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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: For $1,000 How important is ... – PowerPoint PPT presentation

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

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

The Selection of Patients
  • The material has disturbingly disjunctive
  • 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,

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 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
  • 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
  • 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


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
  • They will use the therapist as the transitional
  • Parloff has demonstrated that this will help pts
    approach others with a positive perception.

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.

The Selection of Patients
  • Selection of patients is the process of
  • 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

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 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
  • 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 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
  • 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
  • Lieberman, Yalom and Miles concluded that such
    pts will not benefit and possible adversely
  • According to Schacters 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.

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

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

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

Questions to Consider
  • 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.

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
  • Interaction in previous groups future

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

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 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.

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
  • Two major approaches are
  • heterogeneous approach
  • homogeneous approach

Heterogeneous approach
  • Advantageous for long term intensive
  • 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
  • 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 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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