2.8 The doctor as drug

The Tavistock Clinic, a world famous centre for psychotherapy research and practice, now occupies an unprepossessing concrete building which sticks out like a sore thumb among the redbrick villas of Hampstead. In the 1950s, however, the Tavistock Clinic was based in Hallam Street, in the Tavistock Estate, that part of London south of the Euston Road and north of Oxford Street, including Bloomsbury and Fitzrovia, which was the heartland of the capital's intellectual life in the 20th century. One of the luminaries of the Tavistock Clinic, the psychotherapist Michael Balint, worked with a number of general practitioners in what became known as Balint Groups, which destroyed for ever the concept of the doctor as watchmaker.

2.8.1 Patients consult doctors for many reasons

Patients consult doctors for many reasons but until the insights provided by the Balint groups, it was assumed that patients took their health problem along to the doctor in the same way as they took a watch along to the watchmaker when it no longer kept good time. The job of the doctor, like that of the watchmaker, was to identify the cause of the problem and fix it, returning health to the patient like the well functioning watch which was returned to the customer after it was repaired or cleaned. The Balint groups, however, started to articulate a new way of looking at consultations and gave a clear and explicit statement of their purpose which was 'the examination of the ever changing doctor/patient relationships, i.e. the study of the pharmacology of the drug 'doctor'.

2.8.2 'The doctor, the patient and his illness'

'The doctor, the patient and his illness' is the title of Michael Balint's classic book. The work of the Balint groups was controversial and although the groups, in their original form at any rate, are not part of the landscape of medical practice or education today, the impact of this book has been tremendous.

The book, summarising the work of the groups, sets out the simple story that:

• the doctor and the patient developed an emotional relationship during the consultation
• both doctor and patient had the power to influence the other
• this power could be used for good or ill
• collusion can develop between doctor and patient about which problems will be recognised and which will not
• power flows between doctor and patient

In this book Balint gives advice on ways in which psychotherapy may be used in either a single consultation or an ongoing series of consultations, but the book is most remarkable for its analysis of the process of diagnosis and the relationship between doctor, patient and illness in the long-term management of chronic health problems.

2.8.3 The apostolic function

Balint's definition of the role of the doctor emphasised the 'apostolic mission or function' which he described by saying that 'it was almost as if every doctor had revealed knowledge of what was right and what was wrong for patients to expect and to endure, and further, as if he had a sacred duty to convert to his faith all the ignorant and unbelieving among his patients.' Patients devised their own techniques for challenging the power of the doctor.

2.8.4 The games patients sometimes have to play

The apostolic function of the doctor is a powerful image but Balint's theories and 'Weltanschauung' were subsequently overtaken, in a move from what was called the psycho-dynamic view of the consultation, to a transactional view of the consultation. Transactional analysis of a social function was developed by Eric Berne, a North American psychiatrist most famous for his books such as Games People Play and What do you say after you say Hello? and in these books he described social interactions as a game.

The language of game playing is sophisticated and esoteric, for example:

• the initiator starts a game by issuing a 'con', which is an invitation to join in the game
• the second party joins the game if they have a 'gimmick' i.e. a weakness or a need,, and because they have a 'gimmick', they make a response to the 'con.'

The initiator can at any moment shift the whole basis of the game by making what is known as a switch. In the book on Understanding the Consultation, Tim Usherwood gives the following example:

Patient: Do you think I will get better (con)?

Doctor: Of course you will (response).

Patient: That's what you told my neighbour but look how bad she is now (switch).

These games were, however, also described by the British humourist Stephen Potter in his books on one-upmanship and gamesmanship, and parts of those books focus specifically on the doctor/patient relationship, on what he called MD-manship and patientship.

2.8.5 The functions of the consultation

The consultation therefore is a complex negotiation with a number of functions.

• The diagnosis and treatment of disease - the watchmaker function
• The relief of anxiety - the magical function
• The validation of illness - the St Peter function
• Filling out the forms - the bureaucratic function

As doctors seek to concentrate on the increasingly complex technical task of diagnosis and treatment, other professions are assuming the role of healer.

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