Balint with a Twist The Reflecting Team Balint

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

Learning Objectives ¡ Attendees will… l l 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

Overview of Balint Groups ¡ ¡ Michael Balint and collaborators, 1960 s— 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

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 ¡

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

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 ¡

Behavioral Science Education and the IMG ¡ Searight & Gafford, Acad Med 2006 l l 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

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

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

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: l l l Reduce defensiveness, facilitate learning 6 Create sense of success 7 Help put theory (social-constructionist) into practice 8

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 ¡

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

Roles of the Groups ¡ ¡ Inner Circle ¡ Traditional Balint group discussion ¡ l l ¡ ¡ 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: l l l ¡ Physician themes Patient themes Naming emotions Nonverbal behavior, silence Group process and dynamics Reflect themes to inner group during feedback time

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 ¡

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

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

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

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 ¡

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

Selected References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Andersen, T et al. (1991). The Reflecting Team: Dialogues and Dialogues about the Dialogues. NY: Norton Kleist, DM. (1990) Reflecting on the reflecting process: A research perspective. Family Journal, 7(3), 270 -275. Smith TE, Yoshioka M, & Winton M. (1993). A qualitative understanding of reflecting teams: Client perspectives. J Systemic Therapies, 12(3), 28 -43. Haley T. (2002). The fit between reflecting teams and a social constructionist approach. J Systemic Therapies, 21(1), 20 -40. Vaz KM. (2005). Reflecting team group therapy and its congruence with feminist principles. Women & Therapy, 28(2), 65 -75. Pare D et al. (2004). Courageous practice: Tales from reflexive supervision. Canadian J of Counseling, 38(2), 18 -130. 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. Biever J & Gardner GT. (1995). The use of reflecting teams in social constructionist training. J Systemic Therapies, 14(3), 47 -56. Branch WT, & Paranjape A (2002). Feedback and reflection: Teaching methods for clinical settings. Acad Med, 77(12 pt 1), 1185 -8. Lockyer J et al. (2004). Knowledge translation: the role and place of practice reflection. J Continuing Ed in Health Professions, 24(1), 50 -6. Branch WT (2000). Supporting the moral development of medical students. J Gen Int Med, 15(7), 503 -8.

For more information ¡ Contact info: Mary Dankoski, Ph. D mdankosk@iupui. edu Kathy Zoppi, Ph. D, MPH kzoppi@iupui. edu http: //www. iufammed. iupui. edu/