Hermeneutic Single Case Experimental Design: Assessment, Treatment, and Long-term Outcome of Paranoid Personality Disord

1. “Hermeneutic Single Case Experimental Design: An example of the methodology in action, description of the multi-site study and call for an expert panel ” Stephen Kellett Consultant Clinical Psychologist IAPT Programme Director University of Sheffield Sheffield S & HC NHS Trust

2. Present Study • Assessment, case description, treatment and long-term outcome of client presenting with Paranoid Personality Disorder (PPD) • Hermeutic single case experimental design (Elliott 2002) (1) traditional outcomes measures (2) personal questionnaire daily (3) perceptions of therapy and therapist (4) post therapy interview (5) well described case (6) expert panel or ‘jury’ to consider the evidence for change

3. PPD : DSM-1V (APA, 1994) DEFINITION • suspects (without sufficient basis) that others are exploiting, harming or deceiving them • pre-occupied with trustworthiness • inability to confide • reads demeaning/threatening meanings into events • grudges • perceives attacks on character • jealous

4. Present Study cont Repetition of measures focal to PPD across phases of CAT treatment and phases within phases (ie. addition of mindfulness) (1) reformulation/assessment phase (2) CAT intervention (3) follow-up

5. The Case • Carl (pseudonym, aged 37, signed off work) • Referred by Consultant Psychiatrist opinion re. thought disorder • Screened and placed on waiting list • Assessed via SCID-II (Spitzer et al, 1997)

6. The Case cont

7. Hermeneutic SCED; what was done and when • Traditional Outcome Measures reported at assessment, termination, and follow-up • Beck Depression Inventory-II (BDI; Beck et al, 1994) • Brief Symptom Inventory (BSI; Derogatis, 1993) • Inventory of Interpersonal Problems (IIP-32; Barkham et al, 1994) • Personality Structure and Questionnaire (PSQ; Pollock et al, 2001)

8. Hermeneutic SCED cont

9. Hermeneutic SCED cont • Perception of therapy and therapist • Session Impact Questionnaire (Stiles et al, 1994) • 5 ‘impacts’ measured after each session (understanding, problem solving, relationship, unwanted thoughts, hindering aspects) • Post-therapy Interview • Therapy change interview (Elliott, Slatick & Urman, 2001)

10. Structure of intervention • co-working and sharing; reformulation letter • SDR (starting to get cognitive) • introduction of mindfulness techniques • integrating RR analysis and mindfulness • homework • in session enactments • termination issues

11. Mindfulness-based cognitive therapy (Segal, Williams & Teasdale, 2002) • Mindfulness of breath • Staying present • Allowing/letting be • Thinking and thought • Dealing with barriers

12. Diagram 1: Sequential Diagrammatic Reformulation for PPD Case obsess about it TOTALLY UNFEELING CUT OFF & EMPTY find this frightening after a while CAPTAIN PARANOIA (though I feel complete) INTERROGATING I INTERROGATED start to believe thoughts start to feel vulnerable only way I know to feel safe `peas in the bag` CORE PAIN anxious fearful insecure hectored try to see a pattern Hard to tolerate this mood plummets try to make sense of confusion need to make sense feel totally exhausted anxiety triggered need something to tie it all together see threat everywhere when with people, always keep my distance `THE GAME` Players versus non-players OBSERVING WATCHING I MONITORED can’t ever relax SOCIAL WITHDRAWAL `the radar` SUSPICIOUS I WARY DISTRUSTFUL win / outwit/ triumph start to play find it hard to `connect` this game is real never develop `true` trust never ever stop thinking `ha ha; I’ve seen you` withdraw into myself start to see threats

13. Key question 1 • At what stage does active therapy start to work and are there any sudden gains?

15. Table 1; means, (SDs) and F-values for the experimental variables * p < 0.05 ** p < 0.01

16. What do significant F-values mean in this context? • An overall change in both the intercept (i.e. start of treatment post formulation) and the slope (regression line)

17. Key question 2 • Is there any clinically significant change in the traditional outcome measures?

19. Key question 3; are some sessions more impactful/helpful than others? • Significant increase in ratings of problem solving in treatment sessions (t = -2.27, P < 0.05) • No difference in understanding, relationship, unwanted thoughts or hindering aspects

20. Key question 4 • can the client describe what changes were due to therapy and what made the difference • the change interview conducted at final follow-up session

21. Change interview results • “feel so much better, not be thinking all the time” • “not playing the game such a relief … I can manage my thoughts now” • 5 = surprised; 1 = expected • In therapy actions … ‘developing trust’ • Key changes (1) use of SDR (2) integrating mindfulness and RRs • “ I see people differently now” • Managing the paranoia with somebody, very difficult at first

22. Conclusions for the case • Integration the key issue • Good evidence of change and change being attributable to the therapy conducted • HSCED effective research methodology in PD populations

23. CAT and BPD multi-site HSCED study • Project team = Stephen Kellett, Dawn Bennett and Tony Ryle • Progress = 8 therapists over 8 sites have completed a 24 plus 4 follow-up session CAT interventions with BPD clients • Sessions sampled from each of the therapies and CCAT conducted to attain competency rating (111 CCATs completed)

24. Methodology

25. Need for an expert panel/jury • We are attempting to recruit a panel of professionals to consider the evidence for change in a number of cases • Professionals not aligned to CAT and sceptical about change • One day meeting • S.Kellett@sheffield.ac.uk