Summary
In this book Irvin Yalom turns to the inpatient psychiatric setting and offers new ways of conceptualizing the techniques of group therapy for use on acute wards.
While some group therapy occurs in all psychiatric hospitals, it is rarely handled systematically and is not properly supported by the psychiatric leadership. Arguing from his own research results and from his years of experience, Yalom makes a strong case for the importance and efficacy of group therapy on all acute wards.
He presents a radical modification of technique, discussing the different ways in which the therapist should structure the sessions, the kinds of support that should be offered, and the emphasis on the here and now, all of which are essential to effective group therapy in hospitals. Yalom then presents two models of groups: one for the higher functioning hospitalized patients and one for the more regressed psychotic patients.
A book for front line clinicians, filled with the examples of cases for which Yalom is famous, Inpatient Group Psychotherapy takes a new step in the application of group therapy. It is especially suitable for the contemporary psychiatric ward where acutely disturbed patients are hospitalized for brief periods of time.
Endorsements
Ira D. Glick, M.D., Professor of Psychiatry, Cornell University Medical College
“Like Dr. Yalom’s Theory and Practice of Group Psychotherapy, this book is destined to be the standard text for inpatient group therapy. A rational, relevant, and timely manual closely attuned to the new realities of the clinical practice of inpatient group therapy…necessary reading for all those referring or treating inpatients.”
Eugene G. Gouton, American Journal of Psychiatry
“The primary reference for the theory and practice of inpatient group psychotherapy.”
Marc Hertzman, M.D., Director of Inpatient Services,
George Washington University Medical Center
“Dr. Yalom has once again found the right subject and handled it in his usual thorough, readable, exciting style. He is an advocate for hospital group therapy who speaks from long and direct experience.
Dr. Yalom has written an eminently practical guide to what works, generously spiced with examples of patient-therapist interchanges, which ring true to life. His methods are interpersonal and especially tailored to short-term work in tumultuous, high-volume settings.”
Videos
Understanding Group Psychotherapy video series
Review: Irv Yalom – Group Psychotherapy (Volume I, II and III)
Understanding Group Psychotherapy – Volume I: Outpatients; Volume II: Inpatients; Volume III: An Interview by Irv Yalom, M.D.
DVD I: $195, 100 min.; II: $195, 100 min.; III: $245, 240 min. Psychotherapy.net, 2005
Over the last half century, Irv Yalom, M.D., has been one of the pioneers and leaders in developing both the existential psychotherapy movement and the group psychotherapy movement. I think he has written the main source books for group psychotherapy: The Theory and Practice of Group Psychotherapy and Inpatient Group Psychotherapy. Understanding Group Psychotherapy: Volume I: Outpatients is a simulation of a long-term outpatient therapy group that theoretically would meet over a period of years. Yalom uses actors to role-play the patients. The patients and the group contents are modeled after his group psychotherapy experiences.
Yalom’s theory of interpersonal group psychotherapy emphasizes exploring, in the here and now in the context of interactive interpersonal relationships, how we keep ourselves from being intimate and how we can remedy that. The interpersonal approach rests on the belief that many of our individual intrapsychic issues are rooted in our inability to relate to others in emotionally accessible and expressive ways. The group is a great venue for resolving these blocks, for it is a tremendous learning laboratory. The group represents a range of relationships in our life outside the group. Thus, understanding and working through our blocks in relating intimately within the group will translate into healthier behaviors and relationships in our lives. This in turn allows us to feel better about ourselves and to develop a healthier self-esteem.
The DVD begins with an introduction by Yalom, then segues to vignettes from the first, third, fifth, and eighth group meetings, showing how the work may progress. After each of these group vignettes, he offers personal commentary.
In the vignette of the first group, the DVD focuses on the last ten minutes of the group meeting. Yalom validates the risks patients have taken by initially letting themselves be known to the other members, then he models his interpersonal approach by asking, “What has come up in your judgments and feelings and impressions of the other group members?”
Yalom underscores that what goes on in the group replicates what goes on in the members’ lives. To one group member, he asks, “Is the experience of feeling you are outside of the group looking in familiar to your experiences in your life?” I like the tremendous respect Yalom has for each individual in the group, even as he challenges them.
I value how in the group Yalom uses silence. He does not intervene too quickly, and he lets the patient voice whatever is going on for them before he responds. He also lets the group work. I also like how Yalom is inclusive and open, sharing his range of thoughts and feelings about the situation occurring in the group including even if he is not sure what to do about it. It is a powerful example of a humanistic psychology tenet: the therapist/facilitator is not all-knowing and omniscient. Ultimately, the patient is the best judge of their life.
In Yalom’s commentary on the third group, he stresses a key value of being in group therapy: a common stimulus within the group will elicit a variety of responses. Examining the diversity of the responses is used as a vehicle to reveal to the patient how they are experienced by the other group members. This allows the patient to change their view of his/her self.
In the vignette of the fifth group, Yalom initiates the feedback to a particular patient by stating, “I’m aware of your silence. It is like you’re miles away from here.” And then he stays silent and again lets the group work with their feelings, thoughts, and reactions toward this particular patient. I like how Yalom facilitates stronger feedback to the patient from other group members by suggesting that they try a thought experiment. He tells them to imagine being with the patient 24/7, not just 1.5 hours a week, and then give the patient feedback.
The eighth group vignette focuses on a risk-taking, intimate self-disclosure of a group member. Yalom is very validating of the patient’s risking. He facilitates the relationship of this patient to other group members by asking questions: “How was it to be in the group for eight weeks and not share this? What did you fantasize would happen if you shared this? What allowed you to bring it up today? Did you think you would be rejected from the group? What did you want to get out of the group by sharing this?”
In the commentary on this group meeting, Yalom emphasizes that the therapist is initially active in facilitating the group members to move into the here-and-now interpersonal material until the group more naturally integrates doing it themselves. The goal is for the group members to ultimately become more empowered in taking responsibility for their relating to each other and collectively as a group.
Understanding Group Psychotherapy – Volume II: Inpatients is a simulation of an inpatient therapy group. Again, Yalom uses actors to role-play the patients. The patients and the group contents are modeled after Yalom’s actual group psychotherapy experiences.
In describing working with inpatient group therapy from an interpersonal here-and-now perspective, Yalom emphasizes that the therapist needs to adjust to the specific inpatient environment. We are beings-in the- world, so we need to be in relationship to the demands, expectations, and contingencies of the particular inpatient setting. This is unlike outpatient group psychotherapy, where the therapist has much more control of who will be in the group, how long it will meet, and the group’s stable structure.
By contrast, in the inpatient group, since the turnover of patients is rapid (a few days to a few weeks), each group needs to be looked at as being complete in each present time. The therapist must be more active and directive in setting up the structure and the immediate goals of the group. Yet, the purpose is identical to the outpatient group, which is to facilitate self-knowledge, conscious change, and healing through exploring and changing relationships in the group.
There are seven patients in the inpatient group. The group is shown in its entirety, with an introduction and commentary between the three phases of the group. The range of pathology and conditions are broad, including chronic depression, hypochondriocal tendencies, anorexia, psychotic mania, a specific suicide attempt, borderline and self-destructive tendencies, and drug addiction and homelessness.
In the first phase, Yalom clearly sets up the structure, ground rules, expectations, and purpose of the group. The second phase of the group is helping each person create an agenda so they can define what their concern is, to be worked on in the group. The agenda is defined in the here and now, and in interpersonally interactive terms. For instance, Yalom helps one member of the group dealing with an overwhelming sense of depression to redefine a piece of her depression as being that she is lonely and feels isolated in the ward, as well as in this group. The third phase is the actual working on the agendas within the group context.
I like how affirming and validating Yalom is both by how he frames an issue and what he chooses to focus upon that defines the patient. For example, when a patient says what she wants from the group is for the group to go on without her, Yalom responds that “the important thing is that you came today. There is a part of you that came today that wants to live.”
One big difference in the inpatient group versus the outpatient group is that while in the outpatient group, conflict at times is encouraged, given the psychological maturity and ego intactness of the patients and the extended structure of the group. In an inpatient therapy group, the therapist wants to facilitate as little conflict as possible. Yalom feels that the therapist should have the interpersonal interactions be as supportive and as constructive and as safe as possible, since the therapist is looking at one session with patients who often have poor ego-intactness and psychological immaturity.
Phase three is the actual working through to some extent of all of the patients’ agendas. The therapist needs to be fairly directive to get this accomplished in the remaining time. Mutual agendas can be addressed simultaneously. For example, for the patient who feels lonely, while she is exploring this, Yalom checks in with another patient who is concerned about her anger to see if she is feeling impatient or irritated. Yalom then has the lonely patient share whom she feels close to in the group, how that person feels about her (that person feels good about the patient), and has them agree to talk more with each other after the group ends. For a male patient whose agenda is to learn how to identify and express his feelings, when there is a poignant interaction between two members of the group, Yalom asks him how he feels about what just happened.
In Yalom’s commentary on the patients working through their agendas, he underscores that the group is interactional. There is an emphasis on patients improving their relationships within the group with each other and setting up time outside the group to continue to relate. Contact is heightened and improved with other patients, and this helps patients feel better about themselves.
Understanding Group Psychotherapy – Volume III: An Interview is conducted by Patricia Gadban. Yalom discusses group psychotherapy and the existential perspective. He also describes the early influences that helped shaped his professional life, as well as his insights into the training of group psychotherapists, the healing factors of group work, death anxiety, and bereavement. While interesting, it covers some of the same group psychotherapy material discussed in I and II. I prefer Randall Wyatt’s interview of Yalom in The Gift of Therapy, also by Psychotherapy.net. In conclusion, it is a rich experience to view Understanding Group Psychotherapy, especially Volumes I and II. I saw myself involved in a similar way that Yalom describes the process for the patients in his groups. I found myself emotionally involved with the life material and concerns of the patient as it became manifested in the here-and-now in their relationship with the other group members. I then found myself reflecting upon what happened in the interpersonal interactions as the patients integrated the affective material. In this sense, the DVDs feel very experiential to me.
I believe healing takes place in both the examination of the connection of the patient to themselves as well as in the examination of the patient to others. Therefore, although I see great value in the healing power of interpersonal here-and-now interactions, I don’t totally agree with Yalom’s almost exclusive emphasis upon it. However, I very much admire both Yalom’s deep conviction in the power of change through the interpersonal here-and-now group therapy modality, and the artistry, thoroughness, and mastery he shows in implementing it. The DVDs are very much worth viewing to see this master psychotherapist at work.
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