Journal of the Balint Society Vol. 32, 2004. Editorial.
There are many different varieties of Balint group, perhaps as many as there are Balint group leaders. But even that allowance of diversity would exclude groups where the leader has a minimal role confined to organisation. Are some groups more authentic than others? Are some that claim the title not really Balint groups at all? Would the founder recognise them? Does it matter?
Let us start with the kind of group that is probably most familiar to readers of this Journal. We think of it as ‘the Balint Society model’1 and it can be experienced every September at the Society’s Oxford weekend. In this version, the two group leaders are likely to be general practitioners. They keep the discussion focused on the agreed subject of the emotional content of the doctor-patient relationship. They don’t use technical terms or make interpretations. They discourage too much questioning of the presenter and they protect the group members from ‘intrusive’ speculation about their personal histories. They do encourage members to imagine how the patient may be feeling and to reflect on their own spontaneous feelings about the presenter’s story.
This is subtly but significantly different from the model developed at the Tavistock clinic and also found in other groups led by psychoanalysts and psychoanalytic psychotherapists. In these groups, the leader may be silent for long periods, making no attempt to guide or intervene. Then she will gather up the threads of the discussion and offer a psychodynamic account of what has been going on in the patient’s life, in the doctor-patient relationship and possibly in the parallel process of the group. This interpretation may be taken up by the group immediately or at a later stage. Alternatively it may be ignored. Those of us who prefer the Balint Society model may argue that this style of leadership makes the group too dependent on the leader and her specialist knowledge and less willing to think for themselves. Advocates of the ‘Tavistock’ style might reply that the group members need access to the leader’s psycho-analytic insights if they are to understand their patients and themselves at a deeper level.
Looking further afield we may find some much more exotic variations which would certainly have made Michael Balint sit up and take notice. At last year’s International Congress in Berlin 2 there were demonstrations of Prismatic Balint Groups, Balint Psychodrama Groups and ‘Balint groups with active and guided imagination’. These groups all employ techniques first developed for use in therapy groups for patients. They have in common the aim of encouraging group members to cultivate an intense awareness of the emotions and fantasies induced in them by the case presentation they have just heard. This may be facilitated by lying down on the floor with eyes closed or by a role- play or a ‘sculpting’ of group members into a symbolic tableau representing the presented patient’s relational network. In all these European Balint variants, group members find themselves experiencing overwhelmingly powerful feelings. Tears are not infrequent and there seems to be a general feeling of emotional release and catharsis after a successful session. British Balinteers may find all this a bit much. After all, on this island of ours, we don’t like to let ourselves go and weep all over the place like our continental cousins. In our groups, there is little or no self-disclosure and emotions are carefully held back. I am exaggerating a little of course, because there are occasions when self-control is allowed to slip and a few tears are shed. I remember an occasion at Oxford when a mature woman group member passed a Kleenex to a tearful young man with the comment: ‘a mother always has a hankie’. All the same, these events are rare and dry eyes are the rule. It occurs to me that Michael and Enid Balint may have designed this kind of restrained Balint group especially for us British, knowing that we would never be able to cope with anything else.
What sort of groups are we most likely to find in the United Kingdom today? Oxford flowers only once a year, the Tavistock struggles to maintain a single ongoing group and we know of only a handful of groups elsewhere in the country for established family doctors. Some groups are being started for students and for hospital doctors and this is most encouraging. But the great majority of UK groups nestle within in Vocational Training Schemes for GP registrars and senior house officers.
Small group work is regarded as supremely important by those who guide and plan GP education and course organisers are more or less expected to include it. The groups are a popular part of the half-day release course — but how many of them are Balint groups? Most of them do not use the name and some course organisers would vigorously repudiate the connection. Many group leaders prefer to use a case presentation only as a starting point for a general discussion on a clinical topic. Nevertheless, the groups discuss patients and they provide a safe space for young doctors to express their feelings and concerns.
How feasible is it to run a traditional Balint group in this context? Even leaders, trained in and committed to the Balint method find it difficult. Our young doctors in training greatly appreciate the opportunities the small group provides for a free and lively interchange of ideas and feelings. But they also want to widen the frame and may feel restricted by the Balint leader’s interpersonal relationship centred agenda. Ruth Pinder’s ethnographic study of a London VTS Balint group 3 shows clearly that the group members have all sorts of other things on their minds that they want and need to bring into the group. These include the difficulties of reconciling their scientific hospital training with the human uncertainties of general practice; the cultural, racial and sexual differences which influence the attitudes of patients and doctors; the degree to which doctors can and should feel responsibility for the huge social and personal problems that they encounter every day.
Those of us who try to do ‘proper Balint’ with our Vocational Training groups are well aware that we have to relax the rules and allow in all sorts of discussions that would not be on the agenda in Oxford or Berlin. Need this be a cause for regret? Perhaps, as Ruth Pinder et al 3 suggest, Balint needs to evolve and develop as the world changes if it is to maintain its usefulness to young doctors. The needs of group members seem to differ in different times as well as in different cultures. We need to be flexible but we also need to preserve our most important core values. The report concludes: ‘The continuing ability of Balint to speak to new generations may lie in its ability to conserve the best of a well respected approach and adapt to new conditions. Getting just «the right» amount of difference means distinguishing between what Balint cannot afford to lose and what it cannot afford to keep.’
Or should we aim to be the guardians of the original Balint method, keeping the sacred tradition alive for anyone who might want to come and consult us about it?
How would you like your Balint? Rare, medium or just well done?
1. Sackin P. What is a Balint group? Journal of the Balint Society 1994;22:36-37.
2. Salinsky J and Otten H. The Doctor, the Patient and their well-being — world wide: proceedings of the thirteenth International Balint Congress, Berlin: H. Ruckdruck Celle, 2003.
3. Pinder R, McKee A, Sackin P, Salinsky J, Samuel O and Suckling H. Just the ‘right’ amount of difference: narrative research into Balint and other small groups for general practice training. A report prepared for the Royal College of General Practitioners and the Balint Society (awaiting publication).
4. Salinsky J. A new kind of Balint research? Journal of the Balint Society 2004;00:00.