Why Does Therapy Work? An Idiographic Approach to Explore ...

The idiographic approach outlined by Fisher et al. (2019) involves intensive, repeated digital assessment measures, ... ThisarticleispartoftheResearchTopic CreatingEvidencefromRealWorldPatientDigitalData Viewall 14 Articles Articles EricHekler UniversityofCalifornia,SanDiego,UnitedStates DavidPincus ChapmanUniversity,UnitedStates JavierFernández-Álvarez CatholicUniversityoftheSacredHeart,Italy Theeditorandreviewers'affiliationsarethelatestprovidedontheirLoopresearchprofilesandmaynotreflecttheirsituationatthetimeofreview. Abstract Introduction MaterialsandMethods Results Discussion Conclusion DataAvailabilityStatement EthicsStatement AuthorContributions Funding ConflictofInterest References SuggestaResearchTopic> DownloadArticle DownloadPDF ReadCube EPUB XML(NLM) Supplementary Material Exportcitation EndNote ReferenceManager SimpleTEXTfile BibTex totalviews ViewArticleImpact SuggestaResearchTopic> SHAREON OpenSupplementalData ORIGINALRESEARCHarticle Front.Psychol.,24April2020 |https://doi.org/10.3389/fpsyg.2020.00782 WhyDoesTherapyWork?AnIdiographicApproachtoExploreMechanismsofChangeOvertheCourseofPsychotherapyUsingDigitalAssessments AllisonDiamondAltman1*,LaurenA.Shapiro2andAaronJ.Fisher1 1IdiographicDynamicLab,PsychologyDepartment,UniversityofCalifornia,Berkeley,Berkeley,CA,UnitedStates 2PsychologyDepartment,TheWrightInstitute,Berkeley,CA,UnitedStates BackgroundandObjective(s):Whilepsychotherapytreatmentsarelargelyeffective,theprocessesandmechanismsunderlyingsuchpositivechangesremainsomewhatunknown.Focusingonasingleparticipantfromatreatmentoutcomestudythatusedamodular-basedcognitivebehaviortherapyprotocol,thisarticleaimstoanswerthisquestionbyidentifyingchangesinspecificsymptomatologyoverthecourseofthetreatment.Usingquantitativedataderivedfromdigitalhealthmethodology,weanalyzedwhetheragiventherapeuticinterventionwasrelatedtodownstreameffectsinpredictedsymptomdomains,toassesstheaccuracyofourinterventions. Methods:ThiscasestudyemployedanobservationalN-of-1studydesign.Theparticipant(n=1)wasafemaleintheagerangeof25–35years.Usingdigitalhealthdatafromambulatoryassessmentsurveyscompletedpriortoandduringtherapy,separatelinearregressionanalyseswereconductedtoassessifhypothesizedtreatmenttargetsreducedafteragivenmodule,orintervention. Results:Supportwasfoundforsomeofthehypothesizedquantitativechanges(e.g.,decreasesinavoidanceafterexposuresmodule),yetnotforothers(e.g.,decreasesinruminationfollowingthemindfulnessmodule). Conclusion:Wepresentdataandresultsfromouranalysestoofferanexampleofanoveldesignthatmayallowforagreaterunderstandingofthenatureofsymptomchangeswithincreasedgranularitythroughoutthecourseofapsychologicaltreatmentfromtheuseofdigitalhealthtools. Introduction Thefieldofclinicalpsychologyhasundergonemanychangesinthepastdecade.AftertheintroductionoftheResearchDomainCriteria(RDoC;Inseletal.,2010)in2010,researchersseekingexternalfundinghavebeenincentivizedtomoveawayfrominvestigatingpsychopathologicalconstructsatadisorder-level,inordertoexploreadimensionalsystemthatencompassesmultiplelevelsunitsandofanalysis,fromgenesatthemostbasic,granularleveltobehavioratthemostmacroscopic.WhilethedevelopmentoftheRDoCwasnotintendedtoreplacetheDiagnosticandStatisticalManualofMentalDisorders(DSM-V)andserveasadiagnosticguide,itsintroductionnonethelessservesasareminderthatourcurrentdiagnosticsystem,andtreatmentdevelopmentefforts,maybestructurallyflawedbythesheerheterogeneityunderlyingdiagnosticlabelsastheycurrentlystand.TakingthediagnosisofPosttraumaticStressDisorder(PTSD)asanexample,currentDSM-5criteriaallow636,120combinationsofpresentingsymptomstoexistinordertomeetcriteriaforthediagnosis,meaningthatitispossiblefor636,120individualstomeetcriteriaforPTSD,withnorepeatsintheexactconstellationofsymptomsfrompersontoperson(Galatzer-LevyandBryant,2013).Treatmentsforsuchconditionshavebeenhistoricallydevelopedbyresearchersbasedondiagnosticcategoriesandgroup-level(i.e.,nomothetic)information.Theseoftenfailtoproducesignificantchangeinalargesubsetofindividuals,andoutcomesforthetreatmentofmanymentalhealthconditionsarelowerthandesired. Overthepast30yearstherehasbeenalonghistoryofresearchersseekingtounderstandunderlyingmechanismsofpsychotherapysuccess,andovertimenumerousmodelsofchangehaveemerged,includingbutnotlimitedtopsychotherapyintegration(StrickerandGold,1996),thecommonfactorsapproach(CF;FrankandFrank,1991;Wampold,2007),theoreticalintegration(StrickerandGold,1996),phasemodels(Howardetal.,1993),andthetranstheoreticalstatesofchangemodel(ProchaskaandDiClemente,1983).Fromthepsychotherapyintegrationapproach,whichaimstolookbeyondsingleapproachesandinsteadhopestointegratemultipleperspectives,tothecommonfactorsapproach,whichproposesthatdifferentapproachesinpsychotherapysharecommonfactorsthataccountforthemajorityoftheeffectivenessofapsychologicaltreatment,eachmodelhasdevelopedtheirownwaysofassessingandunderstandingchangeinpsychotherapy.Whilethesemodelsindicatetheeffortsofresearcherstounderstandwhytreatmentsmaywork,themajorityofworkintreatmentdevelopmentstillfocusesongroups,ratherthanindividuals. Conversely,clinicianstypicallyfocusonsinglepatients,oftenusingcaseconceptualizationmethodssuchasthecaseformulationapproachtocognitive-behaviortherapy(Persons,2012).Theseofteninvolveseriesoflinkedinterventionstypicallyfollowingcomprehensiveassessmentsofthepatient,andallowclinicianstochoosetechniquesbasedonthebestmatchtothepresentingneedsandproblemsofthepatient. Tobridgethegapbetweenresearchandpractice,itisimperativeforresearcherstogatherinformationthatwillbeimmediatelyusefultoclinicians.Suchinformationmaycomefromidiographictreatmentmodels,whereinresearchersinvestigatechangeinindividualpatients,ratherthandiagnosticgroups,toexploremechanismsofchangeoverthecourseofagiventreatment.Recently,andfollowingalongthefootstepsofothermedicaldomainssuchasoncology,therehasbeenapushtowardanidiographic,personalizedapproachtopsychotherapyresearch,focusingontheprecisesymptomatologyofanindividualpatientinsteadofbroaddiagnosticcategoriesforgeneratingtreatmentdecisions.Onesuchapproach,outlinedbyFisher(2015),callsforanidiographic,dynamicmethodologywherebycliniciansconductperson-specificdynamicassessmentsthatyieldinformationaboutsyndromestructuresandstatestoprovideactionableinformationforpersonalizedinterventions.Thisworkrequiresintensive,repeateddigitalassessmentmeasuresforindividualpatients,withthehopethatthisintensivemeasurementwillyieldprescriptiveinformationforimprovedresults.InarecentopentrialofpersonalizedmodularCBTusingtheUnifiedProtocol(UP;Barlowetal.,2011),Fisheretal.(2019)demonstratedaHedge’sgof2.33overanaverageof10sessions,outperforminganhistoricalaverageeffectsizeforfromarecent-meta-analysis(JohnsenandFriborg,2015).TheUPistypicallydeliveredover16sessions,andhasnotbeenshowntodemonstrateequivalenteffectsintrialstodate(c.f.Farchioneetal.,2012).Whileadditionalworkisrequiredtosubstantiatesuchanintensiveapproachtopersonalization,thistrialillustratesthattreatmentbasedoffofidiosyncraticstructuresofpsychopathologymaybeanimportantpartofimprovingoveralltreatmentefficacyinthementalhealthdomain.Thisinformationthencanbeimmediatelyusefultopracticingclinicianshopingtounderstandhowbesttoapproachsingularcases. Thefollowingcasestudyaimstousethesameperson-specificambulatoryassessmentdatatoinvestigatechangesoccurringinanindividualoverthecourseofatreatment,focusingonasingleparticipantfromtheFisheretal.’s(2019)opentrial—participant007(P007).TheidiographicapproachoutlinedbyFisheretal.(2019)involvesintensive,repeateddigitalassessmentmeasures,capturedfour-times-dailyforapproximately30days.Thisprovidessufficientdatatofacilitateperson-specificfactoranalysesanddynamicfactormodeling.Intheopentrial,pre-therapyanalyseswereusedtodeterminepredominanceamonglatentsymptomclustersinordertogeneratetargetedtherapies(usingexistingmodulesoftheUP)personbyperson.Participantswerealsogiventhechancetoextendthesesurveysandcontinuetocompletethemthroughoutthecourseoftherapy,asdidP007.ThecurrentarticleaimstouseP007’sdatatoidentifychangesinspecificsymptomatologyoverthecourseoftreatmentinordertoidentifyifagiventherapeuticintervention,ormodule(e.g.,mindfulness)wasrelatedtodownstreameffectsinpredictedsymptomdomains(e.g.,reducedrestlessness).Itshouldbeacknowledgedthatsomeresearchershaveproposedthatefficacyofpsychotherapyisnotduetospecificinterventionsortechniques,butratherfromfactorsofpsychotherapycommontoalltreatments,referredtoascommonfactors(Luborskyetal.,1975;Wampold,2001,2007).Yet,thecurrentresearchaimstodefinespecificeffectsthatcanbeattributedtocertaininterventions,ratherthancommonfactors.Thisnoveldesignmayallowforagreaterunderstandingofthenatureofsymptomchangeswithincreasedgranularitythroughoutthecourseoftreatment,andmayserveasamodelforcliniciansandresearcherstoincorporatesuchworkintheirownresearchandpractice. Asnotedabove,inthetreatmenttrialfromwhichP007’sdatawasdraw,deliveryoftheUPwaspersonalizedbasedondatagatheredpriortotherapy,whichwasthensubjectedtoananalysisfortheidentificationoflatentsymptomdimensionsanddynamicfactormodelingtodeterminethedynamicsandmoduledeliveryorder(seeFernandezetal.,2017;Fisheretal.,2019).Eachindividualpatientreceivedaspecificdeliveryorderofthemodulesbasedontheirpresentingsymptomsandrelationshipsamongsymptomdimensions.ThemoduleorderforP007isoutlinedinTable1.Forthepresentstudy,hypothesesweredevelopedbasedonspecificmodulesinordertoinvestigatesymptomchangesthroughouttherapy,withexpectedchangestoappearafteragivenmodulewasdelivered.EachhypothesisisoutlinedinTable2andbrieflyreviewedbelow. TABLE1 Table1.SessionsandmoduleordersforP007. TABLE2 Table2.Module-specifichypothesizedrelationshipsindigitalassessmentsurveydataoverthecourseoftherapy. Priortodeliveryofthefirstmodule,theparticipantunderwenta30-daypre-therapyassessment.Althoughthisdatacollectionwasintendedtoreflectstationaryprocesses,engagementwithtreatmentproviderscanhavedistress-reducingeffectsfordysphoricindividuals.Therefore,stationarity,theassumptionthatthemean,variance,andauto-correlationremainrelativelystableovertime,maybeviolatedbecauseofaprocessknownasremoralization(Howardetal.,1993).Howard’sremoralizationtheory(1993),proposesthatpsychotherapyentailssequentialchangesandthefirstchangeisanenhancementinthepatient’ssenseofsubjectivewell-being,whichtypicallyoccursbeforetheprocessofformalpsychotherapybeings(Howardetal.,1993).Inthisstudy,remoralizationmayhaveoccurredduringengagementwiththephonesurveyspriortothestartoftreatmentdelivery.Whilenoformalhypothesesweremadeduringthisinitialpre-therapyperiod,datafromitisincludedinthisstudy. Therapybeganwithanemotionalawarenessandtrackingmodule,andnosignificantchangeswereexpectedafterthismodule,astheinterventionwasprimarilytargetingoverallemotionalawarenessacrossbothpositiveandnegativeaffectdomains.Becausethisrelatestoprocessesalreadyinplacefromthepre-therapyassessment,webelievedthat–tothedegreethatself-monitoringmayelicitsymptomaticchange–thesechangeswouldhavealreadyoccurred. Hypothesis1:Thesecondmoduledeliveredwasamindfulnessmodule,anditwashypothesizedthatafterthedeliveryofthismoduletheparticipantwouldreportreductionsinfeelingsofrestlessnessanddwellingonthepastontheirsurveyresponses.Extantworkacrossavarietyofdomainshasillustratedthesuccessofamindfulness-basedapproachinreducingphysiologicalrestlessness,includingusingamindfulness-basedstressreduction(MBSR)paradigmtoreducesymptomsofrestlesslegsyndrome(Bablasetal.,2016)andusingaMBSRapproachtoreducelevelsofpre-sleeparousal(Cincottaetal.,2010).Extantworkintheliteraturehassimilarlydemonstratedanegativecorrelationbetweenmindfulnessandrumination(Jainetal.,2007;Svendsenetal.,2017),henceweexpectedreductionsinthesurveyitem“dwelledonthepast”followingdeliveryofthismodule. Hypothesis2:Thethirdmodulewasaninvivoexposureintervention,aimedatfacilitatinghabituationandinhibitionoffear-conditioning.Wehypothesizedthattheparticipantwouldreportreductionsinavoidance-relateditems(avoidingpeople,avoidingactivities,procrastinating,andseekingreassurance)afterdeliveryofthismodule,basedonanabundanceofpreviousworkillustratingtheeffectofexposuresonreducingavoidance(e.g.,FoaandKozak,1986). Hypothesis3:Thefourthmodulewasacognitiveappraisalandreappraisalsmodule,anditwashypothesizedthatafterdeliverytheparticipantwouldreportreductionsinworry,anddepression,andincreasesinpositivityandcontentedness,asreappraisalshavepreviouslybeenshowntoreducedsymptomsofstressandstress-relatedsymptoms(Mooreetal.,2008). Hypothesis4:Lastly,thefifthandfinalmodulewasanemotiondrivenbehaviorsandemotionalavoidancemodule.Itwashypothesizedthatafterthismodule,theparticipantwouldreportfurtherreductionsinfeelingsofworryanddepression,asalargebodyofworkhasindicatedreductionsinanxietyanddepressivesymptomsfollowingemotionalexposures(FoaandKozak,1986;Hayesetal.,2005). Thisquantitative,survey-basedapproachallowsforanin-depthinvestigationandquantificationoftherapeuticchangesacrossthecourseofamodularizedindividualizedtherapyinasingleparticipant.Weproposethatthisnoveldesignwilllendgreaterinsightintoindividualsymptomperturbationsthroughoutthecourseoftherapy. MaterialsandMethods SettingandParticipant DatawasobtainedaspartofanongoingresearchstudyattheUniversityofCalifornia,Berkeley.Theparticipant,afemaleintheagerangeof25–35yearsold,wasinitiallyrecruitedtoparticipateinamulti-phasepersonalizedtreatmentstudy,forwhichshecompletedaninitialdiagnosticassessment,14weeksofindividualizedtherapytreatment,andphonesurveysfromafterthediagnosticassessmentthroughtheconclusionoftherapy.Inclusioncriteriaincludedthefollowing:principaldiagnosisofeitherGADorMDD;noconcurrentpsychosocialtreatment;theparticipanthadnotpreviouslyreceivedCBT;nomedicalconditionswereidentifiedascontributorstoanxietyproblems(e.g.,hypoglycemia,thyroidproblems);andmaniaand/orpsychosiswereabsent.AllproceduresofthestudywereconductedundertheapprovaloftheUniversityofCalifornia,BerkeleyInstitutionalReviewBoard.AdditionaldemographicinformationcanbefoundinTable3. TABLE3 Table3.Demographicinformationforparticipant007. Procedure Theparticipantwasinitiallyrecruitedviapaperandelectronicadvertisementsplacedinthecommunity.Afterobtainingverbalconsent,shecompletedabrieftelephonescreening,andbasedonthispreliminaryinformation,theparticipantwasinvitedforanin-personstructuredclinicalinterview.TheypresentedtotheUniversityofCalifornia,Berkeley’sDepartmentofPsychologybuildingforclinicalassessment,duringwhichtheanxietyandrelateddisordersinterviewscheduleforDSM-5(BrownandBarlow,2014),HamiltonAnxietyRatingScale(Hamilton,1959),andHamiltonRatingScaleforDepression(Hamilton,1960)wereadministeredbyanadvancedgraduatestudentinclinicalpsychology.Resultswerereviewedwithasupervisingpsychologistbeforetheparticipantwasinvitedtoenrollinthestudy.Afterconsentpaperworkwasreviewed,theparticipanttookpartinatwo-phasestudy:Phase1requiredthecompletionofdailysurveystoassessmoodandanxietydisordersymptoms,andPhase2involveda14-weekcognitive-behavioraltherapytreatmentbasedonTheUnifiedProtocolforTransdiagnosticTreatmentofEmotionalDisorders(Barlowetal.,2011;detailsdescribedinFisher,2015).DuringPhase2,theparticipantwasinstructedtocontinuethedailysurveysinordertotrackprogressintreatment.Inbothphasesofthestudy,theindividualreceivedfourtextmessagesperday,eachonecontainingahyperlinktoaweb-basedsurvey,resultinginfoursurveysperday.P007completedsurveysforatotalof42daysduringPhase1(pre-therapy)and140daysduringPhase2(duringtherapy),with158and437totalviable,non-missingobservationsforPhase1andPhase2,respectively.Theparticipantcompleted96%oftheirsurveysthroughoutPhase1,and78%throughoutPhase2,withanoverallcompliancerateof82%. Measures •AnxietyandRelatedDisordersInterviewScheduleforDSM-5(ADIS-5;BrownandBarlow,2014).TheADIS-5isasemi-structuredclinicalinterviewdesignedtodiagnosecurrentanxiety,mood,andrelateddisordersaccordingtonewDSM-5criteria.ThisupdatedversionoftheADIS-5buildsuponpreviousversions,whichallexhibitedwell-establishedreliability.TheADIS-5demonstratesgood-to-excellentinterraterreliabilityforDSM-5disorders(kapparangingfrom0.67to0.86,withtheexceptionofdysthymia,kappa=0.31)(DiNardoetal.,1994). •HamiltonAnxietyRatingScale(HAM-A;Hamilton,1959).TheHAM-Aisa14-itemclinicianadministeredscalethatassessesseverityofanxioussymptoms.Thisscaleprovidesaseverityratingofeachoverarchingsymptomclusteronascalefrom0(notpresent)to4(verysevere).ResearchhasshownthatretestreliabilityfortheHAM-Awasgood(intraclasscorrelationcoefficient0.86)andinterraterreliabilityrangedfromanintraclasscorrelationcoefficientof0.74–0.96(Brussetal.,1994).Constructvalidityhasalsobeendemonstratedinclinicalsamples(BeckandSteer,1991). •HamiltonDepressionRatingScale(HAM-D;Hamilton,1960).TheHAM-Disa13-itemclinicianadministeredscaledevelopedtoassesstheseverityofdepressivesymptoms.Thisscaleprovidesseverityratingsofeachoverarchingsymptomclusteronascalefrom0(notpresent)to4(verysevere/incapacitating).InternalconsistencyoftheHAM-Drangesfromadequatetogood(0.73–0.81;Steeretal.,1987;Morasetal.,1992).HAM-Dhavealsobeenshowntocorrelatesignificantlywithself-reportmeasuresofdepressioninclinicalsamples(Steeretal.,1983). •DigitalAssessmentDailySurveyItems.InadditiontotheextantDSM-5GADandMDDsymptomcriterion,dailysurveysincludedfourbehavioralsymptoms:(a)avoidingactivitieswithpossiblenegativeoutcomes,(b)preparingforpossiblenegativeoutcomes,(c)procrastinatingabouttakingactionordecisionmaking,and(d)seekingreassurance,asrecentdatahaveillustratedthesebehavioralsymptomstobesignificantfeaturesofGADandMDDphenomenology(Beesdo-BaumandKnappe,2012).Theparticipantratedtheirexperienceofeachsymptomdomainoverthepreceding4h(thesurveyswererandomizedtoroughlya4-hintervalschedule)ona0–100visualanalogslider,withanchorsofnotatallandasmuchaspossibleanchoredatthe0and100positions,respectively.SurveyitemsarepresentedinTable4. TABLE4 Table4.Dailydigitalassessmentsurveyitems. StatisticalApproachtoQuantitativeSurveyItems Dataforeachspecificmodule-basedhypothesiswassubsetforindividualhypotheses.Foranalysesdoneoneachspecifiedmodule,datafromthatmoduleandthroughouttherestoftherapywasusedinordertoassessthedegreetowhicheachspecificmodule,orintervention,wasassociatedwithchangesinthespecifichypothesizeddownstreamvariables.Forexample,theExposuresmodulewasthe4thmoduleforthisparticipant,sodatawassubsetfromthedatethatmodulestartedthroughthelastdayoftherapyfortheexposuremodule-basedhypotheses,anddatapriortodeliveryofthatmodulewasexcluded.Tothenassesschangesintheparticipant’ssurveyresponsesoverthecourseoftherapy,ordinaryleastsquares(OLS)linearregressionwasemployedtotestresponsetrajectoriesofeachitem.Thatis,separatelinearregressionswereappliedtotesttherelationshipbetweenTime(codedindays)andchangesinthedependentvariableinquestion(e.g.,worry,rumination,procrastination).ThedecisiontouseOLSregressionsfortrendsovertimeinsteadofamultilevelapproachwaschosenduetomuchpriorworkinourlabindicatingthatonecanhandleintraindividualtemporaldependenceequallywellwithtrendorARcomponents. Results ForOLSregressionanalyses,rowsofdatawithmissingsurveyswereexcludedasafunctionoflistwisedeletion.InordertoexplorethepresenceofremoralizationaspredictedbyHoward’stheory,wetestedthedegreetowhichtheclientexperiencedreductionsinnegative-affectitemsandincreasesinpositive-affectitems.Thus,thedatawassubsetintotheportionoftimepriortothestartoftherapy,andthenseparatelinearregressionanalyseswereemployedtopredictspecificnegativeaffectitemsasafunctionoftime.ResultsarepresentedinTable5.Modelsfornegativeaffectitemsof“dwelledonthepast,”“feltworthlessorguilty,”“feltworried,”“feltirritable,”“experiencedalossofinterestorpleasure,”“feltthreatened,judged,orintimidated,”“feltdownordepressed,”and“feltangry”wereallsignificantatthep<0.05level,indicatingsignificantdecreasesinthesenegativeaffectitemsduringthepre-therapyperiod. TABLE5 Table5.Separatelinearregressionmodelsforthetrajectoriesofnegativeaffectitemsasafunctionoftimeduringthepre-therapyperiod. Positiveaffectitemsweretestedinthesamemanner,withseparatesimplelinearregressionstotesttrajectoriesovertimeduringthepre-therapyperiod.Allpositiveaffectitemsemergedassignificant;duringthepre-therapyperiod,feelingpositivesignificantlyincreasedovertime[β=0.30,F(1,156)=176.4,p<0.01,R2=0.53],feelingenergeticsignificantlyincreasedovertime[β=0.30,F(1,156)=184,p<0.01,R2=0.54],feelingenthusiasticsignificantlyincreasedovertime[β=0.32,F(1,156)=173.9,p<0.01,R2=0.52],feelingcontentsignificantlyincreasedovertime[β=0.33,F(1,156)=154.6,p<0.01,R2=0.49],andfeelingacceptedorsupportedsignificantlyincreasedovertime[β=0.17,F(1,156)=29.69,p<0.01,R2=0.15]. Inordertotestourfirsthypothesis,thatparticipantwouldreportreductionsinrestlessnessandruminationfollowingthemindfulnessinterventions,thedatawassubsettothetimeperiodafterthemodulewasdelivered,andseparatelinearregressionanalyseswereemployedtotestthetrajectoryoffeelingsofrestlessnessanddwellingonthepastovertime.Resultsweresignificantforrestlessness,yetintheoppositedirectionthenhypothesized;afterdeliveryofthemodule,theparticipantreportedsignificantlyincreasedfeelingsofrestlessness[β=−0.08,F(1,167)=8.43,p<0.01,R2=0.04]. InordertotestthehypothesisthatP007wouldreportreductionsinavoidance-relateditems(difficultyconcentrating,avoidingpeople,avoidingactivities,procrastinating,andseekingreassurance)followingtheexposuremodule,datawasagainsubsetforafterthemodulewasdelivered,andseparatelinearregressionanalyseswereemployedtotestthetrajectoryofeachavoidance-relateditemovertime.Significantreductionswereobservedfordifficultyconcentrating[β=−0.16,F(1,122)=7.82,p=0.01,R2=0.05],avoidingpeople[β=−0.39,F(1,122)=34.93,p≤0.01,R2=0.22],andprocrastinating[β=−0.25,F(1,122)=19.18,p≤0.01,R2=0.13].Seekingreassurancesignificantlyincreasedovertimefollowingtheexposuresmodule[β=0.18,F(1,122)=7.88,p=0.01,R2=0.05],whichwehypothesizemaybeduetotheparticipantconceptualizingreassuranceseekingasapro-socialqualityratherthanasafetybehavior(moreindiscussion). Inordertotestthehypothesisthattheparticipantwouldreportreductionsinworryanddepressionandincreasesinpositivityandcontentednessfollowingthereappraisalmodule,thedatawasagainsubsetforafterthemodulewasdelivered,andseparatelinearregressionanalyseswereemployedtotestthetrajectoryofworry,depression,positivity,andcontentednessovertime.Nosignificantfindingsemergedfromthesemodels.However,itshouldbeemphasizedthatthismaybeduetotheembeddednatureoftheseconstructsinallmodulesandsymptomaticexperiences.Thus,asasecondaryanalysis,weexaminedtheentiretherapysectionofthetimeseriestoassessthedegreeofchangeindepression,worry,positivity,andcontentednessacrossthecompletetreatmentperiod.Resultsindicatesignificantreductionsindepression[β=−0.04,F(1,434)=28.88,p≤0.00,R2=0.06]andworry[β=−0.07,F(1,434)=95.23,p≤0.00,R2=0.18],andasignificantincreaseincontentedness[β=0.02,F(1,434)=4.69,p=0.03,R2=0.01]overthecompletetreatmentperiod. Inordertotestthefinalhypothesis,thattheparticipantwouldreportfurtherreductionsinfeelingsofworryanddepression,thedatawasagainsubsetforafterthefinalmodulewasdelivered,andseparatelinearregressionanalyseswereemployedtotestthetrajectoryofworryanddepressionovertime.Feelingsofworrysignificantlydecreasedovertimefollowingdeliveryofthismodule[β=−2.05,F(1,17)=5.71,p=0.03,R2=0.21].Nosignificantfindingsemergedforfeelingsofdepression. Inadditiontothemodule-specifichypotheses,wealsoemployedseparatelinearregressionsforeachsurveyitemasafunctionoftimeovertheentiretherapyperiodtothedata.ResultsaredepictedinTable6.Significantreductionswereobservedforthefollowingitems:dwellingonthepast,lossofinterestorpleasure,procrastinated,andfeelingworthlessorguilty,hopeless,worried,irritable,threatenedorjudged,downordepressed,restless,fatigued,andenergetic.Significantincreaseswereobservedforthefollowingitems:soughtreassurance,feelingcontent,andfeelingacceptedorsupported. TABLE6 Table6.Separatelinearregressionmodelsforthetrajectoriesofallsurveyitemsasafunctionoftimeduringtheentiretherapyperiod. Discussion ThecurrentstudyusesanobservationalN-of-1casestudydesignonintensiverepeateddigitalmeasuresdatatoinvestigatethenatureofchangethroughoutthecourseofamodularizedtherapy.Analysisoftheintensiverepeatedmeasuresdatarevealedimprovementsinthepre-therapyperiod,providingadditionalevidenceforHoward’sremoralizationtheory(1993).Thistheorystatesthatthefirstofthreesequentialchangesthroughoutthecourseofpsychotherapyisanimprovementofthepatient’ssenseofwell-being(remoralization),andtypicallyoccursquicklyinresponsetosettingupanappointment,gettingadvice,andotheroccurrencesthattendtohappenpriortoandattheonsetofpsychotherapy,includingtheworkdonewithinthefirstthreesessions.Previousworkinavarietyoftreatmentsettingshasfoundsupportofthistheory,includingearlygainsinoptimismveryearlyinadepressiontreatmentstudy(Schwartz,1997),andearlyincreasesofsubjectivewell-being,followedbyreductionofsymptomdistress,inastudyapplyingthephasemodeltoshort-termpsychodynamicpsychotherapy(Hilsenrothetal.,2001).Inthepresentstudy,duringthefirst30-daymonitoringperiod,theparticipantexhibitedsignificantdecreasesinnegativeaffectandaccompanyingsignificantincreasesinpositiveaffect.Thissuggeststhatthesurveyparadigmemployedinthepresentstudy—whichmightbeconsideredaformofself-monitoring—mayserveasafirst-stepintervention,capableofimprovingwell-being.Extantworkhasalsofoundsupportforself-monitoringasafirststepinbehaviorchange(SpatesandKanfer,1977).Thisunderstandingthatimprovementinsymptomscanresultsolelyfromself-monitoringisimportanttothefirsttherapysessionswithapatient,andmayprovideevidencethatecologicalmomentaryassessmenttechniquesusedpriortotherapymayhaveanintrinsictherapeuticeffectinandofthemselves. Pertainingtothemodulehypotheses,supportwasfoundforsome,butnotall,ofourinitialhypotheses.Afterthemindfulnessmodule,itwaspredictedthatrestlessnesswoulddecrease,yetfindingssupportedchangeintheoppositedirectionthanhypothesized;afterdeliveryofthemodule,theparticipantreportedsignificantlyincreasedfeelingsofrestlessness.However,weshouldnotethatthisincreaseaccountedforonly4%ofthevarianceinrestlessness,leaving96%unexplained.Thus,thisincreasemaybesecondarytoother,predominantphenomena.Nevertheless,oneexplanationforthisfindingisthatwedidnotassesswhetherornottheparticipantcontinuedtousethemindfulnessexercisesfollowingthismodule,andperhapstheydidnotincorporatethemindfulnessworkintoanymoreoftheirtreatment.Asecondexplanationmaybethatrestlessnesscanoccurasonetriestoquietthemindinthebeginningstagesofmeditation;astudyinvestigatingtheeffectsofanMBSRonnursestressandburnoutsimilarlyfoundthat,whiletheprogramwasoveralleffectiveatreducingstress,whentheparticipantswereaskedaboutthechallengesoftheprogramthemostcommonresponsewasrestlessness,whichwasmentionedby52%ofthenurses,withcommentssuchas,“mymindiseverywhere,”“mybodyfeelsrestless,”and“it’ssohardtoconcentrate!”(Cohen-Katzetal.,2004).Perhapsinstitutingamorefrequentmindfulnesspracticefollowingthismodulecouldmitigatetheseissuesinfuturework. Ourhypothesesfollowingtheexposuremoduleweresupported.Significantreductionswereobservedindifficultyconcentrating,avoidingactivities,andprocrastinatingfollowingdeliveryofthemodule,illustratingactualchangesinthehypothesizeddownstreamtargetsoftheintervention.Ofnote,endorsementofreassuranceseekingsignificantlyincreasedovertimefollowingtheexposuresmodule,however,wehypothesizethatthismaybeduetotheparticipantconceptualizingreassuranceseekingasapro-socialqualityratherthanasafetybehavior.Supportwasnotfoundforourhypothesisfollowingdeliveryofthecognitiveappraisalandreappraisalsmodule,whichwebelievemaybeduetothefactthatthepredictedtargetsofworry,depression,positivity,andcontentednessweretoobroad,andthatfutureworkshouldincludemorespecificquestionsaimedatassessingthesuccessofthisintervention(e.g.,questionsaimedatassessingcatastrophizing,overconfidence,andflexiblethinking).Asnotedintheresults,anexploratoryanalysisthatexaminedchangesintheseconstructsoverthecompletetreatmentperiodrevealedsignificantchange—intheexpecteddirection—foreach,demonstratingthatthesevariableswereaffectedbythetreatmentgenerally.Lastly,ourhypothesisthatworrywoulddecreaseaftertheemotiondrivenbehaviorsandemotionalavoidancemodulewassupported,illustratingthattargetingavoidanceinthisoneindividualsubsequentlyimprovedtheirworryoverthecourseofthistreatment. Inadditiontotheindividualhypothesizedchangesandsubsequentfindings,theoveralltreatmentprescriptionforthisindividualparticipantwassuccessfulatreducinghersymptomsofmajordepressivedisorderandgeneralizedanxietydisorder.TheparticipantbegantherapywithHAM-AandHAM-Dscoresof17and11,respectively,indicatingthattheparticipantwasinthemildseverityrangeofbothdepressiveandanxioussymptomatology.Oneweekaftertheparticipantcompletedtherapy,herscoresfortheHAM-AandHAM-Dwere4and3,respectively,indicatingthatshefellinthenormalrangesforbothassessments.Furthermore,separatelinearregressionsforeachsurveyitemsasafunctionoftimewereconductedovertheentiretherapyperiod.Theresults(Table6)showsignificantreductionsforthemajorityofnegativeaffectitems,andsignificantincreasesformanypositiveaffectitems.Theparticipanttherefore,uponself-reportofthesurveys,feltareductioninnegativeaffectandincreaseinpositiveaffectthroughouttherapy. Limitations Limitationsofthepresentstudyincludetheuseofasingleparticipant,aswellasutilizingamethodofassessingchangeperspecificmodule.Thechangesmayhavebeenduetooverallchangesacrosstheentiretherapyperiodandnotduetothespecificinterventiontakingplace.Ourmethodofsubsettingthedataattemptedtominimizethisfromoccurring.Othertimeseriesdesigns,includingmultiplebaselineandinterruptedtimeseries,maybeusefulforaddressingthesequestionsinthefuture;sincewewereperformingsecondaryanalysestoaprimarystudythatdidnotemploythesetypesofdesigns,wewerenotabletoutilizeonehere. FutureDirections Idiographicapproachestotreatmentresearcharegrowinginpopularity.Inordertodevelopmoreefficientandtargetedinterventions,researchersandcliniciansalikehavecalledforidiographichypothesistestingtoinvestigatemechanismsofchangewithinindividualsoverthecourseofatreatmentperiod.Thisapproachisnotnewtoclinicians,asevidencedbyexistingconceptualizationmethodsthatintegratedifferentmodalitiestomeettheneedsofthepresentingproblemsoftheindividualclient,includingcaseformulationdrivenapproachesforcognitivebehaviortherapy(Persons,2012),andpsychotherapyintegrationapproaches(StrickerandGold,1996).Manyrecentresearchgroupshavedemonstratedtheutilityofsuchapproaches,primarilyinvestigatingquantitativechangestoinvestigatewhetheralterationsoncertaintreatmentparametersorsymptomspredictsubsequentchangesovertime(Brownetal.,2019).Thisworkprovidesyetanotherimportantavenuebywhichtoinvestigatetreatmentchangesidiographically,servingasamodelforaquantitativeapproach. Itisimportanttonotethatwhileconductedonasingleindividual,thisworkwasanalyzedideographically,andthusfindingsarenotmeanttogeneralizetootherindividuals,butratheraremeanttoillustratehowidiographicworksuchasthiscanbeutilizedperhapsforpredictionmodels(i.e.,usedtoimprovepredictionofresponseinthefutureforthatspecificN-of-1unit).Previousinferencesmadefrompsychologicalandmedicalresearch(e.g.,treatmentdevelopment,personalityresearch)aretypicallydrawnfromstatisticaltestsconductedonaggregated,group-leveldata,withtheimplicitassumptionthatgroup-levelinferences,orfindings,willgeneralizetotheindividualswhocomprisethosegroups.Oftenoverlookedinthisassumptionistheproblemofergodicity.Broadlyspeaking,ergodicityreferstoaprocessbywhichindividualvariationcanbeinferredfromgroup-leveldata.Historically,thefieldofpsychologyhasassumedthatmostprocessesareergodicinnature.Butthisassumptionisnotalwaysupheld,andrecentworkbyFisheretal.(2018)foundthatinself-reportedemotiondata(andothertypesofdata)theprocesseswerenotergodic.Infact,theyfoundthatthevarianceattheindividuallevelofanalysiswasuptofourtimeslargerthanatthegrouplevel.Assumingergodicityfornon-ergodicprocessesleadstomisinterpretationsoffindingsthatstallthepaceofprogressinthefield.Idiographicworksuchasthiscanhelptomitigatethisgapandprovideagroundworkforpersonalizedpredictionmodels. Furthermore,asnotedintheintroduction,someresearchersbelievethattherapeuticelementsoftherapyareduetocommonfactorsacrossalltechniques,notspecificinterventionsthemselves.Ourapproach,andsupportingevidence,howeverillustratestheabilitytodiscernspecificeffectsattributedtocertaininterventions. Themethodsemployedandfindingsindicatedherealsohavethepotentialtoaidpsychotherapistsinroutinecarebyhelpingthemassesswhethertheirinterventionsareworking.Byemployingroutineprogressmonitoring,whetherthroughdailyphonesurveysorothermethodssuchasone-timedailydiaries,psychotherapistscanvisualizereductionsinsymptomsovertimeandassesswhethertheyaretargetingthesymptomstheyhope,andthusconcludethattheirprescribedtreatmentcourseiseffective,oriftheyneedtochangecourse.MethodstocollectintensiverepeatedmeasurespriortotherapydeliveryhavealreadybeenemployedinnaturalisticsettingssuchasaUniversityhealthcenter(e.g.,theUCBerkeleyPsychologyClinic).Thesetherapistscouldcontinuetocollectsimilardataandemploythemethodsoutlinedhereinordertoassesstheefficacyandaccuracyoftheirinterventions. Conclusion Inconclusion,futureworkshouldcontinuetoutilizedigitalhealthtoolstoadministerquantitativesurveys,suchasthis,aswellasothermethodologies(e.g.,multiplebaselinesandinterruptedtimeseriesdesigns)inordertobetterunderstandthenatureofchangeinpsychotherapeutictreatment. DataAvailabilityStatement Thedatasetsgeneratedforthisstudyareavailableonrequesttothecorrespondingauthor. EthicsStatement ThestudiesinvolvinghumanparticipantswerereviewedandapprovedbytheCommitteeforProtectionofHumanSubjects(CPHS)bytheOfficeforProtectionofHumanSubjects(OPHS)attheUniversityofCalifornia,Berkeley.Thepatients/participantsprovidedtheirwritteninformedconsenttoparticipateinthisstudy. AuthorContributions Allauthorscontributedtotheworkpresentedinthismanuscript.AAandAFdesignedtheexperimentandsubsequentanalyses.LShelpedwithhypothesesanddataorganization.AAranthestatisticalanalyses,analyzedtheoutputdata,createdthetablesandfigures,andcontributedtothewritingofthemanuscript. 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Editedby: EricHekler,UniversityofCalifornia,SanDiego,UnitedStates Reviewedby: DavidPincus,ChapmanUniversity,UnitedStates JavierFernández-Álvarez,CatholicUniversityoftheSacredHeart,Italy Copyright©2020Altman,ShapiroandFisher.Thisisanopen-accessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense(CCBY).Theuse,distributionorreproductioninotherforumsispermitted,providedtheoriginalauthor(s)andthecopyrightowner(s)arecreditedandthattheoriginalpublicationinthisjournaliscited,inaccordancewithacceptedacademicpractice.Nouse,distributionorreproductionispermittedwhichdoesnotcomplywiththeseterms. *Correspondence:AllisonDiamondAltman,[email protected] COMMENTARY ORIGINALARTICLE Peoplealsolookedat SuggestaResearchTopic>