jennifer l. villatte university of nevada, reno acbs world conference 2010 single case designs for...
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Jennifer L. Villatte
University of Nevada, Reno
ACBS World Conference 2010
Single Case Designs for Clinicians:
Bridging the Gap Between Science and Practice
Workshop Objectives
• PART I:– Fundamentals of Single Case
Designs
• PART II:– Using SCDs in Case Formulation,
Treatment Planning, Progress Monitoring
• PART III: – Practical Applications: Designing
and implementing your study
CLINICAL RESEARCH
How do I help the most
people with these kinds of
problems?
CLINICAL PRACTICE
How do I help this person
sitting in front of me right
now?
Single Case Designs Bridge that Gap
Avoids small,
unimportant effects
Facilitates innovation
Creative and flexible
Fits easily into
clinical settings
Links science to practice, practice to science
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
Which EST should I use for this particular
client?
Which problem do I start with?
Does homework
make a difference?
Is one treatment better than another?
Will group or individual
work better for this client?
Which component
do I start with?
Is this intervention helping my
client?
When should I terminate?
Is there a more
efficient way to deliver
treatment?
Single Case Design Essentials
SCDs are experimental, which means we must consider:• Internal Validity: Are effects due to intervention?
→ Adequate comparison conditions• External Validity: Does this data generalize?
→ Replicate, replicate, replicate
This requires:• Repeated, continuous measurement • Systematic manipulation of intervention
Single Case Design Essentials
Step 1: Choose a target behaviorStep 2: Measure it continuously Step 3: Monitor target behavior
until stability is established
Step 4: Systematically apply or alter treatment interventions
Choose Choose intervention intervention
targets that are:targets that are:
Stable without treatment
Frequent
Concrete and quantifiable
Establish a Stable Baseline
Repeatedly collect measures to determine...
TREND
COURSE
LEVEL
• Ideally, 3+ data points
• Withhold treatment until baseline is stable
Baseline Intervention
Is this baseline stable?
Is it stable if I hoped to produce this?
Baseline Intervention
What if I hoped to produce this?
Baseline Intervention
What do I do if the target behavior is not stable?
• Analyze sources of variability
• Block or average data• Wait until it becomes
stable• Begin treatment
anywayAaaarrrggghhhHHHH!!
Days
Perc
ent Tim
e O
n-Ta
sk
100
80
60
40
20
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
AverageTime
On-Taskfor All
Childrenin this
Classroom
Troublesome Days
Unstable Baseline Data
Days
Perc
ent Tim
e O
n-Ta
sk
100
80
60
40
20
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
With-Mother Days
With-Father Days
Analyze Source of Variability
Weeks
Beh
avio
r
Sessions
Data Blocked Every Two Sessions
Raw Data
Beh
avio
r
Hard to make sense
of this...
With blocking, a pattern emerges
Next Step: Measure Continuously
Use as many measures as is practical and meaningful
as often as is practical and meaningful
using what is available
Self-report measuresIdiographic ratings
Diary cardsCollateral reportsChart information
Treat design elements like building blocks
No-treatment assessment (e.g., baseline, follow-up, treatment breaks)
Treatment package (e.g., ACT, DBT)
Delivery method (e.g., group, individual)
Treatment components (e.g., values, mindfulness)
Treat design elements like building blocks
Classic Design: The Reversal
BaselineAssessment
without treatment
InterventionAssessment throughout
treatment delivery
Follow-UpAssessment
without treatment
Classic Design: Alternating Treatments
Treatment 1
ACT
Acceptance
Homework
Individual
Treatment 1
ACT
Acceptance
Homework
Individual
Treatment 2
CBT
Values
No Homework
Group
Treatment 2
CBT
Values
No Homework
Group
Baseline
Assessment without
treatment
Classic Design: Multiple Baselines
#1
#2
#3
• Across participants with similar problems
• Across behaviors in the same participant
• Across treatment processes or components
• Across settings or treatment modalities
Multiple Baseline Across
Participants #1
#2
#3
I have three clients with mixed depression and anxiety, as measured by the DASS.
All will receive ACT, but they won’t begin treatment at the same time due to wait list.
Multiple Baseline Across
ACT Processes #1
#2
#3
I want to see if process measures move when I target specific ACT processes with one client.
According to my case conceptualization, 1st Target mindfulness2nd Target defusion3rd Target values
FFMQ
ATQ-B
ValuesBullseye
Choosing a Design- What questions do I have?
• Is treatment useful for a specific problem/combination of problems?
• Is one treatment better than another?• Which components contribute to efficacy?• Does the order of components matter?• What is the optimal level of treatment?• Does the treatment generalize across contexts?• What is the best way to train/deliver treatment?• Will treatment gains maintain after termination?
Choosing a Design- What is possible with my caseload?
• How many clients do I have with similar presentations?
• Can I collect baseline data and wait long enough to establish stability?
• What is the nature of target behaviors? • How often do I need to collect assessment
measures? • Is it ethical to withdraw treatment? • Can I switch treatments or treatment targets?
• Be curious- Play!
• Be creative with design elements
• Be collaborative and involve your client
• Be flexible and ready to change course- let the data guide you
• Be spontaneous- avoid excessively preconceived designs; take advantage of serendipitous events
Days
100
80
60
40
20
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Graphing and Organizing Data
We Could Organize by Time...
Days
100
80
60
40
20
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
...And Then By Situation
D ay s
100
80
60
40
20
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Basel in e I n terv en tion
But in other situations we could organize them by situation...
D ay s
100
80
60
40
20
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Basel in e
I n terv en tion
...And Then By Time
D ay s
100
80
60
40
20
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Basel in e
I n terv en tion
Analyzing The Data
• Visual inspection of level, course, trend
• Statistical Methods– Test for autocorrelation– Compare the Means – Test effect sizes
Sharing What You Learned• Brief reports on Listservs• Research-Practice networks– PRACTICEground.org– Behavioral Collective SIG
• Conference Presentations• Scholarly Journals
Ethical Considerations
• Research vs. Treatment evaluation– Do you intend to publish this information?
• Institutional Review Boards• Informed consent– Confidentiality– Privacy– Risk/Benefit Analysis
PART 2:Single Case Designs in case formulation,
treatment planning, & progress monitoring
1. Start with a model of psychopathology– Development– Maintenance– Treatment
2. Assessment of relevant targets– Processes– Outcomes
3. Case Formulation4. Treatment Plan5. Assess, Reformulate, Modify Treatment Plan
Case Formulation Approach
= Therapeutic Relationship
Assessment CaseFormulation
Treatment Planning
Treatment Implementation
Case Formulation Approach Treatment Treatment Initiation Termination
Based on J. Persons, 2008
Example: The multi-problem client
• How do I know what to target at what time with what technologies given multiple treatment targets?
• How do I know if what I’m doing is effective, given that these problems are known to be slow to remit?
Initial Assessment
• Current diagnoses– Borderline Personality Disorder– Major Depression, Dysthymia– Post Traumatic Stress Disorder– Eating Disorder NOS– Panic Disorder w/Agoraphobia
• Recent diagnoses– Alcohol, Cocaine, Marijuana Dependence– Bulimia Nervosa– Obsessive Compulsive Disorder
• Treatment History– SSRIs (1 year)– Individual CBT (1.5 years)– Group CBT (4 weeks)– Alcoholics Anonymous (2 years)
• Presenting Problems: “I hate my life.”– Emotional numbing/overwhelming dysphoria;
unstable sense of self; chronic emptiness; shame, self-disgust, self-stigma; urges to use drugs and alcohol; obsessions and ruminations; self-harm and suicidality; binging and purging; avoidance: crowds, touch, emotions; stagnation at school and work; lack of motivation; social isolation/never had a romantic relationship; chaotic family relationships
Initial Assessment
Remember Informed Consent
Choosing a Design
PLAN C:
PLAN A:
A: No Treatment
Baseline
B: Treatment
A: No Treatment
Follow-Up PLAN B:
Subject 1
Subject 2
Subject 3
A: No Tx
Baseline
B: TreatmentPhase #1
C: TreatmentPhase #2
A: No Tx
Follow-Up
A: NoTx
Cognitive Fusion
Psychological Inflexibility
Experiential Avoidance
Lack of Values Clarity;
Dominance of Pliance and
Avoidant Tracking
Dominance of the Conceptualized Past and
Feared Future; Weak Self-Knowledge
Case Formulation
Inaction, Impulsivity, or
Avoidant Persistence
Attachment to the Conceptualized Self
Treatment Planning
Self asContext
Contact with the Present Moment
Defusion
Acceptance
Committed Action
Values
Psychological Flexibility
Experiential Acceptance
Committed Action
Values Clarification
and Induction
Present Moment
Awareness
Defusion
Self-as-Context
PRIMARY TARGETS
SECONDARY TARGETS
Treatment Phase One
Problem Process Measure Experiential Avoidance Experiential Acceptance Acceptance and Action
Q Cognitive Fusion Defusion Automatic Thoughts QPast/Future Dominance Present Moment Focus Five Factor Mindfulness
Q
Goals:– Reduce misery and increase behavioral stability– Increase awareness, reduce reactivity– Break up thought/action fusion (impulsivity)– Reduce dominance of judgment and evaluation
WEEKLY TREATMENT
WEEKLY TREATMENT
BI-WEEKLY TREATMENT
NO Tx
NO Tx
NO Tx
NO TREATMENT
Tx Initiated
Tx Terminated
WEEKS
WEEKS
NO Tx NO Tx NO TxWEEKLY
TREATMENTWEEKLY
TREATMENTBI-WEEKLY
TREATMENT NO Tx
Tx Terminated
Tx Initiated
ATQ-B Range: 30-150Higher Score = Greater Distress
WEEKS
NO Tx NO TxNO Tx NO TxWEEKLY TREATMENT
WEEKLY TREATMENT
BI-WEEKLY TREATMENT
FFMQ: Range: 0-5; Higher scores = ↑ mindfulnessPROCESS MEASURE: MINDFULNESS
Treatment Phase TwoProblem Process Measure• Attachment to Self-as-Context Self Compassion Scale Conceptualized Self • Lack of Clarity/ Values Clarification Personal Values Q Pliant/Avoidant Tacking & Induction• Inaction/Impulsivity Committed Action Values Bullseye
Goals:– Establish stable sense of self– Increase motivation and contact with reinforcers– Increase persistence in goal-directed behavior– Increase sense of purpose and life satisfaction
WEEKS
NO Tx NO Tx NO TxWEEKLY TREATMENT
BI-WEEKLY TREATMENT
Bulls-eye Range: 1-15Higher scores= Values Consistent Action
PROCESS MEASURE-VALUES AND COMMITED ACTION
WEEKS
WEEKLY TREATMENT
NO Tx NO TxNO Tx NO TxWEEKLY
TREATMENTBI-WEEKLY
TREATMENT
Tx Initiated
Tx Terminated
Range: 0-5Higher scores = better functioning
WEEKS
WEEKS
NO Tx NO Tx NO TxNO TxWEEKLY TREATMENT
WEEKLY TREATMENT
BI-WEEKLY TREATMENT
Discussion
• Clinical: Treatment was effective.– All measures below clinical levels at post-treatment– Treatment gains maintained at 4-month follow up
• Research: Model was supported.– Targeted techniques produced expected changes in
process measures– Changes in hypothesized processes of change
preceded changes in outcome measures
PART III:Practical Applications:
Designing and Implementing Your Study
Consider Your Current Caseload
• What outcomes do you hope for?– Behavior change
(frequency, form or situational sensitivity)– Symptom reduction– Quality of Life/Functioning
• What processes do you expect to affect these outcomes?– Based on your model– What causes, maintains, or alleviates problems?
Consider Your Current Caseload
• How could you assess these?– Idiographic self-monitoring, diary cards– Standardized self-report measures– Behavioral measures
• How often to take measures?– How quickly do I expect
treatment targets to change?– How often is feasible for my client?
What elements do you need to build your study?
• No-treatment assessment
• Treatment package• Treatment processes• Treatment components• Delivery method• Setting or context
Baseline Intervention Follow-Up
Treatment 1
ACT
Acceptance
Homework
Individual
Treatment 1
ACT
Acceptance
Homework
Individual
Treatment 2
CBT
Values
No Homework
Group
Treatment 2
CBT
Values
No Homework
Group
Baseline
Assessment without
treatment
You’ve got everything you need
But just in case you want more....
...some additional resources for conducting Single Case Designs
Additional Reading• Barlow, D.H., Nock, M. K., & Hersen, M. (2008). Single Case Experimental
Designs: Strategies for Studying Behavior Change, 3rd edition. Allyn & Bacon.
• Hayes, S. C., Barlow, D. H., & Nelson-Gray, R. O. (1999). The Scientist Practitioner, 2nd edition. Allyn & Bacon.
• Kazdin, A. E. (2008). Behavior Modification in Applied Settings, 6th edition. Wadsworth.
• Hilliard, R. B. (1993). Single-case methodology in psychotherapy process and outcome research. Journal of Consulting and Clinical Psychology, 61, 373-380.
• Nugent, W. R. (2010). Analyzing single system design data. Oxford University Press.
• Persons, J. B. (2008). The case formulation approach to cognitive-behavior therapy. Guilford Press.
Examples of ACT SCDs
• Twohig, M. P., & Crosby, J. M. (2010). Acceptance and commitment therapy as a treatment for problematic internet pornography viewing. Behavior Therapy, 41, 285-295.
• Peterson, B. D., Eifert, G. H., Feingold, T., & Davidson, S. (2009). Using Acceptance and Commitment Therapy to treat distressed couples: A case study with two couples. Cognitive and Behavioral Practice, 16, 430-442.
• Jourdain, R. L., &Dulin, P. L. (2009). "Giving It Space": A case study examining Acceptance and Commitment Therapy for health anxiety in an older male previously exposed to nuclear testing . Clinical Case Studies, 8, 210-225.
• Stotts, A. L., Masuda, A., & Wilson, K. (2009). Using acceptance and commitment therapy during methadone dose reduction: Rationale, treatment description, and a case report. Cognitive and Behavioral Practice, 16(2), 205-213.
Help with Graphing and Analysis
• Villatte’s Excel Scoring and Graphing Template for ACT measures• Online SCD statistical analysis program- W. Paul Jones, UNLV
http://faculty.unlv.edu/pjones/singlecase/scsatool.htm• Helpful papers on analyzing SCDs:
– Parker, R. I., & Vannest, K. (2009). An Improved Effect Size for Single-Case Research: Nonoverlap of All Pairs. Behavior Therapy , 40,357-367.
– Solanas, A., Manolov, R., Onghena, P. (2010). Estimating slope and level change in N = 1 designs. Behavior Modification, 34, 195-218.
– Kratochwill, T.R. & Levin, J.R. (2010). Enhancing the scientific credibility of single-case intervention research: Randomization to the rescue. Psychological Methods, 15, 124-144.
– Fisher, W. W., Kelley, M. E., & Lomas, J. E. (2003). Visual aids and structured criteria for improving inspection and interpretation of single-case designs. Journal of Applied Behavior Analysis, 36, 387-406.
Thank you!
Jennifer Villattejlvillatte@gmail.com
All of the following available at your request:• Presentation notes
• ACT assessment measures• Scoring and graphing templates
• SCD consultation• Reprints of published ACT SCDs
• Reprints of articles mentioned in this presentation
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