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... 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. However, the dropout rates for this study are not greater than other studies that use CBT, CPT and other forms of brief therapy as stated in Leichsenring at al.s (2019) and Fernandez et al.s (2015) papers. This suggests that CCRT can still be considered as effective as other brief therapy models. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 63 References Adawi, M., Zerbetto, R., Re, T. S., Bisharat, B., Mahamid, M., Amital, H., Del Puente, G., & Bragazzi, N. L. (2019). Psychometric properties of the Brief Symptom Inventory in nomophobic subjects: insights from preliminary confirmatory factor, exploratory factor, and clustering analyses in a sample of healthy Italian volunteers. Psychology research and behavior management, 12, 145154. Addolorato, G., Capristo, E., Stefanini, G. F., & Gasbarrini, G. (1997). Inflammatory bowel disease: a study of the association between anxiety and depression, physical morbidity, and nutritional status. 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... BRIEF PSYCHODYNAMIC THERAPY WITH A TRADITIONAL COLLEGE STUDENT DIAGNOSED WITH ADJUSTMENT DISORDER: A CASE STUDY 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 Megan Pethtel March 2023 ii BRIEF PSYCHODYNAMIC THERAPY WITH A TRADITIONAL COLLEGE STUDENT DIAGNOSED WITH ADJUSTMENT DISORDER: A CASE STUDY The signatures below certify that the Doctoral Dissertation of Megan Pethtel 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 M. Warman, PhD Dissertation Advisor John Kuykendall, PhD Dean, College of Applied Behavioral Sciences 3/28/2023 _____________________ Lisa S. Elwood, PhD Committee Member Trevor A. Yuhas, PsyD Committee Member 3/28/2023 ________________________ Date ________________________ Date iii ABSTRACT There is minimal research that examines effective treatment for individuals diagnosed with Adjustment Disorder (AD) (OConner & Cartwright, 2012; Carta et al., 2009; Zelveine & Kazlauskas, 2018). The current case study aimed to examine the effectiveness of brief psychodynamic therapy as a treatment with a traditional aged college student diagnosed with AD. Specifically, the current case study examined an individual diagnosed with AD receiving weekly therapy in a college counseling center for a total of 6 sessions. The client was administered the CCAPS-62 on three separate occasions (e.g., before his intake session, after his third therapy session, and before his sixth and final therapy session). The RCI was calculated using pre, mid, and post mean ratings for each CCAPS-62 subscale. Cutoff scores were also calculated using means and standard deviations from normal and clinical populations, which were provided by the Center for Collegiate Mental Health (CCMH) annual report (2010). The clients scores on some subscales (e.g., Social Anxiety, Eating Concerns, Hostility, and Substance Use) post treatment fell below cutoff points, suggesting the client ended treatment closer to the normal population than to the clinical population for those subscales. Results from the RCI suggest the client demonstrated reliable change on the Depression, Academic Distress, Family Distress, and Substance Use subscales from pre to mid treatment and on the Depression, Generalized Anxiety, Social Anxiety, Academic Distress, Family Distress, and Substance Use subscales from pre to post treatment. iv Table of Contents TITLE PAGEi SIGNATURE PAGE...ii ABSTRACT...iii TABLE OF CONTENTSiv INTRODUCTION...5 Case Study........5 Client Information..16 Adjustment Disorder......23 Brief Psychodynamic Therapy...27 Case Formulation...48 Treatment Plan...50 Clinical Research Question....51 METHOD..52 Counseling Center Assessment of Psychological Symptoms-62.......52 Reliable Change Index.......53 Course of Treatment...54 EMPIRICAL FINDINGS WITH ANALYSIS..60 DISCUSSION64 REFERENCES..71 5 BRIEF PSYCHODYNAMIC THERAPY WITH A TRADITIONAL COLLEGE STUDENT DIAGNOSED WITH ADJUSTMENT DISORDER: A CASE STUDY Introduction Case Study Overview. Psychotherapy research has appeared to gain new interest in being able to study an individual case more in depth (Rice & Greenberg, 1984; Scruggs & Mastropieri, 1998; Yin, 2009). When conducting research, case studies, also referred to as single-case designs, can evaluate interventions effects and can examine questions often developed from between-group studies. Single-case designs are considered to be true experiments and have the capability of demonstrating causal relationships and ruling out threats to validity. Single-case designs are able to make inferences about interventions effects by comparing different conditions that are usually presented to a singular participant over time (Brockardt et al., 2008; Kazdin, 2022; Yin, 2009). An example of a case study includes research conducted by Watson and colleagues (2002) where they used an effective program on a single nine-year-old boy in order to eliminate thumb sucking behaviors. In single-case designs, a participants performance is usually observed repeatedly over time. This allows the investigator to study the pattern of the participants performance initially, before the intervention is introduced, which is referred to as the baseline phase. After the intervention has begun, the investigator can then study changes and if those changes occur in relation with the introduction of the intervention (Brockardt et al., 2008; Kazdin, 2022; Scruggs & Mastropieri, 1998; Yin, 2009). In single-case designs, the examiner holds the ability to further examine the processes that help to promote therapeutic change by analyzing the interaction between the therapist and client (Greenberg, 1986). This ability to further examine the 6 interaction between the therapist and patient allows the examiner to have a better understanding of the processes that encourage therapeutic change and allows for effective clinical treatments to be examined (Jones, 1993). According to sources (Brockardt et al., 2008; Kazdin, 2022; Yin, 2009), data gathered during the baseline phase can inform the investigator about the participants current level of functioning and the severity of the behavior needing to be changed. Multiple data points during the baseline can also predict the participants behavior if the intervention were not introduced. However, it is possible that participants behaviors could change over time without any interventions. In order to be sure of future performance, baseline data would need to be continuously collected before introducing the intervention, which cannot always be done given the purpose of therapy - to provide therapeutic interventions (Brockardt et al., 2008; Kazdin, 2022; Yin, 2009). When reviewing the data once plotted on a graph, the line on a graph shows the direction of the data points collected, which is referred to as a trend line. During the baseline observation period, data might show a horizontal trend line that shows the behavior is remaining steady over time, neither increasing nor decreasing. After the intervention has begun, a decelerating trend line would demonstrate the problematic behavior has decreased. Alternatively, an increasing trend line would demonstrate the problematic behavior has increased (Brockardt et al., 2008; Kazdin, 2022). Strengths and limitations. Single-case designs have provided researchers with solid methodology that has been utilized in countless studies over the span of several decades (Kazdin, 2022; Yin, 2009). Single-case designs have examined psychological processes in research with both animals and diverse human populations. Single-case designs have been used with 7 participants ranging from infancy through late adulthood; participants who had clinical presentations ranging from conduct disorder, autism spectrum disorder, substance use disorders, and anxiety disorders; and participants in settings ranging from educational settings, home settings, military settings, college dorms and athletics, and more. It is from these single-case designs that evidence-based interventions have emerged (Kazdin, 2022). In fact, many early breakthrough discoveries in psychological science were the result of single-organism methods (Ebbinghaus, 1913; Pavlov, 1927; Skinner, 1938; Watson, 1925). Over the last few decades, psychotherapy research has experienced a revived interest in these intensive individual case studies. This revival of case studies has been influenced by multiple factors both in clinical research and clinical practice (Jones, 1993). To begin, there has been more consideration of controlled clinical trials limitations for being able to provide information about how clients change through psychologically mediated interventions and more acknowledgment that being able to understand the processes that develop therapeutic change requires closely analyzing the therapist-patient relationship and interaction (Greenberg, 1986). Notably, multiple researchers over time have shown interest in how laboratory-validated interventions end up translating to clinical practice (Jacobson & Christensen, 1996; Westen & Bradley, 2005; Westen, Novotny, & Thompson-Brenner, 2004). Additionally, there is the demand to test clinical theoretical models. Last but certainly not least, is the notion that psychotherapy research has previously had little influence on theory building and clinical practice (Jones, 1993). However, the case study method establishes itself in naturalistic observations and still upholds the primary means of clinical inquiry, teaching, and learning in psychotherapy (Jones, 1993). 8 In line with this renewed interest in case studies, the American Psychological Associations (APAs) Division 12 Task Force on Promotion and Dissemination of Psychological Procedures has specifically named time-series designs as important methodological approaches that can properly test treatment efficacy and/or effectiveness (Chambless & Ollendick, 2001). Additionally, the APA Task Force on Evidence-Based Practice (2005) even endorsed single-case studies as contributing to effective psychological clinical practice. Despite this endorsement, and even with sincere interest in learning what works for their clients, clinicians are still sometimes intimidated by research and are often unfamiliar with the single-case time-series option (Borckardt et al., 2008). When considering the single-case design, it is important to note both its advantages and disadvantages. According to Kazdin (2022) and Yin (2009), one of the biggest concerns discussed about single-case studies is its external validity. Specifically, the concern is about whether or not the findings from single-case studies are generalizable to others. Searle (1999) also notes concern about the generalizability of the results, given the individual being studied could be atypical. However, single-case design research has long been connected with interventions created from both human and nonhuman animal research, which have shown to be widely generalizable. Single-case design research findings have demonstrated interventions that are widely applicable (Kazdin, 2022). When discussing concerns of generalizability, it is also important to remember that both between-group and single-case designs face challenges with this issue of generalizability. In both instances, a key solution is being able to replicate findings with new participants, though between-group studies typically handle concerns regarding the generalizability of findings better than single-case studies. Because between-group designs often study moderators, which are variables that might influence the direction or magnitude of change, 9 this helps investigators to better understand the generalizability of the intervention utilized in the study based on participants characteristics (Kazdin, 2022). Additional disadvantages of single-case designs include the difficulty for the investigator, who is often the therapist, to remain objective if the nature of the work requires a large amount of contact with the participant being studied. It is also possible that the investigator is selective about what appears in the final report (Searle, 1999). If a case study includes retrospective material, it is possible that this information is not accurate. For example, it can be difficult to determine if an adults recollection of early childhood events is indeed accurate or not (Searle, 1999). There are also concerns about if clients improvements during treatment were in fact actually because of the treatment implemented or because of some external factors in the clients environment and independent of the client and treatment altogether. Even when alternative explanations can be ruled out and the intervention appears to be the cause of improvement, it can be difficult to determine what features of the intervention can actually account for the improvement (Borckardt & Nash, 2008). Despite these limitations of single-case designs, they still have multiple strengths and contributions unique to single-case designs that are worth noting. First, single-case designs expand the scope of opportunities for the study of intervention programs in normal everyday life as administered relative to diverse goals, settings, and domains (Kazdin, 2022). Single-case designs offer rich, in-depth insight into an individual or group that is usually far more detailed and recognizes the uniqueness of individuals. Single-case designs also acknowledge the importance of the subjective feelings of the participants being studied as well as can sometimes highlight extraordinary behaviors and even open new areas of study (Searle, 1999). This was demonstrated by Skeels (1966) when research on deprived babies revealed that intelligence 10 scores are not set at birth but can indeed be impacted by life experiences. Single-case designs can also be pooled together to create a large amount of detailed information that can then be sorted and analyzed, which can then highlight variables to be further studied. Single-case designs are valuable exploratory tools that can lead to the generation of hypotheses for future research (Kazdin, 2022; Searle, 1999; Yin, 2009). Additional advantages of single-case designs include how they can provide a way to evaluate change and the impact of interventions for a single participant without needing to accumulate a large number of participants and then assign these participants to different control or comparison groups. In this sense, single-case designs can provide a method of evaluating change and impact of interventions for a particular participant or a particular setting. Single-case studies are able to address the danger of believing someone is making a difference without ever actually evaluating to see if one has indeed made a difference (Kazdin, 2022; Yin, 2009). According to Kazdin (2022) and Yin (2009), single case designs also allow for an intervention to be gradually implemented on a small-scale before applying it to a larger scale. This allows for an intervention to be tried and then modified as needed before applying the intervention to a larger group or to other individuals. During between-group research, the intervention is pre-planned and administered in full to keep with the plan. The impact of the intervention is then evaluated at the end of treatment during the posttest assessment. During single-case designs, ongoing feedback is provided and can allow for informed decision making to help clients while the intervention is still in effect. This ongoing assessment during the intervention phase of treatment helps to make single-case designs user-friendly to both the investigator and to the participant (Kazdin, 2022; Yin, 2009). 11 Kazdin (2022) highlights single-case designs also allow investigators the chance to examine rare presentations within individuals who would not likely be studied in between-group research. Often times, an individual could be presenting with a primary concern that is not rare but is entangled with other conditions or circumstances that would make it difficult to do a group study to develop or test an intervention on that individual. Single-case studies, however, allow for exactly that. In single-case studies, examiners are able to research and study an individual with a rare primary concern, or an individual with a common primary concern that is entangled with other challenging conditions and circumstances, to develop or test the effectiveness of an intervention (Borckardt et al., 2008; Kazdin, 2022; Yin, 2009). Single case design methods. When conducting a single-case study, multiple methods may be utilized, such as time series analysis, reliable change index (RCI), or percentage of nonoverlapping data (PND). A time-series analysis allows investigators to regularly track symptoms of one, or a few, clients across baseline and intervention phases in hopes to produce data that address whether and when an intervention is effective (Borckardt et al., 2008; Kazdin, 2022). There are multiple types of time-series analyses that all share the fundamental feature of tracking change in at least one target symptom across phases and examining if there is a relationship between implementing the intervention and the status of the target symptom. The simplest time-series analysis includes just two phases: the pretreatment baseline phase, referred to as phase A, and the treatment phase, referred to as phase B (Borckardt & Nash, 2008; Kazdin, 2022). Another variation of this time-series analysis includes four phases: phase A, phase B, followed by another phase A and phase B. This design is similar to the simple A-B designs and tracks the impact of an intervention on the target symptom but is then followed by a 3rd phase 12 where the intervention is no longer implemented before then being resumed in the 4th and final phase. By examining a clients data from the baseline and treatment phases, researchers then may have the ability to determine if a client has made statistically significant change when comparing the baseline and treatment phases (Borckardt & Nash, 2008; Kazdin, 2022). This design is able to nicely address questions of cause and effect. Improvements made during the first intervention phase, however, do not always decline when the intervention is taken away. The goal of therapy, after all, is for clients to continue making improvements even after they have terminated from therapy. Additional notable limitations of this design include the ethical question of removing an intervention that is helping a distressed client as well as the logistical reality of clients being understandably hesitant to agree to discontinue an intervention that is working for them (Borckardt & Nash, 2008; Kazdin, 2022). In addition to time-series analysis, percentage of nonoverlapping data is another method utilized when conducing single-case studies. To calculate the PND, the investigator draws a line through the most extreme data point from the baseline phase that follows the expected direction of treatment effect and extends through the treatment phase (Scruggs & Mastropieri, 1998). Once data is collected and visually analyzed, the portion of plotted data points in the treatment phase that do not overlap with plotted data points from the baseline phase are considered to be statistically reliable (Kazdin, 1978). One notable advantage of the PND approach includes its ability to provide meaningful information about the interventions effectiveness through a visual presentation of data points Additionally, PND combining efforts are seen as generally accurate reflections of the research studies they review (Scruggs & Mastropieri, 1998). Despite these notable strengths, some investigators have still argued that PND is not able to accurately represent the experiment, 13 stating that reducing data to one-number summaries of overlap seen across data abandons some of the most interesting information (Salzburg et al., 1987). Additional concerns have been raised about the PND method not adequately assessing meaningful trends in the data (White, 1982), the PND method not being sensitive to powerful treatment effects (White et al., 1989), and that PND statistics effect size estimates may approach 0.0 with more and more observational data, regardless of treatment efficacy (Allison & Gorman, 1994). Another popular method used in single-case studies, and the method that will be utilized in the current study, is the reliable change index. According to De Souza Costa and Jardim de Paula (2015), the RCI is a statistical procedure that allows investigators to compare two psychometrically derived scores from items such as scales, tests, or questionnaires. The RCI evaluates whether a clients scores difference at two points in time is more likely to be explained by measurement error or if it is because of real significant change. Mathematically, the RCI can be defined as a clients change in score on a psychometrically supported measure divided by the standard error of the difference, which is dependent on the psychometric measures standard error. The psychometric measures standard error includes the standard deviation from the normative sample and the test-retest reliability. The results of this mathematical equation represent a standard score (De Souza Costa & Jardim de Paula, 2015). To understand the RCI, we must first understand that there are multiple ways to identify variability in treatment response and to determine if changes are clinically significant, which is typically demonstrated when the client returns to normal functioning (Jacobson et al., 1999). For any individual, the magnitude of change should be statistically reliable and should be further than the range of what might reasonably be associated to chance or measurement error. This results in a two-part criterion for clinically significant change. First, the magnitude of change has 14 to be statistically reliable. Second, by the end of therapy, clients must end up in a range that shows them as indistinguishable from the population classified as normal functioning. Clients who show statistically reliable change and who end within normal limits on the variable of interest are classified as recovered; clients who show statistically reliable change but are still somewhat dysfunctional and not within normal limits are classified as improved but not recovered; and clients who end in the functional range but do not show statistically reliable change are unable to be classified. Being able to apply this to treated clients allows one to identify the percentage of clients who recovered, the percentage of clients who improved but did not recover, and the percentage of clients who remained unchanged or regressed (Jacobson et al., 1999). In order to demonstrate that a client has moved from the dysfunctional to the functional range of functioning over the course of therapy, three mathematical criteria were proposed in the form of cutoff points (Jacobson et al., 1999). Cutoff point A is achieved when the clients level of functioning falls outside the range of the dysfunctional population, with range being defined as 2 standard deviations more than the populations mean in the direction of functional behavior. Cutoff point B is achieved when the clients level of functioning falls within the range of the normal population, with range being defined as 2 standard deviations less than the normal populations mean. Cutoff point C is when the clients level of functioning suggests that they are statistically more likely to be among the functional population than they are to be with the dysfunctional population. Preferably, cutoff points are based on norms collected for both dysfunctional and normal populations. If the cutoff point is crossed when therapy is terminated, then the client can be labeled as recovered. If the cutoff point is not crossed at the termination of therapy, then the 15 client can be labeled as still dysfunctional, regardless of if the change was statistically reliable or not. The RCI then, as the second criterion for determining clinically significant change, is utilized to ensure that the magnitude of change exceeds the margin of measurement error by diving the magnitude of change during therapy by the standard error of the difference score (Jacobson et al., 1999). When using the RCI method, there are some noteworthy strengths and weaknesses that should be taken into consideration. Jacobson and Revenstorf (1988) identified conditions where the RCI was either irrelevant or misleading as a criterion for defining clinically significant change. Jacobson and Revenstorf (1988) explained the RCI method is irrelevant for any clinical data that surpasses the cutoff point because that alone defines a magnitude of change that is only possible with statistically significant change. Thus, the RCI is no longer necessary to determine clinically significant change. They also argued that the RCI method is misleading when used on its own for clinically significant change, without using cutoff points. It is important to note that when the RCI is used on its own, cannot determine if the change was clinically significant (Jacobson & Revenstorf, 1988). Additional weaknesses include the RCI method working best only when adequate norms are available for both normal and dysfunctional populations as well as the concern over having discrete cutoff points, although Jacobson and Revenstorf (1988) suggested that by forming confidence intervals around cutoff points, one could define boundaries of these intervals using the RCI, allowing participants who fell outside the boundaries to be reliably classified and participants who fell inside the boundaries to not be reliably classified. Additionally, the RCI method is not able to establish a causal relationship between the intervention being used and the outcomes this treatment may be associated with. The RCI method is not able to determine 16 clinically significant deterioration. Although the RCI is necessary when crossing a cutoff point, it does not prove that change is real by itself and cannot be used to validate a measure (Jacobson et al., 1999). Despite these limitations, the RCI method is one of the favored methods to evaluate significant changes associated with both psychotherapy and psychopharmacological treatment, as it supplies a combination of both statistical and clinical components. It has been referred to as a useful method to define the favorable outcome of an intervention on an individual clinical basis and has been highly recommended as being able to objectively describe improved symptoms beyond measurement error. Overall, the RCI is known as a solid method to measure changes in symptoms in both psychiatric and psychological interventions (De Souza Costa & Jardim de Paula, 2015). Client Information Presenting concerns. Client is an undergraduate student at a small university in Indiana in his early twenties. He identifies as a white gay cisgender male. Client attended his intake session in February 2020. He presented with concerns about past issues that had recently resurfaced, as well as with adjustment related concerns. He reported that he found himself dwelling on his past experiences and identified having a turbulent previous month because of the big changes that had reportedly taken place in his life, which he noted as unwelcome changes. Client reported that the following changes had recently taken place in his life: his family, who was previously ten minutes away from him, moved twelve hours away from him and left him feeling lonelier than before; he recently quit his job, which he had held for four years; his lifelong high school friends all moved away; he was placing more focus on his personal life; and he recently learned his mother was very ill, which was reportedly extra stressful for the client 17 because of his moms reported fear of doctors that acted as a barrier to her receiving the proper medical help. During the intake, client reported feeling bogged down and identified having many interpersonal stressors. He stated it was hard to stop thinking about some of his past interpersonal experiences (e.g., his relationship with his ex-boyfriend) to the point where his sleep, focus, homework, and social life were being negatively impacted. He reported feeling melancholy and stated sleeping approximately two to five hours of sleep each night, with reported difficulty falling asleep at night. Client reported eating two meals per day, endorsed a normal appetite, and denied any disordered eating behaviors. At the time of the intake, client stated that he wanted to continue with therapy to explore the possibility of medication. During the first therapy session, client was unable to identify any goals for treatment and identified he was attending therapy because of a friend who had referred him for services. Client provided verbal and written consent for his information to be used for this case study. Developmental/Social History. Client is reportedly the oldest of three children, with his parents married and living together. Per client report, his brother is 6 years younger than him and his sister is 12 years younger than him. He reported that his relationship with his parents has fluctuated over the years and is currently not at its best. He identified that his familys recent move has been challenging for them and has negatively impacted his parents relationship with one another. Client identified having a closer relationship with his mother than his father. Because of clients mothers reported illness and her fear of doctors, client reported often worrying about her. Client reported never feeling close to his father and identified his father as a disciplinary figure rather than a father figure. Clients father, per client report, has been 18 diagnosed with Bipolar, which has made it difficult for client to be able to navigate any relationship with his father. Client reported having a good relationship with his siblings but did not elaborate on their relationship any further. He identified his support system as his fraternity brothers and reported enjoying living in his fraternity house because he felt supported there. Client is currently single, but he did report one previous serious relationship, which will be discussed in more detail in the trauma history section below. Trauma History. During the intake, client reported witnessing his father physically abuse his mother when he was 8 years old. He stated that he went to stay at his grandmothers house, which was reportedly close by, after the incident and reported that the incident was reported to the police. He reported remembering that his father had to go to court but denied being able to remember any further details. Toward the end of treatment, client also identified being in a previous relationship that was traumatic for him. He reported meeting this individual, who client identified as a male, soon after graduating high school. He noted dating this male for approximately one year over the course of his freshman year in college. During this relationship, client reported doing things he would not normally do to make his boyfriend happy. For example, he reported his boyfriend did not want their relationship to be monogamous, so client agreed to a non-monogamous relationship in an effort to make his boyfriend happy. He even stated he switched college majors because of the pressure his boyfriend put on him. Client reported that this relationship was overall very bad for him and identified that during his relationship he had isolated himself from all his other friends. Client identified only having his boyfriend and his family at that time. 19 During clients relationship with this boyfriend, he reported experiencing a traumatic interaction with another male. Because his boyfriend did not want their relationship to be monogamous, client reportedly often felt pressure to also have relations with other men. This led client to be intimate with someone he did not know but had been talking to online. Client said that when he first met this person face to face, he immediately knew they were not who they claimed to be. Client identified feeling fearful but reported not knowing how to actually stop the interaction from taking place. He described that this interaction as mildly violent and painful, but again reiterated that he was unsure how to ask the other individual how to stop. Client reported that the interaction resulted in multiple wounds on his back, which resulted in the client bleeding afterward. He described himself as feeling more scared than ever that night. Client noted he has not had any contact with that individual since the interaction. He reported that he tried to move past this situation by throwing himself into his relationship with his boyfriend, but he identified still feeling guilty and mortified about the event that occurred. After this event, client reported he continued to be intimate with his boyfriend out of fear of losing his attention to the other men his boyfriend was being intimate with, although he reported he did not enjoy the intimacy. Medical/Mental Health History. Client denied any significant medical history but did endorse family history of multiple sclerosis on his mothers side of the family and history of heart disease on his fathers side of the family. Client reported this to be his first time in therapy, though he endorsed a history of anxiety, trauma, and depression. He also reported being prescribed anti-anxiety medication by his primary care physician in spring 2017 for six months. He reported one previous suicide attempt in 2019 but denied any hospitalizations because of mental health concerns. Client reported a history of depression on his fathers side of the family, 20 with his father reportedly being diagnosed with and medicated for Bipolar Disorder. He also identified that his paternal great grandparents, his paternal great aunts, and his paternal great uncles all died by suicide. Self-Harm/Suicidal Ideation History. During the intake, client endorsed a sporadic history of self-harm, specifically cutting. He identified that this behavior began first in high school and resurfaced in September 2019. He reportedly typically cuts his upper arm. His last time cutting was reported to be right after Christmas 2019. Client identified that after cutting himself, he often felt less frustrated and less agitated long enough for him to be able to fall asleep. Despite reporting occasional thoughts of wanting to cut himself, client denied any cutting behaviors while in therapy. Client also reported recurrent suicidal thoughts at least once per day, usually at night, which he reported often preoccupy him. Client described these suicidal thoughts as usually thinking about cutting deeper and in different spots and by imagining how everything would just be gone. Clients noted suicide attempt in 2019, which was mentioned above, reportedly happened when he was lying in his bedroom in the dark, was thinking about things, and was feeling particularly frustrated with his inability to get out of his thoughts. He claimed he tried to slice [himself] deeply on his left wrist. He denied going to the hospital because of his cut, but instead reported that he cleaned himself up, went to bed, woke up the next morning and went to class like he usually did. He denied any suicide attempts as well as any intent to complete suicide over the course of therapy. Client identified his fraternity brothers as protective factors and reported one of his close friends, who eventually became his roommate, removed all sharp objects from his room so he could not use them to cut himself. 21 Diagnosis. Based on the clients presenting concerns and history, the client was diagnosed with 309.28 (F43.23) Adjustment Disorder with mixed anxiety and depressed mood. This is supported by the clients report of all the recent changes he was experiencing in his life within the past 3 months, such as his family moving, his friends moving, learning his mother was sick, and him quitting his job, that were causing the client significant emotional distress that seemed more severe than expected. Although client reported a history of anxiety, trauma, and depression and reported a history of self-harm and suicidal thoughts, the clients primary presenting concerns for current treatment were related to his adjustment related difficulties. Per the clients report, he was experiencing challenges related to coping with recent changes in his life, thus leading to a diagnosis of AD. At the time of diagnosis, the therapist differentiated between several other mental health diagnoses, such as Generalized Anxiety Disorder (GAD), Major Depressive Disorder (MDD), and PTSD. GAD is often characterized by feelings of excessive worry most days over the course of six months. During these six months, individuals with GAD typically experience symptoms such as restlessness, fatigue, trouble concentrating, irritability, muscle tension, and trouble sleeping. Individuals with GAD may experience symptoms for as little as six months or as long as years at a time (American Psychiatric Association, 2022). Although this client reported experiencing periods where he was unable to control his worry, he reported this to only occur occasionally rather than more days than not. The client also reported trouble falling asleep at night, but he did not endorse other symptoms characteristic of GAD over the course of the previous six months, such as feeling restless or fatigued, trouble concentrating, irritability, or muscle tension occurring more days than not. Further, the client endorsed often feeling worried about specific stressors rather than in general about a number of different activities. 22 MDD is characterized by the presence of five or more symptoms over a two-week period, with at least one of the symptoms including depressed mood or loss of interest. Additional common symptoms of MDD include changes in weight and/or appetite, trouble sleeping, psychomotor agitation, fatigue, feelings of worthlessness, feelings of hopelessness, trouble concentrating, and thoughts of death. Similar to GAD, MDD can last anywhere from as little as two weeks to months or years at a time (American Psychiatric Association, 2022). Although this client reported having a "melancholy mood and feeling bogged down occasionally, he did not endorse these to be present more often than not. This client also failed to endorse any changes in weight or appetite nor any feelings of psychomotor agitation, fatigue, or feelings of worthlessness or hopelessness. The client had a history of suicidal ideation, but he only reported passive suicidal ideation during the first and sixth therapy sessions and denied any suicidal ideation, active or passive, throughout the rest of treatment. The final differential diagnosis considered, PTSD, occurs after an individual has either experienced or witnessed a traumatic event, such as actual or threatened death, serious injury, or sexual violence. Individuals with PTSD experience various symptoms from separate clusters, such as intrusive symptoms associated with the traumatic event, avoidance of triggers related to the traumatic event, negative changes in mood and thoughts related to the traumatic event, and increased reactivity and arousal. These symptoms typically last at least for 30 days one month following the traumatic event occurred and can last for several months or years at a time (American Psychiatric Association, 2022). During his fifth therapy session, this client disclosed a history of sexual abuse occurring approximately two years prior. However, the client did not endorse intrusive symptoms related to the abuse, nor did he report any feelings of increased reactivity or arousal. 23 Therefore, given clients presentation and report of symptoms and the nature of adjustment related concerns as they relate to college students, AD with mixed anxiety and depression appeared to be the best fit for this client. Because of the additional symptoms the client was reporting, such as low mood and feeling down and trouble with feeling nervous and worried, the addition of the specifier with mixed anxiety and depressed mood was included to account for the clients feelings of anxiety and depressed mood. This allowed the clients diagnosis to encapsulate those symptoms that otherwise did not meet full criteria for additional diagnoses. Adjustment Disorder Adjustment disorder background and symptoms. AD is a severe reaction to an identifiable stressor or stressors (American Psychiatric Association, 2022; OConner & Cartwright, 2012; Carta et al., 2009; ODonnell, et al., 2019). These different stressors that result in AD can appear as minor stressors to some but can be majorly distressing to the individual who experiences the stressor themselves. It is critical that clinicians, as well as other observers, recognize the importance of how stressors are perceived by the individual rather than how the stressors may appear to others. Among stressors, continuous stressors are considered more likely to cause AD, although OConner and Cartwright (2012) highlight that the effects of AD are often moderated by social support. AD was first introduced into the third edition of the DSM (American Psychiatric Association, 1980). It then appeared in the DSM-IV-TR (American Psychiatric Association, 2000) with minor changes made to the disorder and now appears in the current DSM-5 TR (American Psychiatric Association, 2022) with the following diagnostic criteria: 24 A) The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s); B) These symptoms of behaviors are clinically significant, as evidenced by one of both of the following: 1) Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation, 2) Significant impairment in social, occupational, or other important areas of functioning; C) The stress-related disturbance does not meet criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder; D) The symptoms do not represent normal bereavement; and E) Once the stressor or its consequence have terminated, the symptoms do not persist for more than an additional 6 months (American Psychiatric Association, 2022, pg. 1133-1134). AD has the following six subtypes: AD with depressed mood, AD with anxiety, AD with mixed anxiety and depressed mood, AD with disturbance of conduct, AD with mixed disturbance of emotions and conduct, and AD unspecified (American Psychiatric Association, 2022). According to the American Psychiatric Association (2022), AD is a common diagnosis, with roughly 5% to 20% of individuals in outpatient mental health treatment settings having a principle diagnosis of AD. AD can occur at any point in an individuals life span, although young people are reportedly more vulnerable to the disorder because of their less well-developed coping skills and resources (OConner & Cartwright, 2012). The prevalence of AD in child and adolescent community samples fluctuate between 2% and 8% (American Psychiatric Association, 2000; Strain & Newcorn, 2003). AD appears to be more common among 25 disadvantaged persons (Vanin, 2008) and among individuals who have previously experienced trauma (OConner & Cartwright, 2012). Among individuals diagnosed with AD, their symptoms can widely vary. Some of the emotional and cognitive symptoms of AD could include hopelessness, sadness, lack of enjoyment, crying episodes, anxiety, irritability, suicidal ideation, worry, difficulty concentrating, and feeling overwhelmed. Some of the behavioral symptoms of AD could include sleep disturbances, fighting, reckless driving, mismanaging finances, truancy, and vandalism. Additionally, AD can have negative effects on close relationships, performance at school and work, and parenting (Carta et al., 2009; OConner & Cartwright, 2012). AD has come to be known as the cornerstone between major psychiatric disturbance and normal functioning. Strain and Diefenbacher (2008) further elaborate that AD straddles the border between normal and significant distress experienced when faced with acute and chronic stressors. Because of this, less research has focused specifically on AD than other Diagnostic Statistical Manual (DSM) disorders (Carta et al., 2009; OConner & Cartwright, 2012). Empirical support for treating adjustment disorders. When considering how to effectively treat individuals with AD, interventions are necessary to ease distress and to reduce the risk of suicide and future psychopathology, especially with younger individuals. Primary goals of interventions specific to AD include symptom relief, restoring typical functioning, and preventing the development of more serious disorders. Additional treatment goals might include helping clients understand their roles in stressful life events, reviewing and reinforcing positive steps clients take to deal with stress, learning to avoid and cope with stressors, and helping clients perceive their experiences as opportunities for growth and development (Carta et al., 2009; OConner & Cartwright, 2012). 26 Some of the recommended interventions for individuals with AD include support groups, individual therapy, and family therapy. Time-limited, or brief, interventions that support the clients attempts to identify and understand stressors, to establish and strengthen coping skills, and to build supportive relationships are desirable. Furthermore, it is important that interventions be specifically tailored to each individual depending on their current and previous difficulties (Carta et al., 2009; OConner & Cartwright, 2012). Despite the apparent need for effective interventions for individuals with AD, not many treatment outcome studies for AD exist in the literature, especially when compared to the extensive literature that exists for other disorders (Carta et al., 2009; OConner & Cartwright, 2012; Zelveine & Kazlauskas, 2018). Multiple factors can help to explain the lack of research pertaining to AD. First, by definition, AD is a brief disorder that is a reaction to stressors and often fades on its own (OConner & Cartwright, 2012). Because ADs are often short-lived and can resolve on their own over time, this may explain the lack of including AD in various research studies (Carta et al., 2009). AD can involve a wide range of stressors, which makes the population of individuals who meet criteria for AD largely heterogeneous. Furthermore, individuals with AD are occasionally a part of treatment outcome studies focused on related disorders when they have related symptoms, such as depression or anxiety. It is possible that these different factors led potential researchers to conclude that treatment outcome studies specific to AD are either difficult, unjustified, or unnecessary because interventions that are effective for other DSM disorders should also be effective when treating less severe versions of the same symptoms that develop in individuals with AD (OConner & Cartwright, 2012). 27 Contrary to this belief of ADs being short-lived and able to resolve over time is a study conducted by ODonnell and colleagues (2016) that found trauma survivors diagnosed with AD three months after the trauma exposure were 2.67 times more likely to eventually meet criteria for additional, more severe, mental health disorders after 12 months when compared to individuals who had no AD diagnosis at 3 months post-exposure. This study (ODonnell et al., 2016) provides support for effective intervention for individuals diagnosed with AD, rather than simply allowing time to resolve the matter on its own. Among current research, psychotherapy stands as the preferred treatment for AD (Kaplan & Sadock, 1998). However, a lack of controlled clinical trials of different psychotherapies makes it challenging to answer which form of psychotherapy may be most effective (Carta et al., 2009). Few between-group studies for AD have been conducted thus far. Some current studies, which provided support for treatment of AD and demonstrated a decrease in reported symptoms, have included a variety of therapeutic approaches, such as cognitive-behavioral therapy (Steinhardt & Dolbier, 2008) and brief group psychodynamic therapy (Ben-Itzhak et al., 2012). Maina and colleagues (2005) acknowledged the effectiveness of brief dynamic psychotherapy and of brief supportive psychotherapy when treating minor depressive episodes. Although this study did not examine the effectiveness of brief psychodynamic therapy in AD, it provides possible direction for future studies given the overlap between AD and depressive diagnoses (Maina et al., 2005). Another study found interpersonal psychotherapy to be effective when working with patients who were human immunodeficiency virus (HIV)-positive with depressive symptoms (Markowitz et al., 1998). Brief Psychodynamic Therapy 28 Qualities of brief psychodynamic therapy. When discussing brief psychodynamic therapy, it is important to acknowledge that it is a modification from traditional psychodynamic therapy (Levenson, 2017). As a modification from traditional psychodynamic therapy, brief psychodynamic therapy leans on different common components of psychodynamic theories, like the importance of childhood experiences and developmental history (Fonagy, 1999), unconscious influences on behavior (Freud, 1900), repetitive behavior, transference and countertransference (Freud, 1936), the role of conflict (Freud, 1931), and the therapeutic alliance. A therapist working within a brief psychodynamic therapy model, compared to a therapist working within a traditional psychodynamic therapy model, is more likely to highlight clients strengths and resources when facing life issues instead of focusing on regression and fantasy. Because of this difference, some popular psychodynamic techniques, such as lying on a couch or free association, are not utilized (Levenson, 2017; Strupp & Binder, 1984). According to Levenson (2017) and Strupp and Binder (1984), another modification made from traditional psychodynamic therapy in brief psychodynamic therapy is the greater emphasis placed on the clients present life rather than their previous childhood life. In addition to using modified psychodynamic interventions, brief psychodynamic therapy also utilizes techniques from other therapeutic models, such as experiential-process therapy and cognitive-behavioral therapy (Abbass, 2015; Fosha, 2000; Lilliengren et al., 2016; McCullough & Magill, 2009; Safran & Muran, 2000). Although the brief psychodynamic therapist might think and conceptualize psychodynamically, they are free to use a variety of intervention strategies (Levenson, 2017). Messer and Holland (1998) acknowledge that there are several different models of brief psychodynamic therapy. Some brief psychodynamic therapies have been developed primarily 29 from ego psychology and drive theory (Freud, 1923), and typically focus on conceptualizations that highlight aggressive, sexual, and dependent impulses and defenses, as well as oedipal conflicts (Messer & Holland, 1998). Other brief psychodynamic therapies, however, are largely focused on object relations and interpersonal relations, which help to identify problems from a perspective of maladaptive interpersonal patterns (Levenson & Strupp, 1997), focus on clients wishes, responses of others and responses of the self (Luborsky, 1997), focus on schemas and role relationships (Horowitz & Eells, 1997), and focus on problematic beliefs and how they play out between the client and therapist (Curtis & Silberschatz, 1997). Additionally, Mann (1991) detailed a brief 12 session therapy that consists of ideas stemming from self-psychology, specifically the use of empathy to help heal clients longstanding feelings of pain. Because there are so many brief psychodynamic therapy models to choose from, the current study will focus on a contemporary brief, time-limited psychodynamic therapy, as proposed by Levenson (2017) and originally Strupp and Binder (1984). There are multiple qualities that help to characterize brief psychodynamic therapy (Levenson, 2017; Levenson et al., 2002; Strupp & Binder, 1984) . The main factor that differentiates brief psychodynamic therapy from long-term psychodynamic therapy is its defined focus. In brief psychodynamic therapy, therapists must focus on a central theme, topic, or problem to help guide their work with their clients because of its brief nature. Additionally, it should be noted that in brief psychodynamic therapy, therapists and clients usually have limited goals. Brief psychodynamic therapy is not meant to be a once and for all cure but should provide clients with opportunities to foster changes in behavior, thinking, and feelings as it pertains to the main problem explored in session. Brief psychodynamic therapy should help clients learn more adaptive coping skills, help clients develop better interpersonal relationships, 30 and/or help clients gain a better sense of ones self. Therefore, brief psychodynamic therapy is seen as a chance for clients to begin a process of change that hopefully persists even after therapy is over (Levenson, 2017; Strupp & Binder, 1984). Another quality of brief psychodynamic therapy is its time limited nature (Levenson, 2017; Strupp & Binder, 1984). Messer and Holland (1998) described that brief psychodynamic therapy can range anywhere from 1 to 40 sessions, although it appears that most brief psychodynamic clinicians working today set a standard of 12 to 20 sessions as their model (Barber et al., 2013; Levenson, 1995; Strupp & Binder, 1984). Levenson (2017) and Strupp and Binder (1984) explain that brief psychodynamic therapists believe that by limiting the length of therapy sessions clients are allowed, clients are encouraged to have a sense of individuation and autonomy as well as positive expectations for treatment. In fact, there is evidence that providing these shorter time limits could encourage clients who might have otherwise prematurely terminated in a longer, open-ended therapy format to stay in therapy longer until they can successfully terminate (Hilsenroth, Ackerman, & Blagys, 2001). Another common belief among brief psychodynamic therapists is the belief that psychological change happens outside of the therapy room and that by setting time limits on therapy, this actually intensifies the therapeutic work done (Bolter, Levenson, & Alvarez, 1990). Additionally, in brief psychodynamic therapy, the therapist needs to be an active participant in the therapy process (Levenson, 2017; Strupp & Binder, 1984). It is important for the therapist to remember, however, that activity is only necessary in order to maintain the focus of therapy, to foster a positive therapeutic alliance, and to make progress within their allotted time. This requires the therapist to have an awareness of the therapy goals and a plan for how to achieve them, all while remaining sensitive to the clients presentation and to the context of the 31 clinical material. A therapists activity in sessions can range from supportive interventions such as validation, reassurance, and strengthening adaptive defenses to more exploratory interventions such as confrontation and interpretation. The therapists level of activity should be dependent on the different factors during the session, such as the strength of the therapeutic alliance, and on the characteristics of the client, such as their psychological health and their quality of interpersonal relationships (Levenson, 2017; Strupp & Binder, 1984). An additional quality of brief psychodynamic therapy is the therapeutic alliance, which has commonly been thought to include the emotional bond between therapist and client, the agreement on treatment goals, and the agreement on the plan on how to accomplish those treatment goals (Levenson, 2017; Strupp & Binder, 1984). The strength of the therapeutic alliance, especially from the clients view, has been consistently shown to be one of the strongest components in predicting treatment outcomes (Martin, Garske, & Davis, 2000; Zilcha-Mano, Dinger, McCarthy, & Barber, 2014). Furthermore, Heinonen and colleagues (2014) discovered that therapists with an engaging and encouraging relational style with their clients were able to foster working alliances with their clients, especially in the case of short-term therapies. Being able to develop a positive therapeutic alliance as quickly as possible is important in all therapy models but is especially important when working with a brief therapy model where the therapist might have fewer chances to repair any ruptures in the therapeutic relationship (Levenson, 2017; Strupp & Binder, 1984). According to Levenson (2017) and Strupp and Binder (1984), some additional qualities of brief psychodynamic therapy include the important ability of the therapist to quickly formulate the clients case and begin intervening and the therapists necessary willingness to terminate with clients in carefully considered style because of the short-term nature of the 32 therapy. The final major difference between long-term psychodynamic therapy and brief psychodynamic therapy includes the idea of establishing a therapeutic contract. Although the specifics of contracts vary and are not always written and should not necessarily be considered as legal contacts, there needs to at least be a mutual understanding between the therapist and client that their work together will be time limited and focused in scope (Levenson, 2017; Strupp & Binder, 1984). Theoretical background. It is important to know that this theoretical approach intertwines three different theories: attachment theory, interpersonal-relational theory, and experiential-affective theory. Let us first explore the components of attachment theory, which helps to provide the motivational explanation for brief psychodynamic therapy (Levenson, 2017; Strupp & Binder, 1984). Attachment theory suggests that infants exhibit a collection of natural behaviors in an effort to maintain physical closeness to caregivers (Bowlby, 1969). From an attachment theory perspective, people are designed to gravitate toward others considered to be older and wiser, especially during times where one feels stressed or threatened. As infants, humans are genetically programmed to seek attention from caregivers they depend on (Bowlby, 1969). One notable name in the attachment theory world, Mary Ainsworth, developed a now famous experiment to examine the attachment patterns of infants called the Strange Situation (Ainsworth, 1967). From this experiment, Ainsworth identified multiple distinct attachment patterns: secure attachment and insecure attachment (e.g., avoidant attachment and anxiousambivalent attachment). Another notable name in the attachment theory world, John Bowlby, developed a triad between attachment, separation, and loss that displayed the importance of the emotional quality 33 of early childhood in order to understand psychopathology (Bowlby, 1969, 1973, 1980). Although attachment initially referred to an infants proximity seeking, Bowlby later explained how attachment needs and behaviors continue later throughout the life cycle, with even adults turning to other adults, especially in stressful times (Bowlby, 1988). Bowlby (1988) explains that individuals have this internal psychological organization that consists of very specific features, such as representational models of the self and of attachment figures, that develops over time and is continuously built upon through early life experiences with caregivers. Therefore, a child has both an internalized expectation about how others will treat them and an internalized model of how they see themselves, feel about themselves, and treat themselves based on how they have been treated by others. Bowlby hypothesized that a child with a secure attachment learns to think that there are not any forms of the self that cannot be noticed, responded to, and dealt with (Levenson, 2017; Strupp & Binder, 1984). Children who do not have a secure attachment, on the other hand, learn that they cannot count on others to keep them safe when they are threatened. Children with an insecure attachment pattern have negative models of the self and/or others. These children have a difficult time being able to correct these negative internalized models because of their difficulties with cognitively and emotionally attending to incoming information that disconfirms their internal model. Because these working models are originated and then maintained out of awareness, this cycle only continues (Levenson, 2017; Strupp & Binder, 1984). Additionally, insecurely attached childrens internal working models persist partially because of the ongoing interactions these children have with the very individuals who contributed to this in the first place. For example, 34 someone who had harsh parents as an infant and child is likely to continue to have those harsh parents through toddler and adolescent ages (Wachtel, 2008). Bowlby viewed attachment as significant from birth through death, although adults typically do not need the proximity to another human in order to physically survive like infants do (Levenson, 2017; Strupp & Binder, 1984). According to Pietromonaco and Barrett (2000), adults feel secure when their attachment figures confirm they are loved, capable of love, and competent. In time, this sense of security internalizes within adults and is carried with them throughout life. Bowlby (1969) recognized that people, celebrities, and even institutions, as well as the mental representations of these figures, could be identified as attachment figures and sources of comfort to people. Recently, Shaver and Mikulincer (2008) were able to demonstrate that when people were asked to visualize the faces of their attachment figures, this promoted positive feelings, reduced painful feelings, and fostered empathy for those people. Although there is not a specific attachment therapy approach for adults, there is a lot of importance in the role of attachment theory for therapeutic formulation and intervention (Levenson, 2017; Strupp & Binder, 1984). Bowlby (1988) defined the five following tasks for the therapist to complete throughout therapy: be a trusted aid and provide a secure base so clients can examine the painful parts of their lives; help clients explore their expectations and biases in connecting with others; encourage clients to connect early parenting experiences to current functioning; help clients view the past as it is and help them identify healthier alternative ways of thinking and behaving; and help clients examine the therapeutic relationship as clients working models of self and others occur in therapy. Additionally, Bowlby (1988) believed that the therapist should explore a clients past only when it is useful in helping to understand the clients current feelings and ways of coping with their interpersonal world. 35 According to Levenson (2017) and Strupp and Binder (1984), the next theory underlying brief psychodynamic therapy is interpersonal-relational theory, which helps to form the frame for brief psychodynamic therapy. Harry Stack Sullivan is often noted for first acknowledging the importance of the interpersonal dimension for psychotherapy when he pushed for interpersonal relatedness over the previous Freudian position that biological drives determined the development of personality (Sullivan, 1953). Sullivan believed that through interactions with their parents, children develop self-other role relationship patterns, which later emerge in strategies that help one to avoid or manage anxiety and to maintain self-esteem. These strategies are also known as interpersonal coping styles. Sullivan originated the term participant observer to explain how in therapy sessions, the therapist is an expert observer that makes note of what is happening during the therapy session, as well as a full participant in the interaction taking place between the therapist and the client. The interpersonal perspective of therapy mirrors a larger shift taking place in psychoanalytic thinking and practice that was previously usually framed as a one-person, focus within model instead of the current two-person, focus between model (Levenson, 2017; Strupp & Binder, 1984). In fact, Messer and Warren (1995) noticed that most psychoanalytic schools are becoming more relationally oriented and less drive oriented. This increase in using interpersonal perspectives can be seen not only in psychoanalysis, but in other therapy models as well, such as cognitive therapy (Castonguay & Beutler, 2005) and behavioral therapy (Kohlenberg & Tsai, 1991). For a clinician in practice, this change to a more relational approach has wide implications, such as what qualifies as pathology, how one conceptualizes a client and their clinical situation, what interventions might be most helpful, and how outcomes are evaluated (Levenson, 2017; Strupp & Binder, 1984). Pincus and Ansell (2003) acknowledged that the 36 existence of others and how they help interpersonal learning can have effects on self-regulation, field regulation, and emotion regulation. This brings us to the final component of brief psychodynamics theoretical underpinnings: experiential-affective theory. According to Levenson (2017) and Strupp and Binder (1984), the experiential-affective theory is an important component of brief psychodynamic therapy because it focuses on the critical change agent part of the model. For psychodynamic therapies, a key feature has been focusing on affect and emotion expression (Hilsenroth, 2007). Early emotion theorists, such as Frijda (1986), Lazarus (1991), and Tomkins (1963) stressed the functions of emotions as motivating, adaptive, and organizing to oneself and to others. Psychodynamic therapists have long spent time acknowledging and exploring the emotions of their clients, but now practitioners and theorists from other therapeutic orientations are acknowledging the key role emotions have in creating change. Back in 2009, Schore declared that we were in an emotional revolution. He further explained that within the field of psychology, there had previously been a focus on behavioral and cognitive theories during the 20th century, but during the 21st century the emphasis will increasingly be on emotions (Schore, 2009). Despite this shifted focus toward emotions, clients are not always consciously aware of their feelings. Therefore, helping clients become aware of their emotions, experience their emotions, and process their emotions are critical components of experiential therapy models (Greenberg, 2012; Greenberg, Rice, & Elliot, 1993). For decades now, being able to be emotionally aware and emotionally intelligent, being able to reprocess emotions, and being able to regulate emotions have been indicated as signs of mental health (Goleman, 1995; Linehan, 1993; Schore, 1994). According to Fonagy, Gergely, Jurist, and Target (2002) and Siegel (2007), 37 someones ability to regulate their emotions is heavily motivated by their early experiences with caregivers. Siegel (2007) proposed that parents who can accommodate their childs emotional state and can stabilize their childs emotions help their child to develop circuits in the brain that promote emotion regulation. This ability to regulate emotions then helps their child to have a source of resilience as they grow, which then evolves into their ability to regulate themselves and engage in empathic relationships with others. This attunement to emotions is not only the pathway to a healthy psychological life, but it may also be the pathway to the development of healthy brain structures and functions and to improved interpersonal and intrapsychic functioning. Once these children who are able to regulate their emotions grow up and have their own children, they can then help build healthy brain structures and functioning in their own children, leading another generation to developing these resilient characteristics (Siegel, 2007). Additional research has supported the use of experiential-affective therapy. Diener, Hilsenroth, and Weinberger (2007) conducted a meta-analysis that consisted of 10 processoutcome studies and discovered that client improvement was significantly related to the extent that therapists accessed and processed emotional experiences. Lilliengren and colleagues (2016) have suggested that experiential dynamic therapy tend to outperform other active methods of treatment. Additional research has found that the depth of emotional experience during therapy is related to positive outcomes, regardless of the theoretical orientation used and with a variety of disorders (Lilliengren et al., 2016; Thoma & McKay, 2015; Whelton, 2004). Assumptions and goals. According to Levenson (2017) and Strupp and Binder (1984), one of the basic assumptions of the brief psychodynamic therapy model is the idea that people are naturally motivated to seek out and maintain human relatedness, which can be a major 38 motivating factor for all human beings. Another basic assumption of the brief psychodynamic therapy model is that maladaptive relationship patterns and their connecting emotions are developed early in life, become schematized, and then underlie many presenting concerns. Often times, how we relate during adulthood connects back to our early relationships with caregivers. These early experiences then form mental representations or working models of someones interpersonal world. These working models then become the foundation that informs an individual about the nature of human relatedness, their own sense of self, and the actions and behaviors necessary to receive and maintain attention from others. Additional basic assumptions, according to Levenson (2017) and Strupp and Binder (1984), of brief psychodynamic therapy are as follows: relationship patterns and their connecting emotions continue because they are managed in current relationships and are consistent with the individuals sense of self and others, also known as circular causality; clients are viewed as stuck, not sick; the focus in therapy is on changing maladaptive relationship patterns and their connected emotions; the therapist is concerned with what goes on within the session and between the therapist and client rather than with specific content; the therapist and client focus on one of the clients main problematic relationship pattern; the therapist acts as both an observer and a participant; and the process of change will continue even after the client terminates from therapy. When it comes to brief psychodynamic therapy, there are two major goals to keep in consideration. The first major goal of this brief psychodynamic therapy model is to provide clients with new experiences within themselves and relationally with others (Levenson, 2017; Strupp & Binder, 1984). By allowing clients to experience this type of experiential learning, they should hopefully encounter healthier and more functional relational interactions that can work to challenge their repetitive maladaptive patterns and promote more positive, less guarded, and 39 widened sense of self, in addition to more positive outlook toward others. This first goal highlights clients ability to feel differently and become aware of feeling differently as well as to act differently and then become aware of acting differently. Experiential learning is also emphasized in this therapy because of the power this type of learning can have on bring about change in clients (Levenson, 2017; Strupp & Binder, 1984). In an effort to spark this change, experiential learning should take place at both interpersonal and intrapersonal levels for our clients. In order for clients to have new interpersonal experiences, they need to take a risk with the therapist and with other individuals in their lives when faced with something that is typically avoided, such as feelings of anxiety, hopelessness, or shame. When clients are able to take this risk and observe how others react, this helps to create a new experience for the client themselves and for other people involved in the interaction. As clients engage in different behaviors than before, these behaviors can be rewarded and lead to new patterns beginning to replace old patterns. It is important to note that since clients previous, dysfunctional interpersonal styles developed through sequences of various antecedents and consequences, they can also learn to develop a more functional interpersonal style through new sequences of antecedents and consequences. Over time then, these new experiences can then help to shift the clients previous internal working model. In addition to new interpersonal experiences, clients also need new intrapersonal experiences to help replace maladaptive emotional states with more positive emotional states. This can be done by therapists providing corrective emotional experiences to clients as well as therapists being empathic toward clients (Levenson, 2017; Strupp & Binder, 1984). According to Siegel (2006), therapists who are empathic toward their clients do more than just helping clients 40 feel better in the moment, but they help clients to create new cases of neural activity that can help to improve clients self-regulation. According to Levenson (2017; Strupp & Binder, 1984), the second major goal of this brief psychodynamic therapy model is to provide clients with new understandings about emotional shifts within themselves and about relational shifts between themselves and other people. By doing this, there is hope that clients will be able to reflect on their emotions and relations with others as well as make meaning of their emotions and relations with others. Again, this goal must be done both interpersonally and intrapersonally for clients. In an effort to help clients grow intrapersonally, therapists need to carefully attend to emotions that clients are experiencing and expressing during therapy sessions and help clients better be able to understand these emotions and understand their meaning. To help clients grow interpersonally, therapists should help clients be able to identify and understand their interpersonal patterns and how these became developed and then maintained. Some common therapeutic techniques therapists might use at this point in therapy include reflection, clarification, interpretation, confrontation, and discussing patterns that emerge in the therapy room between the client and therapist. To help clients better understand their interpersonal patterns, therapists can bring to light repeated patterns that have occurred between client and therapist, between client and previous significant others, and between client and current significant others (Levenson, 2017; Strupp & Binder, 1984). This can help clients start to realize their patterns that occur with different people in their lives. Once clients gain this new perspective, they can then begin to consider their role in maintaining these dysfunctional interactions and can gain the ability of self-observation. As clients begin to be able to identify these dysfunctional patterns and relate them to their emotions, 41 they can then start having awareness in the moment when these dysfunctional interactions begin to occur. This awareness then allows clients to recognize opportunities to be able to break the cycle of dysfunctional interactions and behave differently. It is important here for therapists to realize their role in normalizing clients behavioral and emotional reactions by helping clients learn how their now dysfunctional behaviors were at one point in their life functional and had some sort of purpose for the client (Levenson, 2017; Strupp & Binder, 1984). Interventions. According to Levenson (2017) and Strupp and Binder (1984), interventions for this treatment model are known to be therapeutic strategies that are extremely entangled into the interpersonal relationship between the client and therapist. It is worth noting that any intervention that is related and able to aid the goals of new experiences and new understandings are able to be used. Because of the brief nature of brief psychodynamic therapy, it is important that therapists become comfortable with initiating interventions even before they have all the information they desire. To help with this, tentative statements that allow for client feedback begin to build feelings of collaboration between client and therapist. Interventions can simply draw clients to see and feel things differently and from a different perspective. During brief psychodynamic therapy, it is important that the therapist works with clients in a respectful and nonjudgmental manner, validating their perceptions and feelings, and inviting their collaboration over the course of therapy. It is also important that therapists demonstrate active listening to the client, acknowledge clients strengths, and address any obstacles and opportunities that might influence the therapy process (Levenson, 2017; Strupp & Binder, 1984). Marcolino and Iacoponi (2003) conducted a study to examine the influence of the therapeutic alliance among clients receiving brief psychodynamic therapy and discovered that clients who 42 had higher levels of therapeutic alliance during the first therapy session had more favorable outcomes at the end of treatment. In addition to developing and maintaining that therapeutic alliance, therapists should also: help clients access, label, and process their emotions; utilize empathic exploration to better understand the client; maintain focused questions that pertain to the established goal; facilitate exploration of clients relationships with significant others as well as with the therapist; facilitate exploration of cyclical maladaptive patterns as well encourage new adaptive behaviors to replace the previous maladaptive behaviors; promote change directly to the client by providing the client with chances to have new experiences and new understandings; and discuss the time-limited nature of brief therapy (Levenson, 2017; Strupp & Binder, 1984). Thinking specifically about the importance of emotions, there is large support that emotional processing during therapy sessions and across treatment can be considered a core agent of change for clients engaged in therapy (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996; Jaycox, Foa, & Morral, 1998; Magnavita, 2006; Pos, Greenberg, Goldman, & Korman, 2003; Whelton, 2004). McCullough and colleagues (1991) as well as other studies (Hill, Helms, Spiegel, & Tichenor, 1988; Hilsenroth, Ackerman, Blagys, Baity, & Mooney, 2003; Town, Hardy, McCullough, & Stride, 2012; Diener, Hilsenroth, & Weinberger, 2007) have been able to demonstrate that the number of emotion-oriented interventions was related to clients outcome at the end of brief psychodynamic therapy treatment. Empirical support for brief psychodynamic therapy. According to Lambert (2004), a large number of psychotherapy research conducted in the United States involves brief therapies that last no longer than 20 sessions. In a study done by Falkenstrom, Josefsson, Berggren, and Holmqvist (2016), they found that the rate of change is indeed quicker for clients who attend 43 fewer number of therapy sessions. In 2013, Lambert studied the effectiveness of psychotherapy and observed that approximately 50% of clients responded to therapy by the 8th session. Hansen and associates (2002) discovered that approximately 60-70% of clients showed improvement within 13 sessions, while additional studies (Hoglend, 2003; Kopta, Howard, Lowry, & Beutler, 1994; Shapiro et al., 1995) have found that clients with both acute and chronic symptoms demonstrated clinically meaningful change between 13 and 18 sessions. When looking at the efficacy of brief psychodynamic therapy, Barber and colleagues (2013) gathered the results from multiple studies and found that psychodynamic therapies, most of which were reportedly short-term, appeared to be superior to control groups at the time of termination and during later follow-ups in regard to depressive, anxiety, and personality disorders. Additional meta-analyses found that brief psychodynamic therapy was superior to waiting list control groups and was just as effective as other psychotherapy treatments, such as cognitive-behavioral therapy and solution focused therapy, and medications (Abbass et al., 2008; DeMaat et al., 2008; Leichsenring, Rabung, & Leibing, 2004). Knekt and associates (2008) conducted a randomized trial to examine the effectiveness of short-term and long-term psychodynamic therapy and found that the participants from the brief psychodynamic therapy group were able to demonstrate maintained positive improvements throughout the 3-year post follow up. Empirical support for brief psychodynamic therapy with AD. In clinical settings, AD is a common diagnosis (Carta et al., 2009). Because quick intervention could help to prevent further complications for individuals diagnosed with AD, such as relationship problems or decreased functioning at places like school or work, being able to provide effective treatment for these clients is important (Strain & Diefenbacher, 2008). According to Strain and Diefenbacher 44 (2008), the main goals for therapy when working with an individual diagnosed with AD should include restoring their mental balance, uncovering the concerns and conflicts the client reports experiences, identifying coping skills and supportive relationships to aid in reducing current and future stressors, and helping the client regain perspective on the challenge they have encountered. Despite this need for effective quick intervention for individuals diagnosed with AD, AD is often overlooked by researchers (Azocar & Greenwood, 2007; Carta et al., 2009; Casey, 2009) and few studies have examined the treatment of clients with AD as their primary diagnosis (Stirman et al., 2005). Recently, a study examined the effect of 12 sessions using client-centered therapy among clients diagnosed with AD. This study discovered that these clients did indeed experience symptom relief at the end of treatment and found that this effect was maintained during the 2year post-treatment evaluation period (Gorschenek et al., 2008). Similarly, another study found that client-centered therapy with clients diagnosed with AD was superior to clients in control groups that went untreated (Altenhofer et al., 2007). Psychodynamic therapy has been found to be superior to untreated control groups for clients diagnosed with Minor Depressive Disorder (Maina et al., 2005). Since minor depression and AD share some of their characteristics (Casey, 2009), one might be able to hypothesize that psychodynamic therapy may also be superior to untreated control groups for clients diagnosed with AD (Ben-Itzhak et al., 2012). The amount of literature comparing the overall effectiveness of brief psychodynamic therapy versus longer psychodynamic therapy in general is limited, which has led to not enough evidence to support choosing between a brief or long-term therapy when working with clients diagnosed with different psychiatric disorders (Knekt et al., 2008). In an attempt to fill this gap, Ben-Itzhak and colleagues (2012) conducted a study to compare the effectiveness of brief 45 psychodynamic therapy, which consisted of 12 therapy sessions, to intermediate length psychodynamic therapy, which consisted of one year of therapy, when working with clients diagnosed with AD to see if there was any benefit from intermediate length therapy versus brief therapy. Their study found that after 3 months of therapy, clients from both groups showed significant improvement. Furthermore, the improvement achieved by both therapy groups was equally continued at the 9-month follow up after terminating from therapy. These results help to provide evidence that brief psychodynamic therapy is not inferior to long-term psychodynamic therapy when trying to restore previous psychological functioning prior to developing an AD (Ben-Itzhak et al., 2012). Additionally, Bloom (1997) and Steenbarger (1992a) conducted lengthy reviews of research on brief therapy, and both discovered there to be strong evidence supporting the effectiveness of brief therapy, even stating that brief therapy is often as effective as long-term therapy. Empirical support for brief psychodynamic therapy in college counseling. When considering brief therapy in college counseling centers, it is important to critically examine both the advantages and limitations of brief, time-limited models. Some notable limitations of brief therapy in college counseling centers include the argument that it is important to allow students the freedom and autonomy to decide when to engage in services and when to terminate services, given their developmental stage (Widseth & Webb, 1992). Furthermore, May (1988) supported this limitation by noting the important difference between a goodbye that is chosen by the student and a goodbye that is forced. It is also possible that students respond to time-limits in a negative manner that might hinder their ability to build an alliance with the therapist. Allowing 46 the students to choose just how much therapy they want when facing a development crisis could be especially important (Ghetie, 2007). Some college counseling center clinicians oppose time-limited therapy because they argue that therapy with college students is already inherently brief, with the median number of sessions between 4 to 5 (Rockland-Miller & Eells, 2006), thus making it questionable what the purpose of further limiting treatment is (Whitaker, 1994). Finally, a study conducted by Gyorky, Royalty, and John (1994) discovered that college counseling centers with imposed time-limits had longer wait lists and were not able to serve a high percentage of the study body when compared to college counseling centers without any imposed time-limits. Despite these limitations of brief therapy in college counseling centers, there are also many notable advantages that should be considered, such as the apparent support that brief, timelimited treatment has been shown to be effective in college counseling centers and in other treatment settings (Ghetie, 2007). Supporting this notion, Anderson and Lambert (1995) completed a meta-analysis that consisted of more than 20 empirical studies of brief psychodynamic therapy and discovered a moderate mean effect size. Additional studies have found that even very brief treatments, defined as consisting of less than 5 sessions, have been shown to be effective (Michel, Drapeau, & Despland, 2003; Pinkerton & Rockwell, 1994; Vonk & Thyer, 1999). Medalie (1987) noted that in college counseling centers, brief therapy can be effective in preparing students for long-term therapy completed at settings outside of counseling centers. Additional arguments have been made that brief, time-limited treatment can reduce wait lists, is cost effective, and allows clinicians to have more time for other services, such as outreach (Ghetie, 2007). Further supporting brief therapy in college counseling centers, Wolgast, 47 Lambert, and Puschner (2003) completed a study on the dose-response rate in college students in an effort to conclude how many therapy sessions are needed for significant change to occur. From their study, they discovered that 24% of students obtained significant change after the 7th therapy session and 51% of students obtained significant change after their 14th therapy session (Wolgast, Lambert, & Puschner, 2003). Looking specifically at college counseling centers, multiple research studies have demonstrated that short-term therapy is indeed practiced in these settings, as evidenced by the consistently low average number of therapy sessions students attend (Gallagher, R., & Bruner, L., 1995, 1996, 1997). Archer and Cooper (1998) have outlined six different reasons as to why brief therapy models should be utilized within college counseling centers, such as: the expanding evidence supporting the effectiveness of brief therapy with a wide range of clients and presenting problems; the suitability of the types of developmental and situational problems students often present with for brief therapy; the reality of clinicians in college counseling centers needing to limit their scope in order to equally reach as many students as possible; the need for consultation and prevention type work to address different important issues campus wide; the need for outreach and program development; and the growing demand for services as more students find themselves more accepting of therapy. As previously alluded to, the types of developmental problems that students often present with at college counseling centers, in addition to the reality of time limitations posed by academic calendars, have led most college counseling centers to adopt brief therapy models (Cooper & Archer, 1999; Steenbarger, 1992b). It should be noted that although some clinicians and authors make the argument that college counseling centers should indeed provide brief therapy for most students, typically lasing around 5 to 10 sessions, students in need of long-term 48 therapy should be properly assessed and either referred elsewhere for services or be given an exception and allowed long-term therapy if they are not able to obtain services elsewhere (Stone & Archer, 1990). Empirical support for brief psychodynamic therapy with members of the LGBTQ+ community. When trying to determine an appropriate and effective approach for particular clients, clinicians are faced with a critical decision of the therapeutic process (Fassinger, 1999). While working with clients who are highly verbal and are relatively well-functioning individuals who want to obtain better understandings of their past and how it relates to their current behaviors, psychodynamic approaches appear to be useful (Corey, 1996). For clients who identify as part of the LGBTQ+ community, psychodynamic therapys focus on clients own history and family history may be appropriate, especially when considering analyzing the type of experience a client might have during their process of coming out. Developing a better understanding of the dynamics between the client and their parents could help LGBTQ+ clients who report problems in seeking or accepting social support and in achieving intimacy, as well as help LGBTQ+ clients better understand typical and dysfunctional relationship patterns. As LGBTQ+ clients form strong attachments to their therapists, it is possible that this is the first time the client has been able to be open and honest with someone, has felt known and understood by someone, or experienced an accepting relationship with someone. Since LGBTQ+ clients could have countless numbers of concerns that they bring into the therapy room, an integrative approach is essential to effectively working with these clients (Fassinger, 1999). It is also important to address the high suicide rate of LGBTQ+ youth, who have up to four times the risk of attempting suicide compared to their counterparts that identify as heterosexual. LGBTQ+ youth that come from families who are not accepting of them have up to 49 eight times the risk of attempting suicide (McDaniel, Purcell, & DAugelli, 2001). Often times, LGBTQ+ youth can feel isolated and unsure of who to trust. These youth might not seek out mental health services because of their own fears of treatment or because of previous negative experiences with mental health professionals (Fauman & Hopkinson, 2010). This further highlights the importance of building rapport with clients who identify as members of the LGBTQ+ community as well as the importance of quick and effective interventions. Case Formulation Based on the clients background information, it appeared that in regards to his current treatment, there were a few different major events that contributed to this clients development and functioning: his past and possibly current relationship with his parents; his previous relationship with his ex-boyfriend; the reported sexual trauma the client experienced at the age of 18; and the recent negative changes in clients life (e.g., his family moving away; his quitting his job he previously had for 4 years; his lifelong friends moving away; his learning of his mothers illness; and his placing more focus on his personal life). First, it was important to consider this clients attachment and how it related to his current functioning. Based on the clients reported relationship with his parents, it is possible that his parents inability to appropriately respond to him while growing up could have led the client to developing an insecure attachment with his parents that persisted throughout his life thus far. Specifically, it is possible that the client developed an anxious-ambivalent attachment pattern. Furthermore, when considering this clients relationship with his ex-boyfriend, it seemed that this relationship that had the client constantly worrying about whether he was good enough for his ex-boyfriend and constantly worrying about his boyfriend leaving him could have further reinforced this insecure attachment pattern. This also demonstrated the possibility that the client 50 learned, from this attachment pattern, that he was not able to count on others to keep him safe as well as learned to view himself and others in a negative manner. Taking the interpersonal-relational theory into consideration, which explains that children develop self-other role relationship patterns through interactions with their parents, it is possible that the client witnessed a dysfunctional type of relationship between his mom and dad growing up that then became the clients idea of what a typical relationship looks like. This was demonstrated by the clients relationship with his ex-boyfriend and was then possibly further engrained in the client through the sexual abuse he experienced at the age of 18. Building on the clients foundation of an insecure attachment style from his relationship with his parents, it is possible that his relationship with his ex-boyfriend and the sexual abuse the client experienced both further enhanced this attachment style for this client, who seemed to have repeatedly been exposed to unhealthy relationships throughout his life. When considering the experiential-affective theory and how emotions are motivating, adapting, and organizing to the client and to others, it was important to consider the impact the clients dad possibly had on him. The client reported an inability to form a relationship with his father because the client never knew how his father was emotionally going to act. This suggested that the clients dad was poor at regulating his own emotions and therefore could have modeled this poor emotion regulation to the client, rather than modeling appropriate emotion regulation. That lack of emotion regulation for the client could help to explain the clients history of selfharm as a way to cope in the past. Treatment Plan An important component of this brief psychodynamic therapy was the time-limited aspect of treatment. Although the time-limited component of therapy was never outright discussed at 51 the start of therapy, the structure of the academic calendar and the clients knowledge that therapy services would be ending at the end of the semester made it clear that the therapist and client had roughly 12 weeks to meet for individual therapy sessions on a weekly basis. Because of the impact the COVID-19 pandemic had on the university, the clients therapy lasted a total of six individual therapy sessions. Although the client originally came into therapy without any clear treatment goals, the client later identified a goal of wanting to come to terms with what had previously happened between him and his ex-boyfriend. In accordance with the brief psychodynamic therapy model and the therapists conceptualization of the client, the therapist had the following goals for the clients treatment plan: to build a strong therapeutic alliance with the client; to provide the client with a healthy and functional relationship to challenge his maladaptive relationship pattern in place; and to provide the client with new understandings about his emotions as they occur within him and as they occur within relationships with others. In order to achieve these goals, the therapist utilized appropriate interventions outlined in the brief psychodynamic therapy model, such as: working collaboratively with the client; validating the clients perceptions and feelings; demonstrating active listening to the client; helping the client access, label, and process his emotions; using empathic exploration; facilitating exploration of the clients relationships with others as well as with the therapist; and facilitating exploration of cyclical maladaptive patterns. Clinical Research Question Current research on effective treatments for individuals diagnosed with AD is minimal (Carta et al., 2009; OConner & Cartwright, 2012; Zelveine & Kazlauskas, 2018). However, previous research has demonstrated some support for a variety of therapeutic approaches in the treatment of AD, such as cognitive-behavioral therapy (Steinhardt & Dolbier, 2008) and brief 52 group psychodynamic therapy (Ben-Itzhak et al., 2012). Despite the lack of research surrounding the effectiveness of brief psychodynamic therapy with individuals diagnosed with AD, there have been studies that have found brief psychodynamic therapy to be effective when treating individuals with minor depressive episodes (Maina et al., 2005). Given the current limited research on the effectiveness of brief psychodynamic therapy with individuals diagnosed with AD, there is a significant need for research that provides support for effective treatment for work with individuals diagnosed with AD. The current case study examined a client diagnosed with AD who received outpatient treatment in a college counseling center. The treatment modality used in the current case study was a form a brief psychodynamic therapy. Although the current case study aimed to have roughly 12 individual therapy sessions with the client, the impact of the COVID-19 pandemic caused the current case study to take place over the course of six individual therapy sessions. The current study aims to provide further evidence supporting brief psychodynamic therapy as an effective treatment with this traditional aged college student diagnosed with AD. Based on the existing literature previously reviewed, the clients presentation, and the treatment plan for the client, the current study will ask the following two questions: Is this client better off than before therapy began? Which of this clients symptoms improved and which did not improve? The current study hypothesizes that the client will show improvements in treatment. Method Counseling Center Assessment of Psychological Symptoms-62 (CCAPS-62; Lock et al., 2011) The CCAPS-62 is a 62-item measure that was designed to evaluate a variety of psychological symptoms common to disorders found in the college population. The CCAPS-62 has eight 53 subscales: Depression, Generalized Anxiety, Social Anxiety, Academic Distress, Eating Concerns, Hostility, Family Distress, and Substance Use. Individuals completing the measure are asked to rate themselves on a 5-point Likert-scale ranging from 0 (not at all like me) to 4 (extremely like me) over the course of the last 2 weeks. Of the 62 items on this measure, nine of the items are reverse scored. Subscale scores are calculated by adding together individual item scores, with higher scores indicating more distress. Average item ratings on each subscale can also be calculated across subscales. After the CCAPS was developed, Titanium Software, a common electronic medical record system used in college counseling centers, partnered with the Center for Collegiate Mental Health to incorporate the CCAPS within the Titanium software. This allows therapists in university counseling centers to seamlessly administer, score, and generate reports using the CCAPS (Penn State Student Affairs: Center for Collegiate Mental Health, 2023). In the current study, Titanium software was utilized to administer, score, and generate reports with percentile scores for the clients CCAPS-62. According to Locke and colleagues (2011), subscale scores have demonstrated acceptable internal consistency and test-retest reliability, as well as convergent validity in a largely nonclinical college population. In their studys sample, the test-retest reliability coefficients were r = .93 for Depression, r = .89 for Eating Concerns, r = .87 for Substance Use, r = .78 for Generalized Anxiety, r = .91 for Hostility, r = .83 for Social Anxiety, r = .92 for Family Distress, and r = .92 for Academic Distress. Cronbachs alpha were a =.92 for Depression, a =.85 for Generalized Anxiety, a =.85 for Social Anxiety, a =.83 for Academic Distress, a =.87 for Eating Concerns, a =.85 for Hostility, a =.84 for Family Distress, and a =.85 for Substance Use. These 54 test-retest reliability coefficients can be seen in Table 1 in the Empirical Findings section to further clarify how the RCI was calculated. For the current study, the CCAPS-62 was administered via the Titanium software program on three separate occasions, with the first CCAPS-62 being completed by the client upon arriving for his intake session, again after three individual therapy sessions, and then again before his final, sixth, individual therapy session. Average item rating scores for each subscale were calculated and utilized using each individual item response on every subscale and can be seen in Table 2, in the Empirical Findings section. Reliable Change Index For the current study, the RCI was calculated utilizing pre, mid, and post means for each subscale within the CCAPS-62. Table 2 details the average item rating scores for each subscale at pre, mid, and post phases of treatment and can be seen in the Empirical Findings section. Cutoff scores for each CCAPS-62 subscale were also calculated utilizing means and standard deviations for males in normal and clinical populations, which were provided by the Center for Collegiate Mental Health (CCMH) annual report (2010) and can be seen in Table 3 in the Empirical Findings section. Course of Treatment In accordance with the brief psychodynamic therapy model and in accordance with the Universitys academic calendar, therapist and client were originally planning to meet for approximately 12 individual therapy sessions on a weekly basis for 50 minutes each. Because of the COVID-19 pandemic, however, the therapist and client were only able to meet for six weekly individual therapy sessions for 50 minutes each. The client consistently attended his scheduled therapy sessions and was actively engaged in his treatment during sessions. 55 Through the course of the clients treatment, the therapist engaged as an active participant in collaboratively discussing and reflecting on the clients experiences. To accomplish treatment goals, the therapist utilized techniques from brief psychodynamic therapy. Because of the integrative nature of this brief psychodynamic therapy, the therapist also utilized techniques from other various theoretical orientations to facilitate conversations and discussion surrounding the clients thoughts about his mental health problems, himself and others, and his life experiences. Session one. The client was unable to initially identify goals for his treatment during the first session, but simply explained pursuing therapy after a friend recommended it to him. Given the briefness of this brief psychodynamic therapy, the therapist quickly formulated ideas and began utilizing interventions. Thus, the therapist and client began by discussing the events that led the client to pursue therapy (e.g., close friends and family moving away, quitting his job, placing more focus on his personal life, and learning of his mothers illness). During the first session, the therapist and client also began discussing the clients reported poorly developed sense of self and feelings of not belonging, specifically as it pertained to his degree field at the university. This is also when the client first introduced his past relationship with his ex-boyfriend, whom he dated for approximately one year during his freshman year of college. The therapist also assessed the clients level of risk, during which the client endorsed passive suicidal ideation without any intent. The client denied any self-harm behaviors and denied any active suicidal ideation. Through validating the clients reported experiences and maintaining empathic responses, the therapist was able to begin her attempt at building a strong therapeutic alliance with the client. This validation and empathy also functioned as an introduction into providing the client with a corrective emotional experience and increasing the clients ability to self-regulate. During 56 this first therapy session, the therapist also utilized reflections to demonstrate active and engaged listening, as well as basic interpretations to also demonstrate active listening and to elicit further elaboration from the client at times. This first session also allowed the therapist to begin building an understanding of the clients previous and current relationship patterns. Session two. The therapist continued building a strong therapeutic alliance with the client during the second session. Again, this was done by validating the client and empathically listening. During this session, the therapist and client began discussing the clients relationship with both his mom and dad. The client shared details regarding a recent experience with his mom where they got into a disagreement and the clients mom told the client he had been acting just like his father. The therapist provided a reflective statement providing a basic interpretation about the apparent negative impact that statement had the client. The therapist and client then explored the impact of this statement and the clients beliefs of how he views himself compared to how he views his father. This allowed the therapist to confront the client about some of his feelings surrounding his father. During this second session, the therapist also gained more understanding of the clients relationship with his mom and dad, but more specifically with his dad. The therapist and client discussed the relationship dynamic and patterns the client frequently experienced with his dad, which he described as challenging. The client noted that because his father struggled with Bipolar Disorder, he had little to no relationship with his dad because the client never knew how his dad was going to act. The client described a relationship pattern filled with uncertainty and volatility. With this knowledge of the clients fragile relationship with his dad, the therapist was able to begin emphasizing consistency and predictability within the therapeutic relationship in hopes of promoting an example of a healthy relationship for the client. The therapist also 57 emphasized validating the clients emotional experiences in order to provide the client with corrective emotional experiences to override his previous experiences of being invalidated by his dad. Given the flexibility of this brief psychodynamic therapy model, the therapist pulled techniques from other therapy models to assist the client in making progress toward therapy goals. In this session, that included having the client externalize his thoughts in an attempt to help the client separate his own thoughts from thoughts that may be rooted in anxiety. The client again denied any self-harm behaviors and any active suicidal ideation. Because the client was able to discuss his adaptive coping skills used when any thoughts of self-harm occur (e.g., turning lights on, taking a shower, brushing his teeth, and listening to music), the therapist was able to encourage the client to continue utilizing his adaptive coping skills as necessary. Session three. By the third therapy session, it seemed the client and therapist had the foundation for a strong therapeutic alliance. This allowed the client to begin feeling safe enough within the therapy space to share various stressors from the therapist that may have been viewed as more severe by the client, such as his previous relationship with his ex-boyfriend. Through exploration, the client and therapist were able to explore the impact his past relationship had on his current relationships. The therapist was able to use clarification techniques to explore more in depth the impact this was having on the client (e.g., in his communication with others, in his interactions with others, and in his development of trusting relationships with others). Given the therapeutic alliance at this point, the therapist was also able to begin confronting some of the clients stated thoughts and/or feelings in the session in hopes of guiding the client to new understandings about his thoughts and/or feelings. For example, when the client began discussing the blame he put on himself for his actions in his past relationship with his ex- 58 boyfriend, the therapist was able to confront this feeling of blame and encourage the client to understand that feeling from a different perspective (e.g., Are you to blame? Or were you being manipulated?) all while maintaining a supportive and empathic stance as the therapist. Session four. After spending some time during the fourth session reviewing goals for treatment, the client was able to identify a goal for therapy, which included being able to come to terms with his previous relationship between him and his ex-boyfriend. It was during this session that the client appeared to become more actively focused on this specific goal, which in turn allowed the therapist to become more actively focused and engaged on this specific goal. The client introduced some feelings he had surrounding his previous relationship (e.g., anger and resentment), which allowed the therapist to facilitate conversations with the client about those feelings and the clients understanding of those feelings. As the client shared thoughts surrounding his current pattern in relationships with men, the therapist was able to provide interpretations regarding the therapists understanding of how the clients past relationship was impacting the clients current relationships. The client reported several impacts, such as a fear of being manipulated again and a decreased ability to trust others. The therapist again made a conscious effort to again emphasize a stable, healthy, and functional therapeutic relationship with the client in hopes of challenging the maladaptive relationship patterns he previously experienced among his father and exboyfriend. The therapist also validated the clients hesitations toward men given his previous experiences while encouraging the client to gain new understandings of how different men in his life may be different than his ex-boyfriend. Session five. During the fifth therapy session, the client decided to disclose details to the therapist about a previous sexual assault he experienced the summer before his freshman year of 59 college. The client detailed the experience to the therapist and discussed how it resulted it him trying to move past the experience by throwing himself into his relationship with his exboyfriend. Given the clients goal of wanting to come to terms with what had previously happened between him and his ex-boyfriend, this allowed the client to explore his feeling surrounding the sexual assault and his relationship with his ex-boyfriend in a safe space while being supported by the therapist. The therapist and client were able to explore the clients feelings of blame and anger toward himself. The therapist actively used reflections to communicate active listening, interpretation to help the client label difficult feelings, and empathy and validation to provide the client with reassurance that he is in a safe environment and healthy relationship. This marked an important step in the therapeutic relationship, as it likely signified that the client felt safe and secure enough to share such a vulnerable experience with the therapist. In turn, this allowed the client to process his emotions surrounding the sexual assault and his past relationship in a safe and nonjudgmental environment, which allowed the client an opportunity to continue developing self-regulation skills and continue building new understandings about his different emotions. It was at the end of his fifth therapy session that the client first identified feeling genuinely better since before treatment began. He identified having the ability now to think about and sit with those past memories, whereas prior to counseling he would not have been able to do so. Session six. Because of the COVID-19 pandemic, as previously stated, the clients therapy sessions were abruptly cut short. After receiving news that the campus would be closing and all students would have to return home, the therapist and client were able to meet for a sixth and final therapy session. Much of the time in this session was spent processing the implications 60 of COVID-19 and campus closing. The client reported being in great distress over having to leave campus and live at home with his parents once again. The therapist validated these feelings and assisted the client in clarifying possible options to help make the transition home smoother (e.g., transitioning to see a therapist at home if possible, spending time outside and at nature parks, adopting a cat as a companion). The therapist also took the time to emphasize the strength of the therapeutic alliance that had been built over the course of the last six therapy sessions. Although the client reported experiencing suicidal ideations shortly after receiving the news about the campus closing, he denied any intent to act on these thoughts and denied any active suicidal ideation at the time of the final therapy session. The client reported that although he was feeling sad, he was not feeling as sad as he might have in the past. The therapist was able to reassure the client that he had built tools and coping skills that allowed him to handle the situation better than he would have prior to the start of therapy treatment. The client also denied any self-harm since before starting treatment. The therapist tried to provide the client with one last corrective emotional experience by providing the client with closure about their therapeutic relationship ending. The therapist also attempted to implement a healthy relationship pattern by praising the clients effort during therapy sessions throughout treatment and by providing the client with hope about his future. Empirical Findings with Analysis Results were based on the six individual therapy session with the client using a brief psychodynamic approach. Results were examined utilizing the clients CCAPS-62 scores from before his first session (pre), before his fourth session (mid), and after his sixth session (post). Pre, mid, and post mean ratings were hand calculated by averaging the clients reported responses for each individual subscale item using the CCAPS report generated by Titanium. The 61 RCI was calculated for pre- to mid- treatment, for mid- to post-treatment, and for pre- to posttreatment using the following formula, where X2 represents the post-treatment mean rating, X1 represents the pre-treatment mean rating, and Sdiff represents the standard difference (Jacobsen et al., 1984). Cutoff scores for each of the CCAPS-62 subscales were calculated using means and standard deviations for males both normal and clinical populations provided by Center for Collegiate Mental Health annual report (2010) shown in Table 3 using the following formula, where s1 represents the standard deviation of the normal population, s2 represent the standard deviation of the clinical population, 1 represents the mean of the normal population, and 2 represents the mean of the clinical population (Jacobson & Truax, 1991). The results from the cutoff scores helped to determine if the client made clinically significant progress and the RCI helped to determine if the progress the client made was reliable. By calculating the RCI and using cutoff scores for each of the specific CCAPS-62 subscales, this helped to answer the clinical question of if the client is better off than before therapy began. In order for the client to demonstrate reliable change throughout treatment, the RCI must be greater than 1.96, as pre-determined by Jacobson and Truax (1991). RCI scores below 1.96 demonstrate no reliable change throughout treatment and RCI scores below -1.96 demonstrate deterioration throughout treatment. Examining the results from the specific subscales indicated which symptom areas improved for the client and which did not. Using these criteria, it is possible to 62 classify the client as one of the following: Recovered (passed cutoff point for clinically significant change and passed RCI criteria), Improved (only passed RCI criteria), Unchanged (passed neither criteria), and Deteriorated (passed RCI in the negative direction) (Jacobson & Truax, 1991). Table 2 shows average individual subtest ratings scores for the client on each subscale during the pre-, mid-, and post-phases of treatment, while Table 4 shows the RCI and cutoff points for pre- to post, pre- to mid, and pre- to post treatment. Table 1 CCAPS-62 Subtest Test-Retest Reliability Coefficients CCAPS-62 Subscale Test-Retest Reliability Coefficient Depression 0.93 Generalized Anxiety 0.78 Social Anxiety 0.83 Academic Distress 0.92 Eating Concerns 0.89 Hostility 0.91 Family Distress 0.92 Substance Use 0.87 Note. Test-Retest Reliability Coefficients provided by Locke and colleagues (2011). Table 2 CCAPS-62 Clients Average Individual Subtest Rating Scores for Pre, Mid, and Post Phases of Treatment CCAPS-62 Subscale Depression Generalized Anxiety Social Anxiety Academic Distress Eating Concerns Hostility Family Distress Substance Use Pre-Treatment 2.62 3.22 2.29 3 0.33 0.86 3 2.17 Mid Treatment 1.69 2.56 2.29 2 0.33 0 1.33 1 Post Treatment 2 1.78 0.57 2 0.33 0.43 1.83 0.33 63 Table 3 CCAPS-62 Means and Standard Deviations of Males in Clinical and Non-Clinical Populations CCAPS-62 Subscale Clinical Population Non-Clinical Population Depression 1.44 (0.94) 0.80 (0.74) Generalized Anxiety 1.35 (0.88) 0.87 (0.68) Social Anxiety 1.72 (0.96) 1.46 (0.84) Academic Distress 1.84 (1.03) 1.24 (0.84) Eating Concerns 0.69 (0.69) 0.76 (0.68) Hostility 1.00 (0.88) 0.70 (0.70) Family Distress 1.08 (0.89) 0.70 (0.71) Substance Use 0.86 (0.89) 0.82 (0.89) Note. Standard Deviations shown in parentheses. Means and Standard Deviations were provided by the Center for Collegiate Mental Health (CCMH) Annual Report (2010). 64 Table 4 RCI and Cutoff Points for Pre to Post, Pre to Mid, and Mid to Post Treatment CCAPS-62 Subscale Pre to Post Pre to Mid Mid to Post Depression RCI 2.21* 3.32* -1.11 Cutoff Point 1.08 1.08 1.08 Findings Improved Improved Unchanged Generalized Anxiety RCI 3.20* 1.47 1.73 Cutoff Point 1.08 1.08 1.08 Findings Improved Unchanged Unchanged Social Anxiety RCI 3.50* 0.00 3.50* Cutoff Point 1.58* 1.58 1.58* Findings Recovered Unchanged Recovered Academic Distress RCI 2.86* 2.86* 0.00 Cutoff Point 1.51 1.51 1.51 Findings Improved Improved Unchanged Eating Concerns RCI 0.00 0.00 0.00 Cutoff Point 0.73* 0.73* 0.73* Findings Unchanged Unchanged Unchanged Hostility RCI 1.54 3.07* -1.54 Cutoff Point 0.83 0.83* 0.83 Findings Unchanged Recovered Unchanged Family Distress RCI 4.18* 5.96* -1.79 Cutoff Point 0.87 0.87 0.87 Findings Improved Improved Unchanged Substance Use RCI 4.09* 2.60* 1.49 Cutoff Point 0.84* 0.84 0.84* Findings Recovered Improved Unchanged Note. * indicates statistically reliable change for the RCI and clinically significant change for cutoff points. 65 The clients mean reported scores on the Eating Concerns subscale were identical at pretreatment, mid-treatment, and post-treatment. His average reported score was low, lower than both clinical and non-clinical population means. As a result, the clients Eating Concerns will not be further discussed. Results of cutoff points, found within Table 4, demonstrate the clients average individual subtest ratings scores mid treatment, found within Table 2, fell below the cutoff point and closer to the normal population than clinical population on the Hostility subscale, though this improvement was not maintained through the end of treatment. Results of cutoff points demonstrate the clients average individual subtest ratings scores post treatment fell below the cutoff point and closer to the normal population than clinical population on the Social Anxiety and Substance Use subscales. Results from RCI scores, also found within Table 4, demonstrate the clients average individual subtest rating scores from pre to mid treatment reflect statistically reliable change on the Depression, Academic Distress, Hostility, Family Distress, and Substance Use subscales. Minimal findings emerged for mid- to post treatment; the only finding that emerged was for Social Anxiety, which demonstrated statistically reliable change. In terms of pre- to posttreatment findings, the clients average individual subtest rating scores from pre- to posttreatment reflect statistically reliable change on the Depression, Generalized Anxiety, Social Anxiety, Academic Distress, Family Distress, and Substance Use subscales. Discussion of Findings Currently, although some studies have demonstrated the effectiveness of brief psychodynamic therapy when treating minor depressive episodes (Maina et al., 2005) and when working with patients who were HIV-positive with depressive symptoms (Markowitz et al., 1998), little research examining treatment outcomes for Adjustment Disorder (AD) exists (Carta 66 et al., 2009; OConner & Cartwright, 2012; Zelveine & Kazlauskas, 2018). The current case study aimed to examine the effectiveness of brief psychodynamic therapy as a treatment with a traditional aged college student diagnosed with AD. In this current study, the therapists use of brief psychodynamic therapy provided findings that suggest the client Recovered from pre to post treatment on the Social Anxiety and Substance Use subscales. The findings also suggest the client Improved from pre- to posttreatment on the Depression, Generalized Anxiety, Academic Distress, and Family Distress subscales. From pre- to mid-treatment, results indicate the client Improved on the Depression, Academic Distress, and Family Distress subscales. However, findings suggest the client remained Unchanged on every subscale from mid- to post-treatment, with the exception of the Social Anxiety subscale, suggesting that the majority of changes the client experienced in treatment occurred earlier, as opposed to later, in treatment. The clients change throughout treatment on the Social Anxiety and Substance Use subscales generate various questions regarding why those subscales saw significant, and reliable, change, while others did not. When thinking about types of clients and problems seeking help within a brief amount of time, some data exists that indicates during brief treatment, a clients overall well-being is the first to make a positive change, followed then by improvements in symptoms and later on positive changes in characterological and interpersonal factors (Howard et al., 1993). One study (Hilsenroth et al., 2001) found that by the ninth session of a brief psychodynamic therapy, clients reported the biggest area of change to be their sense of wellbeing, followed by their overall feelings of distress. In this study, the final area to see improvements during treatment were social and interpersonal functioning. In one meta-analysis 67 (Barber et al., 2013) researchers discovered that psychodynamic therapies, most of which were considered brief, were superior to control conditions and produced as effective results compared to alternative therapies at termination and follow-up for clients diagnosed with depressive disorders, anxiety disorders, and personality disorders. In the current study, it is possible that the clients overall sense of well-being began to improve first throughout treatment in the early sessions. Given this clients diagnosis of AD, and OConner and Cartwrights (2012) emphasis that the effects of AD can be moderated by social support, it is possible that the support therapy provided this client allowed the client to begin experiencing relief with some of his symptoms, as reflected in the clients Improved scores on the Depression, Academic Distress, Family Distress, and Substance Use subscales from pre- to mid-treatment. Although the client began to see improvements of the Depression, Academic Distress, Family Distress, and Substance Use subscales from pre- to mid-treatment, those four subscales went Unchanged from mid- to post-treatment, which may be a reflection that the clients early improvements were sustained through the rest of treatment. The onset of COVID-19 occurred during the mid- to post-treatment phase for this client. It is possible this caused an increase in the clients distress and symptoms, thus reflecting minimal improvement in the clients subscales from mid- to post-treatment. Individuals can experience symptoms of AD at any point in life, but younger individuals may be more vulnerable to developing this disorder because of fewer coping skills to utilize in moments of stress (OConner & Cartwright, 2012). Inchausti and colleagues (2020) discuss how one particular group at risk for psychological challenges includes individuals who experienced psychopathology prior to the pandemic, which may be exacerbated by the pandemic and the impact of the pandemic. It is possible that the stressors related to the onset of COVID-19 68 exacerbated this clients mental health challenges, which this client may have lacked appropriate coping skills to effectively manage, thus resulting in the clients reported symptoms to remain Unchanged from mid- to post-treatment. Despite this possible stress with the onset of COVID-19 toward the end of treatment, the client still Improved on the Depression, Generalized Anxiety, Academic Distress, and Family Distress subscales from pre- to post-treatment and Recovered on the Social Anxiety and Substance Use subscales. Thus, despite the client not making significant, reliable changes from mid- to post-treatment, the client was still able to demonstrate significant, reliable change from pre- to post-treatment on the Social Anxiety and Substance Use subscales and demonstrate reliable changes from pre- to post-treatment on the Depression, Generalized Anxiety, Academic Distress, and Family Distress subscales. Although the current treatment only lasted six sessions, one review of effective psychotherapies by Lambert (2013) noted a large number of clients make reliable improvements after just seven therapy sessions. These results provide evidence that even in as little as six therapy sessions, this client was able to begin seeing significant, reliable change in some of his mental health symptoms. When examining the current study, a considerable limitation to be considered includes the onset of the COVID-19 pandemic, which resulted in the clients treatment being cut short from approximately 12 therapy sessions to only six therapy sessions. It is also possible the stress the client reported experiencing after hearing the news of campus closing early because of COVID-19 could have impacted his mid to post treatment scores. An additional limitation includes the choice of the CCAPS to monitor the clients functioning and the overall typical goals for brief psychodynamic therapy. As a reminder, according to Levenson (2017) and Strupp and Binder (1984), brief psychodynamic therapy aims 69 to provide a client with positive new experiences of themselves and others and new understandings of themselves and others. This form of therapy often aims at fostering new relational experiences and enhancing ones attachment in hopes that will then impact other areas of ones life. With this knowledge, it is important to consider how any possible progress may or may not be reflected on the CCAPS, given its subscales. If someone improves relationally and strengthens their attachment style, it is possible that change may not be reflected on a measure looking at mental health symptoms, like the CCAPS (Travis et al., 2001). Thus, a measure that further examined both intrapersonal and interpersonal changes may have provided different results. Another limitation of the current study includes the clients history of sexual abuse. Given the information reported at the start of treatment, the therapist and clinical supervisor concluded an AD diagnosis to be the most appropriate diagnosis for the clients current functioning. However, the clients eventual disclosure to the therapist of prior sexual abuse might suggest a trauma-related diagnosis may have been appropriate. It is possible this alternative diagnosis may have informed the therapist to approach treatment in an alternative way. However, this represents a real-world scenario where therapists must provide treatment with sometimes limited information the client is willing to share. Additional limitations include those commonly associated with single subject research studies, such as issues of generalizability (Kazdin, 2022; Searle, 1999), uncontrollable variables (Cronbach, 1975), and the objectivity of the therapist throughout the research study (Searle, 1999). Because the current study is a case study, it is important to consider that one individual was studied. The client examined in the current study is a unique individual with his own life experiences and mental health challenges who likely does not reflect the experiences and 70 challenges of other individuals with similar life experiences and mental health challenges. Kazdin (2022) and Searle (1999) highlight how although a case study might discover findings that suggest what might take place in similar circumstances, further research is necessary to determine the generalizability of the case study. Despite these limitations, this case study provides research for a real-world application of brief psychodynamic therapy with a traditional aged college student diagnosed with AD. While other studies have examined the effectiveness of brief psychodynamic therapy with individuals experiencing minor depressive episodes (Maina et al., 2005) and with depressive symptoms (Markowitz et al., 1998), the current study allowed brief psychodynamic therapy to be examined after being utilized with someone diagnosed with AD. A significant strength of a case study includes the ability to examine the effectiveness of a modality in real-world scenarios (Kazdin, 2022). Given the limited current research, further research on the effectiveness of brief psychodynamic therapy with individuals diagnosed with AD would be beneficial for the psychology field. Further case studies examining effective treatments for individuals diagnosed with AD would provide useful information and insight into possible effective approaches to treatment. Alternative measures may be utilized to further examine common symptoms reported by individuals with AD. 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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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