An Intensive Training for Balint group leaders, Jonesboruogh, East Tennessee, November 9 - 13, 2006

The conference was perfectly organized. There were about 50 participants. All were teachers in departments of Family medicine, who conduct Balint groups with residents. The main work was done in small groups of about 8 - 10 participants and always two co-leaders. We had 9 Balint groups during these days. At every group one of the participants presented a ”case” (a relationship with a patient). The group discussed this presentation for about 45 minutes; thereafter we discussed the process that had occurred in this group session, the style of the leaders, etc.

The two official leaders of the group conducted the first and last presentation-session, but stayed with the group all the time and conducted all the discussions that took place after the presentations. There was thus a rotation of leaders, so that every participant got the opportunity to demonstrate how he/she leads a group. Of course almost every participant also presented (spontaneously) a ”story”.

They intentionally did not use ”fish bowl” groups. They explained to me that the dynamic process in the outer group of the observers is very much different from the dynamic of the inner group and that there were always tension and frustrations after a ”fish bowl” session.

They were no lectures (only one or two short talks). In the lager group they discussed practical and general questions and issues concerning Balint groups. The questions were written down and given to the members of the faculty before the meeting. There were a lot of evaluation forms that we were asked to fill in. The members of the faculty met several times during the conference.

Some participants did their ”final examinations” for becoming a leader, in these small groups.

Concerning the content, many issues that we all know in general, were discussed in a very accurate and precise way. So that some things became really clear for me for the first time, although I am engaged in Balint work for more than 30 years.

Let me share with you the notes that I made after finishing this very interesting training:

The subject of B.G.s is the doctor - patient relationship.

What is an inter-human relationship? It is a keen communication between two people, in our case, between a physician and a patient. This communication is always partly conscious and partly not. It happens partly in the ”here and now” and partly in our memory and fantasy (transference and counter-transference processes).

When a doctor has some difficulties and/or troubles with a certain patient he/she may decide to present this problematic relationship in a B.G. The doctor always presents a certain aspect and a certain passage in a certain sequence of this relationship, a story that he understands only partly, while feeling that there is something additional, behind the facts, which makes him/her uneasy. A part of the relationship that he/she describes remains thus unconscious and therefore disturbing.

A group of (4 - 12) peers or colleagues, together with a leader and a co-leader (preferable of two genders and two different professions) listen without interruptions, in an empathic and safe atmosphere, to this presentation and will later on discuss it.

Only a doctor who is able to listen to, and to be in touch with his/her own personality is also able to listen empathically to a story and a dilemma of a colleague.

The also partly unconscious processes, which occur in the group, while this discussion takes place (lasting usually between 45 and 75 minutes), are characteristic for a small group.

The members of the B.G., where the case has been presented, discuss this story using free associations. Thus expressing freely what this case has evoked in them and how they perceived it in their fantasy, they may identify with a certain part of it or with certain persons that were described. They are asked not to give advice. The presenter, after finishing the presentation, and after answering some strictly informative questions, is asked to remain silent for a while. He/she has a chance to listen, to observe and reflect. In a later stage he/she will be invited back, to share the group discussion.

The main thing is: that the subject and the focus of this discussion will remain always this specific doctor - patient relationship. Not a discussion of medical diagnosis or treatment, not of organizational or administrative issues, not of legal or ethical problems and also not just giving general support, even when needed.

Participants may tell the group personal issues, as long as these are relevant to a relationship with the patient they represented. But a Balint group is not a therapeutic group. (Sometimes, here in Israel, we agreed to work on a doctor-doctor, or doctor-nurse relationship, but then also on the non conscious, emotional, aspect of this relationship).

It is the task of the leaders, to watch carefully that the focus will be the presenter’s relationship with the presented patient. If necessary they may try, by their interventions to bring back the discussion to this relationship. They may keep the equilibrium between a ”doctor centered” and a ”patient centered” discussion. They may thus remind the group not to forget the doctor or the patient. But their interventions must be as short as possible, usually not real detailed interpretations, so that the group can do the main work and the leaders remain mainly facilitators.

The leaders have to listen very carefully to the presented story, not only intellectually but with all their empathy using their knowledge, experience, emotional intelligence and imagination. They should become aware of the images that this presentation has evoked in them and at the same time be alert for certain clues in the presentation, as: slips of the tongue, changes of voice and expression, blind spots, etc. The presented story is somewhat like a dream, being partly conscious and partly unconscious. When they see that the group has not come to the central images they have thought about and experienced, they will intervene and see if after this redirection the group is doing the work. Only when important aspects of the presented relationship were not related to, the leaders may mention and explain them.

When the group is able to explore the unconscious part and to express it, then this process is usually very powerful, more powerful than an intervention of the leaders.

In a good working B.G. the unconscious part of the presented relationship (which has troubled the presenting doctor!) becomes at least partly conscious. So that the doctor who had presented will see his/her case at the end of the session in another and new light and in a new perspective.

This new inside later-on usually has also an influence on the coming encounters between the doctor and this patient.

We may hear about this change in following group sessions. (Follow ups).

It is not always necessary that the presenter will tell the group at the end of the session what he /she had gained in this B.G. discussion. Things should be left open…

In young B.G.s, or in B.G.s with residents or students, the leaders may be more active and more teaching.

It is very important that the leaders will afterwards review and discuss among themselves critically what had happened in this B.G. session, concerning the case that was presented and the process which has developed in the group. Sometimes Balint group leaders may do this work in a supervision group (A meta-Balint group).

As there are quite clear criteria of a good and of a progressing B.G. these processes can be evaluated by careful qualitative research methods and B.G. leaders can be trained systematically.

B.G.s are an art, every leader leads it somewhat different and every group is different. It is a container of narratives and creates its own narrative. But this art is based on scientific principles.

The basic thinking is psychoanalytical, but its application is pragmatic, flexible and not dogmatic.

Studium der Medizin. Spezialisierung: Psychiatrie und Psychotherapie, Tel Aviv Israel, Spezielle Interessen und Forschungsgebiete: Sozial-Kultur-anthropologische Psychiatrie, Psychosomatik, Verbindungen zwischen Allgemeiner-(Primärer) Medizin und Psychiatrie, Balint-Gruppen