Online Balint groups in healthcare workers caring for the COVID-19 patients in Iran.

In December 2019 a pneumonia outbreak by the novel coronavirus, SARS-CoV-2, occurred in Wuhan City, China (Riou and Althaus, 2020). The disease was named COVID-19, a new respiratory disease that is spreading widely throughout the world (Sohrabi et al., 2020).

As of March 1st 2020, Iran has reported 987 COVID-19 cases, including 54 associated deaths which are increasing day by day (Zhuang et al., 2020). Healthcare workers including physicians and nurses are overwhelmed and show signs of psychological distress (Chen et al., 2020). The mental health of medical staff needs special attention. We believe that in addition to physical protection during this pandemic, Balint groups help healthcare workers to better cope with psychosocial stressors in a supporting and accepting group atmosphere for the purpose of improving participants' insight to their experience and group learning of a more skillful management of doctor-patient relationships (Haude, 2020). Attending a Balint group in person would be difficult during these times due to social distancing and high infection rates. Instead members would prefer attending Balint groups online.

Participants were recruited via message invitations on Telegram and Instagram and up to six groups were formed. Each group had 8 to 12 participants. In each group, participants convened for 1 hour per session, 2-3 times a week via Skype for 6-8 sessions.

Typically in a Balint group one of the participant's volunteers at the beginning of each session to talk about a patient whom s/he has been struggling with lately. The problem may be that the patient has been emotionally disturbing, just difficult to understand, or the doctor has difficulty engaging in treatment. The group listens to the story without interrupting. Others are welcome to ask questions for further clarification when the presenter is finished (e.g.: how old is the patient?).then the leader asks the presenter to ‘sit back’ i.e. to push her/his chair back a little (in Skype groups just turn off the microphone) and remain silent for the next 15-20 minutes (Otten, 2017). the leader invites the group to respond to what they have heard. Responses take various forms. The members take a reflective approach and as a result there may be more questions, advice, emotional reactions induced by the patient's story and speculations about what else might be going on. The group leader will gently discourage too much interrogation of the presenter, as the aim is to get the group members themselves to work on the case. After 15-20 minutes the presenter comes back to the group and can choose to talk about her/his feelings and thoughts, if s/he wants. The group members, including the presenter, can continue processing till the end of the session, in case there is extra time left (Otten, 2017).

The leader of the group is Mansoureh Kiani Dehkordi, psychiatrist, enrolled in psychotherapy fellowship at Tehran University of Medical Science, translator of Balint groups: Theory and Practice leading Balint groups under Dr. Shahin Sakhi's supervision, psychiatrist and consultant therapist, and Najmeh Shahini, Assistant Professor of psychiatry as a co-leader with the assistance of two psychologist co-leaders, Mohammad Azizpoor, and Shakiba Gholamzad, who attend the groups most often.

Online Balint groups were formed because of an emergent situation. We had no other choice to form Balint groups other than doing it online. This unique evolutionary experience, which is showing an effective outcome deserves to be studied for its benefits and possible limitations.

We designed a study to evaluate the impact of online Balint groups on healthcare workers caring for the COVID-19 patients. Below, we report the results of a mixed-methods approach, including a pre-post with Corona Disease Anxiety Scale (CDAS) and Connor–Davidson Resilience Scale (CD-RISC) questionnaire controlled trial and thematic analysis of qualitative data.

The results of the pilot study in 10 healthcare workers (mean age 34.70±6.07) show that the mean CDAS score before the group work sesssions was 35.80±5.09 and post study was 9.7±2.75. These changes were statistically significant (p value ≤0.001). Also, the mean CD-RISC scores before and after the group work sesssions were, respectively, 22.80±8.51 and 75.60±6.63. These changes were also statistically significant (p value ≤0.001). Table 1 . Also the results of Wilcoxon test showed a significant difference between pretest and posttest for CDAS and CD-RISC scales p value: 0.005

Table 1

mean ± SD of variable

P value	Post-test	Pre-test
≤0.001	9.7 ± 2.75	35.80 ± 5.09	CDAS
≤0.001	75.60 ± 6.63	22.80 ± 8.51	CD-RISC

Members of the other 5 groups have expressed satisfaction and willingness to participate in future groups and have been promoting Balint group work among their colleagues. The satisfactory result of online Balint groups has motivated us to continue this work and to further research its efficacy, unique benefits and possible limitations.

Therefore, we are continuing to hold Balint group sessions for all healthcare groups (physician, nurses, paramedics, psychologists, etc.) and the results of the studies will be reported.

It is our hope that, through expanding our online Balint groups for health care workers, we will be able to prevent burnout and related physical and psychological consequences.

Declaration of Competing Interest

All authors declared there was no conflict of interest