Table Of ContentFirst Steps in
Psychotherapy
Teaching Psychotherapy to Medical
Students and
General Practitioners
Edited by
H. H. Wolff W. Knauss W. Brautigam
With Contributions by
H. Becker I. Bloomfield W. Brautigam
W. Knauss W. Senf D. Sturgeon H. H. Wolff
Springer-Verlag
Berlin Heidelberg New York Tokyo
Irene Bloomfield, B. A.
David Sturgeon, M. A., B. M., B. Ch., M. R. C. Psych.
Heinz H. Wolff, M. D., R R. C. P., R R. C. Psych.
University College London, School of Medicine
Department of Mental Health
117, Gower Street, GB-London WClE 6 AS
Priv.-Doz. Dr. med. Hans Becker
Professor Dr. med. Walter Brautigam
Dipl.-Psych. Werner Knauss
Dr. med. Wolfgang Senf
Klinikum der Universitat Heidelberg
Psychosomatische Klinik
ThibautstraBe 2, D-6900 Heidelberg
Title of the German edition: Erste Schritte in der Psychotherapie
© Springer-Verlag Berlin Heidelberg New York 1983
ISBN -13: 978-3-540-15042-8
ISBN-13:978-3-S40-1S042-8 e-ISBN-13:978-3-642-70169-6
DOl: 10.1007/978-3-642-70169-6
Library of Congress Cataloging in Publication Data. Erste Schritte in der Psychotherapie. English.
First steps in psychotherapy. Translation of: Erste Schritte in der Psychotherapie. Bibliography: p.
Includes index. 1. Psychotherapy-Study and teaching-Europe. 2. Medical education-Europe. 3. Family
medicine-Study and teaching-Europe. I. Brautigam, Walter. II. Knauss, W. (Werner), 1946·. III. Wolff,
Heinz, 1916·. IV. Becker, Hans, Priv.·Doz. Dr. med. V. Title. [DNLM: 1. Education, Medical. 2. Family
Practice-education. 3. Psychotherapy-education. WM 18 E73t] RC336.E7813 1985 616.89'14'071
85·2567
ISBN-13:97S-3-S40-1S042-S (U.S.)
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Preface
The contributors to this volume, like many others concerned with medical education
have for a long whilebeen conscious oft he fact that in the training ofm edical students
and in the practice of medicine too little attention is being paid to the psychological
aspects of illness and to the use of psychotherapy in patient care.
In an attempt to fill this gap medical students at University College Hospital,
London, have since 1958 been given the opportunity on a voluntary basis to treat a pa
tient with weekly analytically-orientated psychotherapy under supervision for a year
or longer. In 1977 a similar scheme was started at the Psychosomatic Clinic of Heidel
berg University. We were fortunate in obtaining generous financial support from the
European Community which has enabled teachers and students from our two uni
versities in Great Britain and the Federal Republic of Germany to collaborate in this
student-psychotherapy teaching project and to compare our experiences. In this book
we present an account of this joint educational endeavour, including our successes
and our failures, as well as our attempts to solve some of the problems we have en
countered.
We decided to let individual supervisors and teachers who inevitably differed in
their approach write their own contributions rather than try to present a unified pic
ture which would not have given a fair impression of our work and experience. Ifthis
has led to some repetition in the text we hope readers will appreciate the reason for it.
We also hope that some of the enthusiasm ofthe students and teachers involved and
the interest generated by the collaboration ofo ur two universities will be conveyed to
the reader and lead other universities to develop similar teaching methods concerned
with the psychotherapeutic aspects of medical education and practice.
Whilst parts 1 and 2 of this book are thus concerned with the teaching of
psychological understanding and basic psychotherapeutic skills to medical students,
part 3 consists of an account ofthe teaching methods in Balint groups for the training
ofg eneral practitioners in psychological and psychotherapeutic aspects oftheir work,
including a description ofa Balint group conducted by one of us (W B.) in Heidelberg.
In part 4 one of the contributors (I. B.) who was a member of a roup run by Michael
Balint himself at University College Hospital, London, gives an original account of
her own and the group's experience ofBalirit's personal style and method ofw orking.
One of the difficulties that confronted us was the task of translating the chapters
originally written in English into German and vice versa. This led to some delay
between the publication of the book in German in 1983 and the publication of this
English edition. We would particularly like to thank Springer-Verlag for all their help
and encouragement and Nick Hindley for his help in the translation. We also wish to
thank our secretaries in Heidelberg and in London for their careful work in preparing
the manuscripts.
VI Preface
Lastly, we want to express our gratitude to the medical students whose enthusiasm
was a source ofinspiration to their teachers, and to the doctors in the Balint group who
taught their leader at least as much as they, hopefully, learnt from him.
Heidelberg -London, May 1985
Heinz Wolff Werner Knauss Walter Brautigam
Contents
1 Theoretical Concepts
Heinz H. Wolff . . 1
1.1 The Place of Psychotherapy and Psychodynamic Understanding
in Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Teaching Basic Psychotherapeutic and Psychodynamic Concepts . 4
2 Teaching Psychotherapy to Medical Students . . . . . . . . . . . . . " 18
2.1 Medical Student Training: The Situation in Great Britain
David Sturgeon. . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.2 The Present State of Medical Education in the Federal Republic of
Germany
Wolfgang Senf . . . . . . . . . . . . . . . . . . .. . . . . . . 22
2.3 Development and Organisation of the Student-Psychotherapy Teaching
Scheme at University College Hospital
David Sturgeon. . . . . . . . . . . . . . . . . . . . . . . . . 28
2.4 Organisation of the Student-Psychotherapy Project in Heidelberg
Hans Becker in Collaboration with Werner Knauss . . . . 34
2.5 Problems and Methods used in the Teaching Scheme at UCH
David Sturgeon . . . . . . . . . . . . . . . . . . . . . . . . . .. 44
2.6 Differences and Similarities Between Student-Psychotherapy in London
and Heidelberg
Hans Becker and David Sturgeon. . . . . . . . . . . . . . . . . 50
2.7 The Process of Supervision: Transference and Counter-Transference
Irene Bloomfield . . . . . . . . . . . . . . . . . . . . . . . . . 55
2.8 Anxieties and Difficulties for Student-Psychotherapists
Irene Bloomfield . . . . . . . . . . . . . . . . . . . . . . . . .. 60
2.9 Follow-up Results of the Student-Psychotherapy Project in Heidelberg
Werner Knauss and Wolfgang Senf . . . . . . . . . . . . . . . 65
2.10 Two Case Studies Illustrating Success and Failure of Psychotherapy
Wolfgang Senf in Collaboration with Werner Knauss . . . . . 79
2.11 Examples and Comments by three Students on their Experience with
Patients at UCH, London.
Paul Gamer, Michele Hampson, Simon Prince . . . . . . . . . .. 90
VIII Contents
3 Psychotherapy in General Practice
Walter Brautigam ...... . 100
3.1 Introduction: The Present State of Psychotherapy . 100
3.2 Psychotherapy and General Practice . . . . . . . . 101
3.3 Balint Group: History, Concepts and Aims . . . . . 107
3.4 Psychotherapy in General Practice: Possibilities, Limitations and
Conflicts . . . . . . . . . . . . . . . . . 112
3.5 Interviewing Methods in Psychotherapy . . . . . . . . . . .. 125
3.6 Talking with Cancer Patients . . . . . . . . . . . . . . . . . 133
3. 7 Psychiatric Illness in General Practice and Reasons for Case
Presentations in Balint Groups . . . . . . . . . . 136
3.8 The Group Process in Balint Groups . . . . . . 140
3.9 Prospects for Psychotherapy in General Practice. 147
4 Personal Experience of a Balint Group led by Michael Balint
Irene Bloomfield . . . . . . . . . . . . . . . . . . . . . . 149
5 References . 159
6 Index ... 163
1 Theoretical Concepts
Heinz Wolff
1.1 The Place of Psychotherapy and Psychodynamic Understanding
in Medicine
As the result of scientific advances in medicine in the present century and especially
during the last decades doctors and their patients are often confronted with a
dilemma. On the one hand our increased knowledge of the physical processes and
mechanisms responsible for diseases has greatly improved the methods of preven
tion, diagnosis and treatment of physical illness. Alongside these developments
there has been an increasing degree of specialisation, especially in hospital practice.
As a result doctors have tended to direct their attention more and more towards the
scientific and technological aspects of medical practice; this applies especially to
those doctors who have chosen to practice in one of the more highly specialised
branches of medicine. The advantages which have arisen from these developments
are obvious in terms of greater availability of specialist expertise for diagnosis,
treatment and research.
On the negative side, however, these developments have to some extent de
tracted from the interest paid to the personal, psychological and social aspects of
illness. In other words, medical practice has become more disease-oriented and less
person-oriented (Balint 1957). Many general practitioners and some hospital
specialists have, of course, continued to acknowledge how important it is not only to
"treat the disease the patient has but also the person who has the disease"; however,
this person-oriented approach has, with few exceptions, been left to individual
doctors to develop and practice without systematic instruction or training.
This relative neglect of the person-oriented aspect of medicine has for many
years been equally obvious in medical education. Students are rightly expected in
their pre-clinical years to acquire detailed scientific knowledge of such basic subjects
as anatomy, physiology, biochemistry and pathology. Later in their clinical years,
they learn to apply this knowledge and to develop it further in relation to disease
entities, symptom formation, diagnosis and treatment. The extent to which they
learn about the personal aspects of patient care has until recently been left to the
individual student's initiative and to the interest of clinical teachers in these aspects
of medical practice. In general, medical students in British universities have a
considerable amount of personal contact with patients during their clinical years of
study whilst in German universities even during the clinical years such contact tends
to be more limited.
During the last few decades, however, a number of developments have taken
place to try and remedy this state of affairs. One of these concerns the development
of the field of psychosomatic medicine whose aim it is to integrate the biological,
2 Theoretical Concepts
psychological and social aspects of medical practice and research. Whilst it was
originally concerned mainly with a small group of so-called psychosomatic disorders
this narrower approach is gradually being replaced by a psychosomatic or "bio
psycho-social" approach to all illnesses and to every person who is ill. Psychosomatic
medicine thus concerns itself with the influence which life events, cultural and social
factors and the patient's psychological development and personality structure may
have on the onset and course of physical and mental illness, with processes of
psycho-physical interaction and with the psychological and social effects of the
illness on the patient and his family.
The influence of psychosomatic medicine on the practice of medicine has,
however, remained limited. In the United States there are a few university centres
which have developed specialised liaison departments whose function it is to provide
a medical-psychiatric liaison service and to carry out teaching and research in
psychosomatic medicine. In Britain there are no such departments; medical
psychiatric liaison work is largely carried out by a few psychiatrists in psychiatric
departments of general hospitals who are interested in the psychosomatic approach
and in liaison work. In Germany on the other hand the University Departments of
Medicine have established Departments of Psychosomatic Medicine in order to
teach the subject to medical students. However, these departments tend to be
relatively isolated from the rest of medicine and many of the patients seen are
suffering from psychoneuroses or from psychosomatic disorders in the narrower
sense of the word. It is doubtful, therefore, whether even these departments can
provide the necessary influence and education in an integrated bio-psycho-social
approach to patients in general.
Another development which arose in Britain stems from Michael Balint's work
with general practitioners (Balint 1957) and has led to the establishment of Balint
groups in several countries in Europe and in the USA. These groups were originally
mainly concerned with the nature of the interaction between the patient and his
doctor in the setting of general practice. Balint groups have made those general
practitioners who have chosen to participate in a group more aware of the influence
of themselves as persons on their patients. However, only a small proportion of
general practitioners have joined such groups, and aspects of the· psychosomatic
approach and of psychotherapy other than those related to the doctor-patient
relationship were not usually dealt with specifically in Balint groups when they were
first introduced. This has changed to some extent and a Balint group for general
practitioners run in Heidelberg is described in Part III of this book.
Another important development has been the introduction of the teaching of
behavioural sciences, mainly psychology and medical sociology, into the medical
curriculum. In Britain behavioural sciences are usually taught at some stage during
the pre-clinical years of training; the content and amount of teaching provided varies
from university to university but in general the aim is to make students more aware
of those aspects of psychology and sociology which are relevant to medicine and
psychiatry. This may include an introduction into psychodynamic concepts and
personality development, learning theory and its application to behaviour therapy,
basic psychological concepts and some teaching on psycho-physical mechanisms. As
medical students at this early stage of their medical education have very little, if any,
contact with patients even in Britain, most of what they learn in the pre-clinical
The Place of Psychotherapy and Psychodynamic Understanding in Medicine 3
behavioural science course remains relatively theoretical; its practical applications
need to be taught later on during the clinical years of training. In Britain this is done
mainly during the students' psychiatric clerkship and in some medical schools,
including University College London (see Chap. 2.1), also during medical-psy
chiatric liaison teaching whilst students are attached to various medical firms (Wolff
1966, 1967, 1980).
However, the degree to which such teaching is provided remains very limited and
we are still faced with the question of how best to help medical students and doctors
to acquire the skills needed to understand their patients' psychological problems, to
use such understanding in their day-to-day contact with patients and how to
integrate the psychological and psychotherapeutic aspects of patient care with
whatever physical treatment methods are required. We want to stress that it is not a
question of using either a psychotherapeutic or physical approach. Both are needed
in the majority of patients and these two aspects of patient care need to be
integrated.
What more can, therefore, be done to teach psychological understanding and
basic psychotherapeutic skills to students and medical practitioners in such a way
that they become as competent in this area as they are taught to become in the
physical aspects of medical practice? It is important to stress that these basic skills go
well beyond a humane, empathic and caring attitude to patients. Even this basic
attitude, though patients rightly hope to find it in their general practitioners and
specialists, varies from doctor to doctor. Some have natural gifts in this respect and
others learn to develop these qualities to a greater or lesser extent in the course of
time, often modelling themselves on others whose example impresses them in their
student or postgraduate days. Other doctors lack even these basic qualities; their
patients and students soon recognise this but may admire their other qualities, such
as their technical skills and their scientific expertise in research, teaching and clinical
work. There is room in medicine for a wide range of doctors; it would be as
unreasonable to expect those doctors whose major contribution may be in research
necessarily to be equally outstanding in their ability to relate to patients as it would
be to insist that those who are exceptionally good in their human qualities of relating
to patients also to be experts in a specialised, scientific area or in research.
What we are concerned with here is not primarily the issue of how to foster these
human qualities in students and doctors although this may, indeed, be one of the
favourable additional results of teaching basic psychological understanding. There
is now a whole body of knowledge concerning the development and functioning
of mental processes; this has emerged from the work of Freud, later modified by
himself and by other psychoanalysts, and by psychotherapists outside the psycho
analytic schools. This body of knowledge which I shall refer to as analytically-ori
ented or psychodynamic psychotherapy consists essentially of what is known about
the influence of early and later childhood experiem;e on psychological develop
ment and adult mental functioning; with the way in which intra-psychic and interper
sonal processes interact, and especially with the nature of the psychothera
peutic relationship and the manner in which this can be used to promote personal
growth and symptom relief.
These psychodynamic concepts are particularly needed to understand the mean
ing of psychoneurotic and psychosomatic symptoms, often in terms of underlying
