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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