a guide to conducting case-based , time-series r esearch in gestalt / emotion focused t...
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A Guide to Conducting Case-Based, Time-Series Research in Gestalt / Emotion Focused Therapy
Albert J. Wong, M.A., Mike Finn, B.A., and Michael R. Nash, Ph.D.Department of Psychology University of Tennessee – KnoxvilleKnoxville, TN 37996
The Challenge of Establishing a Research Tradition for Gestalt Therapy: An International Conference
April 17, 2013
Integrating Research and Practice in a Clinical Setting
Structure of Talk• PART I: What is at Stake– Why we should care about Single-Case Experimental
Designs (SCEDs)
• PART II: Background Theory– Fundamentals of Single-Case Experimental Designs
• PART III: Concrete Example– Working step-by-step through an example of a SCED
• PART IV: Your turn– Designing and implementing your own SCED study
PART I. What is at StakeWhy we should care about Single-Case Experimental Designs (SCEDs)
Borckardt, J.J., Nash, M.R., Murphy, M. D., Moore, M., Shaw, D., & O-Neil, P. (2008). Clinical practice as natural laboratory for psychotherapy research. American Psychologist, 63, 77-95.
PART I: What is at StakeThe Wake-up Call
Then one day people realized that in Germany the government had gone to regulating the practice of psychotherapy – and they had not accredited Gestalt Therapy based on the fact that it didn’t have a research base. And so in Germany, the people there had to re-certify as psychoanalysts in order to keep practicing…. and everyone went “uh-oh.”
--- Phil Brownell
Why is being an Empirically Supported Treatment Important?
1. Pragmatic Reasons▪ Ability to practice▪ Ability to get reimbursed▪ Managed Care Organizations▪ Accountable Care Organizations
▪ Ability to influence the collective dialogue
2. Clinical Practice Guidelines▪ Learning when, how, and under what circumstances to
administer Gestalt Therapy▪ To continue to improve the practice of Gestalt Therapy▪ Answer critical questions: Does Gestalt Therapy
work? Under what circumstances does it work? What is the mechanism of action whereby it works?
What does it take to become an Empirically Supported Therapy?
Empirically Supported Therapies (ESTs) are therapies that have demonstrated (a) superiority to a placebo (dummy treatment)
in two or more methodologically rigorous controlled studies,
(b)equivalence to a well-established treatment in several rigorous and independent controlled studies,
(c)efficacy in a large series of single-case controlled designs (Chambless & Hollon, 1998)
How many single-case designs do we need?
1. Number of published single-case experimental designs required to be deemed…
Efficacious ▪ Ten (10) or more single-case design studies
Possibly efficacious pending replication▪ Four (4) or more single-case design studies
2. Number of published single-case experimental designs that support Gestalt…
Many case studies, but NO single-case experimental designs
What is a Single-Case Experimental Design? Different from a “case study”
A case study is a narrative report of a therapeutic intervention and the patient’s response over the course of treatment
Sometimes data are provided, sometimes not No experimental control
SCEDs by contrast… Have an experimental control Utilize statistically rigorous methods to ascertain
presence of treatment effect
Case Study vs. Single-Case Experimental Design
Requirements of single-case designs
Single Case Design studies must…
1. be conducted under the guidance of a treatment manual Task Analysis (Les Greenberg, Roubal) Treatment Fidelity Measure: “Even Jazz has a form”
2. specify the sample population (inclusion / exclusion)
3. use good experimental design (Borckhardt et al, 2008) Have an experimental control Establish a representative baseline Manage the nonindependence of sequential observations (e.g.,
autocorrelation, serial dependence) Interpret single-subject effect sizes Frequently must analyze short data streams
PART II: Background TheoryFundamentals of Single-Case Experimental Designs
What is a Single-Case Experimental Design? Group Experimental Design
Compares one group to another group Experimental group vs. Control group “Between-subjects” design
Single Case Experimental Design Compares one person to themselves Person during Baseline vs. Person during
Treatment “Within-subjects” design
Part II: Background Theory
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1 4 7 10 13 16 19 22 25 28 31 34 37 40Weeks
DEPR
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Generic A-B DesignPHASE A (BASELINE) PHASE B (TREATMEMT)
A-B-A Design
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1 2 3 4 5 6 7 8 9 10 11 12Time
BDI S
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Depression
A-B-C Design
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1 2 3 4 5 6 7 8 9 10 11 12Time
BDI S
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Depression
Multiple Baseline Across Symptoms – or Participants
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Self-
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ores
DepressionAnxiety
Benefits of Single Case Designs for Gestalt
Respects Idiographic Uniqueness No lumping people into groups No random assignment to
manualized treatments Only need Gestalt person, doing
what he or she does, in their own practice and one of their clients
Benefits of Single Case Designs for Researchers
Links science to practice, and practice to science
Facilitates innovation Creative and flexible Inexpensive – can easily add
research into existing clinical settings
Benefits of Single Case Designs for Clinicians and Clients
• Promotes working alliance• Allows problems and solutions to be
seen from a different perspective• May increase treatment efficiency
and effectiveness• May enhance motivation for
clinicians and clients• Logic closely parallels good clinical
decision making
General Procedures of Single-Case Designs
Characteristics of single-case designs:
Repeated measures▪ “[I]nstead of studying a thousand rats for
one hour each, or a hundred rats for ten hours each, the investigator is likely to study one rat for a thousand hours.”
-- BF Skinner Baseline measurement Changing one variable at a time
1 4 7 10 13 16 19 22 25 28 31 34 37 40200
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DAYS
DEPR
ESSI
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Generic A-B Single Case Design
PHASE A (BASELINE) PHASE B (TREATMENT)
Single Case Design: Threats to ValidityInternal Validity: Are effects due to intervention?• Can we conclude that changes in the independent variable
caused the observed changes in the dependent variable?• History Confounds: Did some unanticipated event occur
while the experiment was in progress and did these events affect the dependent variable?
• Mortality / Attrition Confounds: Did a participant begin a study, but fail to complete it for any reason?
Threats to internal validity compromise our confidence in saying that a relationship exists between the independent and dependent variables in our single case experiment.
“Minimize confounds!”
Single Case Design: Threats to Validity
External Validity: Does this data generalize? Population Validity: How representative is the
patient of the population? Ecological Validity: How representative is the
treatment setting of the treatment? Threats to external validity compromise our
confidence in stating whether the study’s results are applicable to other individuals and/or treatment settings.
“Replicate the findings!”
Single Case Design: Step-by-Step
Step 1: Make a hypothesisStep 2: Select a participantStep 3: Choose a target complaintStep 4: Measure it continuously over a
baseline periodStep 5: Systematically apply or alter
treatment interventionsStep 6: Measure target complaint
continuously over treatment periodStep 7: Determine if there is a statistically
significant effect
Single Case Design Essentials
Step 1: Make a hypothesis▪ Treatment intervention▪ Gestalt therapy in general▪ Particular sub-technique of gestalt, e.g., focusing, empty chair, interpersonal contact, etc.▪ “Awareness in and of itself is curative”
▪ Population to which hypothesis refers▪ Depressed individuals▪ Individuals whose primary defense is retroflection, somatization, etc.
Single Case Design Essentials
Step 2: Select a participant Inclusion criteria▪ Depression above cutoff score on BDI▪ Marital Distress above cutoff on DAS▪ Retroflection score on the GIRL
Exclusion criteria▪ Non-psychotic, not a child, not using substances,
not in concurrent other psychotherapy, etc. Informed Consent IRB / Archival
Selecting intervention targets
Step 3: Choose target complaints Concrete and quantifiable Frequent Stable without treatment Consolidate Target Complaints in
the Target Complaints (TC) Measure
Single Case Design Essentials
Step 4: Measure Target Complaints continuously over a baseline period Good to have at least 7 baseline
datapoints▪ More baseline is better; fewer is possible (3)
Typically, ask patient to monitor target complaints daily in between intake session and first treatment session
Can also measure TCs on a weekly basis
Single Case Design Essentials
Step 5: Systematically apply or alter treatment interventions Treatment intervention is the
independent variable The change in intervention separates
the data stream into separate phases▪ Pre-treatment (Baseline) vs. Treatment▪ Phase A vs. Phase B: “A-B Single Case
Design” Treatment fidelity
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Days
DEPR
ESSI
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Generic A-B Single Case Design
PHASE A (BASELINE) PHASE B (TREATMENT)
INTAKE 1st Session
Single Case Design Essentials
Step 6: Measure Target Complaints continuously over treatment period Typically, ask patient to monitor target
complaints daily / weekly after first treatment session
Use same periodic interval for measuring target complaints as in baseline phase
Need at least 7 datapoints; more is better; typical is 30+
Single Case Design: Step-by-Step
Step 7: Determine if there is a significant effect due to treatment Pre-treatment / Post-treatment outcome
measures Data stream analysis: Simulation Modeling
Analysis (SMA)▪ One of the recommended statistical analytic
methodologies for Evidence-Based Case Studies per the journal Psychotherapy▪ SMA is ideal for short, autocorrelated data streams
as are typically found in clinical treatment settings
SAMPLE SERIESBASELINE PHASE TREATMENT
PHASEMean = 6.87 Mean = 3.50
First Order of Business
IS WHAT WE ARE LOOKING AT A PRODUCT OF RANDOM
VARIATION?PUT ANOTHER WAY
HOW LIKELY IS IT THAT THE OBSERVED PHASE EFFECT
WOULD OCCUR UNDER RANDOM CONDITIONS?
Autocorrelation Essentially, the tendency of a serially
dependent stream of data to be able to account for variance in itself
Previous data points predict subsequent data points
Weather, Dow Jones Periodicity, gradualism, stochastic
process.
Estimating Autocorrelation
ar (X i X
_)(Xi1 X
_)
i1
N 1
(Xi X_
)2
i1
N
EXAMPLE:
BASELINE PHASE TREATMENT PHASE (3 observations) (7 observations)
EXAMPLE:
BASELINE PHASE TREATMENT PHASE
EXAMPLE:
BASELINE PHASE TREATMENT PHASE
EXAMPLE:
BASELINE PHASE TREATMENT PHASE
EXAMPLE:
BASELINE PHASE TREATMENT PHASE
Sampling Distribution
FREQ
Actual observed datastream
p = .01
Example 1:
NO EFFECT, AR=.8, N=12 (3,9)
Example 1:
p=.44, Non-significant
Example 2:
NO EFFECT, AR=.9, N=12(3,9)
Example 2:
p=.07, Non-significant
Example 3
Effect=0, AR=.4, N=12 (3,9)
Example 3
p=.03, Significant change
Single Case Design: Step-by-Step -- Review
Step 1: Make a hypothesisStep 2: Select a participantStep 3: Choose a target complaintStep 4: Measure it continuously over a
baseline periodStep 5: Systematically apply or alter
treatment interventionsStep 6: Measure target complaint
continuously over treatment periodStep 7: Determine if there is a statistically
significant effect
A FEW journals publishing single case design studies in past 5-years
Behavior Modification Journal of Applied Behavior Analysis Journal of Consulting and Clinical Psychology School Psychology Quarterly Neuropsychological Rehabilitation Child and Family Behavior Therapy International Journal Clinical & Experimental Hypnosis Journal of Emotional & Behavioral Disorders Behaviour Change: Journal of Behavior therapy and
experimental psychiatry Journal of positive behavior interventions Journal of intellectual and developmental disability Journal of intellectual disability research Education and treatment of children Behavioural processes Behaviour Change
PART III: Concrete ExampleWorking step-by-step through an example of a SCED
Single Case Experimental Design Example: “Wendy” Wendy is a 67-year-old Caucasian female who
sought therapy at a university-affiliated psychological clinic to treat symptoms of complicated grief.
Her husband of six years (Bradley) had passed away several months prior after a prolonged battle with lung cancer.
Normative process of mourning her husband’s death, however, appeared to be derailed.
Patient had made a postmortem discovery that her husband had had a secret life, e.g., multiple previous wives (and possibly children) as well as financial debt that he had not disclosed to Wendy during their marriage.
Presenting Symptoms At the time of intake, Wendy reported
experiencing a number of symptoms including: ruminative thoughts regarding her deceased poor sleep feelings of overwhelming separation anxiety intense crying spells debilitating loneliness persistent intense yearning for the deceased difficulty engaging in activities of daily living anhedonia irritability social withdrawal
Complicating factors Taking Lorazepam to help mitigate anxiety Recently, her depressive symptoms had
worsened and her primary care physician had suggested that she commence Lexapro, but Wendy was reluctant to do so.
Stage 4 ovarian cancer a variety of somatic-related symptoms due to
the cancer and her chemotherapy regimen, e.g., hair loss, becoming easily tired, needing to move slowly, etc.
Pretreatment Measures
Pretreatment Outcome Measures Completed at intake
Minnesota Multiphasic Personality Inventory-2 (MMPI-2)
Symptom Checklist-90-Revised (SCL-90-R) Outcome Questionnaire-45 (OQ-45)
Determined Target Complaints at Intake Overall level of distress Difficulty feeling at peace Difficulty in building a routine for my life
Baseline MeasuresTarget Complaints
1. What is my overall level of distress?2. How much difficulty do I have feeling at
peace?3. How hard has it been for me today to build
a routine for my life? measured over the course of 10 days
during a pre-treatment baseline questions were rated on a 9-point Likert
scale, with higher numbers indicating more problematic symptomatology
Treatment SessionsUtilized Emotion Focused Therapy
an established, evidence-based treatment approach based on gestalt therapy
found to be equally or more effective than a cognitive behavioral treatment (CBT) in multiple studies (e.g., see Ellison et al., 2009)
more effective in reducing interpersonal problems than the CBT treatment (Angus & Greenberg, 2011)
Length of Treatment 4 months for a total of 16 sessions 2 sessions of intake / assessment and 14 sessions
of once weekly individual psychotherapy.
Treatment Fidelity
The therapy was delivered by a clinical psychology doctoral student Supervised by a licensed clinical
psychologist in accordance with EFT-procedural guidelines as outlined in Working with Narrative in Emotion-Focused Therapy by Angus and Greenberg (2011)
Treatment fidelity
Treatment Fidelity
The therapy was delivered by a clinical psychology doctoral student with significant training in Gestalt No clear Gestalt treatment manual Used guidelines as outlined in
Working with Narrative in Emotion-Focused Therapy by Angus and Greenberg (2011)
Treatment fidelity
The TreatmentFirst session
In the midst of Wendy’s debilitating distress, her 6 year old grandson had offered her the following words of comfort: “Grandma, I think he loved you.”
The Central Question Did he really love me?
Stages of Therapy: Stage 1
Basic trust empathic attention to Wendy’s key concerns
Witnessing hallmarks of grief denial (“He can’t be gone. It wasn’t his
time.”) anger (“There was a woman who was saying
how happy she was and I just wanted to hit her”)
depression (“I’ve been crying for the last two days… I can’t stop and I don’t know why.”)
Stages of Therapy: Stage 2
Explore problematic emotions and undo interruptions to emotional experience Connecting anger with their actual
source Contextualizing grief within narrative
of bereavement Shifting from guilt to self-compassion Holding polarities
Stages of Therapy: Stage 3
Wendy discovers a new betrayal and begins to question, yet again, if Bradley’s love for her was real.THERAPIST: So imagine that [Bradley] is here, sitting in this chair. WENDY: (pause) Ok.THERAPIST: Can you see him? I mean really imagine him?Wendy nods. THERAPIST : Ok, now ask him exactly that, that question that you were asking. WENDY : Which question?THERAPIST : The question you had just asked… “Was it real? … Was it real?” WENDY : Oh yeah…. Ok…
Stages of Therapy: Stage 3
Pause.THERAPIST: Are you asking him the question?WENDY: Uh-huh. THERAPIST: How does he respond?Pause.WENDY : He’s crying…. He says,“It was real. It was real.” Pause. THERAPIST: Just sit with that for a moment.Wendy nods. THERAPIST : Does that feel true?Wendy hesitates. Then nods.
Stages of Therapy: Stage 3
THERAPIST: Is there anything you want to ask him?WENDY: (pause) Why didn’t you trust me? THERAPIST: (softly, echoing) “Why didn’t you trust me?” (pause) And what does he say?Pause.WENDY: He says that he was scared and ashamed. THERAPIST: Ah. Scared. Ashamed. Pause.WENDY : (angry – directed to imaginary Bradley) You should have believed that I would still have loved you! I would have loved you anyways!
Stages of Therapy: Stage 3
THERAPIST: And what does he say. WENDY: He says that he’s sorry. Just so sorry. Pause. Wendy weeps. Wendy reenters her own experience and speaks as if to imaginary Bradley.WENDY: (crying) It’s ok. It’s ok. (pause) I forgive you.
Stages of Therapy: Stage 3
Reconsolidating narrative history Answering the question: Did he love
me? Accepting what is Reconnecting with larger social
network – discovering place in the greater gestalt Finding meaning through volunteer work
at cancer center
Time-Series Analysis
0 20 40 60 80 100 120 1401
2
3
4
5
6
7
8
9
Daily Measure of Overall Distress
Time (in Days)
Ove
rall
Dist
ress
wor
se
Time-Series Analysis
0 20 40 60 80 100 120 1401
2
3
4
5
6
7
8
9
Difficulty in Finding Peace
Time (in Days)
Diffi
culty
in F
indi
ng P
eace
wor
se
Time-Series Analysis
0 20 40 60 80 100 120 1401
2
3
4
5
6
7
8
9
Difficulty in Creating a Routine
Time (in Days)
Diffi
culty
in C
reati
ng a
Rou
tine
wor
se
Time-Series Analysis
0 20 40 60 80 100 120 14020
25
30
35
40
45
50
55
60
Change in OQ-45 Symptom Measure over Time
Time (in Days)
OQ
-45
Tota
l Sco
rew
orse
Pre-treatment
Post-treatment
PART IV: Your TurnDesigning and implementing your own SCED study
Your Turn: Step 1
Step 1: Make a hypothesisa. What treatment intervention do you want to study? b. What population do you want to test out the above-listed intervention on? c. What do you hypothesize will be the effect of applying the treatment intervention from (1a) on the population (1b)?
Your Turn: Step 2
Step 2: Select a participanta. How will you select a participant to test your hypothesis? b. What are you inclusion criteria?c. What are your exclusion criteria?d. Are there any established outcome measures that you can use to help select your participant?
Your Turn: Step 3
Step 3: Choose a Target Complaint
List three (3) Target Complaints that the patient you are proposing to study might have
Ideally, these Target Complaints are:▪ Concrete and quantifiable▪ Frequent ▪ Stable without treatment
Your Turn: Step 4
Step 4: Measure the Target Complaints continuously over a baseline period
a. At what periodic interval do you want to measure the Target Complaints? b. How many baseline Target Complaint measurements do you plan to establish for your pre-treatment phase?
Your Turn: Step 5
Step 5: Systematically apply or alter treatment interventions
a. What treatment intervention will you administer to the patient? b. How will you insure treatment fidelity? c. Is there a gestalt protocol to which you can legitimately claim adherence?
Your Turn: Step 6
Step 6: Measure target complaint continuously over treatment period
a. The periodic interval for measuring Target Complaints over the treatment period must be the same as for the baseline period. b. How many Target Complaint measurements during the treatment phase do you plan to have for your patient? c. How will you ensure patient compliance with tracking symptoms?
Your Turn: Step 7
Step 7: Determine if there is a statistically significant effect
a. Download the free SMA software located at http://www.clinicalresearcher.org/software.htm b. Enter data and run “Simulation Test”c. Examine your Level Change and Slope Change p-values. Typically, p <.05 is considered to be significant.d. Congratulations. You have just completed a Single-Case Experimental Design.
Resources
Borckardt, J.J., Nash, M.R., Murphy, M. D., Moore, M., Shaw, D., & O-Neil, P. (2008). Clinical practice as natural laboratory for psychotherapy research. American Psychologist, 63, 77-95.
http://www.clinicalresearcher.orgajwwong@gmail.com
Special thanks to Michael Nash and the University of Tennessee.
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