Balint's Enigma

This was originally written in February, 2015:

From time to time, people who know of my involvement with Balint work ask me about evidence demonstrating that Balint works - whatever ‘works’ means and however it is measured.  So I have had an interest in research to validate and support professional investments in conducting and participating in Balint groups.  I have however struggled with how to approach this challenge.  

Coincidentally, the North American Primary Care Research Group’s (NAPCRG) winter meeting was held in New York City this year - a two hour drive for me - so I decided to attend.  I not only attended NAPCRG, I attended a pre-conference workshop on Realist Methodology.  And I got hooked enough to use this platform to begin an exploration into a research approach to explaining the value and power of Balint work.  Rather than charge forward, I’m thinking I want to get a better picture of what has already been explored and what we can learn from these explorations.  I don’t think there has been a literature review about the benefits of Balint groups, so I began asking questions using a ‘Realist’  approach.

The core Realist question and challenge is to ask: What is working, for whom, and under what circumstances!  Just asking the question this way intrigued me and started a thinking process about the impact balint has with different groups of participants.  What if we examine ‘data’ separately - qualitative and quantitative - depending on who was in the group.  Surely, medical students, residents and physicians in practice would have very different experiences in a Balint group.  Also, measures of empathy (Jefferson scale) and burnout (Maslach inventory) would yield very different conclusions about Balint work.  

One other challenge that Realist Methodology provides is to ask what theory we are testing when we do research about Balint group participation.  Clearly, the overarching approach of Michael Balint is psychoanalysis.  Balint groups are clearly not testing out psychoanalysis.  So, more specifically, how might we articulate a theory on which this process or intervention is based?  This is a very interesting endeavor - try writing down what you think the theory is behind Balint groups, and do it in a way that is testable.  I believe that Balint groups are really an intervention - an intervention into the training of residents or an intervention into the practice of medicine.

Realist Methodology would call an intervention like Balint groups a mechanism, and the result is referred to as an outcome.  The different conditions, different nature of the participants (medical students to practicing physicians), or other distinguishing factors are referred to as contexts.  We might even think about the participant’s receptivity to emotional factors or the nature of their blind spots as contexts to consider. The oversimplified equation then is: C + M = O.  In what contexts will any of a number of mechanisms lead to certain outcomes?  A Realist review is called a Synthesis because it is more than a listing and summary of references - it includes an analysis along the lines of this equation.  In short it seems like a re-examination of reported results through a Realist lens.

One direction this has taken me is to dive back into our (Balint proponents) history, published or not.  It has led me to discoveries written by not only Michael and Enid Balint, but also writings by John Salinsky and Paul Sackin, Greco and Pittinger, Andrew Elder and Oliver Samuel, additional volumes in Balint’s Mind and Medicine monograph series, and finally Philip Hopkins who I want to quote and paraphrase:

Hopkins started as a surgeon but this work failed to satisfy his desire for relationships with patients.  When he was able to shift into general practice, he says he felt ‘lost’ and unprepared by medical school.  “I realized why I had not been fully satisfied by my surgical work when I was treating only parts of my patients.  I found I was interested in patients as people…” 

This need that was not satisfied by ‘refresher courses’ led to Hopkins’ responding to “…an announcement in the medical press in 1950 inviting general practitioners to attend ‘an introductory course in psychotherapy for general practitioners …’ at the Tavistock Clinic in London.”  Hopkins also references another announcement in the medical press in 1952 “…inviting general practitioners to attend ‘a course of research cum training meetings for the purpose of studying psychological problems in general practice.’ ”  As part of these initial seminars, Hopkins also refers to Balint’s oft quoted observation that the most commonly applied mendicant was the doctor him (or her) self, and that there is no pharmacology of this most often used drug.

I’d like to offer a digression which I will connect very shortly.  I recently saw the movie The Imitation Game (which I cannot more highly recommend!).  It is the story about Alan Turing who was instrumental in breaking the code of the German’s WW II cryptography machine - Enigma.  In the movie, there is a conversation that the young 15 year old Alan (Turing) has with his one friend while at Sherborne school for boys:

YOUNG ALAN 

What’s that you’re reading?

Christopher shows him: “A Guide to Codes and Cyphers.”

CHRISTOPHER 

It’s about cryptography.

YOUNG ALAN 

What’s cryptography?

CHRISTOPHER

It’s complicated. You wouldn’t understand.

YOUNG ALAN

I’m only fourteen months younger than you. 

Don’t treat me like a child.

CHRISTOPHER 

Cryptography is the science of codes.

YOUNG ALAN 

Like secret messages?

CHRISTOPHER

Not secret. That’s the brilliant part. 

Messages that anyone can see, but no one knows what they mean, 

unless you have the key.

YOUNG ALAN (confused)

How is that different from talking? 

CHRISTOPHER

Talking?

YOUNG ALAN

When people talk to each other they never say what they mean. 

They say something else. 

And you’re supposed to just know what they mean. 

Only, I never do. So how is that different?

CHRISTOPHER (handing him the book)

Alan, I have a funny feeling that you’re going to be very good at this.

I find this idea of talking as a code fascinating.  I never thought about it this way, and yet, clearly, my training as a psychologist helps me to ask questions about what is not said, but implied - or questions about the sources of people’s beliefs - or other kinds of questions as well.  So, I’m thinking about this metaphor of a code and wonder if it might be useful in understanding some of what a Balint group does for participants: provide an entry to the code of unspoken emotions - the patient’s AND the doctor’s.  Clearly this is not the kind of code with a specific 1:1 key.  But maybe this idea could somehow contribute to developing a specific theory of Balint work.  And maybe it is a code that contributes both to empathy, burnout prevention as well as to overall higher emotional intelligence.  

I also love Hopkins’ (unintended) metaphor of being lost.  Whether we think of being lost in a forest or a ghetto or any other place that is strange to us, figuring out the language, the clues, and the signs that help us find our way is another possible route to understanding and explaining the value and power of Balint work.

If you have followed this far, what has this stirred up in you?  Feel free to share your reactions!

P.S. If you are interested in learning more about Realist Methodology, check out the web site www.ramesesproject.org  there are many resources including links to manuals, videos and many other references.