Learning about Change Processes in Treatment by Studying a Single Case

Jacqueline B. Persons, Ph.D., Cognitive Behavior Therapy and Science Center and University of California, Berkeley will chair a symposium titled
Learning about Change Processes in Treatment by Studying a Single Case
at the annual conference of the Anxiety and Depression Association of America in San Francisco on Saturday, April 8, 2017, from 8:30 AM – 10:00 AM

Description: Although our field has developed effective psychosocial treatments for patients with mood and anxiety disorders, we know much less about the change process than we need to know to develop effective treatment for every patient. The study of a single case allows for intensive examination of the change process that can yield hypotheses that can guide research and clinical work. The single case study is a research design that is uniquely suited to allow practitioners to make a contribution to science. Each participant in this symposium offers hypotheses about the change process in treatment for anxiety and related disorders that are based on data collected from a single patient or a small series of single cases over the course of treatment.

Discussant: Anne Marie Albano, Ph.D.


Changes in Need for Control and Perfectionism Predicted Reductions in Anger During CBT: A Single Case Study

During the course of routine treatment in a university training clinic, we examined relationships among symptoms and hypothesized mechanisms. Self-report data was collected with a patient’s consent at multiple time-points throughout the course of treatment in an effort to monitor change and to test hypotheses about relationships between psychological mechanisms of need for control, perfectionism, and symptoms of anger. The client presented with anxiety about having angry outbursts and an unrealistic fear of losing control of his anger that lead to obsessing. The client and therapist collaboratively developed a case formulation and goals for treatment. The case formulation highlighted the client’s perfectionism, need for control, high standards (for both himself and others), self-criticism, and lack of emotional awareness as mechanisms that led to persistent resentment, fears of losing control of anger, and obsessing about minor displays of anger. Treatment Goals included reducing feelings of anger and fears of losing control, increasing acceptance of imperfections, and reducing perseverative thinking. To meet these goals, the client completed 28 session of Cognitive Behavior Therapy provided by the first author, which included the use of behavior logs, emotion logs, behavioral experiments, and a variety of other cognitive behavioral tools. OLS regression conducted using self-report data from progress monitoring revealed statistically significant declines over the course of treatment in anger, anxiety, depression, perseverative negative thinking, perfectionism, and the need to control thoughts. Time lagged regression revealed that reductions in the need for control and aspects of perfectionism predicted future Reductions in anger. Respiratory sinus arrhythmia, a measure of vagal control of the heart that has been linked with emotion regulatory abilities, was higher after treatment than before treatment began. Findings contribute to our knowledge of mechanistic changes during treatment that can alleviate anger issues, and exemplify the integration of research with routine treatment.


Casey Brown, MA, University of California at Berkeley

Differential Outcomes of Worry, Positive Affect and Negative Affect in CBT for GAD

Cognitive-behavioral therapy (CBT) for generalized anxiety disorder (GAD) targets worry, the putative cardinal feature of GAD. It is often assumed that treating worry will result in generalized improvement of other domains not targeted in psychotherapy. In addition to heightened negative affect (NA; Brown, Chorpita, & Barlow, 1998), GAD is associated with significant deficits in positive affect (PA; Bosley, Fernandez & Fisher). This may result from a maladaptive tendency of anxious individuals to use worry as an emotion regulation strategy, by upregulating NA and downregulating PA. Individuals often see this as protection against the possibility of a sudden shift from PA to NA (Newman & Llera, 2011); this “contrast avoidance” is consistent with findings that GAD patients tend to dampen positive emotions (Eisner et al, 2009). Given the significant emotion-related pathology in GAD, it is crucial to understand whether improvements in worry during CBT actually generalize to changes in NA and PA. This talk presents a person-specific analysis of time series data collected during a trial of CBT for GAD to examine the relative changes in PA, NA and worry in seven participants. While receiving weekly CBT, participants filled out daily web based surveys (M = 64.5 days) assessing worry, PA, and NA. These data were subjected to person-specific regression analysis to delineate individual change trajectories. Results showed that while worry improved in 6/7 participants and NA improved in 5/7 participants, PA improved in only 2/7 and actually worsened in 3/7 individuals during treatment. Treatment gains from traditional CBT for GAD may not generalize to improvements in PA regulation (perhaps maladaptive processes like “contrast avoidance” persist through treatment for some individuals). Utilizing person-specific analysis reveals that increasing the focus on PA regulation may improve treatment outcomes and quality of life for certain GAD patients. Thus, shifting focus toward a personalized psychotherapy for GAD might result in improved outcomes over traditional psychotherapy, especially in light of the finding that a traditional CBT approach leaves other crucial features of psychopathology untreated in some individuals. To this end, ideas to improve PA regulation in GAD treatment will be presented.


Hannah Bosley, BA, University of California at Berkeley

Session-by-session Change for a Latina Client Receiving a Culturally Informed Cognitive Behavioral Group Therapy for Social Anxiety Disorder

Examining session-by-session change in symptoms and potential mechanisms of change can provide detailed information about what treatment elements and experiences may be leading to change for an individual client. Because change processes are often multifaceted, being able to examine this level of detail on a case-by-case basis may provide a more nuanced understanding of how change occurs than is possible in research based on the experiences of a group as a whole. This is particular relevant for understanding how an individual’s specific contextual factors (e.g., ethnicity, gender, etc) may contribute to the change process.
This presentation will focus on the case of a Latina in her early 20’s who presented for treatment for social anxiety disorder. This client was part of a 12-session Cognitive Behavioral Group Therapy (CBGT: Heimberg & Becker, 2002), an empirically-supported treatment which involves restructuring maladaptive thoughts and exposures in social contexts in a group format. Treatment for this client incorporated multicultural principles to address ways that race-based and gender-based discrimination was contributing to her social anxiety. To better understand the relations between specific treatment elements and symptom change for this client, this talk will focus on session-by-session changes in symptoms (Brief Fear of Negative Evaluations scale) to show how changes in symptoms correspond with particular elements of the culturally-informed CBGT that she received. Of particular interest in this case is the connection between the incorporation of multicultural principles and her change in symptoms and potential mechanisms of change, such as decentering, or the ability to observe thoughts and feelings as objective events in the mind rather than personally identifying with the thoughts or feelings (Safran & Segal, 1990, measured by the Experiences Questionnaire: Fresco et al., 2007). Decentering, may be particularly helpful for this client as the skill of being able to separate oneself from the discriminatory comments that she hears rather than seeing the comments as evidence about herself may be what she needed in order to approach and not avoid certain social situations.


Sarah Hayes-Skelton, PhD, University of Massachusetts Boston
Non-Presenting Co-Author(s)

Speshal Walker Gautier, PhD, Atlanta VA Medical Center
Shannon Sorenson, PhD, Massachusetts Mental Health Center
Dr. Jessica Graham, PhD, Salem State University

The Impact of Transdiagnostic Interventions in the Treatment of Depression: An Idiographic Analysis of Change Processes

Background. Cognitive-behavior therapy (CBT) is effective for depressive and anxiety disorders, yet less is known about the process of change. Recent work has highlighted that process-outcome relationships likely vary depending on the patient, yet there is little direct evidence regarding specific intervention effects in individual patients. Idiographic research methods provide a unique opportunity to study functional and temporal relationships among putative change variables, including specific intervention effects. Within the context of the Unified Protocol (UP; Barlow et al., 2011), Boswell, Anderson, and Barlow (2014) identified changes in psychological constructs (e.g., mindfulness and cognitive reappraisal) in relation to the introduction of specific, theoretically linked UP modules utilizing time series analysis. Objective. The goal of this study was to examine the consistency of these specific intervention effects in two new psychotherapy cases with principal major depressive disorder (MDD) and comorbid anxiety disorders. Method. Participants were routinely presenting patients. Case 1 was a 19-year-old, white, female. Case 2 was a 36-year-old, Asian, female. Both participants received treatment that followed the published UP manual. Participants were asked to complete a battery of measures twice weekly that assessed changes in symptoms and targeted psychological constructs. Data analyses comprised: identification of univariate models for each variable time series, and the subsequent testing of a series of intervention time series models where the timing of introduction of each UP module was entered as a step function. Results. Both cases exhibited clinically significant change on all measures. No specific intervention/module effects were statistically significant for Case 1, yet statistically significant results were observed for Case 2. Module 7 (Emotion Exposure) was significantly associated with increases in mindfulness (R2 = .09), and Module 3 (Present-Focused Awareness Training) was associated with reductions in experiential avoidance (R2 = .08). Conclusions. Even when patients appear to similarly benefit from the same treatment, specific intervention effects appear to vary among individual patients. Regular assessment is needed to determine if a patient requires an alternative set of specific intervention strategies. More idiographic research should be conducted to further elucidate inter-individual differences on intra-individual processes.


Matteo Bugatti, MA, University at Albany, State University of New York