Socialization Groups:
Using The Book of
Questions as a Catalyst
for Interaction
Jay
c. Wade
Key Words: activity groups. interpersonal
relations. psychiatry
This article describes the use of The Book of Questions
(Stock, 1987) as a tool for assessment and as a cata~yst for social interaction in an acute short-term inpatient psychiatric unit. Examples of questions and how
they can be used to provide information for the evaluation ofpersonality style and social and interpersonal
skills are prOVided. Group objectives, membershzp criteria and format, and leadershzp techniques are discussed. Analysis of the group activity and patients' responses to the group indicates that a group structured
around The Book of Questions facilitates social interaction and is easily transferable to social activities
outside of the structured therapeutic group setting and
hospital environment.
c.
Jay
Wade, MS. OTR, is Senior Occupational Therapist, Department of Psychiatry, Montefiore Medical Center, New York,
New York. (Mailing address: 89-18 182nd Street, Hollis, New
York 11423)
This article was accepted for publication December 6, /99/.
ccupational therapy groups in psychiatry provide for a variety of social situations and environments in which the assessment and development of interpersonal and social skills can readily take
place (Schwartzberg, 1988). These groups have often
been used for the purpose of increasing social interaction
among psychiatric patients (Schwartzberg, Howe, &
McDermott, 1982). Although these skill areas are frequently used interchangeably in discourse, interpersonal
skills can be viewed as those behaviors involved in relations between persons, as opposed to social skills, which
relate to the interaction between the individual and the
group (Merriam-Webster, 1990). Interpersonal connotes
a more intimate, or personal, interaction with another
person - as in friendships, romantic relationships, and
work relationships with co-workers, subordinates, and
supervisors. Social relationships are often of an interpersonal nature, but the term is broader in its definition,
encompassing superficial interactions with one or more
persons. This includes negotiation of social systems, social etiquette, and cooperative and interdependent relationships in group activities.
Liberman (1982) conceptualized social skills as the
ability to give and obtain information and to express and
exchange attitudes, opinions, and feelings. A5 such, such
skills function to subserve instrumental and socioemotional functions in interpersonal interactions. Liberman
developed three viewpoints for categorizing social skills.
The topographical view includes the verbal content and
nonverbal elements in communication. The functional
view includes the ability to satisfy needs through instrumental and socioemotional role funCtioning. The
information-processing, or problem-solving, view of social skills emphasizes behavioral cognitive functions. Social skills assessment and training focuses primarily on
subjective responses and overt behavior and its consequences. Although Liberman acknowledged that assessors have had to rely on second-best methods of measurement, primarily using face validity in operationalizing
components of communication, he identified the selfreport questionnaire, the interview, and role-play tests as
three methods of measuring social behavior.
Lazare's hypothesis-generation-and-testing approach is a conceptual framework that can be applied in
occupational therapy evaluation. This approach comprises four categories: biologic, psychodynamic, sociocultural, and behavioral (as cited in Schwartzberg,
1988). Psychodynamic factors that affect skills and performance areas may include manifestations of personality style, ego functioning, and related psychodynamic
issues. Through observation of the patient in occupational therapy groups, the therapist can (a) identify
psychodynamic patterns, (b) learn about a person's value system and management of various social roles, (c)
discover the patient's capacity to use social supports,
and (d) gain further understanding of the patient's per-
O
The American Journal of Occupational Therapy
Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930247/ on 06/17/2017 Terms of Use: http://AOTA.org/terms
541
sonality style and emotional vulnerabilities (Schwanzberg, 1988).
A5 a means of evaluating and developing social and
interpersonal skills in acute short-term psychiatric inpa-
rients ar Monrefiore Medica! Cenrer in New York Ciry, a
group was developed whose format was structured
around The Book o/Questions (Stock, 1987). This book is
used in the group as an informal self-repon questionnaire
and interview. It is also used as a social activity that stimulates verbal interaction, whereby the demonstration, observation, and development of social and interpersonal
skills can take place.
Treatment Setting
The psychiatric inpatient unit at Montefiore Medical Center is a 22-bed training and research unit, the population
of which consists primarily of white middle-class patients.
Most of these patients have conditions diagnosed as an
affective disorder, most often major depression. The
average length of stay is approximately 28 days. Premorbid functioning ranges from poor social and interpersonal
skill development, isolation, and leisure time inactivity
to highly developed and productive skills and leisure
interests.
The occupational therapist proVides evaluation information on the patient to a Medical Model treatment
team to aid in diagnosis and treatment planning while
offering opportunities and encouragement for patients to
function at the highest level possible in interpersonal
relationships and activities. The treatment objectives include minimalization of the patient's symptoms and encouragement toward normal behavior as well as maintenance of function and use of abilities and skills that the
patient had before hospitalization (Corry, Sebastian, &
Mosey, 1974). In line with these objectives and as a means
of addressing the various levels of psychosocial skills development in the patient population, a group called Special TOPics was established and included into the overall
program of group activities in occupational therapy.
Group Criteria and Objectives
The Special Topics group is open to all patients from time
of admission - when they may be severely depressed and
withdrawn or psychotic - until discharge. The group is
open ended; attendance and participation are encouraged but not mandatory. Attendance at each group has
ranged from 2 to 12 patients. However, the ideal number
of patients and most active and productive groups have
been those with 8 to 12 patients in attendance.
The primary objectives of the group are to decrease
social isolation and to increase constructive use of leisure
time while in the hospital and to integrate the activity into
one's repertoire of social activities after discharge. Underlying these objectives are the ability to concentrate, to
542
tolerate a group, and to effectively communicate
thoughts and feelings to others. Diminishing depressed
moods through haVing fun and experiencing joy in social
activity is a means by which the primary objectives can be
accomplished.
Group Format
The group meets once a week for 1 hour. Questions
selected from The Book o/Questions are presented to the
group to be answered by each member individually. The
group format can be either loosely structured or highly
structured; issues and themes can range from concrete
and simple, such as how and with whom one spends time
in social activities, to abstract and complex themes, such
as morality and the significance of different types of relationships. The type of question chosen and the amount of
structure needed for the discussion depends on the composition of the group. Because the patient population
changes rapidly, the level of functioning of the membership can vary from week to week. Any number of questions can be discussed in the group depending on the
amount of discussion each question evokes. Certain
questions have follow-up questions in the back of the
book that further explore and expand the central theme
of the question. Each group member can give a shon
answer to each question, which allows for many questions to be asked with equal participation from each
member. However, as few as one question can be asked,
which would allow for more exploration, discussion, and
interaction among the members.
The Group in the Evaluation Process
The Book o/Questions is used and equated with nondysfunctional social activity. Experiences with patients' selfdisclosures in the group have indicated that most patients
are willing to participate and reveal thoughts, feelings,
and experiences within this format, possibly because it is
the group norm. In addition, the group is not associated
with the more structured psychiatric assessment and other traditional analytically oriented groups, in which resistance is often heightened. Questions require a patient to
reveal personal experiences, which can provide the occupational therapist with information about past or current
personal relationships and experiences as well as the patient's level of comfort with self-disclosure. The occupational therapist can also see whether the patient is being
evasive, guarded, or paranoid in his or her reaction or
response to the question. For example, questions from
The Book of Questions might include the follOWing:
• "When were you last in a fight? What caused it and
who won)" (p. 44)
• "How many of your friendships have lasted more
June 1992, Volume 46, Numher 6
Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930247/ on 06/17/2017 Terms of Use: http://AOTA.org/terms
•
•
•
•
than 10 years? Which of your current friends do you
feel will still be important to you 10 years from
now?" (p. 147)
"How close and warm is your family? Do you feel
your childhood was happier than most other people's?" (p. 91)
"How many different sexual partners have you had
in your life? Would you prefer to have had more or
fewer?" (p. 101)
"Who is the most important person in your life?
What could you do to improve the relationship?
Will you ever do it?" (p. 107)
"What was your best experience with drugs or alcohol? Your worst experience?" (p. 40)
There are other questions that are less confrontational and threatening to the ego because they are posed
as hypothetical situations or general questions, as shown
below:
• "What is your most treasured memory?" (p. 33)
• "If you could change anything about the way you
were raised, what would it bel" (p. 110)
• "What do you value most in a relationship?" (p. 129)
• "If you had to spend the next two years inside a
small but fully provisioned Antarctic shelter with
one other person, whom would you like to have
with you?" (p. 133)
Other hypothetical social situations are provided
that can elicit information on the patient's personality
and social skill, including such aspects as problem-solving
ability, assertiveness, judgment, and etiquette. Examples
include the following:
• "At a meal, your friends start belittling a common
acquaintance. If you felt their criticisms were unjustified, would you defend the person?" (p. 93)
• "If you were at a friend's house for Thanksgiving
dinner and you found a dead cockroach in your
salad, what would you dol" (p. 98)
• "If you went to a movie with a friend and it was
lousy, would you leave?" (p. 151)
• "Before making a telephone call, do you ever rehearse what you are going to sayl" (p. 148)
Personality characteristics such as honesty, morality,
narcissism, humanitarianism, self-esteem, and confidence can be revealed through questions such as the
follOWing:
• "Can you be counted on to do what you say you'll
do? What does it take for you to trust someone?"
(p. 157)
• "How forgiVing are you when your friends let you
down?" (p. 191)
• "What sorts of things would you do if you could be
as outgoing and uninhibited as you Wished? Do you
usually initiate friendships or wait to be approached?" (p. 154)
• "If you could wake up tomorrow haVing gained one
ability or quality, what would it be?" (p. 24)
• "Do you find it so hard to say 'no' that you regularly
do favors you do not want to do? If so, why?"
(p. 118)
There are questions that can assist the occupational
therapist in understanding the patient's view of himself
or herself or the world, as in the examples that follow:
• "What do you most strive for in your life: accomplishment, security, love, power, eXCitement,
knowledge, or something else?" (p. 89)
• "What do you like best about your life? least?"
(p. 152)
• "Relative to the population at large, how do you
rate your physical attractiveness? your intelligence?
your personality?" (p. 168)
• "Whom do you admire most? In what way does that
person inspire you?" (p. 22)
• "In love, is intenSity or permanence more important to you? How much do you expect from someone who loves you? What would make you feel
betrayed by your mate - indifference? dishonesty?
infidelity?" (p. 187)
Other valuable information on the patient can be
gathered through the use of The Book of Questions, including the patient's ability to imagine and fantasize, his
or her use of concrete versus abstract thinking, and his or
her use of psychic defenses and coping skills. Information
can also be gained on the person's obsessiveness, cognition, values, belief system, and personal habits. During
the group, the occupational therapist internally analyzes
and interprets the content and emotional tone of the
answers to questions as well as those questions that a
patient does not answer and attempts to validate or revise
hypotheses based on verbal feedback from the patient.
The context of a therapist-led group and all the dynamics
that this involves is considered in order to evaluate with
some accuracy the patient's personality structure. Information from questions answered is combined with observations of the patient's social and interpersonal skills as
he or she functions in the group activity in order to give
the therapist a dynamic assessment of the individual.
After the group, the occupational therapist makes a written record of the group member's participation. This
information is then used as either part of the initial occupational therapy evaluation or in the verbal progress report provided in team meetings. It is also used in the
patient's weekly group progress note documented in his
or her medical record.
The Group in the Treatment Process
The session begins with a discussion of the purpose of
the group, including an explanation of how the source
book can be used in socialization activities either in one-
The American Journal of Occupational Therapy
Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930247/ on 06/17/2017 Terms of Use: http://AOTA.org/terms
543
on-one situations or in a group of friends, family, or social
acquaintances. Examples are given of the kinds of questions to be asked in the group. The leader also reminds
the patients that answers to questions in the therapeutic
group sirua[ion of a hospiral may nor be appropriate in
social situations outside of the hospital.
The therapist-leader of the group sets the norms
or standards for member participation. Members are
encouraged to show respect for differing opinions, to
be honest in their answers, and to provide a generally
supportive environment for the expression of thoughts
and feelings. If a patient does not want to answer a
particular question, he or she is allowed to pass. Allowing members to decline to answer questions reduces
the level of anxiety about participating and gives them
the freedom to participate at their own level of comfort.
This supportive atmosphere sets up an expectation that
makes the situation different from the expectations
generally associated with evaluation and treatment.
During one group session, a patient asked if the leader
was using the information to evaluate the group members. The leader responded affirmatively, yet this did
not appear to affect participation. Honesty, independent answers, and differing opinions are encouraged and reinforced, because they validate the patient's
unique personality and help to build self-esteem. The
therapist helps to develop communication skills by
assisting members with verbal clarity and comprehension. Group members are given the opportunity to
ask questions from the book. The therapist's participation includes answering questions as well as asking
them.
Socialization skills, such as the timing of a social
initiative, the quantity and quality of verbal responses and
nonverbal behaviors, and the ability to self-disclose and
problem solve interpersonal situations, are demonstrated
and developed by the therapist and group members. At
times, a patient answering a question will self-disclose
information and experiences that would not be arpropriate for most situations outside of the hospital. The patient
is then helped to formulate an answer that would be more
appropriate for a situation outside the hospital setting.
Group members often help manic or thought-disordered
patients to focus and control their disruptive and dominating behavior by setting limits. A person's values, opinions, attitudes, beliefs, and worldview are expressed, validated, and supported or are confronted and critically
questioned and examined by others in the grour. Members receive support for personal experiences, whether
they be traumatic or rewarding ones. BOth the questions
and the members' answers are frequently humorous in
their content, which makes for an atmosphere of fun and
enjoyment. This stimulates thoughts and feelings, making
members eager for expression and for response from
others. Through the provision of a structure for conversation, some of the anxiety associated with and inherent in
544
social interaction decreases. It is as if the book, not the
person, is asking the question, so through its use a person can connect socially with Others.
Patients' Responses to the Group
For many of the depressed patients on the unit, getting
out of bed to participate in the occupational therapy program is a monumental achievement and a sign of progress. According to group attendance records, in the 8
months since the inception of the group, it is the most
consistently, regularly, and highly attended group in the
occupational therapy program (average attendance is
40% of the patients on the unit). A review of the weekly
progress notes from the medical charts of patients who
had attended the group showed that each patient had
verbally participated in the group, no matter how minimally. One female group member in her 40s who had
never participated in any other activity group asked about
the group with enthusiasm each week and participated
actively. A 15-year-old female patient, who claimed to be
shy and would not speak in group psychotherapy, selfdisclosed and interacted comfortably within the Special
Topics group. A depressed and suicidal male patient in
his early 20s stated that he felt better after the group, had
found it fun, and had laughed for the first time in a long
time. He purchased the book while in the hospital and
used it in socializing with other patients on the unit. A 16year-old female patient copied questions from the book,
then called her boyfriend on the telephone to ask him the
questions. She reported feeling she had learned things
about her boyfriend she had not previously known. Patients frequently ask to borrow the book to use with each
Other during periods of inaCtivity on the unit. Several
patients have asked for the name and author of the book
and inquired where they could purchase it after
discharge.
Discussion
The Book of Questions is used in the action process or
activity of socializing as a catalytiC agent or stimulus that
elicits intrapsychic and interpersonal responses or reactions. Personality struCture, particularly how it affeCts interpersonal relationships and social situations, is revealed
through projection and the demonstration of social and
interpersonal skills within the group. In addition, historical information on the patient's functioning and satisfaction in interpersonal and social relationships and activities is revealed. Within the acute short-term psychiatric
unit, the occupational therapist's role of evaluating patients' functional skills to aid in diagnosis and treatment
planning is considered a valuable one.
Provision of activities and interpersonal experiences
to maintain functioning or to exercise skills at a premorbid level are the treatment concerns of the occupational
June 1992, Volume 46, Number 6
Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930247/ on 06/17/2017 Terms of Use: http://AOTA.org/terms
therapist in acute shan-term treatment. Skill development is encouraged and underlies the therapeutic interactions and interventions with patients both individually
and in groups. However, there are limitations due to the
shan length of stay, and objectives must be realistic as to
what can be achieved developmentally in this setting. For
depressed patients who tend to withdraw and become
isolative due to internal preoccupation, motivating participation in sociaJ activities is a major task for the occupational therapist and can be quite challenging. In this regard, a group structured around the use of The Book of
Questions has an enormous appeal to patients because of
the fun and enjoyment associated with the activity, the
minimal expectation for participation, and the ease in
which the activity can be incorporated into one's social
activities in and outside of the hospital. ..
References
Cony, S., Sehastian, V., & lvlosey, A. C. (1974). Acute shortterm treatment in psychiatry. American ]oumal of Occupational Therapy, 28, 401-406.
Liberman, R P. (1982). Assessment of social skiJJs. Schizophrenia Bulletin, 8, 62-83.
Merriam-Webster, Inc. (1990). Webster'S ninth new collegiate dictionmy Springfield, MA: Author.
Schwartzberg, S. L. (1988). Generic processes. In H. L.
Hopkins & H. D. Smith (Eds.), Willard and Spackman's occupational therapy (7th eel., pp. 390-403). Philadelphia:
Lippincott.
SchwartZberg, S. L, Howe, M. c., & McDermott, A. (1982).
A comparison of three treatment group formats for facilitating
social interaction. Occupational Tberapv in Mental Health,
2(4), 1-17
Stock, G. (1987). The book 0/ questions. New York
Workman.
Industrial Back Injury
Prevention and Management
Presented by H. Duane Saunders, M.S., P.T.
Chicago, IL
New York, NY
Memphis, TN
Charlotte, NC
Anaheim, CA
Evaluation, Treatment and
Prevention of Spinal Disorders
Presented by H. Duane Saunders, M.S., P.T.
Washington, D.C
July 10 -12
Boston, MA.
September 11·13
San Jose, CA
September 25-27
Minneapolis, MN
October 23-25
June 25
July 17
September 17
October 29
November 13
Reducing Injuries in the Workplace
Presented by Mark A. Anderson, M.A., P.T
and Skip Olson, B.S., P.T.
New York, NY
June 11-13
St. Louis, MO
September 10 -12
Atlanta, GA . .. . .. October 14 - 16
Dallas, TX
November 19 - 21
Basic Spinal Mobilization
Back Injuries in Athletics
Presented by Daniel T. Wolfe, G.D.M.T, P.T.
Presented by H. Duane Saunders, M.S., P.T.
and Greg Johnson, M.S., A.T.e.
Chicago, IL.
St. Louis, MO
New York, NY
September 19,20
_. October 17, 18
November 7,8
Houston, TX
Philadelphia, PA
August 7
August 11
Call for More Information 800-654-8357 or 612-944-1656
The Americun joun7CI1 uj' OccujJutionul TherUjJr
Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930247/ on 06/17/2017 Terms of Use: http://AOTA.org/terms
545