Understanding the emotional content of the therapeutic relationship

Posts in category Balint Groups

Why participate in a group?

Participation in a Balint group can help a health professional in many ways. The way in which it will affect the practitioner is related to the special characteristics of their occupation, their position and the particular characteristics of the setting in which they work.

Since the 1950s, when Balint groups took place for the first time in Great Britain, their goal was to strengthen general practitioners in dealing with difficult cases, through reinforcing the focus on the therapeutic relationship between the clinician and the patient. As time passed by, these groups were also applied to other medical specialists, as well as to mental health professionals and other professionals. Thereby, doctors of all disciplines, nurses, psychiatrists, psychologists, social workers, other clinical therapists (e.g. speech therapists, occupational therapists, physiotherapists) and educators of all educational levels, may be involved in a Balint group.

Balint groups may be part of new professionals’ training and can play an important role in helping them shaping their professional identity, as they begin to encounter patients and face unprecedented and often difficult emotions. Furthermore, Balint groups may be part of the ongoing training and personal development of more experienced professionals, who face the weight of mental exhaustion and reduced job satisfaction.

Participation in a Balint group can help professionals in many levels and the way in which it will affect them is related to the specific characteristics of their occupation, their position, the particular characteristics of the setting in which they work (e.g. hospital, private practice, school), their character, their emotional needs during a specific period and the expectations they have from the group. Relevant research until now and the personal testimonies of professionals who have had a Balint experience, illustrate the benefits one can gain from participating in a Balint group.

Understanding: Often the professional can feel confused about his/her feelings and about what is taking place in the patient’s mind and their relationship. This haziness can hinder therapeutic process and become an emotional burden for the professional. Through their participation in the group, doubt and confusion subside, the participants acquire better understanding of the therapeutic relationship and mobilize their own resources in order to cope more effectively with the present and future situations.

Capacity/Adequacy: The professional develops his/her ability for empathy and he/she enhances his/her ability to recognize his/her own feelings and the patient’s feelings and use this knowledge in order to help. Also the professional becomes able to better withstand listening to unpleasant feelings and his/her patience is reinforced. He/she learns to give more time to understand the therapeutic relationship and this way the emotional weight caused by the difficult cases is dealt more adequately and gradually becomes a challenge.

Exculpation/Distancing: The professional becomes aware of the limits of the impact he/she may have on the life of the patient, handles disappointment when treatment results are not the expected or desired and manage to face their weaknesses through the sharing of their experiences. Moreover, discussing about difficult feelings is helpful in understanding them and keeping a distance from his/her personal life. In addition, the structure of the group is that the presenting participant is also an observer, which allows him/her to distance himself/herself and see things from a different point of view, concerning his/her role and the relationship with the patient.

Boundaries: Often the professional identifies with the patient, has difficulty maintaining clear limits to the relationship and his/her role is not clear. This may create powerful feelings and inhibit treatment. Through the group the participant manages to distinguish the emotional weight he/she has to bear and redefine the boundaries in the relationship.

Security/ Freedom: In a Balint group the participant has the opportunity to present his/her own case or just to participate in the discussion of the case presented or simply listen without the obligation to speak, which creates a sense of freedom. The confidentiality, which is guaranteed by the group and the absence of criticism, fosters a sense of security over time, in which one can feel free to disclose his/her uncertainties and errors.

Something other than supervision and psychotherapy: Balint groups have important influences from psychoanalysis. However, they are not theoretically oriented, but intend to assist the professional in everyday practice. It is a process which fosters free associations and speculations, but without analysing the professional’s internal conflicts or the dynamic of the group, thus this procedure does not replace psychotherapy. The participants present the cases that create difficulty in them and the group listens carefully and then discusses without criticizing and provides support without giving direct guidelines or practical solutions. Participating in such a group appears to be more helpful than the mechanistic theoretical knowledge. The presenter uses as many of the ideas he/she believes that match with his/her way of thinking, while maintaining the sense of control he/she has on his job.

Job satisfaction: Finally, for many professionals the time they spent with the group is a pleasant break from a lonely professional life, during which they have the opportunity to share with their colleagues their concerns and frustrations. They feel relieved from painful experiences and often come to rediscover parts of their work that used to offer enjoyment to them. Their strength increases and the pleasant atmosphere of the group results in increasing the satisfaction deriving from their job and helps to avoid a possible burnout.

Lida Semidala- Avramopoulou

Psychologist- Developmental Psychologist (MSc) – Psychotherapist



Fitzgerald G., Hunter M. D. (2003) Organising and evaluating a Balint group for trainees in psychiatry, Psychiatric Bulletin 27, 434-436

Kjeldmand, D., Holmstrφm I. (2008) Balint Groups as a Means to Increase Job Satisfaction and Prevent Burnout Among General Practitioners, Annals of Family Medicine 2008;6:138-145. DOI: 10.1370/afm.813.

Kulenovic M., Blazekovic- Milakovic S. (2000) Balint Groups as a Driving Force. Collegium Antropologicum 24 Suppl. 1: 103–108, UDC 159.964

Roberts, M. (2012) Balint groups. A tool for personal and professional resilience, Can Fam Physician. Mar 2012; 58(3): 245.

Runkle C., Morgan L., Lipsitt E. (2006) Does Anyone Have a Case? The Balint Group Experience. Permanente Journal. Spring; 10(1): 59-60. Published online Spring 2006. PMCID: PMC3076988

The American Balint Society [homepage on the Internet] The American Balint Society; [updated 2005 May 5; cited 2005 May 19] Available from: http://familymed.musc.edu/balint/mission.html.

Zalidis, S. (2013) The role of Balint Groups in helping first clinical year medical students develop their professional identity and safeguard their boundaries. International Balint Conference, Heidelberg 7/9/13- 11/9/13 READ MORE »

The frame of the group work

The function of the group is based on certain rules that ensure the proper conduct of the group work and maximize the benefits for every member and the group as a system. Responsible for the formulation of and compliance with the parameters of the frame is the leader of the group who uses as a reference the frame set by the Balint Society in which he/she belongs, taking into account -to the extent that this is possible- the specific needs and capabilities that exist in each particular group and its members.

The frame of the groups formed by the Hellenic Balint Group is based on the following basic rules:

  • The groups usually consist of six to ten people who are mostly doctors, psychologists, nurses and social workers and a leader (usually a psychologist or doctor) who has received training and obtained Balint Group leadership accreditation by a Balint Society that is a member of the International Balint Federation. A leader may coordinate groups while still in training, provided that he/she receives supervision by an accredited leader who is a member of a constituent Society of the IBF.
  • Before the introduction of a new member in the group, an introductory meeting (“mutual selection interview” as Balint named it) takes place in order for the leader of the group to meet and evaluate the person concerned and introduce him/her to the Balint method
  • The leader of the group is responsible for the frame in which the group functions, the coordination of the discussions, the compliance with the rules and the spirit which inspires the Balint method and for solving any problems that may arise in the group.
  • In Balint groups there is a confidentiality rule regarding the content of the discussions and the information given about the patients that are presented.
  • The frequency of the meetings, the time and day of these and the composition of the group are determined by the leader and remain stable during the year unless a serious need for change appears.
  • The possibility to observe a group for those who are interested in joining a group but want to see  how a Balint group works first, is given only in demonstration groups (“fishbowls” as it is called in Balint methodology) that are organized for this purpose.
  • The groups are not open to occasional participation which means that each member must participate in all scheduled groups unless of course there is an unforeseen event that impedes his/her participation.
  • Being punctual in the schedule, abstaining from using electroning devices and generally conducting oneself with respect towards the other members, promote the task and effectiveness of the group.
  • Any problems, difficulties or other issues arising in a member or a group with regard to the frame or the procedure, is initially discussed privately with the group leader who is responsible to assist the member in resolving the problem, if this is possible. If the leader decides that the issue needs to be discussed in the context of the group, he/she brings it to the group for discussion.

The frame is intended principally to ensure an atmosphere of security and stability within which the group operates. Although the group leader is mainly responsible for ensuring this condition, the respect of the frame and the leader’s role by the members are in fact the prerequisites that ensure its effectiveness.

The history of the groups

Balint groups and the Balint method were named after the Hungarian doctor and psychoanalyst, Michael Balint.

Michael Balint, the son of a GP, is born in Budapest in 1896. He becomes a medical student at the age of 18 years, but his studies were interrupted by World War 1 when he joins the army. There he gets wounded and he returns to Budapest, where he resums his studies and obtains his doctorate in biochemistry in 1920.

Initially he wants to be a biochemist and works in biochemical laboratories in Berlin, but after hearing Ferenczi’s (1917) speaks about Freud at conferences and reading The Interpretation of Dreams he develops an increasing interest in psychoanalysis. He trains as a psychoanalyst, having as his trainer and mentor Sandor Ferenczi, a hugarian psychoanalyst and Freud’s student and works alongside as a psychoanalyst.

In 1924 he returns to Budapest, where he works as a psychoanalyst with psychosomatic patients and in 1932 he starts the first training-cum-research-group for GPs in Budapest, as he wants to find out about the possibilities the GPs had to integrate psychoanalytic ideas in their practical work. The work of these curtailed (διακόπτονται) in 1939, when due to the radical right-wing government, which controlled the work, the meetings and the discussions of the psychoanalysts, Balint is forced (αναγκάζεται) to leave Hungary and goes to Manchester with his wife and his son as refugees. Unfortunatelly, his wife dies in the same year.

Balint lives in Manchester till 1945, where he becomes Clinical Director of the Child Guidance Clinic. His research focuses on infants, their behaviour and the relationships they develop. He begins publishing his ideas about “primary love”, “primary relation” and “basic fault”.

In 1945 he moves to London and works primarily in a Child Guidance Clinics until attached to the Tavistock Clinic and strengthens his interest about the interaction between individuals. He is now convinced that doctor-patient relationship plays a major role in diagnosis and therapy. Specifically, argues that the doctor’s and the patient’s inner world interfere. Both the patient’s transference and the doctor’s countertransference have great influence on the relationship, on diagnosis and therapy.

In Tavistoc clinic he meets and marries in 1949, Enid, who is a social worker and marriage guidance counsellor and together they develop innovative teams with GPs to study the psychological implications of general medical practice. There they checked their hypotheses, that “the most frequently used drug in general practice is the doctor himself”.

At that time many of the GPs’ patients were traumatized during the war and as Balint says, « A great number of people have lost their roots and connections, the individual thus becomes more and more solitary, even lonely… any mental or emotional stress or strain is either accompanied by, or tantamount to, some bodily sensation… one possible outlet is to drop in to one’s doctor and complain…” and “It is here, then, that the doctor’s attitude about how to prescribe himself to the patient becomes decisive.”

Also, at that time the National Health Service (NHS) establishes, where for the first time free medical care is introduced, leading clinics of general practitioners to be inundated with patients whose demands were high. General practitioners, who at that time had no specific training in general medical practice were poorly equipped to cope with vague diagnoses – particularly of emotional nature – especially now that there was an atmosphere where patients believed that there was a cure for all ills, doctors felt not deriving the expected satisfaction from their work .

Balint wants to find out why this happens. He is one of the first who recognizes the value of consultation itself as a therapeutic tool. As a psychoanalyst, he understands that what happens psychologically between the doctor and the patient is important, although this is not discussed in medical textbooks of the time. This thought is placed before the era of education in the analysis of consultations and communication skills, although of course there are already doctors who recognize the importance of listening to their patients. The Balints get advertised to doctors and encourage them to join a group research-cum-training-seminar for the study of the doctor -patient relationship. The traditional Balint group is born.

Team members meet in a safe and structured environment once a week for two hours. The structure of the meetings includes the presentation of a clinical case of a general practitioner and a subsequent discussion of the emotional relationship that is formed and the forces involved.

To those who have never worked like this, this method sounded very strange and unscientific. Over time, however, and as the doctors feel freer to express their thoughts and feelings, the speculations, assumptions and fantasies of others on the relationship between doctor – patient in each presentation, brought to the surface rich material for treatment, which decongested (αποσυμφόρησε) the doctor and helped him to modify his ideas and his attitude toward the patient, thus launching (δρομολογώντας) a different path for both the therapeutic relationship and for his personal development.

Although Michael and Enid were psychoanalysts, their aim was not to turn family or general practitioners into psychoanalysts but to help them recognize and talk about their feelings, rather than repress or ignore them as a defense. To gain a psychological awareness of both their own experience and the patient’s in the therapeutic relationship and learn how to use their emotions as an instrument, “like a surgeon his knife”.

The outcome of this first group brings the creative and collaborative work of Balint entitled: «The Doctor, His Patient and the Illness», published in 1957 (Balint, 1957). This book became a key text in the renaissance of the UK General Practice in the 1960s and the Balints’ ideas achieve world recognition since then.

In continental Europe, Balint groups are considerably more widespread. In 1972 the International Balint Federation is founded, whose members are more than 32 countries. In England and Germany participating in Balint groups is part of doctors’ specialty. Balint groups are beginning to take root in the U.S. in the early 1990s, where the American Balint Society is formed and later that of Australia’s. In recent years there is a spread of Balint groups in Russia and China.

In Greece Balint groups have not had the luck they had in other European countries and the attempt to introduce them has been fragmentary (αποσπασματική) and based on private initiative of some doctors as the founder of psychosomatic in Greece, Renos Rotas. Within hospital environments, Balint groups for nurses worked for a time in EginitioHospital and groups affected by the method of Balint worked in the psychiatric department of the MetaxaCancerHospital.

Ntina Bezioula

Educational Psychologist – Psychotherapist



Kallergis, G. (2010) Educational – supportive group of health clinicians, Encephalos 2010, 47(4):207-213

Berk, A., Statharou, A. (2003) The function of Balint groups as a means of supporting mental health nurses. NURSING, 42(2), 137-142, 2003

Balint, E. (1985). The history of training and research in Balint – groups. Journal of Psychoanalytic Psychotherapy 1 (2): 1-9.

Balint, M. (1957) The Doctor, his Patient and the Illness, Pitman, London.2e, 1964; Millenium edition, 2000, Churchill Livingstone, Edinburgh.

Otten, H. Balint work in Germany (1998) Journal of the Balint Society 26, 16-19

Salinsky, J., Sackin, P. What are you feeling , doctor? Identifying and avoiding defensive patterns in the consultation. Oxford: Radcliffe Medical Press Ltd; 2000.

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