Research on Balint groups: A literature review

doi:10.1016/j.pec.2015.01.014

Patient Education and Counseling

Volume 98, Issue 6, June 2015, Pages 685-694

https://doi.org/10.1016/j.pec.2015.01.014 Get rights and content

Highlights

•
In general, peer-reviewed literature on Balint groups is scarce.
•
Empirical studies on Balint groups are often of low quality.
•
Qualitative research articles point at the potential value of Balint groups.
•
Further well-conducted research on Balint groups is recommended.

Abstract

Objective

As the scientific literature on Balint groups (BGs) is scattered, this paper provides an overview of the literature on BGs published in peer-reviewed journals. Study characteristics are analyzed and the principal research topics are discussed.

Methods

‘Web of Science’ and ‘Pubmed’ databases were searched and all English-language studies on BGs (empirical and non-empirical) were included.

Results

Of the 94 articles included, 35 are empirical studies adopting a qualitative, quantitative or mixed methodology. The research topics that emerged include outcome, characteristics of BG participants, themes addressed in BGs, BG processes, leadership and BG evaluations. The remaining articles were classified as historical articles, reports and reflective articles, for which the main discussion themes are presented.

Conclusion

Research on BGs proves to be diverse, scarce and often methodologically weak. However, indications of the value of BG work were found. Therefore, further research is strongly indicated.

Practice Implications

Points of interest that could to be further considered by BG workers and researchers are for instance long-term BG participation and ‘modified Balint groups’. Recommendations for future research on BGs are provided.

Introduction

In the 1950s, psychoanalyst Michael Balint introduced seminars for general practitioners (GPs) that were later called ‘Balint groups’ (BGs) [1], [2]. These groups were set up in London and spread worldwide, though on a limited scale [3]. In Balint groups, GPs and/or other (para)medical professionals explore difficult interactions with patients through case presentations and discussions. Generally, BGs comprise six to twelve members and one or two leaders. Groups meet on a weekly to monthly basis over several years. In BG meetings, participants present cases that are subsequently commented on by the group members, expressing their thoughts, ideas and emotions. This process can help participants broaden their perspective on the initial difficulty they experienced, and can influence their overall perception of their practice and interactions with patients [4], [5], [6], [7].

Activities of BG societies (such as registration of BGs, organization of workshops and conferences) [8] and associated literature demonstrate that BGs are still very much alive. Yet, research on the process and outcome of BGs is relatively scarce and sporadic, and therefore not always easy to find. This might explain why the short introductory literature reviews in some articles mention incomplete and sometimes contradictory findings. Therefore, the present study aims to gather the peer-reviewed literature on BGs in one article and to provide an up-to-date perspective on BG research.

Section snippets

Search strategy

Using ‘Balint group’ as a key word, we searched the ‘Web of Science’ and ‘Pubmed’ databases for publications up until March 2014. No restriction was set for year of publication. Abstracts were reviewed and all articles addressing BGs as a subject were included. Duplicates, non-English-language articles, meeting abstracts, book reviews, letters and editorials were excluded, as were articles that mentioned BGs only briefly in the context of another research topic. References from each article

Results

In Fig. 1, the numbers of articles included and excluded throughout the search process are presented. The database search yielded 362 articles. Screening the abstracts led to the exclusion of 32 articles that were not related to BGs. After excluding duplicates (n = 60), non-English-language articles (n = 149), meeting abstracts, book reviews, letters and editorials (n = 24), the number of included articles scaled down to 97. Hand searches and bibliographic reviews yielded an additional 22 papers.

Discussion

The main aim of the present study was to provide an overview of the peer-reviewed articles on Balint groups. We included empirical (n = 35) as well as non-empirical (n = 59) papers. We reviewed the variations in BG setting, diverse outcome variables (such as psychosocial self-efficacy, burnout and change in attitudes), participants’ characteristics, themes, processes, leadership issues, group evaluations, historical information and the main topics addressed in reports and reflective articles. As we

Acknowledgments

We want to thank our colleagues Joachim Cauwe, Virginie Debaere and Femke Truijens for their critical and useful help in revising the manuscript.

All authors are employed by Ghent University who funded this research.

The authors declare no conflicts of interest related to this work.

References (100)

K.E. Adams et al.
Effect of Balint training on resident professionalism
Am J Obstet Gynecol
(2006)
M.A. Torppa et al.
A qualitative analysis of student Balint groups in medical education: contexts and triggers of case presentations and discussion themes
Patient Educ Couns
(2008)
G.E. Amiel et al.
Ability of primary care physician's to break bad news: a performance based assessment of an educational intervention
Patient Educ Couns
(2006)
D. Kjeldmand et al.
Balint training makes GPs thrive better in their job
Patient Educ Couns
(2004)
J. Stern et al.
Teaching psychotherapeutic interventions to general practitioners through Balint groups
J Pragmatics
(1987)
B. Luban-Plozza
Empowerment techniques: from doctor-centered (Balint approach) to patient-centred discussion groups
Patient Educ Couns
(1995)
M. Balint
The doctor, his patient and the illness
(1964)
J. Horder
The first Balint group
Brit J Gen Pract
(2001)
J. Salinsky
The Balint movement worldwide: present state and future outlook: a brief history of Balint around the world
Am J Psychoanal
(2002)
S. Graham et al.
Balint-style case discussion groups in psychiatric training: an evaluation
Acad Psychiatry
(2009)

C. Musham et al.

Family practice residents’ perspectives on Balint group training: in-depth interviews with frequent and infrequent attenders

Fam Med

(1994)

D. Kjeldmand et al.

Balint groups as a means to increase job satisfaction and prevent burnout among general practitioners

Ann Fam Med

(2008)

K. Van Roy et al.

A Lacanian view on Balint group meetings: a qualitative analysis of two case presentations

BMC Fam Pract

(2014)

Balint International....

NICE....

J. Paál

Suicide prophylaxis within a Balint-group with staff of an intensive nursing station in a general hospital

Isr Ann Psychiatr Relat Discip

(1978)

S. Rabinowitz et al.

Developing psychosocial mindedness and sensitivity to mental-health issues among primary-care nurses using the Balint group method

Isr J Psychiatry Relat Sci

(1994)

S. Rabinowitz et al.

Preventing burnout: increasing professional self efficacy in primary care nurses in a Balint Group

AAOHN J

(1996)

W. von Klitzing

Evaluation of reflective learning in a psychodynamic group of nurses caring for terminally ill patients

J Adv Nurs

(1999)

L.G. Chertok et al.

The Balint group and preventive industrial medicine

Psychiatry Med

(1972)

A. Selvini

An internist's experience in a doctor-patient relationship training group (Balint group)

Psychother Psychosom

(1973)

M.A. Dahlgren et al.

Physiotherapists in Balint group training

Physiother Res Int

(2000)

A. Leggett

Transcultural issues in the dynamics of a Balint clinical reflection group for community mental health workers

Transcult Psychiatry

(2012)

G. Bar-Sela et al.

Balint group meetings for oncology residents as a tool to improve therapeutic communication skills and reduce burnout level

J Cancer Educ

(2012)

C.D. Brock

Gearing balint group leadership to resident professional development

Fam Med

(1990)

K.P. Cataldo et al.

Association between Balint training and physician empathy and work satisfaction

Fam Med

(2005)

C. Ghetti et al.

Burnout, psychological skills, and empathy: balint training in obstetrics and gynecology residents

J Grad Med Educ

(2009)

A.H. Johnson et al.

Resident physicians who continue Balint training: a longitudinal study 1982-1999

Fam Med

(2003)

E.S. More

Empathy as a hermeneutic practice

Theor Med

(1996)

M. Smith et al.

Mutiny on the balint: balancing resident developmental needs with the Balint process

Fam Med

(2007)

H.F. Stein

Physician Balint groups as an organizational laboratory of psychohistory – an exploration in historical repetition and transcendence

J Psychohist

(2003)

A.L. Turner et al.

A preliminary investigation of Balint and non-Balint behavioral medicine training

Fam Med

(2004)

M.A. Sekeres et al.

The impact of a physician awareness group and the first year of training on hematology-oncology fellows

J Clin Oncol

(2003)

S. Levenstein

An undergraduate Balint group in Cape Town

S Afr Med J

(1981)

S. Levenstein

An undergraduate Balint group in Cape Town—a follow-up report

S Afr Med J

(1982)

S. Parker et al.

Teaching the clinical encounter in psychiatry: a trial of Balint groups for medical students

Australas Psychiatry

(2012)

S. Parker et al.

Reflecting on our practice: an evaluation of Balint groups for medical students in psychiatry

Australas Psychiatry

(2014)

S. Stephanos et al.

Reflections on the qualities of a Balint group leader

Brit J Med Psychol

(1979)

A.H. Johnson et al.

The current status of Balint groups in US family practice residencies: a 10-year follow-up study, 1990–2000

Fam Med

(2001)

J.H. Merenstein et al.

Balint seminar leaders: what do they do

Fam Med

(1999)

R.J. Botelho et al.

Using a family systems approach in a Balint-style group: an innovative course for continuing medical education

Fam Med

(1990)

M. Keinanen

Cooperation between mental health professionals and doctors in a Balint-oriented supervision group

Israel J Psychiat

(2001)

A. Drees

The establishment of a Balint group among the nurses on a psychosomatic ward

Med Law

(1983)

M.F. Smith et al.

Using a Balint-like group for geriatric education in a nursing-home setting

Educ Gerontol

(1993)

S. Rabin et al.

Balint groups as ‘shared care’ in the area of mental health in primary medicine

Ment Health Fam Med

(2009)

G.A. Pettitt

The Nelson Balint group: evolution of one possible method for continuing postgraduate education and constructive peer-review in smaller centers

New Zeal Med J

(1981)

P.M. Hartmann

A pilot study of a modified Balint group using cognitive approaches to physician attitudes about somatoform disorder patients

Int J Psychosom

(1989)

S. Stojanovic-Spehar et al.

Education about pharmacotherapy and psychotherapy of anxiety among primary care physicians in Croatia: Balint group approach

Croat Med J

(2004)

M.S. Abeni et al.

Psychological care of caregivers, nurses and physicians: a study of a new approach

Cancer Med

(2013)

M. Granek et al.

The third party in general practice consultations

Scand J Prim Health Care

(1996)

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Changes in the empathy of fourth-year French medical students following a mandatory module on doctor–patient relationships
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Certaines études rapportent une chute de l’empathie clinique des étudiants en médecine lors de leur première année d’externat. Or, différentes pédagogies expérientielles et interactives pourraient limiter sa chute, voire favoriser son développement. Cette étude évalue l’efficacité d’un module associant simulations humaines (jeux de rôle et consultations avec patients simulés) et groupes Balint sur l’évolution de l’empathie des étudiants.
Une étude interventionnelle monocentrique prospective avec évaluation avant et après du module pédagogique a été mise en place à destination d’étudiants de quatrième année de médecine en Île-de-France. L’empathie était mesurée par auto-questionnaire Jefferson Scale of Empathy – Medical Students et les connaissances par questions à réponse multiples.
Les scores des 100 étudiants d’empathie autoévaluée montrent une amélioration statistiquement significative entre avant (108,8 ± 11,9) et après (113,7 ± 10,4 ; p < 0,001) le module. Une amélioration statistiquement significative entre avant (2,3 ± 1,1) et après (2,9 ± 1,2 ; p < 0,001) est retrouvée pour les 101 étudiants ayant rempli les questionnaires de connaissances. Enfin, une faible corrélation positive a été retrouvée (r = 0,256) entre les améliorations des questionnaires d’empathie et de connaissances.
La simulation humaine associée aux groupes Balint semble favoriser le développement de l’empathie cognitive des étudiants en médecine en contexte français. Leur transposition sous visioconférence avec jeux en téléconsultation semble une voie pertinente et alternative aux limites de la réalité virtuelle dans les domaines non techniques.
Some studies have reported a decline in medical students’ clinical empathy during their first-year internships. Empathic skills in doctor–patient relationships have proven to have substantial benefit on the physiological as well as psychological parameters, and on the patients’ and physicians’ satisfaction. A range of experiential and interactive training modules have the potential to limit this decline and even foster the development of empathy, and yet French medical schools do not routinely implement such non-technical training. Moreover, there is no consensus about the concept of empathy, and previous studies rarely coordinate their definition with the method chosen to implement how it is measured. This study aims to evaluate the effectiveness of a training module that combines human simulations (simulated patient interviews and role-playing) and Balint groups in order to develop medical students’ empathy as a measured cognitive attribute, declarative knowledge, and their correlation.
We implemented a monocentric prospective study of fourth-year medical students from the Île-de-France area, which included pre/post-test assessment. First-year clinical interns initially completed five role-play sessions of one hour and a half each, with a group of 12 to 14 students led by a trained senior medical doctor. The sessions addressed successively issues of the doctor–patient relationship, breaking bad news scenarios, management of chronic conditions, violence and aggression, inappropriate treatment requests, or communication about medical errors. A pre-briefing session provided oral and written instruction and promoted a non-judgmental approach. Then two students role-played the doctor–patient interaction. Finally, a three-stage debriefing supported reflective learning. Subsequently, the students attended six Balint group sessions of one hour and a half each, within the same groups. One of the students was encouraged to bring up a challenging clinical situation. Then, the trained Balint supervisor invited all the students to share their observations, so as to explore the assumptions, beliefs and emotions raised by this account, and to collectively reframe the multiple perspectives on the case. At the end of the year, each student carried out two ten-minute consultations with a simulated patient, without an observer. The clinical scenarios were an HIV diagnosis disclosure and resisting a request for a prescription for antibiotics for a common cold. After each simulation, the simulated patient (SP) provided direct feedback to the student, with at times additional feedback given by their supervisor. The SP feedback was focused on empathy. The level of the medical students’ empathy was assessed using the self-reported Jefferson Scale of Empathy, which measures their declarative knowledge through multiple-choice questions.
Of the 100 students who completed the empathy questionnaires, we found a statistically significant difference between the pre (108.8 ± 11.9) and post-test (113.7 ± 10.4; P < 0.001). On the three JSPE-MS subscales, two students reported a statistically significant improvement (perspective taking; and the ability to put themselves in the patient's shoes). Of the 101 students who completed the knowledge questionnaires, we found a significant difference between the pre (2.3 ± 1.1) and post-test (2.9 ± 1.2; P < 0.001). Moreover, a weak correlation was found (r = 0.256) between improvements of empathy and knowledge assessments.
These results in the French context are consistent with those reported in international literature on the benefits of implementing simulation training and Balint groups to limit the decline of empathy during the medical students’ first clinical internships. These results are further reinforced by the consistency between the definition of empathy and the implementation of a means to measure it as a cognitive dimension. The reliance on self-assessment of empathy might lessen the validity of these results and stresses the need for a wider multidimensional approach. The quality of the evidence is also limited by a monocentric, non-randomized and non-controlled design, which calls for further research.
The use of human simulations combined with Balint groups seems to support the development of the cognitive empathy of medical students in the French context. Given the recent developments in remote learning worldwide to comply with social distancing measures, their online translation into role-played tele-consultations would appear to be a very topical opportunity, while also avoiding the inherent limitations of virtual reality to address non-technical skills.
Medical students’ learning processes the first time they role-play in psychiatry: A grounded theory study
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Recent changes in psychiatric care and teaching that limit patient contact for medical students can be overcome in part by simulation-based education. Understanding the learning processes of medical students involved in psychiatric simulation-based programmes could usefully inform efforts to improve this teaching. This study explored the learning processes of medical students the first time they role-play in psychiatry.
We used constructivist grounded theory to analyse semi-structured interviews of 13 purposively sampled medical students and the six psychiatrists who trained them. To improve the triangulation process, the results of this analysis were compared with those of the analyses of the role-play video and the debriefing audio-tapes.
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Ces dernières décennies, les opportunités formatives des étudiants en médecine directement auprès des patients ont été limitées par les évolutions des soins psychiatriques (fermetures de lits, spécialisation des services, déplacement des soins vers la pratique ambulatoire, etc.) et des modalités d’enseignement (manque de médecins séniors, complexité et sévérité accrue des patients hospitalisés, etc.). En soutenant un apprentissage expérientiel, la pédagogie par simulation pourrait aider en partie à dépasser ces difficultés. Cette étude explore les processus d’apprentissage des étudiants en médecine lors de leur premier jeu de rôle en psychiatrie, afin de soutenir le développement de la simulation psychiatrique en France.
Dans le cadre de l’enseignement de la psychiatrie à l’Université Paris-Centre, un jeu de rôle était proposé à un tiers des étudiants de 5^e année de médecine en 2018. Ces jeux étaient menés par un binôme d’enseignants, parmi six volontaires : l’un jouant le patient, l’autre assurant les briefings et débriefings. Un des 4 étudiants par groupe menait alors un entretien simulé aux urgences de 10–15 minutes avec l’enseignant–patient, portraiturant soit une dépression avec idées suicidaires, soit les suites d’une attaque de panique. Les 3 étudiants et l’enseignant observateurs visionnaient la retransmission du jeu dans une salle séparée. Un débriefing était ensuite mené suivant la structure « description, analyse, synthèse ». Nous avons utilisé une méthodologie qualitative par théorisation ancrée pour analyser les entretiens menés avec 13 étudiants en médecine recrutés de façon dirigée, et ceux des 6 enseignants qui les ont formés. Afin d’améliorer la triangulation, les analyses ont été confrontées à celles des enregistrements vidéo et audio des jeux, et briefings et débriefings respectivement.
Cinq thèmes organisateurs ont émergé : améliorer la perception immédiate des personnes avec un trouble psychiatrique ; cultiver le raisonnement clinique ; métaboliser les affects ; améliorer les habiletés et attitudes ; et soutenir l’investissement dans l’apprentissage en psychiatrie. Ces résultats sont cohérents avec la littérature scientifique portant sur la simulation développée dans d’autres spécialités médicales. Cette approche pédagogique favorise la réflexivité des étudiants, l’apprentissage entre pairs, l’empathie, et plus globalement, toutes les compétences « non techniques » (communication et relation avec le patient, professionnalisme, etc.). En psychiatrie, la littérature insiste sur l’apprentissage de tableaux psychopathologiques et de compétences d’entretien par la simulation humaine pour les étudiants en médecine. Nos résultats suggèrent que cet apprentissage pourrait passer par une compréhension de ce qui se joue pour les patients, reposant notamment sur les « premiers ressentis » qui émergent chez l’étudiant dans la rencontre des patients. En soutenant la perception première d’une forme holistique, les jeux de rôle pourraient favoriser chez les étudiants le développement de l’intuition dans le raisonnement clinique, complémentaire aux processus analytiques, plus traditionnellement enseignés lors des études de médecine. Cependant, l’identification et l’intégration de ces premiers ressentis au raisonnement clinique supposent une temporalité incompressible, ainsi qu’une qualité d’attention et de bienveillance particulière de l’enseignant et du groupe de pairs lors du débriefing, afin de les faire émerger et leur apporter une réelle pondération dans la pratique clinique ultérieure. Des approches pédagogiques favorisant l’intuition pourraient également trouver leur place pour renforcer cet apprentissage, telles que la médecine narrative ou les groupes Balint. Néanmoins, la méthodologie qualitative, le recrutement monocentrique, l’exploration d’un seul jeu de rôle et la rareté relative de l’implémentation de cette intervention au moment de l’étude limitent la généralisation des résultats.
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ReviewResearch on Balint groups: A literature review

Highlights

Abstract

Objective

Methods

Results

Conclusion

Practice Implications

Introduction

Section snippets

Search strategy

Results

Discussion

Acknowledgments

Am J Obstet Gynecol

Patient Educ Couns

Patient Educ Couns

Patient Educ Couns

J Pragmatics

Patient Educ Couns

The doctor, his patient and the illness

The first Balint group

Brit J Gen Pract

The Balint movement worldwide: present state and future outlook: a brief history of Balint around the world

Am J Psychoanal

Balint-style case discussion groups in psychiatric training: an evaluation

Acad Psychiatry

Family practice residents’ perspectives on Balint group training: in-depth interviews with frequent and infrequent attenders

Fam Med

Balint groups as a means to increase job satisfaction and prevent burnout among general practitioners

Ann Fam Med

A Lacanian view on Balint group meetings: a qualitative analysis of two case presentations

BMC Fam Pract

Suicide prophylaxis within a Balint-group with staff of an intensive nursing station in a general hospital

Isr Ann Psychiatr Relat Discip

Developing psychosocial mindedness and sensitivity to mental-health issues among primary-care nurses using the Balint group method

Isr J Psychiatry Relat Sci

Preventing burnout: increasing professional self efficacy in primary care nurses in a Balint Group

AAOHN J

Evaluation of reflective learning in a psychodynamic group of nurses caring for terminally ill patients

J Adv Nurs

The Balint group and preventive industrial medicine

Psychiatry Med

An internist's experience in a doctor-patient relationship training group (Balint group)

Psychother Psychosom

Physiotherapists in Balint group training

Physiother Res Int

Transcultural issues in the dynamics of a Balint clinical reflection group for community mental health workers

Transcult Psychiatry

Balint group meetings for oncology residents as a tool to improve therapeutic communication skills and reduce burnout level

J Cancer Educ

Gearing balint group leadership to resident professional development

Fam Med

Association between Balint training and physician empathy and work satisfaction

Fam Med

Burnout, psychological skills, and empathy: balint training in obstetrics and gynecology residents

J Grad Med Educ

Resident physicians who continue Balint training: a longitudinal study 1982-1999

Fam Med

Empathy as a hermeneutic practice

Theor Med

Mutiny on the balint: balancing resident developmental needs with the Balint process

Fam Med

Physician Balint groups as an organizational laboratory of psychohistory – an exploration in historical repetition and transcendence

J Psychohist

A preliminary investigation of Balint and non-Balint behavioral medicine training

Fam Med

The impact of a physician awareness group and the first year of training on hematology-oncology fellows

J Clin Oncol

An undergraduate Balint group in Cape Town

S Afr Med J

An undergraduate Balint group in Cape Town—a follow-up report

S Afr Med J

Teaching the clinical encounter in psychiatry: a trial of Balint groups for medical students

Australas Psychiatry

Reflecting on our practice: an evaluation of Balint groups for medical students in psychiatry

Australas Psychiatry

Reflections on the qualities of a Balint group leader

Brit J Med Psychol

The current status of Balint groups in US family practice residencies: a 10-year follow-up study, 1990–2000

Review
Research on Balint groups: A literature review