Introduction
Balint groups, a structured forum for medical professionals to explore the emotional and psychological aspects of the doctor-patient relationship, have been a feature in some countries in undergraduate medical training as well as higher specialist training (HST) programs (e.g., psychiatry, family medicine, and pediatrics) (Salinsky Reference Salinsky2002).
Traditionally these have been for uniprofessional groups. These small groups meet regularly to reflect on the impact of the doctor- patient relationship. Named after Hungarian psychoanalyst Michael Balint, these groups offer a unique space for reflective practice, aiming to deepen empathy, prevent burnout, and improve diagnostic and therapeutic skills by focusing on the impact of the therapeutic relationship or the concept of “drug doctor” – the clinicians themselves as the main drug (Balint Reference Balint1957; Douglas and Feeney Reference Douglas and Feeney2017).
Typically, these groups comprise a recurrent small group (six to twelve participants) who meet regularly in a confidential setting to share clinical dilemmas, struggles, reflections, emotional complexities, and indeed successes or failures. They are led by a leader and often a co-leader, who are trained facilitators (Douglas and Feeney Reference Douglas and Feeney2017; Omer and McCarthy Reference Omer and Mccarthy2010).
Participation in Balint groups has considerable number of advantages for medical students and specialist trainees including increased empathy and patient-centeredness, reduced burnout and isolation, elevated job satisfaction, improved management of transference & countertransference, and better insight into “blind spots” of patient-doctor relationships (Gong et al. Reference Gong, Zhang, Lu, Wu and Yang2024; McKensey and Sullivan Reference McKensey and Sullivan2016).
The implementation of Balint groups, particularly whether participation is mandatory or voluntary, varies significantly across different countries, particularly for medical students and psychiatry trainees (Salinsky Reference Salinsky2002). Similarly, the training of leaders can be variable in different settings. This article will compare the approaches taken in the United Kingdom (UK), the United States (USA), Ireland, Canada, and Germany, highlighting the rationales and implications of each model. Moreover, considering the crucial role of Balint leaders/facilitators in optimizing the group dynamics and efficacy of reflective practice, we will compare the accreditation pathways to become a Balint leader in the above-mentioned countries.
United Kingdom (UK): mixed and evolving models
In the UK, the approach to Balint groups, or similar reflective practice groups, is mixed and often determined by local training program directors and specific institutional requirements, rather than a uniform national mandate. For medical students, while curricula emphasize reflective practice and professionalism, formal Balint groups are rarely a mandatory component. Students are often introduced to reflective learning through various means, such as portfolio work, critical incident reports, and small-group discussions facilitated by communication skills or ethics modules. For Psychiatry trainees (Core and Higher), the picture is different and more structured. The Royal College of Psychiatrists‘ curriculum strongly emphasizes psychotherapy training and reflective practice (Psyhciatrists 2022).
The General Medical Council (GMC) requires every core psychiatry training scheme to have a Medical Psychotherapy Tutor responsible for overseeing the establishment and running of the core trainee Balint or case-based discussion group (Psychiatrists 2017, 2022). A minimum of one year attendance at a Case Based Discussion (Balint) Group during Core Psychiatry Training (CT1-3) is recommended. This usually involves a weekly group meeting for a minimum of an hour, though equivalent arrangements like a two-hour fortnightly meeting may be possible depending on the local training scheme. Trainees are often encouraged to continue attending beyond the minimum requirements in CT2 and CT3, depending on local availability and resources. Satisfactory completion of this requirement is necessary to progress in the Annual Review of Competence Progression (ARCP) (Psychiatrists 2017, 2022) (Table 1).
Comparison of Balint groups’ integration in medical & higher specialist training across 5 countries
Accreditation requirements for Balint leaders
To achieve accreditation as a Balint group leader under the Balint Society (UK), an applicant must complete a comprehensive pathway involving membership, leadership, and supervision. Requirements include attending at least 24 sessions as a regular member of an accredited Balint group – potentially reduced to 12 for those with formal psychoanalytic or psychodynamic training – and leading a minimum of 24 groups, ideally with an accredited co-leader (up to eight of these sessions may be medical student groups, provided they are supervised by an accredited Balint professional) (Society 2025c).
Training is further supported by attending at least two Balint Society weekend leadership events or four equivalent days for an immersive experience, alongside completing a minimum of nine individual supervision sessions with an accredited supervisor (who must be different from one‘s co-leader), and six sessions in a Balint Society-funded Leadership Supervision Group. Progress is regularly reviewed against core leader competencies, and the final application requires a portfolio, reflective writing, and supervisor references to be submitted to the Balint Society Accreditation Team for Council approval (Society 2025c) (Table 2).
Comparison of accreditation pathways for Balint leaders across 5 countries
United States (USA): primarily voluntary, with supervision focus
In the USA, the model for Balint group participation is overwhelmingly voluntary for both medical students and psychiatry residents. For medical students, reflective practice is incorporated into professionalism courses, but rarely in the formal Balint group structure. Participation in Balint groups is generally not a core, mandatory curriculum element in most US medical schools. For Psychiatry residents, the approach prioritizes individual supervision and mandatory psychotherapy training, rather than group reflection focused solely on the doctor-patient relationship. While the Accreditation Council for Graduate Medical Education’s (ACGME) requirements for residency training demand supervision and a focus on professionalism, participation in a formal Balint group is usually voluntary and considered an elective or supplementary learning experience (Society 2025b). Studies of family medicine residency programs (which often utilize Balint groups more frequently than psychiatry) show that while the number of programs offering them is high, the decision to make them mandatory is often a local one, and nationally, the approach leans toward voluntary or mixed attendance (Diaz et al. Reference Diaz, Chessman, Johnson, Brock and Gavin2015) (Table 1).
Accreditation requirements for Balint leaders
To achieve accreditation through the American Balint Society (ABS), candidates must complete a rigorous two-year process that includes attending a Leadership Training Intensive, leading or co-leading groups regularly for at least two years and receiving a minimum of 12 supervision sessions based on video or audio recordings of their work. The ABS also offers the year-long Balint Group Leader Education Fellowship (BGLEF) which can substitute for up to one-third of these supervision sessions. Candidates must attend at least three Balint Intensive training sessions as well, concluding with a Credentialing Intensive where they are formally evaluated while co-leading a group with faculty (Society 2025a) (Table 2).
Ireland: explicit mandatory requirements
Ireland‘s medical education and training framework places a significant emphasis on reflective practice and professional development. For medical students, formal Balint groups are not typically mandatory. Reflective learning is achieved through various clinical tutorials and portfolio assignments. For Psychiatry trainees, the College of Psychiatrists of Ireland has made participation in a reflective practice group, specifically often taking the form of Balint groups, a mandatory requirement (Ireland 2025). Trainees need to attend mandatory 64 Balint sessions [40 sessions for basic specialist training (BST) and 24 sessions for HST] as part of their psychotherapy training component (Ireland 2025). This mandatory group work ensures trainees routinely process the psychological impact of their clinical work, which is seen as essential for developing self-reflective and psychotherapeutic clinical practice (Table 1).
Of note, the requirements for being an accredited Balint leader are the same as in the UK and largely managed by The Balint Society (UK) (Society 2025c) (Table 2).
Canada: localized mandates and strong reflective component
In Canada, medical education and postgraduate training, governed by the Canadian Medical Education Directions for Specialists (CanMEDS) which is a competency-based framework developed by the Royal College of Physicians and Surgeons of Canada, strongly emphasizes professionalism and communicator, necessitating reflective practice (Canada 2025). For medical students, reflective components are required, but mandatory Balint groups are rare. For Psychiatry residents, the specific approach is often localized and determined by the individual university program‘s structure. However, many Canadian psychiatry residency programs mandate participation in a Balint-style group or an equivalent psychodynamic reflective seminar for a portion of the training, particularly in the junior years [often a weekly or fortnightly commitment for at least one academic year during the early residency (PGY-1/PGY-2) stage] (Manning Reference Manning2022; Nalan and Manning Reference Nalan and Manning2022) (Table 1).
Within the Department of Pediatrics at the University of Toronto, Balint groups have been integrated into pediatric residency training for the past eight years which highlights the importance of reflective practice in other higher specialist training programs rather than psychiatry training only (Toronto 2026).
They are a core curricular component across postgraduate years (PGY) 1–3 and represent one of several structured opportunities for trainees to share and explore the challenging emotional and relational aspects of their work within a confidential and psychologically safe space. Small groups meet six times per academic year and are facilitated by faculty physicians who have received formal training through the American Balint Society (Toronto 2026). Participation has also extended to fellows in select programs and, more recently, to faculty members and some established interprofessional teams. Participant feedback has been consistently and overwhelmingly positive, with demand for Balint groups exceeding current capacity. In addition, the development of faculty facilitation skills has had downstream benefits for the department, including strengthening formal peer-support structures and enhancing the quality of clinical debriefing across programs.
The accreditation requirements for Balint leaders in Canada are similar to the USA and mainly supervised by the American Balint Society (Canada 2025) (Table 2).
Germany: central to psychotherapy training and often mandatory
Germany has one of the most structured systems regarding Balint groups, particularly for physicians pursuing specialization that involves psychotherapy. For medical students, mandatory participation in Balint groups is not standard. For Psychiatry trainees and for those specializing in General Practice (Family Medicine) or Psychosomatic Medicine, Balint group participation is often mandatory and directly linked to their certification. The mandatory requirements for psychiatry trainees in Germany are primarily governed by the Weiterbildungsordnung (WBO), or Continuing Medical Education Regulations, set by the German Medical Association (Bundesärztekammer (BÄK)) which mandate attending a minimum number of 15 Balint sessions (90-minute session which is equivalent to one double session) during the 5-year residency program (Weiterbildung) for Psychiatry and Psychotherapy (eV), 2025). This institutionalization makes Balint groups a critical, mandatory gatekeeping element for certain professional certifications, viewing it as a non-negotiable part of developing the reflective skills necessary for psychotherapeutically oriented work (Table 1).
Accreditation requirements for Balint leaders
To initiate an accreditation pathway through the Deutsche Balint-Gesellschaft (DBG), candidates must possess three years of professional experience after completing training as a specialist in psychosomatic medicine and psychotherapy or specialist in psychiatry and psychotherapy (Society 2024). To enrol in the Balint group leader training program, candidates must have previously attended a minimum of 35 double-sessions as a participant in a Balint group which should be followed by an additional 70 double-sessions led by DBG-recognized leaders (Society 2024). Furthermore, candidates must complete a minimum of six dedicated group leader seminars with trainers recognized by the DBG, accumulating at least 30 double hours in total. At least four of these leadership seminars must be completed during official DBG conferences, and seminar leaders must certify that the candidate successfully led two Balint groups as part of these seminars (this final requirement is in addition to 105 double-sessions of general Balint group participation) (Society 2024) (Table 2).
Discussion
The comparison reveals a spectrum of approaches. The UK, Ireland, Canada, and Germany lean toward making some form of Balint-style reflective group mandatory for psychiatry trainees, recognizing it as a fundamental professional competency akin to learning diagnostic skills. Ireland, Germany and the UK have particularly explicit session requirements linked to training progression or certification. Ireland stands out by making Balint group attendance a mandatory, credit-bearing component of basic specialist training in psychiatry. Conversely, the USA largely maintains a voluntary model, prioritizing individual supervision as the main reflective tool (Table 1).
The trend toward mandatory exposure to reflective group work, particularly in psychiatry, reflects a growing global recognition that a clinician‘s emotional awareness of their own reactions which is basically the essence of the Balint method is not an optional extra but a crucial component of safe and effective patient care. The challenge for these mandatory programs is to cultivate an environment of psychological safety and skilled facilitation that can transcend the initial resistance often associated with compulsory self-disclosure, thus preserving the true therapeutic and educational potential of the Balint model (Douglas and Feeney Reference Douglas and Feeney2017). There is much debate in professional circles about the nature of reflection when it is mandatory. The Centre for the Advancement of Interprofessional Education (CAIPE) is a global leader in promoting interprofessional education (IPE) and collaborative practice (CP) within health and social care when professionals come together to learn “for, with and about each other” (Barr et al. Reference Barr, Gray, Helme, Low and Reeves2016). Balint groups can be a good forum for IPE because when people explore the complexities of cases, inevitably professional similarities and differences are explored; ergo shared perspectives and alternative perspectives can be generated. By incorporation of the Balint concept into IPE, people can share guilt/shame but also success/resilience gained through hardships in a safe environment (Wilk Reference Wilk2025).
The accreditation pathways to become a Balint group leader across the UK, USA, Ireland, Canada, and Germany share a core philosophy but differ in specific hour requirements and structural integration into national medical/psychotherapy training. All systems are generally affiliated with the International Balint Federation (IBF) and emphasize experiential learning through participation, co-leadership, and supervision. European accreditation pathways mainly follow the mandatory requirements of The Balint Society (UK) and The German Balint Society (DBG) which consist of highly specific, rigorous hour requirements compared to the more flexible, portfolio-based “sufficient experience” models found in the USA and Canada (Table 2).
Many questions remain. Is consistency important to trainers, to training bodies, and to trainees? What are the elements of good practice in Balint groups that might be universal? Across diverse national Balint societies where clinicians experience various training and clinical systems, “sufficient experience” might be interpreted differently, hence having a shared language and shared understanding of what sorts of experiences trainers have might be important. Some people may argue that the International Balint Federation (IBF) could take the initiative to develop some pragmatic solutions. This might include good practice and training recommendations including defining a global minimum number of hours/sessions for member participation and co-leadership, developing an IBF-wide checklist of essential leadership skills to enhance objectivity in accreditation, encouraging cross-accreditation agreements and the mutual recognition of training hours accumulated across different affiliated national societies, and clarifying the distinct roles of co-leaders, individual supervisors, and group peer supervisors at an international level to eliminate ambiguity and ensure candidates receive a full range of mentorship. This might be different for different professional groups and must be supportive and not prescriptive or restrictive overall. Economic and time barriers, inclusion, and diversity are critical as well and rarely considered.
In terms of curriculum harmonization for psychiatry training across Europe, formalizing Balint Groups within the UEMS (European Union of Medical Specialists) psychiatry curriculum might be beneficial (e.g., standardizing psychotherapy training to include mandatory Balint participation) (Tanyeri Kayahan et al. Reference Tanyeri Kayahan, Dincer, Norgaard Kjaer and Gargot2025).
The scarcity of robust evidence-based research studies on Balint groups indicates that future research needs to move beyond descriptive studies to high-quality, integrated, multicenter randomized controlled trials, which can be supervised by IBF or UEMS to rigorously evaluate the impact of these groups on empathy, teamwork, and burnout prevention.
Funding statement
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
The authors declare none.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. The authors assert that the local ethics committee has determined that ethical approval for publication of this perspective piece was not required by their local Ethics Committee.
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