Difficult Consultations with Adolescents

Donovan Chris, Heather Suckling

• Publisher: CRC Press
• Year: 2018
• eBook ISBN: 9781315344577
• Edition: 1
• Topic: Medicine
• Subtopic: Pediatric Medicine

This book will prove an invaluable resource for all those working in the field of primary healthcare and family medicine. Through case histories the reader will be introduced to adolescents who are depressed, to those who have been failed by the system, to those who cannot communicate their needs, and to those for whom issues of confidentiality have become critical.

Part 1

About the Difficult Consultations
with Adolescents project

Chapter1

Aims and methods of the project

Aims of the project

The primary aim of the project was to study some actual difficult consultations with adolescents, and the emotions engendered in the GP or practice nurse, in order to draw out themes that would shed light on the reasons why professionals label these consultations as ‘difficult’. Our definition of a ‘difficult consultation’ was a consultation that the professional presenting remembered as being difficult for them.

(In this chapter we provide details of the research project so that readers who are interested in evidence can understand the context in which we heard the details of the consultations. For those who are concerned only with the consultations themselves, we recommend that you turn to Part 2, page 11.)

Choice of research method

It was clear that a qualitative rather than quantitative research method would be most appropriate for this project. This decision was supported by various authorities. For example, Pope and Mays have stated that qualitative research is an essential prerequisite of good quantitative research, particularly in areas where there has been little previous investigation.¹ Strong emphasises the value of qualitative methods in developing concepts to aid understanding of complex behaviours, attitudes and interactions.²

Which qualitative research method to use?

It was decided that group discussion would be used as the basis of the work. As the focus was to be on the interaction between the adolescent and the health professional and the emotions engendered, a Balint group was chosen. Hull refers to the use of a Balint group ‘in capturing and amplifying the observation of the doctor/patient interaction revealed to the group.’³ Harris described the Balint group as ‘the only true ethnographic research that General Practice has evolved.’⁴

What is a Balint group?

A traditional Balint group consists of between six and ten GPs with one or two leaders. Originally the leaders were psychoanalysts, but now they are usually GPs. A recent development has been the introduction of multidisciplinary groups, which are becoming increasingly popular. The group meets regularly for one or two hours, usually weekly, for a period of one or more years. The membership is constant. Balint considered this to be essential in order to ensure that the group was ‘safe’ and the participants could build trust in each other. Confidentiality is implicit in any Balint group. (During our group sessions confidentiality was agreed, and in the reporting of cases all names have been changed to ensure anonymity of the patients and doctors involved.)

The leader opens the proceedings by asking ‘Who has a case?’, and one of the members then volunteers a presentation. This is not a traditional case presentation but the story of an encounter with a patient who for some reason continues to occupy the presenter’s mind. No notes are used because, as in psychoanalysis, it is what is remembered (and forgotten) that is significant. After the initial presentation the group discusses the case, working together to try to understand the problem. The emphasis is on the relationship between the doctor and the patient, noting the emotions aroused and speculating about the possible reasons for these emotions. The aim is not to intrude on the doctor’s inner world, but to recognise that the emotions engendered in the doctor and in the group may reflect the emotions in the patient, and to use these findings to aid diagnosis of the problem.

Balint, the doctor who developed the concept of Balint groups, concentrated on diagnosis rather than advice:

‘Advice’ is usually a well-intentioned shot in the dark, is nearly always futile and applies even more strongly to ‘reassurance’. We have found it more profitable for both doctors and patients to diagnose the problem; more often than not, when that is done, there will be no need for either advice or reassurance. The real problem is likely to be unpleasant or even painful, but it will be real and with hard work it is probable that something real can be done about it.⁵

It can be difficult for a Balint group leader to avoid ‘teaching’ and to prevent the giving of ‘advice’ and ‘reassurance’, which come easily to health professionals as they form part of their traditional roles, but these may hamper a deeper exploration of the problem.

For details of the history of Balint groups, see Appendix 2.

Method

Participants

The Balint group for this project was multidisciplinary and consisted of the following:

• nine GPs
• one child/adolescent psychiatrist
• one healthcare researcher
• one health visitor
• one health promotion nurse.

One of the GPs (Dr Chris Donovan, the project director) had considerable experience of Balint work, and another (Dr Heather Suckling) was an accredited Balint leader, so these individuals were identified as the leaders of the group.

Because of the time and place of meetings, many of the original volunteers could not attend, and some new GPs were recruited.

Meetings

There were significant differences between the project group and a traditional Balint group. Only six meetings were held, and the group membership was not constant. The number attending each meeting ranged from six to nine. Five of the members, including the two leaders, attended all of the meetings. The meetings took place in 1998–99.

Refreshments were provided, as many of the participants came straight from their evening surgeries to the meetings.

Group rules

At the first meeting the ground rules were agreed, the need for confidentiality was emphasised, and the group’s aims and objectives were confirmed (see below).

The leaders would like to comment that, despite the lack of constant membership of the group, a safe and trusting environment was established without difficulty from the beginning. This was a tribute to the commitment, experience and integrity of the group members.

Aim and objectives of the group

Aim

To improve communication between the doctor or healthcare worker and the adolescent by studying the interactions between them.

Objectives

• To look at actual consultations with particular reference to the doctor-patient or health worker-client relationship.
• To identify common themes or difficulties in the consultation.
• To identify feelings engendered by the consultation both in the doctor or healthcare worker and in the group.
• To draw together general themes which could be of help when conducting future consultations.

Presentations

The group members were asked to present only adolescent consultations which had proved difficult for them. After the presentation and a period of open group discussion, the group was asked to identify the following:

• feelings engendered in the presenter
• feelings engendered in the group
• themes and difficulties in this consultation
• themes that are common in consultations with adolescents.

This proved more complicated in practice than we had envisaged. To give the reader a feel for the process, we shall illustrate it by presenting the first case in Chapter 2.

In this study we chose to use a Balint group because of its ability to highlight the emotional aspects of the consultations, but we are aware of its limitations. In such groups, conclusions may only be drawn and interpretations made from the material that the presenter remembers and chooses to report, and from the subsequent speculations from members of the group. The readers, like the group members, will...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Foreword by John Coleman
• Foreword by Ann McPherson
• About the authors
• Dedication
• Acknowledgements
• Introduction
• Part 1 About the Difficult Consultations with Adolescents project
• Part 2 The case presentations
• Part 3 Factors that can affect adolescent consultations
• Part 4 Professionals’ perspectives
• Part 5 Conclusions
• Appendices
• Index