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

• 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 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 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 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• 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?

• 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 Patients

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 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

• 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 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 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 (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

• 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

• 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 GroupsThe 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

behavior?

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 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 characteristics.

• 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.

• 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

• 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

• 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 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 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

• 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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