research

MEMORANDUM

TO: Professor R. Sanchez Mayers

FROM: L.G.

RE: Single-System Research Design

DATE: October 12, 2010

Introduction:

A single-system research intervention, using an ABA design, was employed on a 23 year old Caucasian female. An ABA study examines what happens when an intervention follows a baseline period, and then that intervention is removed, followed by a second baseline phase (Royse, Thyer & Padgett, 2010). The subject, DG, is a veterinary technician in Wayne, New Jersey. DG has suffered from chronic hand washing for the past 5 years. She reported washing her hands anywhere between 20-40 times per day. 6 months ago DG went to her primary physician who referred her to see a psychologist to explore the reasoning for her constant hand washing. During a structured clinical interview, the psychologist discussed the nature, severity, and duration of DG’s symptoms. The psychologist determined that DG’s symptoms met the Diagnostic and Statistical Manual (DSM) criteria for Obsessive Compulsive Disorder (OCD) (American Psychiatric Association [DSM-IV-TR], 2000).

The subject, DG, reported to the researcher that her compulsive hand washing is interfering with her everyday life and that she would like to attempt cognitive behavioral therapy to alleviate her symptoms. DG state that she began excessively washing her hands at her veterinary job approximately 5 years ago after a co-worker of hers acquired Sarcoptic Mange. DG explained that Sarcoptic Mange is transferred from dogs to humans and that it causes crusty skin, lesions, and intense itching. DG reported that her compulsive hand washing originally only took place at work but in the past year has been carrying over while she is at home. The subject would like to get control over her compulsive hand washing. The subject is also opposed to taking medication that the psychologist recommended for her. DG indentified chronic hand washing as a target problem that she wanted to change.

The intervention selected was cognitive behavioral therapy (CBT). DG will be recording the frequency of her hand washing on a tally sheet each day. The time frame involved for this ABA research design was 15 days with the baseline, intervention, and follow-up. Each step will be completed in intervals of 5 days. The project began on Monday September 20, 2010 and ended on Monday October 4, 2010. An Informed Consent Form was signed by the subject (see Appendix).

Intervention and Rationale:

Cognitive behavioral therapy was chosen to be applied for 5 days for a total of 1 hour per day. A couple of typed up tally sheets were provided for DG by the researcher. DG was instructed to keep the provided tally sheets next to each sink in her home. The researcher directed DG to mark the tally sheet each time she washed her hands throughout the day. This method was chosen in order to acquire consistency. A baseline of the frequency of hand washing was taken for 5 days. On the sixth day, 60 minutes of CBT was applied in addition to daily recording of hand washing frequencies. The intervention consisted of socializing DG to the CBT model along with assisting DG in understanding and recognizing her automatic thoughts. The intervention also consisted of exposure, response prevention, thought stopping, and worry control. This intervention took place each day at 6:00 p.m. at the subject’s home. After 5 days of the CBT intervention, it was then terminated. DG continued to record the frequency of her hand washing for the 5 succeeding days as a follow-up.

OCD affects approximately 3.3 million people in the United States. However, some estimates have been elevated as high as 6 million. CBT was selected as the intervention for this subject’s compulsive hand washing symptoms due to the extensive research and support of CBT’s efficacy for this target problem.

The research and extensive literature that examines CBT as an intervention method for OCD supports a positive connection between these two variables. Hofmann and Smits (2008) conducted a meta analysis of 1,165 studies in order to review the efficacy of CBT as compared to a placebo for adults with anxiety disorders such as OCD. Of the original 1,165 studies, 27 of them met the inclusion criteria necessary for this review, a total of 1,496 patients. This meta analysis of randomized placebo/controlled trials concluded that CBT is effective for treating anxiety disorders in adults such as OCD (Hofmann & Smits, 2008).

Franklin, Abramowitz, Bux Jr., Zoellner, and Feeny (2002), conducted a study to compare the efficacy of CBT for OCD versus the combination of CBT and serotonin reuptake inhibitors (SRIs) for OCD. The study included a total of 56 outpatients all diagnosed with OCD. 55% of the subjects received only CBT, including exposure and response prevention for 15, 2 hour sessions over the course of 1 month. The remaining 45% also received the same CBT treatment but were also currently taking SRIs. It was found that both groups had significant symptom relief, which clarifies that CBT is an effective treatment for OCD with or without medication (Franklin et. al., 2002). There is extensive literature on the effectiveness of CBT versus the effectiveness of exposure and response prevention (ERP) without the cognitive component. Abramowitz, Taylor, and Mckay (2005), state that CBT has strengths over ERP including, lower treatment dropout rates, greater patient compliance, and greater success in restructuring the patient’s cognitions.

All of the studies above did include both female and male participants. However, the results were not examined regarding gender. Typically, OCD is found across all ethnic groups and affects both women and men equally. However, in childhood, OCD is often more prevalent among boys than girls (OCD Facts and Statistics, 2010).

Results:

Focusing on the subject’s compulsive hand washing, results showed the intervention hand washing frequency was lower than the baseline for hand washing frequency on 4 out of the 5 days compared. The follow-up hand washing frequency was lower than the intervention frequency on 2 out of the 5 days compared. These results are all depicted on Chart # 1 below:

While examining the chart above, the first 5 days demonstrate both a drop and rise in the frequency of hand washing. It is important to note that there was a slight decrease in the frequency of hand washing during the 5 day intervention period. Also the results from the chart above demonstrate that during the 5 day follow-up period, the frequency decreased during the first 2 days but then steadily rose during the remaining 3 days. Both the intervention and follow-up frequencies for hand washing never rose as high as the frequency during the baseline. Based on these numbers, it can be said that implementing CBT is likely to have a positive effect on decreasing compulsive symptoms.

After completing this single system research intervention using an ABA design and carrying out a literature review, this researcher feels that the intervention chosen was appropriate and somewhat effective. The researcher also predicts that if the intervention was administered for a longer period of time that its effectiveness would increase significantly. The chosen intervention, CBT, would be recommended for the treatment of OCD symptoms and used again in the future. Even though this research design took place over 15 days and did not present a significantly large amount of symptom relief, DG reported having greater awareness of her dysfunctional thoughts, therefore, becoming more conscious of her compulsive hand washing behaviors. DG stated that she is going to continue CBT elsewhere in order to further alleviate her compulsive symptoms and gain better control of her dysfunctional cognitions.

There are few modifications and adjustments that should be attempted with this intervention model. Most importantly would be the length of time that CBT is administered. CBT is a structured, present-oriented psychotherapy which is used for modifying dysfunctional thoughts and behaviors and solving current problems. There are several tools used in CBT including, a dysfunctional thought record, emotional charts, problem-solving worksheets and much more (Beck, 1995). In order to present all of these tools in an effective manner, more than 5 days is needed. CBT is considered a short-term therapy so it would not be an ongoing process, however, at least a month would be a more sufficient amount of time to apply the therapy effectively. The goal is to provide the client with the tools and knowledge to become their own therapist in the future. This way the patient can gain better control over their cognitions and behaviors (Beck, 1995). Another modification would be to apply CBT for 2 hours instead of 1 in order to fit more in during the time spent with the patient. These critical increases in time and length of sessions would present the researcher with more data to analyze along with additional time in order to present the patient with all of the important aspects of CBT

References

Abramowitz, J. S., Taylor, S., & McKay, D. (2005). Potentials and Limitations of Cognitive Treatments for Obsessive-Compulsive Disorder. Cognitive Behaviour Therapy , 34 (3), 140-147. doi: 10.1080/16506070510041202

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (Revised 4th ed.). Washington, DC: Author.

Beck, J. (1995). Cognitive Therapy Basics and Beyond. New York: Guilford Press.

Franklin, M. E., Abramowitz, J. S., Bux Jr., D. A., Zoellner, L. A., & Feeny, N. C. (2002). Cognitive Behavioral Therapy With and Without Medication in the Treatment f Obsessive-Compulsive Disorder. Professional Psychology: Research and Practice , 33 (2), 162-168. doi: 10.1037//0735-7028.33.2.162

Hofmann, S. G., & Smits, J. (2008). Cognitive-Behavioral Therapy for Adult Anxiety Disorders: A Meta-Analysis of Randomized Placebo-Controlled Trials. Clinical Psychiatry , 69 (4), 621-632.

OCD Facts and Statistics. (2010). Retrieved September 23, 2010, from Designed Thinking: http://www.designedthinking.com/html/ocd_facts_.html

Royse, D., Thyer, B.A., & Padgett, D.K., (2010). Program Evaluation: An Introduction (5th ed.). Belmont, CA: Wadsworth, Cengage Learning.

Appendix

CONSENT TO PARTICIPATE IN A SINGLE SYSTEM RESEARCH DESIGN

I am aware that this research design is being conducted by L.G., who is a second year Graduate Student in the Rutgers University School of Social Work. This intervention is to fulfill the requirements of a mandatory assignment for Research II, Section 19:910:595:91, with Professor Raymond Sanchez-Mayers.

The purpose of this single system research design is to measure the effect that cognitive behavioral therapy (CBT) has on the target problem of compulsive hand washing. I am the only subject participating in this intervention.

The intervention will take 15 days to complete. The location for recording the number of times I wash my hands will be at my own home in West Milford, NJ. The intervention, cognitive behavioral therapy, will also be employed at my home in West Milford, NJ.

I understand that the following requirements are necessary for this intervention:

Week 1 (Days 1-5) – Record on tally sheet each time hands are washed

Week 2 (Days 6-10) – Record hand washing each day & Application of CBT 1hr per day

Week 3 (Days 11-15) – Record on tally sheet each time hands are washed

Every effort will be made to record on a tally sheet each time I wash my hands throughout the day. The Intervention consists of cognitive behavioral therapy for 1 hour per day for a total of 5 days with L.G.

I realize that there are minor psychological risks involved with CBT. I agree to stop the intervention if at any time I feel any symptoms of discomfort.

It is understood that CBT has been shown through empirical research to be effective in treating obsessive compulsive disorder (OCD) and hand washing compulsions. My focus and reason for volunteering for this research project is to alleviate my symptoms of OCD. I hope to have this assist me in the future to better control my compulsions.

I am aware that there will be no cost to participate nor am I receiving any payment from L.G. for my participation.

If I have any questions about this research that L.G. is not able to answer, or any complaints regarding this intervention, I may contact Professor Sanchez Mayers at:

Rutgers, The State University of New Jersey

School of Social Work

536 George Street

New Brunswick, NJ 08901

(732) 932-7520 Ext. 111

Email: [email protected]

Signature on File Signature on File

________________________________ _____________________________

D. G., Research Subject L. G., Student

Date: September 20, 2010