Balint Groups - A Participant's Experience at the RACGP Conference in Darwin 2005,

Dr Jan Orman

 

In their purest form Balint Groups continue for years with the same closed group of participants meeting fortnightly to discuss the trials and tribulations and sometimes even the joys (!) of the doctor patient relationship. They are carried out in a very structured way. There is a great deal of evidence to suggest that, in the long term, participation in Balint Groups improves confidence and job satisfaction, as well as practitioner efficacy in the delivery of medical and psychological care.

I was somewhat sceptical, given what I already thought I knew about groups in general, about Balint groups in particular and about doctors and their tendency to be a bit competitive and stuck in the medical model. What was the likelihood that 4 x 1.5 - 2 hour meetings on 4 consecutive days of a GP conference in tropical Darwin would produce positive results? However, my preconceived ideas began to get a bit wobbly even before the first session was finished. By the end of the second session I had to admit that in a very short time an extraordinary sense of trust and warmth had developed in the group allowing a good deal of honest sharing of professional experience at many levels.

Balint Groups are not group therapy for GPs, although occasionally participants enter them hoping they will be. The strict frame is designed to provide professional support that extends to transference-countertransference issues (it has a psychoanalytic history) without transgressing the boundary into territory that may be better served by personal therapy. Whilst the participants may well derive personal benefit from the process they need to be prepared to leave their personal issues to the work they do with their own therapist. Adhering to this principle makes the group manageable and also may help explain its success in the kind of time frame the Darwin experience allowed.

Balint groups need leaders. The leader's job is to ensure that the group adheres to the agreed structure, to ensure that everybody who has something to say has an opportunity to say it and to help ensure that the group process does not impact negatively on the individual. We were lucky in Darwin to have some very experienced leaders who gently and unobtrusively guided us, keeping us firmly within Balint boundaries.

My group consisted of 9 GPs and a psychologist and a pair of group leaders, both of whom were very experienced as GPs and as Balint Group leaders. The participants were very diverse in terms of age, experience, background, interest and skill. They had knowledge of Balint groups ranging from having heard about them in a passing way as undergraduates (although one remembered actually having read "the book" in the long distant past) to 2 who had experience in both participating in and leading groups. Most were ordinary GPs without a particular interest in mental health. Structure apparently may vary a little from group to group but is consistent over time within the one group. It seems to me that, despite it all sounding very rigid and paternalistic in the beginning, it was the strict adherence to structure that played the biggest role in developing group cohesion. Let me tell you about the structure of our meetings:

•  The meeting took place in a room large enough to contain a circle of chairs and private enough to allow free discussion. Steps were taken to ensure that the meeting was not interrupted. Note taking was not necessary and was in fact discouraged. Eating and drinking and other activities which would distract from the content of the meeting were not permitted.

•  Participants agreed at the outset that they would respect the confidentiality of the meeting.

•  Each session was divided into equal halves of 45 or 60 minutes depending on the duration of the meeting.

•  There were 2 case presentations per meeting.

•  In the beginning the group decided whether it wanted to follow up anything from cases presented at the previous meeting and, if the group agreed (it's all very democratic), a small amount of time was dedicated to that.

•  Participants volunteered to present. There was an expectation that everyone would have a chance to present. Cases were expected to be those which generated some difficulties in the presenter, usually difficult emotions. Cases were preferably about current patients though former patients who had left behind unresolved emotional discomforts were appropriate as well. The focus was on the relationship between doctor and patient not on clinical details of the case.

•  The presenter spent 5-10 minutes briefly presenting an unprepared case from memory in an informal way. A minute or two followed in which the participants were encouraged to ask whatever questions were needed to clarify factual information.

•  At the end of that period the presenter was asked to move his/her chair back from the circle to remind everyone that the presenter did not participate in the next part of the process.

•  Participants then observed a minute's silence in which they were asked to reflect on the scene in the consultation room from both the doctor's point of view and the patient's point of view and imagine how each person concerned was feeling.

•  The discussion which followed involved everyone except the presenter and consisted of reflection on the situation, exploration and speculation. The leader's job, difficult in the beginning but easier as participants got used to the process, was largely to keep the discussion focussed on the doctor - patient relationship.

•  At an appropriate time the leader invited the presenter to return to the circle and make any comments they felt appropriate. This may have been to add any new information that had initially been forgotten in their presentation of the case or to describe and reflect on any new ideas or perspectives he/she had discovered while listening to the discussion. Further discussion involving all participants including the presenter followed.

•  The leader then called the discussion to a halt. No solutions were attempted, no resolutions, no summing up - part of the point is to leave things somewhat up in the air for future private reflection by all concerned.

The great joy in all this for me was the honesty and openness with which communication occurred and the way in which the opportunity to hear other's perspectives could gently shift attitudes and open minds. You could see it happening very subtly for everyone in the group even before the end of the second session.

I have come away from the experience with a strong desire to explore Balint Groups further to see what they can do and a conviction that even (or maybe even especially) the least psychologically aware medical practitioners could benefit from participation in such a group. Everyone from medical students to senior clinicians should have the opportunity to do this!