Balint – An Underutilized Tool
Jeffrey Sternlieb
Nearly every patient on our schedule evokes some kind of reaction. Even no reaction or recall says something about the nature of the relationship we have or don’t have with a patient. However, some patients stay on our minds long after their appointment – we worry about them, we like (or don’t like) them, we wish we could help them more, we don’t know how to help them, we feel sad, bad or mad about our last interaction, etc., etc. When we look at our schedule for the next day, our mood, thought process and mindset could be significantly impacted by a single name. We may be experiencing significant frustration, or we may know that we will have to spend a significant amount of emotional energy, or we ‘know’ at some level that there are significant as yet unrevealed traumas that could surface at any moment. In some cases we capture, or disguise or deal with our emotional reactions by referring to the patient by their diagnosis – like borderline or personality disorder or bi-polar. Instead of identifying and acknowledging our thoughts, feelings and struggles in our work with certain patients, we, at times, unintentionally project those feelings onto the patient. In short, there’s something about some patients that is difficult to let go of, and the problem is not primarily one of diagnosis or treatment uncertainty.
Now, imagine for a moment that you dedicate a brief time (one hour every other week) when you and a small group of colleagues create an opportunity to explore what it is about a particular patient that touches his/her psychologist in certain ways. You begin by presenting this patient and the dilemma(s) in providing psychotherapy to them. The group gets a chance to ask clarifying questions – not about your diagnostic or treatment decisions – but information to help them get a better picture of this patient and how you see him or her. And then, you are asked to sit back and listen to the group generate a wide range of possible thoughts, feelings and ways of experiencing and understanding what is going on between you and your patient. There have been no case notes in the presentation – it is the impact the patient has made on you that you are presenting, and the group is asked to take in the case at an emotional level and relate and share the feelings that have welled up inside of them as they listened to your presentation.
Balint groups have gained popularity primarily as a tool in the training of family physicians through residency programs throughout the United States
The well-trained and prepared group leader makes sure you are not unduly questioned or challenged about treatment issues. The leader is also prepared to make sure the group explores what it’s like to be the psychologist who is treating this patient as well as what it must or might be like to be the patient. Finally, the leader challenges the group to explore what their thoughts are about the kind of therapist this patient needs. You get a totally different perspective about the nature of your patient’s relationship with you, the kind of a doctor this patient needs, and the challenges you have had in trying to be helpful. You leave this week’s group relieved and renewed about your dilemma because you learn to re-examine and redefine your role with this challenging patient through the eyes and ears and hearts of your colleagues. Inevitably, the issues discussed relate to other members of the group, and they too leave with added insights.
What you have participated in and benefited from is a Balint group (Balint, 1957). Balint training is named after Michael Balint, a Hungarian born British psychoanalyst who did considerable professional work with general practitioners around the psychological implications of general practice. In the 1950’s, Balint and his wife Enid began a unique type of case discussion group for general practice physicians about cases in their practice. Balint groups were conceived in the Tavistock tradition of group process, and they function similar to any small group with standard rules of process applying: honesty, ownership, respect for members, confidentiality, boundaries, safety, tolerance for divergent opinions, etc. (Hayden and Molenkamp, 1977). The work proceeds through regular ongoing sessions, that is, meeting over months to years. The group forms trust and cohesion and will go through its own stages of development. Unlike other medical or psychological case discussions, the purpose is to increase understanding of the patient’s problems, the doctor’s response to the patient and his/her communication, NOT to find solutions, offer advice, question the presenter, out do the presenter or teach medical or psychological content. The group is encouraged to speculate freely and present divergent views.
Balint groups have gained popularity primarily as a tool in the training of family physicians through residency programs throughout the United States. A survey reported in the literature that 298 of 464 family practice residency programs responded to a request for information, and nearly one-half of them included Balint groups in their programs (Brock and Stock, 1990). Further, The American Balint Society (http://familymed.musc.edu/balint/) has developed a process for training and evaluating the skills of group leaders as a way to recognize leaders who have attained an advanced level of skill in leading Balint Seminars.
In context of one of my jobs as faculty member at the Lehigh Valley (PA) Family Practice Residency program that I was introduced to Balint groups. All of our residents participate in regularly meeting Balint groups that are co-led by a family physician and a mental health professional (psychiatrist or psychologist). In addition, our faculty has met regularly in their own Balint group. There is no doubt that it contributes to the emotional well being of our providers as well as better, more meaningful care for our patients. We are interested in developing and providing leadership for ongoing Balint group(s) for any physicians in our community who have continuity patients and would like to participate in a process that adds perspective and promotes alternative ways of providing care for our patients.
Considering that the primary focus of Balint groups is on the relationship between two people – a professional and a patient – I am amazed that psychologists have not been more active in using this tool as an alternate way to explore blind spots, sensitive areas, or our own emotional challenges in providing services. Balint groups are an alternative to consultation groups and support groups, each of which has their role. However, we get few opportunities to stretch our empathy muscles and at the same time benefit from a process that encourages divergent thinking rather than center on getting the right or best solution.
In the context of meeting residency-training requirements, members of the Accreditation Council of Graduate Medical Education (ACGME) have identified a number of competencies that are met by participation in Balint groups (See http://www.acgme.org/outcome/comp/compFull.asp.) Nearly all of these competencies are applicable to psychologists:
• Improves listening skills with both patients and colleagues
• Allows you to sit with uncertainty (and complexity) without feeling the need to tease it apart.
• Encourages integrative thinking.
• Reveals group dynamics.
• Encourages empathy.
• Encourages reframing.
• Encourages thinking outside the box.
• Method for expressing frustration, pain and joy (strategy).
• Encourages camaraderie with group members.
• Encourages intimacy with group members.
• Improves observation powers.
• Shows value of being and not doing.
• Encourages reflection.
• Encourages self-evaluation.
• Improves satisfaction of practicing family physicians.
• Develops and encourages a repertoire of behaviors that may be therapeutic for a variety of patients.
• Increases capacity to listen and to understand the patient’s state of mind and how it influences the doctor’s care.
• Demonstrates increased sensitivity to and skill in dealing with psychological aspects of the patient’s illness.
• Learn to hear and react to difficult cases of colleagues in a gentle, supportive manner.
Beginning a Balint group should not be difficult., with the challenge being to gather a small group (8-12 people) willing to commit to a time and place in order to delve deeper into the understanding and use of relationship as part of the therapeutic process. I can speak from experience that it is a unique process, not duplicated by any other form of support or case consultation group, which results in a deeper knowing of what transpires between two people in a therapeutic relationship.
Dr. Sternlieb is at the Lehigh Valley Hospital Family Practice Residency program, and has a consulting company, MetaWorks (www.metaworks.bz) .
References
Balint, M. (1957), The Doctor, His Patient and the Illness, New York, International University Press, Inc.
Hayden, C. and Molenkamp, R. (1977), Tavistock Primer II, Jupiter Florida, A.K. Rice Institute.
Brock, C.D., and Stock, R.D., (1990), A Survey of Balint Group Activities in U.S. Family Practice Residency Programs, Family Medicine, 22, (1) 33-37.
Resources
Details about Balint Intensive Leader training conducted in the spring and fall can be found at the following Web site: http://familymed.musc.edu/balint/facdev.html
