) 2.246 (100%9 23.510 (100%)

0 ,2 9

0 ,4 8

0 ,16

0 ,6 1

0 ,0 4

0 ,18

0 ,0 2 0

0 ,51

1,2 7

0

0 ,2

0 ,4

0 ,6

0 ,8

1

1,2

1,4

N am i ng E m o t i o ns U nd er s t and i ngE m o t i o ns

R es p ect i ng E m o t i o ns Sup p o r t i ng E m o t i o ns T o t al

F i r s t Sur v ey Seco nd Suer v ey

If we count together the four intervention techniques of NURS (naming, understanding, respecting, supporting emotions), there is a highly significant difference (p<0.000) between the two surveys (first and second), but no significant difference between the experimental and the control group. Also here the fact of professional experience seems to have a great impact on the development of NURS-interventions

Balint leaders reported an increasing reflection of the accompanying emotions of patients presented in their Balint groups.

5. DiscussionThe working group, within the meaning of Balint,

aims at a better understanding of the patient, a better understanding of the relationship between the patients and themselves and a better self-perception of their own feelings. Balint work helps in inter-subjective corresponding doctor-patient relationship, which is the target of the training in psychosocial and psychosomatic medicine. The described inter-subjective interventions help dealing with transference and counter transference.

Psychosocial and psychosomatic interventions are

always inter-subjective processes of direct (verbal) and comprehensive (also non-verbal) conversation between doctors and patients. Therefore it must be a crucial objective of advanced training for medical doctors to enable them to perceive, to understand and to treat their patients in a more complex and self-contained way than from a somatic perspective.

The results of the study at hand show that we succeeded in essential areas to move doctors towards a more communicative behaviour, so that their patients are capable to convey their own position articulately. The competencies and performances necessary for a more patient-centred communication [the medical interventions of waiting, echoing, mirroring and summarising (WEMS)] could definitely be improved by the advanced training of Psy1 and Psy2. Especially the categories waiting, echoing and mirroring showed a significant increase after the special training. The category of summarising decreased after the training, but this result is due to the differences in the actors’ (= patients’) scripts. Furthermore the patients could keep their right to speak for a longer period and showed a greater amount of uninterrupted narrations after the training of


DescRieRe De cAz

A.M. a prezentat cazul unei experienţe personale trecute în calitate de asis-tentă pe Salvare, experien-ţă ce a implicat a face faţă agresiunii verbale şi fizice a unui pacient violent, necoo-perant. Întrebarea adresa-tă grupului a fost legată de

reacţia iniţială a Alexandrei, reacţie caracterizată printr-o anumită paralizie emoţională, urmată de sentimente de vul-nerabilitate şi îndoială că ar putea face faţă unui caz similar în viitor. Deşi Alexandra nu mai exercită în prezent profesi-unea de asistentă medicală, cazul a fost selectat spre prezen-tare întrucât:

- acoperea o experienţă trecută reală, iar rememorarea cazului a pus în evidenţă faptul că Alexandra mai avea încă

sentimente puternice legate de acea întâmplare;- cazul putea fi interesant pentru studenţii participanţi la

şedinţă, în măsura în care putea ilustra multilateralitatea şi ambivalenţa profesiunii medicale, precum şi limitele şi po-tenţialele riscuri ale acesteia.

Discuţiile din grup au vizat asumarea rolului terapeutului în situaţia relatată de Alexandra, dar şi a unora dintre mem-brii anturajului pacientului, ca şi a pacientului (în special trăirea posibilă a acestuia a situaţiei de agresiune ca „legi-timă” sau „justificată”). În rolul de „Alexandra”, majoritatea participanţilor şi-au imaginat nu numai reacţiile emoţionale ale acesteia, ci şi unele strategii practice pentru a face faţă atât unei posibile agresiuni fizice, cât şi sentimentelor de frustrare, neputinţă sau vulnerabilitate pe care le aduce un asemenea caz.

La revenirea în grup, Alexandra a relatat că s-a simţit foarte bine, discuţiile confirmându-i o parte dintre strate-

DEscriErE DE cAZ - Ovidiu Popa-Velea, Bucureşti

their doctors, which is also a characteristic of patient-centred communication.

Furthermore the results indicate an expansion of the skills for handling with emotions due to the advanced training of Psy1 and Psy2, as well as to experience over time. Utterances that are part of the NURS-technique (naming, understanding, respecting and supporting emotions) show a tendency to increase with time. There is no significant difference between the experimental and the control group. It must be stated, that the utterances in this area are quite rare. There is a significant increase of utterances concerning approval in both groups.

The results indicate that postgraduates of the advanced training - Psy1 / Psy2, acieve higher communication abilities and skills, both concerning the permission of the patient to speak and the advancement of their conversational techniques.

The techniques of NURS, on the contrary, do not develop as well as they should. *This paper was presented at the 16th International Balint Congress, Poiana-Braşov, România

References1 Balint, M. (1957) The Doctor, his Patient and the Illness. 2 Fiedler L. (2002). Medizin im Wandel. In: Consilium 2002; 12 3 Angelelli, C. V. (2008). Medical interpreting and cross-cultural

communication. Cambridge [u.a.]: Cambridge Univ. Press4 Menz, F. / Lalouschek, J. / Gstettner, A. (2008). Effiziente

ärztliche Gesprächsführung. Optimierung kommunikativer

Kompetenz in der ambulanten medizinischen Versorgung.

Ein gesprächsanalytisches Trainingskonzept. Wien: Literatur-

Verlag5 Charon, R. (2006). Narrative medicine: honoring the stories of

illness. New York, NY [u.a.]: Oxford Univ. Press6 Greenhalgh, T. (ed.) (2005). Narrative-based medicine -

Sprechende Medizin. Dialog und Diskurs im klinischen Alltag.

Bern [u.a.]: Huber7 Langewitz W. (2002). Arzt-Patient-Kommunikation, Mitteilen

schlechter Nachrichten. In: Brähler E. / Strauß B. (ed.)

Handlungsfelder in der Psychosozialen Medizin. Göttingen:

Hogrefe: 54-768 Dieter W, Edlhaimb HP. Imaginative Psychotherapie III

Praxeologie. In: Leitner A, Hrsg. Strukturen der Psychotherapie.

Wien: Krammer; 2001: 105-1159 Smith, R. C. / Dwamena, F. C. (2007). Classification and

diagnosis of patients with medically unexplained symptoms.

In: J Gen Intern Med, 22(5), 685-691.10 Langewitz W. / Nübling M. / Weber H. (2003). A theory-

based approach to analysing conversation sequences. In:

Epidemiologia e Psichiatria Sociale Vol. 12(2): 103-10811 Roter D. / Larson S. (2002). The Roter interaction analysis

system (RIAS): utility and flexibility for analysis of medical

interactions. In: Patient Education and Counseling No. 46:

243-25112 Roter D. (2006). The Roter Method of Interaction Process

Analysis. Baltimore: John Hopkins University


DescRieRe De cAz

DEscriErE DE cAZ - Psih. Irina de Hillerin

giile pe care ea însăşi le-a folosit pentru a scăpa de povara psihologică adusă de acest caz (ex. concentrarea pe aspectele pozitive ale situaţiei, precum succesul în referirea pacientu-lui către spitalul de psihiatrie, unde acesta a beneficiat de ajutor medical; perceperea unui grad personal de rezilienţă pentru confruntarea cu situaţii similare din viitor; asuma-rea acestui gen de situaţii ca fiind inevitabile, în special în contextul sistemului sanitar haotic românesc). Singura ob-servaţie critică a fost legată de posibilitatea grupului de a se fi concentrat mai mult pe sentimentul iniţial al Alexandrei, de frică (panică).

Participarea la discuţii a fost prezentă la toţi membrii

grupului, fiind de remarcat spontaneitatea majorităţii re-marcilor, fluenţa desfăşurării şedinţei şi uşurinţa de empa-tizare cu principalele personaje ale întâmplării. Este posibil ca aceste atribute ale întâlnirii să se fi datorat participării, deja stabile, a unor membri, la mai multe / toate şedinţe(le) de grup, de la reînfiinţarea acestuia. Deşi aceşti participanţi „stabili” au fost studenţi, considerăm contribuţia lor drept valoroasă.

Toţi noii participanţi au apreciat pozitiv lucrul în grup şi şi-au exprimat intenţia să mai participe la astfel de întâlniri. Atmosfera a fost caldă, relaxată

Cel care şi-a anunţat imediat dorinţa de a prezen-ta un caz a fost un asistent medical, AT, unul dintre participanţii noi la grup.

Prezentăm cazul cu acor-dul său, respectându-i do-rinţa de a nu dezvălui anu-mite date: lucra ca asistent

medical într-un spital de campanie într-una din zonele de conflict din Orientul Mijlociu. Într-una din zile medicul-şef, femeie, a trebuit să lipsească şi atunci i-au revenit lui sarci-nile din acea zi.

Trebuia să consulte persoane originare din acea ţara şi să le dea avize de muncă pentru a se angaja în armata ameri-cană pe diferite posturi. La consult s-a prezentat un bărbat care nu vorbea foarte bine limba engleză şi părea să ascun-dă cu mâna o parte din corp. Una din cerinţele medicale de admitere pe acel post era ca persoanele selecţionate să nu fi avut intervenţii medicale în ultimii 15 ani. La solicitarea asistentului medical de a se dezbrăca, pacientul iniţial refu-ză, apoi se dezbracă totuşi cu mare greutate. AT constată că are o mare cicatrice de-a curmezişul abdomenului care nu părea recentă. La întrebarea sa despre istoricul acelei cica-trici, bărbatul răspunde că este foarte veche, din copilărie, şi că nu-i afectează cu nimic capacitatea de muncă. Apoi înce-pe să-i spună cât este de important acel post pentru el, că are de hrănit multe persoane acasă şi că nu este deloc relevantă acea cicatrice. AT decide să-i dea un aviz favorabil dar rămâ-ne cu multe frământări interioare.

Întrebarea pe care a adresat-o grupului a fost dacă a procedat bine în acel caz, totodată dorindu-şi să-şi clarifice

sentimentele trăite de atunci şi până în prezent (trecuse mai mult de o lună de la acea întâmplare). A mai dorit să explo-reze în ce măsură se poate lăsa afectat de o întâmplare care la o primă impresie ar putea părea banală, având în vedere că urma să plece într-o expediţie alpină care implica multe riscuri, ca asistent medical.

Grupul i-a pus întrebări despre rolul medicului într-un spital de campanie şi rolul asistentului, presiunea asupra personalului medical din cadrul armatei, specificul persoa-nelor din acea ţară care ajungeau ca pacienţi în acel spital.

Faza de discuţii a fost vie, centrată în special asupra po-tenţialelor emoţii trăite de AT (sentimentele de vinovăţie, lipsa de toleranţă la minciună, la duplicitate), posibila mani-pulare din partea pacientului, gradul de asumare a respon-sabilităţii actului medical, rezistenţa la presiunea emoţiona-lă. S-au implicat toţi participanţii, noi sau vechi, au rezonat puternic cu AT şi cu implicaţiile emoţionale ale istoriei sale.

La revenirea simbolică în grup, AT şi-a exprimat părerea sa cu privire la cele văzute şi auzite. S-a arătat surprins de bogăţia emoţiilor pe care a constatat că le trăise şi el dar nu a ştiut să le exprime în acest fel şi a acceptat că este posibil ca unele sentimente să nu fi dorit să le recunoască. S-a ară-tat foarte încântat de profunzimea explorării sentimentelor realizată de întregul grup.

Persoanele care au fost prezente pentru prima dată la grup s-au arătat entuziasmate de existenţa acestui mod de explorare a relaţiei medic-pacient, inedit pentru ele şi, după cum au declarat, extrem de util în descărcarea tensiunilor acumulate în actul medical.

La final membrii au exprimat feedback-ul cu privire la lucrul în grup, acesta fiind unanim pozitiv.


ŞtiRi Din ViAţA AsociAţiei

Dorim să stabilim schimburi cu alte publicaţii. • On désiré établir l’échange avec d’autres publications.

We wish to establish exchange with other publications. • Wir wünschen mit anderen Herausgaben den Austausch einzuri-

chten. • Desideriamo stabilire cambio con alte publicazioni. • Déseamos establecer intercambio con otras publicaciones.

Evenimente petrecute: 14-16 ianuarie 2011: Weekend Naţional de Iarnă cu Postrevelion, Roman-Dulceşti.

Gazdel noastre, familia Ţubucanu şi Costin au fost şi de această dată la înălţime. Formaţia de dans Amiciţia ne-a delectat cu dansuri greceşti şi moderne. Bazinul de această

dată a avut apa atât de rece încât nimeni nu s-a încumetat să partricipe la grupul Balint acvatic.Doi lideri de grup, Ţubucanu Marilena şi de Hillerin Irina şi-au dovedit din plin aptitudinile de lideri de grup. Eu am prezentat o lucrare (Dragoste la bătrâneţe) care a generat rumoare şi discuţii vii pe marginea celor prezentate (va fi publicat în nr. Jubiliar 50 din iunie!)

ŞTiri Din ViAŢA AsOciAŢiEi - Dr. Albert Veress, Miercurea Ciuc.

Planuri de viitor:13-15 mai 2011 - Weekend Naţional de Vară, la Ocna Şugatag. Taxă de participare: 35 Euro care va cuprinde şi

c.v. banchetului pentru membrii cu cotizaţia achitată la zi. 12 credite EMC. Data limită de exprimare a dorinţei de par-ticipare şi rezervarea camerelor este 10 mai la adresa de e-mail: [email protected] sau prin telefon: 0740-085547(Árvai Zsófia). (Cazare 40 RON/pers./zi -include micul dejun).

7-11 septembrie 2011 - al XVII-lea Congres Internaţional Balint, Philadelphia, USA. Biroul a votat o sponsorizare în valoare totală de 4.500 RON pentru cei care vor participa la congres. Termen de anunţare a dorinţei ferme de participare: 01.05.2011!!! Anunţurile ulterioare nu vor fi luate în considerare! Adresa de site: http://balintcongress2011.eventbrite.com

22-24 septembrie 2011 - a XVIII-a Conferinţă Naţională Balint, probabil la Sfântu Gheorghe. Taxă de participare: 35 Euro care va cuprinde şi c.v. banchetului pentru membrii cu cotizaţia achitată la zi. 23 credite EMC.

Se va alege noul Birou al Asociaţiei. Participaţi cu toţii ca să vă puteţi exprima votul! Veţi avea un Birou pe care îl veţi alege!!!

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