Chapter8and9

Chapter 8: The Selection of Patients

The Theory and Practice of Group Psychotherapy

Irvin Yalom, Ph.D.

Who Wants To Be A Millionaire:

For $1,000

How important is selection of patients for a group?

Why?


For $5,000

Therefore, is it possible that the process of member selection can

lead to the failure of a group? Explain.


For $10,000

So, should any patient be sent to group?

For $20,000How effective is group therapy?


For $40,000

How do group clinicians select their patients?

The Selection of Patients

“The material … has disturbingly disjunctive nature”

Central organizing principle – consider when the punishments or disadvantages of group membership outweigh the rewards or the anticipated rewards.

What the patient must pay and his/her influence on the group.

Patient should also play a role in selection Provide info: expectations, length, objective,

rewards.


The rewards are associated with previously reported benefits. If it meets personal needs If they derive satisfaction from the

interpersonal interaction If they derive satisfaction from their

participating in the group task If they derive satisfaction from group

membership


Satisfying Personal Needs The group must relieve some discomfort This discomfort is associated with the level of

motivation for change. Satisfaction depends on the pt’s position in the group

communication network and how he/she is valued. Hence, in marketing or conditioning – discomfort level

is magnified in order to increase need. How do you do that in group dynamics if you want?

Relationship between the discomfort and suitability for group is curvilinear

The Relationship between Discomfort and Motivation

Yerkes -Dodson Curve

Low= unwilling to pay the price

Moderate= willing to be the price

High = unable to pay the price, over-whelmed,

unable to tolerate These acute points

would be good for what type of group?

Satisfaction from the interpersonal interaction Generally, associated with the attraction

toward the group- this one factor may dwarf others

This above all others is a slow process. Initially, pts are contemptuous of themselves

and others. They will use the therapist as the transitional

object Parloff has demonstrated that this will help pts

approach others with a positive perception.



Satisfaction participating in Group tasks Pts that can’t reveal, introspect, care for others

and manifest feelings will struggle with this one.


Selection of patients is the process of DESELECTION.

In others words, the practice of selecting often is deselecting particular pts and including everyone else.

Empirical studies and clinical observations due more to provide us with data for exclusion or what doesn’t work interpersonally than what works.

Criteria for Exclusion

Almost all pts will fit into some groups. The question becomes which type of group.

Poor candidates for a heterogeneous outpatient therapy group are those with brain damage, paranoid, hypochondriacal, substance abusers, acutely psychotic or sociopaths. But WHY is a better point to focus on.

Because eventually they will manifest their inability to relate and will dominate the group, manipulate or be aloof.


DROP OUTS Drop out during their initial interview were

more hostile and spontaneous or passive. Grotjahn studied long term outpatient analytic

group and concluded that 40% of the dropouts were predictable.

1. pts with dx of pending psychotic breakdowns 2. pts that used group for an acute crisis 3. Highly schizoid Dropouts were more socially ineffective.

Who this class deals with such clients’


Hence studies suggest that drop outs tend to have following characteristics: high denial, high somatization, low motivation, low ses, low social effectiveness, low IQ, psychotic pathology.

Reasons for dropping: External factors Group deviancy Problems with intimacy Fear of emotional contagion Inability to share the therapist Complications of concurrent individual therapy Inadequate orientation Complications from subgrouping

Reasons for Dropping External factors- physical reasons, schedule ,

babysitting, transportation leading to increases stress. Rationalization as well.

Group deviant – someone that represents an extreme in at least one dimension- age, economic, education, gender. They remain as an outsider and slow the group down-

by remaining on another interpersonal level (avoidance,etc)

Lieberman, Yalom and Miles concluded that such pts will not benefit and possible adversely affected

According to Schacter’s study, communication toward a deviant is very high initially then drops off as deviant stands out over time.

Reasons fro Dropping

Problems of Intimacy- Individuals that manifest their intimate conflicts in various ways.

Schizoid withdrawal Maladaptive self disclosure Unrealistic demands for instant intimacy

Fear of Emotional Contagion- afraid that they may become as depressed or disturbed as others.

This typically comes from individuals that appear to have permeable ego boundaries (i.e. borderline).

Criteria for Inclusion

Desire for change Ability to face one’s deficiencies, even to the point of

undue self criticism and a degree of sensitivity to the feelings of others seem

Pt’s with significant transference issues Pt’s attraction to the group and popularity Popularity = self disclosure, introspective and active

Chapter 9: The Composition of Therapy Groups

The Theory and Practice of Group Psychotherapy

Irvin Yalom, Ph.D.

Questions to Consider:

Is group behavior predictable? Is so, to what degree? How useful do YOU THINK is the DSM or

structured interview in predicting group behavior?

What would you focus in order to assess for group behavior?


Is one’s behavior relatively consistent in different groups with similar tasks at hand?

If so, how would you as a clincian get your best prediction?

Are there any ideal, research based guidelines for the most effective group composition?


Homogenous or Heterogenous? Which do you prefer?

What guidelines would you use?

Predicting Group Behavior

Since the interaction of the group members determine the fate of the group, focusing on certain compositions may allow for a MIX that facilitates this interaction.

Screenings: Standard DX Interview – predictions are highly

remote inferences Dx not as useful as observing function and length

of illness.


Interpersonal Nosological System Karen Horney – move toward, against or away

Toward = conduct with currency of love Against = search for mastery Away = withdrawal in order for withdrawal Personality characteristics: Melnick & Rose

study found that social risk taking propensity and self disclosure most important characteristics.

Interaction in previous groups = future


Interpersonal Intake interview assess interpersonal style hx of interpersonal interaction social network participation in organizations relationships etc


Direct sampling of group relevant behavior Powdermaker and Frank concluded that the

interpersonal interview with a psychiatric interview gives enough information to make valid and reliable predictions.


The more the similar the intake is to the group situation the better.

Yalom’s example of the group of pts with dx of schizoid personality. P258 Despite homogeneity, allow or encourage the

differences to manifest.

Composition of Group

A group’s composition influences certain short term predictable characteristics (e.g. high cohesion, high conflict, high flight, high dependency) which highly predict a groups performance.

Two major approaches are: heterogeneous approach homogeneous approach

Heterogeneous approach

Advantageous for long term intensive interactional

Good for ambitious personality change goals Can lead to an isolate p.256 Role heterogeneity (task leader, champion,

dependent, moral leader) better for self actualization but can lead to additional conflict

Heterogeneous approach

Social Microcosm Theory group = miniature social universe

Dissonance Theory allows for dissonance There is no empirical evidence that

deliberately composed heterogeneous groups facilitate therapy.

Homogeneous approach

Cohesiveness theory there is an attraction to the group less conflicts and better attendance good for short term work not enough dissonance so everyone reinforces

everyone faster sx relief due to faster support A small amount of research support the

cohesiveness theory. This approach allows for factors mentioned above to unfold that directly influence results.

COMPOSITION

Principle - heterogeneity in pt’s conflict areas and

patterns of coping and at the same time striving for homogeneity of the pt’s degree of vulnerability and capacity to tolerate anxiety

The more structure and briefer the group, the less important is composition.

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Chapter8and9