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!

Sunday, March 5, 2017

The Power of Ideas - Bridging a Gap?

If you did not attend the American Balint Society’s (ABS) 2nd National Meeting in July, 2016, you missed a lot!  You missed the opportunity to spend several days with a group of folks who speak the same language (Balint-ese, I’ll call it), and there were great paper presentations, reports on new directions and programs the ABS is creating, Enid Balint essay contest winners and, of course, we all participated in Balint groups that met for each of the four days.  Our next National meeting will probably be held in 2018.  Details will be on the ABS web site when it is  scheduled and announced.  In the meantime, if you need a Balint fix, I encourage you to attend the International Balint Congress to be held in Oxford, U.K. from September 6-10, 2017.  Check out the IBF website for more details (there’s a link on the side of the blog and on the ABS website).  

And “we now return you to: The Power of Ideas!”  

At last summer’s ABS National meeting, two presentations that profoundly impacted me were the invited Keynote presentation by John Salinsky from the U.K. - our society’s midwife (mid-husband?) - and a theoretical paper by John Muench.  Neither paper knocked my socks off at the time, but I have had the opportunity to read and reread them (Shameless Commerce: you too will have an opportunity to read them in an upcoming issue of the International Journal of Psychiatry in Medicine).  

Salinsky’s Keynote (“What Really Happens in Balint?”) was entertaining - as he always is.  However, as usual, I did not fully appreciate the wisdom of his observations.  Among his comments about what really happens in a Balint group is the notion that there may be different levels of impact from participation in Balint groups.  John suggested they could be called Gold, Silver and Bronze levels (in this Olympic year - 2016), and he went on to identify a number of characteristics of each level.

This idea intrigued me!  So, I recently began a conversation with John about these levels, and he shared with me that one source of this idea was embedded in Michael Balint’s curiosity about physicians who discontinued attending his seminars (A Study of Doctors by Michael and Enid Balint and colleagues  and published in 1966).  Recently, I, myself was wondering why everyone who attended Intensives with me was not as excited or passionate about Balint groups as I was - a similar question focussed on people’s differing reactions to the Intensive or to the Balint seminar experience.   

So, one unanswered (and possibly unasked) question is: “What accounts for the differing ways that Balint Leader Training Intensive participants or even ongoing Balint group members are impacted by that experience?”   The answer is not obvious based on the participant evaluations which are universally positive.   Another way to think about this question might be: What draws people to Balint? and What keeps people at a distance?  As one might imagine, I have some thoughts about ways to research and answer that question!  Maybe you have some ideas too - feel free to chime in about your ideas in comments at the end.  

A second question to consider is: “Can the delineations between Bronze, Silver and Gold levels be distinct enough for these levels to be meaningfully useful?”  While I encourage the reader to consider what the content of such levels might be (we all know the value of fresh eyes!), I will also tease you with a promise to share my own variation on John’s very useful beginning - ‘coming attractions.’

John Muench’s presentation (“Balint Work and the Creation of Medical Knowledge”) intrigued me in some very different ways, and he totally lost me at the time of the presentation.  For me, it was the kind of talk that really required more context than the allotted amount of time could provide.  I thought he could have even used an extra slot to provide context for his context.  John briefly outlined a history of scientific inquiry and discussed revolutions in scientific thinking along with an exploration into epistemology - the study of where knowledge comes from (Kuhn, 1963, Toulmin, 1990).  Having a chance to read the paper at my own pace helped to open up these ideas (again, look for the upcoming issue of IJPM).  In particular, John discusses the humanist - rationalist dichotomy or dimension, and the resultant tyranny (my word) of evidence based medicine manifested in the primacy or even exclusivity of placebo controlled, double blind studies.  As you might guess, John describes the failure of medicine to incorporate the kind of experience and knowledge creation that a mature, regularly meeting Balint group produces.  He does so using Aristotle’s distinction of types of knowing, and in particular, references ‘phronesis,’ a type of practical knowledge which might be viewed today as professionalism.  This is distinguished from ‘techne’ which fits more in the realm of the rationally justifiable.  If you are interested in diving into this, John would recommend Aristotle’s Nicomachean Ethics, and in particular Book VI, Intellectual Virtue (or maybe he would say “Just read my paper.”).  

While I might not have done justice to John’s paper, the idea of Balint groups as a creator of knowledge may modify one’s thinking and approach to documenting the impact of Balint group participation.  Maybe, instead of trying to measure someone’s score on a scale of empathy or burnout or even job satisfaction, we might want to think about how could we describe the new knowledge that is created.  The Van Roy et. al.’s literature review of Balint related publications (2015) suggested that more, well designed qualitative research studies were necessary to document the Balint group participation impact.  Now, does it make sense to think more about Salinsky’s three levels of impact and how we might develop such a scale of qualitative changes experienced by Balint group participants?  If one proposes a qualitative shift in the way a physician thinks about their patient, measuring more or less of any variable (empathy, burnout, psychological mindedness) is by definition quantitative and insufficient.  Michael Balint, himself, spoke about a small but significant change in the doctor’s personality.  Let’s use our experience to define the nature of these changes.  We see them; we even experienced them ourselves.  How shall we describe them in ways that capture these qualitative changes?


Stay tuned for the following Coming Attractions:

My next blog post with Salinsky’s three Olympic-named levels and my thoughts about a next step!

The IJPM issue this summer focussed on the ABS 2nd National Meeting

The IBF’s International Balint Congress in Oxford, U.K. - September 6-10

The next ABS Balint Leader Training Intensive in Pittsburgh - October 2017

The ABS 3rd National Meeting - Summer 2018 - to be scheduled

And your own thoughts and reactions which I invite you to share in the comments section of this blog post - Thank You!

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.