Thursday, March 2, 2017

“I’m not sure if this is a good enough post, but …”

I couldn’t resist this title - it is the essence of what follows!

“This isn’t really a case, but …” or “I’m not sure if this is a case, but …”

Everyone who leads Balint groups recognizes this disclaimer.  Even experienced Balint group members and leaders say the exact same thing!   So, this is not a function of not knowing or not having enough Balint experience.  I recently sent a request to members of the American Balint Society asking if they had experienced ‘aha’ moments or epiphanies during their Balint leader training experiences.  One of the responses to this request began with “I’m not sure if this is an epiphany or not, but…” and I had to smile.  And then it turns out that the case or the epiphany is a particularly profound case or observation with issues or connections that the presenter did not anticipate or did not recall before they started talking or writing.  

Why does this happen? and Why are we surprised? or Why do we chuckle? 

I would like to suggest that these disclaimers are the result of two competing un- or less conscious trains of thought:

First, there is the allegiance and even the obligation to the group and one’s desire to provide a ‘good enough’ case for the group to consider.  We either recall or recreate in our minds the experience of the last case which we all concluded was profound.  We partly forget that the previous week’s case started with the same disclaimer.  In other words, we did not know that it would be a profound discussion.  But, we compare the beginning of today’s case to the end of last group’s case.  We do not yet know that our case may also provide the profound experience of previous cases - and we do not recall that the last case began with the same disclaimer.

The competing impulse is that although this case is on our mind, we may not be able to see what is under the surface or what others see.  We all have our blind spots; or we conveniently forget to include  something that does not seem relevant.  What is profound to me is that the case has enough emotional energy to surface in the physician’s mind, even without her knowing what is brewing under the surface.  It is implicit in the nature of reflective practices that we don’t know what’s ‘there’ until we ‘go there.’   Think of an ice berg!   We can see what’s above the surface, and we sense that there is a lot more below the surface - but we have no idea of what it might be, and we certainly do not know its significance.  I can’t help but wonder if there would be less delay in cases surfacing if group members had more awareness and reassurance that any case that stays with us has enough emotional valence.  

I recently wrote about the process of reflection as a three step process (IJPM, Vol. 49 (1) 95-105, 2015).  The first step is recognizing that there is something there - it comes in the form of a sensation, a thought or a feeling.  It is simply the thought of a patient, for some reason.  I called this step “You have to be it to see it.”  The next two steps are naming that thought - the recognition and naming that I might have a case - and then the sharing why a patient stays on my mind.   Step two is “You have to name it to tame it.”  We cannot talk about or discuss a case without giving it a name.  Step three is “You have to share it to bear it.”  The group is the witness to the story, and the support and validation helps us carry the emotional load.  It is the power of the group that all group members recognize after the group has settled in to its process and routine.  

Sometimes, the case is barely at step 1 - just a fleeting thought without major discomfort.  Other times, group members can’t wait to talk about a case of theirs.  Mature group members all recognize the scenario of “This might not be a case…” and they now know there’s much more to it and will do the encouraging of the hesitant presenter.  I also believe that as groups mature, there is a bit less of the obligation to provide the group with a good enough case and a bit more of a self care motive.   “I have a case I could use some help with.”


Our Reactions?  I think that the more experienced we are, the less we are surprised.  We have heard this before; we know there is often a very good case hidden in the uncertainty.  As leaders, we hear the denials and treat them as if they are a neon sign - here is where the emotional juice is likely to be!   The chuckle or a smile?  I’m guessing that they are just signs of recognition - and maybe some reassurance that there will often be some things to talk about here and possibly some surprises for the presenter.  In fact, it may be even a better case than one that seems obvious - there may be some surprises for the leaders as well.

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