Sunday, March 12, 2017

Measuring Balint Group Impact: A Proposal

I loved the idea of three levels of impact from Balint group participation that John Salinsky suggested in his keynote address to the 2nd ABS National meeting in July, 2016.  Sometimes, a participant is impacted profoundly - an aha phenomena or an epiphany - and other times, the impact is more subtle, more along the lines of support and validation, but no epiphany.  I just recently heard a Balint group member ask out loud “What part of me is she (the patient) touching?” and the group continued to discuss this for each of them who felt provoked.  I also heard one participant say “I just realized …”  and she went on to identify new awareness stimulated by the case and the group discussion.  These are examples of knowledge creation as I described it in a previous post.  One remaining challenge is to organize or systematize these ‘learnings.’  One place to begin is to review Salinsky’s levels that follow; can you discern distinct content areas within each level?  What descriptors would you use?

Bronze level
You receive all the benefits of the generic small group effects
You are a member of a group of really nice people doing the same difficult but often rewarding job as yourself
You have a safe protected space to talk about your work, your feelings, even your mistakes
You can get advice from colleagues
You feel that family medicine is not so bad after all

Silver level
You receive all the benefits above, and in addition:
You develop more interest in the patient as a person
You have more time to explore their life history
You have learned to be a better listener
You are more relaxed at work, with a greater tolerance (and more compassion, more patience) for difficult patients
You find work more satisfying, patients less persecutory
Your feelings are still ambushed by personally disturbing patients

 Gold level
You receive all the benefits of Levels 1 and 2, and in addition:
You are aware of projected patient feelings (countertransference)
You are willing to accept a share of painful feelings, helplessness, anger, irritation
You have developed greater self awareness. You recognize why some patients disturb you.
Maybe your clinical practice changes for the better. “As they became more accepting of themselves, they were more open to their patients.” (Gosling, 1996)

As I reviewed these descriptors provided by Salinsky and I recalled  themes that emerged from my own exploration of personal ‘aha’ moments, it seemed that one could separate out three different areas of content that register an impact from participation in a Balint group.  The next challenge is to describe distinctly different levels of impact in each of the three areas, I’m proposing we consider a grid such as the following:

Level 1
Level 2
Level 3
Feeling support and validation
More aware of one’s emotions (sensitivity)
Aware of counter-
transference (specificity)

Dr. - Pt. Relationship
Others have difficult patients
Appreciate patient complexity - get to know the whole patient
Discovery of reciprocal Dr. - Pt. reactions; limited but significant change

Dr. - Group  Relationship
Valuing safe, protected space to discuss patients 
Value the role of the Balint group relationships to one’s practice
Healer vs. Doctor: Greater appreciation of the impact of this work

Table 1: Balint Impact Framework

Three content areas I am suggesting are:
the impact on the individual self, 
the impact on the doctor-patient relationship and finally, 
the impact of sharing my work with a group of colleagues.  

In each of the three content areas, the first level of impact is more externally focussed, the second level is more internal, and the third level is more interactional, relating the doctor to their group as well as to their patients.  Thanks for this observation goes to Kathy Knowlton, with whom I discussed this framework.  We had the benefit of some time together after presenting a full day Balint experiential workshop to about 20 participants at the American Group Psychotherapy Association meeting in NYC (along with Laurel Milberg and Eran Metzger).  

Fresh eyes and new ideas are at the core of Balint groups themselves as well as doctor-patient relationships.  Writing can also be part of this generative process!  As I read what I have written, I’m realizing that these three levels parallel my observations and description of steps in reflective practice which I wrote about previously:  (“A Guide to Introducing and Integrating Reflective Practices in Medical Education,” The International Journal of Psychiatry in Medicine, Vol. 49 (1) 95-105, 2015)

See it to be it (recognize what is happening)
Name it to tame it (names allow us to talk about experiences)
Share it to Bear it (sharing troublesome events reduces the trouble)
Below is a table of examples that fit into these three levels of each of three content categories:

Level 1
Level 2
Level 3
Feeling support and validation from colleagues
More willing to acknowledge painful feelings
Aware of counter-transference

It’s a relief to talk about this patient
Become a better listener
Greater recognition of my emotional reactions to patients

My feelings still get ambushed by disturbing patients
Greater self-awareness - Recognize why some patients disturb you.

Dr.-Pt. relationship
I’m not the only one who has difficulty with this type of patient
Develop more interest in the patient as a person
Changes in the Dr. lead to changes for the patient – more perspective

Getting advice from colleagues - Hearing how colleagues handle these patients
Increased tolerance, compassion and patience for difficult patients
More accepting of myself and More openness to patients

Appreciate the complexity in Dr.-Pt relationships
Recognize the type of patient that triggers my reactions

Dr-Group Relationship
Valuing safe and protected space to talk about work, patients, and concerns
Recognize the role of colleagues and the group process
Greater appreciation of my role as a healer

Having an appreciation of primary care work
Increased satisfaction with work - less bothered by patients
Learn from the group’s parallel process and metaphors

Moved and touched by the sense of community in the group
More relaxed at work

Table 2: Balint Impact Examples

This chart takes the examples Salinsky listed and organizes and, in some areas, expands them into three distinct areas.  What is crucial in order for this chart to be useful is the need to delineate three distinct levels of impact so that the difference from one level to the next is a qualitative shift within the same general content area.  For example, some of the discoveries participants have about themselves as a result of these case discussions start with a sense of being less alone, and feeling validated and supported at one level.  At a second level, they may become aware of being a better listener and more aware of their own emotional experiences, and finally, at a third level, they may develop an awareness of how they react to certain patients and why.  I believe there is a similar progression in each of the other two content areas - doctor-patient relationships and the broader perspective of the physician’s role.

I believe that this or an amended version of this framework can be helpful to identify the knowledge creation that results from participation in Balint groups, and it can further delineate content areas as well as the level or depth of the impact.  I also wonder if it might be interesting to use this chart to organize the comments people make when given the opportunity to summarize their learnings or experience at the end of a Balint group’s contract or even after completing a Balint leader Intensive.   

The origin of my exploration was John Salinsky’s presentation of his musings about levels of impact.  His thinking emerged from returning to Michael and Enid Balint’s book, A Study Of Doctors, written along with Gosling and Hildebrand in 1966.  In this book, Michael Balint suggests that his seminars were not for just any G.P.!  And he developed a Mutual Selection Interview process to aid in identifying who would best benefit, AND to identify who might be disruptive and should be discouraged from attending.  
What if we had a system for screening residents or only required six (6) months participation and allowed it to be optional after that (as I believe some programs do)?  More on this to come!

What are your thoughts about the structure of this chart?  What is missing or what would you organize differently?  Let’s brain storm together!