Thursday, July 31, 2008

Systematic Single Case Studies Made Easy(er) (7/08)

Entry for 29 July 2008:

Revised Presentation/Lecture notes, Day 2 RDI Training the Trainers Summer School on Counselling Research Methods, Leicester, UK, July 2008.

I. Systematic Single Case Studies at Diploma level
1. Convert standard case study requirement into systematic case study
2. Importance of having an example: Find an interesting case that has been studied systematically (e.g., Elliott, 2002; journal: Pragmatic Case Studies in Psychotherapy)
3. Needs support and guidance (Stinckens, Elliott & Leijssen, in press)
4. Systematic case studies can vary enormously in complexity, e.g.,
•Pragmatic Case Study (D. Fishman)
•Legalistic/Adjudicated case study (A. Bohart, R. Miller)
•Hermeneutic Single Case Efficacy Design (HSCED; R. Elliott)
•Uses version of IPEPPT Systematic Case Study Research Protocol
•See: Elliott (2002) Psychotherapy Research

II. General Principles of Systematic Case Studies:
A. Three Key Questions in systematic case studies:
1. Did my client change substantially over the course of counselling?
2. If the client changed, did counselling make a substantial contribution?
3. If the client changed, what brought about those changes?

B. Research Steps
1. Assemble a rich case record:
•Multiple data sources, qualitative/ quantitative
2. Outcome analysis; Analyze and interpret outcome data
3. Change process analysis: Organize and interpret evidence that counselling contributed to client change (include how counselling helped)
4. Critical reflection: Critically evaluate alternative explanations

III. Systematic Case Study Methods
A. Assemble Rich Case Record:
1. Basic descriptive information (demographics, diagnoses, problems, therapy approach)
2. Quantitative outcome measures: one or more (preferably related to theoretical model or client issues)
3. Weekly or fortnightly outcome measure (e.g., Personal Questionnaire or CORE-10)
4. Change Interview (qualitative; can be done by counsellor but better someone else; e.g., students help each other)
5. Helpful Aspects of Therapy (HAT) form (client; significant events)
6. Records of counselling sessions (tapes, therapist process notes)

B. Outcome analysis:
•Weekly change measure & one other
1. Make table showing:
•Clinical cut-off level (“caseness”) (e.g., CORE-OM: 1.25)
•Reliable change minimum value (CORE-OM: .5)
•Client pre-counselling value
•Client post-counselling value
•Indicate which values are (a) above caseness, and (b) show reliable improvement or deterioration
2. Make graph showing weekly outcome measure scores

C. Evaluating Therapeutic Influence: Change Process Analysis
•Looking for evidence of connections between what happened in counselling and outcome:
•Types of Evidence:
1. Change Interview (ratings of changes; attribution question; helpful aspects)
2. HAT descriptions of significant events (Helpfulness: 7+)
3. Sudden gains within therapy (big changes from one week to the next)
4. Changes in stable problems: Quantitative/qualitative changes from pre to post, plus information about how long client has had problem

D. Critical Reflection
•Make good-faith effort to find evidence that client didn’t change and that if they did, it had nothing to do with the counselling
1. Non-change explanations:
•Nonimprovement (trivial amount change, or gets worse)
•Relational artifacts: tries to convince therapist, research team (“hello goodbye” effect)
•Expectancy artifacts: self-deception (cultural or personal “scripts” about therapy)
2. Non-therapy explanations:
•Self-help (efforts separate from therapy)
•Extra-therapy events
•Psychobiological causes (medication or recovery from injury or illness)
•Reactive effects of research (research activities, altruism) [Construct validity]

IV. Example of Systematic Case Study “George”
A. Description of Client
1. Demographic information 61 year-old European-American male; married; some college; retired; former security administrator
2. Psychosocial History: emotional and physical abuse; suicide attempt as teenager (drove car into quarry); estranged from 2 of 3 children; wants to move to SW United States; frustrated that wife won’t.
3. Presenting Problems and Diagnosis
•Presenting problem: Panic attacks; primarily on expressway (4 yrs)
•Fear of heights, boating, and excessive speed
•Interpersonal difficulties due to “abrasive personality”
•Main goal = to cross bridges
4. DSM-IV Diagnosis:
•Axis I [based on SCID]: Panic Disorder w/ Agoraphobia; also Specific Phobia
•Past problems: Major Depressive Disorder, In Full Remission; Alcohol Dependence, Sustained Full Remission
•Axis II: None (but features)

B. Description of Therapy
1. 23 sessions: Client terminated by own choice; regarded treatment as successful
2. Process-Experiential/Emotion-Focused therapy: integration of Person-Centered & Gestalt therapies
3. Center for the Study of Experiential Psychotherapy (University of Toledo)
4. Therapist – 50 yrs. old; experienced PE-EFT therapist; one of originators of approach

C. Outcome Analysis
1. Quantitative Outcome Data:
a. Instrument: SCL-90-R GSI
Caseness cut-off: .93
RCI (p < .2): .51
Pre-Tx: .77
Post-10: .56
Post-Tx: .57

b. Instrument: Inventory of Interpersonal Problems
Caseness cut-off: 1.50
RCI (p < .2): .57
Pre-Tx: 1.96 (=clinical range)
Post-10: 1.46
Post-Tx: 2.27 (=clinical range)

c. Instrument: Personal Questionnaire
Caseness cut-off: 3.00
RCI (p < .2): .53
Pre-Tx: 4.33 (=clinical range)
Post-10: 5.33 (=clinical range; reliable deterioration)
Post-Tx: 4.83 (=clinical range)

d. Weekly Outcome on Personal Questionnaire: Varies erratically throughout therapy, between 4.3 (=Moderately distressing) and 5.8 (Very Considerably distressing)

2. Qualitative Outcome data (Change Interview):
•Can cross bridges now
•Better relationship with wife
•More tolerant
•Less afraid of flying

D. Change Process Analysis:
1. George’s Post-Therapy Account of What Helped Him
•Very general, focused on therapeutic relationship:
•Emphasized nature of relationship with T: T is “a good man”; interactions as pleasant, harmonious; T did not intrude past C’s personal boundaries, but expressed personal pleasure in C’s progress
•T helped C develop a new, broader, more tolerant perspective on others, life.
Conclusion: George describes helpful aspects of therapy, attributes some of his changes to therapy (“would not have happened without therapy”).

2. George’s Highest-Rated Significant Therapy Events (HAT):
•Session 4, extremely helpful (“9”): “When (therapist) mentioned that my childhood experiences could have a direct bearing on my problems now. Never thought of it as having anything to with my fear of bridges…”
•Session 6, extremely helpful: “The part where I talked to my daughter [empty-chair work]. Found out she is one of the bridges I cannot or at least have not tried to cross.”
George’s Highest-Rated Significant Therapy Events - 3
•Session 9, extremely helpful: “When (therapist) told me to confront my mother [empty-chair work] and tell her how disappointed I was and still am with her. Never did this when she was alive. Should have. It was a relief.”
•Session 11, extremely helpful: “Discovery of my deep-seated anger. I never knew how much anger could influence how I feel about almost everything I encounter in life.”
•Session 16, greatly helpful: “I found out that before I tackle a problem, I stop breathing. Upon facing the problem of crossing a bridge I made an effort to breathe clear across the bridge and it worked.”
Conclusion: George’s significant events, as described on the HAT form, are in the clinically significant range (Helpfulness: >7); some are also directly connected to posttherapy changes (Sessions 4, 11, 16)

3. Sudden Gains: George’s PQ scores remained high but erratic throughout therapy, showing no sustained improvements, sudden or not.
Conclusion: No evidence for therapy bringing about change here.

4. Change in stable problems:
a. Change: Can cross bridges now
•Corresponding Problem: Fear of expressway/ heights/ speed [=Bridges]
•Duration: 4 years
b. Change: Better relationship with wife
•Corresponding Problem: Problems with relatives/ Abrasive
•Duration: ??
c. Change: More tolerant
•Corresponding Problem: Problems with relatives/ Abrasive
•Duration: Long-standing
d. Change: Less afraid of flying
•Corresponding Problem: Fear of flying
•Duration: ??
Conclusion: The George showed change on at least some of his stable problems .

D. Critical Reflection:
1. Non-Change Explanations:
•Did not improve on any of the quantitative measures from pre- to posttreatment (small increases on IIP, PQ!)
•Qualitative reported changes not supported by quantitative data
•Spontaneous remarks: “I’ll talk to that nice young lady any time!”
•Discrepant data suggest possibilityof self-deception by client
2. Non-therapy explanations:
•In vivo exposure: George reported stable changes in ability to fly and cross bridges only after he flew to Florida and drove across 90 miles of bridges.
•Recent trip: in vivo exposure; Wife’s changed behavior; recurrence of daughter’s cancer
•Research intensive protocol (repeated use of questionnaires, interviews); research staff repeatedly questioned client about changes

E. Case Update:
1. 6-month Follow-up
•Client maintained ability to cross bridges; still describes himself as “abrasive”
•Recollected helpful aspects of therapy: Therapist is a “truly good man”; therapist actually cared; therapist never actually told client that he COULD cross bridges
•Client requested additional therapy to deal with interpersonal difficulties, bhut heart by-pass surgery prevented
2. 18-month follow-up:
•Able to drive across bridges at least half the time; still attributes this to his therapy
•“People tell me I’m a nicer person.”; attributes this to illnesses
3. Follow-up Outcome Data: Reliable improvement on Personal Questionnaire (6- and 18-month follow-ups)

1 comment:

Anonymous said...

Like panic disorder, agoraphobia is one of several anxiety disorders. Agoraphobia may occur with or without panic disorder, but it is most frequently seen with panic disorder. If treated quickly and properly, panic disorder may not progress to agoraphobia. Once the condition progresses, it is all the more difficult to treat.