Single-Case Research Methods for the Behavioral and Health Sciences

David L. Morgan, Robin K. Morgan

• Publisher: SAGE Publications, Inc
• Year: 2008
• Print ISBN: 9781412950398
• eBook ISBN: 9781483317090
• Edition: 1
• Topic: Social Sciences
• Subtopic: Social Science Research & Methodology
• Index: Social Sciences

This text ntroduces readers to the history, epistemology, and strategies of single-case research design. The authors offer concrete information on how to observe, measure, and interpret change in relevant outcome variables and how to design strategies that promote causal inferences.

Key Features

• Includes case vignettes on specific single-case designs
• Describes clinical and applied case studies
• Draws on multiple examples of single-case designs from published journals across a wide range of disciplines
• Covers recent developments in applied research, including meta-analysis and the distinction between statistical and clinical significance
• Provides pedagogical tools to help readers master the material, including a glossary, interim summaries, end-of-chapter review questions, and activities that encourage active processing of material.

Intended Audience

This text is intended for students and practitioners in a variety of disciplines—including psychology, nursing, physical therapy, and occupational therapy—who are increasingly called upon to document the effectiveness of interventions.

Chapter 1

WHY SINGLE-CASE RESEARCH METHODS?

The methods of science have been enormously successful wherever they have been tried. Let us apply them to human affairs.

—B. F. Skinner (1953, p. 5)

These words, written a half century ago by America’s leading behavioral scientist, reflect the purpose of this book. All around us, human service professionals—be they psychologists, nurses, rehabilitation specialists, or physical and occupational therapists—attempt to salve the aches, pain, and anxieties of being human in the 21st century. Increasingly, their efforts are being informed by the latest findings from the research-oriented disciplines of the behavioral and health sciences. As a consequence, it has become imperative that students in the human service fields acquire an understanding of and appreciation for the many philosophies and methods that characterize research in these areas. Indeed, being a competent professional in any field requires a working familiarity with the latest relevant research, particularly when this research bears important implications for applied interventions.

This book is intended as an introduction to the philosophical and strategic features of single-case research as conducted within the behavioral and health sciences. Single-case research represents a powerful and effective alternative to the large group designs that have characterized much of the history of behavioral science but that often prove impractical, particularly in the applied setting of the field or clinic. The flexibility and sensitivity of single-case designs to “local” factors offer substantial benefits to those charged with conducting research in clinical settings. Moreover, the single-case approach, in both spirit and practice, meshes well with the needs of professionals who are almost exclusively providing care for individual clients. We will be considering the philosophical underpinnings, historical development, design features and advantages, contemporary use, and future prospects of single-case research as conducted by psychologists, nurses, physical and occupational therapists, and other allied health scientists.

MANAGED CARE

Rising health care costs have changed the way health care practitioners offer their services and the ways in which they are reimbursed. Managed care practices affect the work of all health care providers in the United States in some way, whether they are psychologists, physicians, nurses, social workers, physical therapists, or occupational therapists. Given that approximately 170 million Americans subscribe to a managed care insurance plan (Kent & Hersen, 2000), health care providers are affected by the provisions set forth by their patients’ managed care organizations. The managed care market is a product of free enterprise, and health care, like other systems, has not been spared the consequences of a competitive market.

The earliest recognized prepaid health care arrangement occurred in the early 20th century in the Pacific Northwestern portion of the United States with the development of the Western Clinic. The founders of the Western Clinic, physicians Thomas Curran and James Yocum, contracted with several lumber company representatives to provide comprehensive health care for their employees at the rate of 50 cents per employee per month. Curran and Yocum collected this fee independent of the number of patients they saw. The success of the Western Clinic inspired other physicians to build on this idea and to contract with employers from the railroad, mining, and lumber industries in the northwestern states, producing a rapid rise in such prepaid contacts between physicians and industry bosses. A second example of an early prepaid contract occurred in Texas in the early 1930s: Baylor Hospital contracted with 1,250 schoolteachers who agreed to prepay the hospital annual premiums in exchange for a set number of days of hospital care. This agreement is cited as the first group health insurance plan, eventually giving rise to Blue Cross (Rickel & Wise, 1999).

The Great Depression, with the uncertainties created by economic hardship, advanced early forms of managed care. More and more middle-class Americans wanted protection from the hardships brought on by an unexpected injury or illness. As a result, health care providers found more acceptance from Americans with strained incomes in changing their traditional ways of charging for their services.

Perhaps one of the best known and most successful of the Depression-era managed care arrangements came with the development of Kaiser Permanente, today’s leading managed care organization with, as of the year 2004, over 7 million members (Moon, 2004). In 1931, Henry Kaiser and his business partners won a bid from the federal government to build Boulder Dam (now called Hoover Dam). For five cents per employee per work hour, Kaiser hired Sidney Garfield, and a group of physicians recruited by Garfield, to provide health care for his workers. As the dam’s construction began, Kaiser built a 10-bed hospital on wheels that was pulled along in the direction of the construction. This early managed care structure possessed two features that are still found in today’s health maintenance organizations (HMOs): (1) prepaid arrangements and (2) group practice (Hendricks, 1993). Kaiser Permanente expanded its operations throughout the West Coast and eventually spread throughout the country, including states such as Texas, Ohio, and Maryland.

The success of Kaiser Permanente was due, in part, to the willingness of Americans to embrace these concepts. As Americans were becoming more technologically informed, they were generally not offended by the idea of their health statuses viewed as things to be “maintained,” nor could they predict the mechanical approach to patient care that results in part from this philosophy of health (Hendricks, 1993). Interestingly, the American Medical Association (AMA) initially vehemently opposed such prepaid group plans for health care and advocated maintaining the traditional fee-for-service arrangements, for two reasons. First, the AMA argued that prepaid plans ethically compromised the patient–doctor trust. Second, the AMA stated that it would be impossible to hold a corporation accountable for breaches in standards of practice. Additionally, the AMA was disturbed by what it believed was intrusiveness into the lives of employees by their employers. In the early 1950s, the AMA argued against prepaid group health, claiming it was a form of “socialized medicine” (Hendricks, 1993). Despite these objections, prepaid group arrangements flourished.

For the most part, these early prepaid arrangements centered on the mission of providing affordable health care to the laborers of industrial companies. Employers typically provided workers a choice between traditional indemnity coverage and enrollment in an HMO. However, these early prepaid group plans served as models for the development of government-sponsored HMOs of the 1970s that led to the rapid growth of HMOs in the 1980s. Although HMOs in the 1980s were primarily involved in the private sector, they increasingly participated in publicly sponsored programs such as Medicare and Medicaid.

With the development of the social programs Medicaid and Medicare, the federal government fully stepped into the health insurance arena. Medicaid was established in 1965 by the federal government through Title XIX of the Social Security Act to provide health care to poor and disabled Americans (Spidle, 1999). It was modeled on the traditional Blue Cross/Blue Shield service benefits, thus emulating the private sector. Although Medicare was designed to be administered and handled by the federal government, Medicaid’s budgetary spending was to be determined by state need, with each state government deciding how much it needed to spend. Historically, Medicaid has presented huge challenges to state budgets, leading an increasing number of states to look toward managed care operations to provide service for their Medicaid beneficiaries.

In the mid-1960s, President Lyndon Johnson made Medicare one of his administration’s top priorities. By the early 1970s, the federal government spoke of a “national health care crisis.” The Nixon Administration searched for ways to curtail what it perceived as the looming catastrophe associated with social welfare programs. Paul Ellwood, a Minneapolis physician, argued that the existing fee-for-service arrangements rewarded those physicians who kept their patients ill. He proposed a system in which the federal government rewarded physicians for maintaining health. Ellwood’s model was based on the Kaiser Permanente models and led to the HMO Act of 1973, which provided economic incentives for the development of HMOs.

The creation of these HMOs was an effort to curtail the rising U.S. health and mental health care costs. The percentage of the gross national product spent on health care rose from 6% in 1963 to 10% in 1987 (Broskowski, 1994). Advancements in medical technology and pharmacology, although improving health and increasing the life span, cost the federal government more money. Finally, premiums for private insurance were also increasing.

Over the next several years, six amendments were made to the HMO Act of 1973 relaxing the requirements of the original act. The 1974 Employment Retirement Security Act (ERISA) gave early HMOs a great boost by allowing employers an exemption to state laws requiring federally qualified HMOs to base premium rates on the health care costs of the entire community. By basing their premium costs solely on the health care of their employees, HMOs were able to reduce their premium rates, leading to a rapid expansion of HMOs in the 1980s (Zieman, 1998).

The HMO Act of 1973 was of particular interest to mental health providers. The legislation required provision of outpatient mental health care and referral services for drug and alcohol abuse. A 1976 amendment allowed HMOs to utilize clinical expertise of “other health care professionals,” including clinical psychologists, rather than the traditional psychiatrists.

As noted earlier, both general health care and mental health care have experienced soaring costs in the last several decades. These high costs are frequently given as a rationale by insurance companies for increasing control over services provided by utilization review methods. Mental health professionals, embedded in today’s managed care policies, work in an environment much different from the payment arrangements of the 1970s and a large portion of the 1980s. During those times, mental health professionals had more discretion in the types of treatments they chose for their clients. Often, they were not required to provide lengthy evidence and validation for the work they did in therapy. Mental health professionals who contract with HMOs earn a fixed amount per referral, regardless of the number of psychotherapy sessions required for treatment. Rickel and Wise (1999) wrote, “HMOs control costs by putting providers in a position to lose money by extensive or inefficient treatment, or having an unusually sick population” (p. 34). HMOs typically restrict their members’ options for mental health care by limiting which mental health professional they will reimburse for services.

Preferred provider organizations (PPOs), compared with HMOs, are managed care structures that allow for a greater degree of flexibility in enrollees’ choice of providers. When the member desires to see a mental health provider not on the PPO list of providers, the PPO typically reimburses the mental health provider by paying a percentage of the “usual, customary, and reasonable fee” for treatment.

Almost every managed care structure in which mental health providers (psychologists, social workers, occupational therapists, physical therapists, etc.) will be involved uses the practice of utilization review (management). This utilization review involves monitoring the treatment plan, including plans to help the client overcome the problem, diagnosis(es), previous treatments the client has received, and the time frame needed to achieve stated goals. The primary goal of such review is to limit costs that the insurance company must pay. Concerned about variations in practice, the health care community has focused on improving care as well as reducing costs by reviewing the empirical literature, developing protocols, and encouraging practitioners to voluntarily adopt the suggested treatment guidelines. In the early 1990s, for instance, a federal agency called the Agency for Health Care Policy and Research developed a series of treatment guidelines for various conditions (Clay, 2000). The primary treatments endorsed by managed care structures are solution-focused therapies; crisis interventions; group therapies; behaviorally oriented therapies; therapies that involve biopsychosocial assessments; and more recently, computer-assisted therapies.

The range of reactions to the advent of managed care from health care providers spans the gamut from denial and resistance, refusal to cooperate with utilization review demands, and career changes, to acceptance and adjusting and tailoring practices to fit managed care demands (Broskowski, 1994). Supporters of managed care policies assert that by requiring outcome research and the integration of physical and mental health care, managed care encourages the establishment of scientific foundations of practice (Sanchez & Turner, 2003). On the other hand, authors such as Hersch (1995) refer to managed care as “the most tangible and problematic manifestation of health care reform” (p. 16), and even “the corpse in the living room” (Pipal, 1995, p. 323).

Outcome measures, regardless of one’s personal perspective, are becoming part of standard treatment in which service providers must demonstrate their efficacy as they are quantitatively being compared to one another. Cohen (2003) wrote:

Outcome management serves several important functions in the mental health field, including evaluating and refining treatments, providing clear descriptions of therapeutic procedures, and enhancing the credibility of psychotherapy. The current marketplace of mental health care increasingly demands greater accountability of its practitioners. (p. 39)

Evidence suggests that outcome measures are valued by clinicians but are not widely used in practice. In the American Psychological Association’s (APA’s) 1998 Committee for the Advancement of Professional Practice survey on the effects of managed care on psychological practice, 29% of respondents reported that they used some type of outcome measure in their practice. Of these, 40% used a standardized method (e.g., administering the Beck Depression Inventory at multiple intervals), and the remaining 60% used nonstandardized methods of assessing client outcome (Phelps, Eisman, & Kohout, 1998). Hatfield and Ogles (2004) investigated provider factors associated with the use of outcome measures and concluded that clinicians are increasingly using outcome measures both because of the calls for accountability placed on practitioners by managed care and because of the usefulness of the information such measures can provide for treatment decisions.

EVIDENCE-BASED PRACTICE

Like nursing, medicine, social work, and other health care disciplines, psychology is struggling with evidence-based practice (EBP). EBP has become a major movement calling on practitioners in all areas of health care, including mental health care, to use the best available scientific evidence as a basis for formulating treatments for individual clients. In cancer care, for example, EBP may mean informing patients about the most recent advances in chemotherapy and guiding them to the best type for their particular illness (DeAngelis, 2005). In psychology, Division 12 of the APA Task Force on the Promotion and Dissemination of Psychological Procedures created a firestorm when it published guidelines for evidence-based practice. The most recent update of the report (Chambless et al., 1998) lists 16 empirically supported treatments and 56 efficacious treatments (treatments supported, but with fewer studies). The empirically supported treatments (see ...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• Preface
• Chapter 1. Why Single-Case Research Methods?
• Chapter 2. Comparing Group and Single-Case Designs
• Chapter 3. Observational Strategies
• Chapter 4. Dimensions of Single-Case Research Design and Data Display
• Chapter 5. Single-Case Experimental Designs: The Withdrawal Design
• Chapter 6. Multiple-Baseline Designs
• Chapter 7. Changing-Criterion Designs
• Chapter 8. Comparing Treatments: The Alternating-Treatments Designs
• Chapter 9. Data Analysis in Single-Case Research
• Chapter 10. Contemporary Themes and Future Directions in Single-Case Research
• References
• Index
• About the Authors