Chapter 8: The Selection of Patients

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Chapter 8 The Selection of Patients

• The Theory and Practice of Group Psychotherapy
• Irvin Yalom, Ph.D.

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Who Wants To Be A Millionaire

• For 1,000
• How important is selection of patients for a
  group?
• Why?

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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.

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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?

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Who Wants To Be A Millionaire

• For 40,000
• How do group clinicians select their patients?

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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.

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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

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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 pts 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

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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?

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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.

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The Selection of Patients

• Satisfaction participating in Group tasks
• Pts that cant reveal, introspect, care for
  others and manifest feelings will struggle with
  this one.

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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 doesnt work interpersonally than what
  works.

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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.

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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

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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

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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 Schacters study, communication
  toward a deviant is very high initially then
  drops off as deviant stands out over time.

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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).

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Criteria for Inclusion

• Desire for change
• Ability to face ones deficiencies, even to the
  point of undue self criticism and a degree of
  sensitivity to the feelings of others seem
• Pts with significant transference issues
• Pts attraction to the group and popularity
• Popularity self disclosure, introspective and
  active

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Chapter 9 The Composition of Therapy Groups

• The Theory and Practice of Group Psychotherapy
• Irvin Yalom, Ph.D.

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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?

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Questions to Consider

• Is ones 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?

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Questions to Consider

• Homogenous or Heterogenous? Which do you prefer?
• What guidelines would you use?

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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.

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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

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Predicting Group Behavior

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

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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.

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Predicting Group Behavior

• The more the similar the intake is to the group
  situation the better.
• Yaloms example of the group of pts with dx of
  schizoid personality. P258
• Despite homogeneity, allow or encourage the
  differences to manifest.

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Composition of Group

• A groups 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

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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

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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.

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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.

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COMPOSITION

• Principle -
• heterogeneity in pts conflict areas and patterns
  of coping and at the same time striving for
  homogeneity of the pts degree of vulnerability
  and capacity to tolerate anxiety
• The more structure and briefer the group, the
  less important is composition.

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