Scott T. Gaynor

Single-participant assessment of treatment mediators: Strategy description and examples from a behavioral activation intervention for depressed adolescents

Determining the means by which effective psychotherapy works is critical. A generally recommended strategy for identifying the potential causal variables is to conduct group-level statistical tests of treatment mediators. Herein the case is made for also assessing mediators of treatment outcome at the level of the individual participant. Single-participant assessment of mediators requires documenting, for each participant, that treatment was received, that change occurred on the mediator and relevant clinical outcome measures, and that the change on the mediator happened at an expected time in the treatment protocol and prior to substantive change on the dependent variable. Data from four depressed adolescents who demonstrated remission following a behavioral activation intervention illustrate the use of the approach in assessing whether changes in activation level or negative thinking mediated the changes in depression. For two participants, increased activation appeared to be a mediator, whereas decreased dysfunctional thinking never emerged as a plausible mediator. It is concluded that single-participant assessment of mediators of treatment outcome offers a useful additional tool for determining possible mechanisms of action in effective psychotherapy.

Complementing CBT for depressed adolescents with Learning through In Vivo Experience (LIVE): Conceptual analysis, treatment description, and feasibility study.

Based on a behavior-analytic interpretation of the skills acquisition process, a rationale is presented for augmenting a currently available cognitive-behavioral treatment (The Adolescent Coping With Depression course: CWD-A) with a newly developed therapy focusing on the interpersonal interactions and learning occurring in-session (Learning through In-Vivo Experience: LIVE). A description of the practice of LIVE is offered and the results from an initial feasibility study are presented. Using a single-subject methodology, two groups each consisting of 5 adolescents with significant symptoms of depression received the treatment. The intervention consisted of 16 2-hour group sessions occurring over an 8-week period. The first 1-hour of each meeting was taken directly from the CWD-A manual. The second hour was based on the LIVE manual. The adolescents who completed the treatment ( n = 8) improved from pretreatment to posttreatment and those who discontinued treatment ( n = 2) did not. Improvements were maintained at 3 months follow-up. The treatment produced strong group cohesion and both adolescents and their guardians rated the intervention positively. These results provide initial evidence of the efficacy of complementing CWD-A with LIVE.

Acceptance and Commitment Therapy and Behavioral Activation for the Treatment of Depression: Description and Comparison

The field of clinical behavior analysis is growing rapidly and has the potential to affect and transform mainstream cognitive behavior therapy. To have such an impact, the field must provide a formulation of and intervention strategies for clinical depression, the “common cold” of outpatient populations. Two treatments for depression have emerged: acceptance and commitment therapy (ACT) and behavioral activation (BA). At times ACT and BA may suggest largely redundant intervention strategies. However, at other times the two treatments differ dramatically and may present opposing conceptualizations. This paper will compare and contrast these two important treatment approaches. Then, the relevant data will be presented and discussed. We will end with some thoughts on how and when ACT or BA should be employed clinically in the treatment of depression.

Measuring homework compliance in cognitive-behavioral therapy for adolescent depression : Review, preliminary findings, and implications for theory and practice

Despite the importance placed on completion of extra-session homework in cognitive-behavioral therapy (CBT), a review of the available literature suggests there is much about the nature of homework compliance that remains to be empirically evaluated. This is especially true among youth receiving CBT. The present study begins to address how best to measure homework compliance and offers a fine-grained, single-case analysis of homework compliance during acute treatment with depressed adolescents. The results demonstrate that 56% of homework assignments were completed. Also observed was substantial within-subject temporal variability in homework compliance and a tendency for compliance to decrease during the course of treatment. These data call into question the adequacy of any static aggregate measure of homework compliance and have implications for both researchers and clinicians.

Combining individual Cognitive Behaviour Therapy and caregiver–child sessions for childhood depression: An open trial

The objective was to obtain preliminary evidence on the feasibility and efficacy of combining individual cognitive behavior therapy (CBT) with complimentary caregiver–child sessions for depressed youths. Fifteen children participated in an open clinical trial. Treatment included 16 CBT sessions combined with seven caregiver/caregiver–child sessions over 12 weeks. Data were collected at pre-, mid-, and post-treatment and at one- and six-month follow-ups. Significant decreases in depressive symptoms were apparent, with the majority showing clinically meaningful improvement. Benchmarked against the literature, the combination equaled or outperformed CBT in other studies and was superior to control conditions. Mother and teacher reports of child functioning significantly improved, providing social validation of the effects. Mothers reported improved caregiver–child relationships and less parenting stress. Children did not report acute improvements in relations with their caregivers. However, when a father participated, improved father–child relations were reported in the follow-up period. Younger age and lower pretreatment severity predicted greater symptom change. The positive treatment effects provide support for the combined intervention and suggest a further research focus on the effects of caregiver involvement in the treatment of depressed youths.

Depression and a Stepped Care Model

Given the public health significance of depression and the limited resources available for providing evidence-based treatment, there is a need to develop effective models of care to reduce the personal and societal costs of the disorder. Within stepped care service provisions, all patients presenting with symptoms of depression generally are first offered the lowest intensity and least intrusive intervention deemed necessary following assessment and triage. Only when patients do not show improvement do they move to higher, more intensive levels of care. However, stepped care models also provide information to aid clinicians in decision making regarding selection of treatment strategies that are most appropriate for an individual patient. For some individuals, lower levels of care would never be appropriate or may not be preferred by the consumer. Thus, stepped interventions offer a variety of treatment options to match the intensity of the patient’s presenting problem as well as potential patient preference.

Assessing Outcome in Cognitive Behavior Therapy for Child Depression: An Illustrative Case Series

Recent meta-analytic data suggest a need for ongoing evaluation of treatments for youth depression. The present article calls attention to a number of issues relevant to the empirical evaluation of if and how cognitive behavior therapy for child depression works. A case series of 6 children and a primary caregiver received treatment—individual CBT for the child and behavioral parent training involving the caregiver and caregiver–child dyad. The effects were generally promising and illustrate how selection of inclusion criteria, measures, measurement intervals, and informants can alter conclusions. These areas warrant attention in studies of child depression and are important not only in interpreting treatment outcome data but also for conducting sound clinical practice.

Circumventing the Vasovagal Fainting Response: A Novel Method of In Vivo Exposure for Injection Phobia

A novel method of in vivo exposure therapy was administered to a 26-year-old female with injection phobia. She had a history of fainting at the sight of syringes, needles, and other medical devices and went to great lengths to avoid physicians and optometrists, putting off receiving necessary examinations and vaccinations. The patient was treated in one long session. The session began with presentation of a series of noninvasive fear-evoking stimuli (i.e., still and video images) shown briefly, but repeatedly, with increasing trial durations, followed by invasive exposures (i.e., finger pricks & a sham injection). Self-report measures showed significant changes that were maintained after 10 months. In addition, the patient donated blood, had an eye examination, and received three vaccinations, all without fainting. Traditional treatments employ prolonged exposures to fear-evoking stimuli; the results of this intervention suggest that a massed series of brief exposures might provide a less aversive alternative.

Behavior therapy: Distinct but acculturated

Over the last 30 years, behavior therapy has gone from being a contentious outlier in the clinical sciences to an acculturated and respected participant. Behavior therapy has achieved acculturation through increasing recognition of its many efficacious treatments and increasing investment in psychopathology research. With the trend toward acculturation and confederation with the larger psychological community comes the risk and potential cost of losing our unique identity. It is argued that acculturation has not threatened behavior therapys distinctive foundation in behavior principles and learning theory. Recently developed behavioral psychotherapies are described as examples of behavior therapys ability to retain its distinct theory-driven basic science foundation. It is concluded that meeting the challenge of acculturation need not compromise behavior therapys unique identity as a paradigm within psychology.

Identifying Mechanisms of Change Utilizing Single-Participant Methodology to Better Understand Behavior Therapy for Child Depression

This study examined therapeutic mechanisms of action at the single-participant level in a behavior therapy (BT) for youth depression. By controlling for non-specific early responses, identifying potential mechanisms of action a priori, taking frequent measures of hypothesized mechanisms and dependent variables, rigorously evaluating internal validity, and using a variety of analytic methods, a unique model for analysis of potential mediators was created. Eleven children (M age = 9.84) meeting criteria on the Children’s Depression Rating Scale–Revised (M = 55.36) and Children’s Depression Inventory (M = 23.45) received non-directive therapy (NDT), followed by BT for those still displaying significant symptoms. Four participants (36%) had a clinically significant response to NDT. For the remaining seven, statistically significant changes in depressive symptoms and family interactions during the BT interval were found at the group level. At the single-participant level, evidence suggesting that outcome was at least partially mediated by changes in treatment targets was obtained for four of seven (57%). As the field further embraces efforts to learn not only whether treatments work but also how they work, the single-participant approach to evaluating mediators provides a useful framework for evaluating theories of therapeutic change.