Clinical Teacher’s Experiences of the Influence of Participation in the Balint Group on their Work Life in Clinical Settings: A Qualitative Study
2 Freiburg Institute of Advanced Studies (FRIAS), Interdisciplinary Research Groups, Albert-Ludwigs-University Freiburg, Germany
Citation: Yazdankhahfard M, et al. Clinical Teachers Experiences of the Influence of Participation in the Balint Group on their Work Life in Clinical Settings: A Qualitative Study. Ann Med Health Sci Res. 2019;9: 575-585.
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Introduction: Balint group is a method widely used for enhancing understanding of the relationship and communication between health professionals and their patients. Participants meet in small groups, on a regular basis, with a leader to discuss their experiences of problem cases. The method was originally developed in the 1950s for enhancing understanding of the doctor-patient relationship. No studies have focused on the Balint group and clinical teachers’. The aim of the present study was to describe and analyze clinical teachers’ experiences of participation in the Balint group and its influence on their work life in clinical settings.
Method: Semi-structured, in-depth interviews were conducted with ten clinical teachers’ working in Iran and Isfahan University of medical sciences, all participating in the Balint group. The participants were selected by purposive sampling. The interviews were recorded, transcribed and subjected to a qualitative analysis. Credibility, dependability, confirmability, and transferability of the data were confirmed.
Results: The clinical teachers perceived that their Balint group participation influenced their work life. Analyses revealed two interrelated themes: behavioral metamorphosis cycle and dimensions of professional interactions development, thus enabling the clinical teachers to rediscover the joy of being a teacher.
Conclusion: The results suggest that Balint group and sharing the experiences of others may be considered a way of enhancing understanding of the clinical teachers encounter in work life, possibly to the benefit of clinical teachers and their students. Further research is needed to evaluate the feasibility of teacher Balint groups in the clinical setting.
Balint; Clinical setting; Experiences; Qualitative study
The mission of medical sciences universities to empower graduates to accept momentous occupational roles is of particular importance and sensitivity.  Medical schools are considered as the most important centers of higher education in Iran and worldwide, which are responsible for the important task of training of physicians; these individuals, while competency, should adequately understand the society requirements and be able to solve the social and personal problems of individuals and try to protect the health of the society. This will not be accomplished except in the light of appropriate instruction and teaching, in such a way that the researchers consider faculty members as the principal factors in higher education, whose qualitative development has a significant influence on the performance of universities, and as the cornerstone of higher education, provides the infrastructure of development of other sections. [2-4] Baldwin believes that the concept of university or faculty is actually summarized in its faculty members, and the enhancement of knowledge and ability among this group is the real example of quality improvement in universities.  The performance scope of faculty members is widespread and derived from the functions of higher education in different areas. In this context, Boyer, in his book entitled “A Look Back at Research”, has divided the main functions of higher education in four fields of Scholarship of discovery (original research), Scholarship of teaching, Scholarship of service, and Scholarship of integration.  In addition, in a study on the six roles of teachers, Harden considers a good teacher more than a lecturer and educator. 
It is worth mentioning that teaching and education do not take place merely in the classroom, rather clinical environment is one of the environments in which learning takes place. In clinical education, in fact, the students’ classroom is a clinical environment and their experiences in this environment make them achieve their goals. In this period, unlike the controlled environment (classroom), students are scattered in different geographical environments; hence monitoring and evaluating students’ experiences and controlling how they achieve clinical objectives are of the challenges ahead of educational planners.  It may not be surprising to note that time constraints play a determining role in the way of teaching of clinical teachers in the hospital environment. Research findings support this idea, indicating that with such constraints, teachers essentially consider their teaching ambiguous.  In this regard, Zubair Amin also considers the patient-centered, exposure specificity, unpredictability, time constraints, and clinical reasoning as the difference between clinical and other forms of education.  clinical education is a major concern for clinical teachers because of its special difficulties and restrictions that should be recognized and resolved by authorities and teachers.  Therefore, regarding the importance of the clinical environment in forming the professional identity of clinical teachers and their students, one should try to use methods to improve clinical teachers’ work-life. Michael Balint is one of the individuals who have been overwhelmingly trying to improve professional interactions and clinical environment.
Michael Balint was a general practitioner and began presenting seminars for general practitioners in 1950. [11,12] He concentrated on examining the doctor-patient relationship to determine why this relationship was often problematic and how it could be improved. In the Balint group, doctors narrate the cases that they find difficult under the guidance of the psychoanalysts who play a leading role. Then, the narrated cases are processed. The goal of the Balint group is to provide a better understanding of the emotional content of the doctor-patient relationship for physicians in order to make them more capable physicians.  Generally, the Balint groups have between 4 to 10 members and meet regularly (usually once a week to once a month.  Olds and Malone, quoting from Michael Balint stated that traditional Balint groups include more than 10 general practitioners and 90-minute weekly sessions in the presence of a trained leader. With the aim of increasing their knowledge, participants have the opportunity to the reflection of for their works through reporting of the desired patient and conducting group discussions in a safe psychoanalysis environment.  In this regard, review of various literatures indicated that the number of participants in different Balint groups, the time of each session, and the number of sessions varied from 3 to 17 individuals, between 55-120 minutes, and between 5 to 104 sessions, respectively, which lasted from 6 weeks to 2 years. [16-31] The main objective of the Balint workgroup was to make opportunities for improving early emotional experiences through facilitated reflection  In Balint sessions, members of the group disclose their experiences, feelings, and internal reflection to other members of the group. Talking about feelings can make a person aware of his/her strength and ability, thus enabling them to be analyzed and understood. Balint suggests that recognizing, acknowledging, and understanding the emotions and feelings of clinical specialists in clinical work can be beneficial to patients only if they are tolerated, understood, and controlled by the doctor. The traditional styles of Balint groups have been modified in order to meet the requirements of specific participants. 
Over the past few decades, the popularity of the Balint group has increased in various group programs, and a noticeable number of studies have examined the prevalence, combination, leadership, outcomes, and evaluation of the Balint group. In addition, numerous literatures has stressed the importance of the relationship between clinical groups (including physicians, nurses, physiotherapists, and students of these fields) and the patient, and its effects on patient compliance, treatment outcomes, and the risk of litigations. Furthermore, several studies have provided evidence on the improvement of the clinical understanding of the therapeutic groups of the dynamics of the relationship between them and the patient after participating in the Balint sessions. [15,18,20,22,28,32-36] A phenomenological study was conducted by Dahlgren et al. in 2000 with semi-structured in-depth interviews with three physiotherapists at their own work in Sweden. Eight themes were extracted from the interviews in this study and the final result was obtained as the Balint group and sharing experiences were strategies to enhance understanding when facing patients in clinical work, which was likely beneficial to the physiotherapists and patients.  Another phenomenological study was carried out in 2008 by Kjeldmand and Holmstrom at the University of Uppsala, Sweden. The result of this study was five themes and general practitioners described the participation in the Balint group as highly beneficial to their professional lives. Therefore, Balint groups may help general practitioners to prevent burnouts.  In 2009, a mixed study was performed by Graham et al. on 17 psychiatric residents and counselors. The results indicated that the groups were disturbing, and most participants were able to increasingly adapt to and benefit from the psychological learning process, however, some of the participants tried to match the group.  A study was performed by Manouchehri et al. in Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran. 55 nurses were selected and randomly divided into experimental and control groups in this study, however, 12 cases were finally analyzed in each group. The results obtained from this study revealed that the Balint group was effective only on the level of stress of the private life scales. 
The literature indicates that the members of the Balint group in its traditional and original form were general physicians, however, currently, the Balint group participants could include all those who, in their careers, always deal with individuals ask for professional help from them for treatment, care, problemsolving, training, and advice. Therefore, today teachers, nurses, physiotherapists, lawyers, judges, clerics, social workers, psychologists, counselors, and interns of these disciplines who engage in referents, participate in the Balint groups in addition to the general practitioners, medical specialists, and psychiatrists. It is worth mentioning that there is no necessity that the members of the Balint groups are completely homogeneous in terms of occupation, and many of the most experienced Balint groups consist of physicians in different disciplines, nurses, and other members of the treatment team. [21,22,25,28,31,35,37]
Balint groups are active worldwide, but in Iran, there was no evidence of using the Balint group as a formal educational activity for teachers (clinical teachers) or students from medical sciences universities. A useful strategy for overcoming of difficult experiences may be to share them with others. For the clinical teacher, however, this is not easily accomplished. In Iran, clinical teachers are limited in their ability to share their experiences because of their busy time due to therapeutic and educational roles. Therefore, clinical teachers are suppressing their emotions and in the long run, it may cause psychological stress on them so reflection in peer groups might be an approach for avoiding psychological stress. No previous rigorous qualitative studies exist on teacher Balint groups. The aim of this study was therefore to explore clinical teachers’ experiences of Balint group participation and its influence on their work life in clinical settings. To date, that is the only published study considering the influence of Balint group participation on the clinical teachers’ work-life in the clinical environment.
This qualitative study applied conventional content analysis. The study participants included clinical teachers from Iran and Isfahan University of medical sciences. Inclusion criteria were having at least 3 years of clinical training experience and willingness to participate in the study. Similarly, the study exclusion criterion was the lack of attendance in more than half of the Balint group sessions. After performing Balint sessions (eight two-hours) from the 13 clinical teachers who participant in, all 10 clinical teachers who had inclusion criteria, were selected by purposive sampling. For transferability and acceptability of the data, the clinical teachers were selected with the maximum variation in terms of field of specialty and number of service years as the faculty member.
The data were collected through individual semi-structured, indepth interviews were conducted with all ten clinical teachers, which continued until data saturation. The time and place of the interviews were arranged according to the participants’ preference, and the interviews were held in quiet settings. The anonymity of the participants, confidentiality of their data, the need to record voices, and the possibility of withdrawal from the study were explained to all participants, and informed consent was obtained from them before commencing interviews. Interviews were conducted by the researcher and began with a general open question (“What experience did you have in the Balint group?”), and probing questions were asked according to the participants’ responses and interview process (“In your opinion how will this experience change your behavior?”, or “How will this experience change your professional interactions?”), and the interviewer assessed the accuracy of their understanding by asking deeper questions (“What do you mean by saying so?” or phrases such as “Please explain in more details”). Each interview lasted 30-60 minutes depending on participant responses to interview questions and was face-toface.
The Graneheim and Lundman’s methods were used to analyze the data  such a method includes:
1) Transcription of the interviews and field notes right after the end of interview sessions;
2) Reading the transcription of the interviews for a better understanding of the contents;
3) Identifying meaning units and primary codes;
4) Categorizing similar codes into main categories; and
5) Identifying the main themes of the categories.
To assess data accuracy, the authors have used credibility, dependability, conformability, and transferability criterion. To determine the credibility of data, there was a constant link between the subject and data (constant comparison). The opinions of the research team regarding the process of interviews and data analysis were considered (peer checking). The interview transcripts and findings were also shared with some of the participants (member checking). In addition, the researcher had a prolonged engagement with participants. In order to determine the dependability of the data, an external observer out of the research team, who was familiar with the methodology of qualitative research, was consulted who had a consensus about the results (external checking). To determine the conformability of the findings, the researcher also attempted which records all activities and a report of the research process was prepared. The transferability was confirmed by sharing the results with two faculty members out of the study who were in a similar situation as that of the participants of the present study who confirmed the findings.
In this study, ten clinical teachers (seven females and three male) that participate in 8 Balint group sessions were interviewed. The age of participants varied between 30 and 54 years old. The population varied in terms of field of specialty and number of service years as a faculty member (Table 1).
|Participant No||Age||Sex||Marital status||Academic rank||Field of Specialty||Number of service years as faculty member|
|1||40||Female||Married||Assistant Professor||Endocrinology and Adult Metabolism||3-10|
|2||49||Female||Single||Assistant Professor||Pediatrics’ Infectious diseases||11-18|
|3||43||Female||Married||Assistant Professor||Women's Infectious diseases||3-10|
|9||47||Male||Married||Assistant Professor||Traditional medicine||3-10|
Table 1: Demographic characteristics of clinical teachers interviewed in the role of Balint group in the behavioral metamorphosis cycle and the development of professional interactions of clinical teachers.
From the analysis of participants’ narratives, two themes including “behavioral metamorphosis cycle” and “dimensions of professional interactions development” were extracted. Each of the themes included the categories and subcategories that are explained in detail in this section. In order to provide documentation and examples related to these intrinsic categories and subcategories, the quotations of their narrators are presented exactly as they have been expressed.
The behavioral metamorphosis cycle included categories of “self-awareness”, “other-awareness”, “building personal Identity” and “building social Identity”. The dimensions of professional interactions development also included categories of “the process of promoting interaction with the student”, “promoting interaction with the patient” and “building professional identity” (Table 2).
|Revising of feelings, experiences, and behaviors of oneself||Self-awareness||Behavioral metamorphosis cycle|
|Changing interactions' nature|
|Putting yourself in others' shoes||Other-awareness|
|Understanding others' feelings and developing a holistic approach|
|Modifying feelings||Building individual identity|
|Enhancing interaction with family||Building social identity|
|Enhancing interaction with society|
|Sharing feelings and experiences in face with the student||The process of enhancing interaction with the student||Dimensions of professional interactions development|
|Critical thinking about interaction with the student|
|Changing the nature of interaction with the student|
|-||Enhancing interaction with the patient|
|-||Building professional identity|
Table 2: Subcategories, categories, and themes about the role of Balint group in the behavioral metamorphosis cycle and the development of professional interactions of clinical teachers.
Behavioral metamorphosis cycle
In this theme, clinical teachers change their behavior in interaction with their students purposefully, and for this to happen, they must pass through four stages of the behavioral metamorphosis cycle (Figure 1). Almost all clinical teachers participating in the study following the attendance in Balint group sessions had a positive experience in their behavioral change with students.
Self-awareness: Most of the participants acknowledged this experience that if it is expected that behavioral change occurs in the face with a student, the individual has to develop selfawareness. This category refers to subcategories such as “Revising feelings, experiences, and behaviors of oneself” and “Changing interactions’ nature”.
Revising feelings, experiences, and behaviors of oneself: The participants of this study made this point in different ways that the experience of attending 8 sessions of Balint group meetings had allowed them to revise their feelings, experiences, and behaviors.
In this regard, one of the participants says how presence at Balint group has made him identify his feelings: “I mean these meetings made me get to know these feelings practically. It was very good in this regard” (Participant no. 7).
Regarding the revision of experiences, another clinical teacher also says, “Attending Balint sessions helps us review both what we have done and what others have made us face, which is very good in this regard” (Participant no. 10).
In addition, concerning the revision of our behaviors, another clinical teacher states, “I think these sessions at least help us stop judging ourselves one-dimensionally and listen to others’ judgments as well and understand what others may feel about us. As a result, this causes us to better understand the other party or even our own behaviors, i.e. we can see how others think or feel about our behavior” (Participant no. 4).
Changing the interactions’ nature: Changing the nature of interactions is another possibility provided to create the opportunity to attend Balint meetings for clinical teachers, in a way that one of the participants refers to gaining new insight in interaction with the student and considers avoiding looking down on students and not judging them in this interaction as evidence of this subcategory: “Joining the Balint group, I obtained more insight, experience, and understanding of the teacher-student interaction and learned not to try to always look down on and judge students or residents. In fact, attending Balint sessions made me know that senses, behaviors, deeds, and words a student has and displays might have originated from a series of senses I have not been aware of and always tried to control, but now, a new window has opened before my eyes” (Participant no. 9).
Furthermore, another clinical teacher implies maintaining the distance from the student as another evidence of change in interaction nature of clinical teacher-student: “The doctor she felt very close to a particular student. You should neither get so close to the student that you get involved nor stay so away that you cannot establish communication with him/her. In my opinion, I gained very good experience at Balint…it was a good experience for me regarding the fact that how I should treat the student and how close I should get to them” (Participant no. 3).
Moreover, another teacher mentioned more maturity of behavior or more dominance over oneself as signs of change in interactions with the student: “From my point of view, these sessions helped us to perform more maturely while interacting with all people, not just students, and have more dominance over you” (Participant no. 7).
Other-awareness: The clinical teachers’ words also indicate that another stage that has to be passed through and brings about behavioral change in the face with students is developing “otherawareness”. This category is also on the basis of subcategories like “putting yourself in others’ shoes” and “understanding others’ feelings and developing a holistic approach”.
Putting yourself in others’ shoes: One of the subcategories that were formed as a result of analyzing the contents of the participants’ interviews in Balint sessions about how clinical teachers developed “other-awareness” was “putting yourself in others’ shoes”. In this regard, one of the participants says, “For example, when a student makes a mistake or builds an inappropriate interaction with you, you are able to put yourself in his/her shoes in this meeting” (Participant no. 2).
The same teacher mentions putting yourself in the student’s family’s shoes as well as in the student’s shoes: “When we are with students, it is obvious that all students do not show the same behavior; a student might not have studied well, may become involved in argument with you, come late, and so on. Before the Balint, I only thought that he/she was a student, arrived late and had to be punished so that he/she would not be late anymore, but now, I put myself in the student’s and his/her family’s shoes” (Participant no. 2).
In his interview, another teacher mentions paying attention to other aspects of students’ lives as one of the methods of putting ourselves in their shoes: “Although a human thinks he might be considering different aspects, there are some aspects that may be hidden to him…we have to be very careful that a student is a person with all aspects of a human a part of which has come to us to learn something” (Participant no. 3).
Another clinical teacher speaks more generally and points out looking at the problems from other people’s point of view (not particularly from the student’s or his family’s viewpoint): “I think the most important thing which was very considerable for me is that in face with an issue, the person should put himself in different people’s shoes involved in that issue and look at it from their point of view, which affects the way I, myself, behave in face with that issue” (Participant no. 8).
Understanding others’ feelings and developing a holistic approach: Participants of this study approved “understanding others’ feelings and developing a holistic approach” and perceived that as another stage toward “other-awareness”. The clinical teachers mentioned important points to describe their viewpoints.
One of the teachers explains his experience of understanding the feelings of the teachers in the Balint meetings as follows: “For example, as I see one of the teachers here has had a problem with one of the residents and ask myself how I would feel if I were in his shoes…may help me in problem-solving” (Participant no. 6).
Another clinical teacher expresses his perception of other teachers in Balint meetings and the reverse use of them in developing “other-awareness” and eventually behavioral change: “Before attending this session, I always thought the problem between me and my student might be specific to me and might lose my self-confidence that way, but when I see there are other people with the same problems, I regain my initial selfconfidence and come to the conclusion that these challenges are specific to teacher-student relations and may happen to everyone” (Participant no. 9).
In this regard, another teacher believes, “When I have a problem with a student and express it in these meetings, what cheers me up is that I realize that I am not alone and there are other people with the same problem” (Participant no. 2).
Regarding the development of a holistic approach, the same participant says, “For example, when you think a student has made a mistake or has an improper interaction with you, the fact that in this meeting you are able to put yourself in the student’s, personnel’s and your shoes and even see yourself from the viewpoint of someone superior to you helps you develop a holistic approach. When you develop a holistic approach in a problem, you can analyze the problem more carefully” (Participant no. 2).
In another part of the interview, the same teacher talks about developing a holistic approach: “The approach that a person looks down on other people is exactly this Balint” (Participant no. 2).
Building individual identity: The clinical teachers’ words imply that “building individual identity” is another stage to pass through in order to change behavior in the face with a student. This category is made up of subcategories including “modifying feelings” and “modifying behavior”.
Modifying feelings: “Modifying feelings” is a subcategory that we developed as a result of analyzing the interview contents of the participants in Balint meetings about how to “build individual identity” among the clinical teachers present at the meetings. One of the participant’s talks about modifying feelings toward family, colleagues, friends, and students: “During past weeks, I faced some cases. For example, I had a conflict with my wife over an issue, and I noticed I was immediately flying off the handle and getting upset about that. After a moment, however, I came to my senses and told myself that what she just said stimulated anger in me, so why am I so angry now? Because I have become so tired today and my threshold of tolerance has been lowered and I cannot behave logically. Therefore, I honestly told my wife I’d had a hard day that day and she shouldn’t expect me to listen to her and answer her logically. Then I asked her to let me sleep then so that we could discuss that issue the next day. So, I went to bed, and she became so sad, but if I had stayed awake, she would have become much more upset…But I want to say that modifying feelings makes you have a better life. A lot of the arguments between families, colleagues, friends, and between teachers and students result from a lack of awareness of feelings” (Participant no. 7).
Another clinical teacher talks about moderation in attitude and feelings: “Look, when a person reaches moderation in his/her, let’s say, attitude and behavior, it doesn’t matter where he/she is; I mean, it isn’t specific to workplace and helps him/her in all of his/her relationships at home, work, etc…” (Participant no. 2).
In this regard, another clinical teacher says, “Personally, when I saw others have the same feelings I had and realized where I could have behaved better and where it wasn’t really my fault, I felt so relieved, which was really good for me in this regard. It seemed that a hidden burden was heavy on my shoulders and I was ignoring it” (Participant no. 10).
Regarding the effect of Balint meetings in removing past unpleasant feelings and emotions, the same participant says, “These meetings made my past unpleasant and negative feelings and emotions lose their power as they are disclosed… Anyway, this is an achievement and, as I said, helps you lessen the negative burdens” (Participant no. 10).
Modifying behavior: One of the subcategories associated with the category of “building individual identity”, which has been frequently mentioned in the participants’ words, is “modifying behavior” that is expected to take place after “modifying feelings”. In this regard, one of the teachers describes “modifying behavior” as a change in decision-making in all aspects of life: “The quality of our decision-making and our viewpoint toward life or education completely changed” (Participant no. 2).
The same teacher mentions avoiding haste and judgment as evidence of “modifying behavior”: “You are not allowed to judge in these meetings, so you avoid haste and judgment to some extent” (Participant no.2).
Another teacher refers to becoming a better person as a result of “modifying behavior”: “Balint group is a window to a new world that helps you have a tool with which you can live more easily, help each other more, and in the whole, be a better person. However, it takes practice” (Participant no.7).
Another clinical teacher mentions becoming stronger as a sign of “modifying behavior”, which occurs in Balint group: “Of course, sometimes the unpleasant things come back to you like fire under ash, and you feel that experience again. However, it makes you stronger because other people also give their remarks” (Participant no.10).
Another teacher mentions changes in a person’s disposition as the effect of attending these meetings on “modifying behavior”: “For example, when you face a problem that has bothered and made you worried, whether in the workplace with a student, in the hospital between you as a doctor and a patient, between you and your child, and between you and your spouse or family, if you learn to look at the issue from the other party’s viewpoint and this becomes a part of your disposition, you can extend it in all other areas and situations” (Participant no. 1).
Building social identity: According to the teachers’ words, “building social identity” is another stage to go through so as to change behavior in the face with students. The category consists of subcategories including “enhancing interaction with family” and “enhancing interaction with society”.
Enhancing interaction with family: “Enhancing interaction with family” is considered one of the two subcategories of “building social identity” and is developed from the participants’ point of view by attending Balint meetings. In this regard, one of the clinical teachers says, “Certainly, when you are influenced by something somewhere, other aspects of your life including behavior toward every single family member and patients as well as other members of society are influenced, and this is not limited to students for whom these meetings have been held” (Participant no. 6).
Another participant says, “It is true that our meetings were about students, but they have positively affected my relations with others, i.e. my family members and colleagues” (Participant no. 10).
Another teacher perceives the improving relationship with your children and spouse as a result of enhancing interaction with family: “In my opinion, these relations, i.e. teacher-student, father-child, or husband-wife relations change your attitude toward problems and issues” (Participant no. 3).
Another participant considers the effect of attending Balint meetings on enhancing interaction with family in personal life: “I didn’t use to put myself in others’ shoes a lot, but now, I do, which is definitely effective in my personal life as well” (Participant no. 4).
Enhancing interaction with society: “Enhancing interaction with society” makes up another component of “building social identity” that is met by attending Balint meetings. One of the clinical teachers defines it as avoiding hasty decision and recognizing others’ rights in daily interactions with them: “In fact, the same thing I said about interaction with students applies to interaction with people present in your life including your spouse, children, parents, and other members of society, and you have to give them rights in communications and interactions and shouldn’t decide quickly” (Participant no. 5).
Another clinical teacher perceives “enhancing interaction with society” as looking at problems from the viewpoint of the society members: “To begin with, it was a new experience for me and I learned to put myself in different people’s shoes and look at problems from the point of view in face with different things happening in my life, which is not ineffective in my opinion” (Participant no. 8).
One of the participants believes that despite the fact that Balint meetings were held to improve teacher-student interactions, it has led to the improvement of interaction with society in addition to the enhancement of the individual aspect of interaction: “Certainly, when you are influenced by something somewhere, other aspects of your life including behavior toward every single family member and patients as well as other members of society are influenced, and this is not limited to students for whom these meetings have been held” (Participant no. 6).
All in all, the theme of “behavioral metamorphosis cycle and its categories and subcategories was focused on some specific changes in hidden and evident behavior of clinical teachers and tried to show why and how attending Balint meetings led to gradual behavioral change”.
Dimensions of professional interactions development
Given the words of the clinical teachers, Balint meetings had managed to create a theme called “dimensions of professional interactions development” consisting of three dimensions or categories including “the process of enhancing interaction with the student”, “enhancing interaction with the patient”, and “building professional identity” all of which a person needs to develop (Figure 2).
The process of enhancing interaction with the student: Based on the participants’ words in Balint meetings, it was concluded that “the process of enhancing interaction with the student” is a dimension of “dimensions of professional interactions development” in a clinical teacher, and the origin of this category itself is made up of stages or subcategories including “sharing feelings and experiences in face with the student”, “critical thinking about interaction with the student”, and finally “changing the nature of interaction with the student”.
Sharing feelings and experiences in face with the student: “Sharing feelings and experiences in the face with the student” is a subcategory of “the process of enhancing interaction with the student” that occurs in different forms in Balint meetings. One of the participant’s states that this happening also takes place in the face with the student by sharing the narrator’s feeling, other teachers in the meeting, and even the leader of the group: “This happening occurs through a narration of the person, his colleagues and words of the leader of the group. Also, the experiences that others discussed had definitely happened to different people more or less, so everyone had a shared feeling about this issue” (Participant no. 8).
In this regard, another clinical teacher says, “As soon as I felt there was a shared feeling between me and others in the similar conditions, i.e. both of us might become sad, happy or angry in the same situation, made me feel that my feelings were totally natural, rather than unusual; I had shared feelings with others, and the same situations would make others feel the way I did. In addition, discussing these feelings helps you feel relieved and understand that this is something normal and you don’t need to be worried about it” (Participant no. 4).
Another clinical teacher refers to his enthusiasm for sharing feelings: “It was interesting to me to listen to others’ feelings about a problem and the way they think or feel about it” (Participant no. 1).
Another participant describes sharing feelings with the participants in Balint meetings as follows: “Balint wants us to put ourselves in the persons’ shoes raising the problem and then face the problem from his emotional viewpoint” (Participant no. 2).
Concerning sharing experiences in Balint meetings and how to use that in interactions with the student, another clinical teacher says, “Through participation in these meetings and using other teachers’ experiences, I perform a simulation about the particular cases about which those teachers talk so that I can behave like that if I have a similar student” (Participant no. 5).
Regarding learning the teacher-student interaction through sharing experiences, the same participant says, “I have been teaching only for four years, and when a colleague with around 20 years of experience working with students expresses his experiences, especially with special students whom you may face twice in every ten years or even never, you won’t behave that student like it is your first time because you know something similar has happened before and one of your colleagues has told you about his experience. Therefore, if something similar happens, you can definitely show a better reaction because some case may occur once or never” (Participant no.5).
Regarding learning the teacher-student interaction through sharing feelings, another clinical teacher says, “For example, I may have an unpleasant experience and convey this feeling, and some people give positive sense and some negative sense; now that different feelings are discussed, I receive those feelings, and if I am faced with similar conditions later, not necessarily the same conditions, I’ll consider this before making a decision, which makes me look at and feel an issue in another way. As a result, I think negative and aggressive behavior will decrease and your mood changes will be reduced and reach a moderate level” (Participant no. 1).
Critical thinking about interaction with the student: “Critical thinking about Interaction with the student” is another subcategory of “the process of enhancing interaction with the student” about which one of the clinical teachers expresses his feeling after attending Balint meetings: “I believe the teacherstudent relationship, which was probably considered a one-way relationship before in which always the teacher was right and the student was guilty, has now changed and I’m sure that I have to consider different components of the student and consider him convergent with me and before judging his behavior, do a behavioral analysis first” (Participant no. 9).
In this regard, another teacher says, “We have to look at the student multi-dimensionally, i.e. he has other problems and concerns rather than a person who has come just to study here; I really consider such things more after I attended Balint meetings” (Participant no. 3).
Another clinical teacher describes critical thinking about interaction with the student as looking from outside: “Balint allowed us to stay away from the middle of every event and look at what is happening in the middle as a spectator, which helps us understand the situation better or find a solution to improve the current situation” (Participant no. 8).
Changing the nature of interaction with the student: Another subcategory associated with “the process of enhancing interaction with the student” category to which the participants referred is “ changing the nature of interaction with the student” that is expected to occur after “sharing feelings and experiences in the face with the student” and “critical thinking about interaction with the student”. In this regard, one of the teachers describes his achievement as follows: “I gained a lot of interesting experience at Balint. Perhaps if people had discussed other problems or experiences, we would have had more experience, but this was a good experience for me in terms of how to behave students and how much to get involved with them” (Participant no. 3).
Another clinical teacher says, “I think these meeting at least makes us avoid our own one-dimensional judgment and understand how others may feel as well and then it helps us better understand the other party or even our own behavior, i.e. we can see how others think or feel about our behavior” (Participant no. 4).
Another teacher mentions changing the nature of interaction with the student: “Taking part in Balint group certainly changes the nature of interactions with the student because joining this group and listening to others’ opinion from the students’ points of view enlighten many factors that I had not noticed before and helped me not judge or behave hastily” (Participant no. 9).
Another clinical teacher says, “I think participating in Balint meetings has changed the nature of my interactions with my students to some extent” (Participant no. 3).
Another teacher describes the value of sharing experience in “changing the nature of interaction with the student” as follows: “Within the Balint group, some teachers are more experienced, have seen more students, and more things have happened inside their groups. So, you definitely learn from them. You really don’ think what will happen if you behave your student like this or how different people should behave. I mean, the experience which is shared can affect your understanding in your relations” (Participant no. 5).
Enhancing interaction with the patient: Another dimension or category of the “dimensions of professional interactions development” was “enhancing interaction with the patients” that is resulted from analyzing the contents of interviews.
In this regard, one of the clinical teachers says, “It can be definitely effective in our professional work because everyone may be involved with patients with different characteristics… for example, a Balint group consisting of some colleagues can be definitely very helpful professionally in terms of how to communicate with different cases, which cases are not suitable to work on because they may trouble both us and them and so on” (Participant no. 5).
Another clinical teacher explains, “This is also applied to a doctor in the face with a patient. For example, I learn not to make a quick decision about every case and think about the behavior I want to have toward a student or patient before I react” (Participant no. 6).
Another participant mentions the necessity of attending Balint meetings for “enhancing interaction with the patient” as follows: “Regarding the last meeting I had, I took advantage of that in my behavior toward my patients” (Participant no. 7).
Building professional identity: The participants of this study mentioned “building professional identity” as another dimensions or category of the “dimensions of professional interactions development.”
In this regard, one of the clinical teachers says, “I think the professions of medicine and therapy, and especially teaching can create so much burnout and lead to monotonous routines. So, attending Balint meetings and listening to his/her colleagues’, the group leader’ and others’ viewpoints from the students’ points of view are very helpful for that teacher and can really help the teacher in class management and facing the students” (Participant no. 9).
Another participant describes his own “building professional identity” by attending such meetings as follows: “Regarding its effect on my professional life, I can say that my self-confidence has been boosted, i.e. I used to feel that when something happened or something was said, other did not feel the same as I did, but now in understanding that others have the same feeling as well, which boosts my self-confidence” (Participant no. 4).
Another colleague considers attending Balint meetings very effective in forming professional identity: “I believe Balint group can make a person reach moderation in behavior and feelings and feel this moderation in the face with students in professional environments, i.e. work environments. It means when you share a feeling and experience and others reflect that…and express different viewpoints, you reach moderation in behavior, which helps you reduce inappropriate behavior and feelings. Also, you can manage those conditions better, which helps you be able to show better behavior in other situations similar to those shared among you and other participants. These meetings were held in a way that even if new experiences come up, you will be stronger as a result of the very moderation I just mentioned” (Participant no. 7).
What is evident is that the theme of the “dimensions of professional interactions development” generally consists of dimensions or categories like the process of enhancing interaction with the student, enhancing interaction with the patient, and finally building professional identity each of which is concentrated on an aspect of professional interactions.
This study is the first study carried out with the purpose of explaining the clinical teachers’ experiences of the effect of participating in Balint group meetings in their work life in clinical environments of Isfahan University of Medical Sciences, Iran, concentrating on teacher-student relationships. The participants described a part of their experiences in this research in the form of two themes, i.e. “behavioral metamorphosis cycle” and “dimensions of professional interactions development”. The researchers believe that these experiences function as a framework for change in a way that they may finally lead to the enhancement of clinical teachers’ relations in their work and professional life (relationships with students/patients).
The findings of this research emphasize the viewpoint that changes occur in the Balint group, which is greatly in line with the results of other qualitative and quantitative studies on participation of different professional groups in Balint meetings, [31,39,40] and these changes are evident in various areas such as behavioral change and interactions development and seem to be parallel processes resulting in the increase in the ability to conceptualize interpersonal relations and behavior and overgeneralizing it to the professional life of the Balint group’s participants.
The results of this study led to the identification of “behavioral metamorphosis cycle” following the presence of clinical teachers in Balint meetings. During their presence in such meetings, the clinical teachers developed awareness of their feelings, experiences, and behavior and finally changing interactions. Therefore, this stage was named “self-awareness”, and the findings were in line with those of Graham et al. in which developing awareness of own feelings from others are mentioned as one of the discovered themes.  In this regard, Stelcer believes that participating in Balint meetings helps us to gain insight into the unconscious of their own behavior, self-knowledge or even limited transformation of personality features and also allows physicians to listen to the feelings and develop an awareness of their existence so that they can be used in conjunction with clinical skills. [17,41] In fact, Smith and Anandarajah consider teaching self-awareness to be one of the central goals of residential education, which improves patient care and professional relationships. 
Another point that the clinical teachers mentioned was putting yourself in others’ shoes, understanding their feelings and developing a holistic approach, which we named “otherawareness”. This finding is in line with that of a study carried out by Diaz et al. with the aim of updating understanding of organization, purpose, and leadership of Balint groups in residential programs of US family medicine. They found out that the main objective of the Balint group was to understand the patient as a person.  Moreover, our finding was in line with that of ‘the Balint group experience for medical students’ conducted by O’Neill et al. Among the five themes introduced by them, one of them was named “putting yourself in the patient’s shoes”.  According to Stelcer, listening to and recording the opinions of the narrators participating in Balint groups helps us gain rich insight into unknown aspects of relations between narrators and patients, which leads to recognizing the personal style and enhancing such relations. 
Another category of the theme of “behavioral metamorphosis cycle” which we reached in our study was “building individual identity” which was the result of important factors such as feelings modification and behavior modification in the participants’ opinion. This finding was in line with one of the concepts of the study by Koppe et al., i.e. ‘personal change’.  In this regard, Brazeau et al., quoted by Bacal, suggest that Balint groups can cause personality changes and improve communication skills.  In addition, Adams et al. suggest that participating in the Balint group helps to gain multiple personal insights. 
“Building social identity” is another category of this theme consisting of subcategories like enhancing interaction with family and society. The researchers did not find any studies in line with ours, but what is certainly true is that this social identity is an ever-changing multidimensional complicated issue, and whatever has surrounded us in the world and social life has a role in building a social identity.
The “dimensions of professional interactions development” was another theme we reached following interviews with clinical teachers. One of the categories or dimensions of this theme was named “the process of enhancing interaction with the student” because it involved sharing feelings and experiences in the face with the student, critical thinking about interaction with the student, and changing the nature of interaction with the student. It should be noted that Balint groups have been particularly created to contribute to professions associated with health and students of medicine so as to develop empathy skills and reduce interpersonal problems.  Educational activities and teaching can be effectively carried out in places where there is serious interaction between teachers and learners and the teacher can act as a manager, leader, and instructor. Different studies have shown that interaction between teacher and student at university can affect the quality of teaching and learning. The results of the qualitative study conducted by Yaghoubinia et al. revealed that one of the categories of this study is called relationship necessitates, i.e. the participants have emphasized the necessity of an appropriate pleasant relationship between a teacher and a student in clinical education environments, which is in line with the findings of the present study.
“Enhancing interaction with the patient” was another category or dimension of the theme above, and this finding was in line with that of Lichtenstein et al. in which having meaningful therapeutic relationships with patients and families and having effective communicates with patients, families, and public were considered the most important qualifications mentioned in Balint group. Scott et al. believe that attending the Balint group changes one’s perspective and possibly allowing one to see new ways to re-approach the patient or regain one’s professional role.
Based on the words of the participants in Balint meetings, the last category of the theme of “dimensions of professional interactions development” was “building professional identity”. This finding was in line with the results of the study by Olds and Malone (Constructing Professional Identity) in which they suggested that attending Balint groups increased the level of sharing professional viewpoints with other fellows.  Furthermore, this finding was in line with that of Troppa et al. (building professional identity) in a way that they demonstrated that Balint groups might boost the professional development of students of medicine.  Professional identity development is an important issue, and explicit discussions about professional identity have to be supported and encouraged because we know that a part of professional identity is transferred and taught through the hours in a curriculum.
In the end, our findings point out that Balint groups are a means of managing difficult work conditions, gradually changing behavior and developing professional interactions because this method is based on reflection on the face of difficult conditions and using disappointing experiences and feelings. In the present study, we did not directly investigate whether this competency has been gained or not, but we believe that mechanisms like fixing and improving the effect of painful experiences in narrations, increasing understanding of reality or complicated relations probably play important roles in this regard through reflection in a professional environment, empathetic access to involved peers in an upsetting situation. The group leader also facilitates this process while maintaining a safe environment and focusing on the clinical teacher-student relationship.
Teachers are precious human capitals, and we have to try to protect and conserve them at the workplace. According to the authors, clinical teachers need guidance, feedback, and support as much as they need knowledge, and Balint groups provide them with a safe and confidential environment to express their feelings and reconsider their relationships with students. It is noteworthy that Balint groups may not be suitable for all clinical teachers, and other methods have to be presented to change the behavior and enhance the professional interaction of teachers in their work life.
Although there were limitations in our study that may restrict the generalizability of the results, this is the first study to describe the experiences of clinical teachers in the Balint group. A limitation is the method of data collection. Although our study population was small and the groups of clinical teachers were selected, we systematically used qualitative methods (content analysis) to analyze the contents of the group experiences that can provide theoretical foundations for further studies. Clearly, the findings of this study are limited to the experience of a group of medical clinical teachers at one medical sciences university, Iran. For further understanding, qualitative studies involving students and other medical sciences universities should be pursued.
The results suggest that Balint group and sharing the experiences of others may be considered a way of enhancing understanding of the clinical teachers encounter in work life, possibly to the benefit of clinical teachers and their students. Balint groups for clinical teachers may be valuable educational sessions for fostering behavior change and professional interactions in the development of a mature professional identity as a teacher. The clinical teacher groups are modifications of the traditional Balint groups and should accept contexts other than merely patient cases into the discussion. Balint groups present educational potential, allowing participants to be accepted as they are and to share one’s inner reality with others in an emotionally safe environment. Further research is needed to evaluate the feasibility of teacher Balint groups in the clinical environment.
Conflict of Interest
The authors disclose that they have no conflicts of interest.
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