Balint Groups: History, Aims and Methods

by John Salinsky, June 1997

Michael and Enid Balint were psychoanalysts who started seminars for GPs (Family Physicians) in London in the 1950's.

The aim was to help the doctors with the psychological aspect of their patients' problems - and their problems with their patients. The focus of the work was on the doctor-patient relationship: what it meant, how it could be used helpfully, why it so often broke down with doctor and patient failing to understand each other.

The doctors were invited to present cases from their practices and these would be discussed by the seminar members under the guidance of one or two leaders, who were psychoanalysts. In this way the doctors were able to benefit from the analysts' way of looking at the material although they did not often make analytical interpretations.

In the early years the doctors were encouraged to hold "long interviews" before presenting a patient and saw themselves as a offering a kind of formal psychotherapy to certain patients over a limited period.

Later on, the Balints became more interested in what went on between doctor and patient in ordinary brief consultations, sometimes over a period of years. The long interview was now described as "a foreign body" in general practice. The emphasis had shifted to understanding the ordinary discourse of general practice rather than trying to turn GPs into psychotherapists for selected patients.

The Balints traveled a good deal in Europe and groups were started in a number of countries. Balint Societies were formed to promote the formation of new groups and in 1972 the International Balint Federation was formed by the Societies of Britain, France, Belgium, Holland and West Germany. There are now 12 affiliated National Societies and the Federation has organized 10 International Balint Conferences. The last two were in Charleston, South Carolina, USA (1994) and the Balint Centenary Congress in Budapest, Hungary (1996). The next one will be in Oxford, England in September 1998.

What is special about Balint groups and how do they differ from case discussion groups or physician support groups ? Both of these are to be found in VTS courses and other forms of postgraduate education.

Unlike a case discussion group, the Balint group concentrates only on the presented patient and his/her doctor. Furthermore the group does not aim to tell the doctor how to treat or refer the patient; only to look at what has been going on between doctor and patient in the hope of understanding what they mean to each other and what they are doing to each other. In the Balint group members listen to the presenting doctor's story and then discuss the case, trying to concentrate on the doctor patient relationship. In particular they try to be aware of the feelings aroused in them by the patient. This may provide important evidence about the patients own feelings as transmitted by the presenting doctor. There is a tendency, in the group, for the presenting doctor to behave like the patient and for the group to behave like the doctor. The situation in the consulting room is thus dramatically reproduced in the group. This is sometimes called "the parallel process'.

Unlike a support group, the Balint group does not consider the doctors' personal difficulties in relation to colleagues, family or personal psychological history. These matters may be touched on but are not usually pursued in depth. As a result of working in a group over a period of time the doctors will ideally learn something useful about themselves and may even undergo what Michael Balint described as "a limited but significant change in personality". But these insights are gained through discussion of the relationships with patients rather than material from the doctor's private life.

The role of the group leader

If the group is to pursue these aims and fulfill its purpose, the work of the group leaders is crucial. Of course, leaders have different personalities and will lead groups in different styles, but if the leaders are not committed to the principles described above the group will very easily be pulled off course. It may be enjoyable, it may be useful, but it will not be a Balint group!

Originally group leaders were always psychoanalysts with a special interest in this sort of work with family physicians or other health professionals. In some countries this is still the case. However in Britain and the USA groups are now being led by experienced family doctors and clinical psychologists. The International Federation is trying to develop a consensus about the kind of qualifications expected of a group leader and perhaps even more importantly, the kind of competencies which are needed in order to be an effective leader. There is already quite a lot of agreement about how a "good enough leader" behaves in a group.

Characteristics of effective Balint group leadership

The leaders will:

• Try to keep the discussion centered on the doctor patient relationship
• Discourage too much interrogation of the presenting doctor.
• Encourage people to express their own thoughts and feelings about what they have heard.
• Protect group members from unwelcome intrusions on their privacy or criticism which is hurtful without being helpful.
• Represent the patient if he/she is in danger of being ignored.

John Salinsky, June 1997

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