Jennifer L. Villatte

Single Case Designs for Clinicians: Bridging the Gap Between Science and Practice Jennifer L. Villatte University of Nevada, Reno ACBS World Conference 2010

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 PRACTICE How do I help this person sitting in front of me right now? CLINICAL RESEARCH How do I help the most people with these kinds of problems?

Single Case Designs Bridge that Gap Facilitates innovation Avoids small, unimportant effects Fits easily into clinical settings Links science to practice, practice to science Creative and flexible

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? Is one treatment better than another? Does homework make a difference? Will group or individual work better for this client? Is this intervention helping my client? Is there a more efficient way to deliver treatment? Which problem do I start with? When should I terminate? Which component do I start with?

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 behavior Step 2: Measure it continuously Step 3: Monitor target behavior until stability is established Step 4: Systematically apply or alter treatment interventions

Choose intervention targets that are: Stable without treatment • Frequent • Concrete and quantifiable

Establish a Stable Baseline Repeatedly collect measures to determine... LEVEL • Ideally, 3+ data points • Withhold treatment until baseline is stable TREND COURSE

Is this baseline stable?

Is it stable if I hoped to produce this?

What if I hoped to produce this?

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 anyway AaaarrrggghhhHHHH!!

Unstable Baseline Data

Analyze Source of Variability

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 measures • Idiographic ratings • Diary cards • Collateral reports • Chart information

Treat design elements like building blocks No-treatment assessment (e.g., baseline, follow-up, treatment breaks) Treatment package (e.g., ACT, DBT)

Treat design elements like building blocks Delivery method (e.g., group, individual) Treatment components (e.g., values, mindfulness)

Classic Design: The Reversal Baseline Assessment without treatment Intervention Assessment throughout treatment delivery Follow-Up Assessment without treatment

Classic Design: Alternating Treatments Baseline Assessment without treatment Treatment 1 ACT Acceptance Homework Individual Treatment 2 CBT Values No Homework Group Treatment 1 ACT Acceptance Homework Individual Treatment 2 CBT Values No Homework Group

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 FFMQ #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 mindfulness 2nd Target defusion 3rd Target values ATQ-B Values Bullseye

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

Graphing and Organizing Data

We Could Organize by Time...

...And Then By Situation

But in other situations we could organize them by situation...

...And Then By Time

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 • Behavior Modification • Behavior Therapy • Behavioural and Cognitive Psychotherapy • Clinical Case Studies • Clinical Psychology: Science and Practice • Cognitive and Behavioral Practice • Journal of Applied Behavior Analysis • Journal of Contextual Behavioral Science • Journal of Behavioral Therapy and Experimental Psychiatry

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

Case Formulation Approach • Start with a model of psychopathology • Development • Maintenance • Treatment • Assessment of relevant targets • Processes • Outcomes • Case Formulation • Treatment Plan • Assess, Reformulate, Modify Treatment Plan

Case Formulation Approach Treatment Treatment Initiation Termination Treatment Planning Case Formulation Assessment Treatment Implementation Based on J. Persons, 2008 = Therapeutic Relationship

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

Initial Assessment • 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 Remember Informed Consent

Choosing a Design Subject 1 PLAN A: Subject 2 Subject 3 A: No Treatment Baseline A: No Treatment Follow-Up PLAN B: B: Treatment A: No Tx Baseline B: Treatment Phase #1 A: No Tx C: Treatment Phase #2 A: No Tx Follow-Up PLAN C:

Case Formulation Dominance of the Conceptualized Past and Feared Future; Weak Self-Knowledge Lack of Values Clarity; Dominance of Pliance and Avoidant Tracking Experiential Avoidance Psychological Inflexibility Cognitive Fusion Inaction, Impulsivity, or Avoidant Persistence Attachment to the Conceptualized Self

Treatment Planning Present Moment Awareness Values Clarification and Induction Experiential Acceptance Psychological Flexibility Defusion Committed Action PRIMARY TARGETS Self-as-Context SECONDARY TARGETS

Treatment Phase One Problem Process Measure Experiential Avoidance Experiential Acceptance Acceptance and Action Q Cognitive Fusion Defusion Automatic Thoughts Q Past/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

NO Tx WEEKLY TREATMENT NO Tx WEEKLY TREATMENT NO Tx BI-WEEKLY TREATMENT NO TREATMENT Tx Terminated Tx Initiated WEEKS

ATQ-B Range: 30-150 Higher Score = Greater Distress WEEKLY TREATMENT WEEKLY TREATMENT BI-WEEKLY TREATMENT NO Tx NO Tx NO Tx NO Tx Tx Initiated Tx Terminated WEEKS

PROCESS MEASURE: MINDFULNESS FFMQ: Range: 0-5; Higher scores = ↑ mindfulness WEEKLY TREATMENT WEEKLY TREATMENT BI-WEEKLY TREATMENT NO Tx NO Tx NO Tx NO Tx WEEKS

Treatment Phase Two Problem 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

Jennifer L. Villatte