BALINT GROUPS: Achieving Professional Resilience & Preventing Burnout Through A Relationship-Centered Approach
One of the worst impacts of the modern healthcare system has been on the culture of medicine. Whereas in the past, we had time to connect- sit down and chat between patients, celebrate a small victory or process a troubling interaction- the current environment has drained us of our time and space to talk. The relentless push towards efficiency and productivity has completely neglected our basic need to connect, share, and discuss in a safe and relaxed way. In short, the water cooler is gone! This very unfortunate drift away from each other has led most of us to feel isolated, unsupported, and sometimes even as strangers to each other. Nothing sabotages our well-being and resilience more than alienation from each other! Needless to say, the pandemic has lagely just excelerated these trends.
We may have plenty of group meetings, whether virtually because of COVID or in-person, but many of these gatherings don’t have the ingredients for truly supportive connection. Administrative meetings are filled to overflowing with urgent problems and detailed to-do lists. Case discussion forums focus on medical details and thought processes of clinical practice without giving space for personal or relational issues. Check-ins can gravitate towards colleagues’ inherent tendencies to fix, teach, or advise each other, and easily slide into toxic venting sessions or a particularly upset colleague's harangue. All of these types of interactions can leave us feeling unheard, unsupported, if not judged or criticized, and possibly worse than before.
The Balint method was formulated by the Hungarian psychoanalyst Michael Balint and his wife Enid in Britain after another global trauma worse than the pandemic- World War II. Regular meetings were set up for burned out British general practitioners and other clinicians who needed both support and community as well as to better understand themselves and their role in the clinician-patient relationship. While traditional medical training focuses on liner, logical thinking and deductive reasoning to arrive at one “right” answer, Balint groups were designed to foster the capacity for empathic reflection, imaginative conjecture, and divergent thinking. These processes actually broaden, deepen, and enrich participants appreciation of patients, colleagues, and their inter-relationships, all the while stimulating appreciation of the universally shared aspects of medicine, thereby building community.
At Resilience in Healthcare, we appreciate the deep need for group processes that help providers reflect, process, share, and learn in a safe and supportive milieu- in other words a relationship-centered grouo approach! Dr. Christophe Gimmler, a former hospitalist and current outpatient internist who also works as a community psychotherapist, and Teja Patil who works both as a hospitalist and physician coach, have spent over five years at the intersection of clinical medicine, mental health, and education. We’ve had Balint training with the American Balint Society and led groups across the SF Bay Area and nationally.
In this article, we’ll give you a sense of what Balint groups are, how they work, and how they can benefit you and your group in lowering or avoiding burnout, functioning more relationally, and building a stronger sense of collegial support and community in your group.
What Are Balint Groups?
Balint groups are a circle of doctors and/or non-physician clinicians who meet regularly, usually bi-monthly, to discuss cases with a focus on the doctor-patient relationship. Participants choose a case which is frustrating, brought up strong emotions, made them feel stuck or ineffective, or which seem confusing or unresolved. From group discussion, new insights, patterns, or choices emerge from which enhance and inform the doctor-patient relationship. This process often expands physicians’ perspective and empathy and, over time, increases their sense of self awareness and self-efficacy. The witnessing and hearing of divergent but overlapping experiences in colleagues builds an organic appreciation of the shared struggles, challenges, successes and capacities of medical providers. This shared experience cuts across and bridges fields, specialties, and sub-specialties to build a capacity for communication as well as a rich sense of camaraderie.
What Balint Groups is Not…
Psychotherapy Group: It’s not about personal process
You’re not put on the spot to share how you feel
Encounter Group: It’s not about confrontational or argumentative
Case Consultation Group: It’s not about medical content & decision-making
Topic Discussion Group: It’s not didactic or content/information-based
What Happens in a Balint Group Case Discussion?
Small group participants and the Balint group leaders or facilitators, usually two, sit in a circle (or virtual circle) and group members are asked ‘who has a case?’ Whomever is moved to volunteers to discuss a case that has been on their mind. Again, the case may be emotionally charged or evocative, the patient or family dynamics may have been confusing or challenging, or inter-professional dynamics may have been disturbing. The provider may just feel stuck or unresolved for unclear reasons. The circle listens to the presentation without interrupting and then asks simple clarifying questions (how old was the patient?) Then the presenter is asked to “sit back” from the circle for a period of 30-40 minutes. This allows them to simply listen and observe the group process of reflecting upon, reacting to, and imagining elements of the case, without any questioning from the group. If participants stray into judging, advising, fixing, teaching, or critiquing, facilitators may gently re-direct them. For the final 5-10 minutes, the presenter is allowed back into the circle to respond to what they have heard, or simply to join in the process if they prefer without commenting.
How do Healthcare Professionals Benefit from Balint?
Multiple studies of medical students, trainees and providers in many specialties and especially in family practice and other primary care arenas, published across medical and psychiatry journals, have demonstrated the great dividends of Balint group work. These effects can be divided between personal and relational domains.
The Upshot
The time and space to connect with, relate to, and draw support from colleagues has been sapped from our professional work life day-to-day. Many of the opportunities for meeting do not have the structure or intention of supporting safe, respectful, empathic, and reflective communication and interaction that we all want and need in our ongoing professional development and medical education. The Balint group experience offers just the right environment to build this sort of relationship-centered discussion at our personal and our group's organic pace. You may find that, with some help from RIH, you can build a trusted collegial group process that fosters ongoing reflection, discussion, compassion, and community. We have found that, quite often, participants in these groups go on to facilitate their group of providers into the future and maintain the momentum started with RIH facilitation.
References:
Johnson AH, Nease DE Jr, Milberg LC, Addison RB. Essential characteristics of effective Balint group leadership. Fam Med. 2004;36(4):253-259.
Kjeldmand D, Holmstrom I. Balint Groups as a Means to Increase Job Satisfaction and Prevent Burnout Among General Practitioners. The Annals of Family Medicine. Mar 2008;6(2):138-145.
Kjeldmand D, Holmström I, Rosenqvist U. Balint training makes GPs thrive better in their job. Patient Educ Couns. 2004;55(2):230-235.
Lichtenstein, A., & Lustig, M. (2006). Integrating intuition and reasoning: how Balint groups can help medical decision making. Australian Family Physician. 2006; 35(12).
Nease DE Jr, Lichtenstein A, Pinho-Costa L, Hoedebecke K. Balint 2.0: A virtual Balint group for doctors around the world. Int J Psychiatry Med. 2018;53(3):115-125.
Salinsky J. Balint under the microscope: What really happens in Balint groups?. Int J Psychiatry Med. 2018;53(1-2):7-14.
Scott CP, Milberg L, Addison R. Characterizing the good-enough Balint group: A work in progress. Int J Psychiatry Med. 2018;53(1-2):70-74.
Van Roy K, Vanheule S, Inslegers S. Research on Balint groups: A literature review, Patient Education and Counseling, 2015; 98(6):685-694.