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Buletinul Asociaiei Balint

Martie, 2011,
Volumul XIII, Nr. 49
Periodic trimestrial, apare n ultima
decad a lunii a treia din trimestru.

Fondat: 1999
Redactor ef:
Albert VERESS M.D. Sc.D.
Lector: Almo Bela TRIF M.D.,
Sc.D., J.D., M.A.
Tehnoredactor, coperta:
Botond Mikls FORR
Editat de:
Asociaia Balint din Romnia
Tiprit la: Tipografia
Alutus, Miercurea-Ciuc
Adresa redaciei:
530.111 - MIERCUREA CIUC,
str. Gbor ron 10,
tel./fax 0266-371.136;
0744-812.900

cuprins
PROBLEME ETICE DIFICILE
ALE CERCETRII MEDICALE CONTEMPORANE
- Almo Bela Trif, MD, PhD, JD, U.S.A

MOVIES PSYCHOLOGICAL IMPACT ON THE AUDIENCE


WITH SPECIAL REGARD TO DALDRYS THE HOURS
- Baka Dorottya, esthete of art and literature, Budapest, Hungary

BALINT GROUPS WITH HOSPITAL PHYSICIANS


- JKjell Reichenberg The Nordic School of Public Health, Gteborg, Sweden

ESTABLISHING A BALINT GROUP FOR MENTAL HEALTH WORKERS


THE INALA COMMUNITY MENTAL HEALTH EXPERIENCE
- Andrew Leggett - Princess Alexandra Hospital, Brisbane, Australia

11

The medical conversation, CONVERSATIONAL TECHNIQUES


AND The handling of emotions
- C. Hfner, A. Koschier, HP. Edlhaimb, A. Leitner - Danube-University Krems

16

E-mail:
berciveress@asociatiabalint.ro
alveress@clicknet.ro

DESCRIERI DE CAZURI
- Ovidiu Popa-Velea, Bucureti

26

Comitetul de redacie:
Tnde BAKA
Doina COZMAN
Dan Lucian DUMITRACU
Evelyn FARKAS
Liana FODORANU
Ioan-Bradu IAMANDESCU
Cristian KERNETZKY (D)
Mircea LZRESCU
Holger Ortwin LUX
Drago MARINESCU
Ioana MICLUIA
Csilla MOLDOVAN
Aurel NIRETEAN,
Iuliu OLTEAN
Gheorghe PAINA
Ovidiu POPA-VELEA
Almos Bela TRIF (USA)
Ionel UBUCANU
va VERESS
Nicolae VLAD

DESCRIERI DE CAZURI
- Psih. Irina de Hillerin

27

Manuscrisele sunt lecturate de un comitet de refereni, care primete


manuscrisele cu parol, fr s cunoasc numele autorilor i propune
eventualele modificri care sunt apoi transmise autorului prin intermediul
redaciei. Decizia lor este necontestabil. Toate drepturile de multiplicare sau
reeditare, chiar i numai a unor pri din materiale aparin Asociaiei Balint.
Plata abonamentului i a cotizaiei se face n cont CEC Miercurea Ciuc, nr.
RO26CECEHR0143RON0029733, titular Asociaia Balint, cod fiscal: 5023579
(virament) sau 25.11.01.03.19.19 (depunere n numerar)
Preul unui numr la vnzare liber este de 2 EURO/numr la cursul BNR din
ziua respectiv. Abonamentele pentru rile occidentale cost 50 EURO/an,
incluznd taxele potale i comisionul de ridicare a sumei din banc.
INDEX: ISSN - 1454-6051

www.asociatiabalint.ro

Buletinul AsociAiei BAlint

prEZEnTArEA AsOciAiEi BALinT Din rOMniA


de a mbunti prin cuvnt calitatea
relaiei terapeutice medic-pacient i a
comunicrii dintre membrii diferitelor
categorii profesionale. Rol de punte
ntre etnii, confesiuni, categorii sociale, regiuni, ri.

Michael BALINT: Psihanalist


englez de origine maghiar

Data nfiinrii: 25 iulie 1993


Grupul BALINT: Grup specific alctuit din cei care se ocup de bolnavi i
care se reunesc sub conducerea a unui
sau doi lideri, avnd ca obiect de studiu relaia medic-bolnav prin analiza
transferului i contra-transferului ntre subieci.
Specificul Asociaiei: apolitic, nereligioas, inter-universitar, multidisciplinar, de formaie polivalent.
Obiective: Formarea psihologic
continu a participanilor. ncercarea

cTrE AuTOri
Se primesc articole cu tematic legat de activitatea grupurilor Balint
din Romnia i din strintate, de
orice fel de terapie de grup, de psihoterapie, de psihologie aplicat i de alte
abordri de ordin psihologic al relaiei medic - pacient (medicin social,
responsabilitate medical, bioetic,
psihosomatic, tanatologie). Materialele scrise la solicitarea redaciei vor fi
remunerate. Buletinul este creditat de
ctre CMR ca prestator de EMC, deci
orice articol publicat se crediteaz cu
25 de credite EMC. Abonamentul la
Buletin se crediteaz cu 5 credite. Redactorul ef i / sau lectorul au dreptul
de a face cuvenitele corecturi de form,
iar n cazul neconcordanelor de fond
vor retrimite articolele autorilor cu sugestiile pentru corectare.

Activitatea Asociaiei:
grupuri Balint,
editarea Buletinului,
formarea i supervizarea liderilor,
colaborare la scar internaional.
Cotizaia se achit pn la 31 martie
a.c. Cvantumul ei se hotrte anual de ctre Biroul Asociaiei. n cazul
cnd ambii soi dintr-o familie sunt
membrii Asociaiei, unul din ei poate
cere scutirea de la plata abonamentului la Buletinul Asociaiei, al crui cost

se stabilete anual. Cei care nu achit


cotizaia pn la data de 31 martie a
anului n curs nu vor mai primi Buletinul din luna iunie, iar cei care nu vor
plti cotizaia nici pn la data de 31
martie a anului urmtor vor fi penalizai cu o majorare de 50%!!! Cei cu o
restan de doi ani vor fi exclui disciplinar din Asociaie.
Studenii i pensionarii sunt scutii
de plata cotizaiei, fiind necesar doar
abonarea la Buletinul Asociaiei. Cotizaia pentru anul 2011 este de 20
EURO (la cursul oficial BNR din ziua
n care se face plata), n care se include
i abonamentul la Buletin. Taxa de nscriere n Asociaie este de 20 EURO
(nu se face reducere nici unei categorii
socio-profesionale).
Abonamentul cost 6 EURO.

BIROUL ASOCIAIEI:
Preedinte: Tnde BAKA tundeb13@freemail.hu
Vicepreedinte: Istvn VRADI istvanvaradi@inbox.com
Secretar: Csilla VAJDA-HEGYI cs_hegyi@yahoo.com
Trezorier: Albert VERESS alveress@clicknet.ro
Membri: Rita-Lenke FERENCZ, Holger Ortwin LUX, Attila MUNZLINGER,
Ovidiu POPA-VELEA, va VERESS.
Deoarece revista se difuzeaz i n
alte ri, articolele care nu se limiteaz
doar la descrierea evenimentelor balintiene, trebuie s aib un rezumat n
limba romn i englez, de maximum
10 rnduri dactilografiate. Lectorul i
impune responsabilitatea de a face la
nevoie corectura rezumatului
Pentru rigoarea tiinific apreciem
menionarea bibliografiei ct mai complet i mai corect, conform normelor
Vancouver, att pentru articolele din
periodice ct i pentru monografii (citarea n text se noteaz cu cifre n parantez, iar n bibliografie se nir autorii n ordinea citrii nu cea alfabetic
i doar acei autori care au fost citai n
lucrare).
Recenziile crilor trebuie s cuprind datele de identificare a crii
n cauz - autorii, titlul, toate subtitlurile, anul apariiei, editura, oraul,
numrul de pagini i ISBN-ul. Se tri-

Buletinul AsociAiei BAlint, vol. xiii., nr. 49, MArtie 2011

mite n fiier separat imaginea scanat


a copertei. Se primesc doar materiale
trimise pe diskete floppy de 3,5, CD
room, memory-stick sau prin e-mail
ca fiier ataat. Se vor folosi numai
caractere romneti din fontul Times
New Roman, culese la mrimea 12, n
WORD 6.0 sau 7.0 din WINDOWS.
Imaginile - fotografii, desene, caricaturi, grafice - vor fi trimise ca fiiere
separate, cu specificarea locului unde
trebuie inserate n text pentru justa lor
lectur. Pentru grafice este important
s se specifice programul n care au
fost realizate.
Articolele trimise vor fi nsoite de
numele autorului, cu precizarea gradului tiinific, a funciei i a adresei
de contact, pentru a li se putea solicita
exrase. Autorii vor scana o fotografie
tip paaport sau eseu pe care o vor trimite ca fiier ataat, sau pe o disket la
adresa redaciei.

Referate

PROBLEME ETICE DIFICILE ALE CERCETRII MEDICALE


CONTEMPORANE - Almo Bela Trif - MD, PhD, JD, U.S.A
Abstract: Despite the effervescent scientific atmosphere dominating todays medical world, some flaws
tend to ruin the good intentions of the majority of researchers and academics, working in the most advanced medical schools, and the most prestigious medical research institutions. The article makes reference to research misconduct, duplicate publication, and sloppy data analysis, generating data rushed
to publication, followed by the needed public retractions of the untruthful data, published because of a
thirst of glory.
Key words: ethics in medical research, bad science, defining scientific misconduct, scientific retractions, prevention of scientific misconduct
Rezumat: n ciuda atmosferei de fervoare tiinific care domin lumea medical de astzi, cteva racile tind s ruineze bunele intenii
ale majoritii cercettorilor i profesorilor de medicin, care lucreaz la cele mai avansate scoli medicale i mai prestigioase institute
de cercetare tiinific medical. Articolul se refer la noiunile de research misconduct, duplicate publication, sloppy data analysis
(fraud de cercetare tiinific, publicri redundante, analiz statistic a datelor fcut neglijent i superficial), care genereaz publicarea pripit a unor date, urmat de necesara retragere public a neadevrurilor tiinifice publicate din setea de glorie.
Cuvinte cheie: etica cercetrii medicale, tiin greit, definiia fraudei n cercetare, retragerea aseriunilor tiinifice, prevenirea
fraudei n cercetarea tiinific.

Cum anul trecut am fost plagiat de un medic legist din


Piteti, dar am lsat balt urmrirea individului, am citit o
sumedenie de articole despre frauda tiinific. Unul dintre
ele mi-a atras n mod special atenia (1), iar de aceea m-am
hotart s scriu despre acest fenomen nociv, ce paraziteaz
cercetarea tiinific de pretutindeni.
Ce poate fi mai ru n tiin dect o retragere a unei
afirmaii tiinifice care a fost deja preluat i citat n
literatura de specialitate, iar cercettori din lumea ntreag
i bazeaz deja raionamentul tiinific i ipotezele pe date
false sau parial false? V recomand cu cldur s parcurgeti
listele citate, ca s putei nelege exact la ce nivel se situeaz
frauda tiinific i unde ncepe pseudo-tiina.
Numai in ultimul an, 2010, au trebuit retrase aseriunile
false despre: mecanismul semnalizrii estrogenilor;
cancerizarea celulelor stem; autismul generat de vaccinri;
reactomul proteinelor; factorul de ntinerire transferabil al
celulelor stem de la oarecii tineri la cei btrni, iar lista nu
se oprete aici. (2)
Poate nu ntmpltor, cele mai senzaionale descoperiri
au fost intens mediatizate, iar cohorte de amatori, care nu
au nimic n comun cu tiina, au diseminat la nesfrit prin
E-mailuri repetate ad nauseum unele din descoperirile care
s-au dovedit a fi false, de parc dumnealor ar fi ndeplinit o
datorie de onoare. Din nefericire, unele dintre aceste date
false au ajuns s fie prezentate pe diverse bloguri de pe net
ca elemente inerent secrete ale cercetrii, care vor fi aduse n
practic pe viitor, doar pentru beneficiul elitelor.
Se pune ntrebarea legitim: Ce i face pe oamenii de

rnd s accepte cu frenezie gogomniile pseudo-tiinifice i


s dea ap la moar falselor descoperiri?
Un rspuns coerent la aceast ntrebare este dat de
Ben Goldacre, tnr psihiatru britanic, educat la Oxford i
Londra, n cartea lui tiina greit i pe website-ul sau
www.badscience.net. El face referiri extrem de detaliate la
efectul placebo, la trialurile de medicamente unde cazurile
care nu rspund bine sunt eliminate din statistic i, nu n
ultimul rnd, la statisticele aa zis trase din condei, unde la o analiz mai atent - se poate decela tendina de a nela,
pentru ca studiul respectiv s dovedeasc neaprat, cu orice
pre, Quod erat demonstrandum. (3)
O a doua ntrebare ce se impune ar fi: Ce i face
pe cercettori s scoat la iveal asemenea minciuni
tiinifice!? Voi ncerca s v prezint n continuare nite
rspunsuri aparinnd unor autori care au publicat n acest
incomod i delicat domeniu al eticii cercetrii tiinifice.
Consultnd nite lucrri mai vechi de-ale mele din domeniul
bioeticii i al eticii cercetrii tiinifice medicale i pe animale
(4); (5), am gsit o minunat referin unde se definete
frauda tiinific (scientific misconduct) ca orice fabricare
sau falsificare de date, plagiat sau orice deviere grav de
la practicile tiinifice acceptate, survenit n procesul de a
propune, a conduce sau a raporta o cercetare. (7)
Exist un text recent publicat de David Goodstein,
profesor de fizic la Institutul Tehnologic din California,
care a devenit extrem de repede clasic, fiind citat i rscitat,
mai ales pe Internet (ironic nu-i aa?) Despre fapt i
fraud: Poveti cu tlc despre linia nti a tiinei. Autorul

Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

Referate
se refer la lipsa de integritate tiinific, la epidemia de
greeli tiinifice trecute cu vederea din neglijena sau
nepsarea cercettorului insulte directe la nsi noiunea
de CERCETARE TIINIFIC, dup definiia ei din
dicionar. Se pleac de la premiza c integritatea tiinific
este elementul de baz a adevratei tiine, fie c e vorba
de o cercetare de laborator, de un trial al unui medicament
nou sau de observaiile unui psiholog - etolog, care studiaz
comportamentul animalelor. (6)
David Goodstein prezint cazul lui Marc Hauser, doctor
n tiine psihologice, cercettor de frunte n domeniul
cogniiei la oameni i animale la Universitatea Harvard,
care a publicat n 2002 o carte intitulat Moral Minds: How
Nature designed our universal sense of right and wrong
(Minile morale: Cum a proiectat Natura simul nostru
universal de bine i ru). Tot n anul 2002 Hauser a publicat
n revista Cognition un studiu despre nite primate
(tamarinul Saguinus oedipus), un fel de maimuici cu faa
i spatele negre, dar cu o coam alb ciufulit i picioarele
i burtica albe. Hauser a strnit interesul lumii tiinifice
mondiale, afirmnd c acestea animale plcute la nfiare
sunt capabile s creeze tipare generale n procesul de cogniie
- cunoatere, asemenea copiilor mici. n decursul anilor el a
fost citat de 38 de ori, dar n august 2010, consiliul tiinific
al Universitii Harvard l-a gsit vinovat de opt cazuri de
omisiune n cercetare i fraud tiinific. n mod necesar a
urmat retragerea public a concluziilor studiului publicat n
2002. (6)
D. Goodstein ntrevede trei motive aparente ca rspuns
la cea de a doua ntrebare:
Mai nti exist presiune generat de carier orice
cercettor e obligat prin natura muncii lui s publice ceva din
cercetarea personal, ca s i justifice existena. (6) Toat
lumea medical murmur astzi PUBLISH-OR-PERISH
adagio pe care l-am auzit prima oar de la neuitatul Profesor
de Fiziologie Ioan Hulic de la Universitatea de Medicin i
Farmacie din Iai minunat Alma Mater pentru generaii
ntregi de medici, profesori de medicin i cercettori
tiinifici.
n al doilea rnd vine o anumit trstur de caracter ce
se poate vedea doar la unii cercettori acei mai ambiioi
sau cu un surplus de ncredere n sine care cred c tiu
dinainte rspunsul la unele probleme, iar dac ar sta s
demonstreze cu migal ceea ce este de demonstrat, ar pierde
timp preios n cercetare. Ei nu sunt de loc lenei sau ncei,
ba dimpotriv, sunt extrem de vioi ca minte, iar de aceea
sar peste etapele necesare demonstraiei, dintr-o necesitate
teleologic, de a termina cercetarea ct mai curnd. (6)
O a treia explicaie a lui Goodstein cea mai dur dup
prerea mea a fi c cercettorii ce lucreaz cu experimente
greu de reprodus sunt tentai prin nsi natura muncii
lor - s aduc din condei datele sau in extremis chiar s le
fabrice pe loc. El citeaz un alt caz extrem, unde un fizician
n tehnologia semi-conductorilor organici, aflat n culmea
carierei, publica frenetic aa-zise noi descoperiri, aproape

Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

de la o sptamn la alta. ntreaga comunitate de biofizicieni


i bioingineri care sorbea cu nesa cele publicate au fost
cutremurai i jenai la sfrit, deoarece nu numai c nu era
vorba de nici o descoperire, dar nici vreun experiment nu
fusese fcut. (6)
Acum s-ar ntrevedea o a treia ntrebare: Ct de scump
pltete comunitatea de cercetare tiinific pentru fraudele
tiinifice i cum pot fi prevenite aceste fraude?!
Toi autorii pe care i-am consultat, nu numai cei pe care
i-am citat, afirm c este greu de imaginat - cu resursele
actuale - ct de ru a fcut n lumea tiinific frauda
n cercetare. Exist ns texte referitoare la prevenirea
fraudei tiinifice, unde se face clar diferena ntre eroarea
tiinific ne-intenionat i frauda comis prin nepsare
sau introducerea intenionat de date fabricate sau complet
false. (7) Metodele de prevenie ale oricrui forme de abuz
n cercetarea tiinific medical includ ceea ce s-ar putea
denumi prevenie primar identificarea i ndeprtarea
cauzelor care duc la publicarea prematur de date, la
prelucrare incomplet de date sau la publicarea excesiv redundant a acelorai date. (8)
Prevenia secundar a fraudelor n cercetare se refer la
doua lucruri pe de o parte la o posibilitate crescut de a
descoperi eventuala fraud, folosind o alternative la statistica
iniial, iar pe de alt parte la aplicare unor sanciuni acelor
care sunt dovedii c au comis una din faptele listate n
definiia fraudei tiinifice. (8)

1.

2.

3.
4.

5.
6.

7.

8.

Bibliografie:
R Grant Steen - Retractions in the scientific literature: is
the incidence of research fraud increasing?; J Med Ethics
doi:10.1136/jme.2010.040923; Published Online First 15
November 2010
Jef Akst - Top retractions of 2010: A list of the biggest papers
-- and scientists -- involved in retractions in the last year;
Published 16th December 2010 01:12 PM GMT
Ben Goldacre - Bad Science, published by HarperCollins
Publishers, Fourth Estate in 2009, 370 pages
Trif, A. B. - Ideas and controversies about the role of Bioethics
in passing laws; the consensus conferences, Clinica, vol. II,
nr.5, 1997, p. 43-44.
Trif, A. B. - Experiments on Animals contradictions and
incertitude, Clinica, vol. III, nr.3, 1998, p.46-49.
David Goodstein On fact and fraud; Cautionary tales from
the frontlines of science, Princeton, NJ; Princeton University
Press; 2010
Douglas L. Weed, MD, PhD - Preventing Scientific Misconduct;
Health Law and Ethics; American Journal of Public Health,
1998; 88 (1): 125-129
Patrick Hardigan, PhD Scientific misconduct; Focus on
research NSU HPD, vol. 4; n. 4, December 2010

Referate

MOVIES PSYCHOLOGICAL IMPACT ON THE AUDIENCE WITH


SPECIAL REGARD TO DALDRYS THE HOURS *
- Baka Dorottya - esthete of art and literature, Budapest, Hungary
Abstract: It happens frequently after having seen an immersive movie that we feel it has offered us a real
experience. This experience points at the basic effect of this genre of visual arts: the identification. Our minds
visualize the generated thoughts, which do also generate feelings in us. The extent of identification depends on
the realism, proximity of the visually represented sphere, and on the level of verisimilitude. The natural flow
of our thoughts received its greatest fulfillment in the stream of consciousness method of writing, whose main
representative in English literature has been Virginia Woolf and her work entitled Mrs. Dalloway. Daldrys
creation constitutes the visual reconstruction of this flow-like method, revolutionizing the relationship
between viewer and creation, receiver and creator to an extent that completes identification, and the movies
atmosphere pervades the audiences psychological dimensions.
Keywords: Stephen Daldry, The Hours, identification, stream of consciousness
Rezumat: Ni se ntmpl des ca dup vizionarea unui film artistic reuit s avem sentimentul c am avut parte de o real experien.
Experiena pune n eviden acest efect fundamental al acestui gen de art vizual: identificarea. Mintea noastr vizualizeaz gndurile
care s-au generat, iar acestea la rndul lor dau natere la sentimente. Msura identificrii depinde de realismul, proximitatea sferei
reprezntate vizual, i de nivelul verosimilitii acesteia. Fluxul natural al gndurilor noastre s-a mplinit cel mai din plin n stilul de
scriere numit stream of consciousness, al crui reprezentant principal a fost scriitoarea englez Virginia Wolf cu opera sa intitulat
Mrs. Dalloway. Reconstrucia vizual a acestei metode scris flow-like, este opera lui Stephen Daldry, care revoluioneaz relaia
dintre spectator i creaie, receptor i creator pn ce identificarea devine complet i dimensiunile psihologice ale spectatorului se
impregneaz n totalitate cu atmosfera filmului.
Cuvinte cheie: Stephen Daldry, The Hours, identificare, stream of consciousness

It is common after watching an immersive movie that


spectators profess: It was such a realistic experience!
However, we almost never ask ourselves the question:
what could be the reason for the audience living through a
visual illusion, a prefabricated semblance, a work of art that
is obviously an untruthful picture of reality? The answer
does not come as a surprise: identification is the process
that makes a psychological empathy appears and a lifelike
experience of the story come about in the audience.
To begin from the very beginning, dear reader, think
about Your first years when You contacted the world of visual
arts, television and movies. Unless Your parents had time to
read out fairy tales before going to bed, they played cartoons
that made You calm, sleep well and have sweet dreams.
Naive, inexperienced, unprejudiced children are even more
able to identify with the main characters of the tales they hear
or see, and parents purposefully use these means to have the
desired optimal psychological impact on them. Moreover, I
believe every single person can declare that these early visual
experiences had a great impact on their adult lives as well.
As a next and higher stepping stone we have to consider
the more developed phase of our lives when our literacy in
and attitude towards visual culture became much broader

and much more conscious. Think broadly of the movies you


can recall, that had the greatest impact on you. I assume,
whats more, I am certain that to a large degree these movies
had an open ending. This constitutes a further method to
expand the illusion of the prefabricated story transforming
into a personal experience, and, as a consequence, the depth
of psychological impact as well.
In addition, commercials constitute a constant
participant through our cinematographic perception. It is
unquestioned their intentional psychological effect that
makes even the non-conscious audience an unconsciously
influenced potential consumer. Commercials present Your
basic needs in familiar, everyday situations and engaging
ways of satisfying these needs. These fundamental aspects of
commercials make powerful identification possible and this
identification generates feelings and impressions that create
the illusion of personal concern.
Finally, I would like to present an example that confirms
the psychological creative power of visual fantasy. It has been
tested and scientifically proved that when mentally visualizing
the process of running the same muscles are stimulated as
when going through the physical process of running. This
test has also proved the intensified psychological impact of

Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

Referate
movies considering the fact that in their case the visualization
is facilitated by the ready-made visual material that the
viewers adapt to their own imaginative sphere.
So we have affirmed that psychological impact
depends on the possibility of identification. Furthermore,
identification depends on whether the viewers mental
sphere and the movies audiovisual dimensions and its epic
thread share some common features. As a consequence, the
extent of identification is defined by the forcefulness of these
overlaps between the personal and the visually represented
worlds.
We have reached the point when You could ask me: why
Daldry and why The Hours? My arguments roots go back
even to the early 20th century modernist literary stream in
English literature. The main representative of this period
was Virginia Woolf with her stream of consciousness method
of writing. This method imitates the natural flow of thoughts
occurring randomly in the human mind, and creates their
almost mechanic documentation. Mrs. Dalloway is the
novel that wonderfully exemplifies this revolutionary way of
expression, and Stephen Daldrys The Hours constitutes the
adaptation that proves to be capable of adapting the stream
of consciousness method onto a totally different medium, of
creating a natural visual flow of Woolfs mental processes.
This later ability results in the viewers revolutionary
position: Daldry invites the audience to take an active part
in the process of creation of the central literary work, of Mrs.
Dalloway itself.
As a further point You could ask me to justify the later
assumption, and I will gladly do it for you. Henceforward
I am going to present You the main items that confirm
the permanent presence of the stream of consciousness
method throughout Daldrys visual work getting closer
to the viewers natural flow of thoughts, presenting them
the process of a creation instead of the ready-made work,
stimulating them to adapt the visual sphere to their own
mental dimensions, think together, and receive as if the
mental process took place in their own minds. These will also

Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

lead You to the conclusion that the movie provides us with


the possibility of an unexpectedly high level of identification
and thus of a great degree of psychological impact.
First and foremost we have to consider the authentic
biographical aspects of Daldrys work. I suppose the audience
has the basic background information about Virginia Woolfs
mental illness, her homosexual preferences, her remarkable
contribution to English literature, and her final, tragic suicide.
In addition, the audience is also supposed to be aware of the
basic plot of Mrs. Dalloway. The main character, Woolf,
and the basic epic line is familiar thus, and it facilitates the
deepened reception.
Secondly, the plot is also familiar: an ordinary day in
an ordinary housewifes life. All of us go sometimes to buy
flowers, cook, make the preparations for a party, love, and
feel loved. In this way Daldry does also facilitate the mental
visualization for the viewer, and presents him/her a situation
that he/she does not have to interpret, reconstruct and adapt,
but only to evoke, to pick out from a bracket of the mind.
Leonard Woolf tells Virginia:Work then!, and at this
moment he does also make a call to the audience: identify
with the omnipotent author and create the work, create the
story, make the decisions, choose the characters, choose
between alternatives, create the movie itself! Be part of it and
create it Yourself!
In order the active audience to perceive its omnipotent
position to a higher degree, Daldry does also provide them
with a subjective perspective: when Virginias perspective is
presented, we see the happenings from a higher angle. All of
the characters live on the ground floor, together with their
family, while the artist, the creator, and at the same time the
audience as well live on the first floor, from where they can
glance down, follow the happenings, the storyline from an
outsiders position, make the decisions, shape the epic span,
see everything, know everything, and feel the omnipotence
of a narrators point of view. Characters move in their own
sphere, and actions happen in a random way, illogical changes
are made that are not characteristic of a traditional plot. On
the contrary, they are sudden decisions of a narrator whose
thoughts are in a constant flow. The viewer experiences the
visual work from Woolfs position, and her creative mental
process becomes adapted to the viewers own mental sphere.
Identification happens, and we suddenly find ourselves
in the body of an all-mighty author. We are creating the
work, and we do also feel every single feeling occurring in
Virginias psyche. We see, we feel, we create. The position
of the traditional passive receiver gets transformed into an
active initiation and identification.
The authenticity to become fulfilled the end of the movie
provides us with a mythical sacrifice: Woolf commits suicide,
so she has to sacrifice her alter ego, the poet, the visionary as
well. She makes a decision: the poet has to die, Richard, in
order each and every connection to be confirmed.

Referate
The protagonist dies, her alter ego is sacrificed, and
considering the total identification -, the audience becomes
able to experience the catharsis, see the death, feel the death,
experience the death, then rise above the tragedy, exit the
scene, and become purified by the transcendental power of
a tragedy experienced directly by identification, but at the
same time being aware of the receivers position, the constant
ability to move apart and regain the initial conditions.
*This is an extract of the Thesis paper entitled:
Mrs. Dalloway and The Hours

4.

Ulpius-hz Knyvkiad, 2002


5.
6.

2.
3.

Kovcs, Andrs Blint: A film szerint a vilg, Budapest:


Palatinus, 2002

7.

McFarlane, Brian: Novel to Film. An Introduction to the Theory


of Adaptation, Oxford: Clarendon Press, 1996

8.

Woolf, Virginia: Mrs. Dalloway, Ford. Tandori Dezs,


Budapest: Magyar Helikon, 1971
Zsigmond, Adl: A filmes adaptci, mint rtelmezi mvelet,
in: Lt, 2010. Februr. Net. 2010.10.19.

References:
Abel,

Guiguet, Jean: Virginia Woolf and her Works, London: The


Hogarth Press, 1965

9.
1.

Cunningham, Michael: Az rk, Ford. Ttisz Andrs, Budapest:

Elizabeth:

Virginia

Woolf

and

the Fictions

of

Psychoanalysis, Chicago: The University of Chicago Press, 1989

Filmography: The Hours. Dir. Stephen Daldry. Perf. Meryl

Adoptcik: Film s irodalom egymsra hatsa, Szerk. Gcs,

Streep, Julianne Moore, Nicole Kidman. Miramax International &

Anna & Gelencsr, Gbor, Budapest: Kijrat Kiad, 2000

Paramount Pictures, 2002. DVD.

Bennett, Joan: Virginia Woolf: her art as a novelist,


Cambridge: Cambridge University Press, 1964

BALINT GROUPS WITH HOSPITAL PHYSICIANS*


- Kjell Reichenberg - The Nordic School of Public Health, Gteborg, Sweden
Abstract: The paper describes a study with 132 hospital physicians participating in Balint groups, lasting
from to 4 years. The physicians were senior registrars and junior consultants in non-psychiatric
department at a large university hospital. 5-8 physicians in 19 groups met for 90 minutes every other week.
Participants were invited to reflect upon how their personal situation affected their professional duties as
doctors and, conversely, how their professional duties touched upon personal issues. Key words: doctors
professional duty, doctors personal issues, mutual interference between professional and personal life
Rezumat: Articolul descrie un studiu pe 132 de medici de spital care participau deja la grupuri Balint, cu
vechime de la 6 luni pn la 4 ani i 6 luni. Medicii aveau diverse poziii la unele departamente ale spitalului
separate de departamantul de pshihiatrie. Participanii au fost rugai s descrie cum situaiile lor personale influeneaz datoria lor
profesional ca medici, iar apoi cum activitatea lor profesional afecteaz viaa lor personal.
Cuvinte cheie: datoria profesina a medicilor, situiile personale ale medicilor, interferena reciproc ntre viaa profesional i cea
personal

The development from a newly graduated doctor into a


hospital specialist consists not only of improvement within
one's own subject and enhancement of practical skills. The
individual doctor becomes responsible for representing her
or his own speciality at other clinics. Organisational changes
mean doctors must also represent the medical profession
in discussions about leadership and in disputes with other
professions and they must learn to exchange views with the
hospital administration.
In many cases, their period of clinical training coincides
with research education and, later, responsibility for leading
independent research projects. The process of becoming

a self-reliant hospital doctor often occurs at a stage of life


when marriage and other changes in family situation are also
taking place.
The object of this paper is to contribute to the
understanding of how hospital physicians together reflect
upon issues arising in their clinical encounters and upon
challenges in their roles as members of staff in the hospital
and clinical teams.
Methods
This paper analyses a project with 132 hospital
physicians participating in Balint groups, lasting from

Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

Referate
to 4 years. The physicians were senior registrars and
junior consultants in non-psychiatric department at a large
university hospital. 5-8 physicians in 19 groups met for 90
minutes every other week. Participants were invited to reflect
upon how their personal situation affected their professional
duties as doctors and, conversely, how their professional
duties touched upon personal issues and development.
Balint leaders were psychologists or physicians with training
in psychotherapy.
There are two main sources of analysis. The first one
is notes from 150 instances when 2-4 Balint group leaders,
together with an outside supervisor, met to consider the
developments within the Balint groups some 10 groups. The
second one is the authors own field notes from 171 sessions
in 5 Balint groups who met from 18 to 65 times. The author
is a paediatrician who has training in psychodynamic and
systemic therapy with experience of counselling ill children
and their families and of conducting research in families that
are coping with chronic illness.
The analysis started following a qualitative methods
tradition with the aim of finding concepts useful for
describing how hospital specialists reflected on becoming
and being a hospital specialist. Coding was performed using
everyday terms denoting feelings, reactions, thoughts,
relations and ideas such as "anger", "pride", "undoing",
"loyalty towards colleagues" and "justice". The code words
were combined into concepts. Early in the stage of analysis,
the concepts of contexts of cases, triggering incidents for
the cases presented and main themes in group discussions
were found in a report from medical student Balint groups
[1]. These concepts were found useful in making sense of the
material and were used as three headings in the analysis.
Time process, being a recurrent theme in the
supervision of the Balint leaders, were used as the
fourth heading. Groupings among main themes in group
discussions were formed inductively. An iterative approach
was used, comparisons between previous theory, such as
that of transference and counter-transference, were used
alternately with reading of the field notes and forming new
groupings of concepts and conducting discussions with
research colleagues. An aim is to use terms as defined in the
fourth edition of Diagnostic and statistical manual of mental
disorders from the American Psychiatric Association, DSMIV-TR [2].
Results
The context of the professional situation of the hospital
physicians, as told by members in the groups, is described.
Then I tell how triggering incidents and aspects of cases that
the Balint group members reflect upon in the groups can be
related to the professional context, then how themes of the
group discussions can be connected to triggers of the specific
professional context and, lastly, how the temporal process

Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

as to presenting cases and reflecting upon organizational


matters in the groups can be understood.
Contexts of cases
The contexts of the presented material were: limited
freedom to decide and take responsibility in critical matters
of patient care, downsizing of hospital staff due to economic
decline, the tribulations of struggling with members of
the hospital team, physicians losing initiative to other
professional groups in both biomedical research as well as
health research with a qualitative approach and working
hours well beyond what is considered normal.
Triggering incidents for the cases presented
Events that triggered presenting cases episodes from
professional life or private experience were: appreciation
of the varied experiences of patients and their families,
personal reactions in clinical encounters that were difficult
to understand, being disregarded by superiors,being tasked
with acknowledging non-physician staff's abilities and
demands from family members to participate in family life.
Main themes in group discussions
Themes grouped according to content were demands
of being competent and constantly available to patients
and colleagues, building professional identity, hospital
physicians being trained to always being able to present an
action as response to a clinical challenge or dilemma, getting
tired of patients with a chronic illness, the death of young
patients, the discovery that elder colleagues not necessarily
express maturity but rather lack of independent thinking and
shallow emotional reactions, patients demanding more and
more of expensive and unnecessary diagnostic procedures,
the pain of acknowledging that there are patients who
prefer another doctor, envy towards colleagues with a
happy appearance who seem to be able to combine clinical
excellence, research originality and a rich personal life.
Temporal process
With time, four processes were seen in the groups.
Firstly, the members of the group moved from training and
organisational matters to questions of personal reactions
and contributions in the clinical encounter. Secondly, it
became more possible for the Balint group leader to use the
terms transference and counter-transference, or their everyday language equivalents. Thirdly, group members became
increasingly aware of the opportunity to understand their
reactions in patient encounters as defence mechanisms
against emotional involvement, mechanisms such as
isolation, intellectualization, rationalization, humour and
suppression. Fourthly, the members of the groups developed
their ability to use each other for guidance, relief and comfort.
Factors rendering it difficult for a group to move from
organisational matters to case-oriented reflections were
members missing sessions, especially unannounced absence,
groups where members happened to share responsibility for
the same patient, a member being promoted to a superior

Referate

Discussion and conclusion


The analysis yields results similar to those reported from
a resident training programme, participants moving from a
wish to discuss optimal training chances to reflecting on,
in psychoanalytical terminology, transference and countertransference [3].
What are the differences between the ways in which
hospital physicians reflect in a Balint group setting to that
of general practitioners? How can these differences be
explained?
While general practitioners are prepared to utilize the
Balint case approach, hospital physicians seem to require a
number of initial sessions for discussing what constitutes good
clinical training and organisational obstacles to good clinical
practice. They need to discuss their own situation of being
subordinates and being given roles to support the professional
demands of other groups before being able to reflect upon
their own and the group members' personal reactions in
clinical encounters. A similar process is reported from a group
of residents training to become general practitioners [4].
Hospitals are hierarchically organized and physicians have
simultaneous duties as both medical specialists and teamworkers with other professionals. This situation, together
with feelings of limited influence over leadership, conveys
attention in the Balint groups to areas of transference
and counter-transference in the working group and
the organization rather than upon these phenomena in
interactions with patients and their relatives.

Hospital physicians lack the general practitioners


tradition with its attention to ones own personal importance
in interaction with patients. Thus far there has been no
movement equivalent to that of general practitioners new
professionalism [5]. This new professionalism comprises
"nice work", which is characterized by a toning down of
vocational training, putting to rest the idea of the role of
doctor as a calling and an ability to enter into dialogue with
patients in a less paternalistic manner than before.
*This paper was presented at the 16th International Balint
Congress, Poiana-Braov, Romnia

References
1.

Torppa MA, Makkonen E, Mrtenson C, Pitkl KH. A


qualitative analysis of student Balint groups in medical
education: contexts and triggers of case presentations and
discussion themes. Patient Education and Counselling 2008;
72: 5-11.

2.

Diagnostic and statistical manual of mental disorders: DSMIV-TR. Washington, DC: American Psychiatric Association,
2000.

3.

Smith M, Anandarajah G. Mutiny on the Balint: balancing


resident developmental needs with the Balint process. Family
Medicine 2007; 39: 495-7.

4.

Merenstein JH, Chillag, K. Balint seminar leaders: what do


they do? Family Medicine 1999; 31:182-6.

5.

Jones L, Green J. Shifting discourses of professionalism: a


case study of general practitioners in the United Kingdom.
Sociology of Health and Illness 2006; 28: 927-50.

Dans grecesc la Roman - Dulceti

in the hierarchical hospital system and groups leaking


information to outsiders, or raised suspicions of this being
the case.

Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

Referate

BETWEEN RITUALS AND PLAY: ORGANIZING AND LEADING


BALINT GROUPS IN A GENERAL HOSPITAL* - Yuval Shorer - Israel
Rezumat: Articolul e un eseu ce ii are originile n practica de zi cu zi. El abordeaz denominarea instrumentelor de lucru i grijile
leaderului de grup n practica Balint. Se face o paralel cu situaia n care medicii deleg surorile medicale s invite afar din secie
familiile bolnavilor, nainte de inceperea vizitei medicilor, n loc s o fac ei nii. Autorul susine c grupurile de tip Balint, dei
oarecum diferite, sunt croite dupa aceai paradigm Balintian. El crede c este posibil s se onoreze regulile organizaionale pe de o
parte i s se uzeze de creativitate, n acelai timp. El vede aceasta posibilitate prin eliberarea de regulile ierarhiei prestabilite, n aa fel
nct s existe un grad de libertate de micare n sistemul total de reguli.
Cuvinte cheie: ritual, grup Balint, medici, surori medicale, vizitatori, familia pacientului
Abstract: This article is an essay rooted in everydays practice. It treats about the names of instruments of work and leaders procedural
concerns in the practice of Balint group. There is a parallel made with doctors delegating to the nurses some of the most inconvenient
gestures toward patients families. The author maintains that the Balint-like groups are somewhat different, yet similar to the Balint
paradigm. He things that it is possible to bridge the gap between honoring organizational rules on the one hand, and expressing
creativity on the other hand, by trying to free ourselves from the hierarchical rules, so we can find our way to freely play within the
constrictions of the system.
Key words: ritual, Balint group, doctors, nurse, visitors, patients family

The consulting psychiatrist is received by the hospital


team with ambivalent feelings: on the one hand the team
assumes that he-she can solve all the psychological problems
of patients, while on the other hand, he-she is considered to be
a stranger to the ward. "What are your tools?" they often ask,
"Can you help us, the staff, too?" are two "ritual questions"
welcoming the consulting mental health professional. As far
as "globalization and the creative freedom" is concerned,
the feelings of the mental health worker as he-she consults
with the wards is like moving out of the provinciality of
mental health where there is legitimization for both the
expressive enterprises and the expression of feelings, to the
huge "Globus"- the pulsating world of the general hospital.
Here there are different, more confined and often restrictive
rules. So how can one change this professional milieu into
a playground for creative expression? Perhaps one way is
forming a Balint group, which is to play without threatening
the unwritten directives.
Rituals are behaviors that people or groups need
emotionally. In rituals, there is both the covert as well as the
overt public messages, such as in confirmation or Barmitzvah
ceremonies. Then there are also personal rituals (like in
OCD) or group rituals that may be hidden. We, as Balint
leaders, have our rituals too: abiding by the strict rules of
the organization, defining the place of our groups and the
time frame in which the groups are held. Then we carefully
select the members of our groups, seeing that they do not
work together in the same system, without the boss, carefully
differentiating between informative questions in the group
and taking careful note of the emotional involvement of the
group members. We also confine and avoid exposure of too

10

Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

much or too deep personal/family dynamics, although we


may not have explicitly requested this from the group.
I ask: what is the interplay between Balint leader's rituals
and staff/ system rituals in group forming and conducting
groups in a hospital setting?
This question arises after our experience in leading Balint
groups for nurses and paramedical professionals in a general
hospital in the south of Israel over the past five years.
Rituals involved in building a team in the general hospital:
We try and identify health professionals from the various
sectors who want help, often during informal meetings in
the" corridors of the hospital". These professionals, together
with us, serve as catalysts for change. Through them, we
attempt to seek the blessings of senior management, when
we try and adapt our needs to theirs, for example where the
group will be held and its time frame.
The ritual of "choosing the name" and the "working tools"
expressed in a Balint group in the general hospital:
Our colleagues in the system are interested and inquisitive
about our "working tools." They may therefore seek ways to
help them cope with difficult families and patients. This
leads us to redefine the group in this setting: Me and the
family at work (double significance) is a broad subject in one
of our groups which led members to talk both about their
patients' families, as well as about their own. For example,
a nurse told us of a family that was not satisfied with the
room that the patient was allocated, blaming the nurse: "You
would not behave that way towards your own father". She felt
offended and hurt, and the discussion followed in the CBT
and family therapy modes of how this criticism affected her
so personally: her absolute need to be perfectly OK and to

Referate
satisfy everyone, all the time, on one hand, and the family
messages she received from her father before she chose her
profession on the other hand. In this case, the utilization of
role-playing helped to illustrate the problem. The use of a
wide range of psychotherapeutic approaches help openness
and experiential learning within the group and also tones
down the exclusivity of the psychodynamic approach on
which Balint groups were founded.
Rituals that are seen within the Balint group itself:
Implicit rituals in the ward. The nurse mentions the ritual
of the doctors ward round. Every morning the doctors ask
us to discharge families from the ward. This is not my job!
Why does he take advantage of us?" We looked at the doctors'
ward round as a permanent ritual, which has both overt and
covert messages. The doctors, from their part, want calmness
during the round. They claim that families may interfere with
the process. Yet can this practice not be broken? Perhaps one
member of the family can be present during this almost "holy
ritual" and provide relevant information to the team? In the

group discussion, different ways of breaking this inbuilt


ritual are discussed.
The nurses frequently complain of task over- load which
lead to discussion about over responsibility they take, both
at work and at home. This" ritual complaining" towards
"the system" was playfully, softened, when we read to them
an imaginary letter from their "invisible group partner"the doctor. Here the imaginary physician praises their
dedication, but asks to discuss, as work partners, issues with
them. In this way, the narratives enriched the group work.
In summary: These changes made our "Balint- like
groups" somewhat different, yet similar to the Balint
paradigm. I maintain that it is possible to bridge the gap
between honoring organizational rules on the one hand,
and expressing creativity on the other hand, by trying to free
ourselves from the hierarchical rules, so we can find our way
to freely play within the constrictions of the system.
*This paper was presented at the 16th International Balint
Congress, Poiana-Braov, Romnia

ESTABLISHING A BALINT GROUP FOR MENTAL HEALTH


WORKERS THE INALA COMMUNITY MENTAL HEALTH
EXPERIENCE* - Andrew Leggett - Senior Lecturer in Psychiatry, University of Queensland
School of Medicine, , Senior Staff Specialist Psychiatrist, Princess Alexandra Hospital, Brisbane, Australia
Abstract: The paper describes the context in which a new Balint group for mental health workers arises in a suburban Australian
community clinic, the process of the formation of the group and the evolution of the first five group meetings. The author expresses his hope
that the group might serve to ameliorate the tendency to demoralisation of mental health workers engaging with their clients in a setting
of socioeconomic disadvantage and cultural diversity.
Key words: immigrants, English as a second language, multiculturalism, sensitivity to cultural differences, taking offences
RRezumat: Articolul descrie contextul n care un nou grup Balint pentru personalul de sntate mintal ia fiin ntr-o comunitate
suburban din Australia, procesul de formare al grupului i cum s-au desfurat primele cinci edine de grup. Autorul sper c grupul
poate fi folosit la ameliorarea tendinei de demoralizare a personalului de sntate mintal care lucreaz cu pacienii lor aflai n condiii
socio-economice dezavantajoase i aparinnd la medii culturale diferite.
Cuvinte cheie: imigrani, limba englez nvat ca o a doua limb, medii culturale diverse, nelegere pentru deosebirile de cultur, ase simi jicnit

Inala Community Mental Health services a population of


approximately 200 000 people in the southwest of Brisbane,
a subtropical east coast Australian city of 1.75 million people,
most of whom live in detached timber or brick houses in
suburbs that sprawl out on either side of a wide meandering
river that opens on to Morton Bay, separated from the Pacific
Ocean by the worlds largest sand islands. Inala, prior to
settlement by ten pound British immigrants in the 1960s,
had a substantial indigenous population. From that time,
the name of the suburb, which was isolated in a semirural
setting some 25km from the CBD, with poor access to public

transport, came to be despised and associated with social


disadvantage.
Since the 1960s, successive waves of immigrants have
settled there in low cost housing, and a community of
pensioners and unemployed people have come to populate
the public housing projects and privately owned caravan
parks that have proliferated in the area. The largest buildings
are a shopping complex known as Inala Civic Centre,
Centrelink (the Australian governments social welfare
agency) and the Inala Community Health Centre, the ground
floor of which is shared by the Community Mental Health

Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

11

Referate
Service, the Indigenous Health Service and the Alcohol,
Tobacco and Other Drugs Service. Upstairs is the University
Of Queensland School Of Medicines general practice clinic,
established in the 1970s by the Whitlam Labor government
as a research centre for socialised family medicine.
Other legacies that reformist government gifted to
the Australian people included free tertiary education and
universal health insurance, gradually eroded by subsequent
governments into generously subsidised user-pays systems.
The reforms still prevailed when I entered medical school,
and contributed to the culture of hope and generosity
within which I was taught primary care medicine as an
undergraduate at the Inala Community Health Centre.
While Balint groups were not a part of our undergraduate
program, Michael Balints emphasis on psychological
medicine and the doctor-patient relationship were taught
and practised, and The Doctor, His Patient and the Illness
and The Fifteen Minute Hour were textbooks supporting our
curriculum
Twenty-four years after completing my undergraduate
final rotation in Community Practice, and after 16 years
in private practice as a consultant psychiatrist and
psychotherapist with postgraduate trainings in psychiatry,
psychoanalytic psychotherapy and creative writing, I
returned to public sector practice in order to increase my
involvement in teaching and training, obtaining a permanent
appointment as Senior Staff Specialist at Inala Community
Mental Health.
I found that in spite of those waves of poor migrants,
Inala remained a long way from the ocean; that Michael
Balint had been forgotten; that the second hand clothing
shops at the Civic Centre had been replaced by rows of
Vietnamese greengrocers; that one of the many forensic
patients in my outpatient practice had attempted to burn
down Centrelink and the Civic Centre; that the only place to
park my car was at the roadside next to the park in which a
young woman had been recently murdered and from which a
drug-crazed man wielding a samurai sword had been taken
to the hospital to which my patients are admitted; and that
patients discharged from other services were prone to attend
demanding attention by drawing their machetes.
I found myself working with a team of idealistic mental
health workers bearing the appellation of case managers
nurses, psychologists, social workers and occupational
therapists, struggling to sustain hope in their capacity to
benefit their clients in spite of their heavy caseloads, but
mostly espousing devotion to a highly medicalised model
of intervention. When I was not involved in direct clinical
assessments, which were always performed jointly with the
case managers, I found them to be hungry for support and
advice, especially that which facilitated psychological insight
into their clients problems, and that which left room for
explanations of the failure of medical treatment other than for
the wrong psychiatric diagnosis, medication dose reductions,

12

Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

the patients perversity or the case managers incompetence.


Initially I found myself rerolled, deskilled and regarded with
suspicion as though I either must be joining them because
I was too gormless to make a go of private practice, or else
I might be sent there as the sinister agent-messenger of the
corporate Big Other.
In spite of this, I found myself constantly mobbed for
advice, with consultations often sought in the corridors and
tremendous pressure exerted to provide solutions without
prior knowledge and outside of the context of the careful
development of a therapeutic alliance. One day I found myself
hunting for a patient file at the back of a large compactus in
the administration area. Two of the case mangers blocked
the exit and simultaneously began their agitated narrations
of their clients woeful situations. I had a panic attack. In
its aftermath, and that of my first Balint group leadership
training workshop, I resolved to offer the case managers the
opportunity to receive a kind of supportive intervention very
different to that which they were accustomed the possibility
of receiving regular peer supervision and support focussed
on consideration of the direct experience of the clinicianclient relationship in the context of Balint group.
I broached the idea with our team leader, a nurse
manager with extensive prior experience as a clinician in
emergency psychiatry, a woman whom I had observed to
have considerable capacity for emotional containment, and
for approaching stressful situations in a calm and thoughtful
manner. She was curious to know what the leadership
workshop that I had recently attended might be about, and
listened attentively to my explanation of the Balint group
process and its historical relationship to the ideology that
had sustained the Inala Community Health Service in its
earlier years. She agreed that I should offer the possibility of
forming a Balint group to the case managers at our next team
meeting, and responded positively to my request that she
join me as a co-leader for the group, initially by time keeping
and debriefing with me after each session.
I suggested that I would welcome her more active
support and intervention as she gradually became
accustomed to the process. At the team meeting, there was
considerable interest in the idea, and six or so of the case
managers expressed their intention to join the group, with a
few others expressing ambivalence. One raised the potential
problems arising out of clinicians with different trainings and
expertise, and potentially antagonistic ideologies attempting
to join in supervision as peers. Others seemed to view the
plan as potentially subversive of existing vertical hierarchies
within the corporate culture of the health service. I could say
nothing to allay this latter anxiety.
I suggested that we should meet fortnightly for an hourlong presentation and discussion of a single case, focussing
on the psychological aspects of the case, especially on the
case manager-client relationship. The first three meetings
were arranged to immediately follow the team meeting on

Referate
Wednesday mornings, in a timeslot usually set aside for
staff development and training. The first meeting was well
attended, but there was a long silence before one of the
participants offered to present a case. In this meeting and
the next, I noticed reluctance on the part of the presenters
to talk about their own feelings, with some cautious testing
of the consequences of expressions of frustration related to
disempowerment.
I attempted interventions that encouraged imaginative
discussion of the feelings and thoughts of those the case
managers believed were powerful in relation to them and
their clients, usually the senior medical staff, among whom
I was numbered. I found some of the defensive responses
painful, including those to the effect that whatever our clinical
director might have to say about the situation, it would be
right. The case managers fear of saying something that
might be construed as subversive or disrespectful awakened
in me wishes to transgress in just such a fashion, wishes that
I attempted to consciously acknowledge but to refrain from
overtly enacting. There were moments when I had to remind
myself of the potential benefits of neutrality and restraint in
leadership, traits that I admired in my co-leader, new as she
was to the Balint process.
The third Balint group meeting fell outside of the
intended fortnightly sequence, due to me being required to
participate in a corporate orientation process that followed
my appointment to permanency. Only one of the case
managers attended. The team leader and I offered her a joint
supervision of the case that was troubling her. It is impossible
to conduct a Balint group with only one participant. I found
this experience quite demoralising, but after debriefing with
my co-leader, I raised the issue again at the team meeting,
where most of the case managers expressed their continuing
interest, but raised various concerns about the timing of the
meetings, and their difficulties attending when pressed by
other commitments. I empathised with these difficulties,
and announced the need for a change in the timeslot for the
group, as much due to changes in my schedule as due to the
problems with theirs.
We settled on an early Tuesday morning time as the
alternative and agreed to meet fortnightly. My clinical
director, although he was not familiar with the Balint
process, supported it by publicly announcing to the team
that the Balint group was to be considered a compulsory part
of the professional development program. I had previously
emphasised the voluntary nature of the commitment, but I
appreciated this expression of support, and I was relieved to
find that the first meeting at the new time was well attended,
and that the presenter, a nurse in his thirties whom I had
noticed as having a capacity for calm and sound clinical
judgement in emergencies, began his presentation by
acknowledging his feelings of demoralisation and frustration
in relation to the patient whose care he was discussing, a 22

year old man born in New Zealand (from whence one in six
residents of Brisbane have originated) to Polynesian parents
who had migrated there from Pacific Islands further to the
north.
The presenter told us that he had been called to advise
and assist the previous day after the patients parents had
called the police to pick up their son from the park where he
had spent the morning lying out in the sun sniffing petrol,
across the road from the family home, within eyeshot of
his mother, who became too distressed to be able to bear to
watch him any longer. The patient had a four year history
of schizophrenia in which the onset of positive symptoms
including command hallucinations, disorganised thinking
and behaviour had followed a period of gradual deterioration
involving increased impulsivity, massive weight gain, lethargy
and turpitude, punctuated by outbreaks of petty crime and
the progressively relentless abuse of psychoactive substances
including alcohol, cannabis, amphetamines and inhalants.
The patient had no interest in his case managers efforts to
involve him in social and rehabilitative groups and to refer
him to the drug and alcohol service. When the patient had
been hospitalised, his condition had considerably improved
with antipsychotic medication and enforced abstinence from
substance abuse, but he rapidly relapsed each time he was
discharged from hospital, in spite of his compliance with
medication being ensured by fortnightly depot intramuscular
injections.
When asked by another member of the group about what
he thought motivated the patients petrol sniffing, the case
manager responded that he thought that it was the pursuit
of pleasure to the exclusion of all other goals, that his patient
seemed oblivious to the mental anguish that his actions
caused his mother, the impotent rage that they aroused in
his father and the feelings of frustration, helplessness and
futility experienced by his case manager.
After the presenter told the group about the case and
a period of factual questions from the group followed, I
invited him to push back and observe the process in silence
until invited to rejoin the group for the last ten minutes.
The patients we work with are a culturally diverse group, as
are the clinicians who make up our team. Case managers of
indigenous Australian, Chinese, Vietnamese, Persian, and
Anglo-Celtic Australian backgrounds have participated in
the Inala Balint group, including several for whom English
is a second language. Sensitivity to cultural difference is one
of the teams strengths. The discussion did not go far before
the issue of the difficulty of making a culturally attuned
response to the problems the patient presented to his family,
his case manager were raised, as was the marginal position
he had taken up with respect to the community within which
he lived. A lot of sympathy was expressed for the patients
mother, and the cultural meaning of eating and growing big
was speculated upon. The intervention I offered in response

Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

13

Referate
to this was to ask the group to imagine what the patients
father might want to say to the group about the problem.
When the case manager rejoined the group, he was able to
express more of his frustration and demoralisation, and to
put words to his sense of being entirely at a loss as to how
intervene helpfully.
After the group, I had half an hour to debrief with the
team leader and address other administrative issues before
seeing my first patient for the day the patient who had been
presented to the group and whom I was meeting for the first
time today, jointly with his case manager, for the purpose
of making an assessment and preparing a report regarding
the relationship of his illness to his recent offending by
driving without a license. Two days later the case manager
approached me and told me about the fresh approach he
had taken in dealing with the patients family asking them
how the patients problem would have been dealt with had it
arisen in a traditional village setting on the island they had
come from. This resulted in a family decision to take the
patient back to that island for a holiday and seek the advice
and assistance of community elders.
Between the fourth and the fifth meetings of our new
Balint group, a malfunction in the air condition caused
water to leak into the ceiling of our clinic, which collapsed
into one of our consulting rooms. Somehow the emergency

repairs were negotiated without the presentation of a formal


business case, in spite of Christmas coming. At the fifth
meeting today, I noticed that the presenter launched readily
into talking about how he had been touched emotionally by
the response of a schizophrenic patient with a history of
violent sexual offences when the case manager had passed
on to the patient a Christmas gift donated by a charitable
organisation. A discussion of the emotional difficulties case
managers encountered in dealing with the many patients
we manage who have a history of violent offending. When
I began my clinic after the group this morning, I found that
once again my first patient was the one chosen for discussion
in the group, and the presenter and I were working together
with the patient as a treating team, both of us having to
negotiate a rapid switch in roles. The possibility occurs to
me that a pattern is emerging, but two fish do not constitute
a school, and I will endeavour to keep my mind open to the
possibility of something different all together coming out of
our next Balint group meeting, trusting that while the ceiling
of the clinic may cave in, the sky will not fall on us. We will
continue with our work, and not be crushed.
*This paper was presented at the 16th International Balint
Congress, Poiana-Braov, Romnia

The medical conversation, CONVERSATIONAL


TECHNIQUES AND The handling of emotions*
- C. Hfner, A. Koschier, HP. Edlhaimb, A. Leitner - Danube-University Krems; Department for
Psychosocial Medicine and Psychotherapy; Krems; Austria
Abstract: Medical Treatment from a holistic point of view, in terms of psychosocial and psychosomatic intervention, always consists of
inter-subjective processes between doctor and patient. This is consistent with Balints idea that by far the most frequently used drug in
general practice is the doctor himself. Therefore, it is a primary goal of the advanced training in psychosocial and psychosomatic medicine
to enable the doctors to perceive, understand and treat their patients in a more complex way than only from a somatic perspective. A
considerable instrument to achieve this goal is a communication, which allows the patients to bring in their own points of view, their lively
experience and their feelings as completely as possible. We investigated the doctor-patient interaction within a controlled intervention
study before and after the practitioners attended an advanced training course in Psychosocial Medicine (Psy1) and Psychosomatic
Medicine (Psy2) in order to find out if there is an increase in the their communication skills with patients. The analysis was made in
accordance with the criteria of a system called RIAS (Roter Interaction Analysis System, www.rias.org) where we specifically considered
the changes in interventional competencies. The results of the present study show that this goal was achieved with respect to communication
and intervention techniques. Improvement through intervention in the categories Naming Emotions and Understanding Emotions can
be documented, particularly in the handling of emotions (NURS-model; advanced training within the courses Psy1 and Psy2 /Austrian
Medical Chamber).
Keywords: Psychosocial medicine, psychosomatic medicine, Balint-work, doctor-patient interaction, Roter Interaction Analysis System (RIAS)

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Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

Referate

Rezumat: Tratamentul medical holistic, ca intervenie psiho-social i psiho-somatic const n interaciunile subiective dintre medic
i pacient. Aceast afirmaie st alturi de idea lui Balint c cel mai folosit medicament n medicina general este nsui medicul. n
consecin, educarea i formarea n medicina psiho-social i psiho-somatic au ca scop principal crearea unor medici capabili s perceap,
s neleag i s-i trateze pacienii ntro manier mai complex dect prin simpla abordare somatic. Comunicarea ntre pacient i
medic este un instrument de valoare n ndeplinirea acestui scop, permind pacienilor s-i exprime punctele de vedere, experiena lor de
via i sentimentele pe deplin. Echipa noastr a investigat relaia medic pacient n cadrul unui studiu de intervenie controlat fcut
nainte i dup un curs avansat de Medicin psiho-social (Psy1) i de Medicin Psiho-somatic (Psy2) cu scopul de a afla dac exist o
mbuntire a capacitii de comunicare cu pacienii. Analiza s-a fcut cu ajutorul sistemului RIAS (vezi adresa website-ului), unde noi
am luat n consideraie schimbrile specifice n capacitile de intervenie. Rezultatele studiului demonstreaz c scopul a fost atins n ceea
ce privete comunicarea i tehnicile de intervenie. Ameliorarea prin intervenie la categoriile Denumirea Strii de spirit i nelegere a
strii de spirit poate fi dovedit, mai ales n ceea ce privete controlul strii de spirit (Modelul NURS; formarea avansat prin cursurile
Psy1 i Psy2 / Camera medical a Austriei).
Cuvinte cheie: medicin psiho-social, medicin psiho-somatic, activitate Balint, relaia medic pacient, Sistemul Roter de analiz
a interaciunii (RIAS)

1. Theoretical Background
In the last few decades, the medical system has
sometimes unfortunately turned away from the human
beings, according to Fiedler (2002[2]). In his opinion, we
have all become captured in a cycle of rapid scientific
improvements, technical advances, and pharmacological
innovations. Recently we have also become trapped in health
care politics and strategies. We cannot escape from this
environment of brand-new surgery methods, medications,
equipment, and exceedingly higher administration efforts,
as a result of which, the disease comes to the fore instead of
the patient.
Fortunately, there are also other movements and forces
that focus on the individual and inter-subjective level.
Communication between doctors and their patients has
become a more prominent topic in the last years (Angelelli
2008[3], Menz et al. 2008[4], Charon 2006[5], Greenhalgh
2005[6]). The objective of improved communication is a
better relationship between doctor and patient, as Balint
in the early fifties of the last century claimed, which finally
leads to a superior understanding and therapy. An important
element in the context of the training and inter-subjective
communication are Balint groups, which facilitate the daily
work of GPs and all other clinical specialists in handling
patients with chronic, psychosocial and psychosomatic
illness.
A primary part of communication within the interaction
of doctors and patients is the mutual process of getting to know
each others subjective perception of realities (Langewitz
2002[7]). Patients cannot develop an idea of their disease
without an adequate understanding of their health problems
and a comprehensible explanation from their doctor. If
physicians or specialists cannot identify the patients point
of view and fail to explain somatic as well as psychic aspects
of the health problem, this leads to uncertainty and fear.
As a further consequence, coping strategies in biological,

emotional, mental and social concerns diminish and become


rigid and insufficient. The individual patient is no longer
capable of finding a solution that is as satisfying as possible.
The health-promoting inner and outer spheres of life
become more and more constrained by a negative spiral of
disease (Dieter/ Edlhaimb 2001[8]). Against this background,
the medical fraternity itself designed the advanced training of
Psychosocial Medicine (Psy1) and Psychosomatic Medicine
(Psy2) in Austria.
Trainees in these curricula must have a total of 120
hours reflective work in Balint groups, and those who
have completed this advanced training see this part of the
curriculum as a central and effective core of their training.
On the one hand, doctors generally are highly qualified
in scientific medicine and evidence-based medicine;
but, on the other hand, there is limited time and space
for patients narratives in traditional medicine and a
regrettable shortcoming in the communication skills of
doctors. Especially in the field of chronic, psychosocial and
psychosomatic illness, the transversal and inter-subjective
movements through the patients narratives are the only
way to get close to solutions to stop the disastrous spiral of
diseases. However, the Balint group is a legitimate forum
enabling doctors to engage unconditionally in discussing
patients' stories within a safe environment. Patients with
multiple unexplained symptoms are characterized by their
complaint of symptoms for which no cause can be found or
for which there are only insufficient biomedical explanations.
They are probably one of the largest groups of patients for
doctors in polyclinics in hospitals (Smith et al. 2007[9]).
So we had the ambitious goal of training GPs and other
specialists in inter-subjective communication, and especially
in learning to understand the doctor-patient relationship in
the manner developed by Michael Balint.

Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

17

Referate
2. Research Questions
In this study we investigated the abilities that doctors
acquired in the advanced training of Psy1 and Psy2 in
order to be able to make sophisticated psychosocial and
psychosomatic interventions. The training consists of:
1) 11 weekends per 20 teaching units
2) the acquisition of stress relieving techniques
3) 120 units of Balint groups over a period of 2 years
4) 300 confirmed psychosocial and psychosomatic medical
visits and a written thesis.
The main research questions are:
1.)
Do the communication skills of physicians
and specialists in the medical interview increase after
the advanced training?
2.)
Do the abilities and skills of doctors to
intervene in the medical interview increase after the
advanced training?

Furthermore, we wanted to find out if there is a change in


communication and intervention techniques in the following
the following categories:
Creating a good atmosphere and structuring
Addressing the psycho-social characteristics of the
patient
Permitting the patient to speak
Augmentation of the adaptation phase, the dynamic
and creative matching of the doctors and the patients
realities, within the course of inter-subjective
communication.
Conversational
techniques
(Langewitz
2002[7],
[10]
Langewitz et al. 2003 ) such as (a) Waiting, (b)
Echoing, (c) Mirroring, (d) Summarising (WEMS)
Handling of emotions (Langewitz 2002[7], Langewitz et
al. 2003[10]) such as (a) Naming, (b) Understanding, (c)
Respecting, (d) Supporting (NURS)

One-way mirror: professional =>


live-rating + questionnaire

One-way mirror: layperson =>


live-rating + questionnaire

Degree of concordance between


professionals and laypersons
Usability Lab => interaction between
physicians and patients
Degree of concordance between
physicians and laypersons

Figure 1: Research Design

Physician => questionnaire

experimental group
+ control group
Patient (Actor) => questionnaire
2 times of inquiries

2 patients per physician

3. Methods
We conducted a controlled intervention study to
investigate the processes of interaction between doctors and
patients during a medical visit. The objective of the advanced
training Psy1 and Psy2 is to enhance the abilities of medical
doctors to create a comfortable atmosphere, to interact
clearly and in a structured manner, to address psychosocial
characteristics of the patient, to permit the patient to speak
and to improve their communication skills in terms of
patient-centred conversation.
Before the physicians and specialists started their first

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Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

lecture, they conducted two medical visits in the usability lab


of the Danube-University Krems that lasted approximately 20
minutes each. Two years later, after the end of the advanced
training, the same procedure was repeated. Parallel to this
experimental group, we observed doctors who did not plan to
graduate in Psy1 and Psy2 in order to control the variable of
experience over time.
Each doctor had to examine and treat two different
patients one with a severe diagnosis [HIV or cancer (Hodgkin
lymphoma)] and one with a harmless illness (abdominal
pain or asthma). Due to ethical concerns, the patients were

Referate
adequately trained and well instructed actors and actresses,
who practiced their scripts in a special preparation course to
assure that they acted as authentically as possible.
The medical visits were recorded by video. For our
data analysis we chose the Roter Interaction Analysis
System (RIAS) invented by Debra Roter et al. (2002[11];
German translation: Langewitz et al. 2003[10]), which is a
computerised method of coding doctor-patient interaction
during the medical visit. The identification and classification
of verbal expressions are coded directly from videotapes and
not from transcripts. Therefore, assessment is possible of
the tonal qualities, which transmit the emotional context of
the visit beyond the significance of the words spoken. The
communication units are defined as "utterances", which are
the smallest discriminable speech segments for classification
and which may vary in length. The rating is based upon their
general affective impression of both the patient and the
doctor and on global affective parameters, such as anger,
anxiety, dominance, friendliness and interest. All videos
were analysed by the same Balint group-Leader to avoid the
problem of inter-rater inconsistency.

4. Results
The analysis of the experimental and the control group
is based upon 156 interviews with a total amount of 23,510
utterances. 120 videos were made with the experimental
group and 36 interviews with the control group. 52% of the
23,510 utterances were made by the doctors and 48% by the
patients.
4.1.
Sample
At the time of the first data collection, our sample
consisted of 65 doctors (43 female, 22 male). Two years later
at the time of the second data acquisition, 39 (23 female,
16 male) of those 65 doctors participated in the study. The
reduced number of probands was due to the fact that not all of
the surveyed persons completed the postgraduate training of
Psychosomatic Medicine (Psy2) after Psychosocial Medicine
(Psy1).
The experimental group consisted of 56 doctors (39
female, 17 male) and the control group was composed of
only 9 doctors (4 female, 5 male). 73% of the doctors worked

predominantly in a hospital and 27% worked in their own


doctors office. 19% were medical specialists, 35% were
general practitioners and 48% were still in medical training
(multiple answers were permitted).
5 actors played the different patients. 42 videos were
made with a male patient and 114 with a female patient.
4.2.
Most frequent statements of doctors
Typical clinical visits generally follow a specific pattern
of (1) opening, (2) anamnesis, (3) physical examination, (4)
counselling and (5) closing. Those segments are typically
characterised by certain categories, although any category
may occur within any segment of the interaction.
The most frequent statements of the doctors were (see Figure 2):
(1) Back-channelling (1,469 utterances; 6.2% of
all statements) as an invitation for the patient to continue
talking and indicate sustained interest or attentive listening
(Roter 2006[12]).
(2) Asking closed-ended questions medical
condition showed totally 1,431 questions (6.1% of all statements).
(3) Giving information medical condition (1,277
utterances; 5.4% of all statements) includes statements
of facts or opinions which relate to the medical condition,
symptoms, diagnosis, prognosis, past tests and their results,
medical background, personal and family medical histories,
practices and allergies, as well as a basic identification of
information or vital statistics as part of the medical record
(Roter 2006[12]).
(4) Summarising (1,173 utterances; 5.0% of all
statements) means to give a resume of the patients
statements in own words (Roter 2006[12]).
(5) Transition words (661 utterances; 2.8% of all
statements) are sentence fragments that indicate a movement
to another topic or area of discussion or a train of thought
or action. Many of those statements or fragments are placeholders (Roter 2006[12]).
(6) Waiting (791 utterances; 3.4% of all statements)
is an essential part of patient-centred conversation and
comprises a time period longer than 3 seconds, in which the
awareness and attention is directed to the patient, who is
invited to speak (Roter 2006[12]).

Most frequent statements of doctors


Waiting

661
791

Transition words
Summarising

1173
1277

Giving information - medical condition


Asking closed-ended questions - medical condition

1431
1469

Back-channeling
0

200

400

600

800

1000

1200

1400

1600

utterances

Figure 2: Most frequent statements of doctors (absolute frequencies of utterances)


Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

19

Referate
4.3.

Most frequent statements of patients


The most frequent utterances of the patients were (see Figure 3):
(1) Giving information medical condition (3,330 utterances; 14.2% of all statements) was the most frequent RIAS
category of all. Compared to the doctors utterances of this kind, it is almost three times higher.
(2) Showing agreement or understanding (1,198 utterances; 5.1% of all statements) includes all signs of agreement
(phrased positively and negatively) or understanding (Roter 2006[12]).
(3) Giving information lifestyle (1,192 utterances; 5.1% of all statements).
(4) Giving information psychosocial (1,110 utterances; 4.7% of all statements).
(5) Back-channelling (1,053 utterances; 4.5% of all statements).
(6) Worry or concern (844 utterances; 3.6% of all statements) are non-verbal expressions which show that a condition
or an event is rather serious, distressing, worrisome or deserving special attention like comforting or another special
consideration. (Roter 2006[12]).
(7) Transition words (757 utterances; 3.2% of all statements) is almost ex aequo with those of the doctors.

Most frequent statements of patients


757

Transition words

844

Worry or concern

1053

Back-channeling
Giving information - psychosocial

1110

Giving information - lifestyle

1192

Showing agreement or understanding

1198

Giving information - medical condition

3330
0

500

1000

1500

2000

2500

3000

3500

utterances

Figure 3: Most frequent statements of patients (absolute frequencies of utterances)

4.4.

Interventions in interpersonal
communication
The videos were analysed with regard to all utterances
that dealt with communication techniques.
Orientation statements tell the other person what
is about to happen and what is expected during the medical
visit, to direct the others behaviour and to facilitate the
process of the visit. They serve to orient the patient to the
major topics of conversation. This technique helps the
patient to cooperate. Instruction statements however include
directive statements relating to the examination, including
those in imperative form. They are often used to facilitate
progress through the medical visit and include statements
referring to procedural or administrative aspects (Roter
2006[12]) (see Table 1).
A very essential part of patient-centred conversation is
Waiting, Echoing, Mirroring and Summarising (WEMS).
Waiting comprises a time period longer than 3 seconds
is not an ignorant doing nothing. It is an important
intervention and the advertence and attention is addressed
to the patient, who is invited to speak. In the study at hand,
661 interventions classified as waiting could be registered,

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Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

which represent 2.8% of all interventions and utterances.


575 of these utterances came from physicians and specialists
of the experimental group (4.2% of all utterances from this
group). 86 statements were done by doctors of the control
group (0.9% of all utterances from this group, see Table 1).
Another crucial communication technique is echoing.
Hereby the physician or specialist repeats the phrases used
by the patient, like an echo, in order to encourage the patient
to continue the narrative. There are also mechanisms for
requesting repetition of the patients previous statement.
Such requests are used when words have not been clearly
heard (Roter 2006[12]). The surveyed doctors echoed 178
times, which represents 0.8% of all utterances. Doctors made
154 statements before and after their training (1.1% of all
statements from this group) and the rest of 24 utterances by
those without training (0.2% of all utterances of the control
group). The patients echoed the words of the doctor 13 times
(0.1%, see Table 1).
In mirroring, the doctor re-states the information
given by the patient for the purpose of confirming a shared
understanding of the facts being discussed. 93 utterances
could be classified as mirroring feedback to emotional

Referate
utterances of the patients. This includes communication
techniques by which the doctor reflects back contextual or
emotional information, which he or she has just been told
by the patient. The purpose is to check the accuracy of the
information (Roter 2006[12]). Mirroring represents only 0.4%
of all utterances of the doctors. 80 statements came from
the experimental group before and after training (0.6% of
all utterances from the experimental group) and 13 from the
control group (0% of all their utterances, see Table 1).
Doctors made many summarising utterances with
a total amount of 1,173 (5%), whereas patients made 62
summarising comments (0.3%). The major part (891
statements, 6.5% of all their utterances) came from the
experimental group, whereas the control group only
summarised 282 times (2.9% of all their statements, see
Table 1). This category means giving a resume of the patients
statements in ones own words or making statements that are
shorter than the patients statements but strongly referring to
them. The aim is to feed back the essence of a verbal message.
Besides paraphrases or repetitions, the doctors also ascertain
that they have a correct understanding of the meaning. The
utterances can be in either question or statement form, but
the function is to clarify or to ask for clarification of the
others communication (Roter 2006[12]).
Prosodic interventions are non-verbal expressions and
almost inaudible under-talk that accompanies the patients
words. They are not meant to be responses to the patients
questions, but an invitation to continue the conversation.

They indicate a sustained interest and attentive listening or


encouragement emitted by the doctor when he or she does
not hold the speaking floor. They do not serve to take the
floor from the speaker. The right to speak remains with the
patient (Roter 2006[12]). The doctors made 1,469 utterances
of this kind (6.2%), whereas the patients showed 1,053
(4.5%) utterances of this category, also called back-channel
responses. 1,159 statements came from the Psy1 and Psy2
doctors (8.4% of all their utterances) and 310 (3.2%) came
from the control group (see Table 1)In all the videotaped
medical visits the doctors undertook a total of 2,105
interventions of (WEMS) waiting, echoing, mirroring and
summarising, which represents 9% of all communication.
If we include also interventions like giving orientation and
back-channel responses, this amount climbs up to 16.7%
(3,924 utterances). The amount of WEMS was three times
higher in the group of Psy1 and Psy2 doctors (12.3% of all
their utterances before and after the training) than in the
control group (4.2% of all their utterances within two years,
see Table 1). The difference between the two groups is smaller,
if we also take giving orientation and back channelling into
account (22.8% of the experimental group and 8.1% of the
control group). This reduction is due to the large part of
back channelling compared to the other categories of the
doctors without training (3.2%). Both differences are highly
significant (p=0.000).

Intervention

Frequency of
Utterances (total)

Giving orientation
Waiting
Echoing
Mirroring
Summarising
Back Channel
WEMS
WEMS incl. orientation + back-channel
All statements (doc + pat)

350
661
178
93
1,173
1,469
2,105
3,924
23,510

1,5%
2,8%
0,8%
0,4%
5,0%
6,2%
9,0%
16,7%
100,0%

Frequency of
Utterances
(Experimental Group)
278
2,0%
575
4,2%
154
1,1%
80
0,6%
981
6,5%
1,159
8,4%
1,700
12,3%
3,137
22,8%
13,774
100,0%

Frequency of
Utterances
(Control Group)
72
0,7%
86
0,9%
24
0,2%
13
0,0%
282
2,9%
310
3,2%
405
4,2%
787
8,1%
9,736
100,0%

Table 1: Interventions of the Doctors

4.5.

Effects of advanced training on the interpersonal communication


It is noteworthy that the medical conversation at the second time of survey two years after the first one becomes slower.
Although the medical visits last longer (9 minutes 39 seconds on average), they contain fewer utterances, and the identified
change of the right to speak declines. After the advanced training of Psy1 and Psy2, the patients show slightly more utterances
(see Figure 4).

Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

21

Referate

160

159

150

140
120
89,9

100

76,4

80

48

60

49

40
20
0

Utterances of the
physician

Permitting the patient


to speak
first survey

Utterances of patient

second survey

Figure 4: Comparison of First and Second Survey (absolute frequencies per visit)

If we focus on all interactions between doctors and patients, which are important for person-centred communication,
such as waiting, echoing, mirroring and summarising (WEMS), the following development over time emerges.
Professional waiting increases from 2.0% to 4.3% after the advanced training, while the control group declines within
the two years from 2.3% to only 1.0%. The percentage refers to all utterances within one group (experimental group or control
group) (see Table 2 & Figure 5).
All in all, echoing occurs relatively scarcely, but ascends from 0.6% to 1.0% after the training of Psy1 and Psy2. The
doctors without training decrease from 0.6% to 0.4% (see Table 2 & Figure 5).
Also the technique of mirroring, which occurs very seldom, rises from 0.2% to 0.7% after the training, whereas the
control group rises from 0.1% to 0.4% (which are 3 and 10 utterances, respectively) (see Table 2 & Figure 5).

Summarising declines in both groups in the experimental group from 5.3% to 4.3% after the advanced training
and in the control group from 6.5% to 4.7%. This result may be explained by the fact that different diseases were presented at
the two different times of survey, and the second illnesses did not require as much information from the patients as the first
(see Table 2 & Figure 5).

WEMS Doctors
Exp. Group First Survey

Exp. Group Second Survey

Cont. Group First Survey

Cont. Group Second Survey

Total

Waiting
Echoing
Mirroring
Summarising

192 (2.0%)
61 (0.6%)
16 (0.2%)
503 (5.3%)

383 (4.3%)
93 (1.0%)
64 (0.7%)
388 (4.3%)

63 (2.3%)
16 (0.6%)
3 (0.1%)
177 (6.5%)

23 (1.0%)
8 (0.4%)
10 (0.4%)
105 (4.7%)

661 (2.8%)
178 (0.8%)
93 (0.4%)
1.173 (5.0%)

All statements

9.554 (100%)

9.005 (100%)

2.705 (100%)

2.246 (100%9

23.510 (100%)

Category
107
108
109
110

Table 2: Combination: Time and Group Variables

22

Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

Referate
Comparison of WEMS
7

6,5

5,3

4,3

4,3

4,7

4
3
2

2,3
1

1
0

Waiting
(exp. gr.)

0,6

Waiting
(control gr.)

Echoing
(exp. gr.)

0,7

0,6 0,4

0,2

0,1

Echoing
(control gr.)

M irroring
(exp. gr.)

first survey

second survey

0,4

M irroring Summarising Summarising


(control gr.) (exp. gr.) (control gr.)

Figure 5: Comparison of Conversation Techniques (percentage of all utterances)

There is a highly significant increase in the use of the relevant intervention techniques of WEMS (waiting, echoing,
mirroring and summarising) in the second survey (p<0.001). While the frequencies of these interventions of the experimental
group increases over time, it decreases for doctors who did not do the training (see Figure 6).
Effect of Interaction WEMS
12
10,74

10

9,65
8,28

6,85

6
4
2
0
first survey

second survey
Experimental Group

Control Group

Figure 6: Effects of Training

Regarding the utterances of the patients, they certainly reflect the content of the script, i.e. their role as actors and actresses.
But even more relevantly, they reflect as well how much doctors are capable to open up the time and space for special
utterances of the patients. It is important to impress upon the doctors that important information not only is the product of
questioning and answering but also emerges from the interplay of questioning and answering and is offered unexpectedly and
spontaneously by the patient. Therefore, we investigated how far patients of the experimental group get the chance to bring in
interrelated chains of utterances in the medical conversation. The analysis of verbal fluency is based upon 23,510 individual
utterances altogether. After excluding the back-channel utterances with which the doctors tried not to take the floor from the
speaking patient and to encourage the patient to continue the conversation, there remained 18,679 utterances for our analysis
to determine the trend to longer chains of uninterrupted patient narrations after the training of Psy1 and Psy2. The average
amount of uninterrupted patient narrations increased from 1.37% to 1.83% in the experimental group of trained doctors,
whereas it declined from 1.31% to 1.1% in the control group. This correlation is highly significant and implies that the advanced
training produced the desired effects (see Figure 7).

Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

23

Referate

2
1,8
1,6
1,4
1,2
1
0,8
0,6
0,4
0,2
0

1,83
1,37

1,31

uninterrupted reactions
(experimental group)

1,11

uninterrupted reactions
(control group)

first survey

second survey

Figure 7: Speaking Right of the Patient (percentage)

4.6.

NURS - The handling of emotions


There are 4 main categories of dealing with the patients emotions that are crucial for a successful intervention:
(1) Naming emotions
(2) Understanding emotions,
(3) Respecting emotions and
(4) Supporting emotions
Naming emotions means empathy statements that paraphrase, interpret, name or recognize the emotional state of the
patient during the visit (Roter 2006[12]).
Understanding emotions includes statements that indicate that the patients emotional situation, actions or thoughts
are understandable and normal. The purpose is to normalise the patients emotions, actions and thoughts by making them
universal (Roter 2006[12]).
Respecting emotions implies statements that express a regardful handling with the patients emotions.
Supporting emotions could not be found in the study at hand.

Intervention
Naming Emotions
Understanding E.
Respecting E.
Supporting E.
All statements (doc + pat)

Frequency of
Utterances (total)
85 (0.4%)
92 (0.4%)
24 (0.1%)
3 (0%)
23.510 (100%)

Frequency of Utterances
(Experimental Group)
71 (0.5%)
70 (0.5%)
20 (0.1%)
2 (0.0%)
13.774 (100%)

Frequency of Utterances
(Control Group)
14 (0.1%)
22 (0.2%)
4 (0.0%)
1 (0.0%)
9.736 (100%)

Table 3: Interventions of the Doctors

Furthermore there were several sub-categories such as approval, disapproval, reassurance, and worry or concern, which we
do not want to continue reporting in this context.
4.7.

Effects of advanced training on the handling of emotions

The described technique NURS (naming, understanding, respecting and supporting emotions) was part of the advanced
training in Psy1 / Psy2 and was reflected in the containing Balint groups within at least two years. Comparing the experimental
group of trained doctors with the control group of
untrained doctors, we found the following differences (see Table 4 and and figure 8).

24

Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

Referate
Handling of disclosed and hidden Emotions - Doctors
Category
107
108
109
110
111
112
113
114

Naming Emotions
Understanding E.
Respecting E.
Supporting E.
Approval
Disapproval
Reassurance
Worry or Concern
All statements

Exp. Group First Survey

Exp. Group Second Survey

Cont. Group First Survey

Cont. Group Second Survey

Total

28 (0.3%)
15 (0.2%)
4 (0.0%)
2 (0.0%)
5 (0.1%)
3 (0.0%)
49 (0.5%)
11 (0.1%)
9.554 (100%)

43 (0.5%)
55 (0.6%)
16 (0.2%)
0 (0.0%)
11 (0.1%)
29 (0.3%)
184 (2.0%)
14 (0.2%)
9.005 (100%)

6 (0.2%)
5 (0.2%)
1 (0.0%)
0 (0.0%)
1 (0.0%)
0 (0.0%)
10 (0.4%)
0 (0.0%)
2.705 (100%)

8 (0.4%)
17 (0.8%)
3 (0.1%)
1 (0.0%)
7 (0.3%)
3 (0.1%)
85 (3.8%)
2 (0.1%)
2.246 (100%9

85 (0.4%)
92 (0.4%)
24 (0.1%)
3 (0%)
24 (0.1%)
35 (0.1%)
328 (1.4%)
27 (0.1%)
23.510 (100%)

Table 4: Frequencies of the RIAS-Categories 107-114

1,4

1,2 7

1,2
1
0 ,8

0 ,6 1

0 ,6
0 ,4

0 ,2 9
0 ,18

0 ,16

0 ,2
0

0 ,51

0 ,4 8

0 ,0 4
N am ing E m o t io ns

U nd er s t and ing
E m o t io ns

0 ,0 2

R es p ect ing E m o t io ns Sup p o r t ing E m o t io ns

F ir s t Sur v ey

T o t al

Seco nd Suer v ey

Figure 8: Handling with Emotions (percentage) Utterances of the Doctors

If we count together the four intervention techniques


of NURS (naming, understanding, respecting, supporting
emotions), there is a highly significant difference (p<0.000)
between the two surveys (first and second), but no significant
difference between the experimental and the control group.
Also here the fact of professional experience seems to have
a great impact on the development of NURS-interventions
Balint leaders reported an increasing reflection of the
accompanying emotions of patients presented in their Balint
groups.
5. Discussion
The working group, within the meaning of Balint,
aims at a better understanding of the patient, a better
understanding of the relationship between the patients and
themselves and a better self-perception of their own feelings.
Balint work helps in inter-subjective corresponding doctorpatient relationship, which is the target of the training in
psychosocial and psychosomatic medicine. The described
inter-subjective interventions help dealing with transference
and counter transference.
Psychosocial and psychosomatic interventions are

always inter-subjective processes of direct (verbal) and


comprehensive (also non-verbal) conversation between
doctors and patients. Therefore it must be a crucial objective
of advanced training for medical doctors to enable them
to perceive, to understand and to treat their patients in a
more complex and self-contained way than from a somatic
perspective.
The results of the study at hand show that we
succeeded in essential areas to move doctors towards a
more communicative behaviour, so that their patients
are capable to convey their own position articulately. The
competencies and performances necessary for a more
patient-centred communication [the medical interventions
of waiting, echoing, mirroring and summarising (WEMS)]
could definitely be improved by the advanced training of
Psy1 and Psy2. Especially the categories waiting, echoing
and mirroring showed a significant increase after the special
training. The category of summarising decreased after the
training, but this result is due to the differences in the actors
(= patients) scripts. Furthermore the patients could keep
their right to speak for a longer period and showed a greater
amount of uninterrupted narrations after the training of

Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

25

Descriere de Caz
their doctors, which is also a characteristic of patient-centred
communication.
Furthermore the results indicate an expansion of the
skills for handling with emotions due to the advanced
training of Psy1 and Psy2, as well as to experience over time.
Utterances that are part of the NURS-technique (naming,
understanding, respecting and supporting emotions) show
a tendency to increase with time. There is no significant
difference between the experimental and the control group.
It must be stated, that the utterances in this area are quite
rare. There is a significant increase of utterances concerning
approval in both groups.
The results indicate that postgraduates of the advanced
training - Psy1 / Psy2, acieve higher communication abilities
and skills, both concerning the permission of the patient
to speak and the advancement of their conversational
techniques.
The techniques of NURS, on the contrary, do not develop
as well as they should.
*This paper was presented at the 16th International Balint
Congress, Poiana-Braov, Romnia

rztliche Gesprchsfhrung. Optimierung kommunikativer


Kompetenz in der ambulanten medizinischen Versorgung.
Ein gesprchsanalytisches Trainingskonzept. Wien: LiteraturVerlag
5

Charon, R. (2006). Narrative medicine: honoring the stories of


illness. New York, NY [u.a.]: Oxford Univ. Press

Greenhalgh, T. (ed.) (2005). Narrative-based medicine Sprechende Medizin. Dialog und Diskurs im klinischen Alltag.
Bern [u.a.]: Huber

Langewitz W. (2002). Arzt-Patient-Kommunikation, Mitteilen


schlechter Nachrichten. In: Brhler E. / Strau B. (ed.)
Handlungsfelder in der Psychosozialen Medizin. Gttingen:
Hogrefe: 54-76

Dieter W, Edlhaimb HP. Imaginative Psychotherapie III


Praxeologie. In: Leitner A, Hrsg. Strukturen der Psychotherapie.
Wien: Krammer; 2001: 105-115

Smith, R. C. / Dwamena, F. C. (2007). Classification and


diagnosis of patients with medically unexplained symptoms.
In: J Gen Intern Med, 22(5), 685-691.

10

Langewitz W. / Nbling M. / Weber H. (2003). A theorybased approach to analysing conversation sequences. In:
Epidemiologia e Psichiatria Sociale Vol. 12(2): 103-108

References

11

Roter D. / Larson S. (2002). The Roter interaction analysis

Balint, M. (1957) The Doctor, his Patient and the Illness.

system (RIAS): utility and flexibility for analysis of medical

Fiedler L. (2002). Medizin im Wandel. In: Consilium 2002; 12

interactions. In: Patient Education and Counseling No. 46:

Angelelli, C. V. (2008). Medical interpreting and cross-cultural


communication. Cambridge [u.a.]: Cambridge Univ. Press

Menz, F. / Lalouschek, J. / Gstettner, A. (2008). Effiziente

243-251
12

Roter D. (2006). The Roter Method of Interaction Process


Analysis. Baltimore: John Hopkins University

DESCRIERE DE CAZ - Ovidiu Popa-Velea, Bucureti


A.M. a prezentat cazul
unei experiene personale
trecute n calitate de asistent pe Salvare, experien ce a implicat a face fa
agresiunii verbale i fizice a
unui pacient violent, necooperant. ntrebarea adresat grupului a fost legat de
reacia iniial a Alexandrei, reacie caracterizat printr-o
anumit paralizie emoional, urmat de sentimente de vulnerabilitate i ndoial c ar putea face fa unui caz similar
n viitor. Dei Alexandra nu mai exercit n prezent profesiunea de asistent medical, cazul a fost selectat spre prezentare ntruct:
- acoperea o experien trecut real, iar rememorarea
cazului a pus n eviden faptul c Alexandra mai avea nc

26

Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

sentimente puternice legate de acea ntmplare;


- cazul putea fi interesant pentru studenii participani la
edin, n msura n care putea ilustra multilateralitatea i
ambivalena profesiunii medicale, precum i limitele i potenialele riscuri ale acesteia.
Discuiile din grup au vizat asumarea rolului terapeutului
n situaia relatat de Alexandra, dar i a unora dintre membrii anturajului pacientului, ca i a pacientului (n special
trirea posibil a acestuia a situaiei de agresiune ca legitim sau justificat). n rolul de Alexandra, majoritatea
participanilor i-au imaginat nu numai reaciile emoionale
ale acesteia, ci i unele strategii practice pentru a face fa
att unei posibile agresiuni fizice, ct i sentimentelor de
frustrare, neputin sau vulnerabilitate pe care le aduce un
asemenea caz.
La revenirea n grup, Alexandra a relatat c s-a simit
foarte bine, discuiile confirmndu-i o parte dintre strate-

Descriere de Caz
giile pe care ea nsi le-a folosit pentru a scpa de povara
psihologic adus de acest caz (ex. concentrarea pe aspectele
pozitive ale situaiei, precum succesul n referirea pacientului ctre spitalul de psihiatrie, unde acesta a beneficiat de
ajutor medical; perceperea unui grad personal de rezilien
pentru confruntarea cu situaii similare din viitor; asumarea acestui gen de situaii ca fiind inevitabile, n special n
contextul sistemului sanitar haotic romnesc). Singura observaie critic a fost legat de posibilitatea grupului de a se
fi concentrat mai mult pe sentimentul iniial al Alexandrei,
de fric (panic).
Participarea la discuii a fost prezent la toi membrii

grupului, fiind de remarcat spontaneitatea majoritii remarcilor, fluena desfurrii edinei i uurina de empatizare cu principalele personaje ale ntmplrii. Este posibil
ca aceste atribute ale ntlnirii s se fi datorat participrii,
deja stabile, a unor membri, la mai multe / toate edine(le)
de grup, de la renfiinarea acestuia. Dei aceti participani
stabili au fost studeni, considerm contribuia lor drept
valoroas.
Toi noii participani au apreciat pozitiv lucrul n grup i
i-au exprimat intenia s mai participe la astfel de ntlniri.
Atmosfera a fost cald, relaxat

DESCRIERE DE CAZ - Psih. Irina de Hillerin


Cel care i-a anunat
imediat dorina de a prezenta un caz a fost un asistent
medical, AT, unul dintre
participanii noi la grup.
Prezentm cazul cu acordul su, respectndu-i dorina de a nu dezvlui anumite date: lucra ca asistent
medical ntr-un spital de campanie ntr-una din zonele de
conflict din Orientul Mijlociu. ntr-una din zile medicul-ef,
femeie, a trebuit s lipseasc i atunci i-au revenit lui sarcinile din acea zi.
Trebuia s consulte persoane originare din acea ara i s
le dea avize de munc pentru a se angaja n armata american pe diferite posturi. La consult s-a prezentat un brbat
care nu vorbea foarte bine limba englez i prea s ascund cu mna o parte din corp. Una din cerinele medicale de
admitere pe acel post era ca persoanele selecionate s nu
fi avut intervenii medicale n ultimii 15 ani. La solicitarea
asistentului medical de a se dezbrca, pacientul iniial refuz, apoi se dezbrac totui cu mare greutate. AT constat c
are o mare cicatrice de-a curmeziul abdomenului care nu
prea recent. La ntrebarea sa despre istoricul acelei cicatrici, brbatul rspunde c este foarte veche, din copilrie, i
c nu-i afecteaz cu nimic capacitatea de munc. Apoi ncepe s-i spun ct este de important acel post pentru el, c are
de hrnit multe persoane acas i c nu este deloc relevant
acea cicatrice. AT decide s-i dea un aviz favorabil dar rmne cu multe frmntri interioare.
ntrebarea pe care a adresat-o grupului a fost dac a
procedat bine n acel caz, totodat dorindu-i s-i clarifice

sentimentele trite de atunci i pn n prezent (trecuse mai


mult de o lun de la acea ntmplare). A mai dorit s exploreze n ce msur se poate lsa afectat de o ntmplare care
la o prim impresie ar putea prea banal, avnd n vedere
c urma s plece ntr-o expediie alpin care implica multe
riscuri, ca asistent medical.
Grupul i-a pus ntrebri despre rolul medicului ntr-un
spital de campanie i rolul asistentului, presiunea asupra
personalului medical din cadrul armatei, specificul persoanelor din acea ar care ajungeau ca pacieni n acel spital.
Faza de discuii a fost vie, centrat n special asupra potenialelor emoii trite de AT (sentimentele de vinovie,
lipsa de toleran la minciun, la duplicitate), posibila manipulare din partea pacientului, gradul de asumare a responsabilitii actului medical, rezistena la presiunea emoional. S-au implicat toi participanii, noi sau vechi, au rezonat
puternic cu AT i cu implicaiile emoionale ale istoriei sale.
La revenirea simbolic n grup, AT i-a exprimat prerea
sa cu privire la cele vzute i auzite. S-a artat surprins de
bogia emoiilor pe care a constatat c le trise i el dar nu
a tiut s le exprime n acest fel i a acceptat c este posibil
ca unele sentimente s nu fi dorit s le recunoasc. S-a artat foarte ncntat de profunzimea explorrii sentimentelor
realizat de ntregul grup.
Persoanele care au fost prezente pentru prima dat la
grup s-au artat entuziasmate de existena acestui mod de
explorare a relaiei medic-pacient, inedit pentru ele i, dup
cum au declarat, extrem de util n descrcarea tensiunilor
acumulate n actul medical.
La final membrii au exprimat feedback-ul cu privire la
lucrul n grup, acesta fiind unanim pozitiv.

Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011

27

tiri din Viaa Asociaiei

TIRI DIN VIAA ASOCIAIEI - Dr. Albert Veress, Miercurea Ciuc.


Evenimente petrecute:
14-16 ianuarie 2011: Weekend Naional de Iarn cu Postrevelion, Roman-Dulceti.
Gazdel noastre, familia ubucanu i Costin au fost i de aceast dat la nlime.
Formaia de dans Amiciia ne-a delectat cu dansuri greceti i moderne. Bazinul de aceast
dat a avut apa att de rece nct nimeni nu s-a ncumetat s partricipe la grupul Balint acvatic.
Doi lideri de grup, ubucanu Marilena i de Hillerin Irina i-au dovedit din plin aptitudinile
de lideri de grup. Eu am prezentat o lucrare (Dragoste la btrnee) care a generat rumoare i
discuii vii pe marginea celor prezentate (va fi publicat n nr. Jubiliar 50 din iunie!)

Planuri de viitor:
13-15 mai 2011 - Weekend Naional de Var, la Ocna ugatag. Tax de participare: 35 Euro care va cuprinde i
c.v. banchetului pentru membrii cu cotizaia achitat la zi. 12 credite EMC. Data limit de exprimare a dorinei de participare i rezervarea camerelor este 10 mai la adresa de e-mail: alveress@clicknet.ro sau prin telefon: 0740-085547(rvai
Zsfia). (Cazare 40 RON/pers./zi -include micul dejun).
7-11 septembrie 2011 - al XVII-lea Congres Internaional Balint, Philadelphia, USA. Biroul a votat o sponsorizare n
valoare total de 4.500 RON pentru cei care vor participa la congres. Termen de anunare a dorinei ferme de participare:
01.05.2011!!! Anunurile ulterioare nu vor fi luate n considerare! Adresa de site: http://balintcongress2011.eventbrite.com
22-24 septembrie 2011 - a XVIII-a Conferin Naional Balint, probabil la Sfntu Gheorghe. Tax de participare:
35 Euro care va cuprinde i c.v. banchetului pentru membrii cu cotizaia achitat la zi. 23 credite EMC.
Se va alege noul Birou al Asociaiei. Participai cu toii ca s v putei exprima votul! Vei avea un Birou
pe care l vei alege!!!

Dorim s stabilim schimburi cu alte publicaii. On dsir tablir lchange avec dautres publications.
We wish to establish exchange with other publications. Wir wnschen mit anderen Herausgaben den Austausch einzurichten. Desideriamo stabilire cambio con alte publicazioni. Dseamos establecer intercambio con otras publicaciones.

28

Buletinul Asociaiei Balint, vol. xiii., nr. 49, Martie 2011