Chapter 8: The Selection of Patients

1. Chapter 8: The Selection of Patients The Theory and Practice of Group Psychotherapy Irvin Yalom, Ph.D.

2. Who Wants To Be A Millionaire: • For $1,000 • How important is selection of patients for a group? • Why?

3. 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.

4. 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?

5. Who Wants To Be A Millionaire: • For $40,000 • How do group clinicians select their patients?

6. 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.

7. 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

8. 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

9. 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?

10. 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.

11. 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.

12. 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.

13. 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.

14. 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’

15. 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

16. 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.

17. 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).

18. 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

19. Chapter 9: The Composition of Therapy Groups The Theory and Practice of Group Psychotherapy Irvin Yalom, Ph.D.

20. 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?

21. 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?

22. Questions to Consider: • Homogenous or Heterogenous? Which do you prefer? • What guidelines would you use?

23. 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.

24. 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

25. Predicting Group Behavior • Interpersonal Intake interview • assess interpersonal style • hx of interpersonal interaction • social network • participation in organizations • relationships • etc

26. 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.

27. 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.

28. 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

29. 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

30. 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.

31. 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.

32. 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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