Cultivating Understanding and Compassion in Diverse Communities: An opportunity to Promote Ethical Thinking in Everyday Psychoanalytic Work

Leonie Sullivan

ABSTRACT 

My paper relates to revisiting the Australasian Confederation of Psychoanalytic Psychotherapies’ conference theme of Unity and Diversity. I will describe the generative effect of working with difference, in group situations, psychoanalytic community outreach, committee and clinical work. This rests on making use of the agreement about the group or psychoanalytic task. The common thread I will use, is based on offering “a classic Balint group” across a variety of settings. Another area of interest in this work, comes from the experience of seeing oneself from the outside and others from the inside (a common feature of Balint Work). This can address “blind spots” as well as leading to cultivating curiosity, understanding and compassion for oneself, patients and colleagues. 

Introduction

My paper relates to revisiting the theme of Unity and Diversity, I will put forward a case for the generative effect of working with difference, in group situations, psychoanalytic community outreach, committee, and clinical work. I assert the benefit of making use of the agreement about the group or psychoanalytic task. When this “work” focus is in place, it can be informed by or performed by the unique contributions of those involved. If the agreement or terms of reference welcome the diverse perspective of all, over time a forum for thinking together develops. 

In its pre conceptive phase I called this written reflection on my work, my “Dance with the Devil”, to describe my way of working psychoanalytically. As a title, it was too cryptic unless I could put the words together, to describe what this saying means for me as it was likely to be misunderstood out of context.The context for me, is my association to the quote from Walt Whitman’s: Song of Myself, “I am large, I contain multitudes”. What this has to do with my “Dance with the Devil” is, it relates to associations in my work, involving staying open to, at times conflicting possibilities, thoughts, sensations and “rememberings”. 

The examples I am going to refer to have a similar thread connecting them in my mind. That thread is about a link to experiencing “multitudes” and the generative effect of working with diversity in oneself, patients and in groups. I am referring to an inner state of mind not just an external one. 

A long time ago, an old supervisor once said to me, to make the most of my training and the conscious and unconscious processes in myself and in my patients, I must learn to “Dance with the Devil”. She was referring to a very complex internal process of what psychic change involves. Sometimes this can mean having to let go of a previously held idea or belief. In order to accommodate change, work with new ideas or revise one’s habitual ways of coping. It is necessary to be able to tolerate what I call going “back to the drawing board”, oscillating wildly, and widely, (mentally) in order to deal with the conflict within oneself and sometimes in others. Giving up old ways is challenging, which is why my supervisor, (Isca Wittenberg) made the comment about my learning to dance. She was referring to the saying “the devil you know is better than the one you don’t”: Nobody wants to make things worse, yet keeping things the same can also make things worse.

 The use of the therapist’s mind to hold, sense and eventually make sense of these multiple options is complex, hence my association to the terms “I”, “multitudes” and “Dancing with the Devil”. An important part of the dance is to hold in mind, a number of different possibilities, sensations and associations. Something similar is also what happens in a Balint group. The work of the group acts as a digestive system for the dilemma presented. 

Balint Work 

I have chosen to share some of my Balint work, because by its very nature, is along the lines of revisiting the theme of a stronger Unity through Diversity. The task is what unifies the differences in a Balint Group. It is not unusual to have a membership with diverse professional, cultural, political and religious backgrounds. This only works, if all agree to the customs of working with the method. When members listen to the dilemma presented, their role is to notice their own associations to the narrative. This is also coloured by their conscious and unconscious experiences of being together. It also involves members making an imaginative identification with the clinician in the specific situation, as well as their patient or client. This is in order to be able to speculate about what is going on in this particular relationship at this particular time. This is the task of the group and the leader’s role is to facilitate this. It is not uncommon for the dilemma presented to involve a case of over or under identification, or where the therapist feels or has felt a pressure to act.  The learning is experiential rather than didactic.

Balint work was started by Enid and Michael Balint after the Second World War, to help family doctors bear the burden of being able to help their patients enough.  Many health professionals felt the strain of being able to bear the feelings of helplessness in the face of a lot of suffering. Not dissimilar to how things are now in the world. The focus of the discussions then, was on the relationship between the doctor and their patient, with a view to assisting the development of empathy, in order to make better use of the relationship. 

These days the focus or primary task remains the same, but the participants are also commonly, those working in mental health or in hospital or educational settings. In the last 12 months, the effectiveness of the work group culture has been very powerfully demonstrated. There has been a lot of tragedy for many group members and their families as well as their patients. Several groups have been directly impacted by world events and group membership has provided a source of belonging, where in the work of the group, members’ experiences could be listened to. Additionally, use could be made of their experience, in listening to the work of others.

Balint work has in its process a link to making use of diversity. Once the presenter has finished telling the story of their dilemma, they hand the case to the group to work on. They sit out of the discussion and have the experience of the third or observer position. They have the experience of “the multitudes” in the form of each member using their own perspective to add meaning to the relationship dilemma. The leader’s role is to facilitate the group task and protect the presenter’s reflective space. The primary task and working agreement around the basic group customs is crucial to group members being able to speak freely. 

To me this demonstrates, how with a unified task, multiple and diverse perspectives add to the understanding, rather than confusing things. Most presenters report their experience has promoted further thinking and understanding, long after the discussion has finished. In some of the cases presented, the dilemma is around being able to make an empathic connection in one’s professional role, perhaps because the circumstances are too culturally different, too emotionally intense or too similar to the challenges faced by the clinician. Observing or watching the “multitudes” (group members) struggle with the “story” can sometimes assist the person who presented to find a different reflective space or even make an empathic connection with the patient they could not connect with. For instance, the therapist who for some reason is feeling intolerant and may be drawn into being dismissive. 

The case that stands out is that of an experienced therapist, who was considering refusing to see a terminally ill patient, because of the patient’s expression of angry feelings. He was aware that someone else might have been more prepared to listen to the patient’s struggle at being given a terminal diagnosis. He stated he did not have the capacity to listen and unpack the pain the patient was in. He wanted to send this patient to a more junior member of staff. The patient, a hospital orderly, had been shocked by his diagnosis and that he was given so little attention, since in his work he had always gone that bit extra to help. These things were explored in the group. The group was so full of the story, they reacted in a similar way to the presenter, with rejection, which shocked him. Initially, the group members agreed that this wasn’t a case! It was an ongoing group, so the emotional parallels were not lost but utilized in the work.

 Some of these attitudes are not always in our awareness, nor are some of the attitudes that our patients have towards us. Something in the relationship remains unmetallized. It is an awareness of this dimension that I believe can help prevent the more serious boundary violations that are at the extreme end of the continuum of enactment behavior. Developing such awareness is often only possible with the introduction of a third position.

 Background

My interest in Ethical practice as a technical issue goes back to my work at a large teaching hospital. My role was to run both therapy groups, and Balint Groups as part of a liaison psychiatry service. This led to my conviction that ongoing Balint group work could add a low cost and easily accessible method, to promote a culture of interest both in others as well as in ethical thinking in everyday work. It also coincided with my group relations training, where the emphasis on the task and setting as well as the leadership responsibility for the setting, complimented my growing interest in Balint groups. My group relations training gave me an appreciation of how a Balint group makes creative and enlivening use of diversity, the task and the setting. 

As a budding psychanalytic psychotherapist, I was aware that in both the medical world, and in individual and group therapy, the feelings that arise in the clinician could lead to them being drawn into action. In these early and diverse groups, I was “educated”, as group members worked to task, despite significant political, religious and cultural differences. Within the setting, a culture of trust developed, and I was able to see how this contributed to each member’s voice having a place. “Blind spots”, prejudices, and inevitable enactments were shared. Looking back, creating a such a space provided members with an opportunity to have their unique struggle or dilemma appreciated, through the listening of other group members who then took on the dilemma and spoke to it from the perspective of putting their own words to it as they worked with the different identifications. 

An important custom in the work is that members speak on their own behalf. This is another link to the term “I “in the work of the group and one of the things that contribute to the group being a place for all involved, to have a point of view. Members commonly reported that the groups’ thinking, stayed with them long after the group session finished. I use the word “Thinking” to represent the work giving rise to a new appreciation of the emotional reality between clinician and patient. 

The British Psychoanalyst Enid Balint discussed the need that all clinicians have to make an imaginative identification with the patient. When this does not happen there can be a failure in empathic function which also can form the basis of prejudice or discrimination. If it is not completely conscious it could be termed a blind spot. 

Recent Group Example 

This is a deidentified example where a male Psychiatry Registrar in an Emergency Department described himself playing a role ascribed to him by a distressed and critically ill female patient. He was very provoked by her. 

She presented in a highly anxious way and was having panic attacks as she had just found out she was pregnant. He assumed there was a father involved and asked if he could speak with him! After describing this misunderstanding in his initial meeting with this woman, he was happy to hand the encounter over to the group to unpack what was going on in the relationship. He sat out of the discussion, listening to group members making imaginative identifications with both himself and the patient. There were differences in how the story was heard, and members made use of their humanity in speaking about their perspectives. Some speaking from the patient’s point of view felt judged, intimidated and angry. Others identified as the registrar, assuming that of course there was a father, with no thought that this might be a pregnancy to an unmarried Scottish Backpacker. It was an ongoing group, and the presenter had the hope, that in future he could make better use of his relationships both with the woman under his care and in the future with other female patients. Other group members were both male and female, with a mix of belief systems, (Jewish, Muslim, Christian, Agnostic, Buddhist), at different stages of their careers. All contributed to the speculation about the doctor patient expectations and struggles with each other. Group members used the Balint custom of speaking on their own behalf to imagine the situation in the relationship between the two people. 

 I am using this information to try to demonstrate a creative use of the term “I” in the diversity of opinion in service of the unity of the group task. This presenter commented on what he called “a de-shaming” of his struggling with a specific cultural difference as a foreign doctor based in rural Australia. As a group member sitting out of the discussion and appreciating the group’s overwhelming frustration with the patient, helped the doctor to articulate some of his own responses and so “re-find” his professional role. Initially he was surprised by the strong responses to his woman patient. He said that with the help of the group he was able to listen in a different way. He started to feel protective and to be curious about who she was and her life story. Such comments point to ordinary Balint work being an achievable tool to promote a space in service provision for thinking about difference and or ethical/technical dilemmas. The observing self is known as having a capacity for reflective function. I want to stress that this is not the main aim of offering a Balint group but an additional benefit of the work. 

Ethical Thinking and Diversity in Balint Work 

An important possibility for understanding emerges when the therapist has the opportunity to consider and potentially contain or reflect back on their propensity to act or judge. When the feelings and pressure to act can be slowed down and digested emotionally in a group situation and from multiple perspectives, it enables the following process. “Words give meaning to experiences which then become thoughts. They arise out of associations, dreams and bodily feelings”. …When the group members can bring these experiences together it can allow them, to become conscious in words which change the experience of themselves in relation to other people” (E. Balint,1993).

For group members, the setting and specific task makes room for the relationship between clinician and patient to be thought about in an alive way, free from the pressure to formulate, treat, or problem solve. Taking pressure off the “I don’t know what to do about the Mrs. B situation”, where often the mutual helplessness and frustration is the last thing that is considered. 

Many presentations have been about what one group calls the “I just don’t get it, cultural issue “which can impact both on the choice of language used, assessment, transference, counter transference issues, as well as ongoing treatment. There are many patients with significant mental health problems, where the staff have to bear the burden of helplessness or of not being able to help the patient enough. Balint work as well as assisting in self-care, gives an appreciation of diversity thus contributing to an effective work group culture. 

In reviewing the last 12 years of my work, I noticed a common thread. Group members reported at the next meeting, an increase in their capacity to be more comfortable with their own discomfort, thus making better use of their relationships with patients. Becoming aware of this and having this understood, can help any clinician develop a different perspective on themselves and their patient. In such cases, having a group mind to focus on the specifics of each clinician’s story can make the difference in them being able to bear their experience long enough to emotionally digest and speak about it. All of us, are impacted on by what we see and hear in the consulting room. It is when we are not aware of these feelings, we can be pulled towards living them out or enacting them. 

An Area of Additional Interest

My additional interest, developed from reviewing my written recording of dilemmas and themes in my work. What emerged, was that issues of enactment or pressure to enact and the links to what was un mentalised in the relationship, were very prevalent. In over 1,500 presentations, all had dilemmas involving enactments, where over and under identifications were played out within the presentation itself and work of the group. This affirms my conviction of the effectiveness of Balint Work with family doctors, psychotherapists, psychiatrists, medical and cultural educators, psychoanalysts, psychoanalytic candidates, neurologists, oncologists, paediatric staff, physicians, and mental health staff such as perinatal staff.

 These clinicians working with front line mental health isuess,from China, Central Asia, Taiwan, Japan, India, France, USA, New Zealand, and Australia all provided feedback. 

Presentations involved either an empathic failure or a situation of the presenter being puzzeled or troubled by something and prepared to hear another perspective on it.“Blind spots” can be seen as a failure of the participants to mentalise an experience. By this I mean, putting it into words, which then creates a unique meaning, or a possibility of starting to be able “to think about our own thinking” as Jeremy Holmes would say. In the Balint group at the conclusion, there is no summing up. The presenter is left with the luxury of being able to consider the “Multitudes” of associations to the work without the pressure to problem solve or agree or disagree with what has been said.

The additional benefit in the Balint method of working, comes from seeing oneself from the outside and others from the inside, which can address “blind spots” as well as leading to cultivating understanding and compassion for oneself, patients, and colleagues. This use of what I see as diversity, can promote thinking ethically in day-to-day work.

Ethical codes are in the background of our working frame, but all too often people consult them, only once something has gone wrong. I draw on my clinical and teaching work in the Asia Pacific region and as former chair of training for both The Australian Psychoanalytical Society and The NSW Institute for Psycho Analytic Psychotherapy. I also chaired an ethics committee after having been a member for many years. This led to my interest and development of "Ethics and Enactment Workshops” involving the use of Balint Work at the International Psychoanalytical Association (IPA) in Asia Conferences and APAS open days.

Here, diversity produced an experience of a different and unified work group culture for those involved as well as an enriched perspective on a specific clinical issue. These workshops were short term opportunities for members to bring an ethical dilemma to the group to work on. Groups membership included students to senior Psychoanalysts on the verge of retirement, all from diverse professional and cultural backgrounds. The principle of the group needing to be a place for all to speak freely precluded people with dual relationships joining.

 The cases presented since 2017 have been around issues where the person presenting wanted to examine something that they had done which fell outside their usual practice behavior. Issues around lateness, forgetting appointments, falling asleep, using online settings, not being able to think clearly and difficulty in increasing fees were some of the presentations. Using the classic Balint method, the work group took on the task and the multiple meanings of these dilemmas took shape, in terms of what had not been able to be articulated in the consulting room.

 Patrick Casement, (1992) talks about the acquisition of an internal supervisor. In a Balint Group, members of ongoing groups report a similar process, of internalizing and being supported in their thinking capacity, by the group’s mind. Balint Groups provide a simple and low-cost method to keep ethical thinking both interesting and alive in our work.  The method has produced positive outcomes across theoretical, professional and cultural differences.

Conclusion

The Australasian Confederation of Psychoanalytic Psychotherapies (ACPP) as an example of a large work group, potentially offers an opportunity to come together to both represent what our combined resources have to offer the community. In addition, the potential is there to lobby and inform government policy, regarding preventative early intervention mental health care planning and resource allocation. 

This may involve restraint, at times putting the “I” on hold in terms of gratification, in service of a commitment to a common aim but drawing on the individual experiences in service of the group task. This can enhance the lived experience and resources of confederation group members. “Do I contradict myself? Very well then, I contradict myself, (I am large, I contain multitudes.)” Walt Whitman, Song of Myself 1855.   

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