Regression and new beginnings: Michael, Alice and Enid Balint and the circulation of ideas

This article offers a new evaluation of Michael Balint's history. It starts with his growing up in Hungary and examines the central concepts of his writing: the analytic pair, regression and the basic fault and creativity, up to and including his renowned work on the eponymous Balint groups (which forged a unique link between psychoanalysis and medicine). While his name is, of course, well known, this article aims to bring his ideas to the attention of a modern analytic audience. Having trained in the 1920s with Ferenczi, Balint brought Ferenczi's literary inheritance to England where he lived until his death in 1970. His connections to Klein, Winnicott and Lacan, all of whom respected his analytic stance, are also examined. Furthermore, this article argues that his ideas were filtered through the theoretical lens of his first wife Alice Balint and later through Enid Balint, both of whom played a key - and rarely recognised - role in the development of his thought. It ends with a brief discussion of his ideas on analytic training and his quest, successful only after his death, to publish the complete Freud-Ferenczi correspondence, together with Ferenczi's diary.     

Breaking the Solid Ground of Common Sense: Undoing “Structure” with Michael Balint

Balint's great merit was to question what, in the classical perspective, was assumed as a prerequisite for analysis and thus located beyond analysis: the maturity of the ego. A fundamental premise of his work was Ferenczi's distrust for the structural model, which praised the maturity of the ego and its verbal, social, and adaptive abilities. Ferenczi's view of ego maturation as a trauma derivative was strikingly different from the theories of all other psychoanalytic schools and seems to be responsible for Balint's understanding of regression as a sort of inverted process that enables the undoing of the sheltering structures of the mature mind. Balint's understanding of the relation between mature ego and regression diverged not only from the ego psychologists, who emphasized the idea of therapeutic alliance, but also from most of the authors who embraced the object-relational view, like Klein (who considered regression a manifestation of the patient's craving for oral gratification), Fairbairn (who gave up the notion of regression), and Guntrip (who viewed regression as a schizoid phenomenon related to the ego weakness). According to Balint, the clinical appearance of a regression would depend also on the way the regression is recognized, is accepted, and is responded to by the analyst. In this respect, his position was close to Winnicott's reformulation of the therapeutic action. Yet, the work of Balint reflects the persuasion that the progressive fluidification of the solid structure could be enabled only by the analyst's capacity for becoming himself or herself [unsolid].     

Could Balint Have Done More for Ferenczi?

After Ferenczi's death of pernicious anemia in 1933 at the age of 59, Michael Balint became the greatest advocate of his late analyst, teacher, colleague, and friend. He was faced with widespread avoidance, a conspiracy of silence against Ferenczi in the psychoanalytic movement. Ernest Jones, in particular, an analysand of Ferenczi and fellow member of the Secret Committee founded by Freud before World War I, seriously attacked Ferenczi. In the third volume of the Freud biography, Jones alleged that in the last years of his life Ferenczi suffered mental deterioration caused by the pernicious anemia, and that this mental decline was the real cause of Ferenczi's technical experimentations, thereby belittling the importance of Ferenczi's independent work in the last phase of his life. This article answers whether Michael Balint, who later became the literary executor of Ferenczi, was devoted enough in countering the charges that lead to a fifty-year silence on Ferenczi's eminent place in psychoanalysis. Correspondence between Balint and Jones is cited, as are reports of Ferenczi's contemporaries; Balint's efforts are placed within the context of the psychoanalytic rivalries after Freud's death.     

Michael Balint's Group Approach: The Boston Balint Group

Michael Balint was a physician/psychoanalyst who trained in Hungary and emigrated to England in 1939 when Nazi Germany began to dominate Europe. At the Tavistock Clinic, he and his wife met with social workers and physicians around case discussion seminars. With his strong interest in medicine and his curiosity about the patient-physician relationship, he initiated research/training groups with interested physicians, which ultimately led to publication of the now-classic The Doctor, His Patient, and the Illness, a rich text that has become a virtual staple of family practice residencies, along with Balint Groups for training. Balint refrained from considering his groups psychotherapy in order to minimize resistance of his physician-students. But because the groups lasted sometimes for years and explored transference and countertransference in patient-physician relationships, he acknowledged that the result was personal growth of the participants. His techniques are described and an example of a Balint Group (Boston Group) are presented here.     

The Balint movement worldwide: present state and future outlook: a brief history of Balint around the world

Michael and Enid Balint began running seminars for GPs (family physicians) in London in the late 1950s. Balint groups were soon started in other countries leading to the formation of the International Balint Federation. This paper describes the activities of the Federation and surveys the health and strength of the Balint movement in different parts of the world. While formal Balint training seems unlikely to become part of the official curriculum in more than a few countries, Balint's ideas will continue to be influential.     

Balint's Influence on Contemporary Psychoanalytic Theory and Practice

Invited by the Psychoanalytic Psychotherapy Study Center in New York to lecture on my book Michael Balint: Le renouveau de l'Ecole de Budapest, Toulouse, Erès 2000, I first gave my personal and analytic motivations for writing this book. Then I stressed Balint's original contributions to analytical theory and practice: the object relation combined with the theory of instinct, the development of the infant, adolescent and even of old age, the basic fault, archaic defenses (such as ocnophilia and philobatism), as well as his idea about analytic treatment with its phases of regression and "new beginning". His style and his discretion in treatment and mainly the responsibility he recommended to the analysts seem to me very important not to forget. I have shown him as Ferenczi's heir and how he continued his work. His clinical approach and his style are evoked to alert contemporary analysts--who sometimes just know his method to train general practitioners through the Balint group--that they have been influenced unbeknown to them.     

The Balint group experience for medical students: a pilot project

Loss of empathy has been reported in medical students as they move through the clinical phases of their training. Several researchers have attempted to address this issue by exploring ways of heightening students’ awareness of the emotional, non-biomedical aspects of illness and the dynamics of the doctor–patient relationship, using a variety of reflective group discussion methods. This pilot project employed the specific group method developed by Michael Balint for general practitioners working in London after the Second World War. The pilot was based on one group of six third-year graduate students, meeting weekly over six weeks. Evaluation includes pre- and post-questionnaires, a 1000-word essay and leaders’ observations. The results suggest that the traditional Balint method needs to be modified for students at a point in their training where they have not yet been exposed to patients for long enough to develop meaningful patient relationships. Nevertheless, there was some evidence of a heightened awareness of the dynamics of doctor–patient relationships and the importance of psychological/emotional factors (including their own prejudices) when interacting with a patient. Balint-style groups could be an effective way of encouraging medical students to reflect on the importance of emotions in the doctor–patient relationship.     

Balint After Lacan ... and After

This paper examines Balint and Lacan's views about regression and symbolism, language, and transference. The author points out their similarities, their differences, and then proposes a synthesis through his approach of history, genealogy, trauma, and crisis. Freud's notions of masochism, of fixation (innate or phylogenetic) may thus be renewed, leading to the analyst's capacity to cope with deep regression and borderline (Balint) psychosis and perversion (Lacan) or to psychosomatics, including epilepsy.     

Michael Balint: An Introduction

Michael Balint, who used to be known the world over, no longer gets either the fame or the influence that he deserves, and the three special issues of the journal devoted to him are meant to contribute to make him better known. I intend to draw a portrait of Balint—it will necessarily be only an outline, within the limits of the present issue—and to follow his path as a man and as a scholar.     

Being ordinary in extraordinary places: Reflective practice of the total situation in a total institution

This paper examines a ‘Foulkesian type’ Balint group for psychiatry trainees set in a high secure forensic hospital. Within a Balint group, group processes and dynamics are not examined. Deviation from this format is construed as resistance, and destructively getting in the way of the primary task.

This paper reports on a case‐based reflective practice group operating on a more Foulkesian group analytic model and argues that the revised principles of method proposed here – paying attention to context; group processes; and creating an atmosphere where group curative factors are in play – can help trainees to sustain an emotional reservoir for their patients. Further, these principles do not get in the way of the primary task but can add to an understanding of the individual transference and counter‐transference issues, and can place these in context within the organization and society. This is particularly important in total institutions such as forensic units.

Clinical material from this group is used to support this claim.     

Balint groups in undergraduate medical education: a systematic review

Objective: Though Balint groups feature increasingly in UK medical school curricula, there is no evidence-based consensus on what undergraduates might gain from participation, and how this might happen. To address this, we systematically reviewed primary research studies involving medical student Balint groups and their relationship with patient-centredness, using narrative synthesis. Data sources: Four major databases were searched from origin until 9 September 2016. The Journal of the Balint Society was hand-searched from 1971 until 9 September 2016. Study selection: English language studies reporting quantitative and/or qualitative methods examining Balint groups in medical students vs. other/no comparator. Results: Eight studies were included. Quantitative findings report statistically significant improvements to student’s empathy and intellectual interest following group participation vs. control (p = 0.03, p = 0.046, respectively). Discussion content was similar across high-income countries. There was considerable heterogeneity when students rated the efficacy of groups. All evidence had high or unclear risk of bias, or was of medium/low quality. Conclusion: Balint groups might help medical students to become more patient-centred, by increasing students’ empathic abilities and supporting their personal and professional growth. Groups are more subjectively effective when optional rather than compulsory. Discussion content is comparable to groups in continuing medical education.     

借助巴林特小组培训模式提高临床护理质量

通过对巴林特小组培训模式的认识和理解,并将之运用于临床护理研究,使护理人员在处理护患关系中形成新的视角和更具分析性的思考方式,从而能够更深刻地意识到自身对于患者的影响,提高换位思考的敏感性,以便更好地理解和帮助患者;同时还能促进护理人员的心理健康和减少其工作中存在的护患矛盾。这不仅可以提高患者的治疗效果和生活质量,而且还可以提升护理人员自身的职业素养。因此,巴林特小组培训模式对于实现临床护理优质服务具有重要的现实意义。     

Understanding the dynamics of the patient-physician relationship: balancing the fiduciary and stewardship roles of physicians

There has been growing concern about the effects on the patient–physician relationship of the increasing demands on physicians to balance their fiduciary and stewardship responsibilities, what has been called double agency. Various authors have proposed ways to restore patient centeredness to the patient–physician interaction. We have previously discussed the need to establish a patient–physician alliance to achieve this aim and to facilitate achieving this balance in mutual understanding. In this essay, we examine six concepts derived by Michael Balint from research seminars with primary care physicians. These six concepts are (a) the basic fault; (b) the physician's apostolic function; (c) the mutual investment company; (d) the drug doctor; (e) the deeper diagnosis; and (f) the conspiracy of anonymity. We believe these six concepts describe basic forces that shape the patient–physician relationship and allow for the development of an alliance between patients and physicians that can help preserve the essentials of the relationship.     

Zones of Maturation and Regression,and Psychoanalytic Technique

This article summarizes Balint's thoughts on the fundamental problems of psychoanalytic technique and their links with libidinal development as conceived by him.     

Lines of advance in psychoanalytic psychotherapy

Freud's 1919 paper is taken as a starting-point to review how far we have advanced towards fulfilment of his prophetic remarks about the need to develop psychoanalytic psychotherapy for the masses. A glance is taken back to some of the circumstances and characters involved in Budapest where the paper was given at the 1918 congress, where there was much talk about the need to do something about the war neuroses. Similar pressures led to the founding of the Tavistock Clinic and Cassel Hospital in the UK, long before the start of the NHS. The pressures of both world wars advanced the applications of psychoanalysis; the next wave of pressures may come from NHS changes and entry into Europe. The history of psychoanalytic psychotherapy in the UK is also considered via looking briefly at the history and development of psychoanalytic publications, of the Tavistock Clinic, of psychoanalytic training, of child psychotherapy and the emergence of adult (non-medical) psychotherapy. There have always been tensions between exponents of the pure gold of analysis and the needs of its wider applications. More flexible arrangements and boundaries are necessary if we are to spread psychoanalysis beyond London and to fulfil Freud's own hopes about the large-scale application of psychoanalytic therapy.     

Winnicott, Balint, and the Independent Tradition

This article compares and contrasts two main aspects of the work of Winnicott and Balint: their theories of infantile development and their theoretical and clinical work on the use of regression as a therapeutic agent. The relationship of their thinking to aspects of the British Independent Group's theories and clinical work is noted vis-à-vis the basic acceptance of classical theory and technique, acknowledgment and use of some of Klein's contributions, the influence of trauma and the external environment on psychic development and psychopathology, the importance of holding and the setting, and the reintegration of previously split off and lost parts of the self.     

Between the basic fault and second skin

The ideas that are commonly associated with Esther Bick, such as primal skin function, defensive second skin phenomena and adhesive identity, are traditionally seen as affiliated to the larger body of work that constitutes the Kleinian school. I shall argue, however, that Bick's thinking owes a largely communally unrecognised debt to the work of her training analyst, Michael Balint. Beginning with a discussion of Bick's early psychoanalytic formation within the British Psychoanalytic Society, her ideas will be reapproached in the light of her contemporary psychoanalytic milieu, with particular reference to Balint's notions concerning primary object-love, the basic fault and space. A brief history of the Manchester Training Centre, a short-lived but pioneering British attempt to extend psychoanalytic training beyond London, is included incidentally. Bick's early intellectual openness to diverse psychoanalytic streams will then be discussed in relation to the formation of psychoanalytic groups and their relative capacity to tolerate difference.     

Michael Balint: An Overview

Balint's important work extended over a period of 40 years in two directions; firstly the development of individual sexuality, and secondly, the development of object relationships, together with their relationship to psychoanalytical technique. He introduced the concept of primary love and was one of the pioneers in the thinking of the interdependence of mother and infant. He extended Ferenczi's work on therapeutic regression, introducing the concepts, among others, of benign and malignant regression, the basic fault, and the states of ocnophilia and philobatism. His applied psychoanalytic work is world famous, particularly the Balint groups for general practitioners and similar groups for marital therapists, social workers, and psychosexual counselors.     

Learning and teaching the theories of Melanie Klein

I shall attempt to bring together here thoughts of experienced clinicians and teachers who have taught Melanie Klein's theories to child psychotherapists. However, most of the contributors have also taught Klein to clinical trainees in adult psychoanalytic work and to different groups abroad and, in some cases, to already trained psychotherapists or psychoanalysts. Klein's theories are introduced at different stages in the different child psychotherapy programmes in London. For instance, the students at the Tavistock are introduced to Klein's theories before they are necessarily in their own psychoanalysis, while other trainings introduce her theories in the introductory years of the clinical training.

William Halton is one of the longest-running teachers of Klein in the Tavistock Child Psychotherapy Training and brings his 'framework' culled from many years of experience. Maria Rhode has taught the Narrative to students at the Tavistock for many years. Elizabeth Spillius, psychoanalyst, writer and teacher, brings her experiences teaching Klein to non-Kleinians. Karen Proner teaches at the Tavistock, in Italy and the United States.

TEACHING MELANIE KLEIN William Halton 10 Lincoln Road London N2 9DL