Abstract
The Balint Method has been used worldwide since Michael and Enid Balint developed it in the 1950s. Even with the proliferation of Balint groups there were still doctors and other clinicians who did not have local access. The online format was developed to provide Balint groups to those individuals. With the pandemic the majority of clinicians were unable to get together in person. The online format provided a lifeline for Balint work. This article provides a short history of the development of Balint online, how the pandemic affected further development, and a summary of what was learned from that experience.
The history of the balint method online
Prior to the pandemic there was a need to bring Balint to places where there might not be a local in person Balint group. One of the first demonstrations of the potential of Balint at a distance was a group formed by Frank Meumann in Australia to support young doctors working with the aboriginal population in the Northwest Territory (Meumann et al. 2017). 1 That group met from 2012 to 2015, literally over the phone with the help of aboriginal cultural educators and provided support to the young doctors who presented Balint cases.
In 2014 Kyle Hoedebecke and Luis Pinha-Costa reached out to the Balint community to help organize a Balint group for the Young Doctors’ Movement in WONCA as a way of connecting young doctors around the world, many of whom had no access to Balint groups in their setting. Two of us, Don Nease and Albert Lichtenstein, volunteered to co-lead that group. The group included doctors from Africa, the Middle East, Europe, and the United States. After struggling with different platforms and finally settling on Zoom the group met over the next two years (Nease et al. 2018). 2 Preliminary results were presented at the International Balint Federation Congress in Metz in 2015. Despite the positive comments from group members the results were met with some skepticism. Could proper Balint be done online? Could you read body language? Would the group develop connections and trust in the same way?
The project was again presented in Oxford in 2017. However, with this presentation the group got together online and did a demonstration for people at the conference watching on television. The response was much more enthusiastic. The observers’ comments were more of surprise that a proper Balint group seemed to take place and be quite useful.
During the same time the American Balint Society began to explore the possibility of offering online Balint groups for providers who did not have access to a group otherwise or wanted to be part of a group from the convenience of their own home. A working group, which became the was formed in 2016 and the first group offerings took place from 2018 through 2019. These were 8–10 session groups that received enthusiastic feedback and led the ABS to formalize the online Balint working group as a standing committee to promote the work further.
The pandemic hits
After the pandemic hit all in person groups ceased. The Balint community’s options were clear; either move to an online format or stop doing Balint work. It seemed that the choice was clear as well. The three of us, having had some experience doing Balint online became somewhat of de facto resource. We decided to do a series of tutorials to give Balint leaders the benefit of our learning from our mistakes and successes. Over the course of a few months we gave seven tutorial sessions with 25 attendees in each session. The attendees were from around the world and provided input of their own. The Balint community had come together online and were continuing the important work at a very difficult time for clinicians.
As the pandemic became more widespread the American Balint Society decided to offer free, four session groups, as way of providing a service to providers working in such a difficult time and difficult environments. There have been 13 groups held to date with an average of 8–10 members. Many of the group members took the opportunity to learn about Balint for the first time. Three longer term groups also took place from 2020 to 2021 as well.
Preserving the Balint method online
Our goal while moving to an online format has been to maximize the effectiveness of Balint in the online environment. In order to do so we have come to the conclusion that leaders must have a working knowledge of the technical aspects of the online environment as well as an understanding of how to keep the Balint frame. The issues we have identified as important are as follows. (A comprehensive tutorial is available at americanbalintsociety.org) 1. All participants’ cameras should be turned on with sufficient lighting to be able to see facial expressions. 2. Group members should be in a confidential space or in the very least be using headphones. One of the benefits of the online environment is that members can join from anywhere- which in our experience they certainly have done. So, confidentiality is an important issue. 3. Group leaders and members need to be fluent in whatever platform is being used. It is very helpful if group leaders and members practice with the platform and make sure that their equipment is working and that it is clear how to sign on. Co-leaders need to be clear how they will work together using the platform as well. 4. It is important to minimize the use of the “chat function”. Having group members chatting in chat boxes is like having side conversations in the middle of the Balint group. Co-leaders need to decide if and how they will use this function privately. 5. Group members don’t necessarily have to mute themselves unless there is background noise. If people use mute there can be a bit of delay in being able to respond.
Leadership considerations
Given our experience conducting online groups, we feel confident that the Balint method can be used successfully online: the strength of the Balint frame protects some of what is lost in going to a virtual modality. Because this method emphasizes story and the willingness to be vulnerable and empathic, connection between members occurs, even online.
However, there are differences between online groups and in person groups. For example, nonverbal communication between group members is much harder to interpret online. Silences can feel longer in the online setting probably in part due to the lack of nonverbal cues that are more apparent in person. In some in-person groups, the presenter will physically push back a bit when s/he is done with the presentation, and this can be more problematic in an online setting. It is also more challenging for facilitators to “read the room” online.
Given these considerations we have some suggestions for issues that leaders need to be aware of and work to address. 1. Tolerating silences – It can be helpful to practice sitting with silences online by keeping a clock visible so you can see how much time has really passed (it will feel longer than it is). 2. Tolerating increased leader anxiety – The Balint online environment can be new and intimidating. Will I be able to manage the technical aspects, track emotion, make sure everyone is safe, etc? This anxiety is not much different than when we started out leading in person. With time and discussions with a co-leader comfort level increases. 3. How to tell whether a member is engaged – In some ways this is easier online than in person because with a gallery view you can see everyone. In person it is sometimes hard to see the people on the same side of the circle. 4. Watching the presenter during questions to maintain safety – If you use Zoom, Zoom allows you to place the video squares in any order. That means you can move the position of the presenter to a place that is easiest for your eye to watch. In fact, you can keep the presenter and co-leader next to each other to track both people. 5. Intimacy online is different – Certainly in some ways not being in the same room with group members is less personal. On the other hand, there is a sense of intimacy that develops as members share their personal space with the group when they log on. Members also have the ability to choose a background in the virtual space. For some, the online environment may feel less threatening as they are surrounded by their own space. 6. Pushback – It is not quite as evident online when a presenter is pushed back. It is important to keep the presenter’s video on so that leaders can track the impact of the group discussion on the presenter. However, it worth considering having the presenter put themselves on mute to signify that they are ready to listen. 7. Managing emotions online – It isn’t quite possible to hand someone a tissue, sit next to them, or even lean forward to connect to someone who appears to be affected by the emotion of the discussion. For the most part leaders are left with tracking facial expression and acknowledging emotion verbally. Even online a leader’s calm presence tends to help the group manage emotional impact of cases. 8. Managing disruptions in the Balint process - Handling perceived ruptures in the group process is quite similar to dealing with those situations in person. First one can look at whether the break in process is case related. Second, there are times when the group needs to be re-oriented to what the Balint process is and how the group might be redirected. For instance, in a group where there is constant advice giving. Third, as with in person groups, if there is a situation where group functioning is compromised it is important to break the Balint frame and talk about where the struggles in the group are coming from.
Future research considerations
1. Participants in the groups have been from multiple specialties and in various stages of their careers. They were from around the United States with some international participants. That is one of the strengths of online groups. It would useful to begin to investigate if there are participants that do well in an online format and those that might not find it conducive to doing effective Balint work. 2. It is our contention that Balint groups can be energizing and facilitate connection. The group experience is quite different from listening to a lecture or sitting in an administrative meeting. It would be interesting to investigate if Balint groups lead to more “Zoom fatigue” or help to counteract it. 3. It might be of value to compare drop out and attendance rates between online and in person Balint groups to gauge a sense of connection and investment in the process.
Conclusions
Our foremost conclusion is that Balint online works! There are differences but as long as one keeps the frame and is true to the process the Balint method is robust enough to work well online.
There are also some clear advantages to the online format. Balint groups can now have members from all over the world and we have had such groups offered through the American Balint Society. During the pandemic when it was impossible to convene in person, online groups created an important venue for clinicians to come together. We also found that group members may prefer the convenience of not having to travel to attend a Balint group.
Building confidence in doing Balint online is a key. Familiarity with technical aspects and developing experience allows leaders, especially those with in person training only, to maximize effectiveness given the differences between online and in person.
In general, online Balint groups have come quite a way in the seven or eight years they have been in existence. There was initial skepticism about whether Balint could be done at all without being in the same room. Evaluations from ABS online groups have confirmed the value of the online format for participants. We plan to detail these findings in a future paper.
Given the relative success of online groups and their absolute necessity during the pandemic to keep Balint alive, the question about whether Balint can be done online has been answered. As we come back together post pandemic the next questions to be addressed will have to do with how to integrate Balint online most effectively into the general Balint movement. Can training of leaders be done online? Should leaders be trained to do both in person and online groups? Should online work be integrated into conferences and congresses? These questions represent the next horizon.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
