Mixed Methods and Single Case Design

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Post by Day 4 a brief summary of a mixed methods or a single case design peer-reviewed research article related to dialectical behavior therapy applied to working with young adult females between the ages of 17 to late 20s. In your summary, critically analyze the basic components of research: purpose, research question or hypothesis, design, variables of interests (dependent and independent), sampling, instruments, data analysis, ethical considerations, strength and limitations, implications for practice, and implications for future research. Also, compare and contrast your chosen design with a previous design from Week 4 or Week 5.

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School: Purdue University

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Mixed Methods and Single Case Design
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Critical analysis of the basic components of research
The study was a clinical trial that focused on the assessment of the effectiveness of
treatment for adolescent patients with suicidal and self-injurious behavior as well as borderline
symptoms using dialectical behavioral therapy.
Research question or hypothesis
The main hypothesis for the study was that Dialectical behavioral therapy for the
adolescent patients is an effective method of treatment for the population group (Fleischhaker,
Böhme, Sixt, Brück, Schneider & Schulz, 2011).
The research design was a single case research in form of a pilot study involving the use
of dialectical behavioral therapy and the efficacy of the treatment measured by pre and post
comparison as well as a one-year follow-up.
Variables of interests (dependent and independent)
The variables of interest were dialectical behavioral therapy and adolescents with suicidal
and self-harming behavior and borderline symptoms. The dependent variable was the adolescents
and the independent variable was the dialectical behavioral therapy.
The study involved the use of twelve (12) adolescents who underwent the treatment and
had to meet certain inclusion and exclusion criteria for participation. The sample comprised of
all the families with adolescent females showing non-suicidal, self-harming and suicidal
behavior. It was only limited to the female participants to have enhanced homogeneity and the
inclusion and exclusion criteria used for pragmatic factors. The inclusion criteria involved


having ages of 13 to 19 years at the start of the therapy, non-suicidal self-harming and suicidal
conduct, and the diagnosis of borderline personality disorder. The exclusion criteria comprised of
present psychotic disorder, depressive episode, substance abuse, and illiteracy (Fleischhaker,
Böhme, Sixt, Brück, Schneider & Schulz, 2011).
The standard instruments that were used in the study were SKID-I, SKID-II, parts of the
Kiddie-SADS-PL, Lifetime para-suicide count, Treatment history interview, Global assessment
scale of functioning, Clinical global impression, inventory of life quality in children and
adolescents, symptom checklist, child behavior checklist and youth-self-report, and depression
inventory for children and adolescents.
Data analysis
Statistical analysis involved the assessment of the changes that occurred before therapy,
four weeks after therapy, and one year after therapy. The data analysis was assessed in form of
effect size and p-levels of the Wilcoxon signed rank test. Two-tailed p-values for the rank test
were used for explorative data analysis.
Ethical considerations
The study followed the approval guidelines by the review boards of the University of
Freiburg as required before its commencement. The researchers required all the patients and
parents to give written informed consent and the children and adolescent participants gave their
assent as a necessary fulfillment of the ethical guidelines. The participants were also informed
about the details of the study such as the purpose, purported benefits, and the potential risks of
their participation for them to make informed decisions.
Strength and limitations


The identified strength of the study is the use of various instruments of assessment that
helped to gather diverse data and also the use of different methods of data analysis for a
comprehensive analysis. The use of female gender participants enhanced homogeneity of the
data collected from the participants for purposeful analysis. The major limitations of the study
were largely related to the design. It lacked a control group that could be used to compare the
therapeutic impacts throughout the course of therapy with the controls. The failure to fully
evaluate the reliability and validity of the diagnosis of borderline personality disorder in
adolescents and the measurement methods could be a cause of limitation to some level. The
assessment processes by the therapists could also be marred by the potential bias which cannot
be ignored (Fleischhaker, Böhme, Sixt, Brück, Schneider & Schulz, 2011).
Implications for practice
The study was effective in the establishment of dialectical behavior therapy for the
German-speaking countries and helped to provide details for its practicability and findings on the
treatment effectiveness. The findings can be implemented into practice by psychotherapies who
desire to use dialectical behavior therapy for the diagnosis and treatment of borderline
personality disorder in adolescents.
Implications for future research
The study generated promising findings and the treatment program utilized was
considered worth for further evaluation. There is also need for a multicenter, randomized and
controlled study for the comparison of dialectical behavioral therapy for adolescents (DBT-A)
with the conventional outpatient psychotherapy.
Comparison and contrast of the single case design with mixed methods Design


Both the single case and the mixed methods design are appropriate procedures for the
collection, analysis, interpretation, and reporting of data in research studies. Both designs are
useful in the assessment of particular aspects of a phenomenon by observing the changes
encountered from the start of a study throughout till the end.
The single case design has successfully been used to inform and develop a theory,
evaluate interpersonal processes, study behavior, and also establish the effectiveness of
psychological interventions (Smith, 2012). On their part, mixed methods researchers usually
have philosophical assumptions and methods of inquiry (Creswell & Plano Clark, 2007). The
participants in a single case study provide own control data for comparison with the group and
not between two different subjects (Sexton-Radek, 2014). Mixed methods research usually
involves a comparison of data between two experimental groups. There are significant threats to
internal validity of the findings in single subject studies in contrast to mixed methods research
studies that have lower levels of threat to internal validity. Single case design studies usually
involve a repeated and systematic assessment of the variables over time, which is different to a
mixed methods research study which may not involve repeated assessments over time (Creswell
& Plano Clark, 2007). Data analysis in single case design studies is usually complex in
comparison to the mixed methods research studies which are fast and easy (Sexton-Radek,



Creswell, J. W., & Plano Clark, V. L. (2007). Choosing a mixed methods design. Designing and
conducting mixed methods research, 58-88.

Fleischhaker, C., Böhme, R., Sixt, B., Brück, C., Schneider, C., & Schulz, E. (2011). Dialectical
Behavioral Therapy for Adolescents (DBT-A): a Clinical Trial for Patients with suicidal
and self-injurious Behavior and Borderline Symptoms with a one-year Follow-up: Child
and Adolescent Psychiatry and Mental Health, 5, 3. http://doi.org/10.1186/1753-2000-53

Sexton-Radek, K. (2014). Single Case Designs in Psychology Practice: Health Psychology
Research, 2(3), 1551. http://doi.org/10.4081/hpr.2014.1551

Smith, J. D. (2012). Single-Case Experimental Designs: A Systematic Review of Published
Research and Current Standards: Psychological Methods, 17(4), 10.1037/a0029312.

Fleischhaker et al. Child and Adolescent Psychiatry and Mental Health 2011, 5:3


Open Access

Dialectical Behavioral Therapy for Adolescents
(DBT-A): a clinical Trial for Patients with suicidal
and self-injurious Behavior and Borderline
Symptoms with a one-year Follow-up
Christian Fleischhaker1*, Renate Böhme2, Barbara Sixt1†, Christiane Brück1†, Csilla Schneider1†, Eberhard Schulz1†

Background: To date, there are no empirically validated treatments of good quality for adolescents showing
suicidality and non-suicidal self-injurious behavior. Risk factors for suicide are impulsive and non-suicidal selfinjurious behavior, depression, conduct disorders and child abuse. Behind this background, we tested the main
hypothesis of our study; that Dialectical Behavioral Therapy for Adolescents is an effective treatment for these
Methods: Dialectical Behavioral Therapy (DBT) has been developed by Marsha Linehan - especially for the
outpatient treatment of chronically non-suicidal patients diagnosed with borderline personality disorder. The
modified version of DBT for Adolescents (DBT-A) from Rathus & Miller has been adapted for a 16-24 week
outpatient treatment in the German-speaking area by our group. The efficacy of treatment was measured by a
pre-/post- comparison and a one-year follow-up with the aid of standardized instruments (SCL-90-R, CBCL, YSR, ILC,
Results: In the pilot study, 12 adolescents were treated. At the beginning of therapy, 83% of patients fulfilled five
or more DSM-IV criteria for borderline personality disorder. From the beginning of therapy to one year after its
end, the mean value of these diagnostic criteria decreased significantly from 5.8 to 2.75. 75% of patients were kept
in therapy. For the behavioral domains according to the SCL-90-R and YSR, we have found effect sizes between
0.54 and 2.14.
During treatment, non-suicidal self-injurious behavior reduced significantly. Before the start of therapy, 8 of 12
patients had attempted suicide at least once. There were neither suicidal attempts during treatment with DBT-A
nor at the one-year follow-up.
Conclusions: The promising results suggest that the interventions were well accepted by the patients and their
families, and were associated with improvement in multiple domains including suicidality, non-suicidal self-injurious
behavior, emotion dysregulation and depression from the beginning of therapy to the one-year follow-up.

Adolescents with borderline personality disorder (BPD)
show many similarities to adult patients in terms of
early history, current behaviors and coexisting Axis I
* Correspondence: christian.fleischhaker@uniklinik-freiburg.de
† Contributed equally
Division of Child and Adolescent Psychiatry and Psychotherapy, Department
of Psychiatry and Psychosomatic Medicine, Albert Ludwig University Medical
Center Freiburg, Hauptstr. 8, 79104 Freiburg, Germany
Full list of author information is available at the end of the article

disorders. Inpatient studies have demonstrated that BPD
in adolescents can be reliably diagnosed, occurs frequently and has concurrent validity with some temporary instability [1,2]. While caution is warranted, formal
assessment of BPD in adolescents may yield more accurate and effective treatment for adolescents experiencing
BPD symptoma...

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