Three categories of difficulties were found and related to: the individual member; the group including the leader; and the surroundings of the group. The categories are displayed in 1Box 1 and presented in the text, illustrated by quotes.
Box 1 Difficulties in Balint groups resulting from the analysis of the interviews
Difficulties related to the individual member
Approval of method
Needs
Mental health
Empathising capability
Vulnerability
Family
Abode
Sex
Cultural background
Specialty
Workload
Time
Difficulties related to the group including the leader
Secrecy
Frames
Change of leader
Dual relations
Rivalry
Interventions
Antipathy
Hidden agendas
Scapegoat
Difficulties related to the surroundings of the group
Economy
Acceptance
Healthcare paradigm
Obligatory
Difficulties related to the individual member
According to the leaders, some members left the BG because they did not approve of the method, or it did not satisfy their needs; the reasons given would often be the slowness and obscurity of the method because of few explicit rules and instructions:
‘Some of those who dropped out, it is only a handful, some of them wanted more about “elephants and how to hunt them”, that means practical advice on communication. And that has been part of the criticism against the Balint method, that “we are not told how to do things, and we need that”.’
The leaders respected the risks for psychologically vulnerable or mentally ill persons, and none would let physicians with manifest psychotic disorder start in their groups. Some had reluctantly accepted members with known manic–depressive conditions, but with discouraging results:
‘I accepted a manic–depressive doctor and when he was manic it was terrible for the group. He was speaking all the time, and when he was depressive he disappeared or he was very sad, but when he was manic it was terrible!’
None of the leaders conducted individual interviews with presumptive new members, although they all mentioned the possibility. The leaders handled problems with empathising capability in different ways, sometimes with understanding and patience; but sometimes these problems were described by the leaders more as a bad quality and an obstacle to the group work:
‘I could certainly pick one participant in one of the groups, who later actually gave up general practice. He was not appropriate, he was a very, very rigid thinker and was very harmful in the group […] He appeared as extremely interested and a great listener, but that was a defence and so when he got challenged he was exceedingly defensive and would not come off: “Now this is the way, when it comes to me now this is the way I do with the patients and this is the right way. I'm sure this is the way we all do in all situations”, so he couldn't be wrong.
Interviewer (I): ‘And it actually hurt the process in the group?’
‘Yes, because people lost respect for him. When he started talking they would look away or whatever. It was difficult because he was one of the older people in that group and it was a mixed group with young trainees as well.’
The leaders appreciated that members could be extra vulnerable temporarily because of private problems, illness, or fatigue. Sometimes a case in the BG unexpectedly brought back old and hurtful memories with shocking effect:
I: ‘Have you sometimes felt that you have gone too far when you asked questions?’
‘Yes, I have once. I asked a woman who was talking about a case, a man about the same age as her. When she had presented the case and we had talked a lot I asked the question: “Is it possible that this person reminds you of somebody important to you?” She thought for a bit and it proved to be that it reminded her of her former husband. I thought that was too intimate, it was not good and she stopped a while later and I concluded that it had been something that disturbed her.’
I: ‘She was forced to be personal, private or?’
‘No, she got that insight. She said so during that actual group, “I who thought I have worked through it all”. So it doesn't really matter in that I think it was quite good that she got that insight, but it might be that she didn't want to get it from the group or from me and she perhaps was afraid that there would come more.’
These episodes were experienced as borderline cases that the leaders considered it their responsibility to avoid. Some leaders would, after challenging episodes in the group, be self-searching and share their self-criticism with the group at the next meeting. This was regarded as a way to further enlighten the physician–patient relationship as a parallel process.19
The leaders regarded it as their responsibility to know the individual members well and protect them, but they realised that they did not always succeed. Members who were new in the group or had been absent for some time, for example on maternity leave, were considered particularly vulnerable.
The leaders described that common reasons for dropping out of the BG were practical complications concerning private life, family, and abode; such as moving away, maternity leave, or working hours of the spouse.
Sometimes the question of sex was considered significant by the leaders, for instance in single-sex groups, female groups with only one male (a common constellation), or in combination with cultural background. Leaders stated that talking about emotions was not a worldwide phenomenon. Physicians without this experience from their upbringing could not be expected to join voluntary BGs, which explained why this issue was more common in obligatory groups. However, the compulsory attendance sometimes gave amazing results:
‘We had a fellow, I think he was Korean, and just not very – erm – interested or skilled at all in psychosocial issues, because it's not – it's actually something they sort of stay away from. They had never talked about these things in his family; that just wasn't something that he did, so he was very, very concrete about a lot of this. And his growth in this group was – I think – just extraordinary! To move from a place of, not only sort of being able to actively resist it, but literally having no experience with it. It was against the cultural norms of his upbringing.’
The leaders that had experience of group members from different medical specialties found it unrewarding to work with physicians from technical specialties with short patient contacts:
‘In the first groups I had with those specialist doctors, there was a really high number of dropouts! There was a group of only anaesthetists and their boss had said that participation was obligatory! Ha ha. It ended after one meeting!’
High workload among physicians generally was, according to the leaders, a hindrance to BG participation, as some physicians chose not to spend time on their own personal development, although they knew it was beneficial.
Difficulties related to the group including the leader
The leaders emphasised the importance that what was said in the group was kept secret from the world outside, even when indiscretions were motivated by good intentions:
‘A young woman told the group about something that had been difficult for her, so one of the group members had gone to her work and tried to help her, and she was upset. I thought the same, that it was an abuse of confidentiality.’
The leaders acknowledged their primary obligation of keeping the frames and creating the safe environment in which the members could talk freely. Thus a change of leader destabilised and endangered the group. The relation between the leader and the members was described as sensitive to disturbing factors, such as dual relations; for example, being colleagues outside the group. Rivalry could create conflicts:
‘I once had a member in a group who was interested in law, not so much in ethics, and in every case he presented the legal aspect of the case and on the doctor–patient relationship, and on a certain day we really had a dispute in the group and I said: “I don't want that, because it is a kind of escape from more emotional subjective psychological issues”. And he said: “no it is very important”, and we really had a fight, but that has not often happened.’
I: ‘What happened with that participant?’
‘He disappeared […] I think it had to do with that dispute and we both leaders thought it was a struggle between him and me of who was the leader of the group, the formal one and the informal one.’
The leaders tried to balance the interventions so that the group learned as much as possible and nobody was hurt:
‘I don't know whether it played any role if that person later ended or not, I don't know, but there was a woman who presented a case as if she understood it as a very simple case […] and I understood that she herself hadn't understood the emotional tension that existed in that consultation situation. And I have a feeling that I said it too frankly and she wasn't ready for it, wasn't ready to acknowledge that this was bigger than what she had herself understood.’
The leaders described that sometimes antipathies among members made it impossible to continue; and that unevenness among members created unbalance and, in combination with hidden agendas, the result was sometimes malevolent.
Several scapegoat processes were described, where the group expelled a member, either abruptly or in a longer process with subtle means. According to the Balint method, the leader should prevent this, but it seemed as if the leader sometimes joined the group in the process and later described the member as difficult, uncooperative, and lacking the qualities of a good doctor:
‘There was a women who stopped […] she got a sick leave, for mental problems, and then she was gone, and then she was back for two times, and after that I have not seen her. She is some kind of a dropout – from everything […] Once in the group they said what they thought, that they were tired of her, and some of them actually said so.’
I:‘To her?’
‘Yes. She was this kind of person, who, when somebody told something, then she said that she had been there and done it also. If one said that they did research, some of them have a PhD, then she could talk about it as if she had done that too, and everybody knew that it was not so.’
Difficulties related to the surroundings
The leaders experienced that the environment of the BG greatly affected the group. Economy was a strong power, and in the healthcare system translated into patient encounters per hour:
‘… they say they need to see patients, ‘cause if you count all the faculties not seeing patients and earning money, that's a lot of money, so time all of a sudden is a lot of money these days.’
Attending a BG was often considered inefficiently spent time by management, whose acceptance determined the possibility of physicians joining or staying in the group:
‘There are so many other agendas and they have so little time and with the crisis we keep hearing about in government's agenda and so on and so forth, and they are probably right.’
The leaders described how some physicians ended their participation because of a change of employer; and that cultural conceptions in the surrounding society competed with the ideas of the BG, making it unattractive to participate. This would often go hand in hand with a biomedical healthcare paradigm:
‘I think it has to do with the general philosophy of […] you know, evidence-based medicine, anything that can be measured, thinking technically and then the enormous competition – “I'm a better doctor than you, how could you make such a mistake” – all the black and white.’
Three leaders had experience of obligatory groups for young physicians. They raised questions about disciplinary problems influencing the process, and about the leaders' obligation towards the vulnerability of the members, who were young and obliged to attend:
‘We once had a group with such residents in X and I had a feeling that they didn't want to talk because the director of the school, the professor, told them to talk and they had a feeling, “he can give us commands in every area but he cannot force us to talk about ourselves” […] That may happen when it is obligatory.’
One leader did not experience problems having obligatory groups. The interns’ attendance was not reported and did not influence their approval. On the contrary, the obligation of the BG facilitated the young physicians leaving other work tasks to attend the group.
