Balint groups · Atlas

1. Introduction

Version followed: the classical Balint group as described by the UK Balint Society (Salinsky, "Balint groups and the Balint method", 2003, revised 2013; Salinsky, "A very short introduction to Balint groups", 2009) and the International Balint Federation (IBF) leadership guidelines (2016), with the UK/US "push-back" variant marked as optional. Balint-psychodrama (Caïn/SEPT, France and Germany) is described separately as a distinct frame.

What it is. A Balint group is not a therapy for clients. It is a small, ongoing case-discussion group for clinicians, led by one or (preferably) two trained leaders, in which a member presents a patient or client who is on their mind and the group explores the practitioner–patient relationship rather than the diagnosis or management. It was developed by the psychoanalyst Michael Balint and Enid Balint with London general practitioners in the 1950s ("training cum research" seminars), described in The Doctor, his Patient and the Illness (1957); Balint had earlier led case groups for social workers in Budapest. Groups now run for GPs, trainees, nurses, counsellors, psychologists, psychotherapists and mixed professions, with national Balint societies in some 22 countries. [source: Salinsky 2009; Mattke 2021 (socialnet); Balint Society "Starting a new Balint group"]

For a psychotherapist this guide covers three roles: joining a group as a member, co-leading in training, and leading once accredited. Where sources say "doctor" read "practitioner" and for "patient" read "client". The transfer to psychotherapist groups is supported by the multiprofessional membership the Society describes; anything specific to therapist-only groups is marked [synthesis].

How change happens. The group sits between supervision and self-experience (Selbsterfahrung): members learn to notice the "offers" a patient makes in the relationship and their own reactions to them, so that unconscious doctor–patient interaction becomes usable information. Change is in the clinician, not the patient: a more reflective, less defended way of listening, seeing the patient as a whole person with a life outside the consulting room, and less dread of "difficult" patients. The group acts as a "listening laboratory" whose reflective "third ear" members internalise and carry back into their consultations. The authors also believe it helps protect against burnout, but improved morale is a by-product, not the aim. [source: Mattke 2021; Salinsky 2009; Elder, IBF leadership keynote c.2015]

2. Framework

Balint work has no treatment phases. It has (a) a group life-cycle and (b) a fixed session structure. [source: Salinsky 2003/2013; Balint Society "Starting a new Balint group"]

2a. Group format

Size: 8–10 members is the target so the group survives absences; 6–8 committed people can work; online groups are usually smaller. Mattke gives 8–12. [source: Balint Society "Starting"; Salinsky 2003; Mattke 2021]
Leaders: one, preferably two. Classic UK pairing: one leader from the members' own profession (e.g. a GP) plus a psychotherapist or counsellor; ideally at least one with psychodynamic training. Both need Balint training and supervision. [source: Salinsky 2003; Balint Society "Starting"]
Frequency and length: regular, same time and place, dates known well in advance. Session length is 60 minutes (usually two presentations) or 90 minutes (one or two cases, including follow-ups). Original groups met weekly for years; Salinsky asks for a commitment of at least a year; a US compilation reports groups averaging about 3 years. Sources do not fix a frequency: weekly and fortnightly are both described. [source: Salinsky 2003, 2009; Balint Society "Starting"; Dornfest (compiler), Balint manual; Rezaee 2021]
Membership: closed or stable as far as possible. [source: Salinsky 2003]

2b. Group life-cycle

Stage	Goals	Moving on when
Setting up	Leaders agree aims, roles, how they will share work; recruit; screen (online: interview each applicant); fix venue, dates, fees	Enough committed members (≈8) and a regular slot
First meeting / taster	Introductions, explain Balint aims, agree ground rules (online: up to half the first session)	Ground rules agreed
Early group ("boundary exploration")	Members learn the method: stay with the case, tolerate not-knowing, stop advising	Members bring cases spontaneously and speculate freely
Established group ("intragroup intimacy")	Deeper identification with patients, examining blind spots (e.g. sex, money, death), less leader intervention	[uncertain: no explicit criterion in sources]
Ending	Work on the loss of the group	Agreed end date

[source: Balint Society "Starting"; Brock and Dornfest stages as reported in Dornfest (compiler) Balint manual; Rezaee 2021 on intervening less after about 3 months]

2c. Session structure (classical UK version)

Opening – leader asks who has a case. Cases are spontaneous, not assigned, no notes; urgent cases first, order agreed by the group.
Presentation – presenter tells the story; group listens without interrupting.
Factual questions – brief, purely factual (age, who lives at home). Leader ends this phase when questions stop being factual.
Group discussion – either with the presenter present, or in the push-back variant with the presenter silent and slightly withdrawn (15–20 min per Salinsky 2003/2013; 20–30 min per Salinsky 2009 – [uncertain] which is standard; it varies by leader).
Presenter's return – presenter rejoins and shares thoughts; discussion continues.
Ending – at time; the presenter often has the last word; no summary, no management recommendation; leader thanks the presenter and asks for a follow-up report.

[source: Salinsky 2003/2013; Salinsky 2009]

2d. Becoming a leader (UK Balint Society, criteria from June 2023)

IBF guidelines (2016) ask national societies to require: basic professional training, sufficient time as a group member, co-leading with an accredited leader, a supervisor's reference, assessment on core competencies (safe free group; focus on the relationship rather than solutions or teaching; awareness of own style and of group/unconscious processes), and ongoing supervision. The UK Society requires: Society membership; at least 24 groups as an ordinary member under an accredited leader (12 if holding a psychoanalytic/psychodynamic qualification such as UKCP or BPC); leading at least 24 groups, preferably with an accredited co-leader (up to 8 may be medical-student groups); 2 Society leadership weekends or 4 leadership days; at least 9 individual supervision sessions with an accredited supervisor who is not your co-leader; 6 sessions of a Leadership Supervision Group; then Form A with a reflection, Form R references, and approval by Council. [source: IBF "Guidelines on Balint group leadership"; Balint Society "Leadership accreditation"] Other countries (e.g. the Deutsche Balint-Gesellschaft) have their own pathways [uncertain].

3. Guiding principles

The relationship is the case. Practical meaning: every intervention steers back to what happens between this clinician and this patient, not to what the patient "has". [source: IBF 2016; Johnson et al. 2004]
Exploration, not solutions. Hold back advice, diagnosis and referral ideas; value self-reflection and meaning-making over problem solving. [source: Johnson et al. 2004; Salinsky 2003]
A real patient and a real clinician. Keep the group grounded in this case, not "this kind of patient". [source: Troll ground rules in Dornfest manual]
Not a therapy group, not an encounter group. The presenter's personal life, childhood or losses are not explored unless offered voluntarily and relevant; defences are not broken down. [source: Salinsky 2009, 2003; Troll in Dornfest manual]
Safety and confidentiality. Everything said stays in the group; material is never used for trainee assessment or quality review. Members must be able to speak about mistakes "without being jumped on or ridiculed" (Salinsky 2003). [source: Salinsky 2003; Troll in Dornfest manual]
Protect the presenter. Prevent cross-examination; let the group work on the case rather than on the presenter. [source: Johnson et al. 2004; Salinsky 2009]
Feelings are data. How the patient made each member feel (angry, sad, warm, distant, wanting to help or not) is evidence about the relationship; the leader legitimises emotions. [source: Salinsky 2009; Johnson et al. 2004]
Tolerate uncertainty and silence ("negative capability"). Do not rescue the group from not-knowing; the leader does not reduce anxiety for its own sake. Dornfest's maxim: "don't just do something - stand there". [source: Elder c.2015; Dornfest manual]
The group does the work. The leader is a participant-observer, non-authoritarian and group-centred; keep the group responsible rather than displaying the leader's insight. [source: Johnson et al. 2004; Elder c.2015]
Teach only by example. No lectures; avoid falling into a teacher or therapist role, while knowing that "everything we do is teaching" (Elder). [source: Johnson et al. 2004; Elder c.2015]
Plain language. Avoid jargon such as "projection" or "transference" in the group. [source: Salinsky 2003; Elder c.2015]
Equal voice. Make space for everyone to speak; balance presenter and group, and members among themselves. [source: Johnson et al. 2004; Salinsky 2003]
Parallel process is information. The way the presenter tells the story, and the way the group behaves, often mirror the patient relationship. [source: Salinsky 2003; Johnson et al. 2004]
Examine every intervention. Ask "why now?" and "what's going on?"; beware "writing a prescription" (adding a technique) when you feel helpless. [source: Elder c.2015]
No tidy endings. Leave loose ends; do not reassure or summarise. [source: Salinsky 2009]
Leaders need supervision. Continuing supervision is a standing requirement, not just a training phase. [source: IBF 2016; Balint Society accreditation]
Balint's own lenses that leaders listen with (summaries from the Society's quotations page; not to be lectured): the "drug 'doctor'" (the clinician as the most-prescribed treatment); the "collusion of anonymity" (care passed among specialists with no one owning the person); the "apostolic function" (imposing one's own values on what patients should do); the "mutual investment fund" (trust built over years); the "courage of one's stupidity" (saying the half-formed thought). [source: Balint Society "Famous phrases of Michael Balint"]

4. Intervention inventory

These are the procedures the sources describe for setting up, leading and taking part in a Balint group, in roughly the order they come up. Example language is illustrative unless it is quoted and cited.

4.1 Setting up a group

Purpose / when: before the first session; decides whether the group will survive.
Steps: (1) Co-leaders meet to agree aims, each one's experience, agendas, how roles are shared and how the group will run. (2) Recruit through local professional networks (for therapists: training institutes, counselling services, professional bodies [synthesis]) with a flier that states aims, dates and cost. (3) Fix a regular time and an uninterrupted room where members sit in a circle, the same room every time. (4) Set fees that cover running costs; collect in advance for a term or year to build commitment; consider making the first meeting free. (5) Optionally hold a taster meeting. (6) Set up clear ways for leaders and members to communicate. [source: Balint Society "Starting a new Balint group"]
Example language (illustrative): "This is a group where we bring clients who stay on our minds and think together about the relationship, not about the right intervention."
Watch for: recruiting fewer than about 6 committed people; a venue that changes. Mixed professions can work well; in institutional groups, avoid copying the hierarchy (e.g. head nurse with junior staff). [source: Balint Society "Starting"; Rezaee 2021]

4.2 Screening and preparing members

Purpose / when: before joining, and required for online groups.
Steps: (1) Interview each prospective member about expectations, commitment and (online) their technology. (2) Consider exclusion criteria such as emotional readiness for the Balint structure. (3) Explain that it is not personal therapy and not technique supervision. [source: Balint Society "Starting" (online section); step 3 restates the ground rules of Salinsky 2003]
Example language (illustrative): "You won't be asked about your personal history. You'll be asked how a client makes you feel. Does that sound workable at the moment?"
Watch for: applicants in acute personal crisis or wanting therapy for themselves; signpost to personal therapy [synthesis].

4.3 Contracting ground rules (first meeting, renewed yearly)

Purpose / when: first session and the start of each year; sets the safe frame.
Steps: (1) Introductions (allow up to half of a first online session). (2) State the aim: the relationship with the patient, "less concerned with finding solutions" (Salinsky 2003). (3) Agree: confidentiality; material is not used for assessment or quality review; equal listening; no intrusive questions about members' personal qualities, childhood or losses; punctuality; regular attendance; how members signal they want to speak (online). [source: Salinsky 2003; Troll ground rules in Dornfest manual; Balint Society "Starting"]
Example language (illustrative): "What's said here stays here. You can bring cases where you think you got it wrong. Nobody will ask about your own life unless you choose to bring it."
Watch for: members on the same training programme as an assessor in the group. Keep assessment roles out of the group [synthesis, consistent with Troll's rule].

4.4 Opening: "Who has a case?"

Purpose / when: first minutes of each session.
Steps: (1) Ask who has a patient to talk about. (2) Cases are volunteered, not assigned, no notes. (3) If several are offered, give urgent ones priority and let the group agree the order. In a 60-minute session plan for about two; in 90 minutes, one or two plus follow-ups. (4) Decide whether to take two cases up front or let one lead into another. [source: Salinsky 2003, 2009; Satinsky's timekeeping questions in Dornfest manual]
Example language: the Society's opener is simply "who has a case?" (Salinsky 2009).
Watch for: a pause before anyone offers is normal; don't fill it too quickly. Before the meeting, small talk and the room's main mood are "anchors" the leader can note (Scott, in Dornfest manual).

4.5 Receiving the presentation

Purpose / when: the presenter tells the story of a patient who is on their mind, often one who is disturbing, hard to understand or hard to engage.
Steps: (1) Group and leaders listen without interrupting. (2) The leader listens closely to content, tone and body language, and to what is left out (metaphors, slips, omissions). (3) Note signs of parallel process: the presenter taking on the patient's qualities in how the case is told. [source: Salinsky 2003, 2009; Brock in Dornfest manual]
Example language (illustrative): "Tell us about her however she comes to mind."
Watch for: a presenter reading notes or giving a case conference summary. Gently invite the story as remembered [synthesis, consistent with "no notes"].

4.6 Factual questions phase

Purpose / when: straight after the presentation; fills gaps without interrogation.
Steps: (1) Invite brief factual questions (age, household, how long known). (2) Stop the phase when questions turn into hypotheses, advice or probing ("Did you think of...?", "Why didn't you...?"). [source: Salinsky 2003, 2009]
Example language (illustrative): "Let's keep to facts for now. ... I think we're moving into ideas, so let's stop the questions there and start thinking about what we heard."
Watch for: questions that are really criticism, or a group using questions to avoid its own reactions.

4.7 Push-back (optional variant)

Purpose / when: after the questions; stops the presenter being interrogated or defending themselves, and frees members to speak about their own feelings and fantasies.
Steps: (1) Ask the presenter to move their chair back "a few symbolic inches" (Salinsky 2003). (2) The presenter listens without taking part; the group talks about the case without addressing the presenter. Length: 15–20 min (Salinsky 2003) or 20–30 min (Salinsky 2009). (3) Invite the presenter back in (4.13).
Example language (illustrative): "Would you sit back a little now and just listen? We'll talk among ourselves and bring you back in later."
Watch for: Elder argues it interrupts the parallel process, removes the patient's representative from the room, and can let the group drift into fantasy cut off from clinical reality. If you use it, give the presenter enough time when they return. Many groups, especially outside the UK/US, don't use it [uncertain on how widespread]. [source: Salinsky 2003, 2009; Elder c.2015]

4.8 Opening the discussion with open, group-directed questions

Purpose / when: to start or re-start reflection.
Steps: (1) Address the whole group, not the presenter. (2) Phrase prompts as tentative statements. (3) Then stay quiet and let members take it up. [source: Salinsky 2003; Troll's "throwing the problem out to the group" in Dornfest manual]
Example language: "I wonder how the patient was feeling at the end of that consultation" (Salinsky 2003). Illustrative: "What's it like to be in the room with him?"
Watch for: working when members start offering their own associations rather than answers to the leader.

4.9 Inviting the clinician's and the group's feelings about the patient

Purpose / when: core of the work; use whenever discussion turns technical.
Steps: (1) Ask how the patient made members feel: liking, pity, anger, boredom, indifference, wanting or not wanting to help. (2) Legitimise every response, including negative ones. (3) Link feelings back to what the patient may be evoking in the presenter. [source: Salinsky 2003, 2009; Johnson et al. 2004]
Example language (illustrative): "I noticed I felt irritated while listening. Is anyone else having a reaction to her?"
Watch for: members disowning anger or dislike. The group being able to say "I wouldn't want her on my list" without shame is a sign the frame feels safe [synthesis].

4.10 Speculation and play: imagining the patient

Purpose / when: to widen the picture of the patient as a whole person and see the relationship freshly.
Steps: (1) Encourage free speculation about the patient's life outside the room, their feelings, and "what kind of doctor the patient wants". (2) Encourage playful, associative thinking and "the courage of one's stupidity". (3) Help the group try out different patient–clinician scenarios. [source: Salinsky 2009; Johnson et al. 2004; Dornfest manual; Balint Society quotations]
Example language (illustrative): "Let's imagine her getting home after the session. What happens?" / "What kind of therapist is she hoping for, and what kind did she get?"
Watch for: speculation that drifts free of anything the presenter said (Elder's caution), or that turns into diagnosing the presenter.

4.11 Speaking as the patient (representing the absent patient)

Purpose / when: when the group drifts into generalities, referral talk or theory and the patient as a person drops out of the room, or when nobody voices the patient's feelings.
Steps: (1) Notice that the patient has gone missing. (2) The leader speaks briefly in the patient's voice or from the patient's position, in the first person or conditionally. (3) Fall silent and let the group respond. [source: Salinsky 2003, 2009; Troll "represent the patient's feelings when no one else does" in Dornfest manual]
Example language: "If I were that patient I would be feeling very lost and abandoned" (Salinsky 2003).
Watch for: feeling coming back into the discussion. Don't overuse it, or the leader becomes the group's only source of empathy [synthesis].

4.12 Refocusing ("sheepdog" work)

Purpose / when: the discussion has moved to diagnosis, medication or technique, "this kind of case", system complaints, or members' general professional grievances.
Steps: (1) Let it run a while, since generalities can help, until it becomes uncomfortable or the "patient as a person" focus is at risk. (2) Remind the group of the relationship focus, or re-ask about the specific patient. (3) If useful, acknowledge that specialist advice may help but the patient still needs their clinician. [source: Salinsky 2003; Satinsky in Dornfest manual; Rezaee 2021]
Example language (illustrative): "We've got lots of good ideas about treatment. I'm wondering where Mrs K has gone in all this. What's it like for [presenter] to be her therapist?"
Watch for: Salinsky warns that if generalities run too long "the specific benefits of the Balint process will be lost".

4.13 Protecting the presenter

Purpose / when: throughout; most needed when questions turn into cross-examination, criticism or personal probing.
Steps: (1) Interrupt intrusive questions about the presenter's personal life or history. (2) Discourage drawn-out interrogation so the group works on the case. (3) Avoid making any member the object of a lesson or psychological analysis. (4) Voluntary personal anecdotes are fine if nobody is pressed. [source: Johnson et al. 2004; Salinsky 2009]
Example language (illustrative): "Let's not put [name] on the spot. What does it stir up in the rest of us?"
Watch for: the presenter becoming defensive, justifying, or going quiet in a hurt way.

4.14 Gatekeeping participation

Purpose / when: when talk is unbalanced.
Steps: (1) Notice who is trying, and failing, to speak, and "make a space" for them (Salinsky 2003). (2) Hold back your own contributions until everyone has had a chance. (3) Remind dominant members, gently, of the value of listening. (4) Co-leader role: one steers while the other watches for members who want to speak or are struggling emotionally. [source: Salinsky 2003, 2009; Johnson et al. 2004; Troll in Dornfest manual]
Example language: Salinsky: "it's good to talk, it's also good to listen." Illustrative: "Sam, you looked as if something struck you just then."
Watch for: a member who is silent for whole sessions over weeks (see 5).

4.15 Naming the mood and the avoided theme

Purpose / when: when a feeling fills the room but nobody names it, or a charged theme is circled but not touched.
Steps: (1) Identify the group mood linked to the case. (2) Say it tentatively as the leader's own observation. (3) Note themes the group is avoiding: race, sexuality, sex, money and death come up as blind spots or avoided topics. [source: Johnson et al. 2004; Dornfest/Addison/Ransom in Dornfest manual; Elder c.2015]
Example language: "a good deal of depression is floating in the room" (Dornfest manual). Illustrative: "We've talked about everything except the fact that he's twice her age."
Watch for: this is an observation about the group's response to the case, not an interpretation of individuals.

4.16 Using the parallel process

Purpose / when: when the presenter, or the group with the presenter, starts repeating the case dynamic (e.g. the group feels as helpless or as pushed away as the clinician does).
Steps: (1) Notice the mirroring. (2) Use it to understand the clinician–patient relationship, voicing it as a question to the group. (3) Leaders can model tolerating a member's errors, mirroring how the clinician might tolerate the patient. [source: Salinsky 2003; Johnson et al. 2004; Dornfest manual]
Example language (illustrative): "I notice we're all firing questions at [presenter], and he's getting shorter with us. I wonder if that's a bit like what happens with his client."
Watch for: keep it about the case; don't turn it into a group-analytic interpretation.

4.17 Reframing

Purpose / when: when a patient is labelled ("heartsink", "hateful", "manipulative").
Steps: Turn the label into a description of an interaction, e.g. "hateful patient" into "hateful patient–doctor interaction". Ideally the group does this itself and the leader just prompts. [source: Dornfest manual]
Example language (illustrative): "So something happens between the two of you that leaves you dreading Tuesdays."
Watch for: working when the group begins to speak of "the two of them" rather than "her".

4.18 Active passivity, silence and the leader's restraint

Purpose / when: whenever the leader is tempted to fill a gap, rescue, teach or prescribe.
Steps: Use Troll's leader moves: say less ("shutting up"), withdraw eye contact so members talk to each other, throw the problem back to the group, model reflection, ask the presenter to reflect, reframe, stay accessible and flexible. Listen with a "third ear" to the group. Tolerate silence and being stuck. Before intervening, ask yourself "why now?" and "what's going on?". [source: Troll and Dornfest in Dornfest manual; Elder c.2015]
Example language: usually none; restraint is the intervention. Illustrative after a long silence: "It's hard to know where to go with this one."
Watch for: members starting to take on the reflective function themselves, and leadership passing among members (Elder). That is the goal.

4.19 Sparing comments on group process

Purpose / when: only when a group dynamic is blocking the task (e.g. competition with the leader, favouritism, scapegoating).
Steps: (1) Interpret group process rarely. (2) Use "we" rather than "you". (3) Track the group's developmental stage and pick interventions to suit; consider the consequences before intervening. [source: Satinsky and Scott in Dornfest manual; Johnson et al. 2004]
Example language (illustrative): "We seem to be getting quite sharp with each other today. I wonder if the case is doing that to us."
Watch for: sliding into a therapy or encounter group.

4.20 Bringing the presenter back and the last word

Purpose / when: after push-back, or near the end.
Steps: (1) Invite the presenter to say what struck them, not to answer each point. (2) Expect discussion to swing back to medical or technical ground at first, and refocus gradually. (3) Near time, offer the presenter the last word. [source: Salinsky 2003, 2009]
Example language (illustrative): "What was it like listening to us? Anything you want to say before we stop?"
Watch for: a presenter who feels judged; acknowledge it and thank them [synthesis].

4.21 Ending the session and asking for follow-up

Purpose / when: at time; the leader keeps the clock.
Steps: (1) End on time even if it's unfinished. (2) Don't summarise, reassure or recommend management. (3) Thank the presenter. (4) Ask for a follow-up report on later contacts with the patient. Early groups met long enough to follow patients over years. [source: Salinsky 2003, 2009; Elder c.2015]
Example language (illustrative): "We'll leave it there, unfinished as these things are. Thank you. We'd like to hear how it goes next time you see him."
Watch for: pressure to close the case neatly. It's usually the group's anxiety, and leaving it open is the method.

4.22 Follow-up reports

Purpose / when: at the start of later sessions; the presenter is the only person in real contact with the patient.
Steps: (1) Invite brief updates on previously presented patients. (2) Explore what changed in the relationship, not just the clinical outcome. [source: Elder c.2015; Salinsky 2003, 2009]
Example language (illustrative): "Last month you told us about Ms R. Has anything shifted between you?"
Watch for: a changed attitude in the clinician is what the method aims for.

4.23 Co-leadership practice

Purpose / when: every session with two leaders.
Steps: (1) Meet before each session. (2) Agree roles, e.g. one steers the discussion while the other watches the group and members in difficulty; online, one handles tech and time and the other the process. (3) Support each other's interventions. Either leader can rescue the other if they get over-involved in a case. (4) Debrief together afterwards, noticing what each missed. (5) Online, agree openly how leaders communicate rather than using private chat. [source: Salinsky 2003, 2009; Johnson et al. 2004; Balint Society "Starting"]
Watch for: rivalry and fault lines of profession, gender or seniority between co-leaders. Take them to supervision (Elder c.2015).

4.24 Online Balint groups

Purpose / when: when members can't meet face to face.
Steps: (1) Two experienced leaders, at least one accredited. (2) Interview each member online beforehand. (3) Send a preparatory email: first-session plan, screen visibility, leaders' phone numbers for connection failures, any reading. (4) Ask members to join 5–10 minutes early. Use a computer or laptop (not a phone or tablet) with a good connection. (5) Set the group size by how many faces fit on screen. (6) Agree a way to signal wanting to speak (e.g. raised hand). (7) Leaders review each session privately. [source: Balint Society "Starting"]
Watch for: reduced nonverbal information. Leaders may need to check in more explicitly with quiet members [synthesis].

4.25 Leader development: supervision, rotation and rating

Purpose / when: for anyone working towards leading.
Steps: (1) Gain membership experience, then co-lead with an accredited leader. (2) Have regular individual or peer supervision (see 2d). (3) In training groups, members may take turns leading, presenting and observing, and rate sessions afterwards (leader, co-leader and member forms). [source: IBF 2016; Balint Society accreditation; Johnson et al. 2004; Rezaee 2021]
Watch for: Johnson et al.'s competencies (safe climate, norms, moving the group to new understanding, understanding group process, modelling a style) make a useful self-review checklist.

4.26 Balint-psychodrama (a distinct method)

Purpose / when: a separate frame, not a technique to bolt onto a classical group. Developed from about 1970 by the French psychoanalyst-psychodramatist Anne Caïn with psychoanalytic psychodrama (SEPT, Paris); taught at, for example, the Deutsche Balint-Gesellschaft's Freiburg conference.
Steps (as published): a small regular group with one or two leaders trained in the method. A member presents a relational problem with a patient, and the work stays within the professional role (no private life). The real encounter is staged: setting up the scene and the consulting room, monologue, role change and doubling. Then the group reflects on what the enactment, including its nonverbal side, revealed. [source: Freiburg Balint conference 2026 programme]
Watch for: only use it after specific training. Elder calls it "a distinct frame" with its own training, not a Balint group as such. Detailed step-by-step procedure was not found in the sources [uncertain].

4.27 Sculpting and role-play inside a Balint group

Purpose / when: Mattke describes sculpting (Skulptur aufstellen) and a systemic perspective as helpful for understanding how the social and emotional environment shapes the clinician–patient relationship.
Steps: no published step-by-step procedure is given in the sources [uncertain]. Do not improvise it without training in sculpting/psychodrama [synthesis].
Watch for: Elder is sceptical of bringing role-play or sculpting in mid-session; it can be a shortcut away from staying with not-knowing. Learn the core role first. [source: Mattke 2021; Elder c.2015]

5. Handling problems

Group pushes for solutions, diagnoses or referrals. Let it run until it feels uncomfortable, then name the relationship focus. Acknowledge that specialist input may help but the patient still needs their clinician. Tolerate the pressure; Rezaee found groups gradually shifted to an exploratory stance. [source: Salinsky 2003; Johnson et al. 2004; Rezaee 2021]
Presenter is interrogated or cross-examined. End the factual phase, reflect questions back to the group, or use push-back. [source: Salinsky 2003, 2009; Dornfest manual]
Presenter becomes distressed. Throw the problem out to the group or invite the presenter to reflect. A co-leader can attend to the presenter while the other keeps the group going. Afterwards, check in privately and, if it's personal, signpost to personal support, not group exploration [check-in and signposting: synthesis]. [source: Dornfest manual; Salinsky 2009]
Long silence or a "stuck" group. Model tolerating it. Before intervening ask "why now?" Resist "writing a prescription" (adding a technique) out of your own helplessness. If the silence is about the case (e.g. a hopeless patient), say so tentatively (4.15). [source: Dornfest manual; Elder c.2015]
Retreat into generalities, theory or complaints about the service. Allow a little, then refocus on the specific patient (4.12) or speak as the patient (4.11). [source: Salinsky 2003; Rezaee 2021]
Dominant member. Gentle reminder that listening matters too; actively make space for others. [source: Salinsky 2003]
Silent member. Notice and make a space, but don't force. If it persists over weeks, a brief private conversation about how the group is for them [synthesis]. [source: Salinsky 2003; Rezaee 2021]
Hostility, attacks or scapegoating. Leaders rarely confront or express disapproval directly. Limit attacks, stress collegial "we", and treat excess tension as a cue to look at group process (favouritism, rivalry with the leader). Unchecked aggression can lead to dropouts or the group breaking up. [source: Scott and Dornfest manual material]
Drift into a therapy or encounter group. Restate the ground rule: personal material only as it bears on the relationship; no breaking down defences. [source: Salinsky 2009; Troll in Dornfest manual]
Leader drawn into teaching or therapising. Monitor with co-leader feedback and rating forms; take it to supervision. [source: Johnson et al. 2004; IBF 2016]
Dependency on the leader. Intervene less as the group matures, leave room for members to find their own thinking, and let leadership pass among members. This is harder in single-profession groups. [source: Elder c.2015; Rezaee 2021]
Avoided charged topics (race, sexuality, money, death). Name the avoidance tentatively as a group observation. [source: Elder c.2015; Dornfest manual]
No case offered. Not covered by sources [uncertain]. Suggestions [synthesis]: allow the silence for a while; invite follow-ups on earlier cases (4.22); ask whether anyone has a patient "they keep thinking about", even briefly; or, as a last resort, explore with the group what makes bringing a case hard today. Don't fill the time with teaching.
Non-attendance, lateness, drop-out (non-adherence). Prevent it: screening for commitment, fixed dates announced well ahead, fees collected in advance per term or year. When it happens, raise it in the group as a matter of the frame, and with the member privately [handling: synthesis]. [source: Balint Society "Starting"]
Hierarchy in institutional groups. When composing the group, avoid replicating line-management or training hierarchies. Remember the institution brings its own dynamics into the group. Keep assessors out of the group. [source: Rezaee 2021; Mattke 2021; Troll in Dornfest manual]
Co-leader rivalry or splits. Meet before and debrief after each session; take differences of profession, gender or seniority to joint supervision. [source: Salinsky 2003; Elder c.2015]
Push-back leaves the presenter feeling excluded or fantasy-driven discussion. Give enough time after the return, ground speculation in what the presenter reported, or drop push-back for that group. [source: Elder c.2015]
Online problems (connection loss, people talking over each other). Leaders' phone numbers for dropouts; a raised-hand convention; one leader on tech and time. [source: Balint Society "Starting"]
Psychotherapist-only groups: theorising and technique supervision. Therapists may move into formulation, jargon ("projective identification") or advice on technique. Ask for plain language and the felt experience of the relationship. Elder notes therapists in Balint work should bring an open mind rather than theory. If the group keeps wanting technique, offer separate clinical supervision rather than bending the frame [last point: synthesis]. [source: Salinsky 2003; Elder c.2015]
Confidentiality breach or identifiable client material. Present clients without identifying details; if a breach occurs, address it with the group as a frame issue [synthesis; sources state the confidentiality rule only]. [source: Salinsky 2003]
Risk or safeguarding concern surfaces in a case. The group is not the place to manage it. After the session, the leader prompts the presenter to use their normal supervision, safeguarding and risk procedures [synthesis].
A member in personal crisis or with a strong personal reaction. Acknowledge it briefly, keep the group on the professional role, and offer a private conversation and referral to personal therapy [synthesis, consistent with the not-a-therapy-group rule].

Sources

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