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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?. Who Wants To Be A Millionaire:. For $5,000

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chapter 8 the selection of patients

Chapter 8: The Selection of Patients

The Theory and Practice of Group Psychotherapy

Irvin Yalom, Ph.D.

who wants to be a millionaire
Who Wants To Be A Millionaire:
  • For $1,000
  • How important is selection of patients for a group?
  • Why?
who wants to be a millionaire1
Who Wants To Be A Millionaire:
  • For $5,000
  • Therefore, is it possible that the process of member selection can lead to the failure of a group? Explain.
who wants to be a millionaire2
Who Wants To Be A Millionaire:
      • For $10,000
    • So, should any patient be sent to group?
    • For $20,000
  • How effective is group therapy?
who wants to be a millionaire3
Who Wants To Be A Millionaire:
  • For $40,000
  • How do group clinicians select their patients?
the selection of 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 selection of patients1
The Selection of Patients
  • 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
the selection of patients2
The Selection of Patients
  • 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
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 pts would be good for what type of group?

The Selection of Patients

  • 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.
the selection of patients3
The Selection of Patients
  • Satisfaction participating in Group tasks
    • Pts that can’t reveal, introspect, care for others and manifest feelings will struggle with this one.
the selection of patients4
The Selection of Patients
  • 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
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.
criteria for exclusion1
Criteria for Exclusion
    • 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’
criteria for exclusion2
Criteria for Exclusion
  • 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
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
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
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

Chapter 9: The Composition of Therapy Groups

The Theory and Practice of Group Psychotherapy

Irvin Yalom, Ph.D.

questions to consider
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?
questions to consider1
Questions to Consider:
  • 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?
questions to consider2
Questions to Consider:
  • Homogenous or Heterogenous? Which do you prefer?
  • What guidelines would you use?
predicting group behavior
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.
predicting group behavior1
Predicting Group Behavior
  • 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
predicting group behavior2
Predicting Group Behavior
  • Interpersonal Intake interview
    • assess interpersonal style
    • hx of interpersonal interaction
    • social network
    • participation in organizations
    • relationships
    • etc
predicting group behavior3
Predicting Group Behavior
  • 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.
predicting group behavior4
Predicting Group Behavior
  • 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
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
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 approach1
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
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.
  • 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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