The Balint Evidence Gap - Part 3

The Balint Evidence Gap - Part 3

Why is it that many of the participants in the Balint leader Intensive groups I attended have not been nearly as excited or stimulated or challenged or impacted as I have been by this process?  

What possible ways of measuring of the benefit of Balint group participation can accurately reflect the range of varying impacts on various participants?

The questions I am asking (above) have evolved as my exploration of this research challenge has progressed.  What follows is a bit of a time line of my own research journey with a description of my thinking along the way.  I conclude with a set of hypotheses and assumptions that describe my current thinking and direction on this journey.

In 2008, Don Nease, Mike Floyd and Katie Margo presented a poster describing a multi-site multi-group study measuring empathy change in residents as a result of participation in Balint groups.  Their results did not show a clear significant and positive impact, and I was disappointed.  I thought (because I was hooked on the value of Balint!!!) that surely with a larger N and maybe for a longer exposure, we could show results which would convince the world how great Balint group participation is.   For a number of primarily logistical reasons, this approach did not go anywhere.

Much later, at a NAPCRG conference in 2015, I was introduced to Realist methodology - an approach that is geared specifically to social science research. It combines qualitative and quantitative measures, and maybe most importantly addresses the empiricist - constructivist dimension.  (I wrote about this in “The Balint Evidence Gap - Part II” - 8/2/15)

I spent some time learning more about Realist methodology and explored what it might look like if I thought of the Balint group experience in that frame - Context, Mechanisms, and Outcome - which asks: “What are the outcomes that have occurred due to which interventions and under what circumstances?”  The general principles addressed some of my concerns about research on Balint group experiences - differing contexts, including the varying starting points for most participants and the general context of the group, clarifying the mechanisms of change such as leader interventions, clarifications and redirection, and finally the varying outcomes.  While I have not developed these ideas in greater depth, I continue to see the potential this approach has to account for the settings and process of the Balint group experience.

I have also been impacted by the Van Roy, et. al. literature review of published Balint studies.  I was struck by the number of different questionnaires, their lack of definitive results, and also the authors suggestions of the need for better qualitative studies.  I also discussed this in my 8-2-15 post.

Also, although the Salinsky and Sackin book was published in 2000, I did not read it until recently, and I find myself reading and rereading it.  It begins with a challenge that came from a British Balint Society lecture by Tom Main.  He made the profound observation during WW II that those farthest away from the battlefield were the most bellicose and those closest to the front lines were the most reticent.  He then wondered if this was the case in primary care as well.  Stimulated by this question, Salinsky and Sackin write about a five year experiment conducted by a group of physicians who decided to present Balint cases and then to explore what they learned about the ways we protect ourselves from the assaults we experience while on the front lines of primary care.  What I find most interesting about their conclusions is that everyone identified their own unique area of learning related to the nature of their challenging patient interactions.  

An alternate qualitative approach that I have explored emphasizes not only the process of the Balint group but also considers Balint as a culture and explores the ways this culture interacts with or impacts individual experience.  This approach is called autoethnography - an approach that combines autobiography and ethnography.  One key element of this approach is an exploration of participants’ aha moments or epiphanies.  I presented aspects of this approach at the American Balint Society’s national meeting in July, 2016, and I have prepared a more detailed personal exploration in a paper I have submitted for publication.

John Salinsky, in his keynote talk to the American Balint Society’s 2016 national meeting suggested that Balint group participation may have three different levels of impact!  What a Great Idea!  For all kinds of reasons, participants may be impacted at very different levels - from supportive and validating to a more profound impact on personal style in relating to certain patients, and finally to insight about where that personal style came from in one’s developmental experiences.

Finally, I just read a 1966 paper of Michael Balint’s where he asks the question: “Should we analysts accept responsibility for developing psycho-therapeutic techniques to be used in medical practice?”  In addressing this questions, he suggests that “These two roles (Educator or Research Group Leader) are fundamentally different, and in what follows I will try to discuss the consequences of adopting the one role or the other.”  Balint continues: “We should concentrate our attention on what we know a great deal about and which we can directly observe during the report, and this is the doctor's countertransference to his patient.”  And finally, he suggests “… our aim is first and foremost to enable him to make discoveries on his own…”

MY WORKING ASSUMPTIONS AND HYPOTHESES:

1. Since all Balint group participants start at very different places psychologically, it will be difficult to measure any common impact with an empirical or quantitative approach.   
2. Balint’s own intent is to assist physicians in their relationships with patients who have been troublesome to or for them.  His target is the physician’s counter transference in response to their patient as evidenced in their case presentation.  It is really not empathy!
3. Salinsky and Sackin focussed on physician’s defensive patterns; one could consider these parts of these patterns their counter transference reactions - and each one had a unique pattern specific to their own life experience.
4. The best approach to document counter transference reactions will be qualitative with a focus on asking Balint group participants open ended questions, allowing them to reflect on and report their own identification and description of the impact of Balint group participation.
5. Michael Balint describes both public and private aspects of counter transference reactions in the physician’s reactions to the patient on the one hand and the physician’s unconscious source of that reaction on the other hand.
6. John Salinsky’s suggestion of three levels of impact could be a guide to scoring and rating and understanding responses to a qualitative inquiry.
7. Finally, I will report (in the next several months) on the results of a recent request I made to the membership of the American Balint Society to share anonymously any epiphany or aha experiences they have had in the context of Balint group experiences.

I would like to encourage any interested Balint group participants to ask their own questions about documenting the impact of Balint groups.  If you are interested in doing your own autoethnographic exploration and would like some guidance, I would be happy to assist or collaborate.  If you just want to challenge my assumptions or develop your own, I invite your response or reactions.

Difficult Doctor-Patient Relationship Questionnaire

I recently attended a professional conference and listened to several research reports about relationships between doctors and patients.  One of the reports included in their data was from a ‘Difficult Doctor Patient Relationship Questionnaire.’   The investigator shared some of the items in this questionnaire, and I was surprised that they were all so subjective and included such negative descriptions of the patient.  There were no questions about the doctor from the patient’s point of view, although I guess they would be similarly subjective and negative.  Frankly, I was annoyed!  this seemed to me another example of the doctor blaming the patient for being sick and having multiple sets of symptoms.  It is your fault for being so complicated!

I was curious about the content of the rest of these questions, so I investigated further and found two forms - a ten item form and a 30 item form.  All of the questions were consistent in only asking about a negative and very judgmental picture of the patient.  Also to my surprise this ‘validated’ research instrument was published in the Journal of Clinical Epidemiology in 1994 and used in research published in the Annals of Internal Medicine in 2001 and in other reports discussing this topic.

While it might be useful to record and report the number and nature of patients who are seen in these ways by their physicians, this is only one side of the relationship equation.  So, I wondered how these patients might view their physician.  I changed only one word in each question - replacing “patient” with “doctor.”  I’m a firm believer of not asking anything of others that we do not ask of ourselves!   How would you answer these questions about your doctor or how would your patients answer these questions about you?   What would it take to train or to teach doctors to not be difficult?  Or is this just a product of having a bad day? or what else???

On a 1 - 5 scale, with 1 = Not at all and 5 = A Great Deal, answer the following questions: 

How difficult is this doctor’s personality?

How enthusiastic to you feel about seeing this doctor?

How unreasonable were this doctor’s expectations today?

To what extent does this doctor have health related problems due to drug or alcohol abuse?

How frustrating do you find this doctor?

How upbeat did you feel after seeing this doctor today?

How negative did you feel about this visit?

To what extent are you frustrated by this doctor’s vague comments?

How demanding was this doctor today?

Do you find yourself secretly hoping this doctor will not return?

How manipulative is this doctor?

How tense did you feel when you were with this doctor today?

Does this doctor understand your explanations about physical symptoms?

How much are you looking forward to seeing this doctor’s next visit after seeing them today?

How pleased are you with your working relationship you have with this doctor?

To what extent does this doctor neglect health related self care, e.g., diet, hygiene?

How difficult is it to communicate with this doctor?

Hmm …  doctors do have ‘labels’ for some patients - like heart-sink. However, heartsink is really more about the doctor’s feelings and not about the patient.  Patients do not try to be difficult; they are struggling with complicated sets of symptoms and they are trying to understand their diagnosis because they do not have any relief.  Their body is telling them something is wrong; sadly, their doctor (healer?) is having difficulty identifying what is wrong.  The answer is not to blame the patient.  At worst, listen, validate their experience and be willing to keep talking to explore possibilities.  Even worse than not knowing is being left alone and then being blamed.  The Difficult Doctor-Patient Relationship Questionnaire seems to be more of a measure of how much blame some doctors attribute to their most challenging patients.  It may also be an indirect measure of how burnt out a doctor has become.  It is a sad reflection of what can happen to both doctors and patients in a system that is not designed for the most complex patients.  

What is a Balint group and how does it relate to doctor-patient relationships?

 What is a Balint group and how does it relate to doctor-patient relationships?  This question comes up a lot for me because part of my identity is that of a Balint group leader.  In the U.S., I help to coordinate Balint group leader trainings.  I am particularly interested in Balint groups because I believe it is one of the most powerful methods to help physicians sort through the challenges they sometimes have with some of their patients.  I have been involved in the American Balint Society and I have become friendly with colleagues around the world through a mutual interest in Balint groups.

However, when I try to explain the Balint group process is to other professionals, they nod in acknowledgment, but there is no ‘Wow’ factor in their reaction.  It’s a bit of a disappointment to me.  When the same people observe or participate in a demonstration of a Balint group, they respond with amazement to what they just observed or experienced.  Maybe the problem is my explanation, or maybe you just cannot explain an experience - you have to have the experience.  This problem is a similar challenge to the research question: How does one measure an experience or its impact?   

Balint is not a discrete medical intervention like taking a medication or having surgery.  Those treatments are interventions that are easily researched with experimental and control groups, using placebos and randomized, double blind methods.  Balint group experiences are more about personal and professional development of one’s identity as a physician (and maybe even as a person).  Participating in a regularly meeting Balint group is an experience that may DISRUPT the physician’s pre-determined thinking about their patient or even about themselves, but it does so in a very indirect, thoughtful and respectful way.  

This is the power of Balint - it is not brute force power; it is subtle power.  It is actually the power of not using force.  It is the power of possibility.    It is the power of a culture that values the components of a meaningful healing relationship - listening, emotions, intimacy in relationships (talking about what is meaningful), self awareness and self management.  And, there is a parallel between the doctor-patient relationship and the Balint group-doctor relationship that can produce a meaningful healing experience.  It is the same power in relationships that physicians often use in treating their patients.  Doctors can also disrupt a patients pre-conceived notions about their health or their illness.  In that way, their healing continues long after their doctor’s appointment.  Hopefully, the Balint group experience stays with participants because these discussions are also disruptive.

This difference between an intervention and an experience stimulates for me a question: 

                 What is missing in my typical descriptions of a Balint group?  

• How does one explain the impact of two leaders who function solely to guide the group and to protect group members from themselves?  When leaders are watching the process, I am free to delve into the content of the case without concern about how others in the group will respond.  I know that the leaders have my back!  What possible parallels are there to that separation and clarity of roles, or to the trust that develops between leader and group member - and, could I use that parallel to explain Balint?  
• How does one explain the freedom to speculate about people’s emotional reactions without needing to be correct?  Where else can we share three (or more) different ideas to explain the same event, and not be or feel wrong?
• How does one explain, yet alone describe, the tolerance of ambiguity and uncertainty?  When one does not have to fix a situation, there is much less pressure to generate a good enough or even a better or a best solution.   
• How does one explain the absence of competition among group members?  And in what other ways does a less competitive environment impact the group members and their conversations?  
• How does one explain an emotionally safe learning and sharing group environment?  We are not even aware we have dropped some of our usual defensiveness until we return to our usual world of competition, stresses, and accountabilities.

Some of what I have written above reminds me of an anecdote that captures an aspect of what is unique about Balint.  A number of years ago, I was invited to prepare a talk for a meeting of the International Balint Federation that was held in Chicago.  I talked about the possibilities of using the Balint method with other groups of professionals who had similar types of relationships as doctors with their patients.  In making my case for a broader decimination of the Balint method, I referenced the image of a poster that was created in Portland, OR.  It pictures a group of paintings propped up in front of a museum and in the foreground is the back of a man wearing a trench coat, and he is holding it wide open.  He is presumably wearing nothing else because the caption was “Expose Yourself to Art.”  

I described this image to the group and wondered out loud what a parallel poster saying “Expose Yourself to Balint” would look like.  In the Q. and A. after sharing my thoughts, one questioner astutely suggested that this is part of the problem - participating in a Balint group involves exposing oneself.  I have thought about that observation frequently when I wonder why more people do not participate in Balint.  Exposing oneself feels risky.  I’m concerned about how others will view me after I share my case.  I don’t want anyone to try to change my mind when they hear how I react to some patients.  And until I participate in a Balint group, I don’t know or I can’t imagine what it would be like to feel free to share these thoughts and feelings.  How potentially freeing, and how scary!

Balint is a Culture!

More specifically, it is a culture of relationships; even more specifically, it is a culture of healing relationships between and among health care professionals, their patients and each other.  

Balint is a culture of being as well as doing - The Balint process encourages participants to be in touch with the feelings that get stirred up when they are with their patients - or the feelings that get stirred up when they are with a group of colleagues and hear a case that is presented.   These emotions that get stirred up are at least as important as the medical intervention - they are essential in helping to develop the kind of relationship essential to the healing process.  These emotions and the healing relationship that emerges are at the core of patient centered care.

Balint is a culture of slow, not fast - it takes time to recognize all that transpires in the space between doctor and patient, yet alone within ourselves about our own and our patient’s humanity.  Developing a healing relationship requires an investment of time to listen to and hear the patient’s story and then time to listen to and hear our own self talk about that story.

Balint is a culture of listening, active listening, listening to understand - it is easy to think we understand what is wrong and what is needed if we focus more on the symptom than on the patient.  

Balint is a culture of intimacy, personal and emotional safety - it is helpful to identify what we do to encourage or discourage relationships with our patients as well as with each other.

Balint is a culture of process more than product - creating an emotionally safe, non-judgmental learning environment is essential to being open to our colleagues’ perspectives.  

Balint is a culture of sharing, generosity - We all take a risk by participating, and we all trust the group leadership to protect us all from ourselves as well as each other.  It is the training of our leaders that helps us have the freedom to dig deep into each of our emotional wells to discover, to learn, and to grow.

Balint is a culture of personal and professional growth - The benefit of regular participation includes what we learn about ourselves as people as well as in our work roles.

Balint is a culture that values a diversity of points of view, that celebrates differing perspectives, that invites the less popular constructions of an experience - Often the less popular voice is the less frequently expressed voice and it may be the one we need to hear.  

   Balint is a culture that encourages, values and supports meaningful healing relationships between doctors and patients.  Participation in a Balint group led by a trained leader is an opportunity to learn about the impact that emotions have on doctor-patient relationships, to learn about our own emotional reactions to a wide range of patients and patient challenges, and to share with colleagues one’s own emotional challenges.

Becoming part of the Balint culture requires only a willingness to look at and share of oneself, be open to others’ perspectives, recognize the impact that emotional reactions have on relationships and on health, and realize that, as Michael Balint once said, the doctor is like a drug in his or her impact on patients.   Participating in Balint groups or Balint leader training provides a common experience and an immediate bond among participants, a shared language and in interest in similar goals.

Given all of these descriptors of the Balint culture, it makes no sense to me to do a group that is Balint-like or what some may call Balint-light.  Either the group will be safe enough to explore emotional reactions to patient dilemmas or it’s not.  Either a group is free of judging or it’s not.  Either a group runs the risk of marginalizing a member or it doesn’t.  Either a group member can feel safe to name and acknowledge having a socially undesirable feeling or they can’t.  Balint means a safe space - a group cannot be kind of safe or safe-like.  

If the idea of an emotionally safe group is appealing, try learning how to achieve that goal.  Balint leader trainings are one way to learn, but they are not the only way to learn about group leadership.  And it may take more than one attempt to learn, develop and eventually feel competent at group leadership.  The rewards for the group are immeasurable.

Is Empathy Playing Hide and Seek?

 Is Empathy Playing Hide and Seek?

  I think that there are at least two ‘belief orthodoxies’ in the Balint community: “Participation in Balint groups teaches empathy,” and “Participation in Balint groups combats (if not prevents) burnout.”  It is not surprising, then that so many efforts at documenting (researching) the impact of Balint rely on measures of these two ‘outcomes’ - Jefferson Empathy Scale and the Maslach Burnout Inventory.  However, as I have written previously, most of these research efforts have only modestly positive results.  While it is possible that in fact these are two of the outcomes that Balint group participants may experience, I believe that these two ‘outcomes’ are indirect or second or third tier effects, and that the Balint group process and experience is much more complex and multi-level.  One framework I have used to explore this complexity is a ‘Realistic' research approach which seeks to identify the varying contexts under which an intervention or mechanism of action has its impact and produces some outcome (the C-M-O configuration). 

The implication of “Participation in Balint groups teaches empathy” is that empathy is lacking among participants of Balint groups.  Very often, the cases that are brought to the Balint group are cases in which the physician has difficulty connecting with the patient or a case in which the physician experiences some interference in his/her developing a full understanding of his/her patient’s challenges.  I would like to suggest that these physicians are not lacking empathy at all; however, they have become distracted in the course of providing medical care.  (Thanks to Clive Brock for this idea of distraction!)

What could possibly be distracting a physician who is meeting with a patient seeking their help?   In order to get a better sense of possible or likely distractions, one need only look at a typical day of a physician.  They are scheduled to see patients every 15-20 minutes and very often patients have multiple concerns that need to be evaluated.  There is probably a long list of return phone calls and prescription refill requests to respond to, and the doctor has to record everything he or she does in their electronic health record.  Add to this already full day complications from a patient’s chronic illnesses, interference from insurance regulations that limit payment for preferred treatment strategies, concerns about patients who are seeking narcotics for their intractable pain, delivery of worrisome lab results from patients he saw yesterday,  and on and on.  

Empathy has not disappeared!  Rather, empathy is hiding!  Or possibly empathy is hidden - hidden behind defense mechanisms, hidden behind prejudices about narcotics (or other pet peeves), hidden behind the need to see and fix patients quickly, hidden behind false reassurances, hidden behind medical jargon and procedures and tests.   On many days, many doctors feel like they are under siege.  When any of us feels this way, we hide - we try to disappear- we need time to recoup - 

Nature to the Rescue:

A couple of days ago, after several miserable days of rainy, cloud covered skies, my wife and I were taking a walk in the park, and we were enjoying the emerging sun shine as the cloud covered skies finally began to clear.  My wife commented that “It was great that the sun has finally come out.”  And I thought to myself and then said out loud “The sun hasn’t just come out!  It has always been there - it’s the clouds that have moved, no longer blocking the sun!”   

And it hit me right away!  I have been thinking and doing some writing about the idea that physicians do not lose their empathy.  I would like to make the case that Balint groups do not need to teach empathy!  In fact, like the sun covered by clouds, empathy is always there.  Physicians who are typically empathic did not lose their empathy.  However, it is likely that any one of a number of things have intervened, interfered or otherwise distracted them from a more generous acceptance of their patient’s plight.  So now, the question becomes what is the nature of the interferences or distractions that professionals experience in their efforts to deliver medical care? 

When we are thinking about the sun, the interferences are cirrus, cumulus or stratus clouds, or a low pressure front or a nor’easter.  Wouldn’t it be interesting to have categories of interferences between doctor and patient?  What would the implications be for research?  Clive Brock has published a paper about the roles doctors take on and ways they interfere with the doctor's goals.  It's nice to play the white knight, but there are limits to his ability to rescue!  Maybe Balint group participation teaches emotional intelligence - albeit, indirectly - but E.I. just the same.  Could I possibly give up my fantasy of being a white knight?  I’ll take this on as a future post!  Maybe readers might also make their suggestions …

Medical Students and Physicians: Who is Teaching Whom

Medical Students and Physicians: Who is Teaching Whom

I have recently returned from the 19th International Balint Congress in Metz, France.  What a privilege and an opportunity it is to share and witness the stories that are told in Balint groups with health care professionals from around the world.  In addition, we have the opportunity to listen to scientific papers that are presented by colleagues interested in a better understanding of the doctor patient relationship.  And finally, we have the rare experience of listening to three award winning medical student papers about a specific patient they have cared for and about, along with their reflections of what they have learned in this process.   By the way, the next International Balint Congress will be in Oxford, UK in the fall of 2017.  Check the IBF web site for info.

I continue to be intrigued by the Balint group process and I continue to believe one of the challenges in communicating the value of participation in Balint groups is demonstrating this value in some sort of quantitative way.  Why?  Because if you are not already converted, Balint group participation is not a simple formula for insuring successful patient engagement, and it does not provide simple answers for the challenges that some patients present, and it definitely does not easily or comfortably fit into the tight, fast paced and demanding schedules many physicians endure.  Why should I take even more time away from my private life to fix the problem of not enough time in my private life?

As I alternated attending first, my Balint group, and then medical student papers, and followed again by my Balint group, I observed an interesting irony in this juxtaposition: case presentations about challenging patient encounters in these Balint groups and described by experienced clinicians contrasted with medical student papers about healing relationships with their patients.  Stepping back to look at the bigger picture of the conference, it seems like this is a case of the apprentice teaching the master.  Students don’t need their own Balint groups - they have had the luxury of time with their patients!  In fact, moderators of student paper presentation often remark that it is nice to recall or be reminded of these meaningful experiences that seem less available in practice.  

Not only do these student essays provide evidence of a source of lost joy for physicians, but they also reflect (I believe totally unintentionally) a process that well functioning Balint groups seek to recreate - really getting to know the patient!  Being at this International Congress also gave me access to the recently published The student, the patient and the illness: Ascona Balint Award Essays 2015.   Reading these papers revealed a familiar process of:

identifying barriers to relationships or patient engagement, 

exploring biases and preconceived ideas, 

discovering patient stories, 

developing emotional self awareness 

and making emotional connections. 

In the Forward to this collection of essays, Don Nease, the President of the International Balint Federation, observes that we accompany these medical students on a  

 “…journey (that) passes through stormy seas of illness and emotion toward the  destination of holistic wellness, not just the absence of physical disease. That destination is not always reached, yet through it all the students demonstrate a need to maintain a sure feel on the rudder of their own emotions and a sense of trust in the winds of human relationships.  By accompanying their patients on their journey the students illustrate that even when physical healing is not possible a sense of wellness need not be lost.” 

(Thank you , Don, for this description!)

To me, one of the most interesting of Michael Balint’s suggestions is to consider the doctor as a drug - the idea that doctors impact patients in no less a way than do pharmaceutical agents.  In fact, I recently presented a workshop at the Forum for Behavioral Sciences in Chicago titled:  The Doctor as Drug - Teaching a Pharmacology of Relationships.  However, as I read these student essays and think about the outcomes of Balint group discussions, I wonder who this drug is most impacting - the patient or the doctor!  So, I read and reread the student essays and started to write the patients’ and the ‘doctor’s’ emotions reported by these students.  Stay tuned for that report!

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 …