Balint groups in undergraduate medical education: a systematic review

Objective: Though Balint groups feature increasingly in UK medical school curricula, there is no evidence-based consensus on what undergraduates might gain from participation, and how this might happen. To address this, we systematically reviewed primary research studies involving medical student Balint groups and their relationship with patient-centredness, using narrative synthesis. Data sources: Four major databases were searched from origin until 9 September 2016. The Journal of the Balint Society was hand-searched from 1971 until 9 September 2016. Study selection: English language studies reporting quantitative and/or qualitative methods examining Balint groups in medical students vs. other/no comparator. Results: Eight studies were included. Quantitative findings report statistically significant improvements to student’s empathy and intellectual interest following group participation vs. control (p = 0.03, p = 0.046, respectively). Discussion content was similar across high-income countries. There was considerable heterogeneity when students rated the efficacy of groups. All evidence had high or unclear risk of bias, or was of medium/low quality. Conclusion: Balint groups might help medical students to become more patient-centred, by increasing students’ empathic abilities and supporting their personal and professional growth. Groups are more subjectively effective when optional rather than compulsory. Discussion content is comparable to groups in continuing medical education.     

Michael Balint: An Introduction

Michael Balint, who used to be known the world over, no longer gets either the fame or the influence that he deserves, and the three special issues of the journal devoted to him are meant to contribute to make him better known. I intend to draw a portrait of Balint—it will necessarily be only an outline, within the limits of the present issue—and to follow his path as a man and as a scholar.     

Balint After Lacan ... and After

This paper examines Balint and Lacan's views about regression and symbolism, language, and transference. The author points out their similarities, their differences, and then proposes a synthesis through his approach of history, genealogy, trauma, and crisis. Freud's notions of masochism, of fixation (innate or phylogenetic) may thus be renewed, leading to the analyst's capacity to cope with deep regression and borderline (Balint) psychosis and perversion (Lacan) or to psychosomatics, including epilepsy.     

From the Balint method toward profession-related supervision

This paper focuses on Michael Balint's special application of psychoanalysis, originally conceived as a training of doctors. Then the attempt is made to discover indirectly, since Balint never described his method in context, what he thought mattered in terms of method. Besides Balint's own contributions, those of his own staff are also consulted as well as the cultural background of the Tavistock Clinic and the Tavistock Institute. Then the further developments of the Balint method in the German-speaking world are presented. At the center are the special features of the method: (a) the atmosphere, (b) the narrator's contribution, (c) listening and reactions of the members of the group, (d) the unconscious enactments in transference and countertransference and the mirror-phenomena, respectively. Furthermore, the respective central points of reference are discussed from the viewpoint of communication science: (a) case, (b) group, and (c) institution. In conclusion and based on these foundations, the characteristics of the application of the Balint method in the form of a particular profession-related supervision are presented.     

Regression and new beginnings: Michael, Alice and Enid Balint and the circulation of ideas

This article offers a new evaluation of Michael Balint's history. It starts with his growing up in Hungary and examines the central concepts of his writing: the analytic pair, regression and the basic fault and creativity, up to and including his renowned work on the eponymous Balint groups (which forged a unique link between psychoanalysis and medicine). While his name is, of course, well known, this article aims to bring his ideas to the attention of a modern analytic audience. Having trained in the 1920s with Ferenczi, Balint brought Ferenczi's literary inheritance to England where he lived until his death in 1970. His connections to Klein, Winnicott and Lacan, all of whom respected his analytic stance, are also examined. Furthermore, this article argues that his ideas were filtered through the theoretical lens of his first wife Alice Balint and later through Enid Balint, both of whom played a key - and rarely recognised - role in the development of his thought. It ends with a brief discussion of his ideas on analytic training and his quest, successful only after his death, to publish the complete Freud-Ferenczi correspondence, together with Ferenczi's diary.     

Michael Balint: An Overview

Balint's important work extended over a period of 40 years in two directions; firstly the development of individual sexuality, and secondly, the development of object relationships, together with their relationship to psychoanalytical technique. He introduced the concept of primary love and was one of the pioneers in the thinking of the interdependence of mother and infant. He extended Ferenczi's work on therapeutic regression, introducing the concepts, among others, of benign and malignant regression, the basic fault, and the states of ocnophilia and philobatism. His applied psychoanalytic work is world famous, particularly the Balint groups for general practitioners and similar groups for marital therapists, social workers, and psychosexual counselors.     

Michael Balint's Group Approach: The Boston Balint Group

Michael Balint was a physician/psychoanalyst who trained in Hungary and emigrated to England in 1939 when Nazi Germany began to dominate Europe. At the Tavistock Clinic, he and his wife met with social workers and physicians around case discussion seminars. With his strong interest in medicine and his curiosity about the patient-physician relationship, he initiated research/training groups with interested physicians, which ultimately led to publication of the now-classic The Doctor, His Patient, and the Illness, a rich text that has become a virtual staple of family practice residencies, along with Balint Groups for training. Balint refrained from considering his groups psychotherapy in order to minimize resistance of his physician-students. But because the groups lasted sometimes for years and explored transference and countertransference in patient-physician relationships, he acknowledged that the result was personal growth of the participants. His techniques are described and an example of a Balint Group (Boston Group) are presented here.     

借助巴林特小组培训模式提高临床护理质量

通过对巴林特小组培训模式的认识和理解,并将之运用于临床护理研究,使护理人员在处理护患关系中形成新的视角和更具分析性的思考方式,从而能够更深刻地意识到自身对于患者的影响,提高换位思考的敏感性,以便更好地理解和帮助患者;同时还能促进护理人员的心理健康和减少其工作中存在的护患矛盾。这不仅可以提高患者的治疗效果和生活质量,而且还可以提升护理人员自身的职业素养。因此,巴林特小组培训模式对于实现临床护理优质服务具有重要的现实意义。     

Legalising Toleration: a Reply to Balint

I re-present my account of how a liberal democratic society can be tolerant and do so in a way designed to meet Peter Balint??s objections. In particular, I explain how toleration can be approached from a third-party perspective, which is that of neither tolerator nor tolerated but of rule-makers providing for the toleration that the citizens of a society are to extend to one another. Constructing a regime of toleration should not be confused with engaging in toleration. Negative appraisal and power remain ??possibility conditions?? of toleration but they are not necessary features of either a regime of toleration or the sponsors of such a regime.     

Balint groups. A psychoanalytic critique

The author refers to two examples taken from the work of Balint groups in arguing that the social environment of the several participants is an integral component of what the group must reflect on. The notion of a group process dealing with "pure" cases is ideology. The author relates his argument to Parin's comments about "social critique in the interpretive process".     

The Balint group experience for medical students: a pilot project

Loss of empathy has been reported in medical students as they move through the clinical phases of their training. Several researchers have attempted to address this issue by exploring ways of heightening students’ awareness of the emotional, non-biomedical aspects of illness and the dynamics of the doctor–patient relationship, using a variety of reflective group discussion methods. This pilot project employed the specific group method developed by Michael Balint for general practitioners working in London after the Second World War. The pilot was based on one group of six third-year graduate students, meeting weekly over six weeks. Evaluation includes pre- and post-questionnaires, a 1000-word essay and leaders’ observations. The results suggest that the traditional Balint method needs to be modified for students at a point in their training where they have not yet been exposed to patients for long enough to develop meaningful patient relationships. Nevertheless, there was some evidence of a heightened awareness of the dynamics of doctor–patient relationships and the importance of psychological/emotional factors (including their own prejudices) when interacting with a patient. Balint-style groups could be an effective way of encouraging medical students to reflect on the importance of emotions in the doctor–patient relationship.     

The history of training and research in Balint groups

SUMMARY

The aim of Balint groups has changed very little, if at all, over the last 20 years. Changes, however, have occurred in the techniques which the general practitioners study in the groups, and these are described in this paper.     

Winnicott, Balint, and the Independent Tradition

This article compares and contrasts two main aspects of the work of Winnicott and Balint: their theories of infantile development and their theoretical and clinical work on the use of regression as a therapeutic agent. The relationship of their thinking to aspects of the British Independent Group's theories and clinical work is noted vis-à-vis the basic acceptance of classical theory and technique, acknowledgment and use of some of Klein's contributions, the influence of trauma and the external environment on psychic development and psychopathology, the importance of holding and the setting, and the reintegration of previously split off and lost parts of the self.     

Being ordinary in extraordinary places: Reflective practice of the total situation in a total institution

This paper examines a ‘Foulkesian type’ Balint group for psychiatry trainees set in a high secure forensic hospital. Within a Balint group, group processes and dynamics are not examined. Deviation from this format is construed as resistance, and destructively getting in the way of the primary task.

This paper reports on a case‐based reflective practice group operating on a more Foulkesian group analytic model and argues that the revised principles of method proposed here – paying attention to context; group processes; and creating an atmosphere where group curative factors are in play – can help trainees to sustain an emotional reservoir for their patients. Further, these principles do not get in the way of the primary task but can add to an understanding of the individual transference and counter‐transference issues, and can place these in context within the organization and society. This is particularly important in total institutions such as forensic units.

Clinical material from this group is used to support this claim.     

Could Balint Have Done More for Ferenczi?

After Ferenczi's death of pernicious anemia in 1933 at the age of 59, Michael Balint became the greatest advocate of his late analyst, teacher, colleague, and friend. He was faced with widespread avoidance, a conspiracy of silence against Ferenczi in the psychoanalytic movement. Ernest Jones, in particular, an analysand of Ferenczi and fellow member of the Secret Committee founded by Freud before World War I, seriously attacked Ferenczi. In the third volume of the Freud biography, Jones alleged that in the last years of his life Ferenczi suffered mental deterioration caused by the pernicious anemia, and that this mental decline was the real cause of Ferenczi's technical experimentations, thereby belittling the importance of Ferenczi's independent work in the last phase of his life. This article answers whether Michael Balint, who later became the literary executor of Ferenczi, was devoted enough in countering the charges that lead to a fifty-year silence on Ferenczi's eminent place in psychoanalysis. Correspondence between Balint and Jones is cited, as are reports of Ferenczi's contemporaries; Balint's efforts are placed within the context of the psychoanalytic rivalries after Freud's death.     

Reports and Brief Communications

Abstract

A Balint Seminar at the Therapeia Society in Finland     

Testing Practices and Attitudes Toward Tests and Testing: An International Survey

On behalf of the International Test Commission and the European Federation of Psychologists' Associations a world-wide survey on the opinions of professional psychologists on testing practices was carried out. The main objective of this study was to collect data for a better understanding of the state of psychological testing worldwide. These data could guide the actions and measures taken by ITC, EFPA, and other stakeholders. A questionnaire was administered to 20,467 professional psychologists from 29 countries. Five scales were constructed relating to: concern over incorrect test use, regulations on tests and testing, internet and computerized testing, appreciation of tests, and knowledge and training relating to test use. Equivalence across countries was evaluated using the alignment method, four scales demonstrated acceptable levels of invariance. Multilevel analysis was used to determine how scores were related to age, gender, and specialization, as well as how scores varied between countries. Although the results show a high appreciation of tests in general, the appreciation of internet and computerized testing is much lower. These scales show low variability over countries, whereas differences between countries on the other reported scales are much greater. This implies the need for some overarching improvements as well as country-specific actions.     

Die analytische Monade als Wiege der Realitätsprüfung

The relocation of my practice caused a lot of irritation and trouble, but triggered also psychic improvements in the analytic process with my patients, which is interpreted by referring to the theories of M. Balint and B. Grunberger. It is helpful to focus here on a narcissism concept which is not under instinctual control and to distinguish it from the transference rooted in drive theory. Especially useful proves to be the statement of both M. Balint and B. Grunberger that it is necessary to acknowledge and to affirm the wish of the analysand to establish and experience a pre-objectal “primary love” resp. an analytic monad. In case studies I try to show that the acceptance and affirmation of the projection of not drive-controlled narcissistic omnipotence feelings to the analyst are apt to secure and to preserve the narcissism of the analysand. Only this way can idealization and a stabilizing ego ideal initiate the integration of narcissistic exigencies and instinctual drives and organize the establishment of the reality principle.     

International federation for information processing’s framework for computer ethics

This paper reviews codes of ethics and codes of conduct from different countries. The differences and similarities between code content and between attitudes are considered. Distinction is drawn between a code of ethics and a code of conduct. Recommendations are made for establishing a common framework for IFIP (International Federation for Information Process) Member or Affiliate Societies.     

Balint's Influence on Contemporary Psychoanalytic Theory and Practice

Invited by the Psychoanalytic Psychotherapy Study Center in New York to lecture on my book Michael Balint: Le renouveau de l'Ecole de Budapest, Toulouse, Erès 2000, I first gave my personal and analytic motivations for writing this book. Then I stressed Balint's original contributions to analytical theory and practice: the object relation combined with the theory of instinct, the development of the infant, adolescent and even of old age, the basic fault, archaic defenses (such as ocnophilia and philobatism), as well as his idea about analytic treatment with its phases of regression and "new beginning". His style and his discretion in treatment and mainly the responsibility he recommended to the analysts seem to me very important not to forget. I have shown him as Ferenczi's heir and how he continued his work. His clinical approach and his style are evoked to alert contemporary analysts--who sometimes just know his method to train general practitioners through the Balint group--that they have been influenced unbeknown to them.