Enhancing student empathy, engagement, and support: Balint and Level II fieldwork
Level II fieldwork is crucial in occupational therapy education, allowing students to apply theoretical knowledge practically and develop key competencies in client care, assessment, and intervention with supervision (American Occupational Therapy Association, 2018). Although pivotal for professional growth, the demands of Level II fieldwork can also present significant challenges, including high levels of stress and anxiety among students, which may impede their learning and development (Brown et al., 2018).
As an Academic Fieldwork Coordinator (AFWC), I have observed these challenges firsthand and recognize the need for a structured yet flexible support system that resonates effectively with the needs of our students. Motivated by this need, we initiated a project to implement the use of Balint Groups within our program, aiming to enhance student engagement and provide more meaningful support during this critical stage of their professional development.
Balint Groups, initially developed for physicians by Michael Balint in the late 1950s, are designed to enhance therapeutic relationships through facilitated discussions of clinical cases. This approach helps health care professionals reflect on the emotional and psychological aspects of client care, fostering greater empathy and understanding (Lemogne et al, 2020). Although traditionally utilized in medical education, the application of Balint Groups in other health care disciplines has shown promise in supporting practitioners to deal with the complexities of clinical care (Kjeldmand & Holmström, 2008).
This article delves into the potential of Balint Groups as a supportive framework for occupational therapy students, addressing the dual challenges of maintaining community and managing the anxiety associated with Level II fieldwork. By integrating Balint Group principles into OT education, my department colleagues and I propose a model that not only supports the professional development of students but also nurtures their well-being and sense of connection with their peers. Through this approach, Balint Groups can serve as a powerful tool in preparing OT and OTA students to become empathetic, reflective, and effective practitioners.
Traditional Support Mechanisms and Limitations
Traditional support during Level II fieldwork at the MGH Institute of Health Professions (IHP) included mentoring by fieldwork educators, periodic check-ins by the AFWC, and drop-in group sessions hosted by the university-based fieldwork team, though these were often poorly attended.
Rationale for Choosing Balint Groups
The increased anxiety reported among students during fieldwork can be attributed to several factors. The geographic dispersal of students across various placement sites limits their ability to maintain regular contact with their peers and academic mentors, leading to a sense of isolation (Naylor, 2022). This disconnection from their established support networks at their educational institutions may exacerbate feelings of stress and anxiety, particularly when faced with the intensive demands of fieldwork. Additionally, the transition from a structured academic environment to diverse fieldwork settings can be disorienting, heightening students’ apprehensions about their performance and professional growth (Brown et al., 2018).
Given these challenges, there is a clear need for a more effective support mechanism that addresses both the emotional and professional needs of OT students during fieldwork. Balint Groups, with their emphasis on reflective practice and emotional processing, present a promising alternative. The core objective of Balint Groups is to facilitate discussions that explore interpersonal dynamics, thereby enhancing practitioners’ empathy and self-awareness (Lemogne et al., 2020). In the context of occupational therapy, such discussions are vital as they enable students to process their experiences and feelings in a structured yet empathetic environment, promoting a deeper understanding of interactions and personal reactions with clients, fieldwork educators, or other members of the interprofessional team (Kjeldmand & Holmström, 2008).
The adaptation of Balint Groups for OT students can potentially mitigate feelings of isolation by providing a consistent, supportive community irrespective of students’ geographical locations. This structured yet flexible approach can significantly enhance student engagement, reduce anxiety, and improve the overall fieldwork experience—making it a strategic choice for supporting students during this critical phase of their professional education.
Balint Groups Initial Implementation
In the summer of 2023, the initial implementation of Balint Groups for OT students during their Level II fieldwork was structured to accommodate the geographic and temporal diversity of student placements. The student cohort was divided into four groups, each with no more than 11 members, organized primarily by their geographic location (East Coast versus West Coast) and corresponding fieldwork dates. To facilitate these groups, sessions were conducted via Zoom, which allowed for flexible interaction regardless of the physical location of the participants. Attendance was mandatory and students were required to attend a total of four group sessions, two sessions during each of their two Level II placements.
Each session commenced with two of the four groups together for an introductory review of the Balint process and group expectations. This introductory segment was crucial in setting the tone and ensuring all participants were clear on the goals and methods for the session. Following this, the groups split into two concurrent sessions in different breakout rooms in Zoom. These sessions were co-led by members of the IHP fieldwork team, who were most familiar to the students, with other IHP faculty outside of the OT department who had completed Balint intensive training serving as guest facilitators.
Challenges Encountered
Despite careful planning, several challenges emerged with the initial group dynamics and facilitation styles. One of the primary issues was engaging students effectively; sessions often experienced long periods of silence as students hesitated to present a case. Some facilitators were more comfortable than others with sitting in this silence. This reluctance to speak up might have stemmed from uncertainty about the process, discomfort with exposing personal reflections, or a lack of exposure to experiences that could leave students feeling unsettled. Additionally, when cases were presented, there was a noticeable difficulty among students in taking the perspective of anyone other than the OT student presenting the case. This tunnel vision frequently sidetracked the group’s focus toward problem-solving instead of exploring the emotional and relational aspects of the cases presented—which are central to the Balint method. In addition to these challenges, using Zoom as a platform allowed students across the country to gather, but brought its own set of difficulties. There are various reasons why students might be less likely to contribute to a conversation via Zoom than in an in-person classroom environment. These include reduced non-verbal cues, such as eye contact, body language, and facial expressions—which facilitate communication and engagement. It can also be difficult to gauge when it is an appropriate time to speak, especially if multiple people talk simultaneously. The perceived lower level of accountability in a virtual setting might lead students to feel less pressure to participate actively. Lastly, the home environment or other remote settings often come with more distractions than a controlled in-person setting, and students may be tempted to multitask, reducing their focus and willingness to engage in discussions.
Observational Insights
It became clear that further training or preparatory sessions might be necessary to help students become more comfortable with the format and objectives of the Balint process. Additionally, the facilitation style needed to be more proactive in encouraging participation and guiding the discussions to ensure they remained focused on personal and emotional reflections rather than clinical problem-solving.
The initial implementation phase, despite its challenges, provided valuable insights into how Balint Groups could be tailored to better support OT students during their fieldwork. The lessons learned, including the need for additional training and preparatory sessions for students, adjustments to facilitation styles and facilitators, addressing challenges with student engagement, overcoming difficulties in perspective-taking, and tackling challenges associated with the Zoom platform were crucial for refining the approach and enhancing the effectiveness of support sessions in subsequent meetings.
Restructuring Balint Groups to Increase Engagement
Restructuring Balint Groups for OT students involved several key changes aimed at better aligning the sessions with the needs of the students. Introducing new facilitation techniques was pivotal for reshaping the dynamics of the Balint Groups. The previous format, which involved multiple guest facilitators who were not familiar to the students, was revised. Instead, we consolidated the number of groups from four to two, increasing the size of each group but ensuring that the facilitators were familiar members of the fieldwork team. This change appeared to foster a more trusting and open environment, as students felt more comfortable sharing their experiences with familiar faces.
Additionally, we implemented a structured approach to discussions, scaffolding the therapeutic conversation. This technique involved identifying the stakeholders in the case discussions and structuring the feedback around these stakeholders, one at a time. This methodical approach helped focus the discussion and prevented the conversation from becoming disjointed or overly broad, which had previously led to significant periods of silence and disengagement.
Impact of Changes on Group Dynamics and Student Participation
The impact of these changes on group dynamics and student participation was profound. By providing familiar facilitators and more structured discussion frameworks, students demonstrated increased willingness to engage in the sessions. The focused discussions on specific stakeholders allowed each student to contribute more meaningfully, reducing anxiety around speaking up and enhancing the overall quality of the reflective process.
These adaptations underscored the importance of flexibility and responsiveness in the design and implementation of support structures like Balint Groups in educational settings. Our experience provides valuable insights into how such groups can be effectively used to support students in high-pressure, professional training environments.
Unexpected Results
The Balint group sessions introduced unexpected benefits, one of which was the valuable opportunity for students and fieldwork team members to see each other face to face. This visual connection appeared to enhance students’ comfort and willingness to seek additional support. Recognizing this, we deliberately allocated fifteen minutes at the end of each session to touch base with students in individual breakout rooms as needed. This practice not only facilitated immediate personal interactions but also led to follow-up meetings where students received further support and a compassionate listening ear. These interactions underscored the importance of visibility and personal attention in educational settings, contributing to a more supportive and responsive learning environment.
Next Steps
The next steps for our program involve formally gathering data from students about their experiences in Balint groups after they complete their two Level II fieldwork placements. Initially, we planned to collect this feedback following the summer and fall 2023 sessions. However, due to significant changes and refinements in the structure of the groups, we felt that the approach had not been perfected until the end of the cycle. After modifying the sessions, along with implementing additional training and practice opportunities within students’ final semester of didactic coursework, we are now better prepared. Consequently, we aim to begin collecting student data at the end of the 2024 fieldwork placements. This systematic feedback will help us evaluate the efficacy of the Balint Groups and further tailor our approach to meet the evolving needs of our students.
Discussion
Implementing Balint Groups highlighted the critical role of community and support systems in clinical education. The sense of isolation commonly experienced by students in dispersed clinical placements can significantly impact their learning and emotional well-being. Balint Groups provide a structured yet flexible platform for building community among students by fostering a shared space for emotional and professional support. It reaffirms the notion that the foundation of effective clinical education lies not only in the acquisition of technical skills but also in the cultivation of a supportive educational community that encourages reflective practice and emotional growth (Geller, 2013).
References
American Occupational Therapy Association. (2018). Fieldwork Level II and occupational therapy students. American Journal of Occupational Therapy, 72(Suppl. 2), 7212410020. https://doi.org/10.5014/ajot.2018.72S205
Brown, T., Etherington, J., & Williams, B. (2017). Emotional intelligence and personality traits as predictors of undergraduate occupational therapy students’ teamwork skills: A cross-sectional study. British Journal of Occupational Therapy, 80, 432–439. https://doi.org/10.1177/0308022617691539
Geller, S. M. (2013). Therapeutic presence as a foundation for relational depth. In R. Knox, D. Murphy, S. Wiggins, & M. Cooper (Eds.), Relational depth: New perspectives and developments (pp. 175–184). Palgrave Macmillan/Springer Nature. https://doi.org/10.1007/978-1-137-29831-7_14
Kjeldmand, D., & Holmström, I. (2008). Balint groups as a means to increase job satisfaction and prevent burnout among general practitioners. Annals of Family Medicine, 6, 138–145. https://doi.org/10.1370/afm.813
Lemogne, C., Buffel du Vaure, C., Hoertel, N., Catu-Pinault, A., Limosin, F., Ghasarossian, C., … Jaury, P. (2020). Balint groups and narrative medicine compared to a control condition in promoting students’ empathy. BMC Medical Education, 20, 1–8. https://doi.org/10.1186/s12909-020-02316-w
Naylor, R. (2022). Key factors influencing psychological distress in university students: the effects of tertiary entrance scores. Studies in Higher Education, 47, 630–642. https://doi.org/10.1080/03075079.2020.1776245
Tara Mansour, OTD, MS, OTR, serves as an Assistant Professor and Academic Fieldwork Coordinator at the MGH Institute of Health Professions, where she champions progressive educational methodologies and interdisciplinary collaboration in occupational therapy and clinical education. With more than two decades of diverse clinical experience, Dr. Mansour has transitioned into academia, bringing a wealth of practical knowledge to her teaching and administrative roles. She is currently a PhD candidate in Health Professions Education, underscoring her dedication to elevating OT education through innovative curricular design and advanced pedagogical strategies. Her scholarly work spans a variety of innovative approaches to optimize fieldwork education and enhance learning efficiency, as showcased in her national presentations, including those at AOTA INSPIRE and the Association of Schools Advancing Health Professions (ASAHP).