Balint group – a method for improving the doctor – patient relationship

1. Balint group – a method for improving the doctor – patient relationship Almos Trif, MD, PhD, JD, MA in Medical Ethics Pathology Department; Health Professions Division, Nova Southeastern University

2. The Father of the Balint groupDr. Michael Balint [1896-1970] • Disciple of Alexander (Sandor) Ferenczi [1873-1933] “l’enfant terrible" of the psychoanalysis • Ferenczi was a disciple and friend of Sigmund Freud [1856-1939] • Michael Balint was influenced also by the works of Wilhelm Reich

3. Michael Balint used to say:“I respect Freud, but I love Ferenczi” • Balint well understood the analyst’s influence and technique in the context of his relationship with Sandor Ferenczi, his analyst and mentor • Balint had to flee in England in 1939 to survive the anti-Semitic hunt • He started working in 1949 as a psychiatrist in Tavistock Clinic of London, becoming one of its pillars

4. Using the perspective of Ferenczy & Freud • Michael Balint initiated a movement for humanizing the doctor patient relationship, a holistic approach of the patient, adapting the psycho-somatic medicine for the use of the general practitioner. • After a time, the emphasis had shifted to understanding the ordinary discourse of general practice rather than trying to turn GPs into psychotherapists for selected patients.

5. Where from Balint’s idea started? • It started when he asked himself the following question: “Which is the most used medicine?” • The answer was: “The most used medicine is the doctor!” • So, he introduced the concept “The drug ‘doctor’” . • He said after: “But what are the rules for administrating this drug to the patient?!” • Attack dose? Maintain dose? How often per day, per week? • What about side-effects, idiosyncrasies, getting tired of the doctor and so on? • Apparently it was a lot to consider, so he wrote and published in 1956 a book entitled “The doctor, his patient and the illness”.

6. Other famous ideas of Michael Balint • “The collusion of anonymity” - patients may bounce from one specialist to another, with nobody taking responsibility for the patient as a person, as a whole. • “The doctor's apostolic function” - The doctor's tendency to have unrealistic expectations of the patient, based on the doctor's own values. ('You should give up alcohol. I never touch it') • “The new beginning” – using the positive regression in a constructive mode towards self-analyzing attitudes • “Learning anything new implies first forgetting previous learned attitudes” – re-learning ins essential for self improvement • “Understanding your patient psychological needs doesn’t imply suffering with him!” – being like this needs a lot of training

7. Who was involved in the Balint group? The group consisted of about eight or nine GPs who had answered an advertisement to sign up for a series of seminars on 'the psychological aspect of general practice'. When the group assembled, Michael invited then to present the case histories of patients who were bothering or puzzling them. So the immediate gain was that they were able to share some of their worries about these difficult patients with their colleagues. Balint suggested that they invite difficult patients to come for a long interview outside surgery hours to talk about their lives Besides medical doctors, today groups include: • medical, nursing & physician assistant students • Psychologists / pedagogues / chaplains, theologians • jurisprudence doctors

8. How did Michael Balint spread the Balint group? • Michael worked with Enid Balint his wife who became also a psychoanalyst, from her previous background as a Registered Nurse. • The Balints traveled a good deal in Europe and groups were started in a number of countries. • Because Balint was a charismatic teacher, his work with General Practitioners has become an established worldwide institution. • Balint Societies were formed to promote the formation of new groups. • In 1972 the International Balint Federation was formed by the Societies of Britain, France, Belgium, Holland and West Germany. • There are now more than more than 20 affiliated National Societies and the Federation has organized 15 International Balint Conferences.

9. What represents the Balint group today? • Practical method in the form of group help activity, which tries to emphasize the concept of “patient focused medicine” not the “disease focused medicine” • Using some psycho-analytic concepts like “transference”, “counter-transference” and the affective response of the doctor, it assesses a holistic approach of the patient minding his/her familial, professional and social insertion • It gives a new feeling of responsibility towards the patient needs, beside the diagnosis & therapy of the condition or disease

10. What the Balint group tries to do? • Using words, the group tries to improve the therapeutic relationship and the communication between different professionals working with a patient – physician, nurse, psychologist, chaplain • Tries to build bridges between different ethnicities, religions, social strata, regions and countries

11. How does the Balint group look? • The Balint group consists of 8-12 people [doctors, nurses, students, psychologists]. • The length of the meeting varies from 60 to 90 minutes. • There is a group leader and a co-leader [help the leader not to miss people wanting to speak-up]. • Outside the group there a group supervisor, who just observes, never intervening in the group discussion until finished. • The language used should be understood by all – simultaneous translations are exceptions. • The confidentiality issues are strictly enforced [no actual data & nicknames].

12. Image from a Balint group session

13. Balint people

14. How do Balint groups differ from case discussion groups? • Unlike a case discussion group, the Balint group concentrates only on the presented patient and his/her doctor. • The group does not aim to tell the doctor how to treat or refer the patient; only to look at what has been going on between doctor and patient in the hope of understanding what they mean to each other and what they are doing to each other. • Balint group members listen to the presenting doctor's story and then discuss the case, trying to concentrate on the doctor patient relationship. • No reproaching attitudes, no wise advice providing are allowed. • In particular they try to be aware of the feelings aroused in them by the patient. This may provide important evidence about the patients own feelings as transmitted by the presenting doctor. • There is a tendency, in the group, for the presenting doctor to behave like the patient and for the group to behave like the doctor, reproducing the situation in the consulting room.

15. How do Balint groups differ from physician support groups? • Unlike a support group, the Balint group does not consider the doctors' personal difficulties in relation to colleagues, family or personal psychological history. • These matters may be touched on but are not usually pursued in depth. • As a result of working in a group over a period of time the doctors will ideally learn something useful about themselves and may even undergo what Michael Balint described as "a limited but significant change in personality". • These insights are gained through discussion of the relationships with patients rather than material from the doctor's private life.

16. What is the role of the group leader? • The work of the group leaders is crucial if the group is to pursue these aims and fulfill its purpose. • Leaders have different personalities and will lead groups in different styles, uniformity being far for being a rule. • Originally, group leaders were always psychoanalysts with a special interest in this sort of work with family physicians or other health professionals. • In some countries this is still the case, but in Britain and the USA groups are now being led by experienced family doctors and clinical psychologists. • The IBF tries to establish some competencies which are needed in order to become an effective leader.

17. What a “good enough” Balint group leader will do? • Try to keep the discussion centered on the doctor patient relationship. • Discourage too much interrogation of the presenting doctor. • Encourage people to express their own thoughts and feelings about what they have heard. • Protect group members from unwelcome intrusions on their privacy or criticism, which is hurtful without being helpful. • Represent the patient if he/she is in danger of being ignored.

18. How the presenting doctor may feel during a group session? • Secure  Insecure • Protected  Attacked • Overwhelmed with attention  Frustrated by other’s inability to see how much he/she cares about the patient • Over-criticized  Ignored compared with the attention accorded to the patient by the group • “More experienced” doctors are helpful  “Older doctors suck” • “Sincerity is worthy”  “Sincerity is a wrong tool” • “Why I am losing my time here”  “Why don’t they teach this stuff in the Medical School?”

19. How the group may help the doctors involved with the Balint method? • The doctors in the Balint group begin to understand the powerful feelings which some of these difficult patients can induce in the doctor. • They will stop hating the patients when they will understand them better. • The doctors may realize how important they are to the patients even when they appear to be doing nothing. • Some doctors find with quite a surprise that they are an important person in some of theirs patients' lives. • Just “being there” for the patient, getting along with him, treating him like a fellow human being - may be very therapeutic. • The doctors will became more tolerant, and will spend more time explaining for instance that a complete cure is probably impossible.

20. How the group may help the doctor’s patients? • The patients will appreciate being listened to a bit more and treated as human beings, not as cases of diseases. • A few would lose their symptoms once they will be able to talk about their personal problems to a sympathetic doctor. • And even if they do not improve, they may become more tolerant towards the limits of actual therapy.

21. What is the Balint psychodrama? • Balint psychodrama combines the classical analytical psychodrama Moreno with the Balint group activity • After the presentation of the case in the Balint group, with a special designed occasion, some very well trained members combine the theatrical technique of “role game” using their voices, and body language for best describing how they understood the doctor-patient relationship • The dynamic of the relationship and the “self-identifications” are more obvious for the doctor who brought the case, and he/she may try to adjust the attitudes described