1. “Hermeneutic Single Case Experimental Design: An example of the methodology in action, description of the multi-site study and call for an expert panel ”
Stephen Kellett
Consultant Clinical Psychologist
IAPT Programme Director
University of Sheffield
Sheffield S & HC NHS Trust

2. Hermeutic single case experimental design (Elliott 2002)
Present Study
Assessment, case description, treatment and long-term outcome of client presenting with Paranoid Personality Disorder (PPD)
Hermeutic single case experimental design (Elliott 2002)
(1) traditional outcomes measures
(2) personal questionnaire daily
(3) perceptions of therapy and therapist
(4) post therapy interview
(5) well described case
(6) expert panel or ‘jury’ to consider the evidence for change

3. PPD : DSM-1V (APA, 1994) DEFINITION
suspects (without sufficient basis) that others are exploiting, harming or deceiving them
pre-occupied with trustworthiness
inability to confide
reads demeaning/threatening meanings into events
grudges
perceives attacks on character
jealous

4. Present Study cont
Repetition of measures focal to PPD across phases of CAT treatment and phases within phases (ie. addition of mindfulness) (1) reformulation/assessment phase (2) CAT intervention (3) follow-up

5. The Case Carl (pseudonym, aged 37, signed off work)
Referred by Consultant Psychiatrist opinion re. thought disorder
Screened and placed on waiting list
Assessed via SCID-II (Spitzer et al, 1997)
Factor
Description
CHILDHOOD
father morbidly jealous of mother
used as a ‘spy’
interrogated
sibling
reinforcement of schema by step-father
OCCUPATION
unskilled jobs 2 years
benefit fraud investigator 13 years
DWP currently

6. The Case cont RELATIONSHIPS
married – disconnected & distrustful of partner
1 child – few friends
‘COPING’
drugs & alcohol
MENTAL HEALTH
history of depression
schizoid
anti-depressant/anti psychotic
SYMTOMATOLOGY
disconnected
untrusting
suspicious
‘The Game’
vigilance; ‘the radar’
‘safety’ behaviours
conspiracy theories

7. Hermeneutic SCED; what was done and when
Traditional Outcome Measures reported at assessment, termination, and follow-up
Beck Depression Inventory-II (BDI; Beck et al, 1994)
Brief Symptom Inventory (BSI; Derogatis, 1993)
Inventory of Interpersonal Problems (IIP-32; Barkham et al, 1994)
Personality Structure and Questionnaire (PSQ; Pollock et al, 2001)
(2) Personal Questionnaire
Actual Wording
PPD criteria/concept
Frequency
Scale
Item 1
“I have felt suspicious of other motives today”
DSM-IV
Subjects that others are exploiting, harming or deceiving others
Daily
1 ‘not at all’ to
10 ‘all the time’
Item 2
“I have been scanning my environment today”
Hypervigilance

8. Hermeneutic SCED cont Actual Wording PPD criteria/concept Frequency
Scale
Item 3
“I have been questionning the motives of others today”
Is preoccupied with unjustified doubts about loyalty or trustworthiness of others
Daily
1 ‘not at all’ to
10 ‘all the time’
Item 4
“I have been in a world of my own today”
Dissociation/
Disconnection
Item 5
“I have been looking for connections today”
Conspiracy
Item 6
“I have felt anxious today”
Anxiety

9. Hermeneutic SCED cont Perception of therapy and therapist
Session Impact Questionnaire (Stiles et al, 1994)
5 ‘impacts’ measured after each session (understanding, problem solving, relationship, unwanted thoughts, hindering aspects)
Post-therapy Interview
Therapy change interview (Elliott, Slatick & Urman, 2001)

10. Structure of intervention
co-working and sharing; reformulation letter
SDR (starting to get cognitive)
introduction of mindfulness techniques
integrating RR analysis and mindfulness
homework
in session enactments
termination issues

11. Mindfulness-based cognitive therapy (Segal, Williams & Teasdale, 2002)
Mindfulness of breath
Staying present
Allowing/letting be
Thinking and thought
Dealing with barriers

12. Diagram 1: Sequential Diagrammatic Reformulation for PPD Case
TOTALLY
UNFEELING
CUT OFF
&
EMPTY
CORE PAIN
anxious
fearful
insecure
hectored
CAPTAIN PARANOIA
(though I feel complete)
INTERROGATING I
INTERROGATED
`THE GAME`
Players versus non-players
OBSERVING
WATCHING
MONITORED
SOCIAL
WITHDRAWAL
`the radar`
SUSPICIOUS
WARY
DISTRUSTFUL
find this frightening after a while
start to feel vulnerable
only way I know to feel safe
obsess about it
start to believe thoughts
`peas in the bag`
try to see a pattern
need to make sense
anxiety triggered
see threat everywhere
when with people, always keep my distance
find it hard to `connect`
never develop `true` trust
start to see threats
withdraw into myself
mood
plummets
Hard to tolerate this
feel totally exhausted
can’t ever relax
never ever stop thinking
try to make sense of confusion
need something to tie it all together
start to play
this game is real
`ha ha; I’ve seen you`
win / outwit/
triumph

13. Key question 1
At what stage does active therapy start to work and are there any sudden gains?

15. Table 1; means, (SDs) and F-values for the experimental variables
Baseline mean (SD)
Treatment mean (SD)
Follow-up mean (SD)
F-value
Suspicious
34.33 (2.08)
11.82 (7.12)
7.00 (0.00)
11.60**
Hypervigilent
23.67 (9.81)
9.61 (11.04)
0.06
Questioning
21.67 (16.67)
9.67 (2.76)
1.98
Dissociation
20.33 (14.01)
11.15 (7.15)
1.26
Conspiracy
19.67 (17.78)
10.48 (6.11)
2.49
Anxious
27.33 (11.52)
16.48 (10.30)
17.16 (9.06)
4.24*
* p < 0.05
** p < 0.01

16. What do significant F-values mean in this context?
An overall change in both the intercept (i.e. start of treatment post formulation) and the slope (regression line)

17. Key question 2
Is there any clinically significant change in the traditional outcome measures?

19. Key question 3; are some sessions more impactful/helpful than others?
Significant increase in ratings of problem solving in treatment sessions (t = -2.27, P < 0.05)
No difference in understanding, relationship, unwanted thoughts or hindering aspects

20. Key question 4
can the client describe what changes were due to therapy and what made the difference
the change interview conducted at final follow-up session

21. Change interview results
“feel so much better, not be thinking all the time”
“not playing the game such a relief … I can manage my thoughts now”
5 = surprised; 1 = expected
In therapy actions … ‘developing trust’
Key changes (1) use of SDR (2) integrating mindfulness and RRs
“ I see people differently now”
Managing the paranoia with somebody, very difficult at first

22. Conclusions for the case
Integration the key issue
Good evidence of change and change being attributable to the therapy conducted
HSCED effective research methodology in PD populations

23. CAT and BPD multi-site HSCED study
Project team = Stephen Kellett, Dawn Bennett and Tony Ryle
Progress = 8 therapists over 8 sites have completed a 24 plus 4 follow-up session CAT interventions with BPD clients
Sessions sampled from each of the therapies and CCAT conducted to attain competency rating (111 CCATs completed)

24. Methodology AT EACH SESSION At every 4th Session
At 3 month post-therapy
CORE-OM
Dissociative Experiences Scale
Elliot Change Interview
Personal Questionnaire
Personality Structure Scale
Helpful Aspects of Therapy
Measure of alliance
Audio tape of session

25. Need for an expert panel/jury
We are attempting to recruit a panel of professionals to consider the evidence for change in a number of cases
Professionals not aligned to CAT and sceptical about change
One day meeting