Case Study of a Single Subject Design

Abstract

The case analysis is a qualitative study to investigate the effectiveness of an intervention targeted to an elderly client diagnosed with cancer and negative mental reactions to the diagnosis. Besides the pain of cancer, Mr. Smith suffers from severe depression, schizophrenia, delirium with aggressive behavior. Cognitive Behavior Therapy is the proposed psychotherapy model for the treatment of the mental and emotional conditions affecting the client. The intervention improved the level of compliance with treatment and moderately reduced depression. However, the approach required improvement to deal with delirium with aggressive behavior.

Case Study of a Single Subject Design

Agency and Setting

The setting for the intervention is Memphis Hospital, Palliative Care Unit (PCU). In this setup, services are provided to promote health care across the illness trajectory. Health care is provided at the PCU to relieve pain and suffering, including the end of life care and support for the bereaved. Social workers at the hospital work in Interdisciplinary Teams (IDTs) to provide quality care to address medical, psychological, social, and spiritual needs. One of the groups served at the facility are patients suffering from terminal or life-limiting conditions to provide them with quality life while still alive. At PCU, the care team offers various services, including understanding Living Wills and Health Care Power-of-Attorneys. They also deal with advanced illness with difficult-to-treat symptoms and provide support and gentle care for end-of-life issues when the end approaches. Generally, PCU helps their clients to come to terms with the challenges relating to end-of-life care.

Description of the Client/Biopsychosocial History and Problem Assessment

The case study under analysis is Mr. Smith (not his real name) born in 1955 (63 years old), Male, White Caucasian, widow. Mr. Smith is a veteran of the Persian Gulf war. The client has been diagnosed with metastatic colorectal cancer (mCRC), which is inoperable. Cancer has prevalent comorbidity of cardiovascular disease (CVD). The client has a prior psychiatric history of severe depression, schizophrenia, delirium with aggressive behavior. The patient agrees with radiation treatment, but not concurrent radiation and chemotherapy treatment as recommended by Memphis Hospital-PCU hematology and oncology team. Consequently, it is challenging for the team to use the most effective intervention for the client.  However, the group together with the social worker will implement the best practice for the client.

Concrete, Specific, and Measurable Treatment Goals for Intervention

The intervention will achieve the following objectives:

1. To decrease patient’s high rate of psychiatric delirium and the related aggressive behavior.
2. To minimize psychological complications, including severe depressive mood and the emotional difficulties in dealing with the diagnosis and management of the disease.
3. To increase medication and treatment compliance and the likelihood of working with the Memphis Hospital-PCU hematology and oncology team to manage the disease and its symptoms.

Intervention Literature Review for Client’s Problem

Effects of the Diagnosis

Coping with a chronic illness is a challenge to the affected individual. For instance, the cancer diagnosis is accompanied by anxiety as well as emotional and mental distress. One of the primary effects on individuals suffering from chronic conditions is depression (Safren, Gonzalez, & Soroudi, 2008). The depression emerges as the person tries to cope or come to terms with the diagnosis. According to Selene, Omar, and Silvia (2016), regardless of the medical advances, in some parts of the world, including the developing countries, treatment and management of chronic diseases, such as cancer are still problematic. However, even in the developed economies, such diagnosis is accompanied by uncertainty relating to the outcome of the treatment. Additionally, those diagnosed with a disease such as cancer undergoes debilitating treatments that extends for a long time. Hence, in some cases, patients end up in the palliative care unit.

Although different patient groups experience critical reactions to chronic illness diagnosis, the elderly are the most affected since they are already dealing with health challenges relating to their age. According to Parpa, Tsilika, Gennimata, and Mystakidou (2015), depression is the most common outcome of cancer diagnosis among the elderly. The condition is associated with increased rates of disability, morbidity, and mortality among the patients in this group.  However, Parpa, Tsilika, Gennimata, and Mystakidou (2015) add that depression is not the only psychological challenge that affects the elderly suffering from chronic diseases. Anxiety disorders could be less frequent, but they also affect patients in such situations. The study by Parpa, Tsilika, Gennimata, and Mystakidou (2015) revealed that anxiety appears to be a significant problem in life when an individual has to cope with a cancer diagnosis. Consequently, it is critical for healthcare providers to understand the challenges and implement interventions to support the care and management of chronic disease and the related mental health problems.

Besides depression and anxiety disorders, hallucinations are common in individuals diagnosed with chronic illnesses, such as cancer. Hazell et al. (2018) argue that it is common for such patients to hear voices that do not exist due to the distressing situation. Research reveals that many people are already living with such a condition in the United Kingdom and the rest of the world. For such individuals, it is critical to use effective interventions to address the mental distress that creates the tendency to hallucinate (Hazell et al., 2018). Such interventions should target the causes of the symptoms and not necessarily the actual symptoms since by dealing with the risk factors, it becomes possible to treat the condition effectively. The case analysis reveals hallucinations to be among the mental health conditions affecting Mr. Smith because of the cancer diagnosis.

Research reveals that geriatric patients are among the most problematic to manage because of the complications caused by psychiatric disorders. Parpa, Tsilika, Gennimata, and Mystakidou (2015) conclude that the problem is worse in cases when cancer is diagnosed at advanced stages. As a result, treatment for these patients should focus beyond the cancer diagnosis because such a treatment regimen will not achieve holistic healing. Hence, healthcare professionals should provide treatment for the condition as well as psychological support, which would deal with the challenging mental and emotional reactions to the diagnosis (Gary, Dunbar, Higgins, Musselman, & Smith, 2010). Although data is still limited on the prevalence of the mental disorders in elderly patients with cancer, current cases reveal a problem with a dire need for a practical solution. Therefore, healthcare teams should realize the need for support and implement effective measures to provide the necessary care to such patients.

The Importance of Psychological and Emotional Support 

Support for individuals suffering from chronic illness is meant to empower the individuals to take care of themselves to relieve depression and live a quality life, regardless of the diagnosis (Safren, Gonzalez, & Soroudi, 2008). Besides having medical professionals to implement treatment in the palliative care, psychologists are involved in the interdisciplinary support teams when dealing with the psychological reactions of diagnosis and the effects of the disease (Selene, Omar, & Silvia, 2016). The psychological intervention plays an important role in improving the ability of the patient to cope with the disease and the emerging psychological issues. The interventions are designed to promote physical as well as psychological symptoms among individuals suffering from chronic illnesses, such as cancer. Furthermore, Gary, Dunbar, Higgins, Musselman, and Smith (2010) suggest the critical role the interventions play in improving the quality of life. Consequently, effective programs are critical following a positive diagnosis of a chronic illness.

Research reveals the importance of psychosocial interventions for the treatment of various psychological challenges associated with ailing in old age. The interventions are implemented for different reasons, including the management of psychological distress and pain in chronic conditions as well as to improve the quality of life of the patient (Greer, Park, & Safren, 2010). Greer, Park, and Safren (2010) further established that while interventions targeting anxiety and depression are effective in dealing with the symptoms of the condition, the timing of the implementation plays a significant role in the success of the treatment. For example, when dealing with a cancer patient such as Mr. Smith, it would be more effective if the treatment team recognizes the risk of depression or anxiety to implement the intervention immediately after the diagnosis. After all, the history of emotional and mental instability of the client should inform immediate intervention following a positive cancer diagnosis.

Furthermore, the cancer diagnosis is major news for the patient to comprehend and may create different reactions that the treatment team should anticipate immediately after the diagnosis. Marcus and Mott (2014) reveal that apart from the physical debility caused by cancer, the patient should deal with the psychological effect and the anticipated poor prognosis in cancer treatment. Mr. Smith’s case is particularly challenging because he is a veteran in a war, which means that he might have a history of adverse mental health due to the contact with violence. Thus, the care provision team working on the case should be more proactive in dealing with the physical and psychological pain affecting the client (Hersen & Rosqvist, 2005). The case analysis shows that the patient is not coping well with the cancer diagnosis. Consequently, the factor might adversely affect the outcome of his treatment unless effective steps are initiated to support his treatment. Therefore, the management team should realize the challenge to implement an evidence-based intervention for Mr. Smith’s mental health treatment such as Cognitive Behavioral Therapy.

The Proposed Intervention

The proposed intervention to help Mr. Smith combines Cognitive Behavioral Therapy with regular backing from Memphis Hospital-PCU hematology and oncology team to support his treatment and management of cancer and the related psychological reactions. Greer, Park, and Safren (2010) reveal the importance of tailoring the intervention to the particular psychological needs of the client. The traditional form of Cognitive Behavioral Therapy indicates that the affected person tends to idealistically misjudge adverse outcomes (Greer, Park, & Safren, 2010). Hazell et al. (2018) suggest that Cognitive Behavioral Therapy is a formulation-based and extensive treatment that provides mechanisms for coping with psychological health symptoms that are challenging to the affected person. However, Hazell et al. (2018) include the importance of targeting therapy to the particular mental health symptoms presented by the patient. Generally, the research suggests the importance of tailoring the intervention to the needs of the client.

In a case such as Mr. Smith’s, the medical team should identify the source of the mental challenges to implement a targeted intervention. For example, Hazell et al. (2018) consider the importance of targeting such symptoms as distressing voices that accompany hallucinations in a patient unable to cope with a severe problem such as the cancer diagnosis. Although the patient is suffering from depression or anxiety due to the diagnosis, they are symptoms of serious mental health challenges emanating from the positive chronic illness diagnosis. Hence, Hazell et al. (2018) propose the need to address the factors leading to the symptoms to intervene in the situation effectively. The targeted approach plays a crucial role in addressing the specific causes of negative behaviors as a reaction to the challenging situation such as the cancer diagnosis. Under those premises, the therapist will also discuss the avoidance and maladaptive coping tendencies involved in dealing with the challenging situation.

Cognitive Behavioral Therapy works by addressing the maladaptive behaviors and tendencies and replacing them with more adaptive ones, hence tackling the negative reactions to the challenging health situation. Properly implemented Cognitive Behavioral intervention works on the underlying factors to overcome the psychological issues, including depression, anxiety, and hallucinations (Hazell et al., 2018). However, Hazell et al. (2018) add the importance of combining the psychological intervention with cancer treatment since the related pain is one of the causes of the negative reactions among patients, such as Mr. Smith. Traditional Cognitive Behavioral Therapy might fail to work in such cases, especially if they involve cognitive restructuring due to the pain associated with the cancer. Hence, the treatment team should implement a holistic intervention that includes cancer and pain management for the patient to be convinced about the positive outcome of the treatment (Jacobs et al., 2014). Such interventions have proven effective in addressing the physical and mental issues associated with a chronic illness diagnosis in advanced age.

Effectiveness of the Intervention

Treatment for Mr. Smith should be adequate to achieve the objectives of the intervention. For instance, the patient should positively view the procedure as being helpful and effective in treating the chronic disorder. The patient should move from the place of pain to a more optimistic state for the treatment to be considered effective. In most cases, cancer patients during the advanced age obsess about the impending death to the point that it interferes with their quality of life. Thus, the Cognitive Behavioral Therapy should target the negative thoughts and replace them with more optimistic feelings to achieve positive outcomes and improve the quality of life of the affected patient. One of the measures of effectiveness in Mr. Smith’s treatment is compliance with the treatment options for cancer and the negative emotional reactions to the disease.

Notably, increased compliance with the treatment is the beginning step for the relief of the physical and mental symptoms. Furthermore, through complying with treatment, the Memphis Hospital-PCU hematology and oncology team will effectively work with the patient to support the treatment process and achieve other objectives, including a reduction in the depressive symptoms and pain management. The team also desires that the patient learns to cope with the challenges associated with chronic illness diagnosis. For example, following treatment, Mr. Smith could report having positive feelings about the treatment with few depressive episodes and reduced hallucinations. The treatment should also address the existing psychological disorders and avoid their worsening due to the diagnosis and the complicated treatment process. While there could be other treatment procedures that could have the effect, research has proven the effectiveness of Cognitive Behavioral Therapy in achieving positive results (Greer, Park, & Safren, 2010; Hazell et al., 2018). Hence, the treatment team will work with the psychiatrist in implementing the mental health treatment program targeted to Mr. Smith’s needs.

From the analysis, a Cognitive Behavioral Intervention has a high chance of success in Mr. Smith’s treatment. The program works through talk therapy by encouraging the client to speak about the negative thoughts and working on replacing them with more positive thoughts. The method is effective for Mr. Smith since he loves to talk and engage with other people. Hence, it is the easiest psychotherapy approach since Cognitive Behavioral Therapy is also talk therapy involved in expressing fears and other feelings relating to the diagnosis and treatment (Winterowd, Beck, & Gruener, 2003). The therapist will hold some sessions with the client based on discussing his problems to help him frame his thoughts differently and more positively. With social worker guidance, the patient will work on eliminating negative thoughts and have more control. Cognitive Behavioral Therapy will help Mr. Smith to use logic and reason to flip the script and be in control of his feelings instead of allowing his thoughts to control him. Consequently, he will manage to understand the implications of the disorder and the challenges involved in its management at his age without necessarily suffering from any negative reactions.

Research has proven the positive effect of Cognitive Behavioral Therapy in targeting the particular psychological needs of the patient. The implementing team realizes the problems affecting Mr. Smith, following the needs analysis performed before commencing the treatment.  Consequently, they have targeted the program, and the sessions to the identified need to make the treatment successful. Its success is informed by the fact that it is designed in conjunction with visits from qualified mental health specialists and the Memphis Hospital-PCU hematology and oncology team to achieve holistic treatment. From the analysis of the effectiveness of the treatment, the patient has moved from one level of psychological need to a higher status as a result of the intervention. It is worth noting that the therapy sessions achieved two of the three objectives. In addition, the evidence reveals a high potential for improvement in the quality of life of the client after the treatment.

Description of Intervention Activities

Session	Date	Activity
Session 1	October 1	A talk session with the social worker
Session 2	October 3	A music session-playing guitar
Session 3	October 5	Listening to country music
Session 4	October 8	A talk session with the social worker
Session 5	October 10	Having a session outside the unit for fresh air
Session 6	October 12	Giving the patient  a sense of mastery, competence, or accomplishment
Session 7	October 15	Reading magazine/praying
Session 8	October 22-26	Having a phone call
Session 9	October 29	A conversation with the social worker

 

These are the activities the patient selected to do:

October 1àTalking with a social worker for half an hour

October 3àPlaying guitar for ten minutes

October 5àListening to the radio (country music) for one hour

October 8 àTalking with a social worker for half an hour

October 10àGoing outside the unit for fresh air in a wheelchair with P.T.

October 12àScheduled an activity for the day to give the patient a sense of mastery, competence, or accomplishment (Walking around the unit and doing something small that patient was not able to do for the first few days as an in-patient)

October 15 to October 19àreading magazines, but the patient did not comply and got irritated.

Instead, the patient decided to pray rather than read.

October 22 to 26àCall one person a day. Talk for 5 minutes, 10 minutes, or as a long patient feels necessary. The call could be made to old friends or family members.

October 29 to November 2àTalking with a social worker for about one-half hour.

 Choice of the Activities

Notably, all the activities are selected based on the needs of the client. Indeed, they were selected to produce higher levels of positive emotions in patients’ daily life as well to help the patient to think positively, narrow the minds, and have a self-focused approach to reduce the rate of depressive episodes. The choice of the activities was informed by the need for the client to overcome the negative mental and physical reactions and instead develop a more positive view and feelings about the self and the disease condition. However, the therapist was careful to avoid any activity that focused on the disease itself. Additionally, all the activities involved the client directly since he needed a change and desired to have a positive view of life to overcome the challenges relating to the cancer diagnosis. Activities, including talking, listening to music, playing guitar, going outside for fresh air, and praying promoted the mental and emotional health of the patient and would also play an essential role in other outcomes such as pain management. Therefore, by the end of the nine sessions, the patient would have developed another view of his condition, which does not include depression, aggression, hallucination, or any other negative behavior.

Measurement Method

The therapeutic process is always anticipated to gain positive results in helping the patient to deal with the adverse effects of the disease. Hence, the implementer should evaluate the outcome by collecting data before and after using the program in the patient’s treatment. A comparison of the data before and after treatment will inform the effectiveness of the therapy. One of the focuses of Cognitive Behavioral Therapy in the case of Mr. Smith was to deal with the depression associated with the cancer diagnosis. It was important for the client to experience a reduction in the level of depression after the treatment and adopt a more positive outlook of the condition.

The implementers of the program used an effective tool for the evaluation of the level of depression before and after implementing the Cognitive Behavioral Therapy. The Beck Depression Inventory (BDI; Beck & Steer, 1987, 1993) was used in this study as a pre-post measure of depression. The BDI is a brief (21 questions) and a convenient assessment instrument. The patient selected answers that indicated how he felt during the preceding week. The BDI has been shown to have sensitivity and specificity in measuring depression in persons with chronic pain and terminal illness. Data from the BDI was analyzed pre and post-treatment, and during the 5-weeks follow-up data collection meetings. In the case of Mr. Smith, the data collection process was not difficult because he loves talking. However, the person collecting the data had to be careful to notice any mood change that could cause aggression to Mr. Smith when uncomfortable with any of the questions asked.

Decision on Who Should Collect Data

The data was collected by the program implementer and the writer of the report to include the necessary findings on the effectiveness of the program.

Decision on When and Where to Collect Data

The data required to be collected on a regular basis for a formative assessment of the effect of Cognitive Behavioral Therapy on the patient. Hence, the data was collected every Monday, Wednesday, Friday at the Palliative Care Unit following the sessions and treatment of the patient. However, the data collection procedure was not aggressive or rigorous to give the patient a chance to relax after the therapy. It was also important to avoid intrusive questions to prevent aggression, at least during the initial weeks of the therapy.

Decision on How Often to Collect Data

Three times a week (Monday, Wednesday, and Friday) for five weeks.

Decision on Targets to Record

The measures used to record the progress of the intervention are based on the three objectives that it was anticipated to achieve:

1. To decrease patient’s high rate of psychiatric delirium and the related aggressive behavior.
2. To minimize psychological complications, including the severe depressive mood and the emotional difficulties in dealing with the diagnosis and management of the disease.
3. To increase medication and treatment compliance and the likelihood of working with the Memphis Hospital-PCU hematology and oncology team to manage the disease and its symptoms.

Graph of the Client’s Target(s)

1. The patient demonstrated excellent improvement regarding medication and treatment compliance. By October 8, the patient agreed to receive radiation and chemotherapy concurrently for the treatment of cancer.
2. The patient recorded a modest improvement in the depressed mood and emotional difficulties. The records indicated a decline in the depressive episodes by the seventh session of the therapy.
3. The patient’s delirium did not show much improvement and somewhat increased as the treatment progressed.

The Graph Presents:

• From the analysis of the effectiveness of the treatment, the graph below shows how the patient has moved from one level of psychological need to a higher status as a result of the intervention. The chart illustrates that two of the three objectives of the treatment were achieved after nine sessions of therapy.

A Graph of the Outcome of the Intervention

From the graph, the level of delirium went slightly lower than the baseline. Hence, the results indicate that the client remained delirious regardless of the intervention for the nine sessions. In this case, the graph reveals evidence of no improvement. Moderate improvement was noted in the level of depression after the nine sessions of the intervention. The client exhibited a decline in the episodes of depression from the beginning to the end of the intervention program. Compliance with the treatment, which included a combination of radiation and chemotherapy for cancer, revealed excellent improvement. The client revealed an almost 100% rate of compliance with the treatment.

Description of the Findings Regarding the Client’s Progress

The patient exhibited improvement in some areas while a decline was noted in one of the target objectives. The therapist must have helped the client to address the issues underlying his lack of agreement with the treatment. Cognitive Behavioral Therapy was meant to address his negative feelings about the treatment, which was a combination of radiation and chemotherapy for cancer. The level of depression was also addressed and revealed moderate improvement. The therapy must have discussed some of the concerns and feelings that led to the depression. However, possibly due to the history of the client, including being a war veteran, the level of delirium did not improve with the therapy. Potentially, the therapy did not address some of the concerns inherent in the history of the patient triggered by cancer. Perhaps patient’s medication was subject to titration due to metabolic imbalances after treating other ailments.

A Critical Evaluation of Personal Provision, Positive Feedback, and Areas for Improvement

Cognitive Behavioral Therapy has proven effective in Mr. Smith’s treatment. The therapist successfully helped him to address some of the underlying concerns and feelings that cause negative behavior to replace them with more adaptive attitudes. The therapy was moderately effective given that it did not achieve all the three objectives, especially its effect in reducing the level of delirium. However, the therapist should have included more specific steps to address the underlying conditions, including the mental health challenges emanating from his war history.

Conclusion

As it is evident from the intervention program, Mr. Smith is a typical case of a challenged patient considering the cancer diagnosis at an advanced, and underlying mental health illnesses that date back to his war history. Thus, treatment for his condition should combine the efforts to relieve physical and mental symptoms to improve his quality of life during the final days of his life. Cognitive Behavioral Therapy has proven effective but should be more elaborate and target all areas, including delirium for a holistic health outcome.

References

Beck, A.T. & Steer, R.A. (1987) Manual for the Beck Depression Inventory. San Antonio, TX: The Psychological Corporation

Gary, R.A., Dunbar, S.B., Higgins, M.K., Musselman, D.L., Smith, A.L. (2010). Original article: Combined exercise and cognitive behavioral therapy improves outcomes in patients with heart failure. Journal of Psychosomatic Research, 69, 119-131. doi:10.1016/j.jpsychores.2010.01.013.

Greer, J. A., Park, E. R., Prigerson, H. G., & Safren, S. A. (2010). Tailoring cognitive-behavioral therapy to treat anxiety comorbid with advanced cancer. Journal of cognitive psychotherapy, 24(4), 294-313

Hazell, C. M., Greenwood, K., Fielding-Smith, S., Rammou, A., Bogen-Johnston, L., Berry, C., … Hayward, M. (2018). Understanding the barriers to accessing symptom-specific Cognitive Behavior Therapy (CBT) for distressing voices: Reflecting on and extending the lessons learnt from the CBT for psychosis literature. Frontiers in Psychology, 9, 727- 833. doi:10.3389/fpsyg.2018.00727

Hersen, M., & Rosqvist, J. (Eds.). (2005). Encyclopedia of behavior modification and cognitive  behavior therapy (Counseling and psychotherapy transcripts, client narratives, an reference works). Thousand Oaks Calif.: Sage Publications.

Jacobs, A., Hopton, J., Davies, D., Wright, N., Kelly, O., & Turkington, D. (2014). Treating psychosis: A clinician’s guide to integrating acceptance and commitment therapy, compassion-focused therapy, and mindfulness approaches within the cognitive behavioral therapy tradition. Oakland: New Harbinger Publications.

Lovejoy, L.C., Tabor, D., Matteis, M., & Lillis, P. (2000). Cancer-related depression: part I  neurologic alterations and cognitive-behavioral therapy. Oncology Nursing Forum, 27(4) 667-680.

Marcus, J.D., & Mott F.E. (2014). Difficult Conversations: From Diagnosis to Death. Ochsner Journal, 14(4), 712-717.

Parpa, E., Tsilika, E., Gennimata, V., & Mystakidou, K. (2015). Review: Elderly cancer patients’ psychopathology: A systematic review. Aging and mental health. Archives of Gerontology and Geriatrics. 60, 9-15. doi:10.1016/j.archger.2014.09.008.

Safren, S., Gonzalez, J., & Soroudi, N. (2008). Coping with chronic illness: A cognitive-behavioral therapy approach for adherence and depression workbook (Treatments that work). Oxford: Oxford University Press.

Selene G.C., Omar C.F., & Silvia A.P. (2016). Palliative care, impact of cognitive behavioral therapy to cancer patients. Procedia-Social and Behavioral Sciences, 217:1063-1070. doi:10.1016/j.sbspro.2016.02.110.

Winterowd, C., Beck, A., & Gruener, D. (2003). Cognitive therapy with chronic pain patients. New York: Springer.