Presentation Transcript

1. Albert J. Wong, M.A., Mike Finn, B.A., and Michael R. Nash, Ph.D. Department of Psychology University of Tennessee – Knoxville Knoxville, TN 37996

   A Guide to Conducting Case-Based, Time-Series Research in Gestalt / Emotion Focused Therapy

   Integrating Research and Practice in a Clinical Setting The Challenge of Establishing a Research Tradition for Gestalt Therapy: An International Conference  April 17, 2013
2. 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
3. PART I. What is at Stake Why 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.
4. PART I: What is at Stake The 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
5. Why is being an Empirically Supported Treatment Important? Pragmatic Reasons Ability to practice Ability to get reimbursed Managed Care Organizations Accountable Care Organizations Ability to influence the collective dialogue 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?
6. What does it take to become an Empirically Supported Therapy? Empirically Supported Therapies (ESTs) are therapies that have demonstrated superiority to a placebo (dummy treatment) in two or more methodologically rigorous controlled studies, equivalence to a well-established treatment in several rigorous and independent controlled studies, efficacy in a large series of single-case controlled designs(Chambless& Hollon, 1998)
7. How many single-case designs do we need? 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 Number of published single-case experimental designs that support Gestalt… Many case studies, but NO single-case experimental designs
8. Case Study vs. Single-Case Experimental Design 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
9. Requirements of single-case designs Single Case Design studies must… be conducted under the guidance of a treatment manual Task Analysis (Les Greenberg, Roubal) Treatment Fidelity Measure: “Even Jazz has a form” specify the sample population (inclusion / exclusion) use good experimental design (Borckhardtet al, 2008) Have an experimental control Establish a representative baseline Manage the nonindependenceof sequential observations (e.g., autocorrelation, serial dependence) Interpret single-subject effect sizes Frequently must analyze short data streams
10. PART II: Background Theory Fundamentals of Single-Case Experimental Designs
11. Part II: Background Theory 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
12. Generic A-B Design PHASE A (BASELINE) PHASE B (TREATMEMT)
13. A-B-A Design
14. A-B-C Design
15. Multiple Baseline Across Symptoms – or Participants
16. 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
17. 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
18. 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
19. General Procedures of Single-Case Designs Characteristics of single-case designs: Repeated measures “[I]nsteadof 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
20. Generic A-B Single Case Design PHASE A (BASELINE) PHASE B (TREATMENT)
21. Single Case Design: Threats to Validity Internal 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!”
22. 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!”
23. Single Case Design: Step-by-Step Step 1: Make a hypothesis Step 2: Select a participant Step 3: Choose a target complaint Step 4: Measure it continuously over a baseline period Step 5: Systematically apply or alter treatment interventions Step 6: Measure target complaint continuously over treatment period Step 7: Determine if there is a statistically significant effect
24. 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.
25. 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
26. Selecting intervention targets Step 3: Choose target complaints Concrete and quantifiable Frequent Stable without treatment Consolidate Target Complaints in the Target Complaints (TC) Measure
27. 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
28. 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
29. Generic A-B Single Case Design PHASE A (BASELINE) PHASE B (TREATMENT) 1st Session INTAKE
30. 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+
31. 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
32. SAMPLE SERIES BASELINE PHASE TREATMENT PHASE Mean = 6.87 Mean = 3.50
33. 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?
34. 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.
35. Estimating Autocorrelation
36. EXAMPLE: BASELINE PHASE TREATMENT PHASE (3 observations) (7 observations)
37. EXAMPLE: BASELINE PHASE TREATMENT PHASE
38. EXAMPLE: BASELINE PHASE TREATMENT PHASE
39. EXAMPLE: BASELINE PHASE TREATMENT PHASE
40. EXAMPLE: BASELINE PHASE TREATMENT PHASE
41. Sampling Distribution Actual observed datastream p = .01
42. Example 1: NO EFFECT, AR=.8, N=12 (3,9)
43. Example 1: p=.44, Non-significant
44. Example 2: NO EFFECT, AR=.9, N=12(3,9)
45. Example 2: p=.07, Non-significant
46. Example 3 Effect=0, AR=.4, N=12 (3,9)
47. Example 3 p=.03, Significant change
48. Single Case Design: Step-by-Step -- Review Step 1: Make a hypothesis Step 2: Select a participant Step 3: Choose a target complaint Step 4: Measure it continuously over a baseline period Step 5: Systematically apply or alter treatment interventions Step 6: Measure target complaint continuously over treatment period Step 7: Determine if there is a statistically significant effect
49. 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
50. PART III: Concrete Example Working step-by-step through an example of a SCED
51. 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.
52. 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
53. 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.
54. 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
55. Baseline Measures Target Complaints What is my overall level of distress? How much difficulty do I have feeling at peace? 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
56. Treatment Sessions Utilized 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.
57. 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
58. 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
59. The Treatment First 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?
60. 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.”)
61. 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
62. 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…
63. 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.
64. 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!
65. 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.
66. 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
67. Time-Series Analysis
68. Time-Series Analysis
69. Time-Series Analysis
70. Time-Series Analysis
71. PART IV: Your Turn Designing and implementing your own SCED study
72. Your Turn: Step 1 Step 1: Make a hypothesis a. 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)?
73. Your Turn: Step 2 Step 2: Select a participant a. 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?
74. 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
75. 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?
76. 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?
77. 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?
78. 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.
79. 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.org ajwwong@gmail.com
80. Special thanks to Michael Nashand the University of Tennessee.