A narrative history of the American Balint Society 1990–2020

Introduction

In 2014, in anticipation of the first National Meeting of the American Balint Society (ABS), a timeline history of the organization from its inception to the present was created for its website. ¹ This timeline is an accurate reference for what happened when and who was present at significant milestones, but it is not a living document. To truly understand how the Balint enterprise emerged in the United States, developed, produced its programs and initiatives, and responded to challenges, one must “hear” from people: the people who experienced the transformative insights of participation in Balint seminars and were motivated to create an opportunity for their fellow clinicians to share in that experience. These people brought into being and continue to nurture the ABS (see Figure 1 from Freedy editorial pp. 149–150).

The ABS in choosing to create its historical narrative is confronting a vitally important project both for its members, and for many healthcare educators and clinicians who are deeply invested in promoting and preserving the integrity of the personal relationship between the provider and the client in the treatment of illness—hopefully rescuing both of them from induction into the industrialized management of disease. The Society is striving not only to understand its past, but also move beyond simply following tradition by educating itself through a contextual awareness of how to preserve a personal education for future healthcare providers. However, writing a single narrative history of the ABS, or, for that matter, any organization as geographically dispersed and with such diverse institutional centers of operation is most challenging. To honor the diversity of perspectives within an organization, the authors asked several members of the ABS who have had a long and committed involvement from its inception, formation, and ongoing development to write their personal “Balint Autobiography.” With only textual editing, that met with their approval, the authors have incorporated into this effort 12 original autobiographies from which they hope to draw common themes, and from these themes move to offer several generalizations germane to the history of the ABS. In making these autobiographies available, they hope to allow the reader to make their own inferences as to the history of the ABS.

Readers may be surprised to discover the multiple interconnections of the people whose Balint autobiographies follow. Truly, they began as a kind of clan, not a cult, and remained a group of loving, jousting, mostly collaborating siblings who passed down their enthusiasm for and belief in Balint work from teacher to students, who then became valued teachers as well. An eclectic group of researchers, organizers, trainers, curriculum developers, and international leaders built the ABS piece by piece. They focused on an abiding interest in the person with the illness, their relationship to their healer, and how understanding that relationship might make the healer both better for the patient and more resilient themselves. The authors, as their autobiographies reveal, are woven into the fabric of the Society and want to tell a collective, personal and professional story that is truly integral with an ABS narrative. They are participatory historians. The fabric is really the living, intimate relationships among so many people, not only in America, but colleagues around the world. Readers may also find, amidst the narratives, gems of insight and instruction about the Balint Seminar process, its leadership, and possibly indications of where the ABS should head in the future. However, the real significance of the history of the ABS lies in its potency to stimulate critical reflection on the true purpose(s) of the Society, to elicit new and stronger personal incentives in ABS members, and to initiate challenging, inquiring, and supporting reverberations in the medical-educational-insurance-business-governmental subculture in which it participates.

From individuals to a society

The birth of the ABS had been attended for several decades during its social gestation in the 1980s and 1990s by the Society of Teachers of Family Medicine (STFM) that faithfully supported Balint seminars and a variety of its educational programs at national and regional meetings. From 1990 to 2000, the ABS held its annual meeting concurrently with STFM, which conveniently moved it from the West Coast, Seattle and San Diego, to the East Coast, Boston and Philadelphia, from the deep South, New Orleans, Atlanta, and Orlando, and to the heartland, Chicago and St. Louis.

The real inception of Balint work in the United States began in the late 1950s through the proselytizing efforts of Enid and Dr Michael Balint, British psychoanalysts, through their recurring consultations with psychoanalyst Dr Rex Pittenger at the Staunton Clinic in Pittsburgh, Pennsylvania (eight consultations between 1957 and 1969), and psychoanalyst Dr Paul Ornstein at the University of Cincinnati Medical Center in Cincinnati, Ohio. Through the Balints’ enduring educational commitment to further enrich healthcare delivery through insights achieved in psychoanalytic practice with a particular focus on primary care, the skills of patient-centered medicine came to the United States in the form of Balint seminars. ² With the creation of the specialty of Family Medicine in 1969, a supporting educational environment was established in several residencies that would nurture the Balint seminar seedlings in various regions of the United States. Family medicine affirmed as its central precept that a therapeutic relationship with a personal physician was the primary diagnostic and therapeutic agent of general practice and empathy its primary tool. In the words of Gayle Stephens:

… empathy is the sine qua non of clinical practice. The capacity to use one’s own feelings to vicariously experience what patients feel is a highly refined skill that wise physicians use as adroitly as digitalis or delicate surgery. … It is this perspective that allows for decisions about specific treatments and their potential benefit, risk and cost to be assessed objectively and honestly. This is the essence of clinical wisdom. To treat or not to treat is a question that can only be answered within the context of a therapeutic relationship. ³

A communication network slowly developed among these family medicine residencies that eventually began to include a few other medical specialties that also saw the immediate educational relevance of this personal training for physicians. The ABS did not establish its own, independent national meeting until 2014, and continued thereafter to hold national meetings biannually. The ABS Council independently held annual retreats starting in 2001, several in Spokane, Washington, others in Portland, Oregon; Pittsburgh, Pennsylvania; Jonesborough, Tennessee; and Charleston, South Carolina. These diverse meetings sites illustrate the attempt of the ABS to honor the diverse geographic locations of its active members. Some of these locations became centers of Balint activity, hosting Leader Intensives, Weekends, and even International Balint Federation (IBF) Congresses, made possible by the financial and conceptual support of university and medical center departments of Family Medicine. It is central to note that much of the sustained educational activity of the ABS throughout the United States has relied on the support of departments of family medicine and their faculty. In 1995, a Balint-L Society listserv was started as yet another means of establishing a more immediate connectedness among geographically dispersed ABS leaders often working in programs with minimal departmental or institutional support.

An international, national society

A significant theme that is explicit in 8 of the 12 autobiographies is one of an international fellowship and personal friendships. One could truly say that the ABS was welcomed into an international family that had been anticipating its birth. This is something much deeper and more binding than a verbal affirmation of connectedness to other nations in which individuals are participating in Balint seminars. It is important to note that the first two presidents of the ABS, Frank Dornfest and Clive Brock, were first organizers of Balint seminars in South Africa and then founding officers in the formation of their national Balint society. They also continued their relationship with colleagues in South Africa and their mentors and colleagues in England. Coincidental with the formation of the ABS, the first president, Dr Dornfest, became the president for several successive terms of the IBF. By 2004, the ABS sensed the need to establish an official ongoing contact with the IBF. It would support annually one of its members regularly attending IBF Counsel and Congress meeting. Don Nease maintained that intimate bond between the ABS and the IBF by serving as IBF’s president for three successive terms from 2012 to 2018, and before that serving as vice president for six years. Starting in 1994, the ABS hosted the 9th IBF Congress in Charleston, South Carolina, and in 2011, hosted the 17th IBF Congress in Philadelphia, Pennsylvania.

During such congresses, all participants are engaged in ongoing Balint seminars. This is an intimate, professional exchange that makes these congresses more than just the passive acceptance of information from a lecture; though, there are lectures and animated intellectual discussions as well. Members of the ABS attend IBF Congresses in other countries and share their personal, doctor–patient cases in Balint seminars, present lectures, and also lead such Balint seminars. Over a period of years, more intimate international relationships are formed which greatly influence how it is that an ABS member comes to understand the truly universal emotional character of the doctor–patient relationship. They also understand empathically the issues their international colleagues are confronting because human emotional currents that move through pain, shame, fear, death, killing, birth, caring for infants and the elderly, marriage, separation, success, and failure are universally present.

The international character of the ABS is also illustrated most recently, in 2014, by the work of Don Nease and Albert Lichtenstein leading collaboratively efforts to develop an international videoconferencing Balint seminar for young doctors, “Balint 2.0,” in partnership with the World Organization of Family Doctors, regional Young Doctors Movements, and the IBF. An internationally co-edited article in 2018 nicely framed their first study of this successful project. ⁶ ABS members have also been mobilized to work with general practitioners in Australia and most recently in China. For two years, Clive Brock and Alan H Johnson bimonthly monitored and mentored via videoconferencing two family physicians at the American University of Beirut conducting Balint seminars for third- and fourth-year family medicine residents as part of their meeting requirements for Balint leader credentialing. Several jointly edited publications resulting from these consultations.^7,8

Continuing communications among Balint members not only share ongoing professional concerns, but also personal traits of deep friendship, so consistently exemplified in many of the Balint autobiographies. Both internationally and nationally, the history of the ABS appears to engage over time the full scope of its members’ intellect and emotions. These, in fact, are the same attributes they want to support and nurture in their students, residents, and fellow practitioners.

The international involvement of the ABS is a constant reminder and stimulus to honor a diversity of perspectives that various cultures bring to interpreting the doctor–patient relationship and how that relationship can imaginatively be explored, enriched, and studied. The IBF functions more like a family system than a superordinate administrative structure. Seniority of leadership at any one time does not reside in any one country but rather in the helpful relevance of initiation and support of individuals from various countries. While the goal of enhancing the doctor-patient relationship is common among all countries, the means to address that goal vary by cultural value structures, social institutional policies, and the particular psychological disposition of each individual member. There is no one-way to be a best family member, nor is there any one best family. The ABS and the IBF strive to nourish and support each other to achieve global improvements in researching and educating healthcare providers and their clients.

The evolving formal structure of the ABS

While expectant parents of a first child make all kinds of elaborate arrangements to accommodate a neonate many of whose needs have been medically, psychologically, socially, and familiarly defined, just what the needs of the ABS would be remained largely undefined at its inception. In fact, one might say this narrative history of the ABS is really the first attempt of the Society to describe itself beyond the fervent desires of a group of enthusiastic Balint seminar leaders to present Balint educational programs at various forums where there seemed to be some interest on the part of medical educators to know what Balint really was. Consequently, the initial organizational structure was quite minimal: president, vice president, secretary-treasurer, a five-person council, and a newsletter editor. A Constitution and Bylaws was written on April 24, 1991, closely following the Constitution and Bylaws of the British Balint Society.

By 1995, the ABS Council had increased to 10 members plus 2 former presidents who had rotated onto Council following their two-year term of office. The following year Council began to confer on a monthly basis through conference calls. By 1997, separate officer roles for a secretary and a treasurer were formalized. An annual Council retreat was created to establish more fully developed operating procedures and oversight for the Society. A small administrative structural change occurred in 2001, when the role of vice president was changed to president-elect, again attempting to achieve continuity within the administrative structure of the Society. By 2002, the annual ABS meeting became a virtual online meeting. Several new committees were formed: a research committee, a membership committee, and a meeting of active supervisors—a meta-supervision group. By June 12, 2006, the Council adopted a revised vision of the Society’s Constitution and Bylaws. Another such revision would occur on March 14, 2011, and most recently on June 11, 2018. The original Bylaws stated, the primary purpose of the Society was to:

… advance research and studies on the psychological aspects of primary medical practice, with special reference to the doctor-patient relationship, and to disseminate this knowledge beyond the Society for the improvement of the medical care of the public at large … To provide an opportunity for the study of problems in the Doctor-Patient relationship, by supporting and promoting seminars of the Balint type already established in this country and elsewhere.

As diversity became an issue of awareness in the larger culture so it brought to awareness the lack of diversity in the ABS Council. The Council then moved to create a task force to address that very issue in the Society. The Council, wanting to stay in touch with its younger resident membership, created the role of a Council Fellow beginning in 2007. Finally, in 2015, confronting the limits of a purely volunteer organization in meeting its ever-expanding administrative responsibilities, the Council, hired a part-time administrative assistant.

The educational focus expands

Very early on the Society judged that its professional integrity over time would be determined by the number of available, appropriately trained Balint seminar leaders. So once again education was a primary focus of the Society; this time not only the education of a general population of medical educators but those specifically desiring to become credentialed leaders. Consequently in 1993 the Society, independent of any other medical education society, offered the Balint Leader Intensive Training program, a four-day workshop designed by Alan Johnson. Scheduled twice annually after 1997, one on the East and one on the West coast, these Intensives became a recurring and central educational activity of the Society. By 2016, the ABS Council approved that three Intensives would be held annually.

The year 1999 was very significant for the ABS, marked by the development of a credentialing procedure for Balint seminar leaders. A Balint leader certification workshop was convened at Sayre, Pennsylvania, during which accomplished Balint leaders each rotated into a leadership role and were evaluated by their peers with prototypic forms that had been created in advance identifying assumed essential Leader behaviors. A focus group of these leaders then discussed what had gone on in their two separate groups and what further factors should necessarily be considered in credentialing. The purpose of the workshop was to identify the necessary and unique characteristics of Balint group leadership and determine how these could be evaluated in future candidates. ⁹ Several pathways to become a credentialed Balint group leader were proposed. It also was apparent to the participants that the final step of credentialing would need to be the demonstration of leadership skills at some points during a Balint Leadership Intensive workshop. In 2003, the ABS passed “The Organization and Procedures of Credentialing Intensives” which specified the roles, processes, and procedures for evaluating a credentialing candidate at an Intensive.

To guide and support the training and credentialing of Balint leaders there was now formed, in 2000, a standing Credentialing Coordinating Committee (CCC), a Coordinator of Intensives and a Coordinator of Supervision. A rigorous process of direct or recorded observation, supervision, and evaluation was provided to ensure the development of a skilled Balint seminar leader. At least six evaluation forms per year over a two-year period would be forwarded to the CCC. In fact, the Society also provided for a grievance mechanism if a candidate felt that he or she had been unjustly treated. This procedure of the ABS reflects its conscientious attention to discharge its responsibility in creating a credible certification process that is also a valid measure of a candidate’s ability to perform as a competent Balint seminar leader.

The year 2003 also marked the first of what would become an ongoing series of events around the nation, the “Balint Weekend.” This was a shorter series of Balint seminars one following the other without an intervening session to interpret the group process. It was an attempt to acquaint people in more diverse settings with the Balint seminar without securing a large, expensive venue and a larger faculty. This in no way would serve as an evaluative venue for a potential credentialing candidate.

Then in 2014, the ABS initiated the student/resident essay contest, the Enid Balint Essay Contest, open to all students and residents in healthcare professions in the United States and Canada. Its goal is to ask participants to reflect on a specific patient encounter that seemed most likely to affect the way in which their future patient encounters would be significantly influenced. Also they might reflect on the way in which formal education had or could support, and improve such enhanced therapeutic encounters. A personal narrative style was encouraged. Winning essays are presented by their authors at the Biennial National Meeting of the ABS. Winning and honorable mention essays have been published in issues of the International Journal of Psychiatry in Medicine (IJPM). This activity of the ABS is an example of its attempt to address the personal scope of the doctor–patient relationship, moving beyond the Balint seminar as its exclusive teaching/learning modality, and honoring the psychotherapeutic dynamic in all healer–client relationships.

In 2015, the ABS approved a one-year, Balint Leader Education Fellowship program, established to address the Society’s need to continue training competent Balint group leaders and at same time address the challenge posed by the large commitment of time and money that is required for credentialing.

In 2016, for the first time, the ABS contracted to do Balint leadership training with multiple employees at their work site. These Intensives on the Road are continuing in various locations and will no doubt be a fixture in the ABS’s attempts at outreach.

Finally, encouraged by the success of the International Balint 2.0 experiment, the ABS started offering Balint-On-Line groups via video conferencing to clinicians in the United States. These educational events illustrate a Society that is evolving, aware and interactive with its environment, and at the same time attempting to preserve its educational and research focus on the very personal and emotional interaction between the healthcare provider and the client/patient.

Opening up

A recurrent theme in the recent history of the ABS is its determination to be more open. As reflected in the 2018 revision of the Bylaws, the ABS seeks to be more diverse in its membership of healing professionals and in the relationships that are the focus of its Balint seminars. In addition to this focus on diversity and inclusion, the ABS seeks to shed some of the opaque aspects of its psychoanalytic roots and become more transparent about the purpose, techniques, and pitfalls of its method. Writing, research, and articulation of an educational curriculum for learning to lead Balint seminars have become important initiatives of the Society. ¹⁰ The Balint method itself has been subject to less stringent orthodoxy, seeking to allow variations of the method where necessary and effective while still holding a basic structure that is a recognizable Balint seminar process.

Conclusion

As the ABS approaches its 30th year anniversary, it can claim success in achieving much of its primary purpose, as evidenced by the accounts in the 12 Balint autobiographies. The ABS has built a compassionate and relationship centric organization for a diverse group of like-minded professionals, affording them a professional home and a model of teacher/learner/leader that nurtures their professional growth. Founded on the concepts of biopsychosocial and patient centered medicine Balint work, spread by the ABS, provides a usable set of psychological skills for primary healthcare providers to become better physicians for complex, troubling patients while opening themselves to the possibility of using their clinical relationship as a diagnostic and therapeutic tool. The fresh perspective gained in a Balint group discussion of their case releases the clinician from negative and confusing feelings about themselves and their patient, allowing them to return to their professional role and perhaps giving them insight into and greater empathy for the patient’s true misery—misery they briefly shared. This is accomplished, not in a continuing education lecture or hospital in-service program, but in the non-judgmental, supportive atmosphere of a group of their peers, focusing on their particular practice dilemma and having the added benefit of decreasing the debilitating isolation felt by so many practicing modern medicine. ¹¹

The ABS has hosted Balint Leader Intensives all over the country and fostered local “shops” of Balint leaders and teachers. It has studied, researched, and written about the Balint group method and its leadership. It developed a sustainable process for preserving the Balint group method, credentialing leaders, and made leadership education more accessible by creating a fellowship curriculum. The ABS has cultivated collegiality with other Balint societies, taking leadership roles in the IBF and helping to establish and grow Balint societies in other countries. Using new technology for online groups and remote supervision, it is bringing young clinicians into Balint work and developing new leaders in other parts of the world.

Challenges and growth into the future

Cultivating empathic understanding of patients along with a deeper understanding of one’s own responses is something that Balint training does uniquely well. However, it appears expediency has replaced listening and caring; productivity and documentation have pushed aside relationship. Continuity of care has given way to large practices with a parade of available doctors seeing patients whose personal histories they don’t know. Expertise has superseded trust and compassion, even when illnesses are chronic and vague symptoms have no diagnosis or treatment that expertise can address. This is clearly part of a larger cultural trend that is causing the healing professions emotional isolation and distress. No wonder Balint work and the ABS struggle. The method is an anathema to the current culture of medical practice and training. This is precisely its power as well as the challenge to its existence.

There are very few long-term supportive supervision groups for qualified care professionals or trainees. Time pressures, trainees anxious about their technical knowledge and skills, and clinicians varying in their valuation of the relevance of psychodynamics have been roadblocks since the beginning of the ABS. Lack of continuity with patients in medical practice leaves little opportunity to form a personal physician relationship with a patient and removes some of the incentive. Learning from Balint groups requires a willingness to be vulnerable, to acknowledge, “I may not know everything,” with some humility, and the ability to tolerate occasional embarrassment; it is hard personal work. Competition in medical training also conflicts with this type of learning. A plethora of other educational offerings in the medical world, and online, to learn about the clinician–patient relationship may dilute a perceived need for Balint group training as a resource for residency directors to include in their curriculum. Residents may also fail to see it as a priority, let alone, embrace it enthusiastically.

Finally, the relentless increase in workload and the length of the working day for clinicians make them feel too tired to come to the source of refreshment, friendship, and discovery. Balint himself recognized that practitioners may not be comfortable with continuing education that is long-term and evolving, rather than a series of lectures offering answers and treatment procedures. Yet, despite the pressures of time and workload, perhaps it is time for the ABS to remember the roots of Balint work—practicing physicians. A major topic of discussion in the medical profession is physician well-being and burnout. Balint work can serve as an antidote to burnout. The ABS can make a significant contribution to many provider resilience programs surfacing around the country.

Our history demonstrates that ABS activity has been primarily rooted in the academic arena with primary emphasis on training teachers to lead Balint Seminars. The ABS has primarily relied on making itself available to train those in family medicine residencies who have shown interest. However, survey data on regional Balint activity in family medicine residencies indicate that there are geographic areas still greatly underserved. ¹² Missing has been a strategic introduction of itself, and its unique contribution to the medical curriculum to residency directors, deans of medical colleges, regional directors of hospitals, and healthcare facilities; nor has it profiled its availability and contributions to medical education in journals, newsletters or direct mailing to individuals, boards of medical education or family medicine societies.

Such an initiative would need to be preceded by a well-focused survey of these same individuals or groups as to their perceived needs and what relevance they might see in the ABS addressing those needs. It appears that the Society has been looking within its own organization to find a way of approaching its relationship to the medical subculture. It has not given strategic thought as to how it might come to better understand the administrative, regional and national political structures let alone the business and insurance contracts that are framing the larger system in which it operates. Metaphorically speaking, the question could be raised, what is the code for a Balint informed patient consultation, and what credential does a healthcare provider need to hold in order to be reimbursed for such service? Of note, Germany’s healthcare system recognizes specific doctor–patient relationship education and honors it in its billing system. ¹³

The ABS has begun to grow beyond the family medicine specialty, incorporating other specialties and disciplines. As more specialties respond to the call to include more psychosocial training in their programs, pediatrics, internal medicine, obstetrics and gynecology, psychiatry, palliative care, and neurology have started Balint groups. ¹⁴ Specialties in dermatology and oncology could naturally benefit from the inclusion of Balint seminars in their curriculum; yet, the ABS has never directly consulted them to present in more detail the relevant contribution Balint training would offer their specialty. This does not address the even larger potential interests of mental health workers: psychologists, social workers, nurses, clergy, pharmacists, teachers, or lawyers.

Finally, recent survey results show that Balint Seminars, even in family medicine residencies, have now become diffuse group activities with scattered goals that seem to compromise the well-defined limits of this professional curriculum and its desired outcomes. ¹² A too large gap needs to be addressed between the number of programs who report they are conducting Balint Seminars and the number of credentialed leaders who can lead groups that would be recognizable as Balint Seminars.

While the history of the ABS reflects an organization that has focused attention primarily on establishing the integrity of leader training in family medicine residencies, it has neglected to communicate to the larger medical subculture an equally clear and well-defined professional image of itself. It has yet to negotiate with that medical subculture the necessary physical, social, and time structures that are the prerequisites of conducting a meaningful Balint seminar on an ongoing basis. This has left the Balint group process subject to alterations from administrators attempting to meet other competing needs and goals.

Each of these initiatives requires the development of a succinct and accessible body of literature. Credible research methodology must show the efficacy of Balint training to increase patient and provider satisfaction and decrease providers’ use of resources while producing better patient outcomes. The future also imagines, not only current, but evolving practices while promoting increased participation in Balint work. To truly stand out in what has become a crowded field of approaches to enhancing caring relationships, Balint work and the ABS must be open to some change. Adapting to a changing culture without losing its integrity as a discipline is its greatest challenge, while breaking out of its past insularity and orthodoxy will be the way to fully realize its future.