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Tutor: Please provide a detailed answer for a deeper understanding…
Tutor: Please provide a detailed answer for a deeper understanding and the scholarly source of information.
INSTRUCTIONS
Identify either strengths or possible limitations of how that assessment was administered. Think of strengths or weaknesses such as ethical considerations, advantages, and disadvantages of qualitative versus quantitative data gathering, the measurement scale used, the timing, duration or repetition interval of assessments, the validity of what was being measured or the reliability of the results.
Case Study: Examining the Potential Impact of a Family Session in Therapeutic Assessment: A Single-Case Experiment
Therapeutic assessment (TA; Finn, 2007) is the most well-documented and empirically supported collaborative or therapeutic approach to psychological assessment.
CASE EXAMPLE: DAVID The case example of David and his father adheres to the comprehensive TA-C model described previously in the literature The procedures and arrangements of each session, including mini-consultations, a video link for parent observation, and modifications specific to the one-assessor variation of TA-C, are described in detail elsewhere (Smith, Handler, et al., 2010).
The Initial Meeting
Presenting Problem and Assessment Questions. Scott1 referred his son, David, for a psychological evaluation at a university-based outpatient clinic. David was small in stature for his age and had a very slight build. Scott’s reported concerns about David were his lackluster academic performance, problems relating to peers, and apparent self-esteem issues. Scott held many crystallized ideas about his son, for example, reporting that David’s social problems were due to the other children’s jealousy of his intelligence: “They just aren’t as smart as David, and it makes it hard for them to get along,” he remarked. In school, David reportedly had a tendency to rush through assignments and exams, resulting in mediocre grades. When Scott was asked his impression of this behavior, he quickly said, “I think he’s just bored in class. I read that gifted children get bored and get bad grades when they aren’t being challenged.” Scott also expressed concern about David’s self-esteem, given his
David’s Family Session
The development of the family session is informed by the test results and a theory-driven systemic case conceptualization. David’s frustrations appeared to be precipitated by the dichotomy between his father’s messages and the contradictory ones he received from his teacher and peers. Researchers in social psychology have consistently found that expectation affects outcomes. However, there is little agreement about the direction of this effect (McNulty & Karney, 2004). According to the poet Alexander Pope (1737, letter to Fortescue), expectations of any kind leave people vulnerable to disappointment should they fail to be met. Scott’s high expectations of his son could have led to improved academic performance, but David’s failure to meet his father’s high expectations probably affected his performance and self-esteem. This formulation suggests that developing more realistic expectations might be motivating rather than a source of shame for David. From a self-psychology perspective, Kohut (1971) believed that narcissistic character structure stems from a desperate fear of losing a love object, which has yet to be experienced as separate and independent from the self. For David, his father was the love object whose expectations of intelligence and success were hopelessly intertwined with his sense of self. Thus, disappointing his father might mean losing the needed supplier of self-esteem (Kohut, 1971). Conversely, David’s father’s self-esteem also seemed to be embedded within his son’s intelligence and achievement, meaning these aspects of David were both needed by Scott and by David to maintain a connection between them defined by mutual confirmation and narcissistic sustenance. We (the first and third authors) believed that Scott’s high expectations and his tendency to rationalize and justify David’s struggles perpetuated this dynamic. Addressing issues related to this dyadic pattern was thought to be crucial to the success of the family session. One of the most difficult aspects of family sessions is designing a task or activity that results in the desired outcomes. The brief, time-limited nature of TA-C necessitates a well-planned, purposeful approach, in which a family session encompassing all of the child’s and family’s problems is not only typically unfeasible but might even be undesirable. In this case, two particular test results accurately illustrated David’s problems and provided the basis for the family session: David’s male figure drawing was in stark contrast to his slight physical stature and seemed to reflect exaggerated confidence and expectations. Second, the results of the Bender were quite poor, which was likely due to David’s rushed approach to the task. We utilized both of these tests during the family session to achieve the session’s goals, which were congruent with Scott’s assessment questions and the case conceptualization. At the beginning of the family session, the first author met with Scott to ARRANGE and enlist his assistance in the session. Scott was told that the focus of the session was to help him and David work through systemic issues that have contributed to the problems reflected in his assessment questions. The first author presented Scott with the computer-generated table of results from David’s WISC-IV scores, to provide a realistic picture of his son’s abilities. The first author was somewhat concerned about how Scott would receive this news, given his high expectations. Scott immediately noticed the qualitative description.
THE CASE-BASED TIME-SERIES EXPERIMENT
Procedures
Case-based time-series methodology has been described as a potentially useful method of tracking clients’ improvement in psychotherapy and has been advocated as a means of examining real-world clinical effectiveness, thus bridging the gap between science and practice (e.g., Borckardt et al., 2008; Kazdin, 2008). Smith, Handler, et al. (2010) and Smith et al. (2009) provide detailed descriptions of this methodology in the study of TA-C, and we refer the reader to those sources for additional description of the research procedures used in this study. Based on the assessment questions, Scott and the first author identified the following metrics during the initial meeting that would be measured daily: (a) overall family distress, (b) David felt good about himself today, and (c) David had positive social interactions today. On the first two items, Scott and David were instructed to come to an agreement between them for each day’s ratings, using a Likert-type scale ranging from 1 to 9. Scott was provided with paper tracking sheets and was scheduled to return in 2 weeks so that a baseline period could be obtained prior to the first session with David.
Hypotheses
The aims of this experimental case study are twofold: (a) Test the extent to which changes in the reported daily measures coincided with the onset of TA-C, and (b) examine the potential impact the family session might have had on the course of improvement. We hypothesized that the child and his father would experience significant improvements in the measured areas of functioning after receiving a TA-C, and we predicted that the family session was the point at which a shift in the trajectory of improvement occurred. The second hypothesis received informal support after the TA-C was completed, based on the clinician’s impression of the success of the family session and the father’s report during the follow-up session, which suggested that the goals of the family session had been achieved.
Data Analysis
Analyses were conducted using Simulation Modeling Analysis (SMA; Borckardt, 2006b) for time-series. SMA is a bootstrapping approach that accounts for autocorrelation, the nonindependence of sequential observations inherent in a stream of data. SMA is capable of conducting phase-effect, or levelchange analyses, and slope-change analyses. Level-change analyses determine the effect for the observed difference between two specified streams of data. Slope-change analyses determine the strength of the relationship between the reported, dependent variable(s) and an a priori model of the trajectory of improvement. Both analyses are discussed in greater detail in the Results section. Finally, because three nonindependent variables were measured on a daily basis, the highly conservative Bonferroni correction was used to determine the significance of observed effects (Bonferroni, 1935). Using an alpha value of .05, the resultant corrected p-value is .017 (i.e., 0.05/3).
Cautionary Notes Regarding Inference of Causality in Single-Case Experimental Designs
Although the single-case ABC design involves an experimental manipulation, causality cannot be determined from this research design. The main premise of experimental single-case research is that changes in stable behaviors coinciding with treatment suggest that the intervention might have led to change (Kazdin, 2010). We have included elements in the research design that strengthen the probability that changes can be attributed to the treatment, such as gathering a stable baseline measurement, conducting a specified intervention, and including daily assessment of multiple markers of improvement (e.g., Barlow & Hersen, 1984; Kazdin, 2010). However, due to rival hypotheses and threats to internal validity, causality must be assessed using research designs with greater experimental control.
CONCLUSIONS
This article provides a clinically useful example of the development and execution of a family session in TA-C. We illustrate how to use assessment results, observations, and a theoretically informed case conceptualization to design a task that accomplishes therapeutic goals in regard to the systemic nature of the problem. McNulty and Karney (2004) found that expectations running counter to the facts can be detrimental when one member of the family unit feels that he or she is disappointing another by not meeting the other’s expectations. This situation in David’s family had a profound effect on his self-esteem and self-image, not to mention the secondary effects on his academic performance and social interactions. As Scott’s expectations changed and he began to view David more accurately, David’s self-esteem seemed to improve and he felt more secure in this relationship, leading to more positive peer interactions. In conjunction with the Tharinger et al. (2009) study, the results of this and other case-based time-series studies (Smith, Handler, et al., 2010; Smith et al., 2009) suggest that children and families improve after participating in TA-C. However, change seems to occur somewhat idiographically, following different trajectories in individual cases. Finn (2007) suggested that TA practitioners be mindful of clients’ “tipping points” that could move them toward change. The results of this study suggest that the family session might be one such opportunity to address clients’ tipping points in TA-C. The successful family session with David and his father appeared to be related to the statistically significant improvement found in Analysis 1. Further support for this observation, albeit nonexperimental, is provided by the post-hoc slope-change analysis (Analysis 2), suggesting that the family session coincided with a shift in the course of reported symptoms. We hope these findings can inform future TA-C research on differential response and the mechanisms of improvement, which are currently not well understood.
Limitations and Future Directions
Despite the systemic emphasis on case conceptualization and intervention during the family session, we did not include measures of family or dyadic functioning. The consequences of not being able to include David’s mother in the TA-C are unknown. Second, our conceptualization of this case was a psychodynamic systems approach, somewhat similar to that described by Cierpka (2005), which resulted in a specific understanding of the family and related approach to the family session. Clinicians from other orientations might have approached the case much differently. Future studies of TA-C would likely benefit from including daily measures of greater specificity and a broader spectrum of functioning, as these indexes were found to be highly related and likely non-independent constructs. Future research designs would require greater experimental control to determine treatment efficacy and the potential causal role the family session might have on observed improvement.
