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... Mindfulness-Based Interventions During Play for Parents of Children with Down Syndrome: Two Case Studies Dr. Alison Nichols, OTR, Samantha Trench, Serena Good, Caroline Stone, Marissa Cavanaugh, Carissa Anderson, Caitlyn Naghdi, Krystal Scott December 15, 2023 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the research advisor: Alison Nichols, OTR, OTD A Research Project Entitled Mindfulness-Based Interventions During Play for Parents of Children with Down Syndrome: Two Case Studies Submitted to the School of Occupational Therapy at the University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Alison Nichols, OTR, OTD, Samantha Trench, Serena Good, Caroline Stone, Marissa Cavanaugh, Carissa Anderson, Caitlyn Naghdi, Krystal Scott Occupational Therapy Doctorate Students Accepted on this date by the OTD Program Director: 12/15/23 Alison Nichols, OTR, OTD OTD Program Director Associate Professor of Occupational Therapy Date Abstract Parents of children with disabilities are known to experience stressful or anxious feelings in their role as both parents and caregivers but it is less known about what, if any, effective strategies may be used to reduce these feelings. The following study aimed to explore the use of mindfulness-based interventions (MBI) for parents of a child with a disability and consider the effects these may have on stressful or anxious feelings experienced by those parents during parent-child play interactions. Parents with a child with a disability included in the study met the following inclusion criteria: parents must be at least 18 years of age with a child with a disability between the ages of two and twelve and must be English-speaking. This study was conducted virtually in the format of a researcher-led focus group. To assess the effectiveness of the mindfulness strategies provided, follow-up surveys were conducted six weeks post-intervention, and qualitative data was collected through audio transcripts. One theme identified in the followup survey responses was the positive effects of mindfulness techniques during parent-child play in public or private settings. Based on the follow-up survey results, both participants expressed positive experiences and decreased instances of stressful or anxious feelings using mindfulness techniques. Limitations of the study include a limited sample size indicated by only having two participants who both identify as female and mothers to a child with Down syndrome, lack of standardized assessment tools, and participants located in the same geographical location. Implications for future studies and practice include the effects of prolonged use of mindfulness techniques on the anxiety of caregivers and parents of children with diversified diagnoses. Keywords: Down syndrome, play, caregivers, anxiety, mindfulness Mindfulness-Based Interventions During Play for Parents of Children with Down Syndrome: Two Case Studies When raising a child, parents typically will encounter physical, emotional, and financial stressors. When raising a child with a disability, these are amplified and may lead to parents experiencing increased anxious feelings. As described by Nichols et al. (2021), parents of a child with a disability experience anxious feelings from stressors, which may include low socioeconomic status, loss of a family member, or parenting a child with a disability, among many others (p. 3). These anxious feelings have the potential to penetrate every aspect of the parents life, impacting their ability to engage in meaningful occupations and sustain current levels of satisfaction and quality of life. Anxious feelings experienced by parents may also impact playful interactions with their children. Romn-Oyola et al. (2018) explained that playfulness is a relationship-based phenomenon and an important factor for the development of social relationships between children and their main caregivers (p. 2). The purpose of this study is to address the significant gap in the literature on resources or strategies and their effects on parents who experience stressful or anxious feelings during parent-child play interactions. Play Play is the primary occupation of children and is displayed in multiple forms across various settings including imaginative, physical, group, and individual. Play provides critical support for optimal child development. According to Tamm and Skr (2000), play has been viewed as an all-encompassing activity through which a child develops skills in self-awareness, communications, and socialization (p.174). Play is recognized by the United Nations High Commission for Human Rights (2022), as a right of every child (Article 31.1). Play teaches children important motor, cognitive, and social skills as well as creativity and self-confidence which are skills required throughout life (Romn-Oyola et al., 2018, p.1). However, it may be more difficult for children with disabilities to engage in play as their play is often described as skill-based with a focus on therapeutic intervention rather than exploration and discovery (Parham & Fazio, 2007). Due to this focus on therapeutic intervention, these children could be missing out on essential experiences afforded by unstructured free play. Down Syndrome According to the Centers for Disease Control and Prevention (CDC, 2023), Each year, about 6,000 babies born in the United States have Down syndrome. This means that Down syndrome occurs in about 1 in every 700 babies (How Many Babies Are Born section). Down syndrome is the most common genomic disorder of intellectual disability and is caused by trisomy of Homo sapiens chromosome 21 (Antonarakis et al., 2020, p. 2). Like all children, children with Down syndrome (DS) have unique characteristics and individualized needs that may change throughout their lifespan. De Weger et al. (2021) mention that it is common for children with DS to have developmental delays impacting multiple developmental processes, such as vulnerabilities in motor, cognitive, language, social and attentional domainsall aspects of adaptive behaviour (pp. 1-2). According to Antonarakis et al. (2020), the social stigma around the diagnosis of DS and the inability to fit within cultural norms are barriers to successful community engagement of individuals with DS. The impact of developmental barriers and social stigmatism surrounding DS not only the well-being and quality of life of the child but also those of their caregiver. Parental Well-Being Many parents who care for children with disabilities experience anxiety, stress, and other psychological symptoms (Rani et al., 2014). These low-level feelings of anxiousness, tension, fear, and distress are caused by the everyday demands and stressors involved in caring for children with disabilities. A study by Hedov et al. (2000) concluded that mothers of children with Down syndrome had much lower self-reported ratings of vitality and mental health than mothers of neurotypically developing children. While numerous parents of children with disabilities seek coping strategies and social support to manage anxious feelings and distress, some parents still experience clinically significant levels of anxiety and/or depression (Martin et al., 2019, p. 980). It is crucial to address parental distress experienced by caregivers of a child with a disability because poor parental well-being can have a negative effect on both quality of life and functional performance. Research indicates that parents of children with disabilities who report having anxious feelings typically have difficulty interacting with their children, particularly through play (Nichols et al., 2021). One research study by Rani et al. (2014) evaluated anxiety levels and coping strategies in mothers of children with cerebral palsy. In the discussion, it was found that parenting stress was related to the mothers style of interaction with their childrenwhich means that a high level of maternal stress interferes with the mothers effectiveness for engaging in quality interaction with their children (Rani et al., 2014, p. 248). In other words, parental anxiety and stress significantly affected parent-child interactions. Moreover, the study found that there was a strong association between parenting stress and interaction style suggests the need for therapists to develop and implement interventions to enhance the quality of mother-child interaction along with other rehabilitation services for children with disabilities (Rani et al., 2014, p. 248). For parents dealing with anxious feelings and stress when interacting with children with disabilities, rehabilitation services may be useful to improve levels of satisfaction and quality of life (Rani et al., 2014). Caregivers experiencing a decrease in well-being resulting from anxious feelings may benefit from mindfulness-based interventions that are accessible and usable in the home. Mindfulness Mindfulness is a psychological practice that allows an individual to become increasingly aware of the internal and external factors that surround them. Keng et al. (2011) also describes mindfulness as awareness and nonjudgmental acceptance of ones moment-to-moment experience (p. 2). The application of mindfulness to psychological health has been proven to be an effective solution in relieving worry, fear, stress, and anxiety in various situations (Keng et al., 2011). Therefore, a strategy that mentally re-engages the parents back to the present moment when playing with their child may be a beneficial approach when taught correctly. A review by Creswell (2017) demonstrates that mindfulness interventions can improve mental and physical health, cognitive and affective factors, and interpersonal outcomes (p. 508). The research indicates there are consistent findings on the benefits of mindfulness-based interventions for parents of children with disabilities. Sarang et al. (2020) demonstrated that mindfulness-based interventions specifically benefited parents of children with ASD, specifically concerning anxiety symptoms and parental stress. Similarly, Burke et al. (2017) and Neece et al. (2019) also demonstrated mindfulness benefits for parents of children with intellectual and developmental disabilities or delays including improvements in personal well-being, advocacy skills, professional relationships, children's services, reactivity, and being present in the moment. Overall, the findings related to Mindfulness-Based Interventions (MBI) have demonstrated a positive effect on the parents to whom they were administered. As previously described, mindfulness-based practices have become more mainstream in recent decades. Though popular, there is still limited research on the impact of mindfulness- based practice in occupational therapy. As reported by Nichols et al. (2021), parents of children with disabilities have demonstrated increased parental stress which can present as difficulty with being in the moment with their children, specifically during play. A mindfulness approach would be beneficial to help parents develop strategies to be present in the moment at any point with simple mindfulness-based exercises and tasks. These tools are meant to provide relief from stress, not add to the parents responsibilities; therefore, it will be imperative to emphasize to parents both the simplicity of mindfulness along with its effectiveness. Model The chosen model for this study is the Model of Co-Occupation, created by Pickens and Pizur-Barnekow (2009). This model focuses on three categories of interrelated social occupations: parallel occupations, shared occupations, and co-occupations. Of these three, we will be specifically focusing on co-occupations, which require two or more people to be active agents during the occupation. As mentioned above, play for a child with a disability can look different, often requiring the caregiver to be more actively engaged with the child during play. Pickens and Pizur-Barnekow (2009) talk about the importance of co-occupations between mothers and children as imperative to the childs growth and development (p. 151). Play is a critical co-occupation between a child and caregiver, where both are actively engaged. Pickens and Pizur-Barnekow (2009) also make a proposition specifically toward children with disabilities, writing, Impairment or disability across the lifespan may influence how cooccupation is manifested and co-occupation has the potential to influence disability outcomes'' (p. 154). Understanding that co-occupations for children with disabilities may be different than typically developing children supports the need for understanding what these differences may look like. These understandings can lead to how we can better support caregivers in being successful in engaging in play with their children. This model provides support for the importance of co-occupations between children and caregivers, along with addressing that these co-occupations can look different due to a disability. Occupational Therapists Role Occupational therapists primary goal is to help clients engage in their chosen occupations. When aspects of an individuals life, such as activities of daily living (ADL) or instrumental activities of daily living (IADL) are impacted by anxious thoughts and feelings, occupational therapists provide extensive support and treatment to these individuals. While occupational therapists do not diagnose anxiety, occupational therapists play an important role in helping clients with anxious feelings manage their symptoms and minimize the overwhelming impact on the clients occupational performance. In this study, anxious feelings experienced by parents were the predominant barrier identified while participating in the co-occupation of play with their child. Play has an integral role in the development of children across all developmental domains and is the primary occupation for a child. While the literature indicates that parental anxiety is occurring while parents play with their child with a disability, there are little to no interventions focused on helping reduce anxiety during play. The purpose of this study is to explore the effectiveness of utilizing a mindfulness-based intervention that is focused on the co-occupation of play, specifically when looking at parental coping skills, self-efficacy, and anxious feelings. Method Participants For this study, parents who have a child with a disability were recruited. The parents were required to be at least 18 years old, with a child or children with a disability between the ages of two and twelve years old. All participants were required to speak English. To recruit participants, we reached out via email, posted flyers at local Indianapolis occupational therapy clinics, and advertised on various social media accounts. We recruited two participants who were each the mother of a child with Down syndrome, ages six and eleven. This study (#10676) was approved by the University of Indianapolis Human Research Protection Program (HRPP). Study Design The study was guided by the following questions: Is MBI a useful tool to decrease parents anxious feelings during play with their child? We hypothesized that MBI will provide effective coping mechanisms for parents and decrease anxious feelings during play. The study design consisted of caregiver recruitment, followed by virtual delivery of mindfulness-based interventions for caregivers, and concluded with a virtual post-intervention survey after six weeks. Measures and Procedures Before the session, both participants received a sample mindfulness breathing activity to try with their child and a video discussing the basic concepts of mindfulness. The researcher-led session was completed virtually in a single session format and lasted approximately one hour (see Figure 1). Participants were asked open-ended questions by researchers to gain insight into their levels of stress and anxious feelings experienced during play, how mindfulness activities impacted them and their anxious feelings, and the feasibility of using these techniques during play. Researchers first conducted the 5-4-3-2-1 mindfulness activity (see Appendix) that could be used by participants when playing with their children. This activity incorporated grounding techniques, meant to lower stressful or anxious feelings during play. Follow-up questions regarding the grounding techniques were asked by the researchers to reflect on how participants could incorporate the mindfulness approach into their everyday routines. Following this activity, the researchers introduced a self-compassion practice and discussion that allowed participants to reflect on their emotions, recognition, and reflection. At the end of the session, participants reflected on the feelings they experienced while playing with their child, the impact mindfulness has on their stress and anxiety levels, and how these techniques could be incorporated into their daily lives and, more specifically, during play. After the session was complete, the participants were provided with an evidence-based practice journal article called Healing Parent-Child Relationships Through Mindfulness (Smith, 2021). This article was provided to the participants as a resource, showing the benefits of mindfulness and several activities that parents can engage in with their children. The participants were also provided with a link to additional mindfulness activities to be used on their own for them to gain more experience with mindfulness-based practices. These activities can be found in the Appendix. Six weeks after the researcher-led session was completed, participants received a virtual survey to assess the carryover of mindfulness techniques and how mindfulness has since impacted their daily lives. Within the survey, participants were asked about their perspectives on the mindfulness-based exercises that they were requested to complete before the session with their child. Figure 1 Mindfulness Curriculum for the Virtual Session Data Analysis Qualitative data were collected through the transcriptions of the audio recording of the intervention session. Due to the limited number of participants, the research team decided to focus primarily on the responses from one participant. Researchers analyzed her responses to the semi-structured interview questions provided during the session. After the responses from the first case study were examined, researchers compared them to the responses found in the second case study. Differences between the two participants were then highlighted and described. The follow-up survey was completed by both participants six weeks after the initial session. Researchers collected qualitative and quantitative data to address the carryover of mindfulness activities in the home and their effectiveness. Once the responses were submitted, researchers analyzed the results to determine similarities and differences between the participants responses. Findings Case Study 1 (Sharon & Sabrina): Sharon is the mother of Sabrina, an 11-year-old child with Down syndrome. Although Sharon had previous exposure to mindfulness before the intervention session, she expressed her excitement to learn more about how to incorporate mindfulness-based interventions into her and Sabrinas routines. Specifically discussing her play with Sabrina, Sharon stated, I definitely probably struggle with that more in the area of play and engaging with my child. Like sometimes I really have to think with so much going on. It's hard to stay in the moment. Sharon mentioned being distracted by her phone or cleaning commonly takes attention away from Sabrina while they play. Though these are her more typical distractions, Sharon describes her solution of focusing on Sabrina and, the pride and joy that I feel with all the stuff that she's doing. That's usually my grounding piece. Sharon described herself as a perfectionist which can be specifically seen in feelings of guilt surrounding play if its not therapeutic enough. On the other hand, being a part of a local Down syndrome parent organization has helped Sharon to let go of other unspecified parenting mistakes. Overall, Sharon responded positively to the mindfulness interventions performed in the session but did not think the pre-session breathing activity was as successful in comparison to other intervention ideas provided. The main issue Sharon addressed was the lack of compliance from Sabrina when attempting the activity together. During the 5-4-3-2-1 activity, Sharon reported feel[ing] more relaxed and in a better mood. One aspect of the 5-4-3-2-1 activity Sharon did not like was the five things she saw section because she felt her surroundings were cluttered, and this increased her anxious feelings because she was now thinking of all the other things she should be doing instead. Additionally, Sharon enjoyed the Self-Compassion experience, stating that self-compassion can be used to create a more positive and mindful environment. Sharon is only raising one child, Sabrina, and she explains that she has nothing to compare it to. From years 0-4, she was still coming to terms with the diagnosis, but each year she feels that she experiences an increase in personal growth. Sharon states that she has: A lot more compassion when it comes togiving people grace and stopping to smell the roses and just likeenjoying the slow route, I guess. And without Sabrina, I would never have been okay with the pace of my current lifeso it makes me a lot more patient with other people and what they're going through. When asked about self-compassion, Sharon explained that comparing her own family with other families is the hardest thing she deals with. Because the Down syndrome community is very tight-knitwe have an amazing community especially compared to other disability group(s). There are families in ourcommunity whose kids are like academically light years beyond where my daughter is, and they're younger than my daughter and they're doing all of these therapies every single day and their parents don't work and basically homeschool them in addition to all the stuff they do at school. Regarding play, Sharon feels that she does a great job letting Sabrina participate in play like a typically developing child and does not make play activities therapy-based. During the self-compassion activity, Sharon and Lola both showed physical signs of emotion during the activity. Sharon explained that she does not give herself enough positive selftalk. There is a lot to balance required as a mother, and for Sharon, her job is a large stressor and distraction. Another instance where Sharon feels she struggles with anxious feelings is out in public. She states, I think my most anxious and stressful time with Sabrina is when other people are around. She also indicated that, I want perfection out in public and as a result, that's probably when I look my worst as a parent. Sharon feels the pressure to be successful and good and put on a good show in public. Sharon also says there are times that she cannot understand what Sabrina is saying, and this results in frustration for both parties. The guilt Sharon feels from these occurrences ties back to the fear that she did not put her in the right, best, or earliest speech therapies she could have. It is seen through the session results that both participants experience a lot of stress for similar or different reasons. In the follow-up survey, Sharon marked the following as stressors present during play: (a) thinking about other things I should be doing, (b) wanting to avoid play, and (c) thinking about potential delays of your child. Sharon commented that she used mindfulness techniques once a day, with the 5-4-3-2-1 Exercise, the STOP Exercise, and additional activities from the mindfulness activities link (see Appendix) being the most beneficial. When asked about the effect on parent-child relationships, Sharon stated, When I am calm and less stressed, I am a better mom. Additionally, she stated, I was amazed at how impactful it was even thinking back to an issue that had happened previously. It helped me realize that taking a moment, in the moment, to give myself grace can be so freeing, when referring to the value mindfulness has added to her life. Case Study 2 (Lola & Lyle) Lola is a single mother to her 6-year-old child Lyle, who has Down syndrome. In comparison to Sharons self-perspective, Lola views herself as less emotional. She expresses that like Sharon, she focuses on putting more of her effort into her child rather than into herself. Lola explained to researchers how good it felt to let go of emotions during the activities completed. There were some notable differences between Sharon and Lola. One of these concerns was that Lola experiences worries about other kids mistreating her son. She gives an example that there was one boy who was really sweet and another little boy came making fun of Lyle, and I was getting anxiety just from really watching the other kids. Another difference is Lola faces difficulty at home with Lyles defiant behavior which causes her to experience anxious feelings as opposed to Sharons anxious feelings in public places. Another large concern from Lola is that she cannot physically manhandle him to do what he needs to do for fear that she will harm him or herself. Lola lastly expressed that her biggest challenge with her son comes during transitions of activities. In the follow-up survey, Lola explained that her stressors during play with her child include: (a) hurting or being hurt by her child, (b) feelings of frustration, and (c) thinking about potential delays of her child. Lola stated that she integrated mindfulness-based interventions, more specifically breathing work and observation activities, once a day. The most impactful intervention completed during the session was the Self-Compassion Exercise. Lola felt it was reaffirming to her as a mother and reminded her of the accomplishments and goals she is meeting every day. Discussion Impact of Mindfulness on Play and Routines Romn-Oyola et al. (2018) report that play is the primary occupation for children and interaction influences the parent-child relationship. Promoting these interactions can have a systemic impact on this necessary relationship, reducing the likelihood of anxious feelings experienced by parents during play with their children with a disability. The goal of the researcher-led session was to help parents combat these stressors by incorporating mindfulness activities into their day. Our findings support the use of these mindfulness techniques during play, whether that is in a public or private setting, as it provides the ability to alleviate stressful and anxious feelings experienced by the parents. Based on the follow-up results, both participants practiced mindfulness once a day, adding value to their lives through feelings of being refreshed and/or liberated. Responses to Specific Mindfulness Activities Parents perceptions and experiences of mindfulness-based activities determine how effective mindfulness practices will be (Bazzano et al., 2015). In research with children with disabilities, mindfulness-based techniques have shown that parents can intentionally attend to their child's problematic behavior, improve satisfaction with parenting skills and interactions with their children, and reduce the stress associated with caring for their children (Bazzano et al., 2015). Our findings highlight how parents of children with Down syndrome perceive mindfulness as part of their everyday routine, particularly playing with their children. We propose that to improve interactions during play with their children and decrease caregiver stress, mindfulness-based techniques may enhance intentional awareness in parent-child relationships. After completing a mindfulness exercise, participants indicated they were feeling more relaxed and in a better mood. Incorporating mindfulness-based techniques into a daily routine has been shown to have many benefits, as many parents report that mindfulness practice has helped them slow down, notice impulses before they act, really listen to their children, and come to a more relaxed and peaceful state of mind when they interact with their children (Neece et al., 2019, p. 13). As with Neece et al. (2019), participants in our study noted that even though changing their routine to do mindfulness activities with their child throughout the day was different and took more time, it helped parents improve perceptions of their child's behavior and reduce overall stress. In the follow-up surveys, both participants found the mindfulness exercises helpful and relieving their anxieties during play and interactions with their child. One participant reported that the Self-Compassion exercise was most beneficial to her as it helped to create a relaxing, calm environment, and she was able to fully engage in mindful thinking. Similarly, the other participant exhibited positive feelings after completion of the Self-Compassion activity as it allowed her to let go of her emotions throughout the activity. The Self-Compassion activity had the most impact on the participants as it reaffirmed their primary roles as mothers, which allowed them to build compassion for themselves as well as build resilience, equanimity, and determination. Self-Compassion Though self-compassion was not originally a focus of this study, it came to be a large barrier that the parents reported facing daily. Self-compassion is defined as being touched by and open to ones suffering, not avoiding or disconnecting from it, generating the desire to alleviate ones suffering and to heal oneself with kindness (Neff, 2003, p. 87). A lack of selfcompassion can cause parents to experience additional anxious feelings. The parents in this study were more worried about themselves and their performance as a parent than they were about their children. Additionally, Stenz et al. (2022) looked at self-compassion in parents who had children with psychological disorders and found that increasing self-compassion can reduce the stress that these parents experience daily. As demonstrated in the virtual intervention session, mindfulness can be a means for encouraging parents to engage in self-compassion. As noted in the results, there was an obvious emotional release following the self-compassion activity that was viewed by the participants as an overall positive experience. A parents internalized expectations can lead to an overwhelming amount of pressure to be successful with little room for error. Self-compassion directly addresses the need for patience and grace for parents for them to have the same attitude of patience and grace toward their children. Willards (2017) work guided our self-compassion activity and states, I work to be a good parent, and I may not be perfect, but I am a good-enough parent (p. 154). Self-compassion is addressing the root problem of unrealistic expectations in parents to alleviate anxious feelings that may present during play. Anxious Feelings Previous research explains that parents of children with disabilities encounter anxious feelings throughout their daily lives from stressors beyond their control (Nichols et al., 2021). Additionally, Sarang et al. (2020) found that MBI interventions provided benefits to parents of children with disabilities by decreasing anxious feelings. Within our study, the parents reported anxious feelings when trying to enforce appropriate behavior both in the home and in public, as well as play in public settings. The collected qualitative data in our study is supported by the findings of Sarang et al. (2020) as the parents responded positively to the MBI activities by stating feelings of relaxation and improved mood at the conclusion. Limitations A limitation of the current study includes a limited sample size indicated by only having two participants who both identify as female and mothers to a child with Down syndrome. By only having mothers participating in the study, limitations in gender differences are present in the responses. Both participants focused on how stress and anxiety impact their psychological view of themselves specifically as mothers. This sample was also narrowed because both children of the participants have a diagnosis of Down syndrome. The participants for the case studies were also from the same geographical area which limits the ability to generalize the results. Another limitation of this study is the limited follow-up with participants after the conclusion of the initial session. The follow-up survey was provided to participants six weeks after the initial session, limiting this study to a short time frame for mindfulness impacts to influence both the parents and their children. By not gathering data with an extended time frame or through additional follow-up interactions, support for the impacts of mindfulness on play and routines was limited to initial effects. Therefore, generalized effects on the anxious feelings of participants long-term are not fully understood in the scope of this study. Lastly, while gathering the data, researchers did not utilize standardized assessment tools. The data collected was primarily qualitative self-reporting obtained during the virtual session and through the completion of a researcher-developed follow-up survey. These methods of data collection are limited due to relying on how much the participants are willing to disclose through conversation and self-reporting measures. There is an underrepresentation in the literature on parents of children with disabilities and how mindfulness interventions provide benefits specifically during play. Future recommendations for assessing this population include a larger, more diverse sample size. This may include fathers or foster parents, children with different diagnoses, caregivers from different locations, and more diversity in race, ethnicity, age, education, and socioeconomic status of parents. Including the children of the participants in a session may provide a view of parent-child interactions and anxious feelings that may arise specifically during play, as well as help participants better understand how to incorporate the child into mindfulness-based activities. It is recommended to continue using a virtual platform to assist with participant recruitment and follow-up interactions including additional sessions and surveys. Conclusion The findings of this study indicate that mindfulness-based activities for parents of a child with a disability can decrease anxious feelings during the co-occupation of play. We observed both a positive physical and emotional impact on caregivers during the virtual mindfulness session. Both participants indicated in the follow-up survey that at least three, if not all, of the mindfulness-based activities completed with researchers were advantageous to them. It would be beneficial for future studies to examine mindfulness-based intervention strategies and their effect on anxious feelings experienced by caregivers with a more quantitative measure of anxiety during play. It may also be beneficial to examine the effects of prolonged use of mindfulness techniques on the anxious feelings of caregivers. The scope of occupational therapy includes addressing mental health and dimensions of well-being that may negatively impact an individuals everyday roles and task completion. Play is viewed as an important co-occupation between parent and child for both individuals. Therefore, addressing the influence of anxious feelings on play for parents addresses multiple aspects within the scope of occupational therapy. 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American Journal of Engineering Research, 3(3), 245-250. https://doi.org/10.13140/RG.2.2.15056.92161 Romn-Oyola, R., Figueroa-Feliciano, V., Torres-Martnez, Y., Torres-Vlez, J., EncarnacinPizarro, K., Fragoso-Pagn, S., & Torres-Coln, L. (2018). Play, playfulness, and selfefficacy: Parental experiences with children on the autism spectrum. Occupational Therapy International, 2018(4636780). https://doi.org/10.1155/2018/4636780 Sarang, S.D., Karnam, A., Vanmali, B., & Phulpagar, P. (2020). Effect of mindfulness-based stress reduction occupational therapy program in parents of children with autism spectrum disorder: An interventional study. The Indian Journal of Occupational Therapy, 52, 132 - 138. https://doi.org/10.4103/ijoth.ijoth_25_20 Smith, S. (2021). Healing parent-child relationships through mindfulness. International Journal of Birth & Parent Education, 8(4), 2932. Stenz, C. F., Breitmeyer, A. M., & Jansen, K. L. (2022). Parenting stress and self-compassion in parents of children with and without psychological disorders. The Family Journal, 31(2), 308313. https://doi.org/10.1177/10664807221123557 Tamm, M., & Skr, L. (2000). How I play: Roles and relations in the play situations of children with restricted mobility. Scandinavian Journal of Occupational Therapy, 7(4), 174-182. Willard, C. (2017). Raising resilience: The wisdom and science of happy families and their thriving children. Sounds True. Appendix Mindfulness-Based Activities Provided to the Participants Title of Activity Description Self-Compassion Letter to Self Sit in a comfortable setting and think through the details of a difficult parenting situation, reflecting on that moment. When thinking of this time, remind yourself, you are a good-enough parent and all parents struggle. Take a few more grounding breaths, recognizing any physical or emotional feelings that arise. Grounding and Centering Exercise Find a comfortable, quiet space. Stand up and notice the feeling of the ground beneath your feet. Slowly shift your weight back and forth and bring awareness to this sensation. Begin to notice how this shift in weight affects your legs, hips, and lower stomach. S.T.O.P. Exercise S.T.O.P. is an acronym standing for Stop what you are doing, Take a few deep breaths, Observe your bodys physical and emotional sensations, and Proceed with what you were doing once you feel grounded. Feel Your Hand Activity Sit in a comfortable position and close your eyes. Take your right hand and stroke your left hand for a few seconds. Switch hands. Continue to repeat this process for several minutes to help bring yourself to reality. Name a Goodie This activity can be completed within a group of individuals or alone. Participants go around the circle naming something that is good or positive in their life (ex. A smell, something they had to eat recently, getting engaged, etc.). Remember what you pick does not have to be positive for everyone. Adult Coloring Find an adult mindfulness coloring page or create your own to color. Pay attention to your senses as your are coloring- what you see, hear, smell, feel, and taste. To increase the sensory experience, you may add scented oils or markers, food, beverages, or music. One Big Mindfulness Day Set aside one day every week to focus on mindfulness activities that help you feel grounded. These activities can vary from person to person, or even day to day. Candle Study Exercise Light your favorite scented or unscented candle and observe how the flame flickers. Complete this for five to ten minutes, allowing your mind to wander and observing the thoughts that drift through. Gratitude Scavenger This activity can be completed alone or with your child. During this Hunt activity, there are numerous things to be searching for including: something you enjoy first thing in the morning, something that makes you happy, something you enjoy playing with, your favorite game to play, a place you feel the most comfortable, etc. Walking Meditation Find a walking path where you will not be disturbed. Take ten-fifteen steps or propel yourself twenty to forty feet and stop, breathing for as long as you need. When ready, repeat this movement and focus on making small, slow movements. During these slow movements, observe one or more sensations that you would normally take for granted. It is okay for your mind to wander during this mediation. Adjustments can be made to this daily walk to fit the individuals needs for that day. Acceptance of Thoughts and Feelings Sit in a comfortable place and focus on your breath. Allow your mind to wander, noticing each thought that passes by. Guide your attention back to the sensation of breathing and bring a quality of compassion to your awareness. As you become aware of various bodily sensations that arise, shift your attention to these sensations briefly. Acknowledge the comfort or discomfort that surfaces and begin to differentiate yourself from your thoughts and feelings. Without judgment, label the thought or feeling and move on. Remind yourself you are not what those thoughts or feelings convey to you. Mindfulness Parenting Tool Kit The mindfulness tool kit is something you and your family can create together that will include various mindfulness activities you and your family enjoy. There is not a limit on how many activities are needed, just make sure they are meaningful and beneficial. The Body Scan Find a comfortable and quiet place to complete this activity. It can last anywhere from five to thirty minutes depending on the style you choose. A typical body scan will have you lying on your back and focusing on different parts of your body at a time, starting from your feet and slowing making its way to your head. Morning Page Every morning when you wake up write whatever comes to mind. What you write does not have to be creative or have any structure as long as it is helpful and meaningful to you. Three-Minute Breathing Space Find a comfortable and quiet space to help you relax and feel grounded. During these three-minutes, you will start with closing your eyes and thinking about what you are doing. Bring your attention to your breathing, making sure to take deep breaths in through your nose and out through your mouth. Shift your attention to how your body feels and focus on the environment around you. Who Am I Beyond My Formatted questions are provided, focusing on self-reflection. Anxiety Reflection These questions have you list positive characteristics about yourself, activities you do and do not enjoy, describe which relationships in your life are most important to you and why, and what you feel like you are best at.  ...

... EFFECTIVENESS OF CCRT APPROACH: TWO CASE STUDIES EFFECTIVENESS OF CCRT APPROACH WITH CLIENTS WITH ANXIETY AND DEPRESSION: TWO CASE STUDIES. A Doctoral Dissertation presented to the Graduate Department of Clinical Psychology University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Psychology Mrnalini Rao, M.A. March, 2023 i EFFECTIVENESS OF CCRT: TWO CASE STUDIES EFFECTIVENESS OF CCRT APPROACH WITH CLIENTS WITH ANXIETY AND DEPRESSION: TWO CASE STUDIES The signatures below certify that the Doctoral Dissertation Defense of Mrnalini Rao has been approved by the Graduate Department of Clinical Psychology of the University of Indianapolis in partial fulfillment of the requirements for the degree Doctor of Psychology Approved: Accepted: ______________________________ Aaron Kivisto, PhD Dissertation Advisor John Kuykendall, PhD Dean, College of Applied Behavioral Sciences 3/9/2023 ____________________________ Samantha Gray, PhD Committee Member Michael Poulakis, PsyD Committee Member 3/3/3023 _________________________ Date ________________________ Date ii EFFECTIVENESS OF CCRT: TWO CASE STUDIES iii Abstract Evidenced-based practices are extremely valuable in the field of psychology. Randomized clinical trials have been considered the gold standard of evaluating the effectiveness of treatments. However, the importance of single-subject design and its focus on individual differences to understanding what therapeutic interventions works for whom offers complementary evidence. This study examined the efficacy of brief psychodynamic therapy using Luborskys (1999) core conflictual relationship theme (CCRT) approach with two clinical case studies in the treatment of major depressive disorder and generalized anxiety disorder. The participants were selected based on convenience sampling. A single-subject method with time series data was utilized. Statistical methods of Percentage of NonOverlapping Data (PND) and Reliable Change Index (RCI) were used for analysis. Outcome measures used to assess change across treatment included the Brief Symptom Inventory (BSI) and Participant Health Questionnaire-depression and anxiety disorders (PHQ-SADS). The results of the present study indicate that CCRT approach provided clinically significant improvement for depression and anxiety concerns for both clients. All areas of functioning assessed using BSI and PHQ-SADS demonstrated significant and positive changes. Keywords: Core Conflictual Relationship Theme (CCRT), Short-term psychodynamic treatment, depression, anxiety, brief therapy, single-subject design, PND, RCI, clinical case study EFFECTIVENESS OF CCRT: TWO CASE STUDIES iv Acknowledgments I would like to thank my parents for always supporting, encouraging and for believing in me. I would like to express my sincere gratitude to my dissertation chair Dr. Aaron Kivisto for the continuous support of my dissertation, for his patience, motivation, enthusiasm, and immense knowledge. He has been incredibly supportive from the beginning. He has guided me through the initial stages where I was formulating my thesis and helped me brainstorm and carry the idea through. He has encouraged me to organically organize and coherently approach the topic and its various facets. I would also like to thank my friends for being supportive and helping me remain motivated through the process. EFFECTIVENESS OF CCRT: TWO CASE STUDIES v Table of Contents SIGNATURE PAGE .................................................................................................................. ii ABSTRACT ........................................................................................................................................... iii ACKNOWLEDGEMENTS ................................................................................................................... iv LIST OF TABLES ................................................................................................................................. vi LITERATURE REVIEW ........................................................................................................................ 6 Review of Single-subject Case Design ............................................................................................... 6 Analytic Approaches to Case Study Research ...................................................................... 9 Evidence for Psychodynamic Therapy ................................................................................. 11 CCRT description ................................................................................................................ 15 Evidence for CCRT with anxiety disorders and depressive disorders ................................. 20 CLIENT DESCRIPTION ......................................................................................................... 21 Presenting Problem Client 1 .............................................................................................. 22 History and Background .............................................................................................. 22 Diagnosis ...................................................................................................................... 25 Treatment Plan ............................................................................................................. 26 CCRT Conceptualization ............................................................................................. 26 Course of Treatment ..................................................................................................... 28 Presenting Problem Client 2 ............................................................................................... 32 History and Background .............................................................................................. 32 Diagnosis ...................................................................................................................... 35 Treatment Plan ............................................................................................................. 36 CCRT Conceptualization ............................................................................................. 36 Course of Treatment ..................................................................................................... 38 CLINICAL RESEARCH QUESTIONS .................................................................................. 42 EFFECTIVENESS OF CCRT: TWO CASE STUDIES vi METHOD ................................................................................................................................. 43 Research Design .......................................................................................................... 43 Participants ................................................................................................................... 43 Measures....................................................................................................................... 43 Statistical Approach .................................................................................................... 45 RESULTS Testing results Client 1 ................................................................................................. 48 Testing results Client 2 ................................................................................................. 54 DISCUSSION .......................................................................................................................... 60 REFERENCES ......................................................................................................................... 63 EFFECTIVENESS OF CCRT: TWO CASE STUDIES vii LIST OF TABLES AND FIGURES Table 1. .....18 Tallberg et al. (2020) CCRT categories for Wish, Response to self and Response from Others Table 2. .....46 PND Scores and interpretation Table 3. .....48 PHQ-SADS Scores for Client 1 Table 4. .....49 BSI scores for client 1 Table 5. .52 RCI Data for BSI, Client 1 Table 6. .53 RCI Data for PHQ-SADS, Client 1 Table 7. .....54 PHQ-SADS Scores Client 2 Table 8. .55 BSI Scores for client 2 Table 9. .55 RCI data for BSI, Client 2 Table 10. .56 RCI Data for PHQ-SADS, Client 2 Figure 1. .....50 PND analysis for BSI scores client 1 Figure 2 .....50 PND analysis for PHQ-SADS scores client 1 Figure 3. .....56 PND analysis for BSI scores client 2 Figure 4. .....56 PND analysis for PHQ-SADS scores client 2 EFFECTIVENESS OF CCRT: TWO CASE STUDIES 6 Chapter 1 Literature Review Although group-level randomized controlled trials (RCTs) are frequently regarded as the gold standard for psychotherapy research, single-subject research designs provide complementary, idiographic data that is not obtainable with group-level designs. Proponents of single-subject designs have described clinical practice as a natural laboratory for psychotherapy research (Borckardt et al., 2008). Kazdin (2018) notes that the term singlesubject could be misleading, since this design is not necessarily limited to just one individual, but could be utilized with a large group of participants where the data analytic approach remains individualized. A key feature of single-subject designs is that it combines actual clinical treatment, as it occurs naturally, and empirical evaluation. Whether carried out with one or more clients, single-subject designs enable clinicians to use the client as their own control, which means treatment effects can be investigated in terms of clients symptoms and adaptive functioning over time. In other words, single-subject designs emphasize withinsubject change, whereas group-level designs emphasize between-subject change. Strengths and Limitations of Randomized Controlled Trials Hariton and Locascio (2018) described the strengths of RCTs that have led these designs to be regarded as the gold standard of evidence-based practice. One of the major factors that make RCT exceptional is its ability to evaluate causality and reduce bias by using randomization. Biases such as selection bias, performance bias, assessment bias and confounding errors are minimized when using RCT method. This also allows researchers to account for individual differences, which are presumably washed out between groups through the randomization process. Another advantage of RCTs is that they allow for comparisons between treatment modalities and are able to establish relative superiority and EFFECTIVENESS OF CCRT: TWO CASE STUDIES 7 non-inferiority. This makes it the strongest source of evidence regarding the efficacy of psychological treatments. However, it is important to understand the limitations of this gold-standard group level design. Westen (2004) argues that RCTs are far from perfect and cites several limitations of this methodology. First, he contends that many RCTs make assumptions that are not validated or applicable to all disorders and treatments. For example, many RCTs assume that psychopathology can be controlled, that most clients can be treated for a single disorder, and that psychopathology can be treated independent of personality aspects. Second, he notes that many RCTs do not account for comorbidities due to ruling out participants with particular comorbid conditions that are common in clinical practice. Goldfried (2000) found that RCTs for brief therapy frequently lacked systematic data to guide the length of treatment. Instead, psychotherapy researchers commonly based the prescribed length of treatment on assumptions adopted from medication studies. There were also problems with basing treatment research on DSM categories, as the sheer number of distinct disorders listed in the DSM makes having manuals for all unrealistic. Westen and colleagues (2006) also identified significant limitations in the evidence obtained from psychotherapy RCTs. For instance, they found RCTs of treatment for major depressive disorder commonly excluded participants with symptoms of suicidality or substance abuse, resulting in questionable generalizability for patients with depression seen in practice. This creates challenges for clinicians, as they might be trying to apply results of an RCT to a client that may likely have been excluded from the RCTs (Zane, 2004). Strengths and Limitations of Single-Subject Designs Kazdin (2018) suggests that single-subject methodologies provide viable designs for clinicians as data provides information regarding whether therapeutic change has occurred. Borckardt et al. (2008) suggest that all practitioners might want to assess whether there is an EFFECTIVENESS OF CCRT: TWO CASE STUDIES 8 effective change from the baseline to treatment phase, and single-subject designs can provide relevant evidence regarding psychotherapy outcomes and processes (e.g., how change in treatment unfolds over time and under what circumstances). Single-subject time series methods are also advantageous in bridging the gap between evidence derived under highly controlled experimental settings and practice-based knowledge. Single-case designs are considered to provide systematic and detailed analysis for clinical interventions and allow for valid results (American Psychological Association, 2018) Elaborating on using single-subject methodologies as a way to evaluate treatment in clinical settings, Kazdin (1983) suggested that single-subject designs compliment research from experimental settings where conditions often differ from those in actual clinical practice. For clinicians wanting to conduct single-subject research, Kazdin (1983) recommends first identifying a specific treatment and a measurable goal that would be expected to be achieved through treatment. This entails selecting measures that can reflect client progress in treatment (e.g., measures that quantify mutable, clinically relevant constructs rather than trait-based measures that would be insensitive to change). Second, Kazdin emphasizes the importance of continuous assessment that examines clients clinical status over time. He concludes that single-subject methods help strengthen inferences beyond those derived from uncontrolled case studies. Psychotherapy process and outcome data provided by single-subject research designs help clarify group-level validity evidence of psychological treatments (Sexton-Radek, 2014). Benefits of single-subject designs include the fact that they are relatively cost-effective, easy to implement, and able to provide immediate feedback to clients. Rapoff and Stark (2008) and Lenz (2015) further note that single-subject designs are flexible and allow clinicians to make modifications as new information comes to light. Further, this method is amenable to small samples, which allows for studying rare disorders where group-level research designs would EFFECTIVENESS OF CCRT: TWO CASE STUDIES 9 be prohibitive. Single-subject methods also allow for flexibility as it might include marginalized populations that might be difficult to recruit for large scale RCTs. Whereas group-based designs ideally aim to ensure standard procedures for all through fidelity checks, single case designs are flexible to accommodating treatment depending on individualized client needs. The data that is provided by single-subject designs enables clinicians to obtain in-depth understanding of the client and understanding of not just whether treatment works, but whom it might not work with (Lobo et al., 2017). Through the use of repeated measures, single-subject designs are able to test for causal relationships regarding the impact of treatment that can be directly interpreted. Lastly, it promotes meaningful evidence-based practice. As noted by Romeiser and colleagues (2008), by capturing the ebb and flow of symptoms over the course of treatment, single-subject designs offer a particularly nuanced window into psychotherapy process that if often neglected in group-based designs. Although single-subject designs afford considerable benefits, these strengths come at the cost of external validity, creating challenges to the generalizability of results. Rather than generalizing results of single-subject psychotherapy research to large and heterogeneous groups of individuals, a more conservative approach is warranted to focus on individuals who have similar characteristics to the research subject(s), psychological concerns, and prognostic characteristics. However, generalizability might not be of paramount importance for clinicians seeking to specifically test the effectiveness of their treatment modality with their specific client. Further, because individual clinicians frequently see similar types of clients, it is possible that the evidence derived from their single-subject studies might generalize quite directly to groups of clients typically seen in their own practice. Analytic Approaches to Case Study Research EFFECTIVENESS OF CCRT: TWO CASE STUDIES 10 There are several empirical approaches to analyzing psychotherapy process and outcome in single-subject designs. Common across these approaches, single-subject designs require, at a minimum, one pre-treatment and one post-treatment data point. For several empirical approaches, multiple baseline and treatment data points are required, with daily measures typically representing the high end of the measurement frequency spectrum. Percentage of Non-Overlapping Data. Alresheed and colleagues (2013) described the percentage of non-overlapping data (PND) approach as one of the oldest methods of calculating effect sizes in single-subject research designs. To determine if the treatment is effective using the PND approach, the percentage of non-overlapping data between baseline and treatment is calculated. Alresheed et al. (2013) describe several circumstances under which the PND approach is limited. First, if the data has many outliers, it can misrepresent the effectiveness of the intervention. Second, the PND approach must be interpreted carefully in order to identify situations in which the treatment had negative effects (e.g., a decrease in desirable behavior or increase in undesirable behavior), as these situations might lead to low levels of overlapping data between baseline and treatment phases that carry distinct implications. Another disadvantage, the PND approach is sensitive to extreme baseline scores. For example, if a client obtains a score of zero at baseline on a symptom inventory, the PND approach would not be able to detect any symptom improvement (Olive & Franco, 2008). Lastly, PND is unable to analyze continuous trends in the data (Allison & Gorman, 1993). Alresheed and colleagues (2013) recommend scoring based on multiple matrices for estimating effectiveness of treatment and combining statistical analysis with visual analysis. There are several notable strengths of the PND approach, which is one of the most used methods for testing meaningfulness of change (Lenz, 2013; Olive & Franco, 2008). One major advantage of the PND score is that researchers are able to easily interpret data. A PND EFFECTIVENESS OF CCRT: TWO CASE STUDIES 11 score is also easy to calculate and intuitive. It also lends itself to visual analysis, which enables researchers to understand what it means when 90% of data are not overlapping with baseline. Further, because the method relies on individual data points rather than the distribution, it does not require parametric assumptions about the distribution of data (Parker et al., 2011). Reliable Change Index Another approach created by Jacobsen and Truax (1991) is the Reliable Change Index (RCI). The RCI is used to evaluate clinically significant changes between pretest and posttest. They defined clinical significance as when clients in therapy move from a dysfunctional range to a functional one. Statistically, the RCI measures whether symptom change is larger than would be expected due to simple measurement error, and as a result the RCI is calculated as a function of the pre- and post-treatment scores, along with the standard error of the measurement instrument. When the amount of change is small or within the range of expected measurement error it is deemed unreliable. For treatment effects to be considered reliable it should pass two stages. Firstly, it must prove to be statistically reliable using RCI, and secondly, clients must pass from a dysfunctional to functional range. This means that each client in the treatment study could be classified as recovered (if passed clinical significance criteria and RCI), improved (passed only RCI criteria), unchanged or indeterminate (passed neither) or deteriorated (if RCI is significant in the opposite direction as that expected, indicating an increase in symptoms larger than would be expected from simple measurement error). Evidence for Psychodynamic Therapy This research focuses on testing the effectiveness of Luborskys (1999) Core Conflictual Relationship Theme (CCRT) approach to brief psychodynamic therapy with two clients suffering from depression and generalized anxiety disorder (GAD). The following EFFECTIVENESS OF CCRT: TWO CASE STUDIES 12 section describes the efficacy of psychodynamic therapy generally before discussing CCRT specifically. Hilsenroth and colleagues (2003) and Barber et al. (2012) studied the effectiveness of brief psychodynamic therapy for patients with depression. In Hilsenroth et al.s (2003) study, 27 participants were recruited with a diagnosis of major depressive disorder from a community outpatient setting. Four participants prematurely terminated after about four sessions. A total of 21 participants (11 men, 10 women) completed the study. Treatment involved twice weekly sessions of short-term psychodynamic therapy (STPP) across 30 sessions. Treatment was aided by integrating four STPP treatment manuals based on management of depression. The therapists were ten advanced graduate students enrolled in an APA-accredited program. Participants were assessed before and after treatment using three self-report measures: the Symptom Checklist-90-Revised (SCL-90-R), Social Adjustment Scale (SAS), and DSM-IV rating scales. The participants also answered two questions assessing their confidence in treatment and credibility. Sessions were rated using the Comparative Psychotherapy Process Scale (CPPS-PI). Results were calculated using paired ttests assessing pre- and post-treatment changes. The mean CPPS-PI pre-test score was 1.21 (SD = 0.27) and the posttest was 3.56 (SD = 0.79). Therapeutic focus was found to be significantly associated with reduced depression symptoms (t = 11.54, p < .001) indicating that this therapy worked to reduce depression symptoms. Results indicated that the credibility, satisfaction, and perceived effectiveness were all high. Driessen and colleagues (2013) compared the relative efficacy of psychodynamic therapy and CBT for depression in a randomized controlled trial designed to test noninferiority. The sample of 341 patients were treated for depression in psychiatric outpatient clinics. Participants were selected based on meeting DSM-IV criteria for Major Depressive Disorder and a score above 14 on the Hamilton Depression Rating Scale (HAM-D). EFFECTIVENESS OF CCRT: TWO CASE STUDIES 13 Participants were randomly assigned to 16 sessions of short-term psychodynamic therapy or manualized CBT treatment. Results were calculated using HAM-D scores to examine treatment effectiveness immediately following treatment and at one-year follow-up. The primary outcome measure was posttreatment remission rate, defined as HAM-D scores below seven. Secondary outcomes were measured at one-year follow using HAM-D scores and score on the Inventory of Depressive Symptomology-Self Report (IDS-SR). Results showed that 22.7% of all patients met remission criteria at posttreatment and after one year follow up 26.8% showed remission rates. No differences were observed between the psychodynamic and CBT conditions, supporting the non-inferiority of psychodynamic therapy for depression relative to CBT. Leichsenring (2001) also compared the effectiveness of psychodynamic treatment and CBT for clients with depression. A sample of sixty participants were recruited from outpatient clinics with a DSM-IV diagnosis of depressive disorder. Participants were randomly assigned to CBT or psychodynamic intervention groups. Manualized CBT and short-term psychodynamic therapy were applied for 16 sessions. The Beck Depression Inventory (BDI) was utilized to assess depression symptoms pre- and post-treatment. Results showed significant symptom reduction in both conditions, with effect sizes ranging between 0.94 and 2.44. Consistent with Driessen et al.s (2013) non-inferiority trial, psychodynamic therapy was found to be as effective as CBT with regard to symptom reduction. Ajilchi et al. (2016) examined whether intensive short-term dynamic therapy (ISTDP) would result in reduced symptoms of depression and improved executive functioning. Participants with a DSM-IV diagnosis of Major Depressive Disorder (MDD) and a score of over 20 on the Beck Depression Inventory-II (BDI-II) were recruited from a mental health outpatient clinic in Iran. This study recruited sixteen participants who were randomized to ISTDP or a to a waitlist control group. Pre- and post-test measures were used to calculate EFFECTIVENESS OF CCRT: TWO CASE STUDIES 14 differences between groups. Outcome measures included the BDI-II, which was used to measure depression symptoms, and the Wisconsin Card Sorting Task (WCST) and Stroop test, both of which measure executive functioning. Results showed significant improvements in depressive symptoms and executive functioning from pre- to post-treatment for the ISTDP group, and participants in the active treatment condition showed significantly greater improvements than those in the waitlist control condition. Monti et al. (2014) analyzed the effectiveness of psychodynamic therapy (PDT) (n = 29) and CBT (n = 40) for anxiety disorders in university students at the University of Bologna. Dropout rates were higher in the CBT (n = 10) condition than in the PDT condition (n = 5). Participants were administered the Symptom Questionnaire (SQ) at the beginning, middle, and end of treatment to measure symptom change. There were no specific manuals used for CBT or PDT, only core principles of each therapy were applied. The duration of treatment was one year of weekly 50-minute sessions. Results showed significant effect within-group effects of treatment on the SQ anxiety scale, such that post-treatment scores were significantly lower than pretest scores (ps < .001). There were no significant differences in between-group scores or the interaction between within and between group scores. Both treatments led to significant decrease in anxiety symptoms after one year, and consistent with the findings above, no differences were detected between CBT and psychodynamic psychotherapy. Leichsenring et al. (2013) conducted a multicenter randomized trial to study the effectiveness of psychodynamic therapy and CBT for social anxiety disorder. Patients (N = 495) from an outpatient clinical setting were randomly assigned to a manualized CBT condition, manualized psychodynamic condition, or a waitlist condition. All participants had a diagnosis of social anxiety disorder and were administered the Structural Clinical Interview for DSM-IV (SCID-IV) and Liebowitz Social Anxiety Scale. Assessments were conducted at EFFECTIVENESS OF CCRT: TWO CASE STUDIES 15 the start, week eight, week 15, and at the end of treatment. CBT and psychodynamic treatment went on for 25 sessions (once a week and 50 minutes). Results indicated that CBT and psychodynamic therapy were superior to the waitlist condition. In this study, remission rate is understood as treatment leading to no longer meeting criteria for diagnosis and response rate is a patients reduction in symptoms over the course of treatment. There were significant differences when comparing CBT and psychodynamic therapy in terms of remission rate in favor of CBT, such that remission rates for CBT, psychodynamic, and waitlist conditions were 36%, 26%, and 9%, respectively. However, results showed no difference in response rates between CBT (60%) and psychodynamic (52%) conditions, with improvements in depressive and anxiety symptoms found with each of these therapies. Bgels et al. (2014) researched the efficacy of CBT versus psychodynamic therapy for social anxiety disorder (SAD). Forty-seven participants were recruited based on a SAD diagnosis according DSM-IV based on evaluation with the SCID. Outcome measures used at pre- and post-test included the Social Phobia and Anxiety Inventory- Social Phobia subscale (SPAI), the Social Sensitivity subscale from the Symptom Checklist-90 (SCL-90), Social Phobia Disorders Severity and Change Scales (SPDSC), Social Phobic Beliefs Inventory (SPB), and the Defense Mechanism Inventory (DMI). Participants were randomly assigned to psychodynamic (n = 22) or CBT (n = 27) conditions. Psychodynamic treatment was time limited and focused and guided by Malans principles. CBT treatment was manualized. Results showed that there was no difference between PDT and CBT treatments and indicated that both treatments were highly efficacious, with remission rates over 50%. These results also were similar to Driessen et al.s (2013) study in finding no difference in SAD remission rates between CBT and PDT. CCRT description EFFECTIVENESS OF CCRT: TWO CASE STUDIES 16 Luborsky et al. (1994) developed the Core Conflictual Relationship Theme (CCRT) as a brief psychodynamic treatment model. Luborsky described that the CCRT model as focused on self-other narratives as a way of identifying relationship episodes for the purpose of understanding the ways in which these episodes illuminate the etiology and maintenance of psychological distress. Depending on a clients psychological resources and level of impairment, Luborsky suggested that clients require different types of interventions that fall on a continuum, from supportive to expressive. Supportive interventions are described as those that strengthen ego functioning and existing defenses. By contrast, expressive interventions are described as aiming to develop increased self-understanding, such as bringing previously unconscious material to conscious awareness. In essence, supportive and expressive approaches can be considered interventions aimed at either bolstering existing psychological resources versus loosening overly restrictive defenses, respectively. Interventions along both ends of the supportive-expressive continuum focus on relationship patterns as they impact clients current difficulties. Luborskys development of a CCRT manual was unique among psychodynamic theorists and, as a result, his approach has become widely adopted by psychodynamic psychotherapy researchers. Luborskys (1994) CCRT manual includes selection criteria for clients working with expressive and insight-oriented therapy. These include client having good ego strength, in terms of having intact reality testing, adequate capacity to be reflective and not impulsive, adequate frustration tolerance, and adaptive defenses. Other factors include a clients capacity to be psychologically minded, that is, able to see connections between past and present, an ability to view oneself as agent as much as victim, and the motivation and capacity to engage and disengage readily. Book (1998) developed a guided manual to practice the CCRT approach. This manual is an extensive guide that helps practitioners apply a 16-session version of CCRT. According EFFECTIVENESS OF CCRT: TWO CASE STUDIES 17 to Book (1998), CCRT has three phases of treatment. Phase one is between the first and fourth sessions. This period involves helping clients to identify their wish (W) in narratives and to develop insight. The Wish, is an impulse, what a individual wants to do, and needs to do to effectively deal with a situation. However, the wish can also be something thats very often blocked by defenses and maladaptive efforts avoid the anxieties that are aroused by the wish. The aim is to enable the client to see how the CCRT affects a persons day-to-day life. The therapists role is to be active, direct, and to focus on relationship episodes (RE). The therapist also encourages clients to discuss interactions and relationships. Phase two of treatment occurs between sessions five and 12. This phase involves identifying and working through the response from others (RO) and response to self (RS), which entails helping the client understand how the response of others, whether real or imagined, influences their reactions to their wish. The RO is often anxiety-arousing, and so the psychological operations that follow are aimed at minimizing this anxiety. That is, it is the product of defenses doing what they are originated to do, which is, reduce anxiety. The RS consists of a behavioral component and an affective component. It pertains to what the client did and what he, she or they felt. The therapist at this stage supports the client in understanding how others might shape their own response and to begin working with transference that might arise in the therapeutic alliance. In CCRT, the transference is referred to as enactments, which are seen as a way of helping the client process the responses of others in the here-and-now of the therapy office. The clients ability to understand repetitive patterns is strengthened in this phase as they become better able to understand the patterned and selfdefeating nature of their relationship episodes. Finally, phase three of treatment is between sessions 13 and 16. This phase involves the termination process. The therapist must pay particular attention to termination-related unconscious comments by the eighth session. In this phase therapist shares the progress made EFFECTIVENESS OF CCRT: TWO CASE STUDIES 18 in the CCRT developed with the client. The therapist also engages the patient in discussions surrounding the patients thoughts, concerns, and fears regarding ending therapy. CCRT Conceptualization Wilczek and Weinryb (2010) examined the validity of CCRT conceptualizations in distinguishing between different psychological disorders. The aim of the study was to assess if CCRT patterns differed for patients with different DSM-III diagnoses. Another objective was to compare CCRT conceptualizations of clients with and without a DSM diagnosis. They recruited 55 participants from clients who had registered to participate in therapy. Trained clinicians collected relationship episodes (REs) and identified and scored each component to identify the primary W, RO, and RS for each client. Results indicated that participants mostly had a diagnosis of depression (65%) and their CCRT reflected a negative perception of response of other (RO) and an immature dependency in object relation terms in their interpersonal patterns. Other common diagnoses included anxiety disorders (59%); these participants tended to have more paranoid responses to ROs and had problems establishing meaningful relationships. Clients without a DSM diagnosis tended to have both positive and negative ROs. Based on these patterned differences across diagnostic (and undiagnosed) groups, these authors concluded that CCRT conceptualizations provide discriminant validity. Tallberg et al. (2020) analyzed the inter-rater reliability of CCRT conceptualizations using a limited set of categories to classify clients wishes, response from others, and response to self. In this study, patients were randomly assigned to seven therapists who were trained in CCRT. Relationship episode coding options were limited to create a user-friendly CCRT conceptualization tool. They provided clinicians with eight categories of W, eight categories of RO, and eight categories of RS. The categories are shown in the table below: Table 1 Tallberg et al. (2020) categories EFFECTIVENESS OF CCRT: TWO CASE STUDIES Wishes (W) Response from Others 19 Response to Self (RS) (RO) Wishes (W) Response from Others (RO) Response to Self (RS) Achieve and help others Strong and independent Helpful Asserting self and being independent Opposing hurt and controlling others Be controlled, hurt and not responsible Be distant and avoid conflict Controlling Unreceptive Upset Respected and accepted Bad Oppose and hurt others Rejecting and opposing Be close and accepting Helpful Self-controlled and selfconfident Helpless Be loved and understood Likes me Disappointed and depressed To feel good and Understanding Anxious and shameful comfortable Note. Items are derived from Tallberg et al. (2020). Results indicated inter-rater reliabilities ranging from .33 to .75, which ranged from unacceptable to good. Despite these limitations, the authors suggest that the reliability demonstrated in this study is generally on par with previous, more complex CCRT conceptualization coding systems. Additionally, given that case conceptualization is a complex process known to result in lower reliability than is typically seen with psychological tests, the authors conclude that these results are promising. It should be noted that this study was only concerned with the inter-rater reliability of generating a CCRT conceptualization regarding the W, RO, and RS and did not examine whether the resultant conceptualizations were associated with treatment outcomes. The method involved using the semi-structured dynamic interviews for 2 hours and the raters rated based on those interviews. The inter-rater reliability for assessing results was measured by Cohens kappa coefficient. There were eight standardized clusters for wish, relationship with others and relationship with self-themes. The EFFECTIVENESS OF CCRT: TWO CASE STUDIES 20 research scored one or more categories in each theme. The mean Kappa for Wishes (W) was .33, Response from others (RO) was .71 and Response from Self (RS) was .75. The results indicated that rater agreements of wish theme showed the lowest level of agreement and the agreements for relationship with self and others theme showed the highest level of agreement. The researchers discuss that moderate level of inter-rater reliability was found and this was mainly due to the difficulty to score what categorizes as wishes for participants. Evidence for CCRT with Anxiety Disorders and Depressive Disorders Crits-Christoph and colleagues (1996) evaluated brief supportive therapy for individuals suffering from generalized anxiety disorder (GAD). In a sample of 26 individuals with GAD from different clinical settings, participants were provided 16 weeks of supportive expressive CCRT therapy provided by trained clinicians. The interpersonal conflicts that emerged in therapy were analyzed by clinicians using the CCRT approach emphasizing wishes, responses of others, and responses to self. The SCID and Hamilton scales was used to measure anxiety and depression. Results showed a statistically significant reduction in symptoms and overall quality of life after 16 weeks of CCRT therapy. Specifically, the authors reported that 79% of the participants did not meet criteria for GAD any longer, a remission rate much higher than that observed by Leichsenring et al. (2013). Additionally, the average symptom severity rating for non-remitted participants was 4.2 at post-treatment, compared to 7.8 at baseline. Connolly and colleagues (1998) recruited 33 patients with a diagnosis of depression and provided 16 weekly sessions of Supportive-Expressive therapy following CCRT principles. Participants were administered the Schedule for Affective Disorders and Schizophrenia Change version (SADS-C) and Penn Adherence/Competence scale for SE therapy (PACS-SE) to evaluate clinicians fidelity to the treatment. Results showed that SADS-C scores decreased significantly, from 17.9 to 7.8, across treatment. Results indicated EFFECTIVENESS OF CCRT: TWO CASE STUDIES 21 that 16 weekly sessions using SE therapy helped participants reduce symptoms, improve relationships, and improve overall quality of life. Dos Santos and colleagues (2020) compared the effectiveness of cognitive behavioral therapy (CBT) and brief psychodynamic therapy using the CCRT approach for Major Depressive Disorder using a randomized clinical trial. They recruited 50 patients between 18 to 60 years old. All participants diagnosis was based on DSM-IV and they were administered the Beck Depression Inventory-II (BDI-II) and Functioning Assessment Short Test (FAST). CBT was conducted using Becks manual and short-term dynamic therapy for 16 weeks using Luborskys manual. Across all participants, 82% showed significant symptom reduction. BDI-II total scores from baseline were 29 and post-treatment scores dropped to 6 for participants in CCRT group. Further, results showed that social functioning improved for participants who participated in brief psychodynamic therapy to a greater extent than those who participated in CBT. However, both psychotherapies were found to be equally effective and efficient forms of treatment for depressive symptoms. In a small study, Jarry (2010) assessed the effectiveness of brief psychodynamic therapy using CCRT to reduce anxiety and depression and improve overall self-growth. The Rosenberg Self Esteem Scale (RSES) was used to measure self-esteem, the Symptom Checklist-90 Revised (SCL-90-R) was used to test for clinical symptoms, the BDI-II was used to measure depression, and the State Trait Anxiety Inventory (STAI) was used to assess for anxiety. These measures were administered once during the pre-treatment phase and again after 16 sessions. Results showed that patients who received CCRT showed significantly increased self-esteem and significantly decreased anxiety. Additionally, CCRT appeared to improve relationship styles and defenses in interpersonal situations. Jarry (2010) recommended conducting future studies on clients diagnosed with depression to study the effectiveness of CCRT since participants in their study did not have a formal diagnosis. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 22 Client Descriptions These case studies focus on two clients, a male and female. Presenting problem (Client 1) The client is a 25-year-old Caucasian female, residing with her partner and 8-monthold infant. She recently stopped working outside the home following the birth of her child and is currently a homemaker. The client has three siblings and her mother and father are separated. She had several stepfathers and two stepmothers in her childhood. Her siblings are all younger than her; she adores them and finds herself frequently placed in the role of being their caregiver. She shared that her maternal grandparents also lived with her as a child and she feels extremely close to her grandmother. She sought therapy services due to feeling anxious, experiencing physical symptoms, and stress. Additionally, she was facing family and relationship issues which she described as further heightening her symptoms. Recently, she reported feeling extremely worried about her infants health and well-being. The client described experiencing tightness in her chest quite often. She mentioned going to the doctor for this and he suggested that she might be feeling anxious. She shared being affected by her family problems and feeling anxious when her siblings have any problems in their life. She described having difficulty sleeping, worrying constantly about something bad happening, and feeling upset often about her relationship with partner. For instance, client reported waking up two to three times each night and finding it difficult to sleep as she is worried about her sister. Client shared that sometimes she also worries about health concerns and Googles them, which increases her anxiety. History and Background The client was born to a low SES family. She described being Caucasian and also identifies with Black and Latinx experiences and culture more than White mainstream culture. This she shared for her means living in a neighborhood with people of color and EFFECTIVENESS OF CCRT: TWO CASE STUDIES 23 struggling with issues similar to them such as lacking resources and living in difficult situations. As a child she used to live with her mother and grandparents as her father was suffering from substance use problems. Her parents separated in her early years, and she does not recall much from this time. She has three siblings and they had lived separately for a few years. Her three siblings came in to her life beginning when she was 10 years old. She shared being extremely close to them and practically raising them. She believes that her mother was not as supportive and involved as she should have been. Client described herself as a parental figure for her siblings. Her father returned to their lives when she was about 12 years old and visited her frequently. She described always wanting to live with her father but, because his schedule was busy, she was never able. She shared that her stepbrothers father raised her until she caught her mother being unfaithful to him. Clients relationship with her mother has always been complicated. She felt like her mother did not validate her feelings or support her throughout her childhood. She described that her mother was a child of an abusive father and developed poor communication skills. Her mother tends to avoid taking responsibility, which has caused distress for client. After client graduated from high school she moved out of her house and has not reached out to her mother since. Client has always been independent and believes her mother does not feel that she needs to worry about her. She also believes that her mothers anxious nature has rubbed off on her. However, client described being close to her stepmother, whom she viewed as a trusting caregiver and relied on her for support. She also felt supported by her grandmother who lived next door at the time. Clients relationship with her biological father has been good, despite his lengthy absence during her childhood she perceives him as a source of support and views him in a positive lens. She did not get to spend time with him when she was a child as he was traveling EFFECTIVENESS OF CCRT: TWO CASE STUDIES 24 for work and her mother had custody of her. Presently, her father messages her a lot. He is often saying something positive and visits her too. Client is attached to her siblings and loves them like a mother. She feels the need to advocate for them because of their age differences. Her sister has had suicide attempts, which make her feel protective of her. Her brother identifies, as transgender but is not comfortable around their mother as his mother is unaccepting. Client is extremely concerned for her brother and resents the way her mother treats them. She feels responsible for her siblings as she took care of them as children. Moreover, regarding her social relationships, she discussed that she has had close and meaningful relationships. Prior to giving birth she was in a relationship where she became very attached to this person; however, the relationship ended because he moved to another city. She tried to reach out and connect with him but he became dismissive of her. Her current relationship has lasted for five years; she is with the father of her child. She shared that her partner is extremely supportive and they are happy. However, she has recently been having problems in the relationship because of partner's frequent decision to watch pornography. She believes it is an addiction and feels insecure about his choice to watch it. She also seems to suspect that her partner has been unfaithful in the past as she found another womans clothing in his bag. Although, at the time they had a roommate who was female and clarified that it became entangled with his belongings. Client fails to believe this entirely. Client is a social person but is not able to maintain friendships as she recently became a mother and is busy with that. She described that she is close to family and is mostly the support system for everyone else. She feels that she can rely on her partner for somethings but recently he is busy at work and she feels emotionally distanced. Client has previously worked and kept herself extremely busy. She has had diverse jobs some related to health services and few that required to her to travel. She enjoyed EFFECTIVENESS OF CCRT: TWO CASE STUDIES 25 working. However, after giving birth she has not worked and finds it challenging to just be at home. She has been informed that because she was liked, she would be permitted to join back again in the future. Client has an interest in further pursuing her Masters degree as she enjoys studying. Additionally, relevant to her medical and mental history she reported that her mother and sister both are diagnosed with an anxiety disorder and her sister is diagnosed with depression as well. Her father suffers from a history of substance use problems. She shared that she has had therapy in the past and worked on coping skills. She believes that therapy was helpful and seeks services again as she has been anxious and had some panic attacks. She described her physical health as being good and she does not take any medication. Regarding trauma history, she described that as a child her maternal uncle had molested her and when she told her mother about it, her mother did not believe her. This has been a constant struggle in her relationship with her mother. However, her father believed her and wanted to get her tested and file a report but her mother convinced her not to report this. At the time she never realized that this was abuse and as an adult she feels it does significantly affect her life. Client denied any substance use. She used to smoke cigarettes but quit after she became pregnant. She denied any suicidal ideation or attempts. The strengths of this client include that she is able to recognize that she is struggling and sought therapy and she is hopeful about life. She is goal oriented. Diagnosis F41.9 Generalized Anxiety Disorder Z63.0 Relationship Distress with Intimate Partner Client reported feeling anxious about self, others, relationships which she is not able to control, and anxiety interfering with day-to-day tasks at home and at work. She also EFFECTIVENESS OF CCRT: TWO CASE STUDIES 26 mentioned feeling irritable, fatigued, restlessness, and experiencing difficulty sleeping as she over thinks. Therefore, she meets criteria for generalized anxiety disorder. Client also reported having relationship issues and feeling stressed because of interactions with her partner, therefore meeting criteria for relationship distress with intimate partner. Treatment Plan Based on the CCRT approach her treatment plan included objectives related to her Wish, Response to self, and Response from others. 1. Client will note down what triggers her anxious thoughts and the wishes/reactions that come to mind. 2. Client will identify relationship patterns in therapy in her daily reactions 3. Client will develop healthy communication pattern in treatment based on expressing her wishes. 4. Clients anxious thoughts and feelings will decrease based on ratings on screeners administered in the beginning, middle and end of treatment. CCRT Case Formulation Client presented as insightful, confident, and guarded. She described feeling like the caregiver in all situations and not receiving support from anybody. She described wanting to be needed in relationships and having this underlying Wish of having her emotional needs met and understood. Client desired to protect self from the world and felt like she could not trust anybody completely. She shared being hesitant to trust her partner or mother as they both seemed to have betrayed her when she wanted to be cared for. Her mother, though physically present, emotionally abandoned her as a child. This gave way to her feeling like needing to step in and take responsibility of others. Her partner seemed to have triggered feelings of anxiousness for her, as she had constant thoughts of him being unfaithful to her. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 27 She believed that her partner did not understand her, but she did love him and he was a great caregiver to her infant daughter. Throughout her childhood she expressed feeling burdened by this need to be perfect that caused anxious feelings of failure. She described feeling anxious regarding every small detail in life. While growing up she was anxious about not living up to her parents expectations, her siblings falling apart, not being loved and falling ill. She shared being worried about her health and her familys well-being. Client is consciously trying to be someone who her partner can rely on and can be supported. She wishes to have this love and support that she gives others for herself. She is able to understand everyones needs and work towards making everyone happy. However, she wishes that she were the one receiving this love and attention. As a child, Client had witnessed her parents divorce and arguing, and does not want the same thing for her relationship. She tends to avoid conflict and be open with her feelings as, she fears her partner will reject her. She unconsciously compares her relationship with her parents and is consciously afraid of losing partner and the relationship ending which prevents her from discussing her difficulty around trust. As a child, she tended to blame herself for the divorce and this is the same pattern playing out in her relationship. Client blames herself for her partner dismissing her or rejecting her needs. Moreover, Client believes her infant is a way to strengthen their relationship. Her partners constant rejection of her needs of support has triggered her to seek therapy and she wants to learn to express her needs. Her fear of asserting herself again arises from the idea that if she does that their relationship will somehow weaken and they would separate. Client feels insecure of relationship as partner is watching porn and is anxious about him rejecting her and not valuing her body. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 28 Client struggles with establishing boundaries with family members, and later becomes upset when they cross those boundaries and take advantage of her. She identifies as a mother for her siblings which cause immense anxiety related to their wellbeing and feeling responsible for their shortcomings in life. Overall, client wants people in her life to understand her, maintain healthy boundaries and support her needs like she does with them. Her anxious feelings seem to be related to this main theme of trust and communication patterns in her relationships with others. Course of Treatment Pretreatment phase involved a two-hour intake which included socialization process, where in, clinician gathered information and appropriateness of client for CCRT was established. Client was shared information about how CCRT would work and based on mutually agreed upon consent CCRT was adopted as the treatment model. During phase one of treatment client was made aware of the CCRT approach and what we would work on in our 16 sessions. Sessions one to four she described feelings of hurt, distrust and difficulty expressing her needs with family members and her partner. Client explored and identified her wishes in intersections with others with the help of clinician. She seemed to have motivation to address agreed upon goals for treatment. Client felt misunderstood in her interactions and described always trying to help others but people did not understand her or care for her needs. For instance, she shared a conversation with her partner where she wanted to discuss with him that she did not appreciate him working overnight. However, before starting this discussion her partner talked about needing to spend more time at work and she agreed since she wanted to be understanding of him. Client also shared that when talking to anyone she tends to be extremely understanding and supportive except for her mother. She described underlying feelings of anger and resentment towards her. For instance, in one conversation her mother talked about EFFECTIVENESS OF CCRT: TWO CASE STUDIES 29 sharing pictures of clients baby on social media and client became annoyed with her. Client shared in session that she wished that her mother called and asked how she and her baby were doing instead of posting pictures and acting like she cared. Applying Tallberg et al.s (2020) typology of CCRT themes, client showed clear themes of a desire for others to be close and accepting, to achieve and help others, be loved and understood, and to feel good and comfortable. By session 4 we solidified her exploration and identification of wishes. While sharing the CCRT with client it was made sure that it was a collaborative process. Client seemed to be reflecting on her conversations outside of therapy and bringing them to sessions to be able to identify her patterns of interactions. The CCRT formulation involved clarification questions, in-depth discussion of patterns and collaborative reflections. Client described wanting to be cared for, loved and supported in any relation, however, in her patterns of interaction she felt others controlling her, taking advantage of her and her response was to be helpful and secretly feel angry with self and others. Her response to self included, being silent based on expectations that others will disappoint. This CCRT was shared on the second session and when shared with her was shared by using her words and being reflective which resonated with the client. She agreed with her CCRT and showed interest in changing her patterns and actualizing her wish. During phase two of treatment (sessions five to twelve), client worked with therapist on identifying relationship with others and understanding the impact of this on her life. We worked on focusing on the uniqueness of her CCRT. Initially clinician and client analyzed relationship episodes for the client. Client described episodes where she felt others misunderstood her, with a tendency to describe interactions where she believed that she was trying to be helpful and she wished for the other person to be helpful in response. However, often experienced the responses from others as angry and contributing to misunderstandings and arguments. For instance, she invited him to spend time with her in order to improve and EFFECTIVENESS OF CCRT: TWO CASE STUDIES 30 nurture their relationship, instead of immediately going to his room and being on his mobile phone. She described that in the conversation she felt hurt as he refused to and wanted his space. Her response to self was becoming upset, withdrawing and started to cry. The response from others she experienced was retaliation and an argument and response to self was to feel helpless and cry. Another example she described was a wish to be loved and understood by her mother. She described calling her mother to talk with her and tell her how she was doing. Her mother responded instead by talking about her problems and things that were going wrong in her life. Client then became an understanding ear for her mother. She described feeling angry with her mother but not being able to express it. Client could not express her wish to be understood and instead her response to self was to feel disappointed and decided to not call her mother again. She also shared a conversation with her mother where she wished that her mother showed her love. She described expressing to her mother that she did not appreciate her putting clients babys photo on social media since she did not call client or behave like she cared for her. Her mother responded (response from others) by becoming angry with client which led to an argument. Clients response to self was to blame self, shut down and not want to talk to her mother again. Client also described interaction with sister where she wished to seek love and support. She described calling her sister to tell her about her day and her sister started talking about how she was feeling suicidal and client had to be supportive of sister instead. In this RE, the RO is to reject clients feeling or what had happened for her to call, and RS is client feeling dissatisfied with the conversation. During the second phase of treatment clinician paid attention to statements like it could have been better, I hoped for this and other statements clients made to indicate her wishes in interactions with others. We also focused on processing clients response to others EFFECTIVENESS OF CCRT: TWO CASE STUDIES 31 and understanding her past interactions that how she felt when others response did not fit her wish. Client expressed feeling upset, having self-doubt and feeling anxious about not feeling loved and supported. This phase also involved enactments with clinician. Client tended to repeat pattern of interaction with clinician. The clinician processed then in the here-and-now therapy space through immediacy clients feelings in session. Client expressed in the sixth session her feeling of mistrust to the world and how she was unable to trust since people would eventually betray her trust. When clinician asked if this is how she felt about therapy she nodded. Client and clinician worked toward working through this enactment to allow for further exploration of CCRT process. Clinician and client discussed several REs like above and slowly moved towards forming clients CCRT and started on the third phase of treatment. Phase two also involved the thrust of therapeutic work where client and clinician processed clients interactions in past that have led to her interactions in the present. We worked through childhood patterns, understanding response to others and response to self. She disclosed on the sixth session pervasive feelings of always being taken for granted, as her mother was never present, she felt the need to be independent and take control of everyone at home, which included siblings and her father. She shared wanting to be supported and not having anyone to go to as she became everybodys support person. She cared and loved for everyone; it became important to be understanding but she believed nobody cared for her. In therapy we worked on understanding patterns in interactions and reframing ways she would express her wish and response to others. Client identified interactions where she was cared for by her partner and father. We worked on actualizing her wish of being understood, loved and supported. During session 13 to 16 the focus was on termination. Client shared her anxieties around termination. She shared being worried that the problem would arise again or she might not be able to express her needs without therapy. We processed her feelings and helped her EFFECTIVENESS OF CCRT: TWO CASE STUDIES 32 understand that she was already using her tool box outside of therapy and would be able to function just has she has been through the therapy process. Client and therapist also discussed alternatives such as coming back for therapy if another problem arises or checking in with another clinician if need be. In the last session client shared her sadness about therapy coming to an end but also discussed the skills she had gained and the ability to express her needs had helped her in all areas of life. She reported better relationship with partner, family and self. She shared her future goals of going to graduate school and accomplishing some other goals that she could not express with others earlier. Presenting problem (Client 2) The client is a 25-year-old Caucasian male. He resides with his wife. Client sought services as he has been struggling with depression and anxiety. He described that recent career changes have led to stress and he wants to prevent it from impacting his relationships and work. As a child, client had requested his parents to take him for therapy as he felt like he was depressed, however his parents refused. Client described that he tends to over think and worries in relationships about people being angry with him. He reported overcompensating and trying to keep people happy or he believes they will leave him. Client reported few obsessions, which involve thinking about doors being locked; compulsions of going back and checking to make sure the door was locked. Also, obsesses on whether or not he left the iron on. He mentioned compulsively picking on his fingernails. He more recently has been constantly thinking about his worth. He said he wants to learn to communicate better in relationship as he feels he has some issues in communicating. Client also reported feeling depressed at times for no reason and at those times he does not want to talk to anybody and portrays a flat affect. History and Background EFFECTIVENESS OF CCRT: TWO CASE STUDIES 33 Client described his childhood, as having challenges but overall, it was good. He lived with his parents and younger brother as a child. His brother and him have a 13-year age gap; client felt like a parent figure for sibling and was almost always left to supervise him. Client scared being close with his mother. His mother is similar to him and mostly they get along well but sometimes they need a break from each other. His mother would encourage him to perform his best academically. His father was always out for work, rarely physically present but they were close. Presently, his father and him have a conflictual relationship as his father has negative feeling about client earning more money than him and choosing his own career path. His parents were going through a divorce during his teen years and this caused him a lot of emotional turmoil. He experienced his parents as being emotionally abusive, as they would manipulate him. For instance, he explained that his father would tell him things like his mother never wanted him to be born and he would blame his mother for clients problems. His father has negative opinions about women that client identified as being unhealthy. Client feels a lot of his perceptions about being a man are also influenced by his father and he understands that he needs to work on these. His mother would be upset and depend on client to take care of her. He wished his mother would stand up to his father. Clients relationship with his younger brother has been good. He always wanted to protect his brother from his mother and father, and would distract brother when parents were arguing. He now feels guilty since his brother is still living with parents and client has moved out. They live in different states so they meet each other once or twice a year. They stay in contact with each other and play video games regularly. Client wants his brother to live with him but parents would not agree. Moreover, client met his current wife in college and they have been together for seven years. They have been married for three years. He described his wife as his best friend. They EFFECTIVENESS OF CCRT: TWO CASE STUDIES 34 are very close and he is able to trust her. He believes she is the single most positive part of his life. Recently, they have been having issues, client expressed that he has been having difficulty being open about his emotions. He believes his mood has been changing and sometimes he becomes quiet for no reason, which starts fights. Client worries about becoming like his parents. Part of seeking therapy was that he does not want his issues to become a part of their relationship. His wife is patient with him, supportive and understands that he is going through some things. Client expressed having few close friends and he was able to get support from them. However, he mentioned that he tends to push people away and create boundaries, which has reduced his friend circle. In school, client had been bullied and this has really bothered him. He described being bullied because of his hair color and physical appearance. Later as a teen he became popular and he resorted to being the bully to protect himself. He stated this was the time his parents were going through a conflictual period and he acted out in school. He said he did not really like school as a child but as a teen he enjoyed it. He pursued his Masters degree and has been working in a company in a head position for a while. He mostly is satisfied with his career but wants to be successful and move out of where he is working currently. Additionally, regarding trauma history, client shared his father was physically abusive towards him when he was 14 years old. He said his brother had a metabolic disorder, his parents were always low on sleep and client was responsible for waking them up to keep check on his brother. He said one day when he woke his father up, his father got furious and just pressed clients arm violently and lay on him in a physically powerful way. Client felt like his father was relieving his aggression on him for no reason. Client has experienced bullying which he found traumatic. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 35 Client reported that his maternal grandmother has been diagnosed with bipolar disorder; paternal grandmother with major depressive disorder and paternal grandfather suffers from anxiety and likely has a drinking problem. He believes that at least two of his aunts on his fathers side have been diagnosed with depression and anxiety. Regarding his medical history, client is suffering from Crohns disease and in the past he has had his rectum removed. He described his overall health as fair. He takes medication for Crohns disease. He shared feeling like his Crohns disease as something he has been dealing with and feels okay about it currently. Furthermore, client was first introduced to alcohol by his father when he was 13 years old. He said he occasionally drinks with his partner on weekends. He does not smoke or use drugs. The strengths for him include that he is able to express his difficulties and he wants to work towards becoming a better version of himself. He also enjoys exercising and taking walks to cope with his mood. Diagnosis F41.9 Generalized Anxiety Disorder F33.0 Major Depressive Disorder, recurrent, Mild Z63.0 Relationship Distress with Intimate Partner Client described feeling anxious about several situations such as meeting new people, leaving the door unlocked and having ruminative negative self-thoughts. He reported worrying about work, family and his marriage. He described frequently feeling irritated, trouble falling asleep due to worry thoughts and difficulty making decisions. Therefore, client meets criteria for generalized anxiety disorder. Client also described feelings of low selfesteem, self-worth, feeling sad and lack of motivation. He described feeling inferior to others and having distressing thoughts about the future. He meets criteria for major depressive EFFECTIVENESS OF CCRT: TWO CASE STUDIES 36 disorder. It is also important to note that his diagnosis of Crohns disease could also be a adding or causing some of his depressive and anxiety concerns. Addolorato et al. (1997) and Panara et al. (2014) discussed the impact of bowel diseases as factors that increase and lead to depression and anxiety concerns when compared to the normal population. Client shared that he was having several arguments with partner, feeling disconnected with his wife and struggling to describe his feelings to her. Therefore, meeting criteria for relationship distress with intimate partner. Treatment Plan Based on the CCRT approach her treatment plan included objectives related to his Wish, Response to self and Response from others. 1. To better understand self, client will identify and report what triggers his depression and anxiety 2. To decrease negative thoughts about self, client will identify interactions in daily life and what he wishes outcomes were. He will develop healthy coping and communication skills. 3. To have more satisfying and meaningful relationship with wife, client will express his needs in therapy and work towards communicating emotions and feelings. 4. Clients depressive and anxious thoughts and feelings will decrease based on ratings on screeners given in the beginning, middle and end of treatment. CCRT Case Formulation Client sought services to improve relationship with self and others. He described being reserved and not sharing how he feels so that he does not hurt the other person. He seemed to foster low self-worth and thoughts of being a failure. His interaction with family seemed to include his father playing a dominant role and telling him what to do and client following this. He presented in therapy with wanting to change this pattern on doing what others expect of EFFECTIVENESS OF CCRT: TWO CASE STUDIES 37 him. He struggled with being assertive and communicating his needs to friends, family, wife and colleagues at work. His interaction with his boss seemed to be based on self-doubt as his boss referred to him as loser and talked down to him a couple of times a day. He described this relationship as dominating and hating feeling like a child but not knowing how to change this. His self-esteem seemed to be dependent on how others in his life thought or expected out of him. He was always wished to please people and be appreciated, however, response from others was always looking at him as inferior to them and not being a man. He described wishing to be able to be kind and assertive at the same time. He felt stuck in this idea of wanting to impress his father and also be respected by him. Clients relationship with mother seemed to be based on one sided care and support. He described that his mother leaned on him for emotional support which was exhausting for him. He shared wishing that he could share how he feels with her and have a balance of needs met. Clients relationship with wife has been healthy, however, recently he feels that feeling depressed as interfered with their interaction. He described avoiding talking about his feelings with her and struggling to feel connected to her. They argue about clients recent emotional withdrawal from her as he is unable to understand his needs. He is struggling to cope with the pressures of a marriage and seems to wish that his wife understands his needs without him expression them. Client wishes to be supportive of wife and take on traditional masculine roles but at the same time struggles with understanding her needs which leads to arguments. For instance, he shared that he was not picking up her phone calls to help her understand that he was busy at work like other men are, however, she perceived this as a sign of ignoring her immediate needs. He also tends to avoid arguments and escape them by emotionally withdrawing form wife. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 38 In conclusion, clients relationship cycles involve him trying to be supportive of others needs, caring for them, however, response from others includes belittling him or shaming him for this support, or taking advantage of his support and response to self is low self-worth and seeing self as inferior to others, especially not seeing self as a typical man. Client wishes to be understood and supported just as he thinks he is doing with others. He perceives self as open, understanding and wanting to care for others but also strong like a man. When he cries or feels emotions other than anger he responds negatively to self and feels ashamed. Course of Treatment Pretreatment phase involved a two-hour intake which included socialization process, where in, clinician gathered information and appropriateness of client for CCRT was established. Client was shared information about how CCRT would work and based on mutually agreed upon consent CCRT was adopted as the treatment model. Phase one of treatment between sessions one to four involved sharing his unique CCRT and identifying his wish, response to others and response to self. Client was open to brief method of treatment and described wanting to try other ways of interacting in relationships. First session therapist and client explored what CCRT means and formulating the base of treatment. From sessions two to four, we focused on uniqueness of his CCRT when making statements like I really want to be more assertive, he was able to identify his wish as accomplishing his needs in relationship and wanting to be assertive. He identified his actual way of conveying this was trying to be supportive and taking care of others needs or becoming angered with another. His response to other as giving up and listening to what somebody else is telling him to do. He tends to be understanding when he wishes to be able to stand up for his needs. He also identified wanting to be a man without having to be this person who is seen as stereotypically strong and not expressing emotions. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 39 He described some relationship episodes, for instance, when his father talked about politics, and client did not agree with his beliefs he tend to shut down since his father spoke in a louder voice which made him seem powerful and client left conversation feeling ashamed about self. Another example, when he went to share with his mother his feelings of depression, his mother was quick to dismiss him and talk about what she needed him to do as a man. He left conversation feeling resentful for bringing this up in the first place. With his wife, he described feeling guilty for putting his needs or telling her that he needs some space in the relationship as she would always take care of him and is considerate of his feelings. He tended to instead only share his feelings when frustrated and drinking which made her feel upset and in turn, he felt upset about sharing this with her. At work, whenever he tried to talk to his boss about wanting to transition to a different department his boss would shame him and yell at him in front of other office members, his response to self then would be to go home and cry and feel ashamed. He described when he felt upset or when he was unable to communicate what he needed his anxious behaviors would increase like checking if the door was locked or worrying that he left the iron on and wanting everybody to check for him. Phase one ended with helping client gain insight about the uniqueness in his patterns of interactions. Whenever he wants to share his needs, he worries about feeling ashamed or feels frustrated with self. By session four we solidified his exploration and identification of wishes. During phase two of treatment (between sessions five and 12) therapist and client worked on response from others and response to self. Clients response from others seems to mostly be dismissal or getting angry with him. Client recalled that as a child whenever he tried to talk to his father about feeling sad or being bullied his father would ignore his feelings and be angry at him for not being tough or acting like a man. He also recalled his mother telling him about her needs and his younger brothers needs come before him and he would have to take care of them once he is older. Therapist and client during middle phase worked EFFECTIVENESS OF CCRT: TWO CASE STUDIES 40 on understanding how these childhood patterns of interactions and experiences are repeating in his current relationships. He explored and identified his wish as a child was to be understood and supported by his parents but when he met with dismissal or disapproval his response to self was feeling dissatisfied and doubting self. This feeling of not understanding self is something he has felt and is repeated in his response to self. While exploring his response to self he identified behavioral aspects such as crying, becoming angry isolating self and often feeling confused about expectations. During session 10 therapist worked on bringing some unconscious aspects such as expecting reactions from others based on his past experiences. He recalled how he withdrew from a conversation with his wife as he expected her to dismiss that his needs. He described wanting to tell her feeling upset about his friend yelling at him and then she shared about her mother being sick and he immediately decided not to tell her about his day since he respected her needs more than his. He tended to put others first instead of taking care of self which is something his mother had said to him in childhood. During phase two he was able to bring his wish of needing to express his needs and take care of self into awareness. We then worked through ways he could actualize his wish. He shared trying out in a conversation with his wife talking about how he felt misunderstood by his father and allowing her to support him and then asking her about her day. He discovered that she did not dismiss his needs and did not react the way he expected or based on previous patterns in his responses from others. During phase two therapist also worked through responses from others that client feared. He described a conversation with a friend wherein he agreed to do something he did not want to. He shared his friend needing him to take care of his pet, however client had allergies to that breed. Client felt compelled to say yes because he was afraid his friend would get angry or they would no longer remain friends. He then explored how his father would never feel like whatever client did was good enough and this feeling kept returning in EFFECTIVENESS OF CCRT: TWO CASE STUDIES 41 conversations which he would expect others to respond similarly to his relationship episodes with his father. When this transference of interaction was made aware to client, he was able to explore the guilt he felt and the anger that he had repressed towards his father. This second phase helped client uncover early experiences and transference reactions that hindered him expressing his actual wish or needs. After client and therapist worked through hindrances and relationship episodes to help actualize his wish, we moved towards phase three. During phase three of treatment (between sessions 13 to 16) the focus was on termination and exploration of gains. We explored clients progress in therapy and experiences where he was able to actualize his wish. There were also instances of client regressing to his core conflictual relationship theme which were processed and focus was kept on ability to identify response to self and actualization of wish. We also explored clients anxiety around separation from therapy and focused on using these insights gained in therapy to practice expressing his wishes and being able to identify response to self and response to others. The client was able to share instances of interactions wherein he identified CCRT and was able to actualize his wish without fear of rejection or dismissal which helped establish termination and dealing with reactivation after termination. He was able to achieve his goals and termination was successful after 16 sessions. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 42 Clinical Research Questions Psychotherapy outcome questions Q1. Does the client get better in terms of reduced symptoms after the 16 sessions of CCRT? Q2. Did treatment improve their interaction in relationships? Q3. If the clients improved on symptom scales, was the improvement on the symptom scales reflected on pre-treatment/post-treatment research measures, and was the magnitude of the symptom change greater than would be expected due to measurement error? EFFECTIVENESS OF CCRT: TWO CASE STUDIES 43 Chapter 2 Method Research design A single-subject time series design was utilized to examine symptom change across phases of treatment (Borckardt & Nash, 2002). Time series analysis is a method used to track changes in target behavior. Pre-treatment data provides a baseline by which to evaluate symptom change across treatment (Hudson et al., 2019), which in this case involved 16 sessions of CCRT therapy. This time series study involved collecting data at three phases of intervention to evaluate symptom change. Participants This case study involved two Caucasian participants, one male and female, both 25 years of age. Initially five participants were selected, however, two dropped out after session three and one after session one. Participants were selected based on convenience sampling from an outpatient private clinic and the two who completed 16 sessions were selected. Client 1 met criteria for diagnosis: Generalized Anxiety Disorder and Relationship Distress with Intimate Partner. Client 2 met criteria for diagnosis: Generalized Anxiety Disorder, Major Depressive Disorder, recurrent, Mild and Relationship Distress with Intimate Partner. They were both assessed during the baseline phase, treatment and post treatment phase to track changes. CCRT therapy was implemented followed using Books (1998) manual. This manual provides a detailed guide for the clinician to practice CCRT, described above. Participants were informed earlier that they were entering CCRT because of dissertation consent and measurement process which required researcher to label the treatment as CCRT earlier than may have happened according to Books treatment manual. Measures EFFECTIVENESS OF CCRT: TWO CASE STUDIES 44 Participants were administered the Patient Health Questionnaire-Depression and Anxiety Disorders (PHQ-SADS) and Brief Symptom Inventory (BSI). Participants completed PHQ-SADS at baseline, after session 8 (mid-treatment), and after 16 sessions (posttreatment). The BSI was administered at baseline and at the last session. The clients were also asked three survey questions designed by this clinician at the end of treatment. These questions included: 1) How do you feel about your relationships? (Good, Could be improved/worked on, Do not have many close friends or relationships); 2) Do you feel a change in your interaction with others? (Yes or No); 3) If yes, in what way? (Positive or Negative). The PHQ-SADS is a self-report measure of somatic symptoms, depression, and anxiety. It is comprised of the PHQ-9, PHQ-15, and GAD-7. The normative data for PHQSADS is based on 5,031 subjects and a mean age of 18 years. The PHQ-9 is a measure screening and assessing depression symptoms and identifying depressive disorders. It consists of 9 questions and questions are scored on a scale of 0 to 3. The scores range from 0 to 27. The score of 5, 10 and 15 act as cut off for mild, medium and severe depressive symptoms respectively. The questions are based on the Diagnostic and Statistical Manual of Mental disorders, 4th edition (DSM-4) criteria for depressive disorders. This scale was initially developed for primary care clients and has since has been validated for the general population. It has a sensitivity and specificity of 88%, internal consistency reliability of .86, and criterion validity with other measures of depression of .89 (Gilbody et al., 2007). The PHQ-15 is a 15-item somatic symptoms questionnaire. It measures 15 somatic symptoms and accounts for more than 90% of physical complaints. Each item is rated on a scale from 0 to 2 with total scores ranging from 0 to 30. Research has shown an internal consistency reliability of 0.85 and relevant criterion validity of 0.80 (Han et al., 2009). The EFFECTIVENESS OF CCRT: TWO CASE STUDIES 45 scores of 5, 10, and 15 have been recommended as cut-offs for classifying mild, moderate, and severe somatic symptoms, respectively. The GAD-7 is a 7-item scale that measure anxiety symptoms. It was developed to identify cases of generalized anxiety disorder and questions are based on diagnostic criteria from DSM-4. Total scores range from 0 to 21 and scores of 5, 10 and 15 have been recommended as cut-offs for classifying mild, moderate, and severe anxiety symptoms, respectively. It has a sensitivity of 89% and specificity of 82% in primary care patients. It has also been shown to correlate with the Beck Anxiety Inventory (BAI) at r = 0.72 (Spitzer et al., 2006). It has been validated in the general population and meta-analytic results support its psychometric properties (Plummer et al., 2006). The BSI is a 53-item self-report measure appropriate for individuals ages 13 years and older. Items are rated on a five-point Likert scale ranging from 0 to 4. It includes nine symptom scales: Somatization (SOM), Obsessive Compulsive (O-C), Interpersonal Sensitivity (I-S), Depression (DEP), Anxiety (ANX), Hostility (HOS), Phobia Anxiety (PHOB), Paranoid Ideation (PAR), and Psychoticism (PSY). It has been shown to correlate with the MMPI-2 scales at .89, supporting its convergent validity (Adawi et al., 2019). Statistical Approach This study uses the percentage of non-overlapping data (PND) approach and Reliable Change Index (RCI) to measure change across treatment. With the PND approach, treatment effectiveness is estimated based upon the percentage of non-overlapping data between baseline and treatment. When values are expected to decrease, such as in the case of measuring depressive symptoms across psychotherapy, PND is calculated as the percentage of treatment and/or post-treatment phase depressive symptom measures that are lower than the lowest depressive symptom value obtained during baseline. When values are expected to increase, such as in the case of a measure of wellness across psychotherapy, PND is the EFFECTIVENESS OF CCRT: TWO CASE STUDIES 46 percentage of treatment phase data that are higher than the highest value obtained during baseline. Possible PND scores range from 0 to 100, and higher scores (closer to 100) indicate higher levels of effectiveness (i.e., there is more discrepancy between baseline and treatment symptoms). Interpretively, Scruggs and Mastropieri (1998) suggest that scores less than 50% indicate that the treatment is ineffective, between 50 and 70% questionable, between 70% and 90% effective, and higher than 90% means the treatment is very effective. Because the current study includes two post-baseline measures from the PHQ-SADS and one post-baseline measure with the BSI, the possible PND values are limited. For the PHQ-SAD, possible PND values include 0, 50, or 100 percent; for the BSI, possible PND values include 0 or 100 percent. Given this limitation, the RCI was also used as a complementary empirical approach. Table 2 PND Scores and interpretation PND Scores Interpretation 0%-50% Not effective 50%-70% Questionable 70%-90% Effective 90%+ Very effective Note. Table is derived from data from Scruggs et al. (1998) Jacobsen and Truax (1991) introduced the reliable change index (RCI) to estimate whether the observed symptom change across treatment is greater than what would be expected solely due to measurement inconsistency. The formula for calculating RCI is: RCI = (x2 x1)/Sdiff. In this equation, x1 is the participants pre-treatment test score and x2 is the participants post-treatment test score, and Sdiff is the standard error of difference between the two test scores. The Sdiff is computed as the standard error of measurement, which will be derived from each tests technical manual or other sources of psychometric information. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 47 The RCI provides an estimate of whether statistically significant change has occurred, accounting for the reliability of the measure(s) used. With the RCI, scores of positive or negative 1.96 correspond to the 95% confidence interval, and therefore RCI scores of at least 1.96 are considered to be statistically significant (i.e., treatment was associated with a reliable change). Scores for RCI scores between -1.96 and 1.96 are considered absence of change. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 48 Chapter 3 Results Client 1 Client was administered Patient Health Questionnaire-depression and anxiety disorders (PHQ-SADS) test three times, including at baseline, mid-treatment, and posttreatment. The PHQ-SADS is a 16-item self-report measure devised for screening functional impairment in the areas of depression, anxiety and somatic concerns. Anxiety, depression and somatic concerns commonly co-occur and hence this measure was developed to reflect this (Miller, 2019). The PHQ-SADS was developed from a combination of three existing measures, including the PHQ-9 (measures depression), PHQ-15 (measures somatic concerns), and GAD-7 (measures anxiety). Client was also administered the Brief Symptom Inventory (BSI) at baseline and posttreatment. The results are displayed in the table below. Table 3 PHQ-SADS Scores for Client 1 PHQ-SADS Baseline Mid-Treatment Post-treatment PHQ-15 10 7 3 GAD-7 10 8 5 PHQ-9 11 7 0 On the PHQ-SADS, clients scores at baseline suggest moderate somatic symptoms, moderate symptoms of anxiety, and moderate symptoms of depression. Client reported panic attack symptoms the night before the session. She described she felt like the baby or she was shaking and she started to feel breathless and her heart was racing. On this questionnaire, when asking her how difficult these problems made it to do her work, take care of things around the home or get along with people, she said, "Very difficult." EFFECTIVENESS OF CCRT: TWO CASE STUDIES 49 The results on her mid-treatment PHQ-SADS suggest mild to moderate somatic symptoms, mild to moderate anxiety symptoms and mild to moderate depression symptoms. Her symptoms in each of these domains were decreased relative to baseline. When asking her how difficult these problems made it to do her work, take care of things around the home or get along with people, she said, "Somewhat difficult." The post-treatment PHQ-SADS results displayed continued improvement in each domain and showed little to no somatic symptoms, mild anxiety symptoms, and no depression symptoms. Client denied having a panic attack in the past 4 weeks. When asking her how difficult these problems made it to do her work, take care of things around the home or get along with people, she said, "Not difficult." Moreover, her BSI profile scores were as displayed: Table 4 BSI scores for Client 1 BSI Baseline Posttreatment Somatization 4 3 Obsession-Compulsion 1 0 Interpersonal Sensitivity 4 0 Depression 8 2 Anxiety 9 2 Hostility 2 0 Phobic anxiety 1 0 Paranoid ideation 6 2 Psychoticism 4 2 Her scores on the baseline BSI measure suggest mild somatic symptoms, minimal obsessive-compulsive symptoms, mild interpersonal sensitivity, mild depression symptoms, EFFECTIVENESS OF CCRT: TWO CASE STUDIES 50 mild to moderate anxiety symptoms, minimal hostility symptoms, minimal phobic anxiety symptoms, mild paranoid ideation, and mild psychoticism. Her total score was 39 indicating moderate psychological distress. On the post-treatment BSI scores suggest minimal somatic symptoms, no obsession compulsion symptoms, no interpersonal sensitivity, minimal depression symptoms, minimal anxiety symptoms, no hostility symptoms, minimal phobic anxiety symptoms, minimal paranoid ideation and minimal psychoticism. Her total score was 11 suggesting minimal psychological distress. In this study, two treatment measures are used to assess effectiveness Brief symptom inventory (BSI) which was administered baseline phase and posttreatment and Patient Health Questionnaire-Depression and Anxiety Disorders (PHQ-SADS) which was administered baseline phase, mid-phase and posttreatment. Figure 1 PND analysis of BSI scores client 1 PND FOR BSI 10 9 8 7 6 5 4 3 2 1 0 SOM OC IS DEP ANX Baseline Figure 2 HOS Post PHOB PAR PSY EFFECTIVENESS OF CCRT: TWO CASE STUDIES 51 PND analysis of PHQ-SADS scores client 1 P ND FOR P HQ -S ADS GAD-7 PHQ-9 PHQ-15 60 50 40 30 20 10 0 BASELIN MID POST-TREATMENT Using the PND to calculate results for BSI for client 1, from baseline phase to posttreatment her scores for the Somatization scale, Obsession-compulsion scale, Interpersonal Sensitivity scale, Depression scale, Anxiety scale, Hostility scale, Phobic anxiety scale, Paranoid ideation scale and Psychoticism all decreased as shown on table 4 and figure 1. That is, the percentage of symptom measures during posttreatment phase are lower than the lowest symptom value obtained during baseline phase for all scales. This means that the treatment PND score is 100% which suggests that treatment was very effective for client 1. For PHQ-SADS, the scores for client 1 for scales PHQ-15, GAD-7 and PHQ-9 consistently decreased from baseline, to mid-treatment to posttreatment as shown on table 3 and figure. This indicates, the percentage of symptom measures during posttreatment phase are lower than the lowest symptom value obtained during baseline phase and mid-treatment phase for all scales. This means that the treatment PND score is 100% which suggests that the CCRT approach to therapy was very effective for client 1. Table 5 below, lists the RCI for 9 Clinical scales of the BSI, for the BSI lower scores from pre to post treatment suggest better functioning. Table 5 showcases the RCI results for EFFECTIVENESS OF CCRT: TWO CASE STUDIES 52 client 1, all the BSI scores have RCI scores>1.96 which means that this client has achieved reliable change (i.e., RCI > 1.96, p < .05). Table 5 RCI Data for BSI, Client 1 BSI Scales Mean SOM 0.945 SD 0.8715 Test-retest reliability 0.68 SEm 0.493 RCI Interpretation 2.87 Reliable change OC 0.884 0.7698 0.85 0.298 2.37 Reliable change IS 0.856 0.7986 0.85 0.309 2.28 Reliable change DEP 1.225 0.8264 0.84 0.331 12.84 Reliable change ANX 1.244 0.7936 0.79 0.364 13.60 Reliable change HOS PHOB 0.978 0.931 0.8103 0.8073 0.81 0.91 0.353 0.242 4.00 Reliable change 2.92 Reliable change PAR 1.101 0.8516 0.79 0.390 7.24 Reliable change PSY 1.239 0.8854 0.78 0.415 3.40 Reliable change For client 1, the Somatic scale score changed from four to two over the course of treatment and the RCI score is 2.87 which means client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Her score for Obsession-Compulsion scale changed from one to zero the RCI score is 2.37 which means client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). For interpersonal sensitivity scale her scores changed from four to zero and RCI score is 2.28 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). For Depression scale her scores changed from eight to two and RCI score is 12.84 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Her Anxiety scale scores changed from nine to two and RCI score is 13.6 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Her Hostility scale scores changed from two to zero and RCI score is 4.00 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Her Phobic Anxiety scale score changed from one to zero and RCI score is 2.92 which suggests client has achieved reliable EFFECTIVENESS OF CCRT: TWO CASE STUDIES 53 change and made improvement (i.e., RCI > 1.96, p < .05). Her Paranoia scale score changed from six to two and RCI score is 7.24 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Lastly, her Psychoticism scale score changed from four to two and RCI score is 3.40 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Overall, results for BSI for client 1 suggests that CCRT was an effective treatment as indicated by her positive and clinically significant RCI scores for all scales. Table 6 RCI Data for PHQ-SADS, Client 1 PHQ-SADS Mean SD Test-Retest Reliability SEm RCI Interpretation PHQ-15 3.2 3.8 0.82 1.62 3.07 Reliable change GAD-7 4.6 4.7 0.88 1.59 1.81 Reliable change PHQ-9 3.3 3.8 0.86 1.42 5.47 Reliable change For client 1, Table 6 above shows PHQ-SADS, RCI scores from baseline to posttreatment. Her PHQ-15 changed from 10 to three and RCI score is 3.07 which suggests client has achieved reliable change and made improvements (i.e., RCI > 1.96, p < .05). Her GAD-7 scale score changed from 10 to five and RCI score is 1.81 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Lastly, her PHQ-9 scale score changed from 11 to zero and RCI score is 5.47 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Overall, results for PHQSADS for client 1 suggests that CCRT was an effective treatment as indicated by her positive and clinically significant RCI scores for all scales. In addition, clients were also asked two survey questions post treatment 1) How do you feel about your relationships? (Good, could be improved/worked on, do not have many close friends or relationships); 2) Do you feel a change in your interaction with others? (Yes EFFECTIVENESS OF CCRT: TWO CASE STUDIES 54 or No); 3) If yes, in what way? (Positive or Negative). Client one responded to survey question one as good and question two as yes and in a positive way. Client 2 Client was administered the PHQ-SADS at baseline, mid-treatment, and posttreatment. Client was also administered the BSI at baseline and post-treatment. The results are displayed in the table below. Table 7 PHQ-SADS Scores Client 2 PHQ-SADS Baseline Mid-Treatment Posttreatment PHQ-15 15 10 4 GAD-7 15 10 5 PHQ-9 22 11 6 On his baseline PHQ-SADS scores suggest severe somatic symptoms, severe symptoms of anxiety, and severe symptoms of depression. Client denied having a panic attack in the past 4 weeks. On this questionnaire, when asking him how difficult these problems made it to do his work, take care of things around the home or get along with people, he said, "Extremely difficult." The results on his mid-treatment PHQ-SADS suggest moderate somatic symptoms, moderate anxiety symptoms and moderate depression symptoms. When asking him how difficult these problems made it to do his work, take care of things around the home or get along with people, he said, "Somewhat difficult." Client mentioned having a panic attack within the past 4 weeks. He described being overwhelmed at work. The results also indicate a decrease in overall symptoms from baseline to mid-phase of treatment. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 55 The results for post-treatment PHQ-SADS show minimal somatic symptoms, mild anxiety symptoms, and mild depression symptoms. Client denied having a panic attack in the past 4 weeks. When asking him how difficult these problems made it to do his work, take care of things around the home or get along with people, he said, "Somewhat difficult." The results in table 7 also indicate a decrease in overall symptoms from mid-phase of treatment to posttreatment. Moreover, his baseline BSI profile scores were as follows: Table 8 BSI Scores for client 2 BSI Baseline Posttreatment Somatization 4 2 Obsession-Compulsion 10 5 Interpersonal Sensitivity 9 1 Depression 13 6 Anxiety 9 4 Hostility 6 0 Phobic anxiety 10 6 Paranoid ideation 5 1 Psychoticism 5 1 His baseline BSI scores suggest minimal somatic symptoms, moderate obsession compulsion symptoms, mild to moderate interpersonal sensitivity, moderate depression symptoms, moderate anxiety symptoms, mild hostility symptoms, moderate phobic anxiety symptoms, mild paranoid ideation and mild psychoticism. His total score was 71 indicating high psychological distress. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 56 On his post-treatment BSI, the scores suggest minimal somatic symptoms, minimal obsession compulsion symptoms, minimal interpersonal sensitivity, mild depression symptoms, minimal anxiety symptoms, no hostility symptoms, mild phobic anxiety symptoms, minimal paranoid ideation and minimal psychoticism. His total score was 26 indicating mild psychological distress. Figure 3 PND analysis for BSI scores client 2 PND FOR BSI 14 12 10 8 6 4 2 0 SOM OC IS DEP ANX HOS Baseline PHOB PAR PSY Post Figure 4 PND analysis for PHQ-SADS scores client 2 P ND FOR P HQ -S ADS GAD-7 PHQ-9 PHQ-15 60 50 40 30 20 10 0 BASELIN MID POST-TREATMENT EFFECTIVENESS OF CCRT: TWO CASE STUDIES 57 Using PND method for client 2, to calculate results for BSI, his scores from baseline phase to posttreatment for the Somatization scale, Obsession-compulsion scale, Interpersonal Sensitivity scale, Depression scale, Anxiety scale, Hostility scale, Phobic anxiety scale, Paranoid ideation scale and Psychoticism all decreased as shown on table 8 and figure 3. That is, the percentage of symptom measures during posttreatment phase are lower than the lowest symptom value obtained during baseline phase for all scales. This means that the treatment PND score is 100% which suggests that the CCRT approach to therapy was very effective for client 2. For PHQ-SADS, the scores for client 2 on scales PHQ-15, GAD-7 and PHQ-9 consistently decreased from baseline, to mid-treatment to posttreatment as shown on table 7 and figure 4. This indicates, the percentage of symptom measures during posttreatment phase are lower than the lowest symptom value obtained during baseline phase and mid-treatment phase for all scales. This means that the treatment PND score is 100% which suggests that the CCRT approach to therapy was very effective for client 2. In addition, the RCI varies due to the factor that the smaller the test-retest reliability coefficient the larger the RCI and since the RCI uses SD in calculation the larger the SD the larger the RCI score. All scores larger than 1.96 signify positive reliable change indicating improvement of client due to treatment. Table 9 below, lists the RCI for 9 Clinical scales of the BSI, for the BSI lower scores from pre to post treatment suggest better functioning. Table 9 showcases the RCI results for client 2, all the BSI scores have RCI scores>1.96 which means that this client has achieved reliable change (i.e., RCI > 1.96, p < .05). Table 9 RCI data for BSI, Client 2 BSI Scales SOM OC IS DEP Mean 0.945 0.884 0.856 SD 0.8715 0.7698 0.7986 1.225 0.8264 Test-retest reliability 0.68 0.85 0.85 SEm 0.493 0.298 0.309 0.84 0.331 RCI Interpretation 3.13 Reliable change 9.13 Reliable change 3.91 Reliable change 11.45 Reliable change EFFECTIVENESS OF CCRT: TWO CASE STUDIES ANX HOS PHOB PAR PSY 1.244 0.978 0.931 1.101 1.239 0.7936 0.8103 0.8073 0.8516 0.8854 0.79 0.81 0.91 0.79 0.78 58 0.364 0.353 0.242 0.390 0.415 7.72 10.47 10.71 6.5 6.93 Reliable change Reliable change Reliable change Reliable change Reliable change For client 2, the Somatic scale score changed from four to two over the course of treatment and the RCI score is 3.13 which means client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). His score for Obsession-Compulsion scale changed from ten to five and RCI score is 9.13 which means client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). For interpersonal sensitivity scale his scores changed from nine to one and RCI score is 3.91 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). For Depression scale his scores changed from 13 to six and RCI score is 11.45 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). His Anxiety scale scores changed from nine to four and RCI score is 7.72 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). His Hostility scale scores changed from six to zero and RCI score is 10.47 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). His Phobic Anxiety scale score changed from ten to six and RCI score is 10.71 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). His Paranoia scale score changed from five to one and RCI score is 6.50 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Lastly, his Psychoticism scale score changed from five to one and RCI score is 6.93 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Overall, results for BSI for client 2 suggests that CCRT was an effective treatment as indicated by her positive and clinically significant RCI scores for all scales. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 59 Table 10 RCI Data for PHQ-SADS, Client 2 PHQ-SADS Mean SD Test-Retest Reliability SEm RCI Interpretation PHQ-15 3.2 3.8 0.82 1.62 4.83 Reliable change GAD-7 4.6 4.7 0.88 1.59 4.34 Reliable change PHQ-9 3.3 3.8 0.86 1.42 7.95 Reliable change For client 2, Table 10 above shows PHQ-SADS, RCI scores from baseline to posttreatment. His scores for PHQ-15 changed from 15 to four and RCI score is 4.83 which suggests client has achieved reliable change and made improvements (i.e., RCI > 1.96, p < .05). His GAD-7 scale score changed from 15 to five and RCI score is 1.81 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Lastly, his PHQ-9 scale score changed from 22 to six and RCI score is 7.95 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Overall, results for PHQ-SADS for client 2 suggests that CCRT was an effective treatment as indicated by his positive and clinically significant RCI scores for all scales. In addition, clients were also asked two survey questions post treatment 1) How do you feel about your relationships? (Good, could be improved/worked on, do not have many close friends or relationships); 2) Do you feel a change in your interaction with others? (Yes or No); 3) If yes, in what way? (Positive or Negative). Client two responded to question one as good and question two as yes and in a positive way. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 60 Chapter 4 Discussion This study aimed to evaluate the effectiveness of Core Conflictual Relationship Theme (CCRT), a brief psychodynamic therapy, in treatment of two clients suffering from depression and anxiety disorders. The CCRT is a 16-session brief therapy it is a manualized treatment (Book, 1998). I conducted CCRT therapy with two clients identified as male and female. This research focused on a single case study method used a time series component. Researcher used Brief Symptom Inventory (BSI), Patient Health Questionnaire Depression and Anxiety Disorders (PHQ-SADS) and two survey developed questions over the course of treatment to evaluate effectiveness. The PHQ-SADS was administered baseline, mid-phase and posttreatment, the BSI was administered pre and posttreatment and the survey questions were asked posttreatment. Statistical measures of Percentage of Non-Overlapping Data (PND) and Reliable Change Index (RCI) were used to assess clinically significant change and effectiveness of treatment. The PND and RCI values indicated that treatment was associated with meaningful reductions in each of these clients primary symptoms. In comparison to previous research conducted by Luborsky (1994), Leichsenring et.al. (2013), Hilsenroth et al. (2003), Ajilchi et.al. (2016) and Jarry (2010) this study also found short-term psychodynamic therapy using CCRT to be an effective treatment to decrease symptoms of depression and anxiety. This study does not compare CCRT with another treatment modality, however, similar to Bgels et al. (2014), Monti et al (2014), Driessen et al. (2013) and Dos Santos (2020) this study found that short-term psychodynamic therapy is comparable to any other treatment modality in allowing for progress in a brief period of time. One unique finding, is that this study was able to also assess effectiveness of CCRT in treatment of interpersonal and relationship concerns that have not been integrated in previous research finding, this study using BSI and research questions designed to understand EFFECTIVENESS OF CCRT: TWO CASE STUDIES 61 effectiveness of treatment specifically with relationships found that CCRT is effective in helping with relationships, as both clients perceived meaningful improvement in their interpersonal interactions. This study also is specifically focused on single-subject design with two clients one male and one female, this specificity allowed for in-depth understanding of gendered navigation of relationships and effectiveness of CCRT particularly with both genders in their different views of the world. It is interesting to note that both clients BSI scale scores for psychoticism and obsessive-compulsive symptoms also reduced, however, there is research yet to be conducted on brief psychodynamic models specifically targeting obsessive compulsive and psychoticism treatment. This study provides some evidence of CCRT being effective with these symptoms, however, the original intent of the study was to only measure effectiveness with depression and anxiety. One of the major limitations of this case study is its inability to generalize findings to a larger clinical body. More generalizability could have been obtained if the sample was larger. There is a need for researchers to further evaluate the effectiveness of CCRT approach with a larger population. Since PND method was used for statistical analysis, in this study, PND was constrained as only two or three follows were possible for BSI and PHQ-SADS over the course of treatment which results in limited data. Another limitation includes diversity variables, this case study is focused on clients who identified as Caucasian and heterosexual. It is recommended that further research must be developed to assess the effectiveness of CCRT with clients from diverse ethnicities, gender and sexual orientations. Moreover, in the case of single subject designs, the lack of a control group has implications. For instance, clients present for therapy typically when they are in acute distress and research shows that with some therapy or, even waitlist controls show some improvement, even if its generally of a smaller magnitude than the treatment groups. It is worth noting that some EFFECTIVENESS OF CCRT: TWO CASE STUDIES 62 decreases are probably expected, regardless of treatment, owing to this fact (Cook et al., 2017). However, the magnitude of the symptom reductions found in this study based on RCI results for both clients being RCI > 1.96, p < .05 were clinically significant and also account for some improvements that could be possible due to general treatment as change here is statistically larger than would be expected from measurement error. Given this, although the lack of a control group is a limitation, even in its absence this data appears to offer fairly reliable evidence that these clients benefited from CCRT. Another limitation included clients dropping out for therapy initially five participants were selected. However, only two moved forward and completed from sessions one to 16. Leichsenring at al. (2019) shared 50 to 60% of participants prematurely terminate from therapy in randomized control trials. In this study, about 40% prematurely dropped out of the three, two of them dropped out after session three and one of them dropped out after session one. 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CBT TREATMENT IN AN ADOLESCENT REFUGEE EFFECTIVENESS OF COGNITIVE-BEHAVIORAL THERAPY FOR ANXIETY AND DEPRESSION IN AN ADOLESCENT REFUGEE: A CASE STUDY A Doctoral Dissertation Presented to the School of Psychological Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Psychology Rachel Walters May 2022 CBT treatment in an adolescent refugee 2 EFFECTIVENESS OF COGNITIVE BEHAVIORAL THERAPY FOR ANXIETY AND DEPRESSION IN AN ADOLESCENT REFUGEE: A CASE STUDY The signatures below certify that the Doctoral Dissertation of Rachel Walters has been approved by the Graduate Department of Clinical Psychology of the University of Indianapolis in partial fulfillment of the requirements for the degree Doctor of Psychology Approved: Accepted: Debbie Warman, Ph.D. Dissertation Advisor John Kuykendall, Ph.D. Dean, College of Applied Behavioral Sciences 5/2/2023 Katie Kivisto, Ph.D. Committee Member Marlyssa Fillmore, Ph.D. Committee Member 5/2/2023 Date Date CBT treatment in an adolescent refugee 3 Abstract Refugee mental health has been very under-researched in terms of the impact and implications their experiences have for treatment (Kim & Keovisai, 2016; Trieu & Vang, 2015). Burmese refugees, specifically, are even less present in refugee mental health research despite being one of the largest groups to relocate in the past 20 years, and the largest to relocate to the United States in the past 10 years (Kim, 2018; Kumar, 2020; Ngo-Metzer et al., 2010). Adolescent mental health has also been relatively under-researched despite this being a common age of onset, the chronicity of disorders, and psychosocial impact of mental health disorders when left untreated (Baker et al., 2021; Kendall et al., 1989; Kendall & Peterman, 2015; Strauss et al., 1987). The overall lack of research of refugee and adolescent mental health is reflected in treatment outcome studies. To date, there is no treatment outcome study for adolescent Burmese refugees in a Western country. The effectiveness of cognitive-behavioral treatment for generalized anxiety disorder and major depressive disorder in an adolescent refugee was examined. The patient, an adolescent Burmese refugee, was selected from an integrated primary care clinic in a Midwestern city. The patient received cognitive-behavioral therapy (CBT) for a diagnosis of generalized anxiety and major depressive disorder. Effectiveness of treatment was measured by comparing pre- and post-treatment scores on the Patient Health Questionnaire-9 and Generalized Anxiety Disorder Scale-7. The data was analyzed for statistical and clinical significance using the reliable change index (RCI). The calculated RCI did not suggest a significant change in the patients pre- and post-treatment scores. Treatment suggestions based on Chomdens treatment outcome and future research directions are presented. CBT treatment in an adolescent refugee 4 TABLE OF CONTENTS TITLE PAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .i SIGNATURE PAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iii TABLE OF CONTENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Reliability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Construct Validity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Internal Validity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 External Validity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Value of a Case Study to Evaluate Psychotherapeutic Effectiveness . . . . . . . . . . . . . .9 Complex Contexts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Flexible Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Research Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Case Study Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Time-Series Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Percentage of Non-Overlapping Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Reliable Change Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 PATIENT DESCRIPTIVE MATERIAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 REVIEW OF PSYCHOLOGICAL LITERATURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 Generalized Anxiety Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Cognitive-Behavioral Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Mindfulness-Based Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Major Depressive Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Cognitive-Behavioral Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Interpersonal Psychotherapy for Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . 27 Attachment-Based Family Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Refugee Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Ethnic Burmese and Chin Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 CLINICAL RESEARCH QUESTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 METHODS/RESEARCH DESIGN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 Outcome Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Generalized Anxiety Disorder-7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Patient Health Questionnaire-9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 CASE FORMULATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Case Conceptualization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 TREATMENT PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 COURSE OF TREATMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 Session 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Session 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 CBT treatment in an adolescent refugee 5 Session 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Session 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Session 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Session 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Session 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Session 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Session 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Session 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Session 11. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Session 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Session 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 EMPIRICAL FINDINGS WITH ANALYSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 CBT treatment in an adolescent refugee 6 Introduction Single-subject case studies have played a key role in the development of theory of personality and behavior within clinical psychology (Widdowson, 2011). However, it was not until recently that they started to gain respect as a valuable research contribution, often being undervalued and overlooked as a true methodology (Perdices & Tate, 2009; Smith, 2012). Case studies were acknowledged for their heuristic value, but not for the ability to draw scientific inferences (Kazdin, 1981). This perception can be traced back to the lack of methodological rigor that impacted findings and ability to form valuable inferences. However, if methodological rigor is ensured, case studies may act as valuable contributions to research. The four criteria that are often used as a measure of rigor are reliability, construct validity, internal validity, and external validity (Crow, 2011; Gibbert et al., 2008; Kazdin, 1981; Schell, 1992; Tsang, 2013). Threats to validity and reliability within a case study will be discussed, and solutions posed by the literature to resolve these issues will be put forth. Reliability Reliability refers to the replicability and consistency of a measure or study. A study is said to have high reliability if future clinicians perform the same study and obtain similar results repeatedly (Kirk & Miller 1986). When engaging in single-case study designs, researchers should create a case study protocol and database. A case study protocol is a report specifying exactly how the case study was conducted. A case study database includes notes, documents, and narratives collected during the case study (Gibbert et al., 2008). By utilizing these tools, it increases the accuracy in which future researchers can replicate the case study. Construct Validity CBT treatment in an adolescent refugee 7 Construct validity refers to the quality of the conceptualization, or the operationalization, of the relevant concept (Gibbert et al., 2008). In the instance of research, construct validity refers to the study investigating what it claims to investigate and that the methods lead to an accurate portrayal of reality (Denzin & Lincoln, 1994). The use of subjective measures may drastically impact construct validity. In order to ensure construct validity, it is recommended that the researchers triangulate data, meaning they use different sources or types of data (Gibbert et al., 2008; Schell, 1992; Turner et al., 2017). For example, it is recommended to use multiple methods such as interviews, performance tasks, and rating scales, as well as multiple reporters, for example, client self-report, collateral reports of the client, or observer reports. Internal Validity Internal validity is the ability to determine a clear, causal relationship between two variables while ruling out random error and influence from external variables (Patino & Ferreira, 2018). It is more difficult to establish internal validity within case studies because the researcher is less able to determine if the change is due to treatment or another variable, as they typically do not control for external variables as tightly as group-designs. Without being able to rule out threats to internal validity, a case study cannot be considered to produce scientific inferences. Kazdin (1981; 2019) provides recommendations to rule out threats to internal validity within non-experimental designs. First, the researcher should utilize consistent, objective assessment outcomes (e.g., the same self- or collateral-report measures, carefully documented behavioral observations), as opposed to relying on anecdotal information alone. It is near impossible to draw scientific inferences from anecdotal evidence, as it is often based on impressions, clinical judgement, or assessments with poor validity that increase the likelihood of operating from cognitive heuristics or biases (Kazdin, 2019). In fact, Kazdin (1981, p. 185) noted the CBT treatment in an adolescent refugee 8 overreliance of anecdotal evidence as being the problem associated with case studies, rather than the use of a single subject. Second, outcome assessment should be continuous. Collecting only pre- and post-treatment data makes it more difficult to confidently say change was due to treatment and not an external variable. By collecting data continuously (e.g., daily or a few times per week), extrapolations for future behavior can be made and compared to the effects of treatment, and the data can be used to rule out alternative hypotheses. Lastly, the more immediate the therapeutic change as measured by symptom improvement, the higher the likelihood that it is due to treatment (Kazdin, 1981). External Validity External validity, or generalizability, is the ability for theories to apply not only to the situation being studied, but also to the population at large (Tsang, 2013). Low levels of external validity have been noted as the most profound issue for case studies (Yin, 1999). The critique of low generalizability derived from case studies stems from the small-N problem (Gerring, 2007; Tsang, 2013). However, the small-N problem does not monopolize deficits in generalizability, as these deficits may be observed within group designs as well. For example, the improvement of each individual subject is not provided. Instead, the aggregate effect of the group is given and thus researchers must generalize from it (Perdices & Tate, 2009). Yin (1999) provides a conceptual solution to the issue of generalizability. He states that if one views a case study as a single unit, then it can be considered equivalent to an experiment, as a unit. Researchers may improve external validity by having multiple subjects, ideally three to four (Borckardt et al., 2002; Kazdin, 1981). In the case where multiple subjects cannot be used, the researcher can improve external validity by providing a clear rationale for the case study selection and details CBT treatment in an adolescent refugee 9 on the case study context so the reader can fully understand the sampling choice (Gibbert et al., 2008). The lack of methodological rigor is not inherent to case studies, but rather a side effect of the lack of research protocol development. When methodological rigor is ensured, single subject case studies can yield valuable scientific inferences (Schell, 1992). These contributions are specifically relevant for psychotherapy outcome research. Value of Case Study to Evaluate Psychotherapy Effectiveness Case studies are a valuable tool when evaluating the effectiveness of psychotherapy and change over time. Psychotherapy effectiveness case studies, specifically, are the most represented in literature (Moeyaert, 2018; Morgan & Morgan, 2001; Shadish, 2014). Psychotherapy effectiveness refers to questions regarding if the intervention is working when administered to a specific client under real world conditions (Singal et al., 2014). Case studies are better equipped to handle questions of effectiveness opposed to efficacy, the performance of an intervention under controlled conditions, which is better measured by group designs like RCTs (Borckardt et al., 2002; Singal et al., 2014). By looking at questions of effectiveness, case studies are able to say for who and how psychotherapy works (Borckardt et al., 2008). They yield valuable information relevant to psychotherapy outcomes because they retain real-life contextual factors, have flexibility, and provide specific benefits relevant to research. Each of these areas is described below. Complex Contexts Case studies are well equipped to answer complex, psychotherapy outcome questions within their real-life context (Flyvbjerg, 2006; Gibbert et al., 2008; Schell, 1992; Yin, 1999). In contrast, group design studies often strip various contextual factors like comorbidities, diversity, CBT treatment in an adolescent refugee 10 and treatment as usual delivery in order to increase internal validity (Tsang, 2013; Widdowson, 2011). While this is needed to determine correlations and causality, it rids the participant and the study of real-life contextual factors. In comparison, case studies retain these uncontrollable differences. Case studies are able to address broad, complex questions within their context, opposed to removing and isolating these questions in a controlled laboratory setting (Yin, 1999). For example, several mental health surveys found that 45-60% of patients with a diagnosable mental illness also met criteria for one or more additional mental illnesses (Bourdon et al., 1992; Kessler et al., 1997; Kessler et al., 2005). Upwards of half the patients surveyed had a comorbid mental illness yet many group design treatment efficacy studies state comorbid mental illnesses in their exclusion criteria (Halvorson & Humphreys, 2015). While this is needed to determine efficacy for treating a specific disorder with a specific intervention, it may make the results of less interest to clinicians in the community where comorbidities are common. In contrast, case studies are able to recognize and include comorbidities because they focus on the individual at hand. By not controlling for as many external variables, the treatment more accurately represents what treatment as usual looks like for clinicians in the community. This is especially beneficial for those clinicians as the case study would accurately reflect their experience, possibly making the findings more relevant and of greater interest to them (Perdices & Tate, 2009). By retaining these variables, case studies remain flexible while recognizing and embracing the uniqueness of each individual (Borckardt et al., 2002). Flexible Implementation Case studies have a level of flexibility that make them well equipped to evaluate treatment effectiveness (Tate et al., 2008). In a group design, the treatment is often rigidly manualized and there is little to no room for change throughout the course of treatment. CBT treatment in an adolescent refugee 11 Additionally, statistical analyses of the outcomes are not performed until the end of the study. While case studies may adhere to a principle-based or detailed manual, the continuous assessment of treatment effectiveness in a single-case design provides the clinician with the ability to adapt and make changes to the treatment as needed if it is not yielding the desired change (Anderson & Kim, 2003; Tate et al., 2008). This makes case studies exceptionally well at coping with uncertainty that inevitably presents during treatment in a community setting (Crow, 2011). Research Benefits RCTs are the cornerstone of psychotherapy outcome research, and should be, however they should not overshadow the valuable contributions that well-designed single-subject research can bring to the field. RCTs provide powerful statistical procedures that allow researchers to confidently find aggregate effects. Single-subject designs should not replace RCTs in this regard, but rather advance the field beside them in the place of research they hold evaluating effectiveness of treatments for an independent client. By engaging in and promoting the use of well-performed case studies, clinicians can enhance the research of treatment effectiveness. They are a critical link in the chain of research, as they are the first step in testing a hypothesis (Crow, 2011). Once the hypothesis has been further explored with group-design studies, a case study uses these results to clarify findings and provide further guidance for other researchers (Borckardt et al., 2008). The applicability of case studies promotes clinicians in the community to function as scientist-practitioners, contributing to the body of research and further enriching the building knowledge of behavioral and psychological sciences (Anderson & Kim, 2003). Case Study Methods CBT treatment in an adolescent refugee 12 There are various ways to measure and analyze client change within a case study. Three methods of measuring change within single-subject designs are time-series analysis, percentage of non-overlapping data, and reliable change index. While each of these methods provides both benefits and limitations, there has yet to be an agreement in the field of which is best to statistically summarize treatment effects (Beretvas & Chung, 2008). These methods, how they are conducted, and the pros and cons of each will be discussed. Time-Series Analysis Time-series designs are often used in group designs (e.g., randomized controlled trial) and are now commonly used in single-subject case studies (Smith et al., 2013). Time-series designs measure a variable equally over time (Crabtree et al., 1989). By continuously tracking client outcomes throughout the duration of treatment and comparing this to a baseline, practitioners can yield valuable information about responses to psychotherapeutic interventions (Nash et al., 2011). Single-case time-series designs answer two types of psychotherapy questions questions of improvement and of process of change (Borckardt et al., 2008). Questions of improvement are generally interested in if there is meaningful change from the pre- to post-treatment phase, and if so, is the change statistically significant? For example, Mariotti et al. 2021 conducted a case study exploring the effectiveness of the Unified Protocol for Children (UP-C) in preadolescents with subthreshold emotional problems. In their case study they were able to monitor anxiety and depression and provide evidence that the UP-C was effective in treating subthreshold emotional disorders. In addition, patterns of response to an intervention can be detected (i.e., delayed, temporary, gradual, and cyclic effects; Crabtree et al., 1989). Questions of process of change are interested in how change occurs and can be either univariate or multivariate. Univariate process CBT treatment in an adolescent refugee 13 change requires the tracking of a single variable (i.e., symptom). This question may be, when does the client start improving? Multivariate process questions of change simultaneously track two or more variables. These questions are capable of addressing mechanism of change or sequencing, the order in which improvement occurs. A case-study by Crane et al. (2003) used multivariate questioning to explore the symptom severity and bi-directional relationship between irritable bowel syndrome (IBS) and bipolar disorder. Their study was able to identify an unusual occurrence where an increase in self-reported depression was associated with less severe IBS symptoms. One protocol for a single-case time-series was developed by the University of Tennessee Psychology Clinics Practice-Research Integrative Project (Nash, 2005), and adopted by Borckardt et al. (2008). To begin, the clinician must first choose a research question and determine which symptom(s) will be tracked. These symptoms can be cognitive (e.g., concentration difficulties), emotional (e.g., depression), or behavioral (e.g., medication adherence). The client is then instructed to rate the chosen symptom on a Likert scale every day, during the baseline and treatment phase. Self-report questionnaires may also be utilized as a measure of symptom severity and change. The baseline phase should yield between seven and 14 data points and the treatment phase must yield a minimum of 35 data points. During analyses, clinical researches must account for autocorrelation inherent in repeated measures. Due to the strict requirements of minimal data collection, time-series does not provide much flexibility in this aspect. In order to accurately gauge the change in outcome variables, observations must be evenly spaced (Borckardt et al., 2008). The intervals between measures must be the same throughout the entire study, either daily, weekly, etc. This is done to prevent statistical artefacts, CBT treatment in an adolescent refugee 14 when the bias in the collection of data interferes with the results (Scott & Marshall, 2005). Collecting equally spaced data on a single-subject allows for valuable data to be collected without the cost associated with other group-designs (Crabtree et al., 1989). Time-series analysis is an empirically grounded method to determine the effectiveness of an intervention. It allows the researcher to ask questions beyond simple intervention effectiveness and ask those of process change. While it proposes many scientific benefits, these are compounded with practical difficulties. When using time-series analysis it is necessary to collect data evenly throughout the treatment, and every day during the baseline phase. If a single day of rating is incomplete, time-series analysis can no longer be used. Percentage of Non-Overlapping Data Percentage of non-overlapping data (PND) is a method developed by Scruggs & Mastropieri (1987) used frequently in single-subject behavior research to measure meaningful change (Beretvas & Chung, 2008; Kazdin, 2006). PND provides a non-parametric (i.e., does not assume the data is normally distributed) descriptor of the data by analyzing the percentage of data in the treatment phase that falls below the lowest point in the baseline phase (if the intended direction of change is negative; Beretvas & Chung, 2008; Parker et al., 2011). To calculate the PND, the clinician needs to identify the intended change and choose an appropriate method of collecting data to measure said change. Similar to time-series analysis, the variable of interest may be cognitive, emotional, or behavioral. The clinician may also opt to use specific brief outcome measures, like the Patient Health Questionnaire 9. Once the data has been collected, the lowest data point within the baseline phase is identified if the intended direction of change is negative. A line is drawn from this point through the treatment phase and all data points below this line are counted. The PND is then calculated by dividing the number of CBT treatment in an adolescent refugee 15 data points below the lowest point in the baseline phase by the total number of data points in the treatment phase (Beretvas & Chung, 2008). PND scores of 90% are regarded as very effective, 70 to 90% are regarded as effective, scores of 50 to 70 are questionable, and scores below 50% are regarded as ineffective. The PND visually displays this meaningful data about the treatment effectiveness (Scruggs & Mastriopieri, 1998). The calculations simplicity does not take away from the applicability and meaningfulness of measuring the effectiveness of treatment outcomes. Overlap between baseline and treatment phases have been noted as an essential measure in evaluating outcomes (Scruggs & Mastropieri, 1998). When there is low overlap between the baseline and treatment phase, the effect is considered reliable (Kazdin, 1978). PND measures have been found to correlate with expert ratings of treatment effectiveness when the reliability of their ratings was also high (Mastropieri & Scruggs, 1985-1986). Using PND to calculate treatment effectiveness replicates benefits similar to time-series design. It requires the same level of planning prior to meeting the client but allows for slightly more flexibility. Compared to the time-series design, PND data points do not need to be collected daily, or in equal intervals, though a baseline does need to be established. This alleviates many of the practical constraints placed on the clinician. PND displays data in a way that allows researchers to readily interpret it (Olive & Franco, 2008). The ease of interpretation may allow for more clinicians in the community to act as researchers. Additionally, it is capable of handling small data sets, which is necessary when using single-subject case studies. However, PND is limited in the types of questions that can be answered, as it is only capable of analyzing treatment effectiveness. The analysis can also be heavily influenced by extreme data collection in CBT treatment in an adolescent refugee 16 the baseline phase which can lead to type 2 errors, which is a potential issue with the approach (Lenz, 2013). Reliable Change Index Statistical comparison between mean changes is often utilized to measure treatment effects. Jacobson & Truax (1991) note two limitations with this method. First, information on the variability of response to treatment is lost. Second, the presence of treatment effects in the statistical sense has little to do with clinical significance of the effects. The simple presence of statistically significant change does not indicate if that change was clinically meaningful to the patient. The example of a weight loss study for obese patients is put forth. A net weight loss of 2 lbs may be statistically significant compared to a control group that lost no weight, however losing two lbs may not put the patient outside the obesity range. In this example, the posttreatment change does not present as meaningful for the patient, which statistical treatment effect does not capture. In contrast, clinical significance by definition captures this type of meaningful change. Clinically significant change occurs when the change is statistically significant (i.e., at least as likely the change did not occur by random error or chance) and the change moves the individual closer to the typical or normal population (Kendall et al., 1999). One method that captures both statistical and clinically significant change is the Reliable Change Index (RCI). The first step in calculating the RCI is determining if the change that occurred between pre- and posttest scores is statistically significant (Lambert et al., 2008). The formula used to calculate statistical significance is RCI = x2 x1 /Sdiff , where x2 is the individuals posttest score, x1 is the individuals pre-test score, and Sdiff is the standard error of difference between the two scores. To calculate the standard error of difference, the following formula is used Sdiff = 2S2E. The standard error of difference is the spread of scores that would be expected if no change CBT treatment in an adolescent refugee 17 occurred (Jacobson & Truax, 1991). Knowledge of the test-retest reliability of the measure being used and standard deviation of the test scores is necessary to calculate the standard error of difference (Unicomb et al., 2016). An RCI of 1.96 is indicative of statistically significant change at the 0.05 significance level, with the valence indicating the direction of change (Jacobson & Truax, 1991). The presence of a positive or negative RCI depends on the measure being used and the targeted change. For example, if the BDI-II was used as the measure, then a negative RCI would be expected, as a significant change would result in a lower posttest score compared to the pre-test score. The final step is to determine if clinically significant change has occurred. To measure clinically significant change, a cutoff point needs to be set (Jacobson & Truax, 1991). The cutoff point refers to the point the client must cross at the post-treatment assessment to be classified as changed to a clinically significant degree. The cut-off point is determined by obtaining normative data for the disordered and normal populations (Unicomb et al., 2016). If the posttest score moves out of the range of the disordered population and into that of the normal population, then clinical change occurred. There are several strengths associated with using RCI to measure treatment outcomes in terms of clinically significant improvement. The use of clinical significance to measure treatment outcomes operationalizes recovery in a relatively objective and unbiased way (Jacobson & Truax, 1991). The definition of recovery is not tied to any one diagnosis and can be used for a variety of different disorders. The wide applicability of the approach gives it the potential to grow within psychotherapy research which could yield comparisons between studies and additional information on variability in treatment outcomes (Jacobson & Truax, 1991). This method may also encourage more clinicians to engage in psychotherapy research due to the CBT treatment in an adolescent refugee 18 emphasis it places on clinically significant change, which is of the utmost importance to working clinicians. Lastly, it is especially useful in small sample studies like a single-case study, as it allows an individual to be tracked across conditions and time (Zahra & Hedge, 2010). Despite its strengths there are limitations to this method which are worth noting. First, it assumes that functional and dysfunctional distributions are normal, which may not always be the case. Second, the assumption that recovery indicates the return into normal functioning may not be accurate depending on the diagnosis. For example, recovery for autism or schizophrenia will look quite different compared to depression or anxiety due to the nature of the disorders (Jacobson & Truax, 1991). Third, because it compares only pre- and post-treatment data, it limits the types of questions that can be asked. This approach would not be able to accommodate process of change questions, only questions regarding if the therapy did or did not work. Lastly, without the use of a psychometrically reliable psychotherapy outcome measures you cannot perform the calculation. Patient Descriptive Material The patient, who from this point forward will be referred to by the pseudonym Chomden, was a 17-year-old Chin female who was referred for therapy by her primary care physician after complaints of anxiety and depression. At her PCP appointment, her GAD-7 score was 8 out of 21 (mild) and PHQ-9 score was 13 out of 27 (moderate). After receiving the referral, the clinician met with Chomden and her father. Chomden was born in Burma (Myanmar) to her mother and father and was the second oldest daughter of four. She has one older sister (19 years old) and two younger sisters (12 and 8 years old). When she was four years old, her family left Burma and moved to Malaysia due to the civil unrest particularly aimed at ethnic minorities including Chin. Her family stayed in CBT treatment in an adolescent refugee 19 Malaysia for several years until relocating again to the United States at age eleven. She described not being able to speak any English when she first moved and that she experienced a lot of bullying in middle school. Her family had lived in the greater Indianapolis area from ages 11 and older. At the time of intake, she was living at home with her mother, father, and two younger sisters. Her older sister had moved out to go to college previously that year. At the time of the intake Chomden was a junior in high school. She was very active in her academics and extracurricular activities, like art club. She described having a small group of friends with whom she was close. However, upon further investigation she explained that while she considers them very close, she is quite reserved around them and does not share much emotional content. Chomdens medical history was positive for well-controlled exercise induced asthma and dysmenorrhea. At the time of intake she was prescribed Zoloft 50mg, which she started one month prior. She denied previous significant medical procedures, surgeries, traumatic brain injury, or seizures. She denied a family history of mental health disorders. Her developmental history was largely unremarkable. She achieved developmental milestones at her expected ages and never had a regression in development. Chomden was asked questions that aligned with DSM-5 criteria of generalized anxiety disorder. She endorsed feeling restless or on edge, being easily fatigued, and difficulty concentrating or mind going blank. She denied experiencing racing thoughts, irritability, muscle tension, and difficulty falling or staying asleep. Although denying experiencing racing anxious thoughts, throughout the intake she described experiencing what would be racing thoughts. Chomden stated that she had experienced several panic attacks before. During these panic attacks she endorsed experiencing shortness of breath, light headedness, nausea, crying, and increased CBT treatment in an adolescent refugee 20 heart rate. She stated that she worries about a variety of things including talking in class, being around a lot of people, failing in school, and pressure from setting high academic standards. She reported that she first started noticing symptoms of anxiety approximately a year prior and that it significantly impacts her socially and academically. She was asked about previous attempts to cope with anxiety, explaining she has tried walking outside to clear her mind which had been mostly successful. She endorsed several symptoms that align with DSM-5 criteria of major depressive disorder including depressed mood most days, loss of interest in pleasure or activities, low energy, loss of appetite and weight loss, hypersomnia, psychomotor retardation, and passive suicidal ideation. She reported that she first started experiencing symptoms of depression when she was 12 years old and that she experiences these symptoms kind of often. She provided further insight into how her depressive symptoms impact her. She reported not being able to eat much because she lacks appetite and it has caused her to lose weight. She stated that when she does eat, she cannot eat much, and she often feels nauseas after. Additionally, she sleeps up to 12 hours a day including at night and daytime naps. She discussed feeling very frustrated by these two symptoms and the way they impact her. When asked about her goals for therapy she explained that she would like to nap less, eat more, talk more to people during class, and talk more to people in general. Review of Psychological Literature Anxiety and depression are the most common mental health problems in children and adolescents today (Farrell and Barrett, 2007). These two mental health problems have been demonstrated to be associated with attention and concentration deficits, academic difficulties, poor peer relations and low self-esteem (Kendall et al., 1989; Strauss et al., 1987). Many CBT treatment in an adolescent refugee 21 disorders emerge during teen years, indicating that this age group deserves special attention in treatment and outcome studies (Kendall & Peterman, 2015). This section will review the current literature on effective treatments for generalized anxiety disorder and major depressive disorder in adolescents. It will also address the current literature and findings on the impact and implications for treatment for refugees. Generalized Anxiety Disorder Anxiety disorders are the most common psychiatric disorders in children and adolescents, with prevalence rates ranging from 6-20% (Baker et al., 2021; Costello et al., 2004; Creswell et al., 2020; Salkosky & Birmaher, 2008). Generalized anxiety disorder (GAD), specifically, is the most common disorder in adolescents (Imran et al., 2017). Adolescence is an essential time for intervention due to the negative impact anxiety disorders can have on psychosocial functioning including social interactions and school achievement (Van Ameringen et al., 2003). If left untreated, anxiety disorders tend to take a chronic course, persisting into adulthood (Hill et al., 2016). Despite the high prevalence rate and critical period of intervention, many studies do not address GAD specifically, but rather anxiety disorders in general or primary separation anxiety disorder (Creswell et al., 2020). The current review of treatment will reflect this issue and provide support based on treatment for anxiety disorders. The effectiveness of cognitive behavioral therapy and mindfulness-based therapies for the treatment of GAD in adolescents will be presented. Cognitive Behavioral Therapy Cognitive behavioral therapy (CBT) is a gold standard treatment for anxiety disorders, including GAD (David & Cristea, 2018). This extends to the treatment of adolescents with GAD. It is a well-established, treatment of choice for GAD in adolescents (Compton et al., 2004; Higa- CBT treatment in an adolescent refugee 22 McMillan et al., 2016) given it is the most studied and has the most empirical support (Baker et al., 2021; Creswell et al., 2020; Salkosky & Birmaher, 2008). CBT for anxiety disorders, including GAD, has several key components: psychoeducation, relaxation training, cognitive restructuring, practicing problem-solving skills, and exposure to feared stimuli (Kendall & Peterman, 2015; Salkosky & Birmaher, 2008; Velting et al., 2004). It has demonstrated to be efficacious and effective in producing short- and long-term improvement in anxiety symptoms. CBT produces effective short-term outcomes treating adolescent anxiety. It has been found to be superior to waitlist or non-treatment control conditions. In one study evaluating the effectiveness of CBT in anxiety disorders, both individual and group formats were superior to the waitlist control condition (Villabo et al., 2018). A separate study found large treatment effects in adolescents with anxiety disorders, however they noted heterogeneity in their findings (James et al., 2020). Meta-analyses and reviews on the status of CBT provide excellent support for short-term outcomes. A 2008 meta-analysis reviewed over 20 RCTs evaluating the effectiveness of CBT for pediatric anxiety disorders and found substantial evidence for acute treatment (Salkosky & Birmaher, 2008). A 2015 review of 16 RCTs provided support for the efficacy and effectiveness of CBT for anxiety disorders in adolescents (Kendall & Peterman). In efficacy studies, clinical improvement rates were between 60-80%. For a more conservative rate of improvement, remission rates were between 50-70%. Brief CBT, specifically, yielded medium to large effect sizes posttreatment. Effectiveness studies were less impressive while significant improvements in symptoms were found, the effect sizes were lower than efficacy trials. In sum, they concluded that approximately two-thirds of children and adolescents receiving CBT showed clinical improvement, in both laboratory and community settings. It is important to note that of studies CBT treatment in an adolescent refugee 23 including mixed children and adolescent age groups, there were no significant differences in the outcomes between age groups. CBT yields effects that persist long-term. In a study looking at the long-term effects of CBT in 139 youths (ages 11-21), they found significant reductions in all anxiety symptom measures and loss of primary anxiety diagnosis in 63% at a long-term follow-up of an average of 3.9 years posttreatment (Kodal et al., 2018). A meta-analysis of over 20 RCTs found long-term efficacy for CBT in treating anxiety (Salkosky & Birmaher, 2008). In the same 2015 review mentioned previously, they found that the medium to large effect sizes persist into the 6-month follow-up after brief CBT (Kendall & Peterman, 2015). Mindfulness-Based Therapy Mindfulness has become increasingly popular in treating mental health problems (Odgers et al., 2020). Mindfulness, a practice originating from the Buddhist religion, is the intentional acceptance and non-judgmental noticing of an individuals emotions, thoughts, and sensation in the present moment (Zgierska et al., 2009). Mindfulness-based therapies (MBTs) are widely used to treat anxiety (Virgili, 2015). MBTs have been demonstrated to be effective in treating anxiety in adolescent populations (Cheung et al., 2021). The limited data available demonstrates good to mixed results in using MBTs to treat adolescent anxiety (Wehry et al., 2015). MBTs demonstrate efficacy and effectiveness in treating adolescent anxiety. Mindfulness-based stress reduction (MBSR) was found to be superior to control conditions in a 2020 meta-analysis of 14 RCTs evaluating the efficacy of mindfulness-based stress reduction (MBSR) in adolescents (Zhou et al., 2020). There was a significant reduction in anxiety symptoms compared to control conditions. However, the authors noted the significance may be affected by treatment duration with short-term interventions of 8-weeks or less showing less CBT treatment in an adolescent refugee 24 significant outcomes. A separate quasi-experimental study from 2016 compared MBSR to notreatment control group and found significant reductions in generalized anxiety symptomology, anxiety sensitivity, and intolerance of uncertainty (Alimehdi et al.). While these results are promising, limitations to note about the study are the small sample size (n = 30), and that it took place in Iran therefore the results may not generalize to treatment in Western countries. Lastly, a 2020 meta-analysis observed the efficacy of mindfulness-based interventions (MBIs) in 20 studies (Odgers et al., 2020). While they found a small effect size on posttreatment anxiety compared to controls, this was limited to children and was not observed in adolescents. Despite the high occurrence of GAD in the adolescent population, they have typically been underrepresented in treatment outcomes studies (Baker et al., 2021). Moreover, additional support is needed for more diverse populations (Creswell, 2020). While CBT is not the sole treatment for adolescent anxiety, RCTs on other modalities are quite limited and this review reflects that lack of literature (Creswell, 2020). Based on the current data available, while studies regarding MBIs are promising, CBT maintains the most substantial support for treating GAD in adolescents. Major Depressive Disorder Depressive disorders are a common mental health problem in adolescents, with prevalence rates ranging from 2-12% (Stikkelbroek et al., 2013; Walter et al., 2021). While it is less common than adolescent anxiety, it is nonetheless a significantly debilitating and interfering condition (Crowe & McKay, 2017). Depressive disorders that present in adolescence take a chronic course, where risk of recurrence in clinical samples have been reported as high as 5070% in a five-year span (Dunn & Goodyer, 2006). The debilitating nature and chronicity of the disorder lead to poor psychosocial functioning that can persist into adulthood (Avenevoli et al., CBT treatment in an adolescent refugee 25 2008; Maughan et al., 2013). These characteristics emphasize the need of effective intervention for adolescent depression (Weersing et al., 2016). This section will review the current literature on effective interventions in treating adolescent depression, specifically CBT, interpersonal psychotherapy (IPT), and attachment-based family therapy (ABFT). Cognitive Behavioral Therapy CBT is a treatment of choice and the most widely researched treatment for depression in adolescents (Compton et al., 2004; Spirito et al., 2011). The key components are similar to that of anxiety treatment and include psychoeducation, coping skills, social problem solving, participation in pleasant activities, behavioral activation, cognitive restructuring (Kazdin & Weisz, 1998). CBT is an efficacious and effective treatment of depression in adolescents capable of producing short- and long-term benefits. The efficacy of CBT for adolescent depression is well-established as evidenced by several meta-analyses and treatment reviews. In a 2016 meta-analysis, 14 RCTs observing the effects of individual CBT in depressed adolescents demonstrated to be a well-established treatment (Weersing et al., 2016). Seven of the RCTs demonstrated statistically significant effects against the control conditions. The authors note that many of these studies included more stringent control conditions like alternate psychosocial treatments. They did, however, find that the other seven studies included found that CBT failed to demonstrate statistical significance compared to control conditions. These trials also compared CBT to more stringent control conditions. However, none of these studies found a negative effect of CBT which is worth noting. In a 2015 systematic review of 52 studies observing treatments for depressed children and adolescents, CBT was determined to be superior to most control conditions and other CBT treatment in an adolescent refugee 26 psychosocial interventions including play therapy, psychodynamic therapy, and problem-solving therapy (Zhou et al., 2015). CBT did not retain this significance at the long-term follow-up. The authors concluded that CBT should be considered one of the best available psychotherapies for depression in children and adolescents. Lastly, a 2004 evidenced-based review of 21 RCTs evaluating the effects of CBT on both anxiety and depression in children and adolescents found that CBT showed medium to large effects for symptom reduction in comparison to wait-list, inactive controls, and active controls (Compton et al., 2004). The authors concluded that CBT was the current treatment of choice for child and adolescent anxiety and depression. Brief CBT is effective when administered in a collaborative, primary care setting. Richardson et al. (2014) examined the effects of brief CBT in depressed adolescents compared to pharmacotherapy, combined brief CBT and pharmacotherapy, or usual care. 101 adolescents were randomly selected for either the collaborative care condition (e.g., brief CBT, pharmacotherapy, or combined treatment) or usual care. Those in the collaborative care condition self-selected which treatment they received. 38% of the total 101 adolescents received CBT alone. At the 12-month follow-up the collaborative care condition had clinically and significantly higher response rates to treatment as defined be a 50% reduction in symptoms. CBT retains its effectiveness when administered under routine care conditions. A 2021 observational study examined the effectiveness of usual-care CBT in adolescents ages 11-18 years with a depressive disorder (Walter et al.). These participants were compared to a historical control group that received treatment as usual from a previous study (Weisz et al., 2009). Their results showed highly significant reductions in depressive symptoms, with effect sizes ranging CBT treatment in an adolescent refugee 27 from small to large across measures. The authors concluded that CBT is effective for adolescents with depressive disorders when administered until routine care conditions. There is evidence to suggest that CBT is a durable treatment for adolescent depression, maintaining treatment effects long-term. A 2018 meta-analysis observing the effects of 101 studies examining the posttreatment and long-term effects of CBT for adolescent depression, anxiety, and posttraumatic stress found that CBT had durable treatment effects (Rith-Najarian et al.). They found large effect sizes at posttreatment, 1-month, 3-month, 6-month, 1-year, and 2+ years follow-up. While the meta-analysis included other presenting problems like anxiety and posttraumatic stress, the effect sizes did not differ significantly by diagnoses. The authors did note, however, that effect sizes diminished across later follow-up assessments and effect sizes were smaller when reported by caregiver or youth respondents compared to evaluator reported. These results provide initial support that CBT has durable effects, but more research in this area is needed. Interpersonal Psychotherapy Interpersonal psychotherapy (IPT) is a manualized psychotherapy that was initially used to treat depression in adults (Duffy et al., 2019). Since its development, it has been expanded to other disorders and populations, including adolescents. IPT for adolescents (IPT-A) is used to treat acute depression in youths between the ages of 12 and 18 over a period of 12-16 sessions. The focus of IPT-A is on relationship issues and how they relate to ongoing depression and its symptoms (Weissman et al., 2008). The goal of IPT-A treatment is to help the adolescents recognize their feelings, increase understanding as to how interpersonal relationships and conflicts affect their mood, and build adaptive interpersonal skills (Miller et al., 2016). IPT-A is an effective treatment for adolescent depression, often yielding treatment effects similar to CBT. CBT treatment in an adolescent refugee 28 IPT-A is effective as evidence by several meta-analyses, reviews, and RCTs. IPT-A is effective when compared to treatment as usual. A 2004 RCT compared IPT-A to treatment as usual in school-based mental health clinics in 63 depressed adolescents (Mufson et al., 2004). Compared to those who received treatment as usual, those who received IPT-A showed greater symptom reduction and improvement in functioning. The authors conclude that IPT-A is an effective treatment for adolescent depression. In a 2019 meta-analysis of 20 studies examining the effects of IPT-A on depression, they found that overall participants experienced large improvements in depressive symptoms postintervention and some evidence that these gains were maintained for up to a year (Duffy et al., 2009). When compared to other psychosocial interventions, IPT-A showed a medium significant effect compared to less-structured, active control conditions. When compared to CBT, there were no differences in postintervention depressive symptoms. These results are also demonstrated when observing remission rates. When compared to non-CBT active controls, IPT-A showed significantly higher remission rates. The authors conclude that IPT-A is an effective intervention for adolescent depression. In the same 2015 systematic review by Zhou et al. previously mentioned, they found that IPT yielded similar results to CBT. IPT was also significantly more effective than control conditions and active control conditions including play therapy, psychodynamic therapy, and problem-solving therapy. Additionally, IPT was the only treatment that remained significant at the long-term follow-up. The authors concluded that along with CBT, IPT is one of the best available psychotherapeutic treatments for adolescent depression. In the same 2016 review by Weersing et al. previously mentioned, the authors conclude that IPT is a well-established intervention for adolescent depression based on the evidence of CBT treatment in an adolescent refugee 29 efficacy from multiple trials. They also note that there is a smaller size of IPT literature which may have impacted their findings. Attachment-Based Family Therapy Attachment-based family therapy (ABFT) is a process-oriented, structured therapy that uses theories from family therapy and attachment theory to understand adolescent depression and suicidality. The creators, Diamond et al. (2014), posit that poor attachment bonds, conflict, harsh criticism, and low affective attunement can lead to physical or emotional neglect, abuse, and abandonment. This negative family environment inhibits children and adolescent from developing internal and interpersonal coping skills needed to buffer against stresses, which can lead to or exacerbate depression (Rudolph et al., 2000). The process of change for this therapy is to then improve the insecure attachment that has formed between caregiver and child (Diamond et al., 2016). While there is some evidence to suggest that ABFT is an effective treatment for depressed adolescents, the results are overall mixed. There are mixed results when comparing ABFT to treatment as usual. A 2010 study evaluated the effects of 14 weeks of ABFT compared to enhanced treatment as usual in 66 depressed, suicidal adolescents (Diamond et al.). The results showed that in comparison to enhanced treatment as usual, those in the ABFT group significantly improved as measured by decreased suicidal ideation during treatment. In a 2013 study observing the effectiveness of ABFT compared to treatment as usual, 20 adolescents were randomly assigned to 12 weeks of either condition (Israel & Diamond, 2013). The results showed significantly greater improvements on depressive outcome measures for the ABFT group. A more recent study compared ABFT to treatment as usual in 60 adolescents diagnosed with MDD (Waraan et al., 2021). While the participants in both groups reported reduced depressive symptoms, the majority CBT treatment in an adolescent refugee 30 were still in a clinically significant range. ABFT was not superior to treatment as usual as evidenced by low remission and response rates for both groups. There is evidence that ABFT is more effective than CBT, specifically when major depression is comorbid with a history of sexual trauma. In a 2012 study observing the effectiveness of ABFT with major depression in individuals with a history of sexual trauma, 66 adolescents were randomly assigned to either ABFT or enhanced care as usual (ECU; Diamond et al., 2012). The results demonstrated ABFT to be more effective than EUC in individuals with or without a history of sexual trauma. ABFT was then compared to CBT in the treatment of adolescents with depression and history of sexual trauma. Using data from the Treatment of Adolescents with Depression Study (TADS; 2004), Lewis et al. (2010) observed the impact that history of sexual trauma had on the treatment outcomes in the TADS study. When comparing the effect sizes from the Diamond et al. (2012) and Lewis et al., (2010) studies, Diamond et al. (2012) found that ABFT outperformed CBT in individuals with a history of sexual trauma. Refugee Status The world is currently experiencing some of the highest rates of displaced individuals since The United Nations High Commissioner for Refugees (UNHCR) started keeping record in 1951 (Kim, 2018). Over 25 million people who are displaced can be categorized as a refugee, or someone who has fled war, violence, conflict, persecution for reasons of race, nationality, membership of a particular social group, or political opinion and have crossed international borders seeking safety in another country (UNHCR, 2001). This is the highest refugee population in the past 20 years (Kumar, 2020). The United States plays an essential role in the resettlement of approximately 70% of refugees annually (Kim, 2018). One of the largest groups of refugees that have resettled in the U.S. are Burmese refugees (Kumar, 2020). CBT treatment in an adolescent refugee 31 Burmese refugees are the largest group to have resettled in the U.S., with over 160,000 coming in a ten-year span (Kim, 2018; Tan et al., 2014). Indiana is home to one of the largest Burmese populations within the U.S. (Asian Learning Center of Indiana, 2011). Approximately 35,000 Burmese people reside in Indiana, many of whom hold a refugee status. Indianapolis has the largest community approximately 24,000, as of 2020 (Contreras, 2021). Many of these refugees belong to one of Burmas major ethnic minorities Karen, Karenni, or Chin, with Chin making up approximately 83% of the population in Indiana (Indiana State Department of Health, 2014). Refugee status has numerous implications for an individuals mental and physical health. Overall, they are at a higher risk for physical and psychological distress (George, 2010). Reasons for relocation may have directly caused trauma or instances of violence, both of which increase their risk of developing mental health disorders including anxiety, depression, and posttraumatic stress (Bolton et al., 2014). In fact, they experience depression at a higher rate than the general population at a rate of 30.8% (Steel et al., 2009). Apart from mental health problems due to violence and trauma, the relocation itself can lead to decreased mental health functioning from the drastic shift in culture (Noom & Vergara, 2011). This can cause culture shock and a rapid need for acculturation. The acculturative stress that Burmese adolescents, specifically, experience has been shown to lead to suicidal ideation and low self-esteem which was correlated with anxiety, hopelessness, and depression (Hovey & Magana, 2002; Noom & Vergara 2011; Sonderegger et al., 2004). One study found that isolation was a leading cause for an increase in psychological illness (Burnett & Gebremikael, 2005). This point is especially relevant now, with isolation at an all-time high from the COVID-19 pandemic and subsequent necessary lockdowns, quarantine, and social distancing (Hwang et al., 2020). CBT treatment in an adolescent refugee 32 Female Burmese refugees are at an even greater disadvantage when it comes to declining mental health. In one study, being female was found to be significantly positively associated with symptoms of depression, anxiety, and PTSD (Kim, 2018). In a separate study, women who resettled in Western countries were found to have had a tenfold risk of developing PTSD compared to their same-aged female counterparts in the general population (Kirmayer et al., 2011). This provides additional insight into how the location after resettlement can influence mental health. While the literature shows that the refugee population can experience overall declines in mental health, knowledge on the mental health experiences of the group is significantly lacking (Kim & Keovisai, 2016; Trieu & Vang, 2015). Burmese refugees are one of the most understudied minority groups with relatively few studies on their mental health and overall health status (Hickey, 2007; Ngo-Metzer et al., 2010). While there are few studies on overall mental health, there are even fewer that look at how to treat mental health concerns most effectively in this population. One study observed the effectiveness of Common Elements Treatment Approach (CETA) in Burmese refugees relocated in Thailand (Bolton et al., 2014). The elements of this treatment were engagement, psychoeducation, anxiety management (relaxation), behavioral activation, cognitive coping/restructuring, suicide risk assessment, and alcohol/substance use assessment/intervention. The results demonstrated that CETA was effective in reducing symptoms of depression, anxiety, and posttraumatic stress. Part of what makes this group specifically so unique is the ethnic and religious diversity. This diversity poses additional need for a significantly greater understanding of their mental health. In one study, ethnicity was a main factor that was consistently associated with the majority of the behavioral health outcomes (Kim, 2018). Additionally, much of what is known of CBT treatment in an adolescent refugee 33 this group is from refugees who relocated to Eastern countries, for example Thailand or Malaysia. While this remains an important contribution in the understanding of this group, it neglects the experience of those who have resettled in the U.S. The unique experience of Burmese refugees in the U.S. should be of interest given the role it has played during their resettlement and the implications it has on their mental health. In sum, there remains a significant need to treat behavioral health concerns with limited understanding or guidance on how to do so (Kim, 2018; OMahony & Donelly, 2010). Ethnic Burmese and Chin Culture Myanmar, formally Burma, is currently the center of the one of the largest refugee crises in the world (Lewis, 2019). For the purpose of this dissertation, the country will be referred to as Myanmar, while people who are from the country are referred to as Burmese, a distinction that is consistent in the literature (Steinberg, 2013). Note that Burmese is different from Burman, which is the ethnic majority in Myanmar. Myanmar is one of the worlds most ethnically diverse countries, with more than 130 different ethnic groups (Fike & Androff, 2016). While majority of the population is ethnically Burman and practices Buddhism, the ethnic minorities make up nearly 40% of the 50 million people who reside in Myanmar (Kramer, 2015). There are eight nationally recognized races in Myanmar Burman (Bamar), Chin, Kachin, Kayah (Karenni), Kayin (Karen), Mon, Rkhine (Arakan), and Shan (Stokke, 2019). The country is divided into seven Burman regions in the center area of the country, with seven ethnic states along the border of the country (Stokke, 2019). Along with ethnic diversity, Myanmar is also rich in religious and linguistic diversity. The main religions that are practiced include Buddhism, Christianity, Islam, and Hinduism. CBT treatment in an adolescent refugee 34 Christianity is especially prevalent within the ethnic minorities, for example Chin (Stokke, 2019). The official language of the country is Burmese, however there are over 118 languages spoken throughout the country (Simons & Fennig, 2017). The Chin state is a very independent, remote part of Myanmar (Lalhriatpuii & Shyamkishor, 2019). It has been politically, socially, and economically discriminated against and isolated from the rest of the country (Bawi, 2015). Chin culture emphasizes family and community. Family, ethnic identity, community, and religion are all vital to their values and identity (Bawi, 2015; Thein, 2015). Myanmars ethnic diversity is central to the refugee crisis that has persisted for decades. The refugee crisis in Myanmar can be traced back to the civil war and ethnic conflict that has afflicted the country since gaining independence in 1948. Many minorities, including religious, ethnic, and political, have been persecuted and displaced by the military regime leading to need to seek refuge (Alexander et al., 2017). The state of conflict worsened after the military coup in 1962 when the country changed from a democracy to military rule, and minorities were further minimized and oppressed (Kramer, 2015). Military seize of power within the country has persisted, with the most recent coup occurring in February of 2021 (Thein-Lemelson, 2021). This conflict, which has given rise to ethnic and religious violence, can be traced back to numerous factors including trauma from colonialism, poverty, transition from a military government to a democratic state, and the global war on terror (Harvard Divinity School, 2018). Decades of civil war has contributed toward the breakdown of education and healthcare systems, militarization, food insecurity, discrimination, and human rights violations (Kramer, 2015). As a result, people of Myanmar started relocating in large numbers to the United States in 2008, however more than 3 million have relocated to the U.S. in the past 40 years (Ballard et al., 2020; Wang, 2022). CBT treatment in an adolescent refugee 35 The decades of war, persecution, and violence has contributed toward violence, suffering, and trauma for ethnic minorities in Myanmar (Kim et al., 2021; Kramer, 2015). The traumatic experiences begin in their home country from persecution; however, they persist at refugee camps and even after resettlement (Kim et al., 2021). These experiences contribute toward a substantial need for mental health care, however there are many barriers that exists some of which are related to the perception of mental health in Burmese culture. There are many cultural barriers that exist and prevent Burmese refugees from seeking treatment. Stigma of mental health has been identified as one of the largest barriers to accessing mental health treatment (Morris et al., 2009). Part of the stigmatization of mental health in Myanmar is due to language and lack of information of mental health (Kim et al., 2021; Saechao et al., 2012). Mental health is often a new concept for Burmese individuals who have relocated to the United States. In Myanmar, the construct of mental health is typically related to being crazy, or is for crazy people (Kim et al., 2021). There is no appropriate translation for the term mental health in languages that are spoken in Myanmar. Individuals are even further dissuaded from bringing mental health up, as it is highly taboo and shameful to discuss. By openly talking about mental health, they jeopardize their face or reputation (Kim et al., 2021). Because family is extremely important in Burmese cultures, and families have a collective face, the possibility of losing face for ones family is avoided (Evason, 2017). Clinical Research Question There is an evident lack of literature focusing on refugees and adolescents with mental health problems. In an attempt to narrow this gap, this case study will address the research question will a female adolescent Burmese refugee with generalized anxiety disorder and major depressive disorder be better off after receiving CBT treatment in a primary care setting? CBT treatment in an adolescent refugee 36 This will be assessed by examining the patients pre- and posttreatment scores on validated assessments for statistical and clinical significance. In order to test this question, a reliable change index will be computed. This method of analysis permits addressing the primary question of study improvement in treatment while also focusing on validated measures that have been used in prior research of depression and anxiety (Delgadillo et al., 2017; Islam et al., 2020; Mewton et al., 2012; Richardson et al., 2009; Richardson et al., 2014) Methods/Research Design Procedure This case study was conducted in an integrated primary care clinic located in the greater Indianapolis area. The patient was selected from a pool of referrals provided to the clinicians from the medical residents in the clinic. The selected patient was seen for weekly, in-person psychotherapy sessions, approximately 30 minutes each, for 13 sessions excluding the intake evaluation. The clinician obtained consent from the patients father at the intake. Both the patient and her father spoke fluent English therefore no interpreter was needed. He was debriefed on limits of confidentiality, expectations for possible audio/video recording, and possibility of patient materials being used for academic/research purposes. The patient was also informed of such information and the patient provided assent for this purpose. Outcome Measures Brief outcome assessment measures were administered in-person pre- and posttreatment at the beginning of the intake interview and termination session. The selected brief outcome measures are the Generalized Anxiety Disorder 7 (GAD-7) and the Patient Health Questionnaire 9 (PHQ-9). Both measures were developed to screen for generalized anxiety CBT treatment in an adolescent refugee 37 disorder and major depression, respectively, in a primary care population (Arroll et al., 2010; Kroenke et al., 2001; Spitzer et al., 2006). Generalized Anxiety Disorder-7 The GAD-7 is a 7-item self-report assessment measured designed to screen for and assess the severity of Generalized Anxiety Disorder in practice and research (Spitzer et al., 2006). Each item assesses the extent to which the individual has been bothered by a symptom of GAD in the past two weeks (e.g., trouble relaxing, feeling nervous, anxious, or on edge, etc.). Each of the seven items is scored on a scale ranging from 0 (not at all bothered) to 3 (bothered nearly every day), with a total score ranging from 0 to 21. The GAD-7 has cut-off scores that differentiate minimal (0-4), mild (5-9), moderate (10-14), and severe (15-21) generalized anxiety. The selected cut-off score of 10 has a sensitivity of 89% and specificity of 82%. The internal consistency of the GAD-7 is well over the acceptable range (Cronbach = 0.92). The test-retest reliability was good (intraclass correlation = 0.83). To determine convergent validity the GAD-7 was compared to the Beck Anxiety Inventory and the anxiety subscale from the Symptom Checklist-90. Convergent validity was determined to be good based on its correlations with the two measures, r = 0.72 and r = 0.74, respectively. The norms for the GAD-7 were calculated from a total of 965 patients in 15 primary care sites. The mean (SD) GAD-7 score was 14.4 (4.7) for those diagnosed with GAD (n = 73) and 4.9 (4.8) for those without GAD (n = 892). The GAD-7 was validated for adolescent populations in primary care. 40 adolescents ages 12-17 were administered the GAD-7 and scores of 11 or higher had a sensitivity of 97% and specificity of 100% at detecting moderate levels of generalized anxiety symptoms (Mossman et al., 2017). The authors concluded the GAD-7 is a measure that should be utilized by clinicians to quickly assess symptom severity in adolescents with GAD. CBT treatment in an adolescent refugee 38 Patient Health Questionnaire-9 The Patient Health Quesionnaire-9 (PHQ-9) is a self-report assessment measure designed to assess the severity of depression in the primary care setting (Kroenke et al., 2001). Each of the nine items corresponds to one of the nine DSM-5 criteria for depression. The individual is instructed to indicate how bothered they were by each symptom, ranging from 0 (not at all bothered) to 3 (bothered nearly every day), with a total score ranging from 0 to 27. The PHQ-9 has cut-off scores to distinguish minimal (0-4) mild (5-9), moderate (10-14), moderately severe (15-19) and severe (20-27) depression. A cut-off score of 10 has a sensitivity of 88% and specificity of 88% for major depression. Internal consistency of the PHQ-9 was acceptable (Cronbachs = 0.89). The test-retest reliability was excellent between scores of the initial primary care visit and 48 hours later with a mental health professional (r = 0.84). The norms were calculated from 580 patients interviewed by a mental health professional after completing the PHQ-9 at a primary care or obstetrician/gynecologic clinic. The mean (SD) of PHQ-9 score for patients (n = 41) diagnosed with major depressive disorder was 17.1 (6.1), 10.4 (5.4) for the patients (n = 65) diagnosed with other depressive disorder, and 3.3 (3.8) for the patients (n = 474) with no depressive disorder. While the PHQ-9 was designed for adults it has been validated with adolescent populations. 442 adolescents ages 13-17 were administered the PHQ-9 and a score of 11 or higher had a sensitivity of 89.5% and specificity of 77.5% for detecting youth meeting DSM criteria for major depression (Richardson et al., 2010). The authors noted that while the optimal cut-off score was slightly higher, the PHQ-9 remained an excellent choice for screening depression among adolescents in primary care settings. CBT treatment in an adolescent refugee 39 Case Formulation The case conceptualization was developed using the cognitive-behavioral model for generalized anxiety and depression. This model places emphasis on early learning and experiences which contribute to current problems, underlying rules and beliefs, ways in which they have coped with their dysfunctional beliefs (e.g., cognitive, affective, and behavioral mechanisms), and current stressors which contribute to their current problems or their ability to solve such problems. (Beck, 2020). Additionally, various distortions of anxiety are present including hypervigilance, false alarms, loss of objectivity, generalization of danger, and no tolerance for uncertainty (Beck et al., 1985; Beck, 2005). Special consideration was given to her experiences as a Burmese refugee including immigrant/refugee status, experiences as a minority, and level of acculturation. In addition, cultural factors were used as essential context throughout the entire conceptualization including increased mental health stigma and family dynamics. Conceptualization of Chomdens anxiety was supplemented using the avoidance model of worry (AMW) and the metacognitive model of worry (MCM). The AMW was developed by Borkevec et al. (2004) which posits that worry functions as an ineffective problem-solving skill to minimize aversive emotional and somatic experiences. Worry becomes negatively reinforced as the avoidance of anxiety-inducing stimuli decreases negative emotional and somatic experiences. Furthermore, worry is reinforced by positive beliefs such as worry is helpful in problem-solving, motivating performance, and avoiding negative outcomes. (Behar et al., 2009). The MCM of GAD developed by Wells (1995) posits that individuals experience two types of worry. The first is Type 1 worry which occurs when they are faced with an anxietyinducing stimuli, coupled with the belief that worry will help them cope with the situation. CBT treatment in an adolescent refugee 40 Individuals then begin to worry about their experience of type 1 worry, where they fear their worry is uncontrollable, also known as Type 2 worry. Case Conceptualization Chomdens relationship with her parents and experiences as an immigrant/refugee played a significant role in the development of her negative core beliefs. She recalled her early life in Burma and feeling as though she was the only child who was not raised by her parents, as she was raised by her grandparents. She explained that her parents were consistently home when both her older and younger sister were young. She recalled feeling as though this was unfair, and that she was unable to develop a relationship with her parents the same way her sisters were. This led to her feeling as though there is something inherently wrong with her such that she was not worthy of a relationship with her parents, or that she did not deserve it. Throughout her life, she reported not feeling loved by her parents, which further contributed to negative beliefs about herself and her inherent worth. She recalled experiencing a significant amount of praise when she was younger. This praise was often related to her performance in academics or extracurriculars. This praise even came from other family members, being told by others that she was gifted. As she became older, the ample praise from her parents stopped. Additionally, she remembered being questioned by the same family members that previously called her gifted, who were now asking what happened to her? such that her achievements were no longer as impressive. This experience confirmed her current assessment of herself, such that she was previously worthy of love and praise but she fell from grace and was no longer worthy. She recalled experiencing her parents praise and attention as love, but that since she was no longer receiving this praise, she no longer felt loved by them. This further confirmed her perception of having a fall from grace in which something about CBT treatment in an adolescent refugee 41 herself inherently changed, ultimately changing her worth. These experiences also connected academic performance with overall worth and being deserving of love. Chomdens early experiences in the United States contributed toward negative beliefs of herself and others. She recalled experiencing bullying in middle school for not knowing English, feeling very embarrassed as a result. This further confirmed previous negative beliefs about herself, in addition to beliefs that other people and social interactions are dangerous and rejection is likely to occur. Lastly, Chomden experienced a significant amount of parentification, or when children assume adult roles and are expected to meet the needs of family members (Early & Cushway, 2002). She recalled learning English much quicker than her parents and is overall more proficient. This is especially relevant with her mother, who does not speak English. As a result, she often interpreted for her parents (i.e., language brokering), and translated and helped manage bills. Language brokering is a common occurrence when there is an acculturation gap between parent and child (Titzman, 2012). Brokering has been found to be associated with higher psychological distress and depression (Oznobishin & Kumar, 2009; Williams & Francis, 2010). Additionally, because her parents were not around very often when she was younger, she felt there were many times where she had to parent herself or help parent her younger sister. At the time of treatment, she felt the responsibility to parent herself. During older adolescence, she experienced emotional parentification from her mother. Her mother vented to her about her father, either complaining about him or saying she regretted marrying him. All of these experiences, in conjunction with the already established belief that she is not worthy or deserving, contributed toward a tendency to minimize or look past her own needs in favor of others, most significantly her parents. CBT treatment in an adolescent refugee 42 The belief that she must minimize or ignore her own needs in favor of others was reinforced culturally, as the Burmese culture highly emphasizes deep respect for elders and it is considered highly inappropriate to challenge or argue with someone of senior status (Evason, 2017). This would make it extremely difficult to question or challenge her parents requests for help, as it goes against social norms. Additionally, it is very common in the Burmese culture to be constantly mindful of how ones actions could offend, embarrass, or inconvenience others. This is referred to as the concept of ah-nar-de, or the feeling of not having the heart to say or do something that may affect another persons feelings (Evason, 2017). This contributes to a significant consideration for others feelings, which Chomden demonstrated in relationship to her parents, in that she often placed their needs higher than hers. Additionally, the conflict of having her own needs increase related to her mental health, with feeling unworthy and placing others needs above her own lead to her feeling as though she is a burden to others. As a consequence of Chomdens early life experiences, she developed the following core beliefs: I am unlovable, I am a burden, I am unworthy, I will be rejected, I am worthless, I will embarrass myself around others, and others are dangerous. As a way to cope with these negative beliefs about herself and others, she developed the following assumptions and rules for living (i.e., intermediate beliefs): 1) if I succeed in school, then my parents will love me, 2) if I am perfect, then my parents will love me, 3) If I decline my parents wants, then they will never love me, 4) if I share my own struggles, then I will scare others away or be rejected, 5) if I struggled when trying to succeed, then the outcome will be more impressive, 6) if I speak to others, then I will embarrass myself, and 7) if I worry, I will be motivated to do well. Chomdens view of her worry aligns with the avoidance model of worry and metacognitive model of worry, as she had positive beliefs of her worry. Chomden explained CBT treatment in an adolescent refugee 43 feeling as though her worry and subsequent negative self-talk motivate her to do well and are significantly responsible for her success. Therefore, she has the belief if she does not worry then she will not succeed. Because her parents love was contingent on her academic success, losing her worry meant losing her parents love. This led to school being a significant cause of anxiety for Chomden. Her early experiences of once being deemed gifted which changed to falling from grace, led to Chomden developing perfectionistic tendencies. She placed a significant amount of pressure to succeed and be the best. This is likely due to the emphasis on external validation and achievement during her childhood. Her increased motivation for success reinforced her positive belief related to worry, such that worry will help her to be perfect. Increased self-criticism plays a similar role in this situation. She believed criticism will act to increase her motivation, improving the outcome of events. The increase of self-criticism, in turn, reinforced depressive symptoms. Additionally, because such large emphasis was placed on her success and outcomes, she believed that if she was able to perform while being hindered by anxiety, the outcome is that much greater, or more impressive. This further reinforced her positive belief of worry, impacting her willingness to decrease worry. Chomdens belief of being a burden and unworthy of love, in conjunction with sacrificing her own needs, negatively affected her ability to seek social support. She would often bottle-up her feelings which increased anxiety and decreased her mood. This behavior occurred with both parents and friends. With her parents, she acted as a martyr sacrificing her own needs. With her friends, she would not open up to them about her mental health or significant stressors, despite wanting to. Her lack of social support, internalization of feelings, and dismissal of personal needs increased depressive and anxiety symptoms. CBT treatment in an adolescent refugee 44 Chomdens early experiences being bullied and feeling embarrassed in social situations led to her developing a fear of social interactions. She explained she did not fear social situations prior moving to the United States and experiencing bullying. While she did not report feeling this anxiety with her close friends, she reported significant anxiety talking to other people or raising her hand in class. She explained wanting to speak to other peers and teachers more often, but that her anxiety of the outcome and possible embarrassment or rejection interfered. In behavioral terms, her anxiety decreased when she avoided social situation, thus her avoidant behavior was negatively reinforced, and, thus, increased in frequency. Additionally, she viewed her perceived inability to talk to others as a personal flaw, acting as additional evidence for being unworthy or undeserving of love. Chomdens intermediate beliefs influenced the automatic thoughts she had in response to triggering events. Triggering events that occurred frequently were parentification, stress from school, social interactions, and social comparison. The following is an example of how Chomdens core and intermediate beliefs influence her automatic thoughts and behavior: Chomden receives a 92% on an exam. She has the automatic thought, you are an idiot and a failure. As a result, her depressed mood increases, and she begins to worry about her grade in the class. The following is another example: She enters the classroom and sees her teacher. She has the automatic thought, if you say hello you will make a fool of and embarrass yourself, and she is going to laugh at you. She then feels anxious and avoids initiating conversation with her teacher. Treatment Plan Chomdens treatment plan was developed considering her diagnoses, personal goals for therapy, and sociocultural factors. Chomdens personal goals for therapy were to nap less, eat CBT treatment in an adolescent refugee 45 more, talk to more people during class, and talk to more people in general. The clinician and Chomden collaboratively identified the following goals at the beginning stage of treatment: 1) decrease hypersomnia, 2) increase food consumption, 3) decrease overall social anxiety, 4) decrease perfectionistic tendencies and distorted thoughts related to unrealistic expectations for herself, and 5) increase ability to seek social support. In order to meet these goals, a CBT treatment plan was adapted utilizing the main components of CBT treatment including psychoeducation, behavioral activation, cognitive restructuring, and exposures (Leahy et al., 2011; Wehry et al., 2015). First, psychoeducation was provided on anxiety, depression, sleep hygiene, and later, cognitive distortions. Because mental health is highly stigmatized in the Burmese culture and non-severe mental health if often less understood, additional time was spent on psychoeducation. This included providing education on the symptoms of anxiety and depression, how they reinforce each other, and prevalence to normalize her experience. As decreasing hypersomnia was a personal goal of Chomden, and likely worsened her depressive symptoms, psychoeducation on sleep hygiene was also given special attention. Specific relevant items included reducing daytime napping and not laying in bed except to sleep at night. Lastly, education on cognitive distortions was provided to enhance her ability to identify, and ultimately challenge, maladaptive thoughts. In order to improve depressive symptoms which would positively contribute to goals one and two, which were both very important to Chomden, behavioral activation was used. Chomden identified going on walks as an adaptive coping skill she had used before. She was encouraged to continue to use it as a coping skill but also as behavioral activation to decrease depressive CBT treatment in an adolescent refugee 46 symptoms. A specific behavioral intervention used to target goal two was to increase snacking throughout the day. Cognitive restructuring and behavioral experiments were used to target Chomdens anxiety in social situations. This was achieved during and outside of sessions as homework. In session, Chomden was encouraged to identify and challenge maladaptive thoughts. Specific cognitive interventions used to achieve this were evidence for and against a thought, examining the logic of a thought, and best/worst/most realistic scenario. For example, a maladaptive thought may be, If I say hello to my teacher, she is going to laugh at me. In order to challenge this thought, Chomden was encouraged to provide evidence for and against this thought. One piece of evidence against this thought is that the teacher has never laughed at a student for saying hello. A piece of evidence supporting the thought is that people have laughed at Chomden in the past. As homework, Chomden identified specific behavioral experiments to target and challenge this thought, for example, say hello to her teacher one day in a week. Cognitive restructuring was used to challenge maladaptive thoughts and beliefs which reinforced her anxiety and depression. After psychoeducation was provided on the various cognitive distortions, Chomden was encouraged to practice identifying maladaptive thoughts outside of session as homework, which would then be discussed during session. During session, cognitive interventions were used to challenge her maladaptive thoughts and beliefs as well as encourage her to explore new perspectives. The most predominant type of maladaptive thoughts was related to her perfectionistic tendencies. An example of how her perfectionist tendencies manifested was harsh self-criticism due to not meeting extremely high standards set for herself. Her maladaptive perfectionistic thoughts often arose in response to school and academic achievement. Specific cognitive interventions that were used to challenge maladaptive thoughts CBT treatment in an adolescent refugee 47 were evidence for and against a thought, role playing as the defense attorney, testing a double standard by applying it to a friend, examining the logic of thought, defining the terms, and vertical descent. Vertical descent was often used, specifically, to aid Chomden in identifying her core beliefs or other maladaptive beliefs she has about herself or others. Lastly, cognitive restructuring and behavioral experiments were used to increase Chomdens ability to seek social support from her friends. Maladaptive thoughts, such as, I am a burden, were challenged during sessions. Specific cognitive interventions used were evidence for and against a thought, testing a double standard by applying it to a friend, and testing predictions. Once Chomdens ability to recognize and challenge her maladaptive thoughts increased, she was encouraged to test her predictions as behavioral experiments for homework between sessions. An example of one self-identified behavioral experiment was seeking social support from her friends about her anxiety and depression. Chomdens experience as a refugee as well as the Burmese culture were heavily considered throughout the treatment plan. For instance, the clinician checked in with Chomdens understanding more frequently since Chomden was less likely to speak up to the clinician due to the power imbalance. Similarly, the clinician offered the opportunity to disagree with the clinician when challenging maladaptive thoughts, again due to the stark power imbalance and subsequent decreased likelihood that Chomden would openly disagree with the therapist. The clinician often checked her understanding with Chomden to ensure the clinician had an appropriate understanding of how Burmese ideals were enforced specifically in Chomdens family. Lastly, in order to ensure traditional Western ideals were not being forced on Chomden by the clinician, supervision was frequently sought. On occasion, the clinician and Chomden would openly discuss and balance Chomdens personal needs and her culture. For example, CBT treatment in an adolescent refugee 48 although it is normalized in Burmese culture not to share personal struggles as other peoples feelings are highly considered, this was negatively impacting Chomdens anxiety and depression (Evason, 2017). The pros and cons of sharing her struggles with friends were discussed with Chomden, along with assessing her personal values. For example, Chomden stated that she valued her friends as social support and therefore wanted to increase her ability to confide and share personal information with them, despite it contradicting aspects of traditional Burmese culture. This is an example of how cultural considerations were made while also keeping the individual in mind. Course of Treatment This section will describe each session of therapy and highlight important differences or deviations from the previously described treatment plan. Chomden had a total of 13 sessions and each will be described. Session 1 Chomden and the clinician discussed her eating and sleeping habits. The clinician provided psychoeducation on depression and anxiety, and how both can affect sleep and appetite. The clinician collaborated with Chomden to problem-solve ways to increase food intake and decrease hypersomnia. Chomdens homework was to decrease daytime napping and increasing snacks throughout the day. The clinician noticed rapport with Chomden was very low and it was challenging for Chomden to offer insights unprompted. Session 2 Chomden followed-up on homework, reporting she did not nap during the day and ate more snacks. This was a large improvement from previous napping habits, which was to take a three to four hour nap each day. Chomden began discussing her expectations of her academic CBT treatment in an adolescent refugee 49 performance and how it negatively affected her. She also began to discuss her relationship with her friends, avoidance of emotional closeness with them, and the ways this impacts her. The clinician continued to provide psychoeducation on anxiety and began to introduce the different types of cognitive distortions. The clinician asked direct and open-ended questions to explore and discuss the importance Chomden placed on academic success and intelligence. For example, why is it important to receive all As? and what would happen if you got a bad grade? Chomdens homework was to practice identifying maladaptive thoughts and cognitive distortions. Session 3 Chomden completed the homework and reported that identifying cognitive distortions was helpful. She discussed upcoming academic events that increased her anxiety. Chomdens idealization of perfectionism was discussed, including how it is unachievable. The clinician continued to provide psychoeducation about cognitive distortions. The clinician aided Chomden in identifying and challenging her black-and-white thinking in regard to her perfectionistic expectations of her academic performance. Chomdens homework was to continue identifying cognitive distortions but to add in a reframe/challenge of the negative thought. By the third session, rapport had significantly increased. The clinician noticed Chomden feeling more relaxed and less anxious during session, as well as the session feeling more collaborative. Session 4 Chomden discussed upcoming events that were increasing her anxiety. Throughout the discussion she was able to identify cognitive distortions with the aid of the clinician. Chomden continued to discuss her perfectionistic tendencies. She reported noticing how her perfectionism impacts other areas of life besides academics, as well as how it contributed to anxiety. The CBT treatment in an adolescent refugee 50 clinician aided Chomden in identifying her cognitive distortions in session. Other cognitive techniques used were discussing the worst-case scenario, and evidence for and against a thought. Chomdens homework was to practice challenging negative thoughts on her own using the techniques practiced in session (i.e., evidence for and against, worst case scenario, etc.). Session 5 Chomden followed-up on her homework, providing examples where she effectively identified and challenged negative thoughts. She discussed improvements in her napping and appetite. She explained that her napping continued to improve because her parents no longer let her sleep during the day. Chomden also said she noticed having midnight cravings, which was an improvement because would often not feel hungry. Chomden discussed her social anxiety and specific situations that trigger it. The clinician asked questions to explore Chomdens anxiety in social situations. For example, what is the worst possible outcome, how would you ideally act in social situations, and what prevents you from acting this way? Homework for the next session was a behavioral experiment they collaboratively set say good morning to her teacher one time within the next week to test her expectation that she would embarrass herself or be made fun of. Session 6 Chomden discussed her homework and the impact it had on her social anxiety. She discussed how she was able to say good morning to her teacher three times throughout the week instead of one, exceeding her goal. Chomden reported how her anxiety significantly decreased from the first time she said hello compared to the third time. She discussed how her social anxiety increased negative self-talk, for example, labeling herself as inadequate or a failure for feeling anxious in social situations. She was able to identify the purpose of the negative self-talk CBT treatment in an adolescent refugee 51 as a way to motivate herself to improve. The clinician aided Chomden in identifying the purpose of negative self-talk by asking questions such as what do you believe would happen if you didnt talk to yourself that way?. Chomdens homework was another behavioral experiment of her choice targeted at decreasing social anxiety. Session 7 Chomden reported her homework, which she chose to initiate conversation with classmates more, was effective in decreasing anxiety. This was the first session where Chomden discussed her family dynamics. She explained her relationship with her mother and the ways in which her mother emotionally parentified Chomden. She reported not feeling as though she had a relationship with her father. The clinician introduced the idea of setting boundaries to decrease emotional parentification, to which there was significant resistance. In order to increase emotional connectedness and social support, Chomdens homework was to confide to a friend about something small, but more than what she normally would. Session 8 The homework was discussed Chomden confided to her friends that she was going to therapy for anxiety. She explained her friends were very understanding and supportive which made her happy that she told them. Chomden continued to open up about her family dynamics and how it contributed to her mental health. She provided other examples of parentification such as language brokering which made her feel burdened. She explained that she did not feel loved by her father and identified academic success as a way to receive acceptance and praise from her parents. The clinician aided Chomden in identifying core beliefs by using the downward arrow technique. When talking about automatic thoughts, the clinician would ask questions such as what would that say about you if it were true? and what would that mean if it were true? Her CBT treatment in an adolescent refugee 52 homework was to write a compassionate letter to herself identifying her successes and as a way to provide internal validation and increase sense of acceptance. Session 9 Chomden discussed that although she completed the letter, she noticed it increased negative self-talk. Chomden did not discuss her family but rather focused on topics related to perfectionism. This included her reasoning for holding herself to a high standard and having high expectations. She discussed her perspective on achievements, explaining a single large achievement is better than accomplishing several realistic achievements, even when the outcome is the same. The clinician used the cognitive technique pros and cons to explore the cost and benefit of engaging in realistic standards. Chomdens homework was to role play as the defense attorney and provide sound reasoning why setting unrealistic goals are better than realistic goals. The clinician noticed a significant increase in resistance during this session compared to previous. Additionally, Chomdens insight into her anxiety and maladaptive thoughts had decreased significantly. The clinician hypothesized this was a reaction and subsequent regression of insight due to discussing the very sensitive topic of her family the previous sessions. This information was used by the clinician to aid her conceptualization of Chomden. Session 10 Chomden discussed her family, explaining there were no changes at home. Chomden continued to be hesitant in setting boundaries with her mother. Relevant cultural factors that impacted Chomdens ability to set boundaries were discussed. During the session, she identified and discussed her core belief of being unworthy of love. Chomden identified relevant history that contributed to the formation of the core belief family members previously described her as gifted and then several years later talked negatively about her. Chomden identified other core CBT treatment in an adolescent refugee 53 beliefs including I am a disappointment, and I am a failure. The clinician provided psychoeducation on core beliefs and the ways they impact beliefs and thoughts. The metaphor of minds doing mental gymnastics was introduced as a way to communicate the extent to which core beliefs can influence our thoughts. Session 11 Chomden reported a decrease in her overall mental health, as she had an argument with her parents since the last session and was not speaking to them. She discussed the argument, explaining it felt as though she had bottled-up her emotions for too long so she finally exploded. Chomden identified aspects of her relationship with her father that she was not happy with, and the ideal version of their relationship. Chomden and the clinician discussed differences in parental-child relationships within the Burmese culture. The clinician aided Chomden in identifying different options she had in order to have her emotional needs met. The clinician introduced acceptance as a way to cope with unfulfilling relationships with her family. As homework, Chomden was encouraged to use problem-solving strategies to create a plan of action to get her emotional needs met. Session 12 Chomden reported she was talking to her mother again but that she was no longer talking to her father. She discussed the different options she had to navigate her relationship with her parents, providing pros and cons of each course of action. Chomden discussed the ways negative treatment from others impacts her sense of self-worth. She reported wanting to be a good role model for her sisters, and that she feared they would pick up on her negative qualities. The clinician asked questions to aid Chomdens exploration of her negative self-worth as a justification for how others treat her for example, it is okay if they treat me badly because I am CBT treatment in an adolescent refugee 54 a bad person. Examples of questions the clinician asked are, why do you not deserve to be treated with respect? and if all people deserve to be treated with respect, why are you different? Chomdens homework was to list positive attributes of herself that she would want her sisters to have. Session 13 During the termination session, Chomden read aloud the list of positive attributes she would want her sisters to have. While processing termination of the therapeutic relationship, Chomden reported wishing she had discussed her family sooner. The clinician prompted Chomden to identify progress she made in therapy, which she then discussed. Summary At the time of referral, Chomdens case presented as uncomplicated anxiety and depression. At the mid-point of therapy, Chomden disclosed dissatisfaction within her family, which changed the trajectory of the therapeutic focus. Chomdens anxiety and depression appeared to be directly correlated with her family dynamics and feeling unloved by her parents in the way she would like. Chomden also directly expressed her feelings toward her familial relationship as being the root of her anxiety and depression. This was also reflected in her core beliefs, which related to her evaluation of her self-worth based on feeling unloved by her parents. While many aspects of the previously set treatment plan were implemented as intended, the clinician shifted the focus of treatment to Chomdens relationship with her parents and the impact it had on her overall mental health. Empirical Findings with Analysis The data was collected at two time points, the start and end of treatment. The reliable change index (RCI) was used to measure clinically and statistically significant change between CBT treatment in an adolescent refugee 55 start and end of treatment. A RCI was calculated for both measures used, the PHQ-9 and GAD-7. The RCI was calculated using the calculation recommended by Jacobson and Truax (1991). Normative data of clinical and non-clinical populations, including test-retest reliability, for the PHQ-9 was used from Kroenke et al. (2001). For the GAD-7, normative data from Spitzer et al. (2006) was used. The standard error of measurement (SE) and standard error of difference (Sdiff) were first computed. SE was calculated using the following equation, SE = SD(1-r), where SD is the standard deviation of the non-clinical population and r is the test-retest reliability of the measure. To calculate Sdiff the following equation was used, Sdiff = 2(SE)2. The RCI was then calculated using the following equation RC = (X2 X1)/Sdiff. According to Jacobson and Truax (1991), if the RCI is greater than or equal to 1.96 reliable change has occurred. An improvement on both the PHQ-9 and GAD-7 would produce a lower post-treatment score, leading to a RCI of -1.96. Using the data from Kroenke et al., (2001) and Spitzer et al., (2006) for the PHQ-9 and GAD-7, it was determined that the change in Chomdens scores at the end of treatment were not statistically significant (see Table 1). Table 1 Reliable Change Index Determination of PHQ-9 (Kroenke et al., 2001) and GAD-7 (Spitzer et al., 2006) Assessment PreTest Score (X1) PostTest Score (X2) Standard Deviation of non-clinical group Test-Retest Reliability PHQ-9 13 15 3.8 GAD-7 9 12 4.8 SE Sdiff RCI Reliable Change? (1.96) 0.84 1.52 2.15 0.93 No 0.83 1.98 2.80 1.07 No CBT treatment in an adolescent refugee 56 To measure clinically significant change, a cut-off point was computed using the method determined by Jacobson and Truax (1991). The following equation was used: Cutoff score = (SDnonclinical x xclinical)x(SDclinical x xnonclinical)/SDclinical + SDnonclinical. Using the data from Kroenke et al. (2001) and Spitzer et al. (2006) for the PHQ-9 and GAD-7, it was determined that Chomdens scores did not achieve the cutoff score by the end of treatment (see Table 2). This indicates that Chomdens scores did not move closer to the mean of the nonclinical population than the clinical population. The calculated RCI and cutoff score comparing Chomdens scores before and after treatment were not statistically or clinically significant. This indicates that there was no meaningful change that occurred for her anxiety and depression after treatment. It is important to note that although the RCI is approaching 1.96, which would suggest approaching statistical significance, Chomdens scores worsened after treatment. Improvement of her scores would produce a negative RCI due to the assessments used to measure change. Table 2 Cutoff Score Determination Using Normative Data for the PHQ-9 (Kroenke et al., 2001) and GAD-7 (Spitzer et al., 2006) Assessment Mean of Mean of nonclinical clinical population population Standard deviation of nonclinical population Standard Cutoff deviation score of clinical population Post- Cutoff Test score Score achieved by patient? PHQ-9 3.3 17.1 3.8 6.1 8.6 15 No GAD-7 4.9 14.4 4.8 4.7 9.7 12 No CBT treatment in an adolescent refugee 57 Discussion At the time of literature review, there were no studies that observed the effectiveness of mental health treatment for Burmese refugees who relocated to the United States. Due to the saliency of Burmese mental health treatment in the United States, understudied nature of this group, and known negative outcomes associated with refugee relocation, further research on mental health intervention is needed (George, 2010; Hickey, 2007; Kim & Keovisai, 2016; NgoMentzer et al., 2004). Because of the increased stigma and minimal mental health psychoeducation within this population (Morris et al., 2009; Saechao et al., 2012), it may be particularly beneficial to observe treatment effects in primary care, as primary care physicians provide a significant proportion of mental health care (Jetty et al., 2021; Olfson, 2016). Additionally, racial and ethnic minorities are more likely to receive mental health services in primary care settings (Chapa, 2004; Henry et al., 2020). This case study sought to determine if 13 sessions of CBT administered in a primary care setting would effectively treat Chomdens generalized anxiety and major depressive disorder, as determined by decreased PHQ-9 and GAD-7 scores. The treatment was not found to be effective, as the RCI calculation did not reach significance. Although her scores did not significantly change by the end of treatment, to indicate improvement or decline, it is important to note her scores were higher after treatment, in the direction of an increase in symptoms, relative to the beginning of treatment. Hypersomnia and lack of appetite were particularly distressing symptoms for Chomden; however, these symptoms did not significantly decrease as determined by items on the PHQ-9. When considering why treatment was ineffective, it is important to consider the therapeutic alliance. The therapeutic alliance between the therapist and patient is one of the most CBT treatment in an adolescent refugee 58 important common factors related to treatment outcomes, regardless of length of session or treatment modality (Gergov et al., 2021). Various factors could have hindered the development of the therapeutic alliance between Chomden and the clinician, including personality traits and attachment style. Perfectionism has been demonstrated to negatively impact the development of the therapeutic alliance (Lingiardi et al., 2005; Miller 2017). Additionally, in patients who are high in perfectionism, there are smaller increases in the therapeutic relationship over the course of treatment (Zuroff 2000). The effect perfectionism has on the therapeutic alliance is an important factor to consider when treating Burmese individuals, given that studies have shown that Asian Americans demonstrate perfectionistic tendencies (Peng & Wright, 1994). In fact, stress of meeting parental expectations of high academic achievement, as well as living up to the model minority stereotype has been shown to be a common source of stress for Asian Americans (Lee et al., 2009). This unique stress that Asian Americans experience may have negative consequences for the development of the therapeutic alliance, and ultimately treatment outcomes. Long-term, as opposed to short-term CBT may produce more desirable outcomes when perfectionism is present. Studies have found that individuals high in perfectionism view their therapist as less empathetic and understanding early in therapy (Hewitt et al., 2008; Miller et al., 2017). It is possible the patient needs a longer time in therapy to develop trust in and create an emotional bond with the therapist (Miller et al., 2017). While this has not been observed specifically with CBT, long-term therapy has been more effective for other treatment modalities (Blatt, 1992; Blatt & Ford, 1994). Additionally, the therapist can help the patient develop selfcompassion by creating a compassionate and accepting therapeutic environment which may then CBT treatment in an adolescent refugee 59 be internalized (Gilbert, 2009). It is possible treatment was too short for Chomden to benefit given her perfectionism and that longer-term therapy would have been a better match for her. Chomdens perfectionism may have made it difficult to engage in self-compassion. Selfcriticism is highly associated with perfectionism (Gilbert et al., 2006). Chomden reported viewing her self-criticism as a motivating tool that enabled her to perform to her perfectionistic standards. This aligns with the AMW where worry, or in this case self-criticism, is viewed positively by the patient as a motivating tool (Behar et al., 2009). Self-compassion may have been particularly difficult for Chomden, as she may have feared that self-compassion would lower her standards and decrease her motivation. Studies suggest this negative view of selfcompassion is a common barrier (Kelly et al., 2021). This perspective is particularly relevant with perfectionistic individuals, such that they fear self-compassion (Gilbert & Procter, 2006). One definition of self-compassion is noticing ones suffering, then responding in an accepting and non-judgmental way with motivation to decrease ones suffering, all while tolerating difficult emotions (Gilbert, 2010). Self-compassion is not accepting yourself as you currently are with no desire to change or improve. In fact, there is evidence that self-compassion increases motivation following failure and promotes adjustment after failure to achieve a goal, which contradicts the perfectionistic fear of self-compassion (Breines & Chen, 2012; Miyagawa et al., 2018). In Chomdens treatment, providing more psychoeducation on self-compassion, and explaining it as an approach of non-judgement and curiosity may have been more tolerable and thus improved her willingness to let go of self-criticism and increase self-compassion (Gilbert, 2010). Attachment style, or the way in which a person relates to others as formed by early childhood experiences and relationships, can impact the development of the therapeutic alliance CBT treatment in an adolescent refugee 60 (Bowlby, 1988). Specifically, insecure attachment styles have been shown to be negatively associated with the development of the therapeutic alliance (Bachelor et al., 2010). Some theorize that the patients attachment style is then projected onto the therapist-patient relationship, which ultimately impacts the development and formation of the alliance (Bowlby, 1988; Smith et al., 2009). An insecure attachment style can delay the formation of the therapeutic alliance and can contribute to an overall less positive therapeutic alliance (Smith et al., 2009). Burmese refugees may be more vulnerable to this issue through direct pathways, such as the inherently traumatic experience of being displaced, and through indirect pathways, like intergenerational trauma. Some studies have found a link between adverse childhood experiences and attachment style, such that those with childhood traumas were more likely to have an insecure attachment style (zcan et al., 2016). Traumas related to refugee experiences, specifically, have also shown an association with insecure attachment styles (Morina et al., 2016). Within refugee families, parental trauma has been shown to contribute to insecure attachment and diminished parental emotional ability (Flanagan et al., 2020). Other studies have found maternal traumatic experiences and attachment style impact their childs attachment style, suggesting intergenerational transfer (Cooke et al., 2019; zcan et al., 2016). Although Chomdens attachment style was not assessed during treatment, the clinician reflected after treatment and speculated that Chomden likely demonstrated an avoidant attachment type. Those with an avoidant attachment type may suppress and deactivate emotions when caregivers are unable to meet their needs, leading to long-term consequences of becoming overwhelmed by emotions and repressing or dissociating for difficult emotions (Mikulincer et al., 2003). Chomden longed for close relationships with others but feared rejection. This is demonstrated in her relationship with her friends, where she was close with them but greatly CBT treatment in an adolescent refugee 61 feared confiding in them about intimate details of her life and experience. While she considered them close, emotionally they were kept at a distance. This relational pattern aligns with the avoidant attachment style (Akhtar, 2012). Chomdens experiences of rejection in childhood bolster the clinicians hypothesis of Chomdens avoidant attachment style. Chomden experienced repeated rejection from her parents, for example being the only sibling to be parented by her grandmother and having a fall from grace where she no longer received praise. Chomden was also rejected in middle childhood, where she was bullied and made fun of in middle school when first moving to the US. Additionally, she perceived her parents as less warm and reported not feeling loved by them. Repeated rejections and lack of warmth from parents are both core features of an avoidant attachment style (Akhtar, 2012). Chomdens avoidant attachment style may have hindered the development of the therapeutic alliance. As previously stated, it is expected that a persons attachment style is projected onto the patient-therapist relationship (Bowlby, 1988; Smith et al., 2009). In treatment, Chomdens avoidant attachment style may have manifested as a lack of trust of the clinician, difficulty forming trust in the clinician, or a fear of rejection from the clinician, as mistrust and fear of rejection are core features of avoidant attachment (Akhtar, 2012). In order to minimize the negative effects an insecure attachment has on the therapeutic relationship, some suggest assessing for attachment style prior to treatment (Shorey & Snyder, 2006). Self-report measures are often used in clinical settings, as narrative measures take much longer to complete (Smith et al., 2009). A self-report inventory such as the Adult Attachment Inventory (Simpson et al., 1992) may be used to quickly, in conjunction with information gathered during the intake interview, assess attachment style. If the therapist is aware of the patients attachment style, and potential problems that may arise in therapy as a result, the CBT treatment in an adolescent refugee 62 therapist can be more attentive to the development of such issues (Smith, 2009). Additionally, the therapist may benefit from monitoring the therapeutic alliance for signs of distance or discontent, and preemptively repair the alliance as needed (Diener & Monroe, 2011). These recommendations have been made for treatment modalities where relational processes are not the main focus, for example, CBT (Taylor et al., 2015). For the present patient, no assessment of attachment style was done. It is possible that doing say may have improved the course of treatment by incorporating this information, therefore benefiting Chomden. The duty to save face for the collective family may negatively impact therapeutic outcomes (Covelman & Covelman, 1993). Family is extremely important in Burmese culture. As such, so is the collective reputation or face of the family. Because families have a collective face or reputation, the act of an individual in the family can impact the perception of the family unit as a whole (Evason, 2017). This, in conjunction with mental illness remaining highly stigmatized, results in hiding feelings of anger, shame, or other negative emotions that may undermine their face (Chung, 2016). As part of saving face, there is a strong boundary within the family structure to not share family issues with outsiders (Epstein et al., 2012). Sharing such details with a clinician may be seen as increasing the probability of losing face (Anderson et al., 2012). To share personal details to a therapist that could lose face may be very stressful and lead to difficulty opening up in therapy (Liu et al., 2014). Chomden disclosed in session she had wanted to talk about her family dynamics sooner, but that she was hesitant to speak about it, which may be interpreted as an attempt to save face for the family. If the fear of losing face was not present, her family conflict may have been discussed sooner, potentially leading to more desirable outcomes. CBT treatment in an adolescent refugee 63 To combat the fear of losing face and increase sharing in session, it is essential to build trust early in the therapeutic relationship. One way to build this trust is to clearly communicate privacy and confidentiality limits, and openly address any concerns the patient may have (Anderson et al., 2012; Yeung & Ng, 2011). This helps to ensure their understanding that personal information will not be shared outside of the therapeutic settings. Others have found that therapist self-disclosure of personal information helps to build trust and can be important in the development of the therapeutic alliance when working with Asian American patients (Epstein et al., 2013; Jim & Pistrang, 2007). Therapeutically appropriate self-disclosure may build trust and the therapeutic alliance, as the sharing of personal information is an important symbol of trust (Epstein et al., 2013). Although self-disclosure in therapy is controversial amongst clinicians, research further suggests it has the potential to increase positive outcomes (Hill & Knox, 2002). Studies have found it to have an immediate, positive effect such that patients rate their therapist as more helpful (Hill et al., 2001). Other studies have found it to be effective in lowering levels of symptoms distress and improved therapeutic relationship such that those patients liked their therapist more (Barrett & Berman, 2001). Additionally, the use of metaphor, both patient and therapist, may improve the patients ability to discuss family conflicts. Communicating through metaphor allows the patient to communicate this information in an indirect and safe way, increasing their willingness to share (Liu et al., 2014). While the limits to confidentiality and privacy were discussed with both Chomden and her father, it is possible that taking additional time to discuss such limits and emphasizing that information shared with the therapist would not be shared to outside sources would have improved the trust with the therapist. Additionally, the clinician did not strategically use self-disclosure to build trust, which if done in a therapeutically appropriate manner, may have also increased trust and ultimately CBT treatment in an adolescent refugee 64 Chomdens comfort to share information. Lastly, metaphors were occasionally used in session to convey complex ideas in a simplified way, however Chomden was not encouraged to also use metaphors. If the use of metaphor was more frequent and Chomden was also encouraged to use metaphor, she may have felt more comfortable to share information related to family conflict sooner in therapy. One possibility, considering the number of the issues described above, is that familybased interventions, as opposed to individual, may have produced more positive outcomes for Chomden. Although there is a shortage of literature focusing on family interventions for refugees, the research that does exist suggests positive outcomes. Given the impact of trauma exposure and intergenerational transmission of trauma, there is a great need for family support (Slobodin & de Jong, 2015). In addition to trauma exposure, relocation and acculturative stress add additional difficulties to parenting and family relations which may contribute to parent-child conflict or parental withdrawal (Ballard et al., 2020; Lewig et al., 2010). There is preliminary evidence to suggest parent training interventions produce positive outcomes while considering the complex experiences of refugees (Ballard et al., 2018). Culturally relevant parent training interventions for Karen Burmese refugees decreased mental health concerns for parents and children ages 5-13, while positively changing parenting practices. This shift in parenting practices may have enabled parents to support better emotional health. Chomdens experience of feeling unloved, emotionally unsupported, and possible parental emotional withdrawal suggest parent training interventions may have produced more positive outcomes. In addition to directly improving parent-child relationships, parent training may also improve perfectionism. In Asian American families, an increase in parental support and decrease in parental criticism, particularly as it relates to academic achievement, may also serve to CBT treatment in an adolescent refugee 65 decrease perfectionism (Greenberger et al., 2000; Yoon & Lau, 2008). This indicates that parent training interventions may directly improve adolescent mental health, while indirectly improving it via decreases in perfectionism. Additionally, decreases in perfectionism would also improve the therapeutic relationship in individual therapy. It is important to discuss the differences between patient and therapist characteristics and the possible impact it had on treatment outcomes. Chomden was a Burmese, Christian, heterosexual female. The clinician identified as a white, heterosexual female. Patient preferences in regard to therapist characteristics are especially important to consider when working with individuals who have experienced marginalization and other disparities, which Chomden had reported (Jackson, 2015). Some studies have found that Asian Americans are more likely to utilize mental health services when clinicians are the same ethnicity or race (Wu & Windle, 1980). Asian Americans who do show preferences for same-race therapist are more likely to have additional vulnerability factors such as being female, foreign-born, or low acculturation (Jang et al., 2021). Additionally, Asian Americans who adhere highly to Asian cultural values have been found to view Asian American therapists as being more credible and approachable, compared to their white counterparts (Atkinson et al., 1978; Kim & Atkinson, 2002). Despite showing preferences for same-race or ethnicity clinicians, there is not consistent evidence to suggest it significantly impacts treatment outcomes (Ilagan & Heatherington, 2022). Although treatment outcomes may not significantly differ, it is possible that therapy engagement, therapeutic alliance, and retention significantly improves with race/ethnicity-matching for Asian Americans (Smith & Trimble, 2016). In terms of gender matching, female patients show higher preferences for and report greater comfort self-disclosing to female clinicians (Kuusisto & Artkoski, 2013; Landes et al., CBT treatment in an adolescent refugee 66 2013). Similar to race-matching, gender-matching demonstrates inconsistent findings in regard to improving treatment outcomes (Ilagan & Heatherington, 2022). This suggests that while Chomden having a female clinician may have improved self-disclosure and sharing, it is unlikely to have significantly affected overall treatment outcomes. Additionally, having a clinician who was also Asian American may have improved other therapeutic factors such as engagement and alliance; however, the literature suggests that it is unlikely it would have directly, significantly improved treatment outcomes for Chomden. However, due to the possibility that the alliance was weakened by other factors, like perfectionism and insecure attachment, a same-race therapist may have improved the alliance enough to improve treatment outcomes. Limitations to this case study include low generalizability, given it is a single-case subject research design (Tsang, 2014). While conclusions can be formed for the effectiveness of treatment for this specific patient, no such conclusions can be formed for Burmese refugees as a whole (Janosky, 2005). Other limitations include that only pre- and post-treatment data was collected, which is less desirable compared to continuous daily or weekly ratings which allow for additional inferences to be formed (Kazdin, 2019). Future studies, both group and case studies, should focus on treatment outcomes for Burmese refugees given the lack of literature that exists for this group. Refugee status and the complex experiences associated with it, such as relocation, acculturative stress, and traumatic experiences, all contribute toward the mental health of these individuals. When considering the state of civil unrest, with the most recent event being the Myanmar (Burma) coup in early 2021, it is likely that these experiences, and need for treatment, will continue (Thein-Lemelson, 2021). 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