Sunday, August 2, 2015

The Balint Evidence Gap - Part 2

The Balint Evidence Gap - Part 2

Where is the magic in a medical visit?  What does it look like or sound like?  What does the doctor say or do that is healing?  What does the patient need?  What are the conditions that support a healing process?  

Interestingly, we can consider the same questions about a Balint group - where is the magic in a Balint group?  What does it look like or sound like?  What do the leaders or participants say or do that are healing?  What are the conditions that support a healing group process?

It’s not a stretch to suggest that most magic in medicine or in Balint groups doesn’t just happen.  It’s the result of great training, good planning and people who are remarkably well tuned into themselves and each other - especially emotionally.  Patients, like Balint group presenters, come to us (the doctor or the group) in need.  They say: “Help me understand my symptoms (or my patient).”  The doctor knows the continuity patient well - the group and its leaders know each other well after they have been meeting for a while.  Michael Balint suggested that the doctor is the most frequently prescribed medicant.  What has not been deciphered is the pharmacology of that medicant.  What are the mechanisms by which the doctors do their healing - the dosing, titration, side effects, etc.  I believe that digging into the components of a Balint group’s process poses the same challenge - what is the pharmacology of the group?  What are the mechanisms of action?  I believe that deciphering these steps will help researchers target primary effects and distinguish primary, secondary, and tertiary effects which might help distinguish among the variety of measures used to demonstrate the effectiveness of Balint group participation.    

With all of this in mind (including the three ‘models’ I listed and described in Part 1),  I’d like to return to a research approach I introduced several postings ago - Realist Methodology. 

The hallmark question is:  What is working, for whom and under what circumstances?  C-M-O configurations refer to Contexts, Mechanisms and Outcomes.  Realist methods assume that not everyone is impacted in the same way by a particular intervention or mechanism.  At the same time, not everyone is starting at the same line or level.  I’m not sure one can control every variable; however, let’s acknowledge that not all Balint groups are the same!  So, let’s start with several stipulations that matter!  

1. Unless the leader(s) are trained in group process in general and/or Balint group process specifically, it cannot be considered a Balint group.  As will be seen below, without the establishment and maintenance of an emotionally safe group environment (a key responsibility of the group leaders), group members will not have the conditions to consider their own emotional struggles with patients.
2.  All group members have varying access to their own emotional experiences, their own level of emotional humility and their own emotional maturity.  Much of these personal characteristics are a function of one’s own developmental history in our families of origin.  These variations will play out in the dynamics of the group and, along with the leaders’ skills, will determine the pace and depth of the group’s development.
3.  There are significant differences in the impact of patient care experiences among health care professionals who are in school, in training or in practice.  Troubling patient interactions have a very different emotional impact on the observer (who has no responsibility for the patient’s care), the trainee (who has a preceptor to go to) and the physician in his or her own office.  

When I consider the process of a beginning Balint group, each step bears attention.  The diagram below represents a teasing apart of the complexity of a Balint group’s process into a series of C-M-O configurations.  I suggest that there is an initial context - C1, followed by an initial mechanism - M1, which yields an initial outcome - O1.  This is then followed by a second level of C-M-O and a third.  It is possible - in fact, not unusual - that a previous outcome (O2) can become the next context (C3).  The diagram below details one way to diagram these early steps in a Balint group - follow the arrows: 


When I think about the Balint group member’s experience, empathy does not emerge as an immediate result.  Using an Emotional Intelligence framework (see the previous post), empathy fits into the social awareness quadrant, and I think it may be a tertiary result only after better self awareness (recognizing one’s own emotions, expanding one’s own emotional vocabulary), and even self management (delaying one’s reaction or judgment).  What if we thought about these effects as a multi-level process, and then devise a measuring approach to take this into account? 

If I think about a psychoanalytic framework, do I want to ask group members if they became aware of being defensive, or if they were aware of the impact that their patient had on them, or if they thought of alternate ways of managing the challenges our patients bring to us?   This process took in depth explorations by Salinsky and Sackin's group.
If I think of the Johari window, do I want to ask about the presenter’s reaction to sharing a private concern about a patient (hidden quadrant) or do I want to explore the presenter’s awareness of revealing a blind spot?
And finally, are already validated questionnaires about empathy, burnout and others sufficient measures of the Balint group experience, or might we consider developing a method or categories to assess and rate the outcome of qualitative interviews?

What do you think?  Join the conversation …