Converting Balint into online

Abstract

The online format of a Balint Group was thoroughly analyzed to better understand the differences to the face-to-face group. Due to a Covid-19 lockdown an established fa- ce-to-face group was converted to an online-format. Findings underwent an in-depth interpretive phenomenological analysis, comparing similarities and especially diffe- rences in the format, the group process and contributions. The online group seems to partly miss social and dimensional space, while the general setting continues. In com- parison to the face-to-face group, a loss of body and projective phenomena is observed with reduced non-verbal, subliminal communication and reduced negative capability. The online format could possibly be adjusted on special terms yet to be defined. Ne- vertheless, the online Balint Group maintains the underlying Balint Group goals. In conclusion, online Balint Groups continue Balint work under changed circumstances. They maintain the required professional education and self-experience. Online Balint Group could be a means to save time and energy resources.

Full text

Converting Balint into online
Ulrich Rüth, Astrid Holch (München)
The online format of a Balint Group was thoroughly analyzed to better understand the
differences to the face-to-face group. Due to a Covid-19 lockdown an established fa-
ce-to-face group was converted to an online-format. Findings underwent an in-depth
interpretive phenomenological analysis, comparing similarities and especially diffe-
rences in the format, the group process and contributions. The online group seems to
partly miss social and dimensional space, while the general setting continues. In com-
parison to the face-to-face group, a loss of body and projective phenomena is observed
with reduced non-verbal, subliminal communication and reduced negative capability.
The online format could possibly be adjusted on special terms yet to be defined. Ne-
vertheless, the online Balint Group maintains the underlying Balint Group goals. In
conclusion, online Balint Groups continue Balint work under changed circumstances.
They maintain the required professional education and self-experience. Online Balint
Group could be a means to save time and energy resources.
Keywords: Balint online Group, Web-Seminar, non-verbal communication, negative
capability
Covid-19-lockdown and the continuation of Balint work online
Covid-19 confronted humanity with special issues, such as lockdowns
and social distancing. Due to such circumstances, our established Classic
Balint Group came to a stop at the end of March 2020, as about 10 people
meeting in a single closed room was legally no longer possible. On the
suggestion of the participants and with the approval of the Bavarian Me-
dical Board, we changed the established group to a web-based format. Up
to that point we had been running a slow open group since 2011 with two
chairpersons and continually changing participants. Balint work is a com-
pulsory part of the participating MDs’ formal education1. For that reason,
they had a special interest to continue the group online instead of pausing
it until after the lockdown.
Experiences from our online group may give merely preliminary results
and should therefore be looked at as a “case report”. We have decided not
refer to technicalities and preparations, as this topic has already been dis-
cussed by Nease (2019) and Nease et al. (2018).
1
Balint Groups are obligatory in Bavaria/Germany for specialization in General Practice
(Allgemeinmedizin), Obstetrics and Gynecology (Gynäkologie) and, if specialization runs
in psychodynamic psychotherapy, also in Adult Psychiatry, Child and Adolescent
Psychiatry, and Psychosomatics and Psychotherapy.
© 2021 Copyright Mattes Verlag, Heidelberg • Dynamische Psychiatrie • Dynamic Psychiatr y
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.

An Acute Situation: The Setting
Being forced to stop regular meetings in March 2020 after a full lock
down was imposed in Germany, our Balint Group meetings had to be
suspended, despite being part of our participants’ ongoing specialist trai-
ning. In mid-April 2020, we started the conversion into an online format.
After three weekly sessions and with the agreement of the two chairper-
sons the group decided to continue since new regulations on social distan-
cing and the requirement to wear a face mask even in educational settings
made personal meeting practically impossible.2 At that point participants
mentioned that meeting people from outside their own working situation
online during the ongoing lock-down situation – was enjoyable to some
degree –, as cultural activities and social intercourse with friends had
come to a halt. Parallel to the gradual easing of the lockdown restrictions,
the initially high participation in the bi-weekly group seemed to return to
“normal” again because, short journeys being allowed again, people took
the chance to see friends and were then often lacking a working internet
connection during these visits.3
In June 2020, we started to allow new participants to join the online
group. Due to the experimental situation – which all participants were
aware of – everybody was keen on knowing how things would work. There
was no obligation to continue participation online, but for a variety of rea-
sons all members except one wished to continue their professional training
online and in the already familiar group.
A basic requirement for participation turned out to be an obstacle on se-
veral occasions: When trying to join from a remote location an unreliable
internet connection sometimes forced participants to quit during a running
session. Fortunately, the presenters were never affected by this problem.
Method – A phenomenological approach to online Balint
As there are very few papers on online Balint Groups we decided to
use the Covid-19 lock-down situation like an experiment. We informed
the members of the group at the time of our intentions and they happily
2021 (54), S. / pp. 114-123
Converting Balint into online 115
2
Seminars in continuing medical education or in other fields had to cut down the number
of participants in order to meet regulations, or to find bigger rooms which was an unsol-
vable issue for many.
3
In rural areas of Germany internet connection can still be difficult (2020), especially if
you try to connect via a mobile.
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.

agreed to cooperate and continue online. We decided to use a phenome-
nological approach, already used to analyze the Balint format under other
aspects like co-leadership (Holch & Rüth 2013). This approach leads to
an in-depth and scrutinizing examination of the phenomenology encoun-
WHUHGFRPSDULQJRXU¿QGLQJVZLWKWKHIDFHWRIDFHJURXSIRUPDWDQGLQ-
WHUSUHW LQJ ¿QGLQJV RQ WKH EDVLV RI RXU SV\FKRDQDO\WLF XQGHUVWD QGLQJ RI
Balint work. We used an interpretive phenomenological analysis (Levitt
2020), leaving aside technicalities already discussed elsewhere (Nease et
al. 2018). Findings were discussed with participants who contributed their
own impressions and feelings.
Balint online elsewhere
Online Balint work has already been shown to be a workable approach
in remote locations (Antoun et al. 2014; Koppe et al. 2015; Nease et al.
2018) and even during the Covid-19 situation (Dhekordi et al. 2020). Fin-
dings concerning online Balint Groups seemed to be presented mostly as
descriptive narrative for deeper understanding. Due to the need to estab-
lish online Groups elsewhere during Covid-19 restrictions, the American
Balint Society, in cooperation with the International Balint Association,
launched online seminars on the basics of Balint online Groups in Spring
2020, with participants from all continents.
Findings
1. Loss of social space
Before and after the usual face-to-face Balint meeting, members and
chairpersons get into contact via small talk, sharing the atmosphere and
(waiting) time as an open space. In such a situation, participants start to
tell about past holidays or the new workplace, a difficult family one had
contact to, an interesting seminar one had attended or the new shoes or
bracelet worn. When participants sit down to start the group work every-
one gets into a real working contact with the persons they are sitting next
to or even opposite. The digital technology of an online group also re-
quires time for entering, attuning, moving in and out of the session and
some kind of small talk might be possible, but only as long as the group is
still small and incomplete. And the nature of the small-talk is much more
formal compared to the face-to-face situation.
Ulrich Rüth, Astrid Holch
116
Dynamische Psychiatrie • Dynamic Psychiatry
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.

We have not come across literature which deals with a (therapeutic)
group’s social framework before and after the group’s formal meeting and
thereby “outside” the group – and there is still no paper on the social frame
of a Balint group outside the group itself.
Chair and co-chair have to arrange how to coordinate their roles – by
meeting online beforehand and discussing the group process online after-
wards. The chairpersons’ usual pre-meeting at a restaurant on the street
opposite to have a small evening meal and a work session focusing on the
past and the forthcoming group was missed much. This special situation
outside the Balint Group itself couldn’t be fully replaced by other means,
so that the “social space” for the leaders was cut down too.
Ending a session and saying good-by online until text time seemed to be
somewhat strange, as members quit the virtual room and vanish from the
screen in a way otherwise only ghosts can vanish in real space. It’s even
quicker than people were beamed away in Star Trek. Where do they go
then? In the face-to-face situation, members go away through space and
time, and they can even leave together and have some small talk after-
wards.
We made the proposition that members should give themselves at least a
short time to calm down after quitting, allowing impressions that emerged
during the group have a flow, a bit like they do when going downstairs
after the group and being on their way home.
2. Loss of dimensional space
Even in gallery view when looking online at all participants, each parti-
cipant sees a different mix of pictures. The usual group situation in space
flattens down to only two dimensions and gets mingled up. Looking only
at the upper part of the bodies (or even only the faces), the filling of real
space by human beings in the flesh gets lost.
In the virtual session an “opposite side” in space and so within the group
doesn´t exist, and therefore “opposing” positions of what might be brought
into discussion won`t show up, in contrast to the situation in the three-di-
mensional consultation room.
3. Getting more personal
Doing Balint online in your kitchen or personal living room invites
others into your private space. This might have a special effect on the usual
Converting Balint into online 117
2021 (54), S. / pp. 114-123
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.

separation between work and private life, which seems to diminish. Some
participants liked these private aspects, which might even cause some
noise irritation now and then while not going into mute – such as pouring
tea into the cup, which made other participants aware that they hadn´t pre-
pared enough to care for themselves. “Being at home feels more cozy”,
was noticed by some members, and this had helped them to tune in.
To some it was quite helpful to see the names of colleagues at the bottom
of the pictures – as sometimes it’s not so easy to remember all the names,
especially when you are new to the group. That way the online situation
made it even somewhat easier to get acquainted with each other.
4. The general setting continues
The usual frame and format of a Classic Balint Group (Rüth 2009) were
both easily applied, with the exception of the presenter’s pushback, for lack
of dimensional space. The presenter could go into mute if preferred, but
this didn’t make any noticeable difference.
Due to the random arrangement of the participants’ pictures, the chair
had to call out who’s turn was next when participants introduced them-
selves to new members – as presentation calls couldn´t go around from one
seat to the next. But this didn’t cause any awkwardness.
Furthermore, if you don’t use the “hands up” signal before making a
comment, people might end up talking simultaneously. This sometimes
has to be organized or controlled by the leader, as the technology gives
more sound volume to the person speaking first and the ones coming se-
cond could get lost.
5. Loss of eye contact and non-verbal communication
With the camera usually situated at the top of the screen (sometimes
at the side) neither leader chair or co-leader nor participants can have di-
rect eye contact. Most of the body being invisible, usually even the hands,
non-verbal communication is much restricted, with a loss of physically
mediated gestures, expressions or sitting posture. The non-verbal com-
munication between leader and co-leader is shifting mainly into verbal,
like in a reflecting team situation. Using the chat option (e.g. with Zoom)
seemed to be not confidential enough to us – and frankly too complicated
to handle.
Ulrich Rüth, Astrid Holch
118
Dynamische Psychiatrie • Dynamic Psychiatry
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.

6. Loss of the body
With non-verbal communication diminishing, it seemed as if the body
also “vanished”. Being online, although in a situation with a tendency to
get more private, sometimes even more intimate, comments seemed to
refer no longer to body impressions, such as feelings in the belly, stomach,
heart, even head. Nobody showed up to describe oneself getting physically
nervous, or having the urge to run out of the room – yet where to?
7. Internal versus external space
Examining our impressions as, it seemed as if statements by partici-
pants sometimes seemed to stay more individual, less relating to state-
ments from others, with therefore less resonance within the group and as
if a special kind of connection had diminished or even vanished. We still
can’t identify whether this might be due to the character of presented cases
RUWKHFRQVHTXHQFHRIXVLQJWHOHSUHVHQFHRQDÀDWVFUHHQKROGLQJXVDSDUW
– or even both.
8. Loss of projective space
As the group met virtually and not in real space, the participants’ com-
ments, impressions and statements did no longer show a spatial pattern
– being opposite or on a 90-degree level, which sometimes, by looking on
real crossing formations, can lead to a special understanding of splitting
aspects. Statements being “opposite” therefore had to be explicitly named
by leaders if necessary, but unfortunately, they could not be referred to
more explicit by pointing to the positions in space. As such “interpreta-
tion” depends on the style and activity, the loss of such possibility might
not irritate in general. Nevertheless we can conclude that through the loss
of real space there was, at least to some degree, also a loss of projective
space.
Balint online compared to the real space group
Because of being remote from friends and acquaintances during the
lockdown, motivation to participate was high, probably similar to a situa-
tion of geographical remoteness.
At the beginning, when we started with our online sessions, the process
was quite unfamiliar to all of us, it therefore took more time to tune into
Converting Balint into online 119
2021 (54), S. / pp. 114-123
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.

our usual working attitude. Whether concentration and working attitude
are the same online compared to face-to-face seemed to depend on the
participants. After the first sessions group members expressed that online
working seemed to be at least slightly more exhausting.
The size of a group might also have an influence on the effect of online
Balint work. If there are too many participants on the screen (more than
ten including chairs), we seem to lose contact to some degree; on the other
hand, a small group can easily be dominated by one active member – like
in face-to-face.
Going online the co-leader seemed to be more an observer of individual
participants, as no eye-contact can be made, neither with members nor
with the leader. As a consequence, the co-leader’s role might need a slight
re-definition in the online-situation.
Leaders and participants got the impression that the usual well known
Balint work can continue online, with some specific differences with re-
gard to the representation of unconscious aspects within the group and
entering and leaving. Even waiting for a case to show up seemed very
similar.
Vinokur (2017) described social phenomena in Balint Groups that can
also be observed online: Socializing while sharing feelings, mirroring,
condensing unconscious aspects, exchange which increases mutual under-
standing, active social support, assistance in clarification and even ver-
bal communication. Difficulties arising in Balint Groups (Kjeldmand &
Holmstöm 2010) might show up online as well, like defensive moves, ri-
valries, hidden agendas, group dynamics; with the exception that a higher
motivation to participate might have lowered down such difficulties in our
special situation. It could be stated that the conversion to an online situa-
tion had an impact on working as a professional work group and regressive
aspects, described as basic assumption groups by W. R. Bion (1961), might
have been decreased.
Considering that participants within the real group setting would not
usually by themselves start to look at a representation of different aspects
of a case by referring to the three spatial dimensions, and considering that
the pointing out of such phenomena depends on the leader’s style, this as-
pect was not missed much. Thus far we observed that a parallel process in
the Balint Group was lowered down online, a process commonly observed
Ulrich Rüth, Astrid Holch
120
Dynamische Psychiatrie • Dynamic Psychiatry
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.

in face-to-face Balint Groups as well as in psychodynamic supervision
(Schmolke & Hoffmann 2014).
The online situation might lead to a kind of “different” 4, but nevertheless
working energy leaving out some aspects of unconscious physical repre-
sentation. This means that projective identifications might work different-
ly and participants have to develop different, nonverbal ways of subcon-
scious communication.
The role of the co-leader (Holch, Rüth 2013; Rüth & Holch 2014) might
have to be re-visited, as the leaders’ communication is more difficult. In
general, their roles might stay the same with a slight tendency that, due to
diminished contact, the co-leader is less active.
Mirroring processes (see Schmolke & Hoffmann 2014) seem to be less
virulent online, possibly caused by a diminished “negative capacity” of
the group (Betts 2009; Simpson 2010). According to Bion, Negative Ca-
pability is the capacity to tolerate “uncertainty, mystery and doubt” and
to “allow new discoveries to take place” (Lopez-Corvo 2003). The online
situation might reduce the capacity to pick up on projective identifications
sent by the patient via the presenter – as the direct contact “within space
and body” between presenter and group members listening to a patient
history is missing and merely visualized on a screen – and anything else
has to go on within the mind. This could mean that nonverbal, subliminal
communication might be less effective online or sometimes impossible.
Balint sculpture work as an (not yet common) approach to unconscious or
underlying aspects of a case by means of identification, would obviously
be impossible online, as there is no space and physical presence to form
the sculpture.
At first sight any Balint case is just a representation of the “real case”.
In the online format, representations seem to show up more in the mind
and less in the body – as the finding of less frequent physical impressions
would indicate. With fellow participants and with the unconscious going
online there might be a need to define ways how to get into an equal con-
tact with the case.
4
The term “different energy” is owed to an adolescent patient who used it when converting
his therapy sessions into online – he being accustomed to online video contacts to people
all around the world.
Converting Balint into online 121
2021 (54), S. / pp. 114-123
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.

Conclusion
Online Balint is preferable when remoteness makes real participation
impossible. Balint online might also be preferable when we consider to our
ecological footprints, as even short travel to a meeting might use resources
without need. Furthermore, Balint online groups save time which can be
used for recreation or study.
Preliminary findings suggest that Balint groups can easily meet online,
and the process of Balint work can continue with slight differences. A
mixture of 3 or 4 Balint groups face-to-face followed by groups meeting
regularly online for the next 6 sessions could be appropriate due to the
necessity of preserving resources for future generations – and the need
to save time. Gaining more experience by using the online format over a
prolonged period will create opportunities for additional considerations
and enhanced professional development. In any case, Balint online works.
Literatur
Antoun, J.; Romani, M.; Johnson, A. et al. (2014): Balint seminars: the transatlantic experience
through videoconference. Fam Pract 31: 733–738. DOI: https://doi.org/10.1093/fampra/cmu065
Betts, W. (2009): Negative capability. Psychoanalysis downunder, 7B. Online Journal Australian
Psychoanalytic Society 2009; online:https://drive.google.com/file/d/1iDH7yG4AbAZLlH_7T-
zd9DYrlXOfvhwUU/view - Accessed 13.03.2020
Bion, W. R. (1961): Experiences in Groups. London: Tavistock Publications
Dekhordi, M. K.; Sakhi, S.; Gholamzad, S.; Azizpour, M.; Shahini, N. (2020): Online Balint groups
in healthcare workers caring for the COVID-19 patients in Iran. Psychiatry Research, online:
https://doi.org/10.1016/j.psychres.2020.113034
Elder, A. (2020): Hearing secret harmonies: Balint and the re-imagining of medicine.
Balintjournal 21: 5–12. DOI: https://doi.org/10.1055/a-1110-3394
Holch, A.; Rüth, U. (2013): Co-Leadership in the Balint Group. Proceedings of the 18th International
Balint-Congress, Heidelberg, September 7-11: 61–65
Kjeldmand, D.; Holmström, I. (2010): Difficulties in Balint groups: a qualitative study of leaders´
experiences. Brit ish Journal of General Practice 60: 808-814.
DOI: https://dx.doi.org/10.3399%2Fbjgp10X532585
Koppe, H.; van de Mortel, T. F.; Ahern, C.M. (2016): How effective and acceptable is Web 2.0 Balint
group participation for general practitioners and general practitioner registrars in regional Aust-
ralia? A pilot study. Australian Journal of Rural Health 24: 16–22.
DOI: https://doi.org/10.1111/ajr.12212
Dynamische Psychiatrie • Dynamic Psychiatry
Ulrich Rüth, Astrid Holch
122
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.

Levitt, H. M. (2020): Reporting qualitative research in psychology. How to meet APA style journal
article reporting standards. American Psychological Association, Washington DC
Lopez-Corvo, R. E. (2003): The Dictionary of the Work of Bion. London: Karnac
Nease, D. E. (2019): Balintgruppen über das Internet – Balint 2.0. Balint-Journal 20, 3: 86-88.
DOI: https://doi.org/10.1055/a-0984-8917
Nease, D. E.; Lichtenstein, A.; Pinho-Costa, L.; Hoedebecke, K. (2018): Balint 2.0: A virtual Balint
group for doctors around the world. The International Journal of Psychiatry in Medicine 53, 3:
115-125. DOI: https://doi.org/10.1177%2F0091217418765036
Rüth, U. (2009): Classic Balint Group work and the thinking of W.R., Bion: How Balint work
increases the ability to think one´s own thoughts. Group Analysis 42, 4: 380-391.
DOI: https://doi.org/10.1177%2F0533316409345965
Rüth, U.; Holch, A. (2014): Co-Leitung in Balint-Gruppen. Balint Jour nal 15, 1: 11-16.
DOI: https://doi.org/ 10.1055/s-0034-1370969
Schmolke, M.; Hoffmann, N. (2014): Mirror processes in the protected space of psychoanalytic
supervision. Archives of Psychiatry and Psychotherapy 3, 1: 59–63.
DOI: http://dx.doi.org/10.12740/APP/29505
Simpson, P. (2010): Engaging with the Unknowable through Narratives of Personal Experience.
Journal of Organizational Change Management 23, 2: 173-179.
DOI: https://doi.org/10.1108/09534811011031355
Vinokur, V. (2017): Social Phenomena Developing in Supervision Process in Balint Group Work.
Journal of the Balint Society 45, 1: 17-21
Autoren:
Ulrich Rüth, M.D., Child and Adolescent Psychiatrist and Psychotherapist, working in
a private practice and at Munich Training and Research Institute, German Academy of
3V\FKRDQDO\VLV%DOLQW*URXS/HDGHUFHUWL¿HGE\WKH*HU PDQ%DOLQW6RFLHW\
Adresse: Dr. med. Ulrich Rüth • Goethestraße 54 • 80336 München
• E-Mail: ulrich.rueth@mnet-online.de
Astrid Holch, M.D., Child and Adolescent Psychiatrist and Psychotherapist, working as
consultant at the Child and Adolescent Psychosomatic Department, München Kliniken,
0XQLFK%DOLQW*URXS/HDGHUFHUWL¿HGE\WKH*HUPDQ%DOLQW6RFLHW\
Adresse: Astrid Holch • Kölner Platz 1 • 80804 München
• E-Mail: astrid.holch@muenchen-klinik.de
2021 (54), S. / pp. 114-123
Converting Balint into online 123
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.