Advanced Training in Cognitive Behavioural Interventions: Behavioural Change Report
Behavioural Change Report Using A Single Case Study Design
Instructions: 2500 words exclude abstract, tables, graphs, figures, references and
appendices.
Abstract (150-250 words)
Introduction:
Includes a brief literature review as background to the nature of the problem behvaioural – Insomnia.
Any CBT treatments that have been applied to this problem.
A description of the problem behavioural and its operational definition.
Method:
Description of the participant and a short discussion of the problem behavior.
Description of all measures used
Description of the interventions and how it was applied.
Results:
Baseline data (A1) of the problem behavioura before intervention-this will involve developing an appropriate time interval for observing the target behavior and an appropriate length of time for the baseline period (7days)
Results of the intervention (how successful was the intervention-you can determine this by comparing baseline data with treatment data);
Graphical representation with summary data.
Discussion
Discussion of the intervention (any reasons why intervention was effective/not effective? What could be done differently);
Any perceived obstacles when using such interventions with clients
Limitation
Conclusion
References
Appendices
Abstract
Abstract
(150-250 words)
INTRODUCTION
Cognitive Behavioural Therapy for Insomnia
Insomnia is the disruption of sleep. The disorder is characterized by a shortened duration of sleep, difficulty initiating or falling asleep, and frequent waking up during the night (Seow et al., 2018). Given the positive association between quality, timely, and adequate sleep with functioning, insomnia is associated with dysfunctions in cognition, emotion, and behavior, which present with symptoms such as malaise, fatigue, daytime sleepiness, irritability and mood disturbance, reduced motivation, attention, memory, or concertation problems, and social dysfunctions (How & Chan, 2013). According to How and Chan (2013), insomnia is among the commonly reported conditions in mental and other health institutions in Singapore, with an estimated prevalence of 15.3 percent. Subsequently, to manage the high occurrence of insomnia, researchers and clinicians have evaluated various treatment modalities including the use of psychotherapeutic methods such as cognitive-behavioral therapy. This study evaluates the literature on insomnia and the use of CBT methods to manage the condition within the context of Singapore.
Epidemiologically, the prevalence of insomnia in Singapore is unclear, with different studies estimating the occurrence of the disorder/ symptom based on the health aspects under investigation. For instance, How and Chan (2013) evaluated the occurrence of insomnia based on gender and ethnicity. They reported an overall estimation of 15.3 percent with individuals from Malay ethnicity and females being more likely to be predisposed to risk factors of insomnia (How & Chan, 2013). Comparatively, Wong and Ng, 2015 carried out a systematic review of the conditions associated with chronic insomnia. From a sample population of 106 Singaporean patients with insomnia, the authors reported that about 65.4 percent of the insomnia cases could be diagnosed using patient history and physical examination for symptoms. Causatively, Wong and Ng (2015) noted that for individuals diagnosed with insomnia, approximately 42.5 percent had obstructive sleep apnea while 4.7 percent suffered from periodic limb movement disorders. Lastly, in their evaluation of the prevalence of insomnia for Singaporean patients diagnosed with the first episode of psychosis, Subramaniam et al. (2018) observed an occurrence rate of 22.6 percent, with the incidence being lower on older patients using prescribed antipsychotic medications.
Notably, cognitive behavioral therapy is among the recommended psychotherapy for insomnia (Trauer et al., 2015; Anderson, 2018). Anderson (2018) maintain that in the care of insomnia, CBT help patients and individuals to create a connection between sleep and bed, realign their circadian rhythm and homeostatic mechanism, and ruminate about sleep. In practice, techniques such as cognitive restructuring are used to help patients address cognitive distortions such as the fear of going to bed (Rossman, 2019). Experientially, different researchers have been done including ABAB single subject study by Norell-Clarke et al. (2010) who investigated CBT in managing adolescents with insomnia and found the modality to be effective. In the context of Singapore, CBT approaches have been applied in the management of insomnia related to different causes. For example, in a study involving 400 participants enrolled in a tertiary psychiatric institution in Singapore, Chang et al. (2020) found that dysfunctional sleep beliefs had a greater risk factor for developing insomnia in psychiatric patients. In their study, Chang et al. (2020) point out that CBT approaches could be used to target maladaptive cognitions that informed the dysfunctional beliefs associated with poor sleep patterns, especially in patients with psychiatric comorbidities and lower levels of education.
In another study, Hassirim et al. (2019) enrolled 96 participants aged between 17 and 75 years from the Brahm Centre in Singapore for a study evaluating decreases in pre-cognitive arousal after 4 weeks in a behavioral program. The researchers found that being enrolled in cognitive and behavioral programs where participants practice mindfulness-based CBT reduced cognitive arousal and increased the quality of sleep for patients diagnosed with insomnia.
Further, in their study, Seow et al. (2018) evaluated the application of the DSM-5 recommended treatment in the treatment of sleep disorders in a population of 400 individuals seeking outpatient care from Singapore’s Institute of Mental Health. The authors report that while the application of cognitive and behavioral care modalities, besides drug interventions, were recommended for the management of insomnia, only about 12 percent of the Singaporean patients with sleep disorders received and psychotherapy or psychoeducation (Seow et al., 2018). Lastly, Shum et al. (2014) also conducted a study in a Singaporean population investigating whether cognitive relaxation through music improved sleep quality for individuals with insomnia. The authors used a randomized control trial with a sample of 60 patients above the age of 55 years enrolled in a community center in Singapore. They found noted that music affected the cognition of listeners as its distracting properties helped to divert attention from stressors and soothe individuals with insomnia thereby increasing the likelihood of falling asleep (Shum et al., 2014).
In conclusion, few studies have been conducted that evaluate the effectiveness of CBT approaches in managing insomnia in Singapore. However, while the general view is that CBT is relatively effective in the care of sleep disturbances apparent for people with insomnia, most cases of sleep disturbances in Singapore are noted alongside other psychiatric diagnoses. The co-occurrence might inform the limited studies directed on evaluating the effectiveness of CBT in the care of insomnia as a standalone disorder. for instance, using data from a 2016 Singaporean Mental Health Study, Seow et al. (2020) examined the association between insomnia (sleep duration and quality) and other mental and physical disorders from a sample of 6,126 individuals above the age of 18. The authors found that insomnia traits (poor sleep duration and quality) were accompanied by other psychological and physical conditions such as obsessive-compulsive disorder and chronic pain (Seow et al., 2020).
Method
(Measures, Procedures, Results, Discusion, Limitation & Conclusion: 1700 words)
Participant
The participant is a 43-year-old Singaporean, married with two young children aged six and seven. Her husband is an offshore engineer who stationed in China a year ago and he will return Singapore next year for good. She started experiencing anxiety and worry over her sleeping patterns for past three weeks. She has difficulty falling asleep and problem waking up. The worse things were she felt tense when lying in bed and did not felt rested when waking up. Most of her daytime, she experienced fatigue and unable to concentrate at work. She was worry that her sleep problem- insomnia would deterorite and thus affect her daily functioning, caring the children, work performance and church volunteering work. She was feeling very anxious about completing her master counselling course in six months. The participant experienced extremely stress due to study, work, caring of two children where her elder son has started primary one and the younger daughter went to kindergarten beginning of this year. The participant also involves in volunteering work at half-way house and she has sixty hours of practicum to comlete before graduation.
Personal history further reveals that the participant experienced high level of stress when she worked in the general hospital as an occupational therapist. She claimed that she could not make mistkes because all her patients were undergone surgical procedures. A small mistake would affect recovery process or even complicate of the conditions. She has accountability to the patient, surgeon, family members and the stakeholders of hospitial. Her anxious level was intensified by her perfectionist temperament. The participant resigned from her profession after giving birth to her second child because she wanted to give the best to her two children. She values the first six years of life are the most important years to nuture, care and love her children. She started to work part time while her children were in school at a medical clinic, about six months ago.
She came from a close-knit family and she enjoyed her childhood in Singapore. She has two younger brothers but both settled in Australia and San Fransico five years ago. She left with a elderly father who is 80 years old who suffered a stroke two years ago but he is independent currently. Her mother has passed away more than twenty years. The participant has unrelenting the standards and her mother often emphasised success and excellence in everything.
Measures
The Insomnia Severity Index (ISI) is a 7-item scale evaluating the perceived insomnia severity. Rating on a 0-4 point scale were obtained on the perceived seveity of sleep-onset, sleep-maintainence, early morning awakening problems; satisfaction with current sleep pattern; interference with daily functioning, noticeably of impairment atributed to the sleep problem; an level of distress caused by the sleep problem. The total score ranges from 0-28, and higher the scores indicate more severe insomnia. Morin et al. (2007) indicated that ISI has adequate psychometric properties and has been shown to be sensitive to changes in treatment of insomnia. In this study, ISI rating will be based on a 7-day period.
The Depression, Anxiety & Stress Scales (DASS). The the DASS-21, is a self-report questionnaire consisting of 21 items, 7 items per subscale: depression, anxiety and stress. The participant was asked to score every item on a scale from 0 (did not apply to me at all) to 3 (applied to me very much). The Depression Anxiety Stress Scale (DASS) has been shown to be a valid and reliable measure of the dimensions of depression, anxiety, and stress separately to a more dimensional psychological distress( Lovibond & Lovibond, 1995). It is to be rated as experienced over the past week, on a scale from 0 to 3 to rate level of severity/frequency.
Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS-16), a 16-item self-report measure designed to evaluate a subset of those sleep related cognitions. The participant was asked to rate on a scale from 1(strongly disagree) to 10 (Strongly Agree) on the domains of expectation about sleep requirements, attributions of the causes and appraisals of the consequences of insomnia, and issues of worry and helplessness about insomnia. Morin et al. (2007) study found that DBAS total scores were significantly correlated with other self-report measures of insomnia severity, anxiety, and depression and concluded its psychometric quality of DBAS-16 is adequate to evaluate the role of sleep related beliefs and attitudes in insomnia.
Procedure
Interview/Preparation Stage. It was evident that tracking the participant’s sleep pattern, habits, environment factors and mental and emotional status are gathered to form a baseline. The ISI, DASS were used to assess during interview/preparation phase to form a baseline too.
ABAB Design. The ABAB design was used for this case study with a 7-day period for each observation phase. The entire study took place from 1-28 February 2021. The participant was asked to complete all four measures at the end of each observation phase. In A1 (baseline), she was asked to continue with her normal weekly schedule. In B1 (treatment phase), cognitve interventions were introduced, based on the DBAS elicited in Interview/Preparation Stage.
The mindfulness body scan meditation was introduced to the participant. It is a form of relaxation technique aims to change reactions to stress by teaching purposeful awareness and acceptance of the present state. The question “On average, how often did you practice the body scan exercise in the past week?” A sleep diary was given the participant to fill every week. The scores range from 0 to 7. The participant was given prepregrammed MP3 file with music and a guided body scan meditation. The participant was instructed to practice body scan with deep breathing 20 minutes before sleep on daily basis.
Stimulus control and restriction help to establish a regular sleep-wake cycle and associate the bedroom with sleep. Specific instructions given to participant include the following: to lie down to sleep only if you feel sleepy; use the bed for sleeping and sex only; do not watch television in bed or eat in bed; leave the bed if unable to fall asleep within 20 minutes and return to bed only when sleepy. Setting alarm at the same time every morning regardless of how many hours of sleep occurs. The participant was instructed to limit caffine intake after 4pm. The numbers of caffine intake to be record in sleep diary. Sleep hygine was part of the psycho-education. The stimulus control therapy and sleep restrict were introduced at this phase so that personal habits and environmental factors that negatively impact sleep can be identified and corrected.
Physical exercise. The participant was instructed to perform aerobic exercise such as walking or jogging in the morning or regularly (but not within four hours of bedtime).The duration of the exercise at least 30 minutes and the participant could increase to 60 to 90 minutes within her phsycial stemina. The frequency of exercise was recorded in sleep diary and on the scale 0-7, where 0: no exercise and 7: exercise every day.
Behavioural Interventions
The participant was given a sleep diary during the first phase to establish a baseline such as environmental and routine before sleep. Intsrtuctions for stimulus control, for example limit caffine intake, vigorous exercise, large meal or alcohol consumption several hours prior to bed.
Cognitive Interventions
Cognitive Restructuring. The chart of Dysfunctional Beliefs and Sleep Scale which perpetuate the severity and symptoms of insomnia. The followings were the top six dysfunctional beliefs where the participant strongly agree at the of scale-10. They were “I need 8 hours sleep to feel refreshed and function well during the day,” “I am concerned that chronic insomnia may have serious consequences on my physical health,” “I am worried that I may lose control over my ability to sleep,” “After a poor nights sleep, I know that it will interfere with my daily activities on the next day”, “When I feel tired, have no energy, or just seem not to function well during the day, it is generally because I did not sleep well the night before” and “ It usually shows in my physical appearance when I haven’t slep well,” These statements indicate Cognitive Distortion of Catastrophising, fortune telling, all-or-nothing, magnifying the issue, overgeneralisation and emotional reasoning (Appendix A).
Countering technique was to assess the participant’s sense of certainty on the scale of 0 percent centain to 100 percent regarding each thought. It also determines the frequency if occurrence and then set a countering “Mantra.” It was a collaborative process in developing a coping statements which were more positive and realistic thoughts with reality testing
Results (please use graphs such as histrogram, line graph for the ISI, DASS, degree of belief on dysfunctional Assumption/core belief scale (DBAS), measures of physiological & Emotion intensity)
ISI chart
DASS chart
Degree of Belief on Dysfunctional Assumptions & core belief (DBAS)
Measures of Physiological & Emotion Intensity Per Observation Phase.
The table below shows the number of hours of sleep, Most rested, Number of exercise, Number of mindfulness practice (A1, B1, A2 & B2).
Background information: The participant has left knee surgery 7 years ago. Therefore, she chose walking exercise and she did not know how to swim. She learnt mindfulness based stress reduction 3 months ago but she only practice 1-2 times a week. The participant was give psycho-education on sleep hygine and she was instructed to fill the sleep diary and hand it to counsellor after B2 phase. It seemed the participant was very motivated because it was Chinese New Year season, her felt delighted and happy to meet some of her relatives and friends. She was supportd by friends and relatives and it could contribute to the above good results. Her husband has come back for 5 days for reunion dinner and celebrate the Chinese New Year for a few days (phase B1).
Discussion (please write 500 words)
Discussion of the intervention (any reasons why intervention was effective/not effective? What could be done differently);
Any perceived obstacles when using such interventions with the participant?
Limitation (80 words)
Conclusion (80 words)