Balint Groups

by Mario Perini

gruppi BalintBalint Groups is a well-established method to train medical doctors that aims to help them deeply understand the nature and the vicissitudes of their relationship with the patient and to improve their communication with the patient and his environment, using it therapeutically, and to decrease conflicts and professional stress.
The inventor of this method, Michael Balint, was born in Budapest in 1896, his father was a general practitioner, and he became a doctor himself. After his psychoanalytic training in Berlin and Budapest, he emigrated to Great Britain in 1939 and, after World War II, he was part of the staff group at the Tavistock Clinic in London. Here he and his second wife Enid began holding training seminars for “general practitioners”; Balint groups were later named after him.
Today the training in the Balint method is spread across the world and the experiences in different countries have led to the creation of Balint Associations nationally (in Switzerland, Germany, France, the Nederlands, Great Britain, the USA, Italy, etc.). Most of them are part of the International Balint Federation. Even though attending a Balint training is mostly an individual choice made by the physicians, participation in a Balint group is part of the official medical student curriculum and GP trainees and, in Germany, physicians with this background have the right to get higher fees in their out-patient clinical practice (Ransom 1995).

Fundamental lines

The Balint Groups began at the end of 1940’s when the British Ministry for Health, as it launched the National Health System, asked the Tavistock Clinic and in particular Michael and Enid Balint to hold a psychiatric training to GPs so as to compensate the severe lack of mental health specialists. The original idea was to train general practitioners and manage the so-called “small psychiatry”, but the scheme was soon proved to be unfeasable.

However, from this attempt some important concepts arose. The Balints realized that an understanding of the therapeutic (or iatrogenic) potential in the doctor-patient relationship met much more the needs of the GPs than an extra psychiatric training. The physician’s personality – as it was discovered in the seminars at the Tavistock Clinic – was by far the most important medication in the treatment, but the GPs knew very little about this medication (its dynamic and kinetics, its posology and toxicity, its therapeutic action and side effects), as their approach was traditionally based rather on the symptoms and the illness than on the person, and even less on the relationship between the doctor and his/her patient. Balint developed this notion thouroughly in The Doctor, his Patient and the Illness (Balint 1957), a book that apparently changed the features of British medicine (Sutherland 1971).

The assumptions in the Balint Groups approach are four main points, that are currently as important as they were at the end of the 1940’s:
•    Psychological problems manifest themselves often through physical phenomana and, on the other hand, physical illness has psychological consequences.
•    The doctor is not a neutral observer and the patient in not an “isolated fish in a fishbowl”.
•    General medicine offers a fertile ground for the application of psychological thinking.
•    To understand the patient as a person and to show empathy towards him/her has in itself a therapeutic value.

Traditional medical training, focused on a nosological, objective and fragmented clinical practice and on technical and impersonal aspects of treatment, does not provide the doctor with any instrument that enable him/her to use his/her own subjectivity or a relational perspective, despite the evidence showing that a great deal of the phamily physician’s work is devoted to psychological cases and problems. How do the vicissitudes of the doctor-patient relationship lead often to dissatisfaction and anxiety for both of them, as well as being a source of diagnostical and therapeutic mistakes? How come that having technical competence, common sense and good will ultimately is not enough to be a good physician?

But then, what are the Balint Groups? What kind of training do they offer?
The Balint Group is not a didactical workshop or group therapy for doctors, but a “learning environment”, that is, a training institution that gives the physicians a chance:
•    to explore and check continuously their perception of emotional and personality factors– their own and their patients’– that play a role in the illness or interfere with the treatment or affect the therapeutic relationship;
•    to re-define their own role as GPs (without any need to become psychiatrist or psychologist), also in the broader relation with the network of services and social institutions involved in the treament process.

The main goals of this approach are:
•    greater sensitivity about the clients’ needs and an enhanced ability to understand and deal with the anxieties and difficulties implicit in a care-giving relationship, avoinding counterproductive defensive systems
•    an increase in the degree of satisfaction about one’s own work and the quality of relationships and of professional services
•    an understanding of the organisational processes and network relations that affect the work and the institutional climate, with a subsequent improvement of the clinical governement  and decrease in the risks of mistake and professional burnout.

More in details, the expected results are:
-    the ability to manage more easily – that is, with less anxiety, pain, anger or frustration – the patients that were felt as intolerable earlier;
-    the creation of a broader repertoire of strategies and personal styles that can be adapted to different patients, instead of a defensive use of rigid patterns that cannot be changed (in the anamnestic interview or the clinical examination);
-    the possibility to take the proper distance from the pressure exerted by the patients, so as  to examine the meaning before responding and to avoid “reactive”, impulsive, short-circuiting answers or acting-out;
-    an opportunity to critically analyze “in retrospect” the the medical examination process, paying attention to one’s own emotional responses to the patient’s behaviour;
-    the development of a state of mind involving a “non-judgemental curiosity” about the irrational behaviours of the patients;
-    being aware that the emotions stirred during the meeting with the patient reflect his/her state of mind, processes and unconscious conflicts about his/her self-image, life and illness (use of transference and countertransference);
-     enhanced ability to manage the relationships with one’s colleagues, the interprofessional relationships and those with bodies, istitutions and agencies with which the doctor has to interact for the treament;
-    an experience of relief and support for the doctors (both for the one presenting the case and for those who discuss it), although the goal of the group is the professional development and the role maintenance rather than personal therapy.  

Structure, atmosphere and evolution

In Balint Groups a number of doctors meet regularly with one (or two) experienced group leaders to discuss the doctor-patient relationship. In turns each participant reports about one of his/her current clinical cases – preferably a problem patient – and the other members intervene with comments, emotional responses and working hypotheses. Problems related to the patient’s psychology or personality, the interactions occurring in the therapeutic relationship, the family’s role,  the doctor’s relationships with his/her colleagues and the institutions involved in the process – such as the hospital or the local health services, will tend to emerge in the discussion.

The group meetings are not a platform for the discussion of the types of patients or the treatment techniques of “abstract” illnesses. Unlike the biomedical model, which is based on generalization, this approach mainly attends to individual differences that make the encounter between a given doctor and a given patient “unique”. The assumption underlying the Balint Groups process is that all the doctors have their habitual models of response to particular types of patients and problems and in their clinical practice they are periodically confronted with questions, dilemmas and contradictions that depend on environmental factors, such as the work context, and on personal elements, such as their age, gender and emotional life.

In the Balint Group the discussion prompts the participants to examine their individual approaches to different circumstances and to explore alternative ways of responding. The leader’s role is not to teach “contents” or to give advice, but to help the group think creatively and enrich their repertoire personal repertoire to manage difficult situations. The leader stimulates the participants to deepen their understanding of the therapeutic relationship, draws their attenton onto details that can be important clues about the relational processes and monitors the group climate to prevent it from becoming too aggressive or shifting into small-talk.

The atmosphere in Balint Groups is based on listening, acnowledging the emotions as a compass to understand the doctor-patient relationship, a climate of freedom of “giving-and-taking”, where everyone can bring a problem in the hope of learning from the group. This approach does not deal with abstract concepts – in fact it considers theoretical discussions as intellectualized defences that hampers the group’s task – and it has to fight the temptation to idealize the patient, the illness or medicine (or the Balint group itself). The discussion focuses on the feelings, the fantasies and the vicissitudes of interpersonal relationships, not on “medical issues”. Its central axis is the emotional response of the doctor to the patient.

Among the typical difficult situations brought to the Balint Groups there might be:
-    the dying patient
-    the patient to which a bad piece of news has to be told
-    the patient with a thick clinical folder (a “stuck” of medical examinations)
-    the seductive patient
-    the angry patient
-    the demanding patient
-    the dependent patient and the regressed patient
-    the hyper-anxious patient
-    the chronic patient
-    the patient “playing his own game”
-    the non-compliant patient
-    the depressed patient and the suicidal or potentially suicidal patient
-    the manipulative patient
-    the “psychosomatic” patient or the patient with marked somatizations
-    the “crazy” patient
-    the alcoholic or addicted patient
-    the patient who goes to all the consultants
-    the “scapegoat” patient who hides all the other family pathologies behind his/her illness
-    the patient who is also your neighbour, acquaintance, relative, friend, shopkeeper, clerk in your bank, your child’s teacher, etc.
-    the patient who is also one of your colleagues

How does a Balint Group work?

The Balint Group is a natural task-oriented group and, as such, it has its own life with its aging and renewal cycles. Its duration has no set time limit, but the experience shows that one gets the best results when its members participate for about two years. Until the group is working, there can be some participants leaving and other joining in or replacing them. Ideally the groups include between 6 to 12-15 members who meet for  2-3 years. Depending on the circumstances and the time limits, the duration of the meetings range between one and two hours once a week or every two weeks.

Even though the basic approach – that inspired Michael and Enid Balint’s experiences in the 1950’s and 60’s – was maintained, the Balint Groups underwent a remarkable evolution over time, as they came to deal with huge changes in medicine, the social structure, the health culture and the therapeutic relationships. As the traditional paternalistic medical roles have disappeared, the greater and more spread health knowledge, the increase in autonomy and negotiation power of the patient, along with the break-in of technology, “managed care”, and a variety of different institutional agencies at the very heart of the therapeutic alliance have introduced new models and experiences in the Balint method and practice (J. Balint 1996).

In the course of the years the method expanded and later was adapted to an increasing number of medical professionals other than the GPs, such as hospital doctors, nursing staff, psychologists, social workers, medical students, Therapeutic Community workers, educational and teaching staff, judges and lawyers working with minors and famiglie as well as interprofessional groups. The flexibility of the method chiefly depends on it being centered on:

•    the inquiry of the (therapeutic, educational, helping) relationship
•    the group action as a facilitating instrument for thinking
•    ways of experience-based learning not only based on intellectual knowledge

All these elements are not specific of the medical practice but belong to all the “helping professions”.
Compared to the original model, that implied the participation of people coming from the same work environment, in interprofessional Balint Groups a relative heterogeneity among the members in terms of professional disciplines, cultures and working languages is justified
-    as it mirrors the contemporary working models based on multidisciplinary teams and the network of services;
-    for its value in prompting the learning process and a confrontation among different perspectives, as training experiences across the world within the so-called “Tavistock model” of group relations show (Perini 2007).

The focus has not changed: it still emphasizes not the illness or the clinical picture but the patient or, rather, the relationship between the latter and his/her doctor. However, this relationship is more and more complex, as it has to deal with the patient’s family or with a therapeutic staff group that is in charge of the patient in some specific situations (hospital, Therapeutic Community, home care, hospice, ambulance), it has become part of a “case management” in a network of services, it is confronted with group processes among several therapeutic teams, it may be dealt with in the context of group medicine, or it interacts, negotiates and sometimes gets into conflict with the hospitals and their managers. Therefore, the focus of the Balint Group cannot only be on the doctor-patient dyad, but it needs to expand across a network, a relational plexus that includes the following relationships:
-    doctor-patient
-    doctor-doctor
-    general practitioner-consultant-patient
-    doctor-patient’s family
-    doctor-patient-nurse or care-giving staff
-    doctor-clinical team or colleagues
-    doctor-patient-institution (hospital, local health service, insurance, justice, social services, etc.)

As well as
-     doctor introduces the case-Balint Group members
-     Balint Group members-Balint Group leader

Faced with this scenario, which is not so reassuring, doctors often wonder (and ask to the organizers of Balint Groups) why they should engage in this further task, as their job is already so demanding. Consistently with the complexity of the picture, the answer is not as simple. We could talk about supporting the care-giving role, explain how the Balint method helps manage the group relationships and, ultimately, the organisational climate and the work relationships with the patient and all his/her environment, although this may sometimes look like an extra burden than a relief.

We could list all the development and progress indicators occurring in the Balint Groups:
-    doctors capable of “listening” to their patients (letting them talk, seizing the critical points, etc.);
-     enhanced attention paid to details that mirrors the state of the medical-patient relationship;
-    fewer “blind areas” (“unseen” aspects despite their clarity or “overlooked” though important aspects)
-    fewer purely technical or intellectualized discussions about medical or psychological aspects in favour of an action-oriented understanding;
-    fewer diagnostic and therapeutic mistakes;
-    greater and more useful participation in group discussions, greater courage to expose oneself without fearing of loosing one’s face, greater availability to offer one’s own contributions to the group without exibitionism, greater freedom of criticism without manifestations of contempt or destructiveness;
-    higher quality of observations and case reports (more complete, more detailed and more “personal” descriptions);
-    less tension with the patient  and fewer non-compliance cases;
-    less intense “detective-like” approach or interpretative inflation;
-    greater capacity to recognize the emotions at play and the recruited defences (including “role defences” connected with the physician or the patient’s status);
-     talking is less oriented towards the symptoms and more towards the relationship;
-    temporary increase in the duration of the consultancy (including the so-called “psychotherapeutic” phase) followed by greater satisfaction in one’s work;
-    greater tolerance of “uncertain” and “unknown” situations as inevitabile experiences in the medical practice (and recognition of the defensive nature of omniscient certainties)

But these advantages are true mostly for those who are living this experience. What about the others, those who do not know what it is about? What can we say that is convincing?
Maybe just this: the exploration of the therapeutic relationship tends to activate in the group a network of “support among peers”. Sometimes, when being a doctor or taking care of the patients is becoming an increasingly complicated, anxiety-provoking, disavowed and exhausting task, Balint Groups can help decrease the emotional load of the care-giving function, prevent professional burn-out and alienation and make the doctor feel a little less alone.