Jennifer L. Villatte

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 [email protected]

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