Discussion Week 4- Nurse/Patient Empowerment

Discussion Week 4 Nurse/Patient Empowerment

Discussion Week 4 Nurse/Patient Empowerment

Discussion Week 4 Nurse/Patient Empowerment

Discussion Week 4 Nurse/Patient Empowerment

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WK 2 Assign PHARM 6521

WK 2 Assign PHARM 6521

WK 2 Assign PHARM 6521

WK 2 Assign PHARM 6521

Assignment: Pharmacotherapy for Cardiovascular Disorders

…heart disease remains the No. 1 killer in America; nearly half of all Americans have high blood pressure, high cholesterol, or smoke—some of the leading risk factors for heart disease…
—Murphy et al., 2018
Despite the high mortality rates associated with cardiovascular disorders, improved treatment options do exist that can help address those risk factors that afflict the majority of the population today.

Photo Credit: Getty Images/Science Photo Library RF

As an advanced practice nurse, it is your responsibility to recommend appropriate treatment options for patients with cardiovascular disorders. To ensure the safety and effectiveness of drug therapy, advanced practice nurses must consider aspects that might influence pharmacokinetic and pharmacodynamic processes such as medical history, other drugs currently prescribed, and individual patient factors.
Reference: Murphy, S. L., Xu, J., Kochanek, K. D., & Arias, E. (2018). Mortality in the United States, 2017. Retrieved from /orders/www.cdc.gov/nchs/products/databriefs/db328.htm

To Prepare

• Review the Resources for this module and consider the impact of potential pharmacotherapeutics for cardiovascular disorders introduced in the media piece.
• Review the case study assigned by your Instructor for this Assignment.
• Select one the following factors: genetics, gender, ethnicity, age, or behavior factors.
• Reflect on how the factor you selected might influence the patient’s pharmacokinetic and pharmacodynamic processes.
• Consider how changes in the pharmacokinetic and pharmacodynamic processes might impact the patient’s recommended drug therapy.
• Think about how you might improve the patient’s drug therapy plan based on the pharmacokinetic and pharmacodynamic changes. Reflect on whether you would modify the current drug treatment or provide an alternative treatment option for the patient.

By Day 7 of Week 2

Write a 2- to 3-page paper that addresses the following:

• Explain how the factor you selected might influence the pharmacokinetic and pharmacodynamic processes in the patient from the case study you were assigned.
• Describe how changes in the processes might impact the patient’s recommended drug therapy. Be specific and provide examples.
• Explain how you might improve the patient’s drug therapy plan and explain why you would make these recommended improvements.

Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The College of Nursing Writing Template with Instructions provided at the Walden Writing Center offers an example of those required elements (available at /orders/academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632). All papers submitted must use this formatting.

Learning Resources

Required Readings (click to expand/reduce)

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
Chapter 33, “Review of Hemodynamics” (pp. 285–289)
Chapter 37, “Diuretics” (pp. 290–296)
Chapter 38, “Drugs Acting on the Renin-Angiotensin-Aldosterone System” (pp. 297–307)
Chapter 39, “Calcium Channel Blockers” (pp. 308–312)
Chapter 40, “Vasodilators” (pp. 313–317)
Chapter 41, “Drugs for Hypertension” (pp. 316–324)
Chapter 42, “Drugs for Heart Failure” (pp. 325–336)
Chapter 43, “Antidysrhythmic Drugs” (pp. 337–348)
Chapter 44, “Prophylaxis of Atherosclerotic Cardiovascular Disease: Drugs That Help Normalize Cholesterol and Triglyceride Levels” (pp. 349–363)
Chapter 45, “Drugs for Angina Pectoris” (pp. 364–371)
Chapter 46, “Anticoagulant and Antiplatelet Drugs” (pp. 372–388)

Required Media (click to expand/reduce)

Cardiovascular Disorders
Meet Dr. Norbert Myslinski as he discusses ACE inhibitors, angiotensin inhibitors, beta-blockers, calcium channel blockers, and diuretics as different categories of hypertension drugs. What potential drugs might be best recommended for patients suffering from hypertension? (8m)
Accessible player –Downloads–Download Video w/CCDownload AudioDownload Transcript

use 5 resources for this assignment. Introduction and conclusion parts are very important, thanks

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WK10 NURS 6512 ASSIGN

Assignment: Lab Assignment: Assessing the Genitalia and Rectum

Patients are frequently uncomfortable discussing with healthcare professional’s issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam are vital. Examining case studies of genital and rectal abnormalities can help prepare advanced practice nurses to accurately assess patients with problems in these areas.
In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.

To Prepare

• Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
• Based on the Episodic note case study:
  • Review this week’s Learning Resources, and consider the insights they provide about the case study. Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.
  • Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
  • Consider what history would be necessary to collect from the patient in the case study.
  • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
  • Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

The Lab Assignment

Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.

• Analyze the subjective portion of the note. List additional information that should be included in the documentation.
• Analyze the objective portion of the note. List additional information that should be included in the documentation.
• Is the assessment supported by the subjective and objective information? Why or why not?
• Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
• Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.
1- Review this week’s Learning Resources, and consider the insights they provide about the case study. Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.
2- Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
3- Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
4-Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.

• Analyze the subjective portion of the note. List additional information that should be included in the documentation.
• Analyze the objective portion of the note. List additional information that should be included in the documentation.
• Is the assessment supported by the subjective and objective information? Why or why not?
• Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
• Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

Post the assignment By Day 7 of Week 10. Follow the rubric! We grade by the rubric!
GENITALIA ASSESSMENT
Subjective:

• CC: “I have bumps on my bottom that I want to have checked out.”
• HPI: AB, a 21-year-old WF college student reports to your clinic with external bumps on her genital area. She states the bumps are painless and feel rough. She states she is sexually active and has had more than one partner during the past year. Her initial sexual contact occurred at age 18. She reports no abnormal vaginal discharge. She is unsure how long the bumps have been there but noticed them about a week ago. Her last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal. She reports one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed.
• PMH: Asthma
• Medications: Symbicort 160/4.5mcg
• Allergies: NKDA
• FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD
• Social: Denies tobacco use; occasional ETOH married, 3 children (1 girl, 2 boys)

Objective:

• VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs
• Heart: RRR, no murmurs
• Lungs: CTA, chest wall symmetrical
• Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia.
• Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, neg McBurney
• Diagnostics: HSV specimen obtained

Assessment:

• Chancre

Learning Resources

Required Readings (click to expand/reduce)

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 17, “Breasts and Axillae”
This chapter focuses on examining the breasts and axillae. The authors describe the examination procedures and the anatomy and physiology of breasts.
Chapter 19, “Female Genitalia”
In this chapter, the authors explain how to conduct an examination of female genitalia. The chapter also describes the form and function of female genitalia.
Chapter 20, “Male Genitalia”
The authors explain the biology of the penis, testicles, epididymides, scrotum, prostate gland, and seminal vesicles. Additionally, the chapter explains how to perform an exam of these areas.
Chapter 21, “Anus, Rectum, and Prostate”
This chapter focuses on performing an exam of the anus, rectum, and prostate. The authors also explain the anatomy and physiology of the anus, rectum, and prostate.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 5, “Amenorrhea”
Amenorrhea, or the absence of menstruation, is the focus of this chapter. The authors include key questions to ask patients when taking histories and explain what to look for in the physical exam.

Chapter 6, “Breast Lumps and Nipple Discharge”
This chapter focuses on the important topic of breast lumps and nipple discharge. Because breast cancer is the most common type of cancer in women, it is important to get an accurate diagnosis. Information in the chapter includes key questions to ask and what to look for in the physical exam.

Chapter 7, “Breast Pain”
Determining the cause of breast pain can be difficult. This chapter examines how to determine the likely cause of the pain through diagnostic tests, physical examination, and careful analysis of a patient’s health history.

Chapter 27, “Penile Discharge”
The focus of this chapter is on how to diagnose the causes of penile discharge. The authors include specific questions to ask when gathering a patient’s history to narrow down the likely diagnosis. They also give advice on performing a focused physical exam.

Chapter 36, “Vaginal Bleeding”
In this chapter, the causes of vaginal bleeding are explored. The authors focus on symptoms outside the regular menstrual cycle. The authors discuss key questions to ask the patient as well as specific physical examination procedures and laboratory studies that may be useful in reaching a diagnosis.

Chapter 37, “Vaginal Discharge and Itching”
This chapter examines the process of identifying causes of vaginal discharge and itching. The authors include questions on the characteristics of the discharge, the possibility of the issues being the result of a sexually transmitted infection, and how often the discharge occurs. A chart highlights potential diagnoses based on patient history, physical findings, and diagnostic studies.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
Chapter 3, “SOAP Notes” (Previously read in Week 8)

Cucci, E., Santoro, A., DiGesu, C., DiCerce, R., & Sallustio, G. (2015). Sclerosing adenosis of the breast: Report of two cases and review of the literature. Polish Journal of Radiology, 80, 122–127. doi:10.12659/PJR.892706. Retrieved from /orders/www.ncbi.nlm.nih.gov/pmc/articles/PMC4356184/  

Sabbagh , C., Mauvis, F., Vecten, A., Ainseba, N., Cosse, C., Diouf, M., & Regimbeau, J. M. (2014). What is the best position for analyzing the lower and middle rectum and sphincter function in a digital rectal examination? A randomized, controlled study in men. Digestive and Liver Disease, 46(12), 1082–1085. doi:10.1016/j.dld.2014.08.045

Westhoff , C. L., Jones, H. E., & Guiahi, M. (2011). Do new guidelines and technology make the routine pelvic examination obsolete? Journal of Women’s Health, 20(1), 5–10.

This article describes the benefits of new technology and guidelines for pelvic exams. The authors also detail which guidelines and technology may become obsolete.

Centers for Disease Control and Prevention. (2019). Sexually transmitted diseases (STDs). Retrieved from http://www.cdc.gov/std/#
This section of the CDC website provides a range of information on sexually transmitted diseases (STDs). The website includes reports on STDs, related projects and initiatives, treatment information, and program tools.

Document: Final Exam Review (Word document)

Optional Resource

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
Chapter 8, “The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts” (Section 2, “The Breasts,” pp. 434–444)
Section 2 of this chapter focuses on the anatomy and physiology of breasts. The section provides descriptions of breast examinations and common breast conditions.
Chapter 11, “The Female Genitalia and Reproductive System” (pp. 541–562)
In this chapter, the authors provide an overview of the female reproductive system. The authors also describe symptoms of disorders in the reproductive system.
Chapter 12, “The Male Genitalia and Reproductive System” (pp. 563–584)
The authors of this chapter detail the anatomy of the male reproductive system. Additionally, the authors describe how to conduct an exam of the male reproductive system.
Review of Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid” (pp. 445–527)

Required Media (click to expand/reduce)

Special Examinations – Breast, Genital, Prostate, and Rectal – Week 10 (14m)
Accessible player –Downloads–Download Video w/CCDownload AudioDownload Transcript

Online media for Seidel’s Guide to Physical Examination
It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 16 and 18–20 that relate to special examinations, including breast, genital, prostate, and rectal. Refer to the Week 4 Learning Resources area for access instructions on /orders/evolve.elsevier.com/

Rubric Detail

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Name: NURS_6512_Week_10_Assignment_Rubric

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ExcellentGoodFairPoorWith regard to the SOAP note case study provided and using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature:
·   Analyze the subjective portion of the note. List additional information that should be included in the documentation.10 (10%) – 12 (12%)The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation.7 (7%) – 9 (9%)The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation.4 (4%) – 6 (6%)The response vaguely analyzes the subjective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.0 (0%) – 3 (3%)The response inaccurately analyzes the subjective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.·   Analyze the objective portion of the note. List additional information that should be included in the documentation.10 (10%) – 12 (12%)The response clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation.7 (7%) – 9 (9%)The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation.4 (4%) – 6 (6%)The response vaguely analyzes the objective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.0 (0%) – 3 (3%)The response inaccurately analyzes the objective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.·  Is the assessment supported by the subjective and objective information? Why or why not?14 (14%) – 16 (16%)The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation.11 (11%) – 13 (13%)The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a clear explanation.8 (8%) – 10 (10%)The response vaguely identifies whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation.0 (0%) – 7 (7%)The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.·   What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?18 (18%) – 20 (20%)The response thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would be used to make a diagnosis.15 (15%) – 17 (17%)The response accurately describes appropriate diagnostic tests for the case and explains how the test results would be used to make a diagnosis.12 (12%) – 14 (14%)The response vaguely and/or with some inaccuracy describes appropriate diagnostic tests for the case and vaguely and/or with some inaccuracy explains how the test results would be used to make a diagnosis.0 (0%) – 11 (11%)The response inaccurately describes appropriate diagnostic tests for the case, with an inaccurate or missing explanation of how the test results would be used to make a diagnosis.·   Would you reject or accept the current diagnosis? Why or why not?
·   Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.23 (23%) – 25 (25%)The response states clearly whether to accept or reject the current diagnosis, with a thorough, accurate, and detailed explanation of sound reasoning. The response clearly, thoroughly, and accurately identifies three conditions as a differential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using three or more different references from current evidence-based literature.20 (20%) – 22 (22%)The response states whether to accept or reject the current diagnosis, with an accurate explanation of sound reasoning. The response accurately identifies three conditions as a differential diagnosis, with reasoning that is explained using three different references from current evidence-based literature.17 (17%) – 19 (19%)The response states whether to accept or reject the current diagnosis, with a vague explanation of the reasoning. The response identifies two to three conditions as a differential diagnosis, with reasoning that is explained vaguely and/or inaccurately using three or fewer references from current evidence-based literature.0 (0%) – 16 (16%)The response inaccurately states or is missing a statement of whether to accept or reject the current diagnosis, with an explanation that is inaccurate and/or missing. The response identifies three or fewer conditions as a differential diagnosis, with reasoning that is missing or explained inaccurately using two or fewer references from current evidence-based literature.Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.5 (5%) – 5 (5%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.4 (4%) – 4 (4%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.3 (3%) – 3 (3%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.0 (0%) – 2 (2%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation5 (5%) – 5 (5%)Uses correct grammar, spelling, and punctuation with no errors.4 (4%) – 4 (4%)Contains a few (1 or 2) grammar, spelling, and punctuation errors.3 (3%) – 3 (3%)Contains several (3 or 4) grammar, spelling, and punctuation errors.0 (0%) – 2 (2%)Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.5 (5%) – 5 (5%)Uses correct APA format with no errors.4 (4%) – 4 (4%)Contains a few (1 or 2) APA format errors.3 (3%) – 3 (3%)Contains several (3 or 4) APA format errors.0 (0%) – 2 (2%)Contains many (≥ 5) APA format errors. Total Points: 100

Name: NURS_6512_Week_10_Assignment_Rubric

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Assignment 1: Practicum – Week 8 Journal Entry

Select two clients you observed or counseled this week during a group therapy session. Note: The two clients you select must have attended the same group session.
Then, in your Practicum Journal, address the following:
Describe each client (without violating HIPAA regulations), and identify any pertinent history or medical information, including prescribed medications.
Using the DSM-5, explain and justify your diagnosis for each client.
Explain whether cognitive behavioral therapy would be effective with this group. Include expected outcomes based on this therapeutic approach.
Explain any legal and/or ethical implications related to counseling each client.
Support your approach with evidence-based literature.
Assignment 1: Practicum – Week 8 Journal Entry
Select two clients you observed or counseled this week during a group therapy session. Note: The two clients you select must have attended the same group session.
Then, in your Practicum Journal, address the following:
· Using the Group Therapy Progress Note in this week’s Learning Resources, document the group session.
 
Describe each client (without violating HIPAA regulations), and identify any pertinent history or medical information, including prescribed medications.
 
Using the DSM-5, explain and justify your diagnosis for each client.
 
Explain whether cognitive behavioral therapy would be effective with this group. Include expected outcomes based on this therapeutic approach.
 
Explain any legal and/or ethical implications related to counseling each client.
Support your approach with evidence-based literature.
 
Required Readings
 
Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books.
· Chapter 11, “In the Beginning” (pp. 309–344)
 
Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books.
· Chapter 12, “The Advanced Group” (pp. 345–390)
 
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Note: You will access this text from the Walden Library databases.
 
Bjornsson, A. S., Bidwell, L. C., Brosse, A. L., Carey, G., Hauser, M., Mackiewicz Seghete, K. L., … Craighead, W. E. (2011). Cognitive-behavioral group therapy versus group psychotherapy for social anxiety disorder among college students: A randomized controlled trial. Depression and Anxiety, 28(11), 1034–1042. doi:10.1002/da.20877
Note: You will access this text from the Walden Library databases.
 
Safak, Y., Karadere, M. E., Ozdel, K., Ozcan, T., Türkçapar, M. H., Kuru, E., & Yücens, B. (2014). The effectiveness of cognitive behavioral group psychotherapy for obsessive-compulsive disorder. Turkish Journal of Psychiatry, 25(4), 225–233. Retrieved from http://www.turkpsikiyatri.com/
Note: You will access this text from the Walden Library databases.

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Assignment 1: Practicum – Week 8 Journal Entry

Select two clients you observed or counseled this week during a group therapy session. Note: The two clients you select must have attended the same group session.
Then, in your Practicum Journal, address the following:
Describe each client (without violating HIPAA regulations), and identify any pertinent history or medical information, including prescribed medications.
Using the DSM-5, explain and justify your diagnosis for each client.
Explain whether cognitive behavioral therapy would be effective with this group. Include expected outcomes based on this therapeutic approach.
Explain any legal and/or ethical implications related to counseling each client.
Support your approach with evidence-based literature.
Assignment 1: Practicum – Week 8 Journal Entry
Select two clients you observed or counseled this week during a group therapy session. Note: The two clients you select must have attended the same group session.
Then, in your Practicum Journal, address the following:
· Using the Group Therapy Progress Note in this week’s Learning Resources, document the group session.
 
Describe each client (without violating HIPAA regulations), and identify any pertinent history or medical information, including prescribed medications.
 
Using the DSM-5, explain and justify your diagnosis for each client.
 
Explain whether cognitive behavioral therapy would be effective with this group. Include expected outcomes based on this therapeutic approach.
 
Explain any legal and/or ethical implications related to counseling each client.
Support your approach with evidence-based literature.
 
Required Readings
 
Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books.
· Chapter 11, “In the Beginning” (pp. 309–344)
 
Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books.
· Chapter 12, “The Advanced Group” (pp. 345–390)
 
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Note: You will access this text from the Walden Library databases.
 
Bjornsson, A. S., Bidwell, L. C., Brosse, A. L., Carey, G., Hauser, M., Mackiewicz Seghete, K. L., … Craighead, W. E. (2011). Cognitive-behavioral group therapy versus group psychotherapy for social anxiety disorder among college students: A randomized controlled trial. Depression and Anxiety, 28(11), 1034–1042. doi:10.1002/da.20877
Note: You will access this text from the Walden Library databases.
 
Safak, Y., Karadere, M. E., Ozdel, K., Ozcan, T., Türkçapar, M. H., Kuru, E., & Yücens, B. (2014). The effectiveness of cognitive behavioral group psychotherapy for obsessive-compulsive disorder. Turkish Journal of Psychiatry, 25(4), 225–233. Retrieved from http://www.turkpsikiyatri.com/
Note: You will access this text from the Walden Library databases.

Click here  to ORDER an A++ paper from our MASTERS and DOCTORATE WRITERS: 

Health Assessment

Lily is a 20-year-old student at the local community college. When some of her friends and classmates told her about an outbreak of flu-like symptoms sweeping her campus during the past 2 weeks, Lily figured she shouldn’t take her 3-day sore throat lightly. Your clinic has treated a few cases similar to Lily’s. All the patients reported decreased appetite, headaches, and pain with swallowing. As Lily recounts these symptoms to you, you notice that she has a runny nose and a slight hoarseness in her voice but doesn’t sound congested.
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the

 using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.
Episodic/Focused SOAP Note Template
 
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL:  No weight loss, fever, chills, weakness or fatigue.
HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN:  No rash or itching.
CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY:  No shortness of breath, cough or sputum.
GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC:  No anemia, bleeding or bruising.
LYMPHATICS:  No enlarged nodes. No history of splenectomy.
PSYCHIATRIC:  No history of depression or anxiety.
ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES:  No history of asthma, hives, eczema or rhinitis.
O.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
A.
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
P.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.

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Case Study Assignment: Assessment Tools And Diagnostic Tests In Adults And Children

Case Study Assignment: Assessment Tools And Diagnostic Tests In Adults And Children

When seeking to identify a patient’s health condition, advanced practice nurses can use a diverse selection of diagnostic tests and assessment tools; however, different factors affect the validity and reliability of the results produced by these tests or tools. Nurses must be aware of these factors in order to select the most appropriate test or tool and to accurately interpret the results.
Not only do these diagnostic tests affect adults, body measurements can provide a general picture of whether a child is receiving adequate nutrition or is at risk for health issues. These data, however, are just one aspect to be considered. Lifestyle, family history, and culture—among other factors—are also relevant. That said, gathering and communicating this information can be a delicate process.
For this Assignment, you will consider the validity and reliability of different assessment tools and diagnostic tests. You will explore issues such as sensitivity, specificity, and positive and negative predictive values. You will also consider examples of children with various weight issues. You will explore how you could effectively gather information and encourage parents and caregivers to be proactive about their children’s health and weight.
· Search the Walden Library and credible sources for resources explaining the tool or test you were assigned. What is its purpose, how is it conducted, and what information does it gather?
· Also, as you search the Walden library and credible sources, consider what the literature discusses regarding the validity, reliability, sensitivity, specificity, predictive values, ethical dilemmas, and controversies related to the test or tool.
Diagnostic Test: BMI
· The Assignment.
· Assignment (4 pages, not including title and reference pages):
Assignment Option 1: Adult Assessment Tools or Diagnostic Tests:
Include the following:
· A description of how the assessment tool or diagnostic test you were assigned is used in healthcare.
o What is its purpose?
o How is it conducted?
o What information does it gather?
Case Study
Overweight 5-year-old black boy with overweight parents who work full-time and the boy spends his time after school with his grandmother
Question
(Case) Overweight 5-year-old black boy with overweight parents who work full-time and the boy spends his time after school with his grandmother
 
· Explore issues such as sensitivity, specificity, and positive and negative predictive values. You will also consider examples of children with various weight issues.
·  Explore how you could effectively gather information and encourage parents and caregivers to be proactive about their children’s health and weight.
· Based on the risks you identified, consider what further information you would need to gain a full understanding of the child’s health. Think about how you could gather this information in a sensitive fashion.
· Consider how you could encourage parents or caregivers to be proactive toward the child’s health.
 
·        An explanation of the health issues and risks that are relevant to the child
 
·        Describe additional information you would need in order to further assess his or her weight-related health.
 
Answer
According to research that has been done, it shows that overweight is as a result of having a lifestyle that breaks some rules and regulations on how to exercise and the foods that one consumes.
Step-by-step explanation
On the issues of sensitivity it means the capacity to test someone who has the disease and detect it on the patient suffering from the disorder, specificity is the when a test is done and it found that there is no disease that is found when someone is screened, the positive predictive value is the potential of someone having the disorder while negative predictive value is the possible of those not having the disease in a particular population when the screening has been done. Children with overweight issues do have some issues that need to be handled effectively.
As caregivers and parents need there is need to guide the children who are overweight. This is because if this is done it will reduce the risk of the child having some complications like high blood pressure. The caregivers and parents need to follow the following interventions to be proactive about their children who are overweight;
a). The parent or the caregiver should be a good role model by taking healthy foods
b). Ensuring that talk to the child the need to be healthy and the measures one can take to be healthy always
c). Have a discussion on the necessity of having physical exercises and taking of healthy foods
d). Do every effort to make sure that the child have enough sleep
e). By avoiding serving large meals of food to the children
The risk factors of overweight are that one can develop some complications if not well controlled. To gain the full understanding of the child the interventions that has been advised by the nurse they should be followed always. They best way to gather the info ad the best sensitive fashion is by encouraging and following the required sources of information about overweight and the mechanisms that can be taken to regulate the disorder.
The relevant health issue that is available to be known about child overweight is that it can lead it can cause some physical conditions and complications such as asthma and bone fractures. Also, there are some social and emotional issues that can be as a result of overweight such depression and low self-esteem.
Assessing the overweight disorder a nurse has to look at the key issues like the blood pressure, the weight and the height, and the body mass index. These are the most important assessment that should be done on the patient.
The five-year old caregiver should be asked the following sensitive and specific questions on the overweight disorder;
a). The previous weight of the patient
b). The history of the family about the overweight and obesity
c). If the patient is depressed or stressed
It is crucial and critical parents and caregivers to be proactive and have measures and strategies on how to manage the weight of their children. The strategies include;
a). Minding the meals and drinks of the child
b). Ensuring that the caregiver or the parents tracks the intake of the food by the child
 
Another Answer
 
Danger Associated With Overweight
Being overweight can cause several health risks and issues such as diabetes due to high blood sugar, stroke, heart disease, high blood pressure, the liver disease, which occurs due to fats accumulating in the liver, and gall bladder disease, caused when the gall bladder is filled with gallstones.
Step-by-step explanation
Danger Associated With Overweight
Being overweight can cause several health risks and issues such as diabetes due to high blood sugar, stroke, heart disease, high blood pressure, the liver disease, which occurs due to fats accumulating in the liver, and gall bladder disease, caused when the gall bladder is filled with gallstones.
Additionally, I would like to find out what type of food the child eats, which would help understand the child’s health. I want to find out if the boy engages in any sporting activities in school or after school. I would also ask if overweight is hereditary, or it has only occurred for the boy and his parents. This would assist in further assessing the boy’s health.
Due to risk such as high blood pressure, where your heart needs to pump the blood harder due to the fats around the blood vessels, and stroke, which occurs when blood is not reaching the brain, I would like to find out if the boy has any other health issues now or before.
What type of food does the boy eat?
Since overweight is a disorder that can cause health risks, and sometimes it is hereditary, is it possible that the overweight in this family is hereditary?
Does the child have any other health issues?
First, I would educate the parents and caregivers about the risks and health complications of being overweight. I would encourage them to do more exercise and avoid eating fatty and sugary foods since this is the main cause of obesity. I would also give them real examples of people who have recovered from being overweight.

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Assign 1-WK7(G)

                                      Group Processes
Group therapy is an effective treatment option for a wide range of disorders and is much more cost-efficient than individual therapy. As a result, many insurance companies are showing preference for group therapy over individual therapy. This has led to more therapists including group therapy in their practices, making it very likely that you will facilitate group therapy in the future. To successfully develop groups and apply this therapeutic approach, it is essential for you to have an understanding of group processes and formation.
This week, as you examine group processes and stages of formation, you explore curative factors of groups and strategies for managing intragroup conflict. You also assess progress for a client family receiving psychotherapy and develop progress and privileged psychotherapy notes for the family.
 
                         Assignment: Group Processes and Stages of Formation
In your role, you must understand group processes and stages of formation, as this will help you develop groups and determine an individual’s appropriateness for group therapy. Whether you are at the beginning stages of group formation or facilitating a session for a developed group, it is important to consider factors that may influence individual client progress.
For this Assignment, as you examine the video Group Therapy: A Live Demonstration in this week’s Learning Resources, consider the group’s processes, stages of formation, and other factors that might impact the effectiveness of group therapy for clients.
                                                                                To prepare:
· Review this week’s Learning Resources and reflect on the insights they provide
on group processes.
· View the media, Group Therapy: A Live Demonstration, and consider the group
dynamics. (THE VIDEO TRANSCRIPT IS ATTACHED TO THIS ASSIGNMENT)
                                                           
                                               The Assignment
In 3-page paper, address the following:
· Explain the group’s processes and stage of formation.
· Explain curative factors that occurred in the group. Include how these factors
might impact client progress.
· Explain intragroup conflict that occurred and recommend strategies for
managing the conflict. Support your recommendations with evidence-based
literature.
N.B: REMEMBER TO INCLUDE INTRODUCTION, CONCLUSION AND REFERENCES
                                                              Learning Resources
Required Readings
Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books.
The Theory and Practice of Group Psychotherapy, 5th Edition by Yalom, Irvin D. ; Leszcz, Molyn. Copyright 2005 by Hachette Books Group. Reprinted by permission of Hachette Books Group via the Copyright Clearance Center.
Chapter 5, “The Therapist: Basic Tasks” (pp. 117–140)
Chapter 8, “The Selection of Clients” (pp. 231–258)
Chapter 9, “The Composition of Therapy Groups” (pp. 259–280)
Crane-Okada, R. (2012). The concept of presence in group psychotherapy: An operational definition. Perspectives in Psychiatric Care, 48(3), 156–164. doi:10.1111/j.1744-6163.2011.00320.x
Lerner, M. D., McLeod, B. D., & Mikami, A. Y. (2013). Preliminary evaluation of an observational measure of group cohesion for group psychotherapy. Journal of Clinical Psychology, 69(3), 191–208. doi:10.1002/jclp.21933
Nicholson, R. (2002). The dilemma of psychotherapy notes and HIPAA. Journal of AHIMA, 73(2), 38–39. Retrieved from http://library.ahima.org/doc?oid=58162#.V5J0__krLZ4http://library.ahima.org/doc?oid=58162#.V5J0__krLZ4 
U.S. Department of Health & Human Services. (n.d.). HIPAA privacy rule and sharing information related to mental health. Retrieved March 18, 2017, from http://www.hhs.gov/hipaa/for-professionals/special-topics/mental-health/ 
                                                    Required Media
Psychotherapy.net (Producer). (2011a). Group therapy: A live demonstration. [Video file]. Mill Valley, CA: Author. (SEE THE ATTACHED VIDEO TRANSCRIPT)
Optional Resources
American Counseling Association (Producer). (2015). Leading counseling groups with adults: A demonstration of the art of engagement. [Video file]. Alexandria, VA: Author.VICTOR YALOM: Hello, I’m Victor Yalom. I’m pleased to be here today with Dr. Irvin Yalom. He’s made outstanding contributions to the field of group and existential psychotherapy. He’s also written many books, both fiction and nonfiction, all revolving around psychotherapy themes. He’s also my father. Good to be here. IRVIN YALOM: Good to be here for me, too. VICTOR YALOM: In a few minutes, we’re about to see two demonstration groups that were filmed at the American Group Psychotherapy Association annual conference here in San Francisco. Prior to the groups, in your opening remarks, you set the stage for them, so we don’t need to do that here, but suffice it to say that the groups are inspired by your novel, The Schopenhauer Cure, which is really set in group therapy. And the groups are led by Molyn Leszcz, who is your co-author of the fifth edition of your text, The Theory and Practice of Group Psychotherapy. Now, that’s a big book, over 600 pages, so we can’t do justice to it here. But I think it would be helpful if you could summarize the core principles of your model of group psychotherapy. IRVIN YALOM: Basically, I want to make the point–and I do in there–that we’re really talking about group therapies. There are a tremendous number of different types of group therapies–more, it seems, every year–and we do talk about that in the text. But, this type of group that we’re going to be looking at today, I feel, is the central model of group therapy. And we can change it in many different ways to fit different clinical situations, different clinical populations, but primarily, it’s an interpersonal group. This is a group where we’re making the assumption–and it’s an assumption I believe very much–that people come to see us, for the most part, because they can’t establish and maintain nurturing, ongoing interpersonal relationships. VICTOR YALOM: Right. And when you say people come to see “us,” you’re meaning any therapist; not a group therapist, an individual therapist. IRVIN YALOM: Exactly. Any therapist. VICTOR YALOM: Even if they’re depressed or anxious, it often revolves around interpersonal themes, breakups– IRVIN YALOM: Exactly. Interpersonal isolation causes depression, and then depression makes that even worse. In the group, we focus very much on trying to change people’s interpersonal relationships. We try to do this quite directly by focusing on the relationships between people in the group. So this means–and this is what you’re going to see in these next two meetings–this means the group is focused very much on relationships between one another. VICTOR YALOM: This is what you call the here-and-now. IRVIN YALOM: Exactly, the here-and-now. These two groups stay very much in the here-and-now. You won’t hear people talking about the past very much, although sometimes that’s important for some period of time. But you don’t hear people talking about their outside lives. The great majority of the talk in these groups is on the relationships between the people. VICTOR YALOM: Now, of course, when you do this, or you explain it to people in preparation for a group, that seems somewhat counterintuitive to people, because they say, “Well, I’m not here to work on my relationships with people in the group. I’m here to make these changes in my life.” IRVIN YALOM: Right. Some of them won’t even know what you’re talking about. “I’ve got a problem with my boss. What’s talking about my relations with these people I’ll never see again?” But we have to disabuse them of that, and educate them about that. We do that throughout the group, but especially in the early preparatory meetings. We tell them, in effect, that the group is a kind of social microcosm. And by that, we mean that the group is a micro-representative of all kinds of outside issues that you’re going to encounter. With that patient you just mentioned, if you’re having trouble with the boss, great chances are you’re going to have some issues going on with someone in the group who you feel is very aggressive or authoritarian. VICTOR YALOM: Or if you’re a people-pleaser, and you take care of other people but never get your own needs met, that’s going to get reenacted in the relationships in the group. IRVIN YALOM: Absolutely. And the job of the therapist is to begin to call attention to that. “You know, I have a feeling you’re doing here what you’re doing out there.” Or if a person is self-effacing or if a person is grandiose or if a person is monopolistic or has no empathy for others, all these traits will unfold in a group that’s not relatively structured, and will go on for long periods of time. VICTOR YALOM: Providing that the therapist does his or her job, which is to focus the group on the relationships in the group. IRVIN YALOM: Right. And that’s the therapist’s main job in this group: to keep the group focused on the here-and-now. VICTOR YALOM: And that’s a hard skill to learn. IRVIN YALOM: It is. It is a complex group, and it takes a lot of learning. And it’s far more difficult to learn than you have a manual that tells you what to do [at that meeting] and certain kinds of homework. You really have to deal with any kind of issues that are presented by the group. VICTOR YALOM: All right. So, now, as we watch the first group, what should the viewer be looking for to get the most out of it? IRVIN YALOM: Well, look, for one thing, what the leader does. But, you know, these patients have already been trained. They’ve been in the group for quite a while, some of them for quite some time. So look what’s happening. See if the group stays in the here-and-now. Take a look at what happens with disclosure, when people disclose themselves. See how the therapist keeps the themes going in the group. See how much the therapist discloses about himself. Then there’s an unusual situation in this group. Take a look at what the presence of death–in that the leader himself has a fatal disease–what that is beginning to do to people. VICTOR YALOM: Okay, so let’s watch the group, and then you and I will reconvene afterwards. IRVIN YALOM: Glad to. I’m really looking forward to this afternoon. And I don’t know how many times I’ve said that to audiences without really meaning it. This time, I really mean it. I am very excited about this. How rare is it? In fact, it may be unique. This is the first time in history anything like this has been done, where a novelist gets to see his characters come alive; not coming alive in a screenplay or movie, which is more or less following the script of the book, but the characters that are created in my novel are just cut loose, like Pinocchio. And they may follow some things in the book, but the instructions are just to take off. No one will lead them. I told them all, “Don’t worry. Wherever you go or whatever track you do, Molyn will bring you back, as a good group therapist will.” So, they’re not going to follow the script of the book, with this one exception. The first meeting is going to start at a certain time in the book, and I need to give you some backstory. This is a backstory that, of course, Julius knows and all the other group members know, except for one–Pam–who’s been away for a couple of months and she’s just coming back into this meeting today. I have a lot of different reasons for writing this novel, but I’m going to stick simply to what’s relevant to our presentation today. But the major thing I want to say, I’m writing this novel as a way of teaching something about group therapy. And our major hope today is that the result of this is to help you in your group therapy practice. We want to help experienced group leaders feel more supported by our saying and doing things that you all do anyway in your groups, and we want to help beginning group therapists to get some kind of guidelines for how to work with an unusual group meeting. The novel starts, then the part that relates to this group starts with something that is very rare in a group but it’s not unknown–a
nd I’ve known such things–a group therapist getting a terrible, fatal illness. And he has been given a bad prognosis. It’s malignant melanoma. The doctor said, “We think you’ll get one good year of good-functioning life.” So, he is going to be able to function well for a year. That was how I picked out his disease, incidentally. I wanted somebody who could be in relatively good health for a year, and be able to work for a year. So I went through all the possible malignancies, the various things that people could get, talked to all my oncology friends, and malignant melanoma seemed to be the right disease to give poor Julius. Julius at that point went through in his mind what we will see everyone go through, and each of us, having to cope with the idea of his own non-being. He goes through a series of personal investigations; he goes through a great deal of panic; and then finally, the panic subsides–and I won’t go into this in depth–but with some aid of some philosophical help, especially using one of his own favorite philosophical writers–one of mine too, of course. He rereads some passages in Nietzsche, especially the passage surrounding the idea of eternal return, a very wacky kind of notion that Nietzsche developed. He meant it seriously at first, but later recognized it as a thought experiment; not a mere thought experiment, but a thought experiment that could change your life if you really listened to it. And the thought experiment was to imagine a demon coming to you one night, whispering into your ear that this life, as you have lived it, will return to you exactly again and again and again throughout all eternity, and that every event that happened will once again return to you. What would you feel? Would you curse me, as a demon, or would you perhaps bless me for bringing you the gladdest news in your life? So, the object of that, if we think about that, I do think this an important idea and concept in therapy. I use it all the time. The issue is, are you living your life in such a way that you would want this exact same life to be repeated again and again and again, throughout all eternity? Or, would you gnash your teeth and curse the demon? You never want to go through this life again. If that’s the case, then why? And then we get into the concept, in therapy, of regrets. What are you doing in your life that’s causing regrets? Then we can be much more therapeutic by flashing forward: what can we do so that one year from now, two years from now, you won’t have accumulated even more regrets? That helped Julius a great deal. And he thought about it, and he thought that he was living his life right–that he was extremely proud of spending his life having been a therapist. It was an extraordinary delight for him to be able to bring something to life in others, and he would go on living this last life in exactly the same way he had lived all his previous years. So that was why he decided that he would work and lead this group, which was a very important part of his practice. Those of you who are experienced group therapists know how important a really well functioning, long-term group can be. And maybe some of you have experienced the same thing that Julius did and I have, which is that a group often creates a helpful aura about it. It’s like a bath you go into. And it’s not only that all the members in the group may get better at once, but also the therapist is helped, too, by being in this group. So Julius was thinking that. He was thinking how glad he was he had spent his life in this fashion. He was thinking, then, of the people he had helped, wondering about contacting old patients that he’d seen 20, 30 years ago. Then, suddenly, he got the notion of patients he had failed with. And he thought, “Well, some of these failures aren’t really failures. Some of them are late bloomers.” We all know about the concept of patients who take something that they learned in therapy and start using it years later, when they’re ready for our premature interpretation. Julius had always dismissed failures as people who weren’t quite ready for his advanced brand of delivery. But he started thinking about his failures. And then, as he did–and he was looking in his chart room–his eye fell upon a very thick chart, the chart of a man named Philip–Philip, who is right here in this group. And he thought, if ever there were a failure, that was it. Philip had been somebody he’d seen 20 years before. He was a sex addict. He had worked two or three times a week with Philip for at least three years, and hadn’t budged him one inch. He felt absolute failure. Whatever happened to Philip? He’d never heard of him after he stopped therapy. And he began to get an impulsion to get in touch with Philip. The idea of seeing Philip again just sort of burrowed into him, just like the melanoma, and he determined to get in touch with Philip. Maybe he had helped him after all. Or maybe he still had another chance. Maybe he’s older now, and wiser and riper. Maybe he had something still to give. Maybe he could still redeem himself. So he got in touch with Philip. Saw him individually, in an individual session, only Philip said, “Please come to my office. I’m a counselor, too, now.” He had worked as a chemist. And then Julius still learned that Philip had been helped enormously–it changed his whole life. How? He said, “I decided that since our sessions–your sessions, mine–were totally worthless, and very expensive”–and he knew just how much money he had spent on this; Philip was quite tight–he said he decided he was going to read all the books of the Western canon of philosophy. He was going to find something in the accumulated wisdom of the last two thousand years that might be helpful to him. And, while he was doing that, he had a little money saved up and he decided he was going to switch fields and he was going to become a philosopher. So, he got his Ph.D. in philosophy. And, while at Columbia getting his doctorate, he met the perfect therapist for him, someone who had really cured him of his addiction. “Oh, who was that?” Julius was wondering. He was very excited about that. “In New York? What institute was he in?” “His name was Arthur,” Philip said. “Arthur Schopenhauer was the man to whom I owe my life.” So, Philip became a counselor, a philosopher, and then recently had turned to becoming a philosophical counselor, a new kind of development in our field, philosophers who set up shop and offer clinical philosophy consultation. Julius didn’t quite much like what he had seen in Philip–not only the idea that Philip confirmed that he had been useless to him, but also, he didn’t feel that Philip had really changed very much–that he still was the same aggressive, kind of schizoid, uncaring person he had always been. Imagine his surprise a short time later when Philip contacted him and asked him whether or not he, Julius, would be willing to supervise him. He needed a certain number of supervisory hours to get his license in counseling. He didn’t need it for practice, but it would help in other ways, in malpractice unintelligible or so. Julius was astonished at this. “Well, why would you call me when you say I’m a total failure?” “Well, that doesn’t mean you’re a bad therapist. It means you just weren’t good with me. You used the wrong kind of therapy.” Julius thought about it and he said, “No way I’ll supervise you.” And thought to himself, You’re about the worst candidate for being a therapist I’ve ever seen. You’re a hater. Therapy is a calling. You’ve got to care for people. He said, “No, I will never do that.” But then he began thinking about: if he didn’t do it, someone else would. Maybe there was still a chance to redeem himself after all. And he met with Philip at an individual session, and he offered a very strange bargain to Philip. And the bargain was “I agree that I will supervise you in your work if, and only if, you will spend six months in my therapy group.” The last thing in the world Philip wanted to do. Philip was like Schopenhauer. I built him, I constructed him, so that he was a Schopenhauer clone. And being together with other people, bei
ng close and being intimate, would be Schopenhauer’s and Philip’s personal view of hell. But that was the only way he was going to get his license. Philip agreed to come into this strange group as a member. And he had been there for about three meetings when this particular meeting occurred. What happened in those three meetings was that, much to Julius’ surprise, Philip ended up being somewhat–what should I say?–popular in the group. The group sort of valued his contributions, even though they were uttered in a kind of disembodied, uncaring way. But he uttered some wise things–wise things from Schopenhauer and Kierkegaard and Kant–and the group was impressed and felt helped by him. He even gave advice. He advised one of the members in the group, Gill, who will raise his hand, to leave his wife. “She’s a sinking ship. Get out of there and swim as fast as you can. She’s going to leave a big wave, but it’ll suck you down. Start swimming fast!” The group liked that Philip was giving advice to them. So, gradually, what was happening in the group was there was a growing integration of Philip, although not as a real member–he was kind of a disembodied person–but as someone who had concepts and a different way to do the therapy. A growing competition, perhaps, in a young counselor coming into the group in competition with an older, established, experienced–but dying–therapist. That’s one of the motifs that’s happening in this group. The other thing I need to tell you before we start the group is that one of the members, Pam, who is–would you raise your hand, Pam?–who has been an essential key member, kind of the life of the group. All group leaders know there’s one particular person who they don’t like to see absent from a meeting. It’s sort of the life in that group is in that person. She was well liked, and was a key part of that group. Julius liked her very much. But she had been become obsessed in a way that therapy was of no help to her. She got caught up with a lover and a husband. She wanted to leave her husband but her lover wouldn’t leave his wife for her. And she got so caught up with this, she finally took a friend’s advice and went away to India to a meditation retreat for a couple of months, which didn’t help too much, either. And after those two months, Pam returns to the group. People have been eagerly waiting in the group. So, Philip had already been meeting with the group for about four weeks. And then, they’d been getting some emails, and Julius announced to the group the previous meeting, he’d just gotten an email from Pam and she might well be coming back to this meeting. So, this meeting starts. Pam has just walked into the room, has been greeting two or three of the members that she first saw on entering the room. And now the group comes to life. MOLYN LESZCZ: Just before we move into the group therapy setting itself, a few other points. What we hope to be able to demonstrate–Irv has spoken about the existential theme and perspective. We’re also going to focus on the interpersonal perspective as well, using the group as the microcosm in which each individual person’s view of himself influences the way they relate. The way they relate impacts on others in the room–in the group, in their lives–and becomes a kind of self-fulfilling prophecy, a way to maintain a very familiar, albeit very unsatisfying, status quo. Part of the task of a therapist is to try to create a cohesive environment, a social microcosm, where people are able to bring themselves as they genuinely are. We don’t want people on their best behavior. We want them to be real. We want to focus as much as possible on interpersonal feedback–learning from one another, understanding how each person recreates his own environment in the room itself. One of the things that we talked about earlier when we met with the actors together–we have a wonderful cast of characters, I must tell you–is that many therapists, myself included, try to, before people come into a group, have a kind of formulation, or a kind of roadmap in my mind about each individual. Then I look for ways in which we can access that in the course of the group. So I am going to take advantage of that methodology to also flesh out a little bit about the characters beyond what Irv has said. This will also introduce you to the characters. Just before I do that, I want to also comment that we’re going to hopefully illuminate issues to do with therapist transparency, therapist disclosure, counter-transference–its use, its hazards–recognizing this is a bit more complicated than usual because Julius recognizes that he is failing physically. And, although cognitively intact, he knows he has a limited amount of time left to work with this group. But, as Irv commented, this is how he wants to spend his life. This is what revitalizes him. The group knows about this. Pam has learned about it through email before she comes into the group. We have heard about Philip–I’ll start at this end–schizoid, robotic, wanting to make himself completely devoid of any emotion or feeling that links him to people. Attachment emphasizes vulnerability as a recipe for his destruction. There’s a problem with his sexual addiction that he has dealt with by just withdrawing completely from human interaction and human feelings. Bonnie. Want to signal so people will know? Bonnie is a woman who has always seen herself as the frumpy, overweight girl; never part of the central circle; always feeling that any time she was a friend to someone, it was an imposition upon them. Someone who prefers to stay on the margins of life. Self-valuing, undercutting. Has difficulties with her daughter, and is divorced. Tony is a kind of archetype of a man’s man. Primal. Driven. As distant as Philip is from his primal instincts right now, Tony is right in there, knee-deep. There’s a kind of an animal, jungle quality that some of the women in the group quite like, and some of the men might even envy a bit. Tony sees himself as really in this kind of two-dimensional way. Pam, as Irv has commented, is just coming back. A university professor. Angry at men–angry in particular at men who disappoint and exploit, and men who fail because of their own lackings. And her anger is a powerful and formidable force. Gill is a man who Philip counseled about “Get away from your wife. She’s a sinking ship.” Gill does not really make a big presentation of himself in the group. He is more present by virtue of his absence. Soft. Kind of weak. Feeble, in some regards. Unwilling to hold his own emotions; unwilling really to speak his own mind in any substantive way. Rebecca is a woman who came into therapy because, at the age of 30, she recognized that for the first time, people were not stopping to eat when she would walk into a restaurant. She’d grown up all of her life feeling that her beauty was a key that would open any door. When she began to age and lose a sense of her unique beauty, looked inside and didn’t like what she saw. Has a sense of herself as only being the outside. Stuart is a pediatrician who’s in therapy, as we know happens sometimes, because his wife said to him, “If you don’t get into treatment, I’m leaving.” So, a decent man, but lacking emotional motivation, emotional conviction. There’s a very telling scene in the book. Stuart is identified in the group really as the group historian and the group camera: not a real participant, but someone who recalls the details without a lot of emotion. Had a dream about his daughter dying in quicksand, and he couldn’t rescue her because he was busy trying to get a camera to try to record what was happening. It is two-thirty now. We are going to meet in this group. In just a moment, we’re going to start; and once we’re in role, we’re in role for 55 minutes. Then Irv will lead a discussion –Irv will actually discuss and dissect what’s gone on. If any of you have had anxiety about having your work analyzed or scrutinized in supervision, this is a way to overcome any kind of apprehension that you might have. Then we’re going to take a break. Then we’re going to reconvene at a session a few sessions furt
her down the road. Then we will have ample time at the end of our afternoon again for Irv’s comments and critiques, and for your input and perspective. We want to make good use of that dialog at the end. We’re going to stop at 5:45 and ask you please to complete evaluations or critical reviews. I think we’re ready to begin. So, just to remind you, Pam has just returned to the group, has hugged and made contact with all the old members of the group, is just taking her seat now, absolutely overwhelmed by seeing Philip in the group that had been her haven and sanctuary. PAM: You insect! I’m floored! I came back here from India and I can’t believe this. I thought, I was so happy to see everybody. I was so happy to be coming back into the group, and now what do I find? You! JULIUS: You know Philip? PAM: We knew each other many years ago. Fifteen years ago. Can you elaborate on that, Philip? PHILIP: Greetings, Pam. Yes, 15 years ago, we indeed had an encounter. I would like to posit, perhaps, that that was 15 years ago, after all. And I’ve come a long way, and I hope that you have as well. PAM: Oh, just stop right–this is ridiculous, Julius. I can’t believe this. The man–15 years ago, he was my teacher assistant, which basically means he was teaching my class. I’m 18 years old. I’m a virgin. My best friend, Molly, falls in with this guy for three weeks in this class. So, he’s not only our teacher, but then he has a relationship with my best friend. Then, he drops her after three weeks, during which time, he deflowers me. He has sex with me two times and drops me, too. PHILIP: You’ve not heard me deny this, Pam, and I will not deny this. It is all true. I will– PAM: Look at him sitting there! I’m sorry, but you are the same as you were 15 years ago. I don’t know why this man is here. I’m feeling really threatened. PHILIP: You want me to take care of it? I’m just kidding you. I’m trying to quell the mood a little bit. JULIUS: Look, Pam, I’m really sorry about this. I know you came back already with a lot to deal with. I want to say I’m delighted to have you back. I’m stunned at this. It hasn’t happened to me ever before in 40 years of practice. And it’s clear you and Philip have had this history. I’m not sure how we should proceed. But I do very much want you to stay. PAM: I don’t know if I’m going to be able to stay. Julius, I heard about you and what you’re going through. I was very happy you called me on the phone and we talked about it. I was looking forward to coming back into the group. I don’t want to be dealing with this right now. I want to be talking about you, and what’s going on with Julius. And I’m just –I’m floored. REBECCA: Pam, no one wants you to leave. That’s not what this is about whatsoever. STUART: No one. REBECCA: Philip has been here for three weeks. You need to work this out, because Philip has had some really interesting comments for the group. STUART: He’s been very helpful. PAM: Very helpful? STUART: Well, he’s made some good suggestions. PAM: Look at how he’s sitting! He can’t even look at me! I really find this hard to believe. In fact, I find this to be something of a joke. This is my haven. This is where I come to feel safe. And now, the man–do you know that I am no longer friends with the person that –that whole incident broke up me and my best friend. We try to maintain an email relationship, but that’s nothing compared to what we were. That man–you–broke me! PHILIP: If I may– PAM: And broke up this relationship with my best friend. And you don’t even care. PHILIP: If I had a moment to comment upon some of these observations you have thrown my way, I might remind you that, of course, it was 15 years ago. Of course, you were a consensual participant in our action, as was your friend. I am here as part of a contract that I have with Julius, and which I intend to fulfill. I apologize that my hateful reminder sitting here, that you obviously despise this “insect,” as you stated earlier. But this is not something that I am responsible for. I exist. Here I am. And I have used this gaze to reflect inwardly, to look honestly at my intellectual faculties to come up with my view of the world. PAM: You’re just– PHILIP: I’m not affected by your hatred. I’m only affected by my own perception of the world. And this is where I gather strength, and this is where I suggest you could also foster some strength as well. JULIUS: I’ve got to ask you guys, how are you experiencing what’s happening so far? BONNIE: I feel like I don’t have any room to talk, because my husband left me and I don’t know anything about relationships, obviously, but– REBECCA: Bonnie, this really isn’t about you right now. TONY: I’m a little distraught over something I just heard you say just now, Philip, was about that you were here under a contract with Julius. And I was also hoping that you were here for us as well, to be a participant with us and to be part of the group. PHILIP: Being a part of the group is the essence of my contract with Julius. And therefore, I will learn and participate and, as you put it, be there for you. PAM: I don’t even see how this person can be a part of the group if his mandate is to act just like Schopenhauer, who was absolutely about detaching and not personalizing. Look what he just said. He just called deflowering his student a social interaction. He can’t even call me by name. How is this person going to help me by being here? I don’t see it. I don’t see how he’s going to help any of us. GILL: Well, I think already he has helped some of us. I’m sorry that you’ve had this relationship with him that makes you uncomfortable, but some of us need him here. He gave me a lot of good advice. He helped me to leave my wife, which obviously didn’t work out. But it was good advice, and it was a good step, and I just failed. JULIUS: Look, Pam, this is awful. I know how important this group has been for you. I want to know how glad I was that you were coming back. I had no idea about this. I hope you know that. PAM: Well, I appreciate you telling me that, because walking in here, I just felt like I was being punched in the stomach. JULIUS: I’m sure. BONNIE: I’m sorry, I just feel like, as important as this is, it just pales in comparison to you, Julius. I mean, we haven’t even talked about it. And I’m sorry that this situation came up but it just … PAM: I wanted to talk about how you’re feeling, too, Julius. I’m thrown, too. REBECCA: We’re all worried about you, Julius. BONNIE: Uh-huh. JULIUS: I appreciate that. And I want to say a couple of things. First, I’m glad, Bonnie, that you said what you did about me just a moment ago. I was kind of puzzled, Rebecca, by you, in essence, silencing Bonnie, and I wondered what motivated that. So, I’m glad that you didn’t stay silenced. And, talking about me, obviously we’re going to do that. We have to do that. But I don’t know right now whether that’s the priority. No, that’s okay. That’s okay. I’m alert to it. I know you have a lot of feelings about it. But I think the first thing we need to do, to determine, is whether we’re going to be able to work together as a group, whether you’re going to be able to work through this. There have been many times we have used these kinds of awful events as opportunities. What do you guys think? PAM: Well, Julius, that’s just the kind of thing that you’d usually say. And that’s just the kind of thing that pisses me off. But I’m not leaving my group. REBECCA: No one’s asking you to leave the group, Pam. STUART: Yeah. I think, in fact, there’s been a lot of encouragement for you to stay, and I believe that’s what Julius is saying now; that although this is a challenging time, it might be useful– PAM: Stuart, can you say something about how you feel? STUART: Well, there’s a lot of tension among all of us here in the group right now, and we’re feeling what’s happening between you and Philip is clearly very difficult. And I think we’d all like to know that the group is going to hold together, and that you can stay and attempt to work these things out. TONY: Has anybody heard a feeling yet from Stuart? REBECCA: No. BONNIE: I have. STUART: I feel–I f
eel that I would like you to stay. JULIUS: That’s a feeling. That’s a feeling. BNNIE: I’m sorry, I would just like to point out that how can he share a feeling if he’s not within the group? His chair is removed from the circle. STUART: I’m sorry. BONNIE: Thank you, Stuart. TONY: Something that came up for me, Julius, if I may, is that you were asking to not talk about this right now. PAM: Yes. TONY: How does that feel for the group? Can we table this to another time, or is there some sort of resolve that should happen now? GILL: Well, it seems like Julius was asking whether we’re okay to continue. And I think as long as we know that Pam’s going to stay in the group, I’d be okay with us moving on. PHILIP: Tony, some clarification. Are you speaking now of the situation with Julius or the situation between Pam and myself? TONY: I was talking about the situation between Pam and you. PHILIP: I am completely able to continue. I would like to make an observation. A lot of concern has been put the way of your old and dearly beloved member, Pam. And I’ve not noticed one question about whether Philip–myself–shall be staying in the group. This is something that doesn’t affect me, because I do not take my personal worth from the views of others, so that is all. REBECCA: I, for one, would like you to stay, Philip. I think you’ve been absolutely fabulous in this group, and I’ve enjoyed you every second that you’ve been here since you joined. TONY: You would. REBECCA: Hm? TONY: I mean, since the first day he came in here, you were preening and, you know, making flirtatious– REBECCA: Oh, that was flirtatious? I’m sorry. I didn’t realize that when we actually spoke in groups to members of the opposite sex that that was flirtation. BONNIE: I think she’s having trouble hearing you, Tony. Every time we try to give you some sort of criticism or feedback, you just get defensive. And I agree; I think that since the moment that he came in here, you’ve been un-taking and re-putting up your hair and putting on your makeup and general preening for him. REBECCA: Well, thank you, Bonnie, for that really incredibly sensitive statement. Thanks. TONY: I’ve just been noticing that your behavior has been a little different since Philip’s been in the room, so I can understand why you would want him to stay. PAM: I’m just pretty disgusted by that, this thinking that you’d even find him attractive. REBECCA: Okay. “Hi!” At what point did this become flirting? At what point did I say, “Philip, I want to fuck you?” Huh? Did I say that? No. I said, “Philip, thank you for your comments. I appreciate you being in the group, and I think a little new blood in here has actually been a very good thing for all of us.” BONNIE: I don’t think that you’re facing the reason that you came into this group, which was because you don’t feel beautiful anymore, and that you’re not getting the attention that you desire. I’m sorry. I’m sorry. I might not know what I’m talking about, but I think that you need to face that, and that Philip’s presence here is good for all of us, including facing your own issues with needing other people’s attention and approval to feel self-worthy. PHILIP: If I might butt in here. This self-worth is something that I think the great philosophers of our time have something helpful to add, which is if you find your self-worth from the eyes of others–which I believe you are being accused of–this will always go up and down and vary day to day and even minute to minute. But, if you instead take that self-worth inwardly, to the rock foundation of your own self, this is something you can supply yourself with, if not happiness, a cessation from suffering. REBECCA: Thank you, Philip. PAM: Is anyone aware that he can’t make eye contact with anybody in the group? Did anybody else notice that? BONNIE: Uh-huh. PAM: Does it make anybody else uncomfortable? BONNIE: Uh-huh. GILL: Well, Pam, maybe if you’d listen to what he was saying instead of focus on where he’s looking. I think you’re rolling your eyes every time he speaks, and you’re not listening to him. PAM: Gill, I’m having a really hard time just by his being here, okay? And if you knew anything about Schopenhauer, you would know that the man has no social skills at all. I wanted to study him earlier on in my education, but no. I started looking into how he lived his life, his personal life. Sure, he’s a great writer, but come on. The guy had no friends. The guy was totally disconnected from everybody. PHILIP: And thus, my point is established yet again. One of the world’s greatest philosophers, who made a foundation of his work–and the wisdom that we shall remember for centuries–founded upon a foundation of looking inwardly and not to the bobbing cork of outside up-and-down opinion, public opinion–the opinion of others, the opinion that will always vary. It goes with fashion. It is fashionable, the opinion of others. PAM: Julius, I’m at a loss. TONY: And Philip, that’s the most I’ve seen you almost emotional about something in this group. PHILIP: I do apologize. PAM: I’m at a loss as to why you would think that his addition into this group would be important and functional to our group. PHILIP: Perhaps a novel approach to therapy itself is useful. I posit the philosophical counselor as a new approach. This delving into my feelings about this, my feelings about that–perhaps we need to rise above that to a new and different approach. Perhaps this is why I’m popular. BONNIE: I would have to say that I appreciate everything that you’ve said to me. But I feel like he’s just discounting my feelings, which is why I came in here. TONY: I don’t understand. Philip? BONNIE: Philip is discounting my feelings. I feel like he’s telling me that what I feel isn’t important and I should just not care about any of you, the way that I feel like nobody cares about me. PHILIP: A word of reassurance, Bonnie. I discount my own feelings and the feelings of others, but I do in no way discount you, Bonnie. PAM: I’ve forgotten what we were really talking about here. REBECCA: I thought that we were talking about Julius. STUART: We did say, in fact, that we were comfortable tabling this conversation between Pam and Philip until next week, and it seems as if we’ve come back to that instead of talking about the larger issue. TONY: The last question was whether, almost, Stuart, that you were curious why Philip was brought into the group by Julius? STUART: Yes, I believe she said, “How would that help any of us in our process?” JULIUS: I’m going to jump in, because there is an awful lot going on. And, I have to say, as awful as we started, I have a certain hopefulness that this is going to really be more productive, Pam, than I think it feels for you right now. Let’s try to reflect on what’s been happening so far, because I think if we back up a little bit, I think, Tony, you were right in your comment about Philip having a feeling. In fact, if we go back a few minutes, Philip, you said that no one has considered whether you would choose to stay in this meeting. And to me, that’s the first thing that smells like a feeling from you–that this is upsetting for you.. This is hard for you. That there’s something going on with Pam’s reaction that is causing you to feel frustrated. PHILIP: Let me examine that. JULIUS: Stuart? STUART: Yes? JULIUS: Could you help him? STUART: Well, he did ask whether anybody else – yes, he noted that everyone had asked Pam about whether or not she was going to be comfortable staying in the room, and it seemed quite important for people to have that sense of reassurance. And Philip at that point noted that no one had asked whether he were going to stay in the room. And, as you say, it was the first time that he’d said something that almost resembled a feeling, after which Pam pointed out– JULIUS: Stuart. STUART: –that he wasn’t looking at anyone. JULIUS: Stuart. STUART: Yes? JULIUS: When I asked you if you could help Philip right now, what do you think I had in mind? STUART: What he’s feeling right now. JULIUS: And are you able to access that? STUART: I can try, yeah. Well, Philip, it sounds as if you’re having an emoti
onal response right now about the attention that the group is paying to you. How does that feel? PHILIP: Thank you for the observation, Stuart. Let me look into that. And my first thought upon this is I believe I’m being misunderstood. It’s not so much a feeling as I was pointing out merely an inconsistency, and I wanted to know if this was how –I’m a student of group therapy and therapy in general–is this how I am to act in the future as a counselor or therapist? This sort of inconsistency? I didn’t think that that was how one was supposed to behave. STUART: What inconsistency? Can you put your finger on that? PHILIP: Of course. I shall repeat it one more time. The inconsistency of Pam being asked to remain, repeatedly, in the group, and the absence of that same request towards my person. STUART: It does seem we have a longstanding relationship with Pam, and I think maybe that was the source of tension for a lot of people here, was that she seemed uncomfortable in a way that we’re not used to seeing. PHILIP: It is duly noted. JULIUS: I’m going to jump in again, because there is a lot going on here, and I think it would be useful if we could reflect on that. And I’m hoping –obviously, we’re not going to resolve, Pam, your obvious distress with Philip–what happened 15 years ago, 18 years ago–right at this moment. But do we have a commitment from you, and from you, Philip–because I think it’s important for the group to know this–that we’re going to try to continue to work with this? Because I think it’s very unsettling for the group if people are concerned that one of you is going to drop out. TONY: I mean, we’re already concerned enough with you dropping out. JULIUS: Well, I haven’t thought about it in those terms. TONY: Sorry to say it that way. JULIUS: Yeah, but I’m sure that’s a source of real concern. TONY: The whole group process is kind of tenuous. GILL: Yeah. JULIUS: You know, that’s such an astute observation, Tony. TONY: Thanks. It just feels that everything we’ve been working on is … I don’t know, it just doesn’t … it’s not as easy anymore, because … I don’t even know how to put my finger on it. It’s like … I’m just worried, kind of like what Pam was saying, about just this as almost a safe haven. And how much longer … I don’t know, I can’t– STUART: You’re concerned that it feels finite now? TONY: Yeah. I mean, a year. And I love this group, and I need this therapy because I really don’t have anything like it in my life right now. I mean, talking to you guys about me, and finding out more about how I interact, is necessary for me to be able to, I don’t know, live a better life, I guess. JULIUS: I have a comment and a question. TONY: Uh-huh. JULIUS: The comment is that I sense we have an agreement that we’re going to continue to try to work together, in the face of this, and in the face of my illness. Am I correct? PAM: I’m not leaving my group. JULIUS: Okay. I’m really glad to hear that. PHILIP: I shall remain as well. JULIUS: I’m very glad also, Philip, to hear that. TONY: I’ll stay. JULIUS: But Tony, you said something –I’ve got to tell you guys, my head right now is filled with so many different ideas. And I’m aware that if I raise one, it means we’re not going to pursue another one right now. But let me tell you what I’m thinking about. I’m thinking, Tony, about what you value so much about this group that you don’t want to see it end. I’d like us to flesh that out. Bonnie, you’re more in the group today than you’ve been for a while. And I’m not sure what’s going on between you and Rebecca, but, Rebecca, there’s some tension there that would really be productive for us to look at. And, I mean, you were really outraged in response to that feedback about preening. And there’s other stuff, too. And I’m not oblivious to the fact–even though obviously I’m not delighted at the prospect of talking about it–about the impact on you of my being unwell. But I can reassure you that right now, I’m fine. And, in fact, I feel quite a lot of energy being with you guys. And I’m confident in my doctor’s prognosis that I’m going to be good for the next several months. So we’ve got a chunk of time. It’s not an infinite amount of time, but it’s a chunk of time, and I want us to make the best use of it TONY: And you’ve also said, you know, it’s important for us to kind of be here now, in the group, as opposed to –I guess I was just thinking about the future and how –the impermanence of it all. PAM: Tony, I just really want to thank you for expressing yourself, and putting yourself out there. I think that’s great. And I have to say, you know, just being back from India, I thought a lot about the group. And I thought a lot about each of you. And Gill, I actually didn’t think about you. I didn’t think about you at all. And I have to say, I didn’t think about you because I don’t see you putting it out there in the group. I don’t have–who is Gill? I don’t really know who you are, And I needed to say that, you know? Other people, they’re involved. And Gill, when you talk about things, I don’t see Gill. JULIUS: That’s really important feedback. GILL: But I don’t know what to say. I think I’ve shared a lot with this group. Over my marriage, and over the past year or two, I’ve laid everything out there that I’ve come to say. PAM: We know a lot about how Rose feels about you. I don’t know that I see you. GILL: Well, in my dealings with Rose, I just let her do whatever she wants. I mean, the– PAM: And isn’t that the problem, too? REBECCA: You did go back to her after four hours. GILL: Well, about that, I appreciate the support you guys gave me. And, of course, I appreciate you offering me a place to stay. STUART: That was Bonnie. GILL: All of you, in the support in that. STUART: Can I just–Pam, I think maybe there was one thing that you missed while you were gone was Gill actually brought a lot of information to the table about his relationship with Rose and the problems they were having. I just– PAM: Yeah, I got a little filled in from Julius. STUART: He may be feeling a little attacked for– PAM: I was just making an observation about how each person felt to me when I was gone, and I just needed to say that. GILL: I think maybe I shared more when you were gone. Everyone else in this group I feel listens, and I feel comfortable with. But honestly, you’ve always been sort of the Supreme Court justice to me, the judge, when I look at the group. JULIUS: That sounds like it’s really important. Can you say more? Are you okay with this, Pam? I know you’re just back now and– STUART: She did bring it up– PAM: I’m pretty tapped out in terms of –I mean, I needed to make that comment, you know, about India. But I don’t need to deal with too much more. I’m fine with –take it away, Julius. REBECCA: You did bring it up. STUART: Yeah. JULIUS: I think we should respect the fact that you’re feeling tapped out, but your feedback to Gill about him not having any kind of place in your internal world, where everybody else in this room did, is very important feedback. We don’t know, Gill, what your relationship is like with Rose. I have to say, I was very concerned at the way in which the group kind of encouraged you to leave her, without us really knowing fully what’s going on on the other side. So the question I want to ask you is what kind of place would you like to have in Pam’s internal world? How would you like to be known? GILL: I guess I would like to be known as, I think, just as Gill, not as her judgment of me and what she puts on me with what I’ve done. When I talk about Rose, I talk about how she’s controlling of me. She won’t let me have what I want. She won’t give me a child. And it seems to me that you seem to think that’s all my fault. PAM: I just don’t feel like you’re really coming to the table. JULIUS: Any feedback for Gill? Any help for Gill? BONNIE: I’d like to tell Gill I feel the same way. I feel that I know a lot about how people around you feel. Even when you share stories from when you were younger, you tell us about how people are feeling. And if you could share anything right now that would be about you, that would be
–I’m sorry, I’m sorry I’m stuttering–that would be about you right now to let us in, would be great. JULIUS: Bonnie, you don’t need to say “I’m sorry” every time you have a comment to make. Are you aware that you do that? BONNIE: Yeah. Yes. I just feel like I’m wrong. JULIUS: You just feel like what? BONNIE: I’m wrong. I don’t know. JULIUS: Could we flag that and come back to that in a moment? BONNIE: Uh-huh. JULIUS: Because I think that you’re on to something really important with Gill. So, I’m going to ask you to push him. Can you do that? BONNIE: Uh-huh. I think so. So, Gill, in your relationship with Rose, you talk a lot about how she’s very controlling and she won’t give you a child and she’s cold to you. Is there any reason why you might think that she would act that way? GILL: I just still am having a hard time feeling that what’s going on in my life is all that important, Julius. I can only imagine what you’re going through, and here I am complaining about a nagging wife. I mean, in the end, so maybe I don’t have a child. Maybe I’m not supposed to have a child. JULIUS: What would it be like–We don’t have Rose here. We only can imagine what Rose is like. But let me ask you this question–Rebecca, Bonnie, Pam–if you were married to Gill, based upon what you know of Gill through this group, what would it be like to be his wife? How would that feel? PAM: It would feel like I was outside knocking on a door. And then, I would have to knock louder and knock harder and do different things in order to get attention. REBECCA: I was going to say something similar, actually. I would feel like I was screaming at a wall, trying to get through to you. JULIUS: That’s a lot of feedback, Gill. There’s a lot in there. GILL: Yeah, I appreciate that. JULIUS: So if you were to remove some of that wall, what would come out? What would get inside of Pam’s internal world about you? GILL: I think that I am a very caring person, and I think you would see that. And what I’m looking for is to give the best to somebody. I feel that maybe you or maybe Rose are just not open to receiving that. BONNIE: But you’re still talking about other people, Gill. REBECCA: You’re deflecting. GILL: Okay. JULIUS: Something is breaking down. You see yourself as a good, decent, caring man, and Pam has no sense of you inside of her. And Rebecca and Bonnie are saying the same thing. They’re knocking on a door. No one’s home. No one’s coming to the door. They’re withering on the vine. GILL: So, something about myself that hasn’t been–I’ve been dealing with a problem with alcohol for a long time now. STUART: What? BONNIE: What does dealing with a problem with alcohol exactly mean, Gill? REBECCA: He’s an alcoholic. BONNIE: That’s not what it means. He didn’t say that. GILL: I think she’s right, Rebecca’s right, though. That’s right. TONY: How is that affecting your marriage? GILL: Well, I would say it affects it a lot, because what Rose and I had–a lot of what we do, when we meet with our friends, what we do is we go to wine tastings. PAM: Gill, when are you doing this? How long have you been here? How long have you been doing this? You’ve been coming here for like weeks and months. STUART: Three years, I think, almost three years. GILL: It’s hard to say–the thing is, there’s no line where you say, “Oh, hey, now I’m an alcoholic.” JULIUS: Is Rebecca right? Is Rebecca right that your problems are of that kind of proportion? GILL: I would say they are. BONNIE: How often are you drinking? REBECCA: How much do you drink? GILL: Every night. BONNIE: Where do you do it? GILL: At home. REBECCA: Does she not know? GILL: Oh, Rose knows. Yeah, I come home and I –she won’t drink with me anymore. That was what we’d do with our friends. I’d come home, have a couple glasses of wine, something good, and then I move on to some scotch. BONNIE: And all this talk about Rose being such a frigid bitch and she won’t give you a child? No wonder she won’t. REBECCA: No wonder she won’t give you a child. BONNIE: I don’t want to say that. Thank you for sharing. I’m sorry. JULIUS: You’re putting yourself, Bonnie, into Rose’s shoes a little bit there. BONNIE: Uh-huh. JULIUS: What’s it like for people to hear this now? PAM: Well, that was a little bit of coming to the table. STUART: Yeah. PAM: Good job, Gill. REBECCA: I feel like we’re all in this group to talk about those kinds of things, and to say, “At what point do you bring it in?”–I mean, this is group therapy. This is what we do, we come here and talk. So, I feel like maybe you’ve been hiding this for a reason. GILL: I wouldn’t say hiding. When I come to the meetings every week, that’s the first thing on my mind. That’s what I come to say. But it always seems like something else comes up in the group, there are more important things to talk about–especially now. JULIUS: What’s it been like, Gill, to come here session after session after session, thinking that “Tonight’s the night, I’m going to talk about this very important part of my life,” and never do it? What’s it like? What’s it been like? GILL: It’s almost like relief every time I don’t talk about it. You know, building it up beforehand, and then I come through to the group and talk to people, but not saying it has been a relief, but not as big a relief as saying it. The one thing I was hoping was that when I did come out with this, you guys –what I was afraid of, I guess, is that you wouldn’t let me be part of the group anymore; that because of this problem, you would make me leave and go to AA and wouldn’t let me come. JULIUS: So you’ve really been frightened of our judgment, not just Pam’s. GILL: Not just Pam’s, everybody. That’s the way people look at alcoholics. REBECCA: Gill, no one is sending you to AA. TONY: Unless you want to go. BONNIE: And we’ll support you. TONY: Not that I want you to go or leave or anything like that. I’m just saying that– REBECCA: We won’t make you go. TONY: –it is a possibility. JULIUS: In fact, it doesn’t mean that Gill couldn’t continue with us. So let’s not throw that option out. But I think right now what we need to look at is you being able to bring this to us today. What’s made it possible today? Months and months of not, and tonight, you’ve been able to. GILL: I guess I just couldn’t keep it anymore. So much has been happening. And I wanted you to know. JULIUS: Me in particular? Say more. GILL: Well, I feel like I’ve been keeping that, well, from everyone. But especially you, with what’s going on now, I feel like I failed everybody just by keeping that from you. Like I haven’t lived up to my part of the bargain, I guess. JULIUS: You want to own that, living up to your part of the bargain. REBECCA: Can I say something? JULIUS: Just before you do, Rebecca, I think it’s really important that we not miss that last comment. You want to own up to your part of the bargain, which I think is an incredibly important statement for you to make. Do you feel that? GILL: I do, yeah. JULIUS: If you track the emotion that’s attached to that, where does it take you? GILL: I think it starts with shame. And I think it ends up with a bit of pride in taking ownership over. JULIUS: Yeah. I cut you off, Rebecca, but I just didn’t want to lose that. And I see you nodding your head in response to what Gill’s just been saying. REBECCA: Well, I was just going to say in response that over the last year, you keep talking about Rose, and I know that it’s come up a number of times that she won’t give you a child. And though it’s not word for word, you’re basically saying she’s not holding up her end of the bargain of your marriage. And I think, with you saying that just now, I feel like that’s a very big revelation, because maybe you’re not upholding your part of the bargain. I’m not trying to give you shame, but I’m saying that maybe we now know a little bit more of where Rose is coming from. GILL: I think you’re right. JULIUS: What’s it going to be like going home tonight, Gill, after tonight’s meeting? GILL: It’s going to be hard. Rose and I don’t really talk a whole lot right now, so I’m not really sure what I should tell her about today–or our friends. JULIUS: Other react
ions? Comments? Feedback for Gill? Tony, I’m having a little trouble seeing Bonnie. Could I trouble you to move back? Would you mind? BONNIE: Oh, that’s okay. You don’t need to– JULIUS: I just realized that I haven’t been able to see you for the last 20 minutes. BONNIE: I sometimes feel that way in my life. So, I’m used to that. It’s okay. What were you going to say, Philip? TONY: Bonnie, you don’t need to be so accepting of the fact that that’s okay, that you don’t feel seen. BONNIE: Well, I feel like Philip was asked a question that he didn’t get to answer. PHILIP: I did have a comment for Gill. Gill, I’m one who, at one point in my life, struggled with addiction, although it was of a different form. It was a sexual addiction. And I just want to tell you that what you’ve done today is just a very important first step, and congratulations. TONY: Congratulations. REBECCA: Congratulations, Gill. GILL: Thanks. PAM: I want to say, I feel like I’ve been in the room with a stranger. I mean, to reveal this after knowing you for so long. And I’m really feeling for Rose right now. I’m seeing her in a whole different light and that’s just throwing me. BONNIE: I feel like it’s really important that we support Gill in sharing information and not judge him, Pam. JULIUS: You’re going to stick to that position, Bonnie? BONNIE: Uh-huh. JULIUS: I notice you didn’t retract it. BONNIE: Huh-uh. JULIUS: You didn’t say “sorry.” Even added, for emphasis, “Pam.” BONNIE: I just feel very judged–and I know how Gill feels–by Rebecca. REBECCA: You want to talk about that, Bonnie? STUART: Pam did bring up the –you sort of began this with an attack on Gill and his admission is a response to that. PAM: I was speaking truthfully. And I didn’t feel like I was attacking Gill. It was something that was very strong for me that I realized when I was sitting vipassana in India. Gill was nowhere in there. And now, Gill, you’re somewhere. You’re right here right now. And that’s – PHILIP: Due to you, Pam. TONY: Yeah, I mean, Pam, you were a catalyst, in a sense, by calling you out, Gill, and allowing you the opportunity to share what you’ve been holding back from telling us. REBECCA: You asked a question. PHILIP: But the victory is to Gill, not to Pam. TONY: Could you elaborate on that at all? PHILIP: I’ve been noticing in Pam’s brief inclusion, as I’ve been a member of the group, that it does seem to be Pam-centric. Gill has a great personal growth and revelation and it comes back to Pam. No more, no less. PAM: You know, I think I said a long time ago in this session that I was tapped out, and really didn’t need to have the focus on me. PHILIP: And there you are again. PAM: Gill came up with something, and now Bonnie’s come up with something. Can we bring that back? TONY: Knowing that you’re tapped out, is there a way you can receive what Philip just said and not today have to deal with it? Rebecca was right earlier when she said that–or was it you, Gill, that said–you often dismiss what Philip’s been saying? Just saying that you don’t have to deal with it right now but – PAM: Okay, I’ll think about it. JULIUS: Okay. BONNIE: Can I make a comment? JULIUS: You don’t need to raise your hand to make a comment. REBECCA: May I talk in the group? JULIUS: You don’t need to. REBECCA: Good. Stuart has removed himself from the circle again. STUART: Sorry. PHILIP: And what effect did that have on you? REBECCA: Well, I just kept having to turn to see where he was, and he’s incessantly clicking his pen. STUART: Thank you. REBECCA: I’m not angry, it was just bothering me. JULIUS: If you weren’t doing this with your pen, what might you be doing? STUART: Well, I think there’s a lot that’s been going on. I don’t want to take the attention. The focus doesn’t need to be on me right now. Clearly, there’s a lot of energy happening in the room right now. JULIUS: And your relationship to that energy? STUART: Well, I felt the one comment that I did make a few moments ago sort of got shot down by Pam. And my intent was not to attack, but merely to recount the sequence of events that we had gone through. So, I didn’t feel like I was adding anything productive, or it wasn’t received as such by the group. And that’s okay. That’s okay. JULIUS: It’s okay, yet you’re clicking your pen and inching back away from the rest of the group. STUART: I was not intentionally. I apologize. It didn’t even notice until Rebecca said something about it. JULIUS: But you’re communicating something, obviously, that Rebecca picked up on. STUART: I guess, again, I feel like there were some bigger issues at play that maybe I wasn’t a part of, that were happening in the room just then. And I didn’t want to get in the way of those things working themselves out. JULIUS: You didn’t want to get in the way. STUART: Well, I felt that the few times I spoke were not helpful. Or didn’t seem to be helpful. Or they didn’t feel helpful to me. I felt a little disregarded. REBECCA: Stuart just said “feel.” BONNIE: I assure you, I feel that way, too. A lot. TONY: Which way? BONNIE: Disregarded by the group. TONY: All the time? BONNIE: Yes. I mean, Rebecca is so deft at getting the attention brought back to her. Even though she’s talking about somebody else, she’s really talking about herself so that she can get attention. And you always listen to her and give you all of your focus, and I sometimes feel like –may I ask a question to all of you? TONY: Please. BONNIE: Why do you not look me in the eye when I talk, and listen a lot? Why don’t you give me the attention sometimes I feel like you give Rebecca, because she is beautiful? TONY: I’m not really aware that I don’t give you that attention, from my perspective, in answering your question. BONNIE: Just the other session, I was talking about my daughter, and we brought up about the bar that she went to. And you had a story about the bar fight that you had there, and we just dropped all conversation about– JULIUS: Bonnie, I’m aware of the time. I know, I know. But that’s why I want to speak to you. I hope that you’re going to be able to hear me, that I wish we had more time right now. BONNIE: I wish we had more time together, too. JULIUS: Yeah, but we have more time next session and the session after that and after that. And I think that we have done a lot of work today. And again, Pam, it’s great having you back. PAM: Thanks, Julius. JULIUS: I know this has been hard. We’ve got lots of stuff to talk about. But we opened up a lot of really great issues. And your comment, Bonnie, when you addressed Pam directly about judgment, I think is something worth looking at. Because I would hate, Gill, for you to leave this meeting feeling criticized for finally speaking to us. It’s very important that we be able to recognize how important it is for you to bring that here, and not punish you for not having been able to do it before. That’s really an important point. You’ve been instrumental, Bonnie, in bringing that forward. And when you say, “How come no one looks at me?” my response is it is good that you are able to recognize that, and you want to push us to look at that with you. We have worked, I think, a lot today. I’m going to stop now. I look forward to seeing you all next week. IRVIN YALOM: Interesting. Very interesting meeting. Very odd experience for me to hear this, because I wrote this group in another fashion, and I feel critical at some level for them not doing it the way I said to do it. They’re getting to some of the same issues. I have to really get that set out of my mind and just pretend this is a pure, new meeting, the members struggling and doing things in an entirely different way. You may take note, I don’t think Molyn made a single comment today that wasn’t on the process. I can’t remember a single one. And every comment he made had something to do with what was going with some member of the group or other members of the group. It was all addressed. It wasn’t outside stuff. It was all what’s going on here in the group. I do the same thing. I rarely make comments in the group that aren’t in the here-and-now. Molyn started off saying he’s a little worried about –that’s f
unny, because the theme came up in the meeting, wasn’t it, about being judged? And that was an important issue, because Gill felt he was going to be judged by others in the group. He commented that Pam was the chief justice in here. And I think we got at that in an interesting way. It was a slightly different way in the novel, which was if somebody talks about –Molyn did it in this way. Let’s make a backtrack. He makes a comment that he’s an alcoholic, and the group immediately is jumping on that issue–how much do you drink, when? Outraged they hadn’t heard this before. All these things. But Molyn goes back to a cardinal rule of group therapy, which is when people make a revelation, they should not be punished for it in any way. So, he wanted to make sure that Gill wasn’t being punished. And instead, he tried to focus onto process. Not “How much did you drink?” But “What was it like for you to tell us that today?” And then, he even pushed back even further. “What was it like for you to come to this meeting other times and not tell us today?” You see? And then that led into–that could lead into, it wasn’t quite in that sequence in this group, but that would lead into Gill saying, “I was afraid to mention that in this group.” And then, you could say, “What were you afraid of?” “Oh, I’d be judged.” And then, it’s almost reflex on the group therapist’s part, because you say, “You’ll be judged by whom?” People say by everybody. Never buy it. They don’t feel the same about every person in the group. So, you ask them, “Who? Who are the judges in this room?” And that’s, in another version of this meeting, that’s how he got to the chief justice, to Pam, and other people began to talk about their sense of Pam’s judgmentalism also. Almost all the members, first of all, they had to deal a lot with this very, very strange situation, with Pam coming into a meeting where she’s been away for a few meetings. She sees someone in there who had been someone who had been very destructive to her in her life, and she’s full of rage. And, in the way that the group could take place, that could be a chief problem in the group. Molyn did what a therapist has to do. The main thing he’s got to do is to keep the group intact. If the group’s not intact, if the group explodes, then you don’t have anything to work with. So, he’s worried about group cohesion, he’s worried about keeping everyone in the group. He’s getting commitments from each of those members to stay in the group. They’re both pretty stubborn. Philip is saying, in effect, “I paid my six months. I’m going to pay my six months. I may have already. I ain’t leaving no matter what.” And then, Pam is also encouraged to stay because of her long-term and pretty loving relationship with the other members of the group. So, once we get that, we know that we have a big problem there, and we have to see how far it can go. So, the group members and the leader kind of found out from Pam, “How much can you take today?” Members will feel a little bit more in control if there’s a drastic situation and they get to monitor it. They can at least say, “I can do about five more minutes of this.” Or, “I’m just about tapped out at this point.” So, have them –he kept going back to Pam and letting her control about how much of this could she take today. Once both members are in the group, you can bet that two members in great conflict with one another, chances are, they will be two very important members to one another. They will be important. When the group is over years later, they will say they really learned a great deal from that person being in the group. In fact, in the novel, the last chapter starts just with that observation. So, each member got talked about. There was a question of Rebecca preening for Philip and some comments about Stuart being a camera, about Stuart’s chair being pushed slightly out of the circle. That’s a little autobiographical one for me. There was a group that I was meeting with for some time, and suddenly one of the members noticed, “Your chair,” to one of the members, “is always out of the circle. Not much–an inch or two–but it’s always there.” That was an enormously important intervention as we began to get into the fact that he’s never entirely there. And now, we understood why he came in saying, “My wife keeps saying I am not present. I’m there, I’ve there with her, but I ain’t present.” So, in the group, there was that microcosm, a kind of metaphor, where he was not quite present in the group. So on a number of occasions, Stuart talked and the group members began to question “Well, where’s the feeling in there?” At one point, he said, “I would like you to stay” as his feeling. Well, there’s a little bit of a feeling in there. It wasn’t much. Molyn gave him the benefit of the doubt for that being a feeling. I wouldn’t have. But Molyn started this meeting saying that he has this concern about being supervised by me. That feels sort of strange. For years and years and years, when I was lecturing to large audiences, I had the secret internal image of fear as I talked that sometime some gray-haired analytic eminence was going to stand up and say, “This is bullshit!” But for a long time now, I’ve never had to worry about that, because I’m the oldest person around in here and I would never do that. One advantage–there are not a whole lot, but one advantage in growing old. Another advantage is–I’m really free-associating here–another advantage is a metaphor that Schopenhauer pointed out, one that’s really a nice metaphor. I can’t quote it exactly, but it had to do with that when you’re young–he’s looking at a piece of embroidery and how beautiful it seems when you look at the embroidery–when you get old, you see the reverse side of the embroidery. It’s not very pretty to look at, but at least you see all the threads are connected, so that there is some advantage in growing old; you begin to see how things are connected in life. Back to the circle. On several occasions, the group circled back to Molyn, because he’s the big –in a sense, he’s the elephant in the room that can’t be talked about, his death. And they came back to this and came back to this, as they always will. It’s always going to be present in the group. And he is saying, in effect, to them, “I’m willing to talk about it. I’m dealing with it. I’m speaking with a lot of people in my life. I feel I have the energy to be in this group. And, not only that, the group vitalizes me. And the worse thing you can do, really, is to isolate yourselves from me.” Being in a group with a dying person, working in some way–if you’re a therapist or a member, or a member is the dying person in the group–without fail, it will start to stir up a lot of anxiety in the group, because if you’re going to engage that person, it will mean that you’re going to, at some level, begin to confront your own death. Nightmares will start to appear, and anxiety will start to appear, as well. So, that’s always going to be part of the horizon of this group. It makes it a very unusual group. Molyn asked a very interesting question to Bonnie, I think. He asked her the question, “Well, if you were going to be married to”–Was it to Gill? It was to Gill. “If you’re going to be married to Gill –you’re with him here one hour a day, but if you were with him 24 hours a day, what would that be like?” He’s trying to help the members find ways to talk about them, trying to break down the barriers of conventional etiquette. The big revelation in this group had to do, of course, not only with Pam and Philip, but also with the alcoholism. The alcoholism came out, and then work was done there so that he wouldn’t feel scapegoated, so that they would acknowledge that he had done this–it was a brave thing to do. Molyn is suggesting very quickly that AA and group therapy are not incompatible at all, and that a daily AA meeting continue. Because the work is, of course, so different. They’re very different. Occasionally, you go to A.A. meetings where they may be able a little what they call “cross-talking” there. Generally not. You do not do any cross-talking. Members do not ta
lk to one another. It’s not this kind of interaction. A.A. groups just simply don’t work with this sort of direction. They do other kinds of things that are useful, and people tell their stories, they empathize with others, they identify, they get moral lessons taught to them as they see what’s happened to others, they get reminded of what it was like for them to be in the throes of alcoholism, but they do not work on interpersonal interaction and skills. Let’s see. Molyn used a technique with Stuart, when his chair went back and he was clicking on his pen. “So, what would you do if you weren’t clicking on the pen?” It didn’t get huge results in this time, but by and large, it’s using that kind of conditional voice. “If you weren’t doing this, then what might you be doing?” So, it’s a way of asking people to reveal, but at one step removed. It’s a little safer. “If you were going to tell me what’s on your mind, what would you say?” You do that all the time. It usually works like magic. Okay, so those are the comments off the top of my head. Any other thoughts? Molyn, do you want to say anything else? MOLYN: Sure. I found the group kind of really mesmerized my attention very quickly, and that it felt like group. It didn’t feel, in fact, that there was an audience, other than for the occasional laughter, which is, to me, a sign that I’m really involved with what’s happening. I was heartened by that. Oftentimes, we have to activate the group. This was a group that did not need activation, so I felt a lot of my activity was focused on the second part of the therapist’s responsibility, which is to try to make sense of experience, and to maximize the learning that could follow from the risks people were taking. I felt satisfied with the way in which we got to Gill, even though it’s different that the novel. People know one another through the group experience, and through that, can put themselves sometimes into the shoes of important people in that group member’s life. And I found that’s a way to kind of bring back into the room issues around Gill, in terms of what it would be like to be married to him. I thought when Pam said, “I thought about everyone except you, Gill,” that that was a kind of gift to the therapist, because it allows you then to dive right in to what it is about what is it about Gill that keeps him so absent. And then, little by little, we kind of ratcheted up the pressure on Gill, and he was able to make a very significant self-disclosure to the group. And then, interestingly enough–and I think this a reflection of how deep in role Pam is–that everyone in the group quickly was able to get to embracing Gill for his disclosure, except for Pam, who was still kind of holding on to the criticalness. So when Bonnie was able to kind of highlight that, I kind of jumped all over that, for two reasons. One reason, Bonnie, as we know, it’s very hard for her kind of to make her voice felt, make her voice heard. And it kind of struck me, and I commented, that I couldn’t see Bonnie, and hadn’t been aware of the fact that I couldn’t see Bonnie. Once I became aware of the fact that I was unaware of the fact, then it became data, interpersonal data, that had to be mined. And then, you were able to give Pam some feedback about her judgmentalism, which was critically important, so that Gill doesn’t leave feeling the criticism after this important self-disclosure. Groups lock people into roles. And as a therapist, when you see some kind of shift, evolution beyond that role, you want to make sure that it doesn’t get lost, that it doesn’t get extinguished by virtue of people failing to see the advance. The reason that people can’t see the advance often is linked to their own kind of stuff. But some of it has to do with group-wide pressures about keeping people in familiar positions. So I wanted to jump all over that. Similarly, I feel in some ways Philip has the most taxing position to take. So I felt myself paying very, very close attention to any kind of hint, any kind of smell, of a feeling, and wanting to try to jump all over that. Because ultimately, as a therapist, you have to believe that someone like Philip is damaged rather than evil. And you have to, as a therapist, keep working with that principle, so that you can empathize with the behavior that sometimes may be so antagonistic and adversarial to others in the group. Sometimes you have a difficult task of being the advocate for the antagonist. If Philip would have been able to say, “Pam, I’m sorry”–look Pam in the face–of course, he’d be way ahead of where he is right now. But we have to kind of nourish that as much as possible. I felt that we were able to kind of make some movement with that. There was so much going on in the group that I knew that I couldn’t get to everything in the 55 minutes that we had. But I tried to make it a point to not neglect it, but to, in fact, say, “Okay, we’ll flag it. We’ll come back to it later,” so that people know that you’re alert to their change. Because if your patients imagine that what you’ve done is ignored by the therapist, or ignored by others in the group, it’s going to extinguish that risk-taking. It’s going to extinguish that line of work. So we want to behaviorally reinforce that. And I felt, so far, my transparency has really been focused upon my here-and-now reaction to the meaning and feelings I have about what’s been happening in the group. There is, at the same time, as I know, a big agenda, which is the group dealing with my illness. And we will, I imagine, in time, get to that. So, those are some of my preliminary thoughts. IRVIN YALOM: Yeah, I think you’re commenting on the fact that you were sort of opening up your own dilemma. You’re saying, “There are different things here and I’m in a dilemma; if I pay attention to one, I’ll have to pass on the other–for now, at least,” which is an awfully good sharing. In a sense, you’re saying, “I have a dilemma. I want to talk about both things, and I have to take a choice, but we’ll come back to that.” So, I thought that was important. And then, I agree entirely, there’s a big problem with dealing with the illness. And perhaps the therapist is making it a little harder for the group by using slight euphemisms like “I’m unwell.” May be that if he came right out with “I’ve got cancer,” you know, something like that, that that might jar them a little bit and help them be more direct with him, because they’re taking their cues from him in this meeting. So they get a little bit of cues that they shouldn’t be going too far into it. VICTOR YALOM: Well, that was a fascinating group and discussion. In your remarks, you commented that Molyn’s interventions were almost entirely process-oriented. And you’ve talked about that before, but I think it would be helpful to clarify exactly what you mean by that. IRVIN YALOM: Yeah, I think that’s a good question, because “process” is used in so many different ways in our field, and in other fields, too. I’m thinking of process as distinguished from content. If you have two people speaking to one another, what they’re saying, the words they’re saying, the concepts that they’re talking about is content. But if you ask about process, you’re asking another kind of question. It’s, “What do these words tell you about the nature of the relationship of the people involved in there.” And that’s where pay dirt is in a therapy group. We’ll hear content for a while, but then we turn it back to process. What are these people feeling? What are these people saying about one another? VICTOR YALOM: So, just to be real clear, if someone is talking about some difficulties in their marriage, and they’re going on and on and on, oblivious to other group members, the content would be their marriage, but the process might be that they’re really very unaware of other members, or narcissistic even, or something like that? IRVIN YALOM: It’s a terrific example, because if you spend the group talking about their marriage, it’s not going to be a profitable group. But if you spend the group on how they have a lack of empathy for other people in the group, how they’re not asking th
e question, “What do all these people think about my taking 25 minutes and talking about my marriage?” you’re going to get much more work done in that group. The power is in that dimension. The group’s power is not in one person taking the whole group meeting and another person taking the whole group meeting. VICTOR YALOM: So, in this group, we saw some examples of process–Pam got a lot of feedback about how she’s the judger, the Supreme Court judge. And Gill, his problems in his marriage. It would be hard to really find out what–He painted a picture of what’s happening in the marriage, but by focusing on the process of how people experience him in the group, and even Molyn’s asking members what it would be like to be married to him, that’s a way of working on a process basis. IRVIN YALOM: Yes, both of those examples are excellent ways of using a group. The first one, people talk about they feel like they’re being judged by people. It’s one of my traits: “I’m being judged by people.” Well, the good group therapist, I think, will automatically change that into, “Who’s judging you here? Who’s the main judge here?” VICTOR YALOM: So you make it specific. IRVIN YALOM: Make it specific. “Who’s the judge here?” And they may point out a person or two, and then you get some consensual validation from the others–whether they disagree with that, they don’t see these people as judge, and that tell you something about his inner world. If everybody kind of agrees with that, then Pam is really compelled to kind of take a look at her judgmentalism. And the other that you mentioned–was it Gill, I think? VICTOR YALOM: Yes. IRVIN YALOM: Yeah, when Gill talks about his problems with his marriage. It’s always difficult to do marital therapy when only one member of the team is there. You find yourself making mistakes all the time. VICTOR YALOM: Well, in this case, he’s been in the group a long time and he reveals that he actually had a serious alcohol problem. IRVIN YALOM: Right. VICTOR YALOM: So, that’s an example. You could never get the truth just hearing the content of what he’s saying. IRVIN YALOM: Yeah. For a long time, everybody was very angry with the wife for what she was doing. After he mentioned that, people understood the wife a lot better. And the device that Molyn used in that was to ask the other members, “Well, just imagine for a while what it would be like to be married to Gill–not just spend an hour and a half a week, but to spend 24 hours a day. What do you feel like?” He’s not asking for insults here. He’s asking for problems that they would see in not getting close to Gill and not being in a loving relationship with him. I think that’s a terrific question, and it’s a way to really bring out the power of the group. I want to mention, too, that this is a complex situation. We’re letting these patients go wherever they go, and we’re trying to take a look at how these problems enfold in a huge multitude of ways. So, this is, I think, the most complex of all therapies. There are simpler ways of doing a group. You have a manual. They tell you what to do one session, what to do in another session. As the therapist, you feel a lot better, you feel safer. But leading groups like this takes time. You should be in a group like this for yourself. You should be supervised by the group. But when that happens, it becomes a very complex–and also very rich–kind of human experience. VICTOR YALOM: I think as we now watch the second group, one of the things to pay attention to is exactly that: how artfully Molyn is able to attend to many issues of members at the same time. It’s kind of like a traffic cop who’s also juggling balls at the same time. And if two people are having an issue, they’re not the only ones that are working, because someone is observing and they’re having their own reactions they can share later. So, I think he does a masterful job of that. IRVIN YALOM: Exactly. VICTOR YALOM: So let’s take a look, and then we’ll meet back one more time.

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Review Of Current Healthcare Issues

If you were to ask 10 people what they believe to be the most significant issue facing healthcare today, you might get 10 different answers. Escalating costs? Regulation? Technology disruption?
These and many other topics are worthy of discussion. Not surprisingly, much has been said in the research, within the profession, and in the news about these topics. Whether they are issues of finance, quality, workload, or outcomes, there is no shortage of changes to be addressed.
In this Discussion, you examine a national healthcare issue and consider how that issue may impact your work setting. You also analyze how your organization has responded to this issue.
To Prepare:

• Review the Resources and select one current national healthcare issue/stressor to focus on.
• Reflect on the current national healthcare issue/stressor you selected and think about how this issue/stressor may be addressed in your work setting.

By Day 3 of Week 1

Post a description of the national healthcare issue/stressor you selected for analysis, and explain how the healthcare issue/stressor may impact your work setting. Then, describe how your health system work setting has responded to the healthcare issue/stressor, including a description of what changes may have been implemented. Be specific and provide examples.

By Day 6 of Week 1/patient-waiting-time-presentation/

Respond to at least two of your colleagues on two different days who chose a different national healthcare issue/stressor than you selected. Explain how their chosen national healthcare issue/stressor may also impact your work setting and what (if anything) is being done to address the national healthcare issue/stressor.
Click on the Reply button below to reveal the textbox for entering your message. Then click on the Submit button to post your message.
Will be adding two discussions that will need at least three references all in APA 7 format each. will be included in this payment.
The mail discussion will need at least 3 references and also in APA 7 format
Adams Discussion
Current Healthcare Issue
National Healthcare Stressor
The last decade in healthcare has been volatile at best with the adoption of the Affordable Care Act (ACA) and performance-based payment systems, the ever-increasing polar divide between our political party’s healthcare theories and the never ending back and forth political discord that threatens to blow it all up and start over with something better, but never explained in detail. One of the constants that I continue to see is the increase in psychiatric patients coming into the hospital that I work. A number of these patients are undiagnosed with a psychiatric diagnosis or cannot find a provider that is seeing new patients. Many providers that are seeing new patients currently have wait times four weeks out. Someone that is experiencing psychiatric symptoms this wait could have a derailing effect on the efficacy of the treatment.
The number of patients needing psychiatric treatment in the United States is increasing and roughly one-third of the 10 million Americans are diagnosed with a psychiatric disorder but not getting treatment. (Olfson, 2016) One of the reasons for this is the lack of providers in the psychiatric specialty. With reimbursement rates falling lower than many other specialty services many institutions are struggling to cover salaries. With more than 60% of current providers aged 55 years or greater, this is also adding to the decreasing numbers. Another factor, is the increase in acceptability in discussing mental health issues and seeking out treatment. According to Weiner, (2018), with more patients seeking treatment, current providers are unable to increase their treatment numbers.
Impact on work setting
The institution that I work at is a safety net hospital that provides medical and social care to a population where 70% live at or below the poverty line. Many of these patients have undiagnosed or unmanaged psychiatric disorders that provide harm and are a detriment to their medical issues such as diabetes, cardiac issues and COPD. Working nights, I am accustomed to doing more with less. One of the challenges that I face constantly is the lack of psychiatric evaluations once a patient leaves the emergency department. Medical teams are forced to make psychiatric pharmaceutical decisions off the cuff until 7 AM when the psychiatric team rounds on a particular patient. This is particularly difficult on patients and staff alike.
Respondence to the issue
To create a discussion on this our staff used our unit council to speak to the Director of Critical Care, Nursing and Medicine, inviting the Psychiatric department to our monthly unit council meeting in hopes to better understand why this was not a priority as well as speaking to the Vice President of Nursing and the Medical Director about the importance of psychiatric services outside the emergency room on a 24 hour basis. After years of voicing concerns to upper Medicine and Nursing Management our institution increased inpatient psychiatric coverage to 24 hours per day.  Patients in need of psychiatric evaluations who have made in past the emergency room have an opportunity to be treated when they arrive on our unit. Our ICU team now has a partner when questioning what type of medication to give an irate patient who is a danger to himself or others. This intervention exemplifies the use of the quadruple aim approach with its increase in global health, improving patient experience, lowering costs and improving work-life for our staff. (Jacobs et al., 2018)
References:
Jacobs, B., Heinmiller, J., McGovern, J., & Drenkard, K. (2018). Engaging Employees in Well-Being: Moving From the Triple Aim to the Quadruple Aim. Nursing Administration Quarterly, 42(3). /orders/doi.org/10.1097/NAQ.0000000000000303
Olfson, M. (2016). Building The Mental Health Workforce Capacity Needed To Treat Adults With Serious Mental Illnesses. Health Affairs, 35(6), 983–990. /orders/doi.org/10.1377/hlthaff.2015.1619
Weiner, S. (2018, February 12). Addressing the escalating psychiatrist shortage. AAMC. /orders/www.aamc.org/news-insights/addressing-escalating-psychiatrist-shortage.
Rebeccas Discussion
Review of Current Healthcare Issues
National Healthcare Issue/Stressor 
Healthy People is a set of strategic goals released by the U. S. Department of Health and Human Services designed to measure progress toward
specific health objectives aimed at enabling people to live long and healthy lives. Healthy People 2020 is the fourth Healthy People initiative released.
It includes the goal of improving mental health through prevention and by ensuring access to appropriate, quality mental health services (Healthy
People, 2020).  Mental health disorders such as anxiety, depression, and substance abuse are increasing in prevalence and most cases of mental
illness occur earlier in life. The disease burden and costs associated with untreated or under-treated mental health disorders are rapidly increasing.
Mental health disorders are a common cause of disability and suicide is the 10th leading cause of death in the U.S. In addition, our country will see a
heavier mental health burden due to the COVID-19 pandemic (Stephenson, 2020). Therefore, it is crucial to include mental health objectives in the
Healthy People goals, to measure our progress, and to recognize the importance of meeting these goals.
Impact on Work Setting 
Currently, I work for a large health insurance company where I conduct medical necessity reviews of behavioral health treatment modalities to
include both inpatient and outpatient care.  Our company has seen sharp increases in the need for behavioral health treatment to include inpatient
mental health stays, inpatient detox stays, partial hospital stays, and intensive outpatient therapy.  More behavioral health clinicians had to be
brought on and trained to meet this current demand. Another impact to my work setting involves the fact that poor mental health has negative
impacts on physical health. Untreated mental illness can lead to chronic diseases which drive up the cost of health care.  Active treatment of mental
health issues, as opposed to prevention and early intervention, is more costly.
Responding to the issue 
Our company firmly believes in quality, cost-effective care and awards facilities that meet these milestones.  We continuously assess and update
our guidelines and coverage policies to reflect this. The company recognizes that mental health treatment is not a one-size-fits-all approach.  Recently
we changed guidelines for reviewing substance abuse treatment to the American Society of Addiction Medicine (ASAM) guidelines.  This approach
looks at the whole patient by assessing 6 dimensions that consider a person’s needs and severity of illness to help develop a treatment plan. The
premise is that patients can be assigned to treatments that “yield the best outcomes in the least restrictive and costly settings” (Stallvik et al., para 8).
By reviewing against these guidelines, we are ensuring that patients get the appropriate treatment at the appropriate time.
The company has been educating staff on current behavioral health trends, new treatments, and the impact of the COVID pandemic. We have an
active behavioral health case management team that reaches out to patients before, during, and after treatment to ensure they are set up with the
necessary follow up. We encourage and assist patients with finding primary care providers.  Park et al. (2018) state that primary care produces a
higher quality of care, improves access and outcomes, and lowers cost.  Additionally, one of our nurse leaders recently posted an informative series
about the social determinants of health and the importance of helping our patients overcome barriers so they can achieve their best physical and
mental health.  An organization needs effective leaders like this who can bring these issues to the forefront and encourage others to become active
participants in the change process (Broome & Marshall, 2021). The company’s website includes links to many resources such as food pantries, ride-
sharing, and mental health services.  By making this information readily available, we are making efforts to increase prevention and early
intervention. As a whole, I believe the company has responded well to the national healthcare issue of mental illness and I feel confident that we will
continue to look for ways to improve patient access and patient outcomes.
References
Broome, M., & Marshall, E.S. (2021). Transformational leadership in nursing: From expert clinician to influential leader (3rd ed.). New York, NY:
Springer.
Office of Disease Prevention and Health Promotion. (n.d.). Healthy People 2020: Mental health and mental disorders. Retrieved November 28, 2020
from  /orders/www.healthypeople.gov/2020/topics-objectives/topic/mental-health-and-mental-disorders
Park, B., Gold, S.B., Bazemore, A., & Liaw, W. (2018). How evolving United States payment models influence primary care and its impact on the
Quadruple Aim. Journal of the American Board of Family Medicine, 31(4), 588-604.
Stallvik, M., Gastfriend, D.R., & Nordahl, H. M. (2015). Matching patients with substance use disorder to optimal level of care with the ASAM Criteria
software. Journal of Substance Use, 20(6), 389-398.  /orders/doi.org.ezp.waldenulibrary.org/10.3109/14659891.2014.934305
Stephenson, J. (2020). CDC report reveals “considerably elevated” mental health toll from COVID-19 stresses. Retrieved November 29, 2020 from
/orders/jamanetwork.com/channels/health-forum/fullarticle/2770050

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