Teaching Consultation Skills

Balint Method

Who was Balint

Michael Balint (Hungarian: Bálint Mihály, pronounced [ˈbaːlint ˈmihaːj]; 3 December 1896, in Budapest – 31 December 1970, in London) was a Hungarian psychoanalyst who spent most of his adult life in England.  He was a proponent of the Object Relations school which in psychoanalytic psychology is concerned with the exploration of relationships between real and external people as well as internal images and the relations found in them.

In 1950 Balint started his group-work with GPs, in London at the Tavistock-clinic and togehter with his third wife Enid, who was a social worker, “to study the psychological implications of general medical practice”. And they checked their hypotheses, that “the most frequently used drug in general practice was the doctor himself”.

In a nutshell, what is Balint all about?

The Balint group method is a way to discuss cases or situations arising in practice, which have aroused feelings in the trainees. The small group focuses on relationships and feelings (and NOT problem-solving or clinical management) within the doctor-patient relationship.   Balint work leads to Psychosomatic thinking and is an advantage to the well-being of patients and doctors.  His 1957 book ‘The doctor, his patient and the illness’ describes this work.  In a nutshell, when someone says Balint to you, think of two things.

  1. The process they formulated – which we call Balint Group Work – to help doctors (and others; doesn’t just have to be doctors) to think about their relationship with the patient to enable insights about what might be going on in the consultation (especially with difficult or interesting patients).   Remember, this is not another model of the consulation.   It is a general approach which may throw light on the doctor-patient interaction, and add depth to our understanding of it.
  2. Some theories they formulated – which are really helpful in understanding the doctor-patient relationship in the consultion

There is a Balint society which continues to develop this work.  Balint groups are run in many parts of the UK and other countries. The groups often run for 1 1/2 hours every week for years, so in this course we can only hope to get a taste of the approach.

Tell me more about the Balint Group Work

Balint Group Work is about sitting together with colleagues, and talking about the relationship between doctor and patient in a “training cum research group”. The idea is to train GPs in psychological and psychosomatic thinking.  At the same time, through group member interaction, it is hoped the group work enables further insights about the doctor, his patient and their relationship.

What’s the use of this?

  • Awareness of how our own personality, beliefs and behaviour affect our relationship with patients can help us improve our consultation skills.
  • It can also help us understand why we find particular patients difficult, and why consultations have gone wrong.
  • Groups which discuss doctor-patient interactions in these terms are a powerful tool for deepening our understanding
  • Another Balint term is the ‘courage of one’s stupidity’ – if you dare to say what you’re thinking in the group, you’ll be listened to, you may be right and even if you’re wrong the group will forgive you.
The How To Guide for Balint Group Work

Pros and Cons of Balint Group Work

Pros

    • It allows for safe disclosure of uncertainty in a trusting group. It gives participants permission to be fallible and admit to feelings.
    • It results in a deep sense of trust and caring within a group.
    • Good method for seeing things from other perspectives.
    • It liberates creative thinking, which can sometimes help doctors who may feel stuck in some way.

Cons

    • Too ‘touchy-feel’ for some.
    • Some find it frustrating not being able to talk about clinical problems.

Tips for the Balint Facilitator

  • Aim to explore the interpersonal dynamics, and not the clinical questions.
  • Remember that the purpose is to deepen understanding of what’s going on, and not an exercise in solving a problem.
  • Encourage imagination and speculation about the case, fully acknowledging that this is not necessarily the reality of the case.
  • Reinforce the rule that ‘this is not about right or wrong practice’
  • Allow the presenter to sit back in a “safe haven” and simply listen to the bulk of the discussion.  During this time, they must not contribute or chip into the discussion.
  • Keep the focus on the presented case. Avoid a new case being introduced when some part of the discussion reminds someone of a similar case they experienced.

Tell me about some Balint Theories

  • Each doctor’s personality interacts with their medical training to produce a unique way of dealing with patients
  • Doctors shy away from examining themselves as people in their performance as doctors, so they develop a fixed style of behaviour towards patients. 
  • Doctors develop beliefs about how patients should behave when ill, how they should behave with doctors, and how they should behave in order to co-operate in getting better.
  • Balint’s term ‘the apostolic function’ refers to the combination of the last 2 points (doctor’s fixed style of behaviour + doctor’s belief about how patients should behave).   Another way of seeing this is that doctors have expectations based on their own beliefs which they try to impose on patients.
  • Balint also drew attention to ‘the drug “doctor” – the powerful therapeutic effect of doctors as people, separate from the treatments they offer.  In the consultation, the doctor is the drug that patients require, not a pill, investigation or referral.   The doctor’s role in listening, and being there, and allowing the patient’s story to be expressed and the patient to subsequently lament is sometimes the most important thing in therapy.  
  • His term ‘the collusion of anonymity’ refers to the way patients can be bounced from one specialist to another with no-one ever taking responsibility for them as a person.
  • The ‘mutual investment fund’ is all the shared experience and trust that GP and patient build up together over the years
  • Sometimes, when the doctor feels bogged down with the patient’s repeated presentation of seemingly insoluble problems, they may experience ‘the flash’, a moment when they suddenly make sense of what’s going on.

All GPs have experienced ALL of these things.  If you’re a trainee reading this, you will too.  Being aware of it NOW provides invaluable insights later on in your work.

Please leave a comment if you have a tip, spot an error, spot something missing or have a suggestion for a web resource.
And of course, if you have developed a resource of your own, please email it to me to share with others.

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