1. Balint with a Twist: The Reflecting Team Balint Mary E. Dankoski, PhD Kathleen A. Zoppi, PhD, MPH Shobha Pais, PhD Sharron Grannis, MD Ruben Hernandez, MD STFM ANNUAL CONFERENCE APRIL 2006

2. Learning Objectives  Attendees will… learn about the role of Balint groups in family medicine education learn about reflecting teams understand how to implement and facilitate a reflecting team Balint group experience a reflecting team Balint group as a participant

3. Overview of Balint Groups  Michael Balint and collaborators, 1960s— how issues of counter-transference affect quality of patient care: “the doctor as drug”  Balint groups used throughout UK, South Africa, Australia  Began American Balint Society in US in 1998  Balint training more used in family medicine than other medical/health professions

4. Approaches to Use of Balint Training  MUSC uses analytical model  Some programs mandatory, others optional  A few programs use faculty Balint  Many have “modified” Balint  Differences among Balint, support, and professional development groups

5. Balint Groups at our Program  Balint format has changed from year to year since 1994  Currently, all available residents (program is 10/10/10) Large group (12-20)  Size and trainees created challenges to group dynamics  Case presentations get “stuck”: silence or grilling the presenter

6. International Medical Graduate Challenges  Residents: 5 continents; at least 3 generations  Variations in training, little behavioral  Strong emphasis on biomedical training  Need to appear competent; inexperienced, insecure with psychosocial issues

7. Behavioral Science Education and the IMG  Searight & Gafford, Acad Med 2006 Qualitative interviews: 10 residents, 6 countries Themes:  Limited training in behavioral science  MH and psychosocial issues not addressed in primary care  Wide variation in communication training  Differences in physician-patient relationship  Perceptions of family life in U.S.  Specific challenges: “rules” of U.S. clinical practice & medical education; close scrutiny

8. The Reflecting Team Concept  Tom Andersen, Norwegian MFT  Experimented with ways to “unstick” families and therapists by reversing positions

9. Reflecting Teams in Family Therapy  At session midpoint, family and RT switch RT dialogues about what they noticed in the session while family and therapist observe RT avoids advice; use questions, curiosities, observations  Then switch back Family and therapist dialogue about RT discussion Discuss ideas they had while listening

10. Reflecting Teams  Offer multiple perspectives 2 especially when RT is diverse 3  Enhance therapeutic alliance 2  Are collaborative 4 and fit with feminist therapy 5  In supervision with MFT trainees: Reduce defensiveness, facilitate learning 6 Create sense of success 7 Help put theory (social-constructionist) into practice 8

11. Reflection in Health Professions Education  Promotes consideration of larger context 9  Allows assimilation of information into pre-existing knowledge structures 10  Promotes professionalism, individual growth, moral development of medical students 11

12. Reflecting Team Balint Structure  All residents participate  1.5 hours during required didactics  Chairs arranged in 2 circles: Inner and Outer Circles  Residents split into two groups  3 Behavioral science faculty and 1 MD faculty share facilitation  At least 1 faculty per group  Groups switch at mid-point and process is repeated  Facilitators debrief after group

13. Roles of the Groups  Inner Circle  Traditional Balint group discussion Case discussion in context of “self of physician” issues Facilitator may redirect focus on interaction of physician and patient variables  Are silent during feedback time  Outer Circle  Reflecting team  Silently observe: Physician themes Patient themes Naming emotions Nonverbal behavior, silence Group process and dynamics  Reflect themes to inner group during feedback time

14. Observations about Impact  “Meta” position promotes rapid processing, gives freedom  Encourages development of empathy  Integration of psychosocial issues  Recognition and management of “self of the physician” issues

15. IMG Opportunities  Reflecting teams changed dynamic  Specific role definition of RT makes it safer to reflect  Increased safety in peer group allows more depth of discussion, confrontation  Able to focus on cultural/religious (mis)perceptions  Biomedical thinkers gain insight through reflection, broaden perspective

16. Cultural Competencies  Domestic violence  Noncompliant patients  Drug-seeking behavior  End-of-life issues  Patient autonomy in decision-making  Gender stereotypes  Medical ethics  Sexual health issues

17. Reflecting Team Balint in the Behavioral Science Curriculum  Longitudinal curricular components Balint Group (1x/month) Didactic lectures (1x/month) PGY I Professional Development Group (1x/month) Inpatient teaching (1x/week) Videotape Review (10 total prior to graduation) Practicum counseling sessions (6 total prior to graduation)  Behavioral Science block rotation 2 weeks in PGY II 2 weeks in PGY III

18. Experiential Exercise: Reflecting Team Balint  Volunteer group of 6-8 people in inner circle  External reflecting team of 6-8 with observation assignments  Others observe meta-process

19. Summary: Reflecting on the Reflecting Team  Strengths of method?  Liabilities of method?  Logistical challenges for your program?  Questions?

20. Selected References 1. Andersen, T et al. (1991). The Reflecting Team: Dialogues and Dialogues about the Dialogues. NY: Norton 2. Kleist, DM. (1990) Reflecting on the reflecting process: A research perspective. Family Journal, 7(3), 270-275. 3. Smith TE, Yoshioka M, & Winton M. (1993). A qualitative understanding of reflecting teams: Client perspectives. J Systemic Therapies, 12(3), 28-43. 4. Haley T. (2002). The fit between reflecting teams and a social constructionist approach. J Systemic Therapies, 21(1), 20-40. 5. Vaz KM. (2005). Reflecting team group therapy and its congruence with feminist principles. Women & Therapy, 28(2), 65-75. 6. Pare D et al. (2004). Courageous practice: Tales from reflexive supervision. Canadian J of Counseling, 38(2), 18-130. 7. O’Connor T. et al. (2004). Narrative therapy using a reflecting team: An ethnographic study of therapist’s experiences. Contemporary Fam Therapy, 26(1), 23-39. 8. Biever J & Gardner GT. (1995). The use of reflecting teams in social constructionist training. J Systemic Therapies, 14(3), 47-56. 9. Branch WT, & Paranjape A (2002). Feedback and reflection: Teaching methods for clinical settings. Acad Med, 77(12 pt 1), 1185-8. 10. Lockyer J et al. (2004). Knowledge translation: the role and place of practice reflection. J Continuing Ed in Health Professions, 24(1), 50-6. 11. Branch WT (2000). Supporting the moral development of medical students. J Gen Int Med, 15(7), 503-8.

21. For more information  Contact info: Mary Dankoski, PhD mdankosk@iupui.edu Kathy Zoppi, PhD, MPH kzoppi@iupui.edu http://www.iufammed.iupui.edu/