Tuesday, October 06, 2009

aHSCED study finally published: Elliott et al. (2009)

Entry for 4 October 2009:

Reference: Elliott, R., Partyka, R., Wagner, J., Alperin, R. & Dobrenski. R., Messer, S.B., Watson, J.C. & Castonguay, L.G. (2009). An Adjudicated Hermeneutic Single-Case Efficacy Design of Experiential Therapy for Panic/Phobia. Psychotherapy Research, 19, 543-557. [Appendices available at: http://www.informaworld.com/smpp/content~content=a914761426~db=all~tab=multimedia]

Commentary: In developing the Hermeneutic Single Case Efficacy Design (HSCED) method, my students and I at Toledo experimented with various research strategies. The first published HSCED study (Elliott, 2004) was my SPR Presidential Address paper, and was based on the idea that the method could be carried out by single therapists with their own clients. This model of HSCED research still makes some sense to me, but is regarded with suspicion in the Person-centred community in the UK, because of the dual relationship issues. (Incidentally, this is an argument that has never held much water for me, because of the long history of narrative case studies, the great prepounderance of which were therapists written about their own clients. This particular squeamishness seems to come out of general distrust and alienation between research and practice.)

In any case, my team at Toledo also experimented early on with doing case comparisons (which we presented at the 1999 SPR conference in Chicago): These proved unwieldy and were replaced by single-case case studies. Next, inspired by Art Bohart and Carol Humphreys, we began experimenting with a legalistic or adjudicated case study model, built around the HSCED framework of types of evidence and alternative explanations or validity threats. The first of these cases was planned in 2000, even before I gave SPR Presidential Address at the SPR conference in Montevideo, Uruguay. A client came to the Center for the Study of Experiential Psychotherapy (CSEP) suffering from severe anxiety difficulties with panic episodes associated with crossing bridges and heights. He was an older gentleman, had had an earlier unsuccessful CBT treatment for these problems, and looked to the research team to be a challenging case. At the same time, I’d been doing meta-analytic research that pointed to the possibility that person-centred-experiential (PCE)) therapy might be less effective with anxiety problems.

As a result, we assigned this client, whom we eventually renamed as “George”, to me. Although I’d worked with PTSD quite a bit, I hadn’t worked with panic difficulties very much, so I did some reading on experiential approaches to panic difficulties and got a bit of consultation from Barry Wolfe, who done some work on the topic and whom I ran into at a meeting. Rhea Partyka coordinated the study and was the researcher who interviewed George.

I began seeing George, with a fair amount of trepidation: Could George and I find a way of working together that would enable him to overcome his severe anxiety difficulties in a time-limited (up to 40 sessions) therapy? Or had I bitten off more than I could chew?

Fortunately, George and I hit it off really well, worked hard, and after 23 sessions, George, with no pressure from me, felt satisfied with his progress enough to declare himself finished with therapy. At this point, the research team began organizing the adjudication process: We lined up three judges from well-known psychotherapy researchers, each representing a different theoretical orientation: Stan Messer (psychodynamic), Jeanne Watson (humanistic), and Louis Castonguay (cognitive-behavioral). We assembled two teams of two postgrad clinical psychology students each, an affirmative team (Rhea Partyka and Becky Alperin) to argue the case in favor of George having changed and for therapy having been responsible for George’s having changed; and a sceptic team (John Wagner and Rob Dobrenski) to argue the opposite. Rhea and I put together a set of documents summarizing the process and outcome of the therapy and agreed to by affirmative and sceptic teams. Then affirmative sceptic teams each wrote briefs and offered rebuttals to each other’s cases. All of this was sent off to our three judges, who each had instructions to render verdicts on the two questions of client change and the contribution of therapy to possible client change.

What did the judges rule? See the Abstract below, or better yet go look up the article and the Appendix that contains all the case documents, including the judges’ commentaries.

All this sounds fairly straightforward; however, it proved to be challenging to write up this study for publication and to deal with the editorial feedback. First, it took me two years to get it written up and submitted. Our original idea was that it would be published as a suite of three papers: (a) Paper describing the case method and summarizing the Rich Case Record and Affirmative and Sceptic Briefs and Rebuttals (U of Toledo team as co-authors); (b) judging procedure and judges’ opinions (judges as authors); and (c) follow-up data, and general discussion (Elliott & Partyka as co-authors). I submitted this unusual package to Psychotherapy Research, under Bill Stiles’ editorship; Bill gave us a revise and resubmit verdict asking us to combine all this into a single paper. And there the paper sat for 5 years, aside from a couple of false starts, until a year ago, when I began my 20-minute a day writing regime. This was what finally enabled me to gain momentum on the revision, so that when 4 days for writing suddenly opened up in early January of this year, I was able to finish the revisions and resubmit. My co-authors were delighted to see the thing moving again after the long delay, and even more so to see it finally appear in print.

One of the technical challenges of publishing HSCED studies is what to do with the extensive documentation, in this Rich Case Record, Briefs, Rebuttals, and Judges’ Opinions. In this case, that puzzled has been dealt with by publishing these materials online, on the journal’s website.


This paper illustrates the application of an adjudicated form of Hermeneutic Single Case Efficacy Design (HSCED), a critical-reflective method for inferring change and therapeutic influence in single therapy cases. The client was a 61 year-old European-American male diagnosed with panic and bridge phobia. He was seen for 23 sessions of individual Process-Experiential/Emotion-Focused Therapy. In this study, affirmative and skeptic teams of researchers developed opposing arguments regarding whether the client changed over therapy and whether therapy was responsible for these changes. Three judges representing different theoretical orientations then assessed data and arguments, rendering judgments in favor of the affirmative side. We discuss clinical implications and recommendations for the future interpretive case study research.

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