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In this paper, I will attempt to makesense of what is not supposed tohappen in physician groups namedfor Michael Balint,1-4 describingsome of the observed “deviations”and presumed errors i n Bal intgroups. In particular, I will discusswhat happens when the group itself,and not a patient, is allowed to bethe “case.” In my family medicinedepartment, I coordinate and leador facilitate all Balint groups forinterns, residents, and faculty atthree residency training sites, a roleI have occupied since the middle1980s. I have l ed some 1,300groups during that time.

Balint Groups: Ideal and RealWhat kind of group is a Balint

group? What is (are) the purpose(s)of the group, and whose group is aBalint group? The original Balintgroup in England consisted of apsychiatrist and about f ive to sevenpracticing general practi tioners.Group members were physicians

whose professional identities androles had already congealed. In con-trast to the issues and identities ofthose British general practitioners,there are different issues, identities,and roles among the interns, resi-dents, and faculty physicians in-volved with Balint groups in USfamily practice residencies.

Balint groups were origi nallydesi gned to be speci f i c “workgroups” in Bion’s5 sense of theterm. The focus of the group wasthe task of presenting a case, help-ing members to more deeply under-stand the physician-patient relation-ship involved, and returning to clini-cal practice with greater wisdom.The group was not designed to besupportive or to analyze uncon-scious aspects or emotion-basedbasic assumptions5 of the groupprocess itself.

Merenstein and Chillag6 docu-ment from ethnographic observa-tion, interviews, and focus groupshow the actual practice of Balintgroup leadership in family practiceresidencies—and hence the groupprocess itself—wi dely deviatesfrom Mi chael Bal i nt’ s ori ginal

model and from later InternationalBalint Society doctrine. The groupsas constituted in family practice de-partments and programs differ fromtraditional groups in that they pro-vide support, offer reassurance, pro-vide teaching and guidance, provideanswers, are hierarchical, and arewilling to give the “right answer.”6

The remainder of this paper elu-cidates the nature of this discrep-ancy in groups in which I have beenmember and leader. Instead of en-forcing “what should happen,” I payattention to what does happen andwhat can happen when one takescues from the group as well as fromdoctrine. Indeed, I question whetherBalint orthodoxy is always appro-priate, or even possible, for intern,resident, and faculty groups whosemembers’ developmental needs andgroup boundaries differ from thoseof the seasoned practitioners in clas-sic Balint groups.

Key Differences In the US family practice resi-

dency groups, group facili tatorsreadily respond7-10 as issues surface,strive to take priority, and ask to be

Reframing Balint: Thoughts on FamilyMedicine Departmental Balint Groups

Howard F. Stein, PhD

From the Department of Family and PreventiveMedicine, University of Oklahoma.

This paper explores recurrent processes and themes in the 1,300 family medicine faculty, resident,intern, and community Balint groups the author has facilitated/led. The frequent group “ deviation”from the central Balint task of understanding difficult physician-patient relationships is reframed asless “ resistance” or “ obstacle” to work, as it is an expression of unmet developmental needs andorganizational realities. When group members are carefully attended to (by facilitator and one an-other), the group often becomes emotionally capable of addressing a “ case” in the conventional Balintunderstanding of the work the group has assembled to do. The group dynamics of such “ hybrid”Balint groups thus become comprehensible as other than error.

(Fam Med 2003;35(4):289-90.)

Commentary

290 April 2003 Family Medicine

acknowledged and addressed. Inthese residency-based groups,within the boundaries of confiden-ti al ity and respectful l isteni ng(which are core Balint values), welearn together what needs to be ad-dressed.

Often, group goals and processesmust precede the capacity of in-terns, residents, and faculty to pro-cess the human dimensions of dif-f icult or vexing physician-patientinteractions. Intense, case-focuseddiscussions may occur in the sec-ond part of the hour’s meeting, af-ter issues of psychic survival, frag-mentation, and self-worth have f irstcleared the air. Internal and inter-personal issues among interns, resi-dents, and faculty must f irst be rec-ognized and addressed if partici-pants are to have an emotional res-ervoir of empathy toward patients.

Some Balint Themesand Processes

Several core realities converge inthe Balint groups I have led. First,these groups are one of the fewplaces and times in which interns,residents, and faculty (in separategroups or in combinations) see eachother and have the opportunity tomeet. Second, these groups havehistoricall y been one of the fewemotionally safe places in the de-partment and in the health sciencestraining environment. Third, thesegroups are one of the few places inthe larger organization where par-ticipants are able to aff irm theiridentities as family physicians andfeel good and competent about it.Over time, Balint groups have in-creasingly become a kind of re-hearsal place or testing ground forpresenting and addressing group is-sues and ideas in wider departmen-tal settings.

During a typical group, either Ior the co-leader will (1) inquire howthe month’s rotations are going, (2)listen to the group conversation fora theme or a case that might becomethe group focus, or (3) directly askif anyone has a case. Because I havealready provided group memberswith a history of the original groups,and passed out a packet of readingmaterials about Michael Balint andhis early groups, group membersknow what the call for “a case” sig-nif ies. Usually the group will landon a theme, or I will discern one outof the conversation.

Often, a Balint group will con-sist of two groups, the larger groupthat begins the hour together and asmaller group that stays after anumber of members leave for clinicor for other reasons. The former(larger) group will be cathartic andengage on a more superficial level.The latter (smaller) group oftentakes on the intense, introspectivequality of classi c Balint groups.Over the hour, the group frequentlyprogresses from anger, sarcasm,splitting, projection, and blame toreflection, ownership of feelings,and compassion.

Conclusions: Learning FromExperience in Balint Groups

What may appear to be “ob-stacles” or “deviations” of resi-dency Balint groups from classicBalint groups are actually necessarydevelopmental steps that take placethrough “ learning from experi-ence.” 11 By wi deni ng and re-framing—putting a new “ frame”around the same content—the con-cept of “case,” one can foster an at-mosphere where all participants’psychic and real-world realities aretaken seriously. Balint participantsare often able and willing to discuss

a Balint-type clinical case once theirown experiences are given voice,acknowledged, and validated. AsShapiro writes: “People cannot takecare of the ‘work’ until they takecare of themselves” (personal com-munication with Johanna Shapiro,PhD, May 16, 2002)—until theyfeel taken care of in the group con-text. The Balint groups I have dis-cussed in this paper are places inwhich both can occur.

Acknowledgments: A version of this paper waspresented at the International PsychohistoricalAssociation convention, June 5, 2002 in NewYork City.

This paper has benef ited from discussions withJohanna Shapi ro, PhD; Kathy Zoppi, PhD, MPH;and David Levine, PhD, whom I acknowledgewith gratitude.

Correspondence: Address correspondence to DrStein, University of Oklahoma, Health SciencesCenter, Department of Family and PreventiveMedicine, 900 NE 10th Street, Oklahoma CityOK 73104. 405-271-8000, ext. 32211. Fax: 405-271-2784. howard-stein@ouhsc.edu.

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