Saturday, February 11, 2017

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…”

  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.

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