Clinical Case Studies

Published by SAGE Publications
Online ISSN: 1534-6501
Publications
Article
Men's reactions to a partner's abortion are an understudied area. Few studies have examined abortion as it relates to posttraumatic stress disorder (PTSD) in males, and no studies have examined the use of an empirically supported behavioral treatment for PTSD in this population. The current case study examines Prolonged Exposure for the treatment of abortion-related PTSD in a 46-year old Caucasian male who also has alcohol dependence. The patient was involved in a residential substance abuse treatment program at the time of treatment. After receiving 12 sessions of Prolonged Exposure, the patient experienced a decrease in PTSD symptoms as measured by the Clinician Administered PTSD Rating Scale (87%) and Impact of Event Scale-Revised (85%). The results of this study suggest that the literature supporting Prolonged Exposure as a first-line treatment for PTSD can be expanded to include men needing treatment for abortion-related PTSD. Implications for treatment and research are discussed.
 
Article
High rates of co-occurrence between substance abuse and child neglect have been well documented and especially difficult to treat. As a first step in developing a comprehensive evidence-based treatment for use in this population, the present case examination underscores Family Behavior Therapy (FBT) in the treatment of a mother who evidenced Substance Dependence, child neglect, Post-Traumatic Stress Disorder, Bipolar I Disorder, and domestic violence. Utilizing psychometrically validated self-report inventories and objective urinalysis, treatment was found to result in the cessation of substance use, lower risk of child maltreatment, improved parenting attitudes and practices, and reduced instances of violence in the home. The importance of utilizing validity scales in the assessment of referrals from child welfare settings is discussed, and future directions are reported in light of the results.
 
Article
The results of a multiple-baseline case study of family behavior therapy (FBT) is described in a woman formally diagnosed with alcohol dependence, bipolar disorder, generalized anxiety disorder, specific phobia, and panic disorder. She was referred to treatment from the local Department of Family Services for child neglect and domestic violence. After baseline measures were administered, the first phase of treatment involved home safety tours aimed at reducing home hazards and cleanliness. A second phase of treatment additionally targeted family relationships through communication skills training exercises, and a third phase involved administration of the remaining FBT components to assist in comprehensively addressing other problem areas. Results indicated most problem areas were substantially improved, but only after they were comprehensively targeted in therapy.
 
Article
Scientific interest in the nonmotoric symptoms of Parkinson's disease (PD) has increased dramatically, and psychiatric symptoms (e.g., cognitive impairment, anxiety and mood disorders) are now considered prime targets for treatment optimization. Psychiatric complications in PD are quite common, affecting as many as 60 to 80% of patients. This study describes the case of a 74 year-old male with PD who presented with complaints of anxiety and trouble with memory and attention. A combined cognitive behavior therapy and cognitive enhancement intervention was delivered in ten 90-to-120 minute sessions. The patient showed a reduction in anxiety symptoms that was of sufficient magnitude to meet criteria for 'responder' status. His cognitive skills were mostly unchanged, despite the rigorous rehabilitation practice. Implications for treatment and strategies for enhancing therapeutic benefits are discussed.
 
Decrease in Social Anxiety Over the Course of Combined Motivation Enhancement Therapy and Cognitive Behavioral Therapy for Social Anxiety Disorder With Comorbid Alcohol Use Disorder, Including 6-Month Follow-Up Note: Clinical and nonclinical sample means from Weeks et al. (2005). 
Article
Social anxiety disorder (SAD) and alcohol use disorders (AUD) co-occur at particularly high rates, resulting in greater impairment than either disorder alone. Thus, the development of effective treatments for patients with SAD and comorbid AUD is an important clinical and research aim. Yet little work has examined treatments for SAD with comorbid AUD. Given the efficacy of motivation enhancement therapy (MET) for AUD and cognitive-behavioral therapy (CBT) for SAD, combining MET with CBT may decrease symptoms of both AUD and SAD. The present case study outlines the successful use of combined MET-CBT to treat a 33-year-old man with a long history of generalized SAD with AUD. Following 19 sessions of MET-CBT, the patient was considered in remission for both disorders, with notable decreases in social anxiety and alcohol-related problems (with continued gains at 6-month follow-up). Although these data are preliminary, they indicate that the combination of MET and CBT may be a viable approach to the treatment for patients with SAD and comorbid AUD.
 
Article
Social anxiety disorder (SAD), also known as social phobia, is one of the most common anxiety disorders and has been shown to be effectively treated using cognitive-behavioral therapy (CBT). Recently, a manualized CBT treatment for SAD has been developed (Hope, Heimberg, & Turk, 2006), with research demonstrating superior treatment outcomes with CBT relative to alternatives (e.g., psychotropic medication). The current case study of Henry, a 26-year old Caucasian male with SAD, implemented this manualized CBT for SAD. Treatment consisted of 15 individual sessions, with follow-ups occurring 2 and 8 months post-treatment. Henry showed marked reductions in SAD symptoms throughout the course of treatment, resulting in complete remission of SAD at the end of formal treatment. His SAD continued to be in remission at the 2-and 8-month follow-up sessions. This case study demonstrates the usefulness of a manualized, individual CBT treatment for SAD.
 
Article
Cognitive-behavioral therapy (CBT) for the treatment of Social Anxiety Disorder (SAD) has demonstrated efficacy in numerous randomized trials. However, few studies specifically examine the applicability of such treatment for ethnic minority clients. Thus, the purpose of this article is to present two case studies examining the utility of individualized CBT for SAD with two clients who immigrated to the United States, one from Central America and one from China, for whom English was not their primary language. Both clients demonstrated improvement on a semi-structured interview and self-report measures. Necessary adaptations were modest, suggesting that therapy could be conducted in a culturally sensitive manner without much deviation from the treatment protocol. Results are discussed in terms of adapting treatment to enhance acceptability for and better fitting the needs of ethnic minority clients and non-native speakers of English. Implications for treating ethnic minority clients, as well as the practice of culturally sensitive treatment, are discussed.
 
Article
Presented is a case report of exposure and ritual prevention (EX/RP) therapy administered to a 51-year-old, White, heterosexual male with sexual-orientation obsessions in obsessive-compulsive disorder (OCD). The patient had been previously treated with pharmacotherapy, resulting in inadequate symptom reduction and unwanted side effects. OCD symptoms included anxiety about the possibility of becoming gay, mental reassurance, and avoidance of other men, which resulted in depressive symptoms and marital distress. The patient received 17 EX/RP sessions, administered twice per week. The effect of treatment was evaluated using standardized rating instruments and self-monitoring by the patient. OCD symptoms on the Yale-Brown Obsessive Compulsive Scale (YBOCS) fell from 24 at intake to 3 at posttreatment and to 4 at a 6-week follow-up, indicating minimal symptoms. Improvement also occurred in mood, quality of life, and social adjustment. Issues concerning the assessment and treatment of homosexuality-themed obsessions in OCD are highlighted and discussed.
 
Article
The six-point dial of treatment described in this case report was developed to guide graduate student psychological trainees through treatment and includes the following components: assessment of dangerousness, diagnosis, diagnosis-based treatment, ongoing evaluation of treatment response, obstacles to treatment, and motivation. In this case report, we describe the dial of treatment and present a case study of a client with paranoid schizophrenia (John) who presented at a graduate student training clinic to illustrate how this framework can be successfully applied. John has exhibited marked improvement, based on both objective measures and clinician judgment of global functioning.
 
Article
Discusses the rationale for publication of Clinical Case Studies journal. This editor contends that the most important issue with respect to the single case is that the greatest innovation in psychotherapeutics has sprung from its application. The objective is to demythologize and make public to the reader what really transpires in the clinical process, but not simply the sanitized version. A general overview of the articles published in this issue is included. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
 
Article
A longitudinal, intensive treatment program is described that was implemented over an 8-year period in a community-based setting for a young man with mental retardation and oppositional defiant disorder with severe physical aggression. The development of this disorder and its systematic treatment are described, with new components added based on improvement in the individual’s behavior. The individual made steady progress and has maintained good behavioral stability for the final three years of the treatment program. This paper highlights the inherent difficulties of applying empirically validated treatment strategies in community-based settings.
 
Article
This case study describes the successful implementation of a behavioral intervention for the mealtime problem behaviors of a 16-year-old girl with Pervasive Developmental Disorder Not Otherwise Specified attending a private school for students with developmental disabilities. Initially, an analogue-functional analysis using a pairwise single-case experimental design was conducted, and based on the results of this assessment, a multicomponent function-based intervention was developed. The results obtained demonstrated that interventions for problem behaviors developed in hospital-based clinics can be implemented in community-based educational settings successfully. The results also demonstrated that behavioral intervention strategies shown to be effective with young children with developmental disabilities also work for a teenager with an autism spectrum disorder, illustrating the generality of a behavioral approach to feeding difficulties. Methodological limitations of the case study, advantages of a community-based treatment approach, and recommendations for clinicians are provided.
 
Article
Prolonged exposure (PE) therapy is a gold-standard treatment for posttraumatic stress disorder (PTSD) that can be effectively delivered via telehealth modalities. The following case report describes a course of PE delivered to a veteran seeking PTSD treatment for military sexual trauma (MST), who contracted COVID-19 mid-treatment. Considerations for selecting PE as a treatment modality; modifications made due to the COVID-19 pandemic and transition to telehealth more broadly, and following the veteran contracting COVID-19 more specifically; strategies to increase treatment engagement; and assessment of progress over time, are discussed. In particular, treatment considerations during a global pandemic are explored at the patient-, provider-, and systems level, to inform treatment delivery for other providers during this ongoing pandemic. Although there were numerous technological, environmental, and pandemic-related difficulties, the veteran described here persisted through a course of PE and experienced clinically significant reductions in symptoms of PTSD and a great degree of functional recovery.
 
Article
A small but clinically significant number of people experience delayed-onset Post-traumatic stress disorder (PTSD); symptoms of trauma years after the events which are now being re-experienced. The following case report describes the use of the cognitive-behavioural treatment for PTSD with a woman experiencing flashbacks to domestic abuse endured more than 20 years ago. Mask-wearing mandated as a result of the COVID-19 pandemic triggered non-contextualised memories of life-threatening physical violence by an abuser who covered his face. She had been managing her flashbacks and intrusive thoughts with both behavioural and experiential forms of avoidance. An 18-session intervention was provided in her own home due to physical health difficulties. Treatment focused on managing hyper-arousal, reducing thought suppression, in-vivo exposure, stimulus-discrimination and re-contextualising traumatic memories. Regular outcome measurements were kept and results are presented as a single-case experimental design in ‘AB’ format (i.e. baseline period pre intervention). Symptoms of trauma fell to levels non-indicative of PTSD and speak to the evidence base for this modality, even when applied to delayed-onset difficulties in a non-traditional therapy setting. This conclusion is lent extra credence by an experimental design with good internal validity.
 
Article
Social anxiety disorder (SAD) is a condition in which people consistently and persistently experience significant fear and/or anxiety about one or more social situations in which they may be scrutinized and negatively evaluated. SAD has historically been found to respond well to cognitive-behavioral therapy (CBT) delivered both in-person and via telehealth; however, comparatively little information is available regarding response to treatment in the context of Coronavirus Disease 2019 (COVID-19) pandemic social and physical distancing guidelines, which have affected the way in which behavioral health services are delivered, as well as opportunities for interpersonal interactions which are either spontaneous or assigned as exposures. The current case study describes “Jennifer” (a pseudonym), a college student with a primary diagnosis of SAD, who was treated with primarily CBT interventions for 18 individual sessions over the course of approximately 6 months, which included treatment with a psychologist and a graduate student, implemented both in-person and via telehealth, both before and during the COVID-19 pandemic. Jennifer responded well to treatment, as evidenced by her self-report and decreases in symptom measure scores, engaged in CBT adapted to pandemic restrictions, and was able to utilize strategies learned during SAD treatment to address generalized anxiety and pandemic-related concerns. This case study demonstrates the feasibility of transitioning SAD care between providers and formats, as well as the robustness and flexibility of CBT strategies in the face of significant change, stress, and limitations of the external environment.
 
Article
This single case study illustrates the application and utility of Acceptance and Commitment Therapy (ACT) for a 72-year-old Australian male presenting with chronic pain and complex health conditions. Chronic pain often entails complexity among older adults and can impact the patient’s life across a range of domains. Psychological approaches, as stand-alone or adjunct to medical intervention, are widely acknowledged as potentially beneficial to older persons experiencing pain. ACT has been supported as a viable psychological approach for chronic pain and especially suitable for older persons with chronic pain. This study describes an ACT treatment approach for an older person with chronic pain informed via development of an extension of the existing ACT conceptualization of chronic pain. The development of the ACT based model is in keeping with recommendations to seek out mechanisms of change in psychotherapeutic research. Measures of Quality of Life, Depression, Physical Activity, and Acceptance/Avoidance were taken at pre and post treatment, as well as across treatment phases. Improvement was noted in self-reported measures of QOL, depression, and physical activity.
 
Article
Acceptance and Commitment Therapy (ACT) is gaining traction as an effective therapy for a wide range of presenting concerns. Limited research and discussion has been published focused on utilizing ACT with older adults. The ACT model is proposed to be a good fit for this population because many older adults may already be values orientated due to awareness that their lifetime is limited. A trans-diagnostic approach that normalizes experiences common to older age may be advantageous given older adults often present with heterogeneous issues and life experiences. A case study of an 89-year-old woman experiencing late-life clinical depression and generalized anxiety disorder is presented. A significant factor contributing to her distress was her struggle with the cognitive and physical changes associated with aging. Results suggest that a brief ACT course implemented by a relative novice ACT therapist was effective in reducing psychological inflexibility as well as reducing distress to non-clinical levels at 6 weeks post therapy. Potential implications for adapting ACT with older adults are discussed, as well as reflections on some of the potential challenges for clinicians who are ACT beginners.
 
Article
This article summarizes the treatment of an older adult with borderline personality disorder and a co-occurring opioid abuse using an integration of the recovery model, person-centered therapy, and the stages of change. Therapy included rapport building, a nonjudgmental attitude, enhancing understanding of behaviors that interfere with the client’s goals, clarifying consequences of the client’s choices, empathizing with the client’s fear of reducing opioid use, building coping skills, and providing a strong, supportive presence through the opiate reduction process. Over the course of treatment, the client’s overuse of opioids decreased as did her depression and suicidal ideation. This case highlights the importance of understanding medication abuse from the client’s perspective, emphasizing nonjudgment and clarifying the client’s choices and the consequences of her choices.
 
Article
Social anxiety is a common and treatable condition but less is known about how to adapt evidence-based approaches in a culture-sensitive way to Asian clients. We present the case of “Sally,” a 25-year-old Chinese Singaporean female who suffered from severe and long-standing social anxiety disorder (SAD), and secondary low mood. Contributing factors included a history of domestic abuse, as well as culturally influenced authoritarian parenting emphasizing the Confucian value of filial piety and reinforced by Taoist beliefs of karmic retribution and supernatural punishment. Treatment was based on Clark and Wells’s cognitive model of SAD with a focus on behavioral experiments, and was enhanced using a schema mode formulation and imagery rescripting to address relevant early memories that were at the origin of the social anxiety. Sally received a total of 42 sessions over the course of 21 weeks, during which she made steady progress toward recovery. Her self-reported depression and social phobia fell from the “severe clinical” range pretreatment to the “non-clinical” range posttreatment; these gains were maintained at 6 months follow-up. Sally’s functioning fully recovered, and she returned to work and school. While behavioral experiments for dropping safety behaviors were useful for overcoming the social anxiety, schema formulation was important for providing Sally with insight to her thought process, and imagery rescripting was crucial for weakening her self-criticism and internalized black and white thinking on filial piety. The significance of culture and religion in SAD, and the potential of adapting cognitive therapy in a culture-sensitive way is discussed.
 
Helping the Noncompliant Child Program.* Helping the Noncompliant Child strategies (HNC)
Article
Intimate partner violence has been associated with long-term negative effects on mothers’ mental health status, use of positive parenting practices, and their children’s externalizing behavioral difficulties. Especially strong is the association between concurrent experiences of partner violence and maternal parenting. In this case study, we examined the impact of behavioral parent training on parenting and outcomes for a 6-year-old Latino diagnosed with oppositional defiant disorder (ODD). The family was participating in a larger study examining the implementation and cultural adaptations of an evidence-based parent training program, Helping the Noncompliant Child. Mother reported a history of domestic violence and ongoing abusive behavior from her intimate partner but only wanted services focused on addressing child’s behavioral difficulties and improving the quality of parent–child interactions. Adaptations included but were not limited to the translation of all intervention materials, extending the number of sessions focused on each parenting strategy, flexibility with regard to the location and time of therapy sessions, negotiating safe times for the family to participate in treatment, and case management. Parent reports of child behavior and parenting stress moved from the clinical range to the normal range from pre- to post-test. Mother also reported increased use of positive parenting practices. These data, along with closing semi-structured interviews, suggest that within the context of ongoing partner abuse, a mother’s parenting and her child’s behavior can be positively affected by parent training that is adapted and responsive to the context of their family’s situation.
 
Article
Older adults have generally not been included in randomized clinical trials of psychotherapy for posttraumatic stress disorder (PTSD). Of the case reports and treatment outcome studies that have included those aged 55 and older, most did not include men with sexual abuse-related PTSD. This case report presents the successful application of Prolonged Exposure (PE) to a 58-year-old single, Caucasian noncombat U.S. Army veteran with severe, chronic PTSD related to several sexual assaults, including childhood sexual abuse. PE is a manualized, short-term, evidence-based psychotherapy for the treatment of PTSD which involves psychoeducation, breathing retraining, in vivo exposure, and imaginal exposure. PTSD and depressive symptoms demonstrated clinically meaningful improvement during the course of treatment. In addition, he experienced significant improvement in quality of life as well as meaning and purpose from baseline to posttreatment. Implications for clinically working with older men with untreated childhood sexual abuse-related PTSD later in life are presented. Future research directions are discussed.
 
Article
This case study describes the use of trauma-focused cognitive behavioral therapy (TF-CBT) and legal interventions for a 16-year-old girl who was the victim of commercial sexual exploitation (CSE) and suffered from substance abuse, anxiety, and body image issues. Over the course of 1 year, the client was able to discontinue involvement in sexual exploitation, cease substance use, decrease her anxiety level, improve her self-concept, and reduce posttrauma symptoms. The case calls attention to the need for extended rapport building, flexibility in treatment, and tailoring manualized treatments. It highlights the path to CSE for one teenager as well as the resultant emotional and behavioral consequences. Given the extensive nature of her past traumas, case management was continued following the clients’ discharge from treatment to support her adjustment. These follow-up sessions were conducted about once a month and assisted with maintenance of treatment goals.
 
Diagram of longitudinal formulation.
Diagram of vicious flower of strategies used to manage aphonia.
Graph of Becky's psychological distress as measured by CORE-OM Simple Score.
Graph of Becky's Wellbeing, Problem, Functioning, Risk, and Total CORE-OM scores over time.
Graph of Becky's ratings of the therapeutic alliance during two assessment sessions and four intervention sessions.
Article
Foreign accent syndrome (FAS) has historically been attributed to a neurological etiology. However, recent research has identified psychogenic causes of FAS, where patients present to health care services with medically unexplained FAS symptomology. Due to the rare nature of psychogenic FAS, there is currently no evidence-based psychological treatment for this syndrome. Although patients with psychogenic FAS do not meet the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) or the International Classification of Diseases (ICD)-10 diagnostic criteria for a diagnosis of somatization disorder, there are some similarities in presentation between psychogenic FAS and the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) criteria for somatic symptom disorder (SSD). These include the presence of distressing and disruptive symptoms that result in increased health care utilization. Given the emerging evidence for cognitive behavioral therapy (CBT) for SSDs, it is arguable that CBT could help patients with psychogenic FAS to manage the psychological distress they experience. This paper aims to explore the use of CBT in reducing the psychological distress of a patient with no organic explanation for FAS using a single-case (A-B) experimental design. The results suggest that CBT was effective in reducing distress, as measured using the Clinical Outcomes in Routine Evaluation–Outcome Measure (CORE-OM). This paper highlights the value in using an individualized formulation-driven CBT approach for presentations that do not yet have evidence-based guidelines. In this case, cognitive restructuring, activity scheduling, and stress management appear to be key mechanisms of change in reducing psychological distress associated with FAS.
 
Article
Cognitive behavior therapy (CBT) is a psychotherapy approach for the treatment of depression in older adult populations. This article discusses an extension of CBT to include mindfulness and acceptance skills for the treatment of depression in older adults with comorbid medical illness. Findings support that a brief intervention of 12 weeks was effective in producing a clinically significant change in depression and quality of life at the completion of therapy and at follow-up. This suggests that mindfulness and acceptance skills in addition to CBT skills may be an effective intervention for the treatment of depression of older adults with chronic medical illnesses.
 
Article
Although there are many theories of Functional Movement Disorders (FMD), the causes and prognosis remain unclear, and there are no treatments with high-quality empirical support. Acceptance and Commitment Therapy (ACT) is an acceptance-based behaviour therapy which, via altering a process called psychological flexibility, aims to support behaviours that are consistent with a person’s overarching values – even in difficult, uncertain or immutable contexts. It may therefore have pragmatic benefits in the context of FMD. We outline the theoretical basis for ACT and detail a case study of a brief (6 session) intervention for increasing personally meaningful activity with FMD. The participant was in her early twenties and had been diagnosed with functional propriospinal myoclonus. ACT techniques including relational framing, defusion and mindfulness exercises were used to increase psychological flexibility, with the goal of enabling effective functioning within the difficult context created by FMD. Following treatment, the participant showed a reliable change/clinical recovery in psychological flexibility (AAQ-II), FMD symptom interference (WSAS; primary outcome) and mood (CORE-10; secondary outcome). This case study demonstrates an approach that focuses first on improving functioning with FMD, as opposed to eliminating or controlling symptoms.
 
Article
Acceptance and commitment therapy (ACT) is a process-based, transdiagnostic approach to treatment that seeks to increase values-based, adaptive functioning (i.e., engaged living [EL]) in part through attenuating the impact of experiential avoidance (EA). The present case-series study examined EL and EA as mechanisms of change within a 10-week course of individual ACT delivered via a telehealth platform. Participants were two adult women with mental health concerns associated with clinically elevated EA. Throughout the study, we collected (a) daily self-monitored clinically relevant behaviors, (b) daily and weekly measures of EL and EA, and (c) pre-, mid-, post-treatment, and 3-month follow-up measures of psychopathology, quality of life, and ACT-related outcome variables. Results showed support for the efficacy of ACT, with both participants demonstrating slight improvements in clinically relevant behaviors, along with expected improvements in EL and EA. These favorable results were most pronounced for Participant 1. Results are discussed in the context of COVID-19-related adaptations (including telehealth), and within the framework of process-based ACT and its transdiagnostic applicability to a range of mental health concerns.
 
Clinically relevant target behaviors to increase across participants in baseline, treatment, and follow-up phases.
Weekly process measures across participants. Note. AAQ-II = Acceptance and Action Questionnaire-II; BEAQ = Brief Experiential Avoidance Questionnaire; ELS = Engaged Living Scale.
Article
The current study examined the effects of an individual acceptance and commitment therapy (ACT) protocol in three young adults with topographically different, but functionally similar, behavioral health concerns. Using a concurrent multiple baseline design across participants ( N = 3), clinically relevant target behaviors were collected daily as primary outcome measures. In addition, weekly self-report assessment of potential process variables and an assessment package at pretreatment, midpoint, posttreatment, and 3-month follow-up were used to evaluate process and outcomes of treatment. Results provided tentative support for ACT’s efficacy, with effects being most pronounced in Participants 2 and 3 with slight improvements in clinically relevant target behaviors. This study adds to the literature concerning process-based approaches to treatment by highlighting how ACT can be tailored to the needs of individuals with diverse behavioral health concerns.
 
Article
Though anger is a common human emotion, the unfettered behavioral expression of anger is often costly, contributing to a range of functional impairments, poor quality of life, and both physical and mental health problems. The current case illustrates how a third-generation cognitive behavioral therapy, Acceptance and Commitment Therapy (ACT), may be effective in reducing suffering linked with problematic anger. The client (“Robert”), a treatment-naïve man of low socioeconomic status, presented to a university training clinic reporting problematic anger outbursts that interfered with his relationships at work and with his girlfriend. The therapist conceptualized Robert’s problematic anger through the ACT psychological flexibility model, wherein Robert’s anger appeared to function as experiential avoidance to distance him from underlying emotional hurt. The therapist used ACT over 27 sessions to reduce Robert’s psychological inflexibility while promoting more psychological flexibility. Early sessions highlighted the unworkability of Robert’s anger, whereas subsequent sessions focused on clarifying values, loosening cognitive fusion, facilitating present moment awareness, and cultivating mindful acceptance in the service of living a meaningful life. The therapist monitored treatment progress using quantitative measures and qualitative reports. Collectively, the client showed notable gains. The case study adds to the growing body of literature supporting ACT for problematic anger.
 
Article
Emotional eating is characterized by eating in response to intense inner emotions, not hunger. This case-series study presents the outcomes from two adults with problematic emotional eating who voluntarily participated in 10 weekly sessions of Acceptance and Commitment Therapy. Emotional eating was self-monitored daily prior to and throughout the course of treatment. The average number of emotional eating episodes reported weekly across participants at pre-treatment was nine, which decreased to one per week at post-treatment, and was two per week at follow-up. Both participants also showed improvements in body image flexibility, a theoretically consistent process of change, and these improvements were maintained at 3-month follow-up. The results are discussed as well as implications for clinical practice and future research.
 
Weekly and follow-up PCL-5 total scores reflecting PTSD symptom severity. Note. PCL = PTSD Checklist; PTSD = posttraumatic stress disorder.
Weekly and follow-up PCL-5 subscale scores by PTSD symptom cluster. Note. PCL = PTSD Checklist; PTSD = posttraumatic stress disorder.
Weekly and follow-up BDI-II scores reflecting depression severity. Note. BDI-II = Beck Depression Inventory.
Weekly and follow-up Q-LES-Q-SF scores reflecting reported quality of life. Note. Q-LES-Q-SF = Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form.
Article
Posttraumatic stress disorder (PTSD) often negatively impacts social functioning, which can lead to increased risk of morbidity and mortality. Although current evidence-based and exposure-specific treatments can improve PTSD symptoms, they rarely target the interpersonal difficulties that impact quality of life. This case study describes the use of a manualized treatment for a veteran who continues to experience poor social functioning even after previous exposure-based treatment for PTSD. This treatment, ACT to Improve Social Support for Veterans with PTSD (ACT-SS), explicitly targeted the veteran’s maladaptive patterns of interpersonal difficulties, feelings of detachment from others, irritability, and avoidance of social situations. Following treatment, the veteran reported significant improvements in social relationships, quality of life, and depressive symptoms, even though he still met the clinical threshold for PTSD. This case study provides preliminary evidence for the efficacy of a psychosocial intervention that directly targets social functioning issues for veterans with PTSD, and the importance of incorporating social goals and exercises into treatment.
 
Article
Alcohol abuse is common among college students. Acceptance and commitment therapy (ACT) is widely supported as a treatment of alcohol abuse. However, little research has examined how ACT may be paired with other techniques traditionally applied to treat substance abuse, such as motivational interviewing (MI). This clinical case study describes the use of ACT and MI to facilitate treatment of a 20-year-old woman who was referred for treatment for alcohol abuse. The client remained in treatment in spite of her initial self-reported belief that treatment was unnecessary. At follow-up, the client reported increased present moment awareness, particularly of her drinking habits, and demonstrated the ability to behave in ways consistent with her values. At the completion of treatment, the client reported fewer episodes of alcohol consumption and less severe drinking. Implications of these findings are discussed, with an emphasis on the potential benefits of pairing MI techniques with ACT.
 
Article
Symptoms of depression, posttraumatic stress, and substance use disorders commonly co-occur and are a tremendous health burden among the U.S. military veteran population. Acceptance and Commitment Therapy (ACT) is an evidence-based, transdiagnostic, integrated approach that has been used to treat these problems. Delivering psychotherapy via telehealth helps to break down barriers to care. This case study describes the application of ACT via telehealth with a male veteran with co-occurring symptoms of depression, PTSD and nicotine addiction. His depressive symptoms, PTSD symptoms, and nicotine use decreased substantially over the course of therapy. He demonstrated increased willingness to experience negatively evaluated internal experiences such as emotions and urges to use nicotine, defusion from self-critical and other unhelpful thoughts, more consistent engagement in values-consistent behaviors, and increased behavioral engagement in his social life. Treatment implications and unique aspects of the telehealth modality are discussed. Recommendations are made for training clinicians who may be considering providing services via telehealth or using ACT.
 
Article
Acceptance and Commitment Therapy (ACT) is a third-wave behavioral therapy that is an empirically supported treatment for various mental health concerns. ACT has been found to be efficacious for treating different types of anxiety disorders. This case study presents the conceptualization (functional analysis), treatment (ACT), and treatment outcomes of a client who presented with emetophobia, a phobia of vomiting, complicated by a metabolic disorder. Measures of emetophobia symptoms, mindfulness, cognitive fusion, thought control strategies, and believability of anxious thoughts and feelings, were collected at pretreatment, posttreatment, 6-month follow-up, and 12-month follow-up. The Reliable Change Index was used to evaluate changes across time. Large and clinically significant decreases on all measures were observed at posttreatment. At 12-month follow-up, improvements were maintained on all measures except the Reappraisal subscale of the Thought Control scale. The implications of this study are discussed, and recommendations are made for clinicians using ACT for the treatment of emetophobia.
 
Article
A combination of exposure therapy techniques and Acceptance and Commitment Therapy (ACT) strategies were used to treat a 23-year-old pregnant female who was housebound due to symptoms of agoraphobia. The client in this case study had not left her family home in 10 months when she sought treatment for her anxiety. The client was successfully treated over a year, such that she was able to receive prenatal care at an obstetrician’s office and to deliver her infant at a hospital. Neither the client nor her fetus suffered any complications due to treatment. Post-treatment and 1-year follow-up data indicated that the client continued to show significant functional improvements following the birth of her child. Recommendations for integrating ACT strategies into exposure therapy for severe agoraphobia and for anxious pregnant women are provided.
 
Sandra's Assessment Questionnaire Scores. 
Article
A number of studies have found experiential avoidance to mediate the relationship between sexual assault and adverse long-term effects. One treatment approach that has been developed for the treatment of experiential avoidance is Acceptance and Commitment Therapy (ACT). A small body of research has demonstrated preliminary efficacy for the use of ACT with trauma survivors suffering from posttraumatic stress disorder (PTSD). However, no treatment studies to date have evaluated ACT as a treatment model with survivors of adult sexual assault. In this case study, ACT was applied to an 18-year-old survivor of adult sexual assault suffering from PTSD symptoms. The results indicated that ACT was effective in reducing experiential avoidance, thought suppression, trauma symptomatology, and increasing valued action and quality of life. The findings of this study suggest that the use of grounding techniques, visual metaphors, and experiential mindfulness exercises in ACT may be particularly helpful for survivors of adult sexual assault.
 
Article
Anxiety is a common experience for young people with an autism spectrum condition (ASC). This article describes the use of Acceptance and Commitment Therapy (ACT) through the medium of art to increase well-being for a young woman with ASC and significant anxiety. An ACT art protocol was delivered over 8-weekly sessions with outcome measured administered at baseline, pre-, mid- and post-intervention. Follow-up data were also obtained 3 months after the intervention. It was found that the young person experienced improvements in measures of well-being and psychological flexibility. Importantly, these were seen to translate to increased engagement in activities that were in line with the young person’s values. This demonstrates that using third-wave approaches for young people with ASC can result in improvements in well-being and quality of life, but that adaptations in line with person-centered care are crucial to facilitate engagement and produce meaningful change.
 
Article
Pain resulting from chronic medical conditions (CMCs) can create debilitating effects globally across domains of functioning in the lives of those it impacts. There currently remain no treatment options to eliminate associated pain entirely, leaving care efforts often to manage the disabling effects and consequential depression. Acceptance and commitment therapy (ACT) has recently been introduced as an alternative treatment approach, emphasizing the commitment to engage in actions that contribute to a fulfilling life even in the face of disability through the fostering of psychological flexibility. For patients who do not respond to traditional psychological approaches, ACT may offer a sensible substitute. This single-case study delineates ACT for chronic pain and comorbid depression using standardized and patient-centered outcome measures across areas of general symptom functioning, therapeutic processes, and flexibility surrounding pain associated with CMCs. Clinical significance and reliable change were calculated using the reliable change index, in conjunction with patient-reported behavioral engagement and subjective assessment. Results indicate significant improvement across areas of depression, psychological flexibility, and flexibility in relating to pain endured from CMCs. The patient reported perceived improvement in quality of life and no longer viewed herself as a “professional patient.” This case study illustrates the potential of shifting from restraining and extinguishing symptoms to fostering a stance of willingness to reengage in a valued life while continuing to live with CMCs.
 
Article
A man with cerebral palsy was helped to access preferred Internet content through a treatment program involving assistive technology and support from research staff. The assistive technology included an individually configured Apple iPad® and a head pointer that enabled the man to directly select screen icons linked to preferred websites. Staff supported the man by setting up the technology and responding to his instructions and requests for assistance and by performing general troubleshooting operations (e.g., starting up, positioning, rebooting, and charging the iPad® as necessary). Twelve treatment sessions, one per week, provided opportunities for the man to practice using the iPad®. Progress was assessed by rating his (a) degree of independence, (b) level of participation, (c) performance, (d) satisfaction with performance, and (e) overall satisfaction with the head pointer, the iPad®, and the treatment program. The man actively participated in each treatment session and reported better performance over the course of treatment. He was also generally satisfied with the program. The present combination of assistive technology and staff support appeared acceptable and effective in increasing participation. The approach illustrates how aspects of self-determination can be incorporated into assistive technology interventions for adults with cerebral palsy.
 
Assessment scores with PTSD Symptom Scale-Self-Report (PSS-SR, Foa, Riggs, Dancu, & Rothbaum, 1993) during the course of therapy and follow-up. 
Article
Posttraumatic stress disorder (PTSD) is a mental disorder that is known to have deleterious psychological, physical, and social impacts on individuals. Recognition of PTSD in older adults is difficult due to the complicated presentation taking into account that PTSD symptoms may be masked by other psychiatric and/or somatic diagnoses that are more common in older adults. Furthermore, some older adults may underreport their PTSD symptoms, and the relationship between current symptoms and distant traumas may be difficult to detect. Limited empirical research has been done on the manifestation, course, and treatment of PTSD in older adults. In this article, the literature on PTSD in older adults is reviewed, including discussion of common diagnostic problems, illustrated by a case report of an older woman with late-onset PTSD after a cerebral vascular accident (CVA). In conclusion, identifying PTSD in older adults can be difficult. However, detecting PTSD in older adults is critically important so that possibly hidden or masked trauma symptoms can be addressed in treatment, even if there are complicating factors such as a CVA.
 
Article
To foster engagement in treatment and improve therapeutic outcomes for immigrant clients, it is important for therapists to integrate cultural values and to recognize the psychological stressors faced as immigrants learn to adapt and assimilate changes associated with moving to a new country. This case study describes the integration of cultural values when working with immigrant Latino clients who are at an increased risk of experiencing acculturative stress as a result of moving to the United States and having limited English knowledge. The integration of cultural values of familismo and personalismo are also discussed as it related to case conceptualization and treatment process. Finally, the current case provides information about conducting therapy in two languages and transitioning from Spanish to English as part of acculturation process while also addressing multifaceted aspects involved when working with Latino clients.
 
Article
We present the case of a 30-year-old woman who had acquired brain injury (ABI) and demonstrated clinically challenging behaviors (verbally abusive outbursts toward care providers and elopement) within her community-based group home. Following a baseline phase of evaluation, she collaborated with clinicians and care providers in developing a treatment plan that included personal goal setting, differential token reinforcement, communication training, graphic performance feedback, and reinforcement fading. During 10 months of intervention, clinically challenging behaviors steadily decreased from baseline levels and low-frequency occurrence was maintained at 3-, 6-, and 9-month follow-up assessments. As the result of treatment, the woman also avoided prior psychiatric hospitalizations, enjoyed more frequent access to pleasurable activities outside her residence, and enrolled in a college course. The study illustrates an effective person-centered therapy approach combined with behavioral intervention for persons who have ABI and experience community-living adjustment difficulties.
 
Article
The literature describing psychological interventions for co-occurring obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) is limited. Acceptance and Commitment Therapy (ACT) is a transdiagnostic intervention that targets functionally avoidant behavior underlying both OCD and PTSD. The current case report describes how an ACT-informed approach to treatment was implemented over 14 sessions to treat co-occurring OCD and PTSD in a 9-months postpartum adult woman. The patient was initially referred to psychotherapy by her psychiatrist and showed high motivation to engage in treatment. This case presentation outlines how the intervention targeted core ACT processes while also incorporating components from both exposure and response prevention (ERP) and cognitive processing therapy (CPT) to address the patient’s presenting concerns. Measurements of OCD and PTSD symptom severity, as well as of depressive and anxiety symptoms, over the course of treatment are included. Health-related comorbidities, psychiatric medications, and implications are discussed.
 
Article
Contemporary models of attention-deficit/hyperactivity disorder (ADHD) provide frameworks for understanding this condition that move beyond the diagnostic symptom criteria. ADHD is currently viewed as a developmental syndrome of impaired self-regulatory processes that underlie the common symptoms and functional problems. Most clinic-referred adults with ADHD report chronic difficulties executing their intended plans despite recognizing the negative consequences for not doing so. Seeing as the psychosocial treatments for adult ADHD intervene at the level of life impairments and functioning, it is important that interventions directly target these implementation problems. The goal of this article is to discuss the case of a young woman with ADHD who has difficulties engaging in the various tasks she needs to perform to pursue her post-college goals. In particular, a cognitive-behavioral therapy approach that emphasizes implementation strategies designed to help adults with ADHD follow through on their plans is illustrated.
 
Article
Given the long-term negative outcomes associated with depression in adolescence, there is a pressing need to develop brief, evidence-based treatments that are accessible to more young people experiencing low mood. Behavioral Activation (BA) is an effective treatment for adult depression; however, little research has focused on the use of BA with depressed adolescents, particularly with briefer forms of BA. In this article, we outline an adaptation of brief Behavioral Activation Treatment of Depression (BATD) designed for adolescents and delivered in eight sessions (Brief BA). This case example illustrates how a structured, brief intervention was useful for a depressed young person with a number of complicating and risk factors.
 
Sample of Patient's Master Activity Log
Article
Recently developed behavioral activation interventions have shown promise in effectively treating depression through increasing value-based activity levels that elicit response-contingent reinforcement. This case study highlights the implementation of behavioral activation to a breast cancer patient with major depression and generalized anxiety disorder, applied within the context of a medical center oncology clinic. Following an eight-session behavioral activation protocol, the patient demonstrated notable decreases in self-reported depressive and anxious symptoms and an overall increase in quality of life and medical functioning. These treatment gains were maintained through 6-month follow-up. Consistent with an accumulating literature, these data support behavioral activation as an effective and parsimonious intervention for individuals with depression and concurrent medical problems such as breast cancer.
 
Article
Smoking is the leading preventable cause of death and disease in the world and represents a critical public health problem. Smokers with substance use disorders and depressive symptoms have particular difficulties quitting smoking and represent an underserved population. The current study utilized a novel behavioral activation (BA)-enhanced smoking cessation treatment with three clients in residential substance use treatment who had elevated depressive symptoms. We present detailed descriptions of the treatment they received and the challenges they faced. Our clients, who received five individual BA-enhanced smoking cessation sessions and two follow-up booster sessions, benefited significantly from the BA treatment. Over an 8-week follow-up period, they did not relapse to smoking and experienced significant decreases in depressive symptoms. This suggests BA may be a beneficial treatment strategy for this particularly challenging population.
 
Scores on the Spanish version of the ORS and Family subscale and CES-DC. 
Article
The scarcity of accessible culturally competent service providers and a general sense of mistrust in Eurocentric-based mental health settings exacerbate the lack of help seeking and effective therapeutic engagement for Latinos. Thus, clinical interventions that account for diverse values and worldviews may be an important step in the helpful treatment of U.S. Latino populations. Behavioral activation (BA), an evidence-based intervention for the treatment of depression, was recently evaluated through a preliminary clinical trial study in a community clinic primarily serving Spanish-speaking Latinos, and the results were promising. A culturally adapted version of BA was developed for Latinos, which took into consideration the cultural value of familismo (a collectivist worldview and preference for maintaining close connections to family); however, BA has not been previously applied to Latino families. The current case study presents the clinical treatment of a Mexican American family living in the southwest of the United States experiencing numerous stressors resulting in depressive symptoms. Specifically, this family sought therapy having experienced many negative life events, including stressors associated with institutionalized racism, their financial situation, and acculturation process. This led to a disruption of the family hierarchy, anger, unhappiness, fear, and isolation among family members. Outcomes of the intervention include a decrease in depressive symptoms and improved family communication and relationships by their involvement in activities such as attending cultural events in their community, family outings, and the children's participation in extracurricular activities.
 
Changes After FBT-Based Intervention. 
Article
Family-based therapy (FBT) is the evidence-based treatment of choice for anorexia nervosa (AN) in adolescents, with numerous studies providing support for its efficacy in the outpatient realm. This case report describes the application of a brief FBT intervention during an inpatient medical admission for an adolescent presenting with medical instability secondary to new onset AN. The intensive, four-session FBT-guided intervention included (a) psychoeducation and illness externalization, (b) parent skills training, (c) meal coaching, and (d) behavioral contracting. Self-report assessment and anthropometric data collected at pre-, post-, and 5 months following the intervention suggest increase in body mass index (BMI) and percent ideal body weight, increased parental understanding of AN and parental self-efficacy in managing the illness, decreased parent emotional burden of the illness, and decreases in overall adolescent Eating Disorder Examination Questionnaire (EDE-Q) scores. This case report provides preliminary evidence for the acceptability and effectiveness of a brief FBT-based intervention during medical stabilization for adolescents with AN and their families before proceeding to outpatient FBT.
 
Article
This article describes the brief treatment of a Mexican American teenager who presented for family therapy to address major depressive disorder (MDD) and comorbid binge-purge behaviors. Treatment was brief and integrated components of family-based therapy (LeGrange, 2010) and narrative therapy with an overarching multicultural lens. Progress was measured through self-report (Children’s Depression Inventory), parent-report, and concrete behavioral markers (e.g., reduced number of purging events). By the end of treatment, there was a reduction of depressive symptoms (e.g., elimination of suicidal ideation and cutting behaviors, reduction of fatigue, anhedonia, and low mood) as well as disrupted eating behaviors. By supporting the teenager and family to identify and leverage their individual and family strengths, treatment also strengthened family communication, increased shared positive family experiences (e.g., family meals), and supported the teenager in engaging in community activities consistent with the family’s values. This case adds to the existing literature by reviewing ways in which treatment was modified across multiple domains to provide culturally sensitive care, as well as by identifying weaknesses in the approach, which may serve to illuminate gaps in the existing literature and highlight areas where clinicians may want to adapt their treatment so as to strengthen client outcomes.
 
Collateral-Report Questionnaires. 
ADHD symptom severity over the course of treatment. 
Pre-and post-treatment self-report data. Note. With the exception of the AAQoL, higher percentiles suggest worse functioning. ATQ = The Automatic Thoughts Questionnaire; BFIS = Barkley Functional Impairment Scale; BRIEF = Behavior Rating Inventory of Executive Function; BRI = Behavioral Regulation Index; MI = Metacognition Index; GEC = Global Executive Composite; BDEFSSF TS = Barkley Deficits in Executive Functioning Scale-Short Form Total Score; AAQoL = the Adult ADHD Qualityof-Life Scale; EF = executive function symptom count. 
Pre-and post-treatment EF performance on cognitive tests. Note. Higher percentiles suggest better performance. EF = executive functioning; C-W = Color Word Interference Test; TMT-4 = Trail Making Test-4. 
Article
Attention-deficit/hyperactivity disorder (ADHD) is a developmental disorder that regularly persists into adulthood and is associated with a number of maladaptive functional outcomes. Cognitive-behavioral therapy (CBT) is an empirically based treatment that has demonstrated effects on core ADHD symptoms and related impairments in adult samples. One manualized CBT in particular is proposed to target both core symptoms of ADHD and underlying executive functioning (EF) deficits. Targeting underlying dysfunction is important to ongoing treatment development efforts and may enhance efficacy. This manualized CBT was developed for groups. The aims of this case study were twofold. First, we adapted a manualized group-based CBT for adult ADHD for an individual format. Second, we discuss a case study to exemplify how clinicians can measure and track EF symptoms in a clinic setting using a multi-method approach. Self-report and collateral-report questionnaire data provided initial support for adaptation of Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction to an individual format. Outcome data were more limited with cognitive test scores. The discrepancy between questionnaire and cognitive test data along with the complications observed at 2-month follow up are discussed.
 
Top-cited authors
Kathleen H. Armstrong
  • University of South Florida
Brad Donohue
  • University of Nevada, Las Vegas
Heather Agazzi
  • University of South Florida
Yulia Gavrilova
  • Medical University of South Carolina
Chelsea Ale
  • Mayo Clinic Health System