Training general practitioners in mentalization based thinking

  1. General practice is a special field of activity. Patients present with all sorts of problems, sometimes big emotional problems, completely unorganized, directly from the street. Often GPs work under great time constraint and have not got the same time for reflection and working through of problems as for example a psychiatrist or a psychologist carrying out psychotherapy.
  2. Still much of the GP's work is some form of psychotherapy and the same psychodynamic conditions as in a psychotherapeutic relationship contribute to the doctor-patient relationship. But often this may not be realized. Holmes has compared the therapeutic relationship in general practice to a long-term psychotherapeutic relationship broken up into smaller chunks. But to carry out psychotherapy you have to be trained, and you have to get supervision.
  3. Until now training in psychological interventions in general practice has focused on training imported therapeutic models from the secondary sector and not on generating a framework for understanding patients with psychological illness in primary care. This means that there is no formulated theory for psychological interventions. GPs are often left to what some have called 'folk psychology' or 'implicit personality theories' which means that the patients do not always receive professional treatment.5Balint formulated that what was important was the very process of understanding the patient's thoughts and feelings. He also realized the doctors' need to gain reflexive insight into themselves to carry out this psychotherapeutic task.
  4. In the last decades a new concept has been introduced to describe this process of understanding and the form of relationship that should be formed with the patient.
  5. Mentalization means the capacity to understand other people's thoughts, feelings, imaginations, wishes, desires and so on and at the same time realizing your own thoughts and feelings. Being in the other's shoes but still not stepping out of your own; and also keeping a reflexive insight into your own contribution to the relationship. Actually mentalization means the same as the process of understanding which Balint described and trained with GPs in his training groups. Mentalization involves an active process of understanding; it is about process and agency more than about content. 
  6. Mentalization is linked to attachment theory and according to Holmes, Balint anticipated attachment theory by his concept of 'basic fault', which means that a person has some needs which cannot be provided for by the primary caretakers. Holmes links Balint's ideas to current integrative developments in psychotherapy. Balint's idea was to generate the story that made the patient's symptoms meaningful and he wanted to help the GPs to make their representations of this story by using their own thoughts, fantasies, emotions and imaginations, which means mentalizing the patient's situation. Therefore it seems meaningful to use the concept of mentalization as a modern conceptualization of the process of understanding the patient.
  7. Balint realized the GPs' need for training and supervision. He introduced a supervision tradition but later it disappeared in the academic recognition and specialization of general practice.
  8. In my PhD. study I have shown that GPs differ greatly as to which form of relationship they form with the patient and that this difference manifests itself both in consultations with psychological interventions and in normal consultations. Different types of GPs could be described using the concept of mentalization. Some were not mentalizing. There is a need to train GPs' mentalizing skills and we could use the training experience from mentalization based treatment where it is stressed that it is important to train the therapist's mentalizing capacity. They say:
  9. We propose that therapists' mentalizing skills are central to establishing and maintaining an effective treatment relationship and a therapeutic alliance as Bordin (Bordin, 1979) construed it. Thus, we are developing a training programme to foster therapists' mentalizing capacities in the treatment process. We aim not only to promote therapists' attentiveness to mental states in their patients but also to increase their awareness of their own mental states in the conduct of psychotherapy. (Williams et al., 2006) p. 224-225.
  10. Balint's therapy was routed in a psychodynamic thought. It was not manualized but based on a general therapeutic approach. In training programmes of mentalization based treatment it is stressed that the therapy and the training cannot be manualized. Treatment manuals teach specific techniques but not their skilful use. Manuals cannot teach creativity, which is necessary in therapy. But the therapy has to be based on a theory and some well-defined concepts. Mentalization is such a concept describing the process of understanding, but it is not linked to any psychotherapeutic brand and it can be applied in all forms of therapy. However, some structure is needed, and there is a dialectic about providing structure, as unexperienced trainees – and the patients – need some structure to feel sufficiently secure. But – imposing a firm structure is inherently mindless – and premature imposition of structure directly undermines mentalizing as it implies that the therapist already knows what is in the patient's mind.
  11. Therapists' mentalizing skills are central to establishing an effective treatment relationship. In psychological treatment research an association of a positive therapeutic relationship with clinical outcome is one of the most robust findings. This is also true for general practice. Therefore psychotherapy training should focus on teaching of basic relationship skills by increasing metalizing.
  12. Mentalization often fails and it is important to observe that what you think is mentalizing is not pseudo-mentalizing, which means that there is apparent thoughtfulness and both think that they are mentalizing but there is no real emotional understanding.
  13. Programmes for training therapists' mentalizing capacity build on structured exercises. Supervision is in groups and includes demonstration of illustrative videos, role-playing and supervision of own videoclips to identify problems. The focus shifts between watching an expert and practicing. The therapist's mentalizing capacity remains in the forefront. The supervision addresses the multilayered perceptions and relational dynamics among people who have come for help. In mentalization based therapy the therapist is rather active and asks questions to come to know more about the patient's way of thinking and feeling and imagining others' way of thinking and feeling. This inquisitive stance also transpires the supervision. One technique is to ask the trainee to question why they might adopt a particular non-inquisitive approach, e.g. concrete proposals and to think about what impact this is likely to have on the patient. This is a dialectic between structure and open inquiry.
  14. A common remark from doctors or psychologists when they hear about mentalization is 'Oh – but I already do that in this or that therapy.' However, it turns out that it is extremely difficult to apply mentalization skilfully in practice. Emotional distress suppresses mentalization and it is difficult to practice it under the emotional stress of the clinical situation. You must feel sufficiently secure; otherwise the therapy takes on a mechanistic quality that hinders the establishment and the maintenance of the alliance.
  15. GPs training could, as training in mentalization based treatment, be organized as training in supervision groups where the mentalizing capacity is trained. Such training could have a two-fold purpose: to train the GPs in the capacity to understand and to handle the emotional reactions and problems that interfere with the doctor-patient relationship and compromise the treatment in the routine consultations; additionally, to train them to be able to conduct some longer talking therapy sessions with patients with emotional problems or mental disorder. These longer therapies also have a two-fold purpose: often the GP cannot refer these patients to other places, and the patients need treatment. Having these longer therapy sessions and getting supervision on them would gradually influence the GP's understanding and relationship formation also in the routine consultations. Getting this training in supervision groups with other GPs and with a group leader who is a GP trained in supervision or a professional with a thorough knowledge of general practice will ensure the training in handling the doctor-patient relationship in general practice where a specific therapeutic brand is not appropriate.