A Guide to Conducting Case-Based , Time-Series R esearch in Gestalt / Emotion Focused T...

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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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

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DAYS

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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.


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


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


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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PHASE A (BASELINE) PHASE B (TREATMENT)

INTAKE 1st Session


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

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.”)


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


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…


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.


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!


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.


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

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Daily Measure of Overall Distress

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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.

http://www.clinicalresearcher.org/software.htm

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://[email protected]

http://www.clinicalresearcher.org/

Special thanks to Michael Nash and the University of Tennessee.

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