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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 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’


    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.


    Composition
    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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