History and Description (1)
Balint psychodrama stems from the partnership of two practices : the classic Balint group on the one hand and psychoanalytic psychodrama on the other. Following work begun with Guy Bruere-Dawson, Anne Cain, a psychoanalyst and psychodramatist from Marseille, began to apply the practice of psychodrama in 1973 in the Paris Balint group of Charles Brisset. He had requested her help in breaking out of a stagnant situation. This desire for “a refreshing impulse from a technique that puts things back in movement, revivifying situations in the sense of mobilising affects on the verge of dozing off” (Cain, 1994) inaugurated the method. The same desire will be found very often in those stretches where a classic Balint group approaches Balint psychodrama, but also in groups where there is particularly strong pressure toward the didactic on the leaders.
The passage from one form to the other is summarized by the leader’s, “Don’t tell it, show it !”, a formula that often punctuates the session and engages the practitioner in retrieving, in action, moments in the relationship with the patient presented by one of the participants at the start of the session.
Balint psychodrama is distinct from role-playing, a technique stemming from the work of Moreno (1892-1974) who was the inventor of psychodrama. In psychodrama real situations are played out, whereas in role-playing scenarios are specified in advance or constructed with the help of all participants and what is produced represents a general situation.
The reintegrations that accompany the reconstitution of a real professional scene, though the exactness of it may not be known, allow the reflective work on the practitioner and his countertransference called for by Balint, to occur within a new dynamic. While Balint psychodrama is not an educational activity, it allows practitioners “to learn more efficiently the meaning” of professional situations that present them with problems. This happens when they are moved to share such situations, “more nearly reliving their acts.” As with psychoanalytic psychodrama the point is not to provide a secondary rationale for past experiences, nor to acquire control, much less cathartic discharge, but to bring to consciousness unconscious aspects heretofore disavowed and with the group’s associations and the leader’s interventions, to begin their elaboration.
Ann Cain (1989, 1994) proposed naming the four phases of a traditionally hour and a half session “movements.” (2)
(1) The complete version : “Le psychodrame Balint” was published in the “Revue suisse de médecine psychosomatique et psychosomatique” 1995- no 1, 17-22. Dr Jean-Pierre Bachmann, psychiatrist and psychoanalyst (Swiss Psychoanalytical Society), is a Balint leader of the Association Internationale du Psychodrame Balint (Paris) and of the Swiss Balint Society. He works in private practice in Geneva. Translation made by Katherine Knowlton, clinical psychologist (Seattle) and Secretary of the American Balint Society.
(2) Translator’s note : The French is “discours”, which might be rendered many ways, and which is most closely associated to verbal matters, speeches, conversation. The author and translator chose “movements” for its allusion to parts of a single piece of music and for its evocation of motion, celebrating the kinetic component added by Balint psychodrama.
The first movement begins when the group meets in a circle and after some seemingly banal exchanges a case presentation emerges or is prioritised by the leader. The second movement is marked by the placement of the principal players in the enactment space in accordance with the case presentation. In order to discover the real life experience of the moments evoked in that presentation, the leader asks the practitioner to use his body to act them out. This second movement also roughs outs the relations between the presenting practitioner and the setting. During the third movement “the acting allows the subtext to become known” and lets associations lead to further enactments. The fourth movement, an exchange among the protagonists and the leader with all the group, “allows the revelation of that which had been overlooked.” It should be noted that many groups work with two leaders, one of whom takes the role of observer during the session.
Particularly in the course of the last ten years the practice of Balint psychodrama has extended to include many different kinds of practitioners. Until her death in 1994, Anne Cain worked to deepen the method and to widen its application, coordinating both efforts by founding the International Association for Balint Psychodrama, l’Association Internationale du Psychodrame-Balint.
The Technique of Balint Psychodrama
Balint psychodrama has recourse to a certain number of techniques belonging to psychoanalytic psychodrama, except insofar as they may contradict the strict rule of group work in the spirit of Balint : not to intrude on the practitioner beyond the sphere of professional activity or identity.
The layout and the construction of the imaginary setting : Particular and specific attention is given in Balint psychodrama to the description of the physical setting in which the scene to be enacted originally took place : the doctor’s office, hospital room or the patient’s home. Certain elements or characteristics of the setting and its décor lead to vivid memories in the protagonist and are prone, in the course of the enactment, to become revelatory : of the relationship of the practitioner to the space in which she works ; of the distance he establishes with his patient (or indeed with his colleagues) ; of the privacy maintained, or not, in the therapeutic relationship. In this way objects acquire symbolic meaning, becoming foci for condensation or displacement of aspects of the problem being dealt with. Objects may also sometimes enter into the atmosphere of sharing and exchange between the practitioner and the patient.
In the description she gives of her office, Doctor X mentions the presence of a picture of a violin, a picture dear to her which she places facing her patients. The situation she describes is marked with malaise, even irritation, toward her adolescent patient who after some time has presented her with recovered memories that are contradicted by the clinical findings. In the final sequence to be enacted she expresses her irritation in an intervention centered on the relationship between the patient and her father, himself a violinist, and on his disapproval over the patient’s having abandoned her study of the instrument.
The setting, represented by the use of several chairs, quickly acquired an imaginary and symbolic dimension in the course of the acting, and this served to support the associations of all the participants and of the leader.
Doubling and Splits : Psychoanalytic psychodrama has recourse to different forms of splitting or character doubling : a split-off speaker in dialogue with its source character ; a split-off speaker as total or partial mirror to a player ; and a double to the side or behind a player. It is this last technique and practically only this one that is commonly used in Balint psychodrama. The participants in the group, and more rarely the leader, may provide a kind of voiceover to express thoughts and fantasies not only of the practitioner, but also of the patient or other players in the scene. While the use of this doubling technique varies as a function of the situations portrayed and with the degree to which the group work has evolved, it encourages fantasy in the practitioner and in group members and can have a real interpretive function. After the recreation of the remembered scene the leader will ask each participant who has doubled a character to comment on his voiceover. This permits not only explicit explanation of the doubler’s personal understanding of the enacted situation, but also of any actions or movements made in identification with the doubled character.
Role reversal : This is extremely frequent in the course of the enactment in order to retrieve most realistically both the spoken language of the patient and his body language. While this is sometimes hard in practice, or indeed restricting, both for the protagonist and the other players, role reversal becomes a thread in the work of the group that leads to action spontaneously proposed by the protagonist. Changing roles permits the practitioner to see himself in the role of the other, to be confronted by gaps, which for him and all the group may be quite revealing. Particularly telling are the inability to put oneself in the role of such a patient and surfacing of slips of the tongue.
The difficulties tied to these role reversals, often attributed by the participants to their inexperience with the method, may also be a reflection of the dynamic being enacted. Thus, in a recent session the participant chosen to play the role of a patient found herself repeatedly unable to recall or repeat the words of the doctor, as the leader was asking her to do. She was astonished as well that this major difficulty seemed not to be tied to playing a person of another sex. The progress of the session and the sequences enacted demonstrated that since the first meeting with this patient and his family, fifteen years before, the doctor had had to struggle against forceful restriction and control the patient had tried to impose on him. The group member, in an unconscious identification with the doctor, bore direct witness to this problematic dynamic.
The soliloquy : By this device often used at the beginning of a scene, the practitioner is invited to make known the thoughts that were present prior to his meeting with his conversational partner, typically the patient. Soliloquies serve also as transitions between scenes, punctuating the acting at the request of the leaders. They may also be responses to the doublings or voiceovers mentioned earlier, showing acceptance or rejection of the thoughts, affects and fantasies proposed by the other participants. The body and Balint-psychodrama
The reintroduction of the body into the report of the practitioner manifests the originality of Balint-psychodrama, an originality not completely understood until after the fact, but which answered certain concerns of Michael and Enid Balint. According to Michael Sapir (1982), they were persuaded that one of the dangers of
distortion in the Balint method rested in its avoidance of the body’s use in the relationship. Certain things which can be said about the place of the body in this method are in keeping with observations made about the practice of psychoanalytic psychodrama. Mobilising the body has the effect of permitting a lifting of repression, favoring the reemergence of buried motor memory and its accompanying affects (Amar, 1988). In this way psychoanalytic psychodrama restores the importance of the role of affects, all the more so when they may not be entirely amenable to verbal expression (Green, 1984). Words, which are linked to bodily functions, assume the role of liaison between emerging affects and their representations. The bodily involvement of the leader and of the other participants asked to play different parts has the effect of lessening the anxiety inherent in the method over seeing and being seen, and reduces fears of intrusion.
While the mechanics are the same in the two methods, psychoanalytic psychodrama and Balint psychodrama, the intensity of the mobilization of affects is often different : it stays relatively controlled in Balint psychodrama, without mastery becoming the goal, because of the professional character of the approach. Despite the aspect of make believe, the enactment, in its realisation of the relationship, highlights the particular bodily responses of the practitioner - his corporeal countertransference. For example, the avoidance of a look or the hands that never meet in the moment of greeting. A certain form of censorship is at work here, which concerns equally the real-life bodily experience of the practitioner, as well as the phenomena of primary and bodily identification with the patient and his symptoms. A young woman doctor presented her relationship with an older patient suffering from a head tremor. She was very moved by this man, whose body and vitality of spirit contradicted this sign of aging. In the role of her patient she enacted this trembling, and she did not stop it throughout the rest of the scene, whatever her role. The participants in her group insisted on aspects of identification in their colleague with her patient, without ever mentioning her unconscious identification with his symptom.
Vignette I : Resident A is one of a group of young doctors who participate regularly in a Balint psychodrama group. She is bent on presenting her situation, saying right away, addressing the leader, that she hopes for a consultation about the advisability of maintaining medical confidentiality and the limits of that confidentiality. She reports that she is working temporarily in the setting of a jail. She says the work the group has done has made them more attentive to influences that may come from other caregiving disciplines in the way of preconceptions about patients. Pierre X is a young drug addict who came to be detained for the nth time because of petty offences. She had to meet with him for a medical exam and in order to discuss his withdrawal options during an incarceration that would be very brief. When she heard his name and surname pronounced she remembered a former patient, Mrs. X. This very aged lady, presenting with signs of dementia, had a prolonged hospitalisation until her death where Resident A was working. Mrs. X had several times spoken of her only grandson, named Pierre, and expressed to the whole treatment team the importance he held for her. Before meeting Pierre X, resident A asked herself if this could be the cherished grandson. Nothing could be done to settle this question and she thought of the need to respect the confidentiality of the
former patient and not to mention the acquaintance she had with Mrs. X. She reported as well that she had never met Pierre, who had made only three widely spaced visits to his grandmother – a situation which naturally left a gap in her information of a potentially grievous character for Mrs. X. (his addiction and his run- ins with the law).
The leader suggested to Resident A that she remember a scene with Mrs. X in the course of which Pierre was discussed. Resident A chose a participant, Resident B, to play the role of Mrs. X. This scene took place in a dayroom of the hospital. Mrs. X was sitting, a book in hand, reading or pretending to read. In connection with the interest Mrs. X purported to have in recent events, the topic was the very recent and certainly exceptional visit made by Pierre to his grandmother. Frequent role reversals allowed us to grasp how the recollection of Pierre created a transformation in Mrs. X. When Resident A took the role of her patient her face lit up, and she abandoned a certain psychic slowing down to reminisce about the adorable grandchild. Whether playing her own role or that of her patient, Resident A used at times the present tense and at times the past tense in speaking of Pierre, without however, ever becoming aware of it. This scene created a very deep feeling in the participant chosen to play Mrs. X, as well as in the whole group. The intensity of the response of Resident B encouraged the leader to interrupt this scene.
Resident A was surprised and embarrassed by the emotion that this scene had produced. The more moved participants made reference, by allusion and recalling their respect for the rule of this work (not to question the practitioner on matters beyond the professional), to the fact that this situation reminded them of non- professional experiences marked by bereavement. The associations of the group had the quality essentially of feelings of connection, of closeness induced by long accompaniments and the care exercised with patients like Mrs. X.
The second scene enacted was that of the recent meeting with Pierre X. Resident A, after having described him, chose one of the participants to play the role of Pierre. Her colleague, Dr. B, who had played the role of Mrs. X in the preceding scene, accepted the role of the nurse who assisted in this consultation. The scene was set : a medical office in a detention centre. In the course of a soliloquy before meeting Pierre, Resident A asked herself if this next patient was the grandson of Mrs. X. Whatever happened, she told herself, she would not violate the confidentiality that bound her to her former patient.
The nurse introduced the patient. Resident A welcomed him and very quickly and spontaneously replayed a sequence centered on the exchange of looks between herself and Pierre, while taking the place of her patient. Resuming her place she began very quickly to ask Pierre if his grandmother had been hospitalised. The answer given by Pierre led Resident A to tell him that she had been the woman’s doctor and had known her in her last years. This information provoked astonishment filled with pleasure and a lively curiosity from Pierre. Again in the verbal exchanges, time references were marked by shifting from present to past. The consultation finished on the subject of the very strict conditions of withdrawal Pierre would have to submit to during his incarceration. During the whole of the scene the nurse remained silent. The group members were all identified with Resident A, insisting on the important positive effect in their eyes of the liberty she
had taken with the rule she was thinking she’d broken. Resident A did not otherwise display any real discomfort in the face of what she had presented as a transgression. Commentary : The early request to resolve an ethical problem, which could have come out in verbal exchanges marked by generalisation, even rationalisation, was quickly short-circuited by the suggestion to play a scene which didn’t involve Pierre but rather an older memory. At this moment in the meeting neither the leader nor the participants knew clearly whether Resident A had already answered her ethical dilemma, nor whether family ties really existed between Pierre and Mrs. X. The first scene, apparently very banal, was marked by confusion between the present and the past, giving evidence of a reunion with a cherished and lost object. Not only the presenter but also the rest of the group experienced feelings linked to bereavement with unexpected intensity. The leader hoped with his intervention to control the group’s regression, but also to assure himself of the group’s pursuing work that did not encroach on the private lives of the members, all the while having them associate to real life. In the face of the uncertainty about an eventual violation of confidentiality by Resident A, group members responded to this possibility by giving nothing but suggested responses, while the most intense reactions were linked to their personal life and not their professional experiences. They also watched themselves closely in respect to this rule, especially in the moments when they were all playing on “a very narrow crest” (Montgrain, 1993) in terms of finding a way to explain a countertransference without involving themselves in the personal life of the practitioner.
At the point of the second scene Resident A showed how the encounter with Pierre reconnected her with her relationship to Mrs. X. She found it again within herself in an identical look that erased time, separation and death. In taking the role of Pierre she had the same intense look that she had had previously playing the role of Madame X. The temporary muting of her watchful questioning about maintaining confidentiality seemed to be linked to the effect of an illusion shared by Pierre. Each retrieved through the other an object of emotional investment, the loss of which was partially and temporarily annulled. It was this aspect of the relationship which the leader pointed out. Resident A thought that this whole recent incarnation of Pierre was not unfamiliar with her relationship to Mrs. X. It was the other members of the group, in particular two participants who, through identification, experienced most intensely the affects of bereavement, who connected Resident A and Pierre.
The group, the place of the leader, the role of the participants
The preceding vignette testifies to the importance that the group can take in the elaboration of a situation and in the phenomena that occur during a session. While Anne Cain was always very attentive to the reaction of the group and in particular to the transference relationship of the members of a group, she nonetheless always refused to see the group in Balint psychodrama as a whole, made of projections and the subjective reorganisations of the participants. For her “the group as a unit is constituted by so many individual remarks to each person and it is from this multiplicity of remarks that the exchange is born.” (1994, p.31) In the work of the group “the enacted scene is the fertile moment to the extent to which all the participants identify with each other in a movement which combines as well the transference dynamic.” This conception of the group is quite far from that developed
by Gosling and Turquet (1982) in applying the ideas of Bion and group dynamics to Balint, or from the ideas of Anzieu (1982) and his school. Cain’s interest focused “solely on the individual in the group and not on the group itself” had obvious repercussions for the technique used to lead scene enactments during the session and on her conception of the place of the leader. The leader’s interventions and interpretations, such as she recommended, are addressed to the presenter and never to the group and must, of course, be offered prudently.
While pursuing this approach it nonetheless seems to us that allowing attention to range to the group’s dynamics, and the understanding of this by the leader and the observer, are complementary. This awareness by the leader will influence him in the choice of scenes he suggests for enactment, in the direction of the acting itself, without necessarily spilling out to group interpretations.
The richness of group work, even in concentrating on the presenter’s case, depends on the playful and phantasmal contributions of all the participants, on their capacity to identify, indeed to regress. We will illustrate this last point with the following vignette.
Vignette 2 :
A group of public health nurses meet regularly. Their clinical activities with babies and families, the work difficulties they have experienced, and their questions around matters of professional identity have pulled them together for many years. The babies described often live in families in great psychological distress. They are also the objects of projections from their parents, but, sometimes as well from the practitioners. The introduction of Balint psychodrama has allowed these babies to be not just the subjects of a discussion, but also to be represented in the enactments of treatment scenes. After enactments the participants who embody them customarily begin to describe the babies’ affects, their muscle tone. They talk about their sensory perceptions of the surrounding world, of a world perhaps still little differentiated. The talk of the adults around them, who loom over them, often has no precise meaning. The qualities of their perceptions (their intensity and emotional tone), the phenomena of distance and proximity, are in the foreground of these reports.
The speech of the group’s infant, that is to say the adult playing the part of the real life infant in a preverbal state in the psychodramatic sequence, does not recapture the projective representations of which he is so frequently the object. The infant’s speech does not deny nor contradict these projections. It is another message, a counterpoint otherwise unattended, capable of provoking important modifications in the meanings the group (and the leader) make out of the situation.
Isabelle, a young nurse, presents to the group, hoping to understand why she was the object of a massive rejection on the part of a father, for whom she also cared, who accused her of having destabilised his wife Francoise following their two meetings. Francoise has a baby of ten days. She is anxious, depressed, at a loss with her son. She feels herself to be incapable of exclusively breastfeeding him, and complains of his crying continuously. She weighs him at the end of every feeding session and again after the food supplement given by bottle. She is in tears at the time of the nurse’s visit to her home, which is reenacted in the first scene of the session. The baby sleeps at the time of this visit. Despite the recognition of the
depressed state of this mother and the nature of the maternal anxiety displaced onto the subject of feeding, the nurse proposes the mother come to the consulting office, “to weigh him, to measure him,” she says. The first scene stops with these words. Second scene : the feeding consultation, the next day. The accent is placed on feeding and on weight. Francoise’s mother accompanies her daughter and her grandson. A nurse colleague weighs the baby. When he is undressed Isabelle approaches the mother and baby. She tries to mask her visible reaction at the sight of the baby : Daniel is frighteningly thin. Painfully, in a soliloquy, she says that he is “scrawny, a baby from the third world on the television.” The consultation continues in a heavy atmosphere ; everyone seems to be on guard. The grandmother expresses her disapproval of the methods chosen by her daughter to feed her baby. Isabelle writes in the health chart that it is necessary to follow the type of diet prescribed by the pediatrician.
The nurse who has played Daniel, the baby, astonishes several participants when she says : “I cry when I’m hungry, but I’m doing okay.” Isabelle herself is not astonished. “It’s true. She’s right. This baby is doing okay. He has low weight, but he has regained his natal weight. He gains weight regularly. The problem is not there.” In effect, the problem was not there and the group could pursue its work of elaborating where it might be.
Such frequent sequences, in contrast, often permit the group to disengage from its projections on the baby, projections that agree with those of the parents, through their identificatory impulses, or those of the practitioners themselves. This is all the more important in that the intensity and the quality of these projections will play a determining role in the physical and mental health of the infant and their maintenance. The speech of the baby to the group regularly has the effect of establishing a new emotional direction, often overlooked, in the work of the group. Conclusion
Balint psychodrama, like all enterprises which raise questions about the self, arouses a certain number of resistances, all the more because it involves the practitioner in his countertransference, in his physical and emotional experience. While its usefulness and its interest are more and more recognised, at least by a large part of the participants in groups, the method must remain a subject of research, both for its depth of theory and in the application of its clinical methods in working with groups. It is without a doubt this which will allow it to avoid some of the pitfalls encountered by Balint groups, of which it is an extension.
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