Initially set up by Michael Balint in the 1950s to help primary care physicians relate more effectively to their patients, “Balint” groups have had an international influence on the training of different specialties (1–4). Previous research has focused on measures of professional attitudes and confidence such as self-reported psychological medicine skills (5), “comfort in dealing with emotional/clinical situations” (6), “sense of control of work” (7), or “professionalism” (3), although Balint (2) thought that considerable change occurred to the “doctor’s personality.” Rabin (8) and Turner (5), using a specifically designed outcome measure, found that trainees reported increased psychological skills at the end of the Balint-type case discussion groups (CDGs). Maoz (9), Samuel (10), and Pinder (11), using restricted qualitative methods, and Von Klitzing (12), utilizing a more extensive text analysis, found that mental health professionals were able to reflect more on both patients and the professional-patient relationship after a CDG.
Attending a CDG has been a mandatory requirement of psychiatric training in the United Kingdom (13), although the delivery of British medical education is currently under review (14). An important question for psychiatric education is whether a CDG is an effective way of acquiring psychological skills. This study addresses three points:
Does “change” occur in a CDG?
What is changing during the process of the CDG?
What is the process of this change?
The National Health-funded psychotherapy service in Manchester offers a CDG experience to psychiatric residents and other mental health workers, delivered in a block of 12 sessions in combination with four skills tutorials. Sessions take place weekly and last for 75 minutes, and participants take turns presenting a case from their practice, focusing on the relationship between clinician and patient, while other group members reflect on the dynamics and offer opinions. The skills tutorials combine theoretical teaching with experiential learning (through role playing) about basic psychodynamic concepts such as transference, countertransference, defense mechanisms, and containment. The training objectives of the CDGs are to foster reflective thinking about the therapeutic relationship, to introduce psychodynamic concepts, and to prepare residents for starting supervised psychodynamic training cases. To this end facilitators will keep the focus on the therapeutic relationship and only bring in other group issues such as discussing differences within the group (e.g., male and female reactions to a patient) if it is in the service of this objective. Case discussion groups are a mandatory part of residents’ training and three spare places in each group are made available to interested nonmedics in order to foster multidisciplinary perspectives and psychodynamic thinking among a wider group of mental health professionals.
Following ethics committee approval all 21 participants attending two concurrent CDGs were invited to participate in the study.
A modification of the Psychological Medical Inventory (15) asked participants to self-report on 29 questions, covering their current level of psychological (a) interest, (b) skill, (c) awareness, and (d) efficacy. This questionnaire was completed three times: at the start, middle, and endpoint of each CDG. Participants showing the three highest and three lowest change scores between start and midpoint were interviewed (audiotaped and transcribed) and the emerging themes were used to develop eight open-ended questions for use at the completion of the CDG (Table 1). These semistructured interviews were carried out, taped, and transcribed by two of the researchers (SG, GS) who were not involved in running the CDGs.
The 21 participants, 16 psychiatric residents and five counselors, were split between two case discussion groups. One of the two men left after the first session. Of the 17 who consented to the qualitative interview, 11 had previously attended a CDG. The doctors and two cognitive behavior counselors were new to psychodynamic thinking, but the other three counselors identified themselves with this modality.
We read three transcripts to identify emerging categories and develop a coding template (16). This was subsequently elaborated through application of the template to three further transcripts. At regular meetings the other researchers challenged the emerging template, which subsequently consisted of 14 themes, 37 main codes, and 81 subcodes.
Analysis involved application of the template, using MaxQDA software, to the six midpoint and 17 endpoint transcripts. Emerging insights were recorded as memos which formed the basis of a thematic structure to reflect the processes occurring within the CDG. Again these were challenged during meetings with the other authors. The results were shared with two of the original trainees who agreed to attend a meeting (all were invited) and their comments led to minor modifications (recontextualization). One author (ME) was directly involved in one of the CDGs and his dual role as facilitator and researcher enriched understanding of the process within the groups.
Results of the quantitative analysis will not be reported in detail in this article (but are available upon request). However, participants in general felt that they had improved on the self-report measures with 21 of the 29 questions showing significant improvement (p<0.05; Wilcoxon signed-ranks test: nonparametric, paired, two-tailed).
To comply with ethics approval, identifiers that link individuals to the text have not been used. Data are reported in the text and in the tables. Three major themes emerged.
1. Groups Were Anxiety Provoking
Participants reported factors that provoked anxiety. Many knew each other from their work environment and while training with colleagues offered support, some felt exposed to continuing tensions. Counselors were concerned by the limited psychological awareness that psychiatrists showed. Psychiatrists felt they worked with more disturbed patients but envied the established psychological perspective counselors provided.
“… and when the counselors spoke, especially in that kind of [breathy] way, sometimes I did feel it was a little bit annoying.”
“I was dreading working with doctors, I thought they’d be really stuck up and awful and not listen to our opinions.”
At times the groups were experienced as persecutory. Participants felt particularly scrutinized by the facilitator when presenting cases. They were uncertain of the “ground rules” and struggled to keep the focus on patient material rather than their own personal issues. They resisted the primary task of Balint groups in preferring not to disclose their own feelings.
“It was very difficult if one of the patients was affecting you at a personal level; you could not really go into why that was because it was such a big group, so it was all sort of superficial.”
The psychiatric residents and those counselors new to a psychodynamic way of thinking found the shift away from their previous orientation (medical/cognitive) unsettling. The cases presented had a strong emotional impact on both those presenting and those listening. At times they were in touch with strong negative feelings toward their patients. They felt guilty and were uncertain about whether to disclose these feelings.
“And I told this story … I felt very upset by it … and someone said that she felt devastated and thought she might have to leave the room.”
“All my cases were ones that just got me really kind of annoyed … because of the fact that I could not cure them.”
Participants looked to both the facilitator and more experienced colleagues for support. They also requested more theoretical teaching in the hope that this would reduce their disorientation. Lateness and poor attendance were other ways of avoiding anxiety.
2. Groups Were Instrumental in Learning
Most participants reported learning new skills (see Table 2 for themes in descending order of popularity and Table 3 for pathways of change). They found the group a permissive space to think, feel and reflect about difficult patients. They developed an awareness of their own feelings toward patients and increased their ability to stay with, rather than withdraw, from difficult feelings. The groups also helped participants access a new psychological framework for understanding their patients.
As learning progressed, participants moved from the comfort of their own professional mode and slowly adopted a dynamic perspective. Initially, this involved clarification of psychodynamic language and theory. The group then acted as a “container” for participants to process their difficult feelings; with time, this task was internalized in each participant. Reflective practice developed and meaning was increasingly found in interactions with patients. At the end of this process they were more able to identify with a psychodynamic model, more willing to examine their own emotions, and more comfortable working at the interface of their own and patients’ feelings. There was also evidence that psychological perspectives were used to think about their home life as well professional practice. Generally painful private feelings were not taken to the group for discussion. Attending more than one Balint group allowed both familiarization with the model and cumulative learning.
Both the group members and the facilitators were felt to be important resources in learning. Facilitators pulled observations together, maintained a psychological focus, and linked patient problems to participant’s feelings. Psychiatry residents also benefited from the psychological experience of the counselors. However, it was the supportive milieu of the group that seemed to be the most crucial aspect in offering containment, normalization of feelings in the face of working with challenging patients.
“… sharing the awfulness … of those terrible feelings of hopelessness, that I cannot make this person’s life any better, can feel reassuring. You do not feel alone with it.”
When participants had different reactions to cases, new perspectives became available, shedding light on restricted ways of perceiving the patient.
“… You got so many different views about what might be happening with a patient that it helped to enlighten you.”
“I started to look at the patient in a different way … when a patient is very abusive it is hard to be empathic … and then you think ‘Well, maybe this person had a major trauma when they were very little’ … so you try and use this to find a space in your heart, to go again and be empathic with the patient.”
3. Some Participants Struggled to use the Case Discussion Group Productively
Most seemed to benefit but some participants struggled, especially if they were new to a dynamic model.
“I hadn’t ever thought about it as how she made me feel … I just sort of talked about her, but I knew it was too psychiatric and too medical.”
Some disengaged from the task of psychological learning, preferring to use a façade and pretending to go along with the process:
“Sometimes you’d get a person in a group … and you just felt that they’re reading from a script.”
Others felt more at ease but remained skeptical about the lack of scientific certainty in a dynamic approach.
“I could not understand the others … I began to think that is taking it too far? Surely that is just … fancifulness rather than scientifically evidenced fact.”
Others seemed to reach a balanced position, perhaps continuing to identify with a medical model but accepting that a dynamic model might have value.
Participants seemed appropriately aware of issues of personal boundaries. However, other areas were rarely discussed (e.g. the mistrust created by groups and the fact that individual views might be influenced by the gender, race, and professionals background of participants). When discussing difficulties in the doctor-patient relationship, the preference was to keep the focus on patients rather than the responsibilities of the doctor.
“[Personal disclosure] was the most uncomfortable … where your level of discomfort rises … sometimes you have to just disengage … tell myself don’t reveal too much about what I did.”
This study is the first to focus on case discussion group (CDG) participants’ subjective experiences. We formulate these experiences into a framework for change that might further the development of training in psychotherapy. The findings support the view that change does occur in CDGs, which is evident in several domains: participants describe becoming more aware of feelings about their patients, and they are increasingly able to discuss these within the group. There appears to be a parallel process of increased ability to conceptualize the doctor-patient relationship using psychodynamic thinking—generalized to other patients being treated and also to participants’ private lives. These findings are broadly in line with results of other qualitative and quantitative studies of Balint-style training in a range of professional groups (10, 13, 17–19).
However, our findings suggest that some participants struggled with the CDG training. A previous study found that one-third of voluntary participants drop out in primary care programs (20). It is not clear whether this struggle was ultimately productive (“troublesome knowledge”) or whether CDGs are not a useful training environment for all psychiatric residents. Another more unsettling explanation is that CDGs are good at picking out residents who are lacking in empathy, reflective functioning, and/or the ability to work effectively in group settings.
In letting go of the medical model, residents have to sit with feeling deskilled before they feel enriched by entering another culture. The anxiety led to some avoidance: absence, requests for formal teaching, and proceeding in a detached way. The group’s capacity to offer both support and allow for different perspectives was the main factor in allowing trainees to think differently. Extending Bion’s (21) concept of a “container,” the group takes in overwhelming emotions, handing them back in a manageable form, and in so doing acts as a model for a residents to do this for themselves at a later date.
There was also strong evidence of the presence of “group therapeutic factors” as described by Yalom (22). The transcripts contained clear examples of “instillation of hope,” “group cohesiveness,” “imparting information,” “universality” (struggling together), “imitative behavior” (modeling themselves on each other and the group leaders), and catharsis (space to express and resonate with each others’ emotions).
Findings from this study suggest that the primary task of CDGs (as described by Balint), an exploration of the doctor-patient relationship, is a difficult one, often leading to avoidance because of the stress involved (23). Participants generally preferred that the responsibility for difficulties in the relationship remain with the patient. This could be seen as a healthy defense enabling professionals to cope with stressful interactions, but Leggatt (19) cautions against such a withdrawal.
The strengths of the present study are that the presence of a team of researchers facilitated a challenging philosophy to the interpretation of themes. Feeding back findings to residents (triangulation) and their endorsement of them suggests reliability. However, there were limitations. Recruitment was from a mixed group of (mainly) psychiatric residents and counselors, and the findings might not generalize to other groups. Two other unanalyzed variables were the effect of previous resident experience with CDGs and the effect of a CDG running concurrently with skills tutorials.
Changes in the education of psychiatrists in the United Kingdom raises questions about the most appropriate ways of delivering psychological training. Our study suggests that CDGs are an effective method that can be delivered in a multiprofessional setting. The finding that change occurs through a progression of (overlapping) phases raises the question, “How can we optimize this learning progression?” It is clear that residents require some theoretical understanding of relationships as well as the experience of connecting with their own and others’ feelings when discussing patients in a group setting. Further research would help to illuminate the best timing and amount of theoretical teaching. Also, the finding that CDG learning takes time and a period of acclimatization to a new learning culture is required suggests that residents should attend at least two 16-session CDGs in order to get the most out of the experience.
In view of the difficulties some trainees experience, facilitators need to titrate the optimal level of anxiety so that the group does not become paralyzed or avoidant. We would suggest that containment be achieved by active personable facilitators who avoid jargon, do not allow prolonged silences, do not interpret group dynamics, are clear about the focus of the group as well as other boundary issues and who maintain a safe, structured setting. The likelihood that some psychiatric residents will still find CDGs persecutory has significant implications if they remain mandatory in educational programs. Thought must be given to developing targeted training for such individuals who may find group settings particularly challenging. A key issue here would be whether to insist on this occurring in another CDG or whether this could be achieved in a separate individual setting.