1. SINGLE-CASE DESIGN PAPER
Summary of Individual Contributions to Project
Our group consisted of Mimi Tran, Holly Lark, and Leah McNulty. All three team
members stayed in contact via email and Google docs to work on the assignment. They met early
in the semester to discuss project options and select the self-change goal. The whole team met to
create and practice the project presentation for the class. Leah contributed to the overall project
by volunteering to be the subject of the single-case design and completing the Description of
Methods and Rationale for Methods sections of the paper. She researched single-case designs,
evidence-based anxiety measurements, and created the timeline for the study. Leah took self-
administered anxiety measurements while the other two team members sent her reminders and
check-ins throughout the process. Holly contributed to the project by helping come up with the
project proposal idea. Holly helped look up meditation apps and anxiety measurement scales that
we could chose from for our project. The parts of the paper she completed were the Introduction
to the Context of the Project, Background Information and Purpose of Project, and the Summary
section. Mimi contributed to the project by using the collected data to create charts and graphs to
analyze the subject’s anxiety levels throughout the evaluation. Mimi has interpreted and
discussed with the rest of the group other plausible interpretations that affected the data. Mimi
has listed out possible limitations of the evaluation and discussed what could have been done to
prevent these limitations in the future.
Introduction to the Context of The Project
Anxiety disorders are the most common mental disorders among people living in the
United States. Forty million people 18 years and older, equaling eighteen percent of the
population, suffer from some type of anxiety disorder. The United States spends $148 billion on
2. mental health with one third of it being used anxiety disorders (ADDA, 2016.) A member in our
group who will be referred to in this report as “the subject” has symptoms of Generalized
Anxiety Disorder (GAD), and we decided to conduct a single-case design evaluation on reducing
her anxiety through the intervention of Mindfulness Meditation. GAD affects 6.8 million adults,
and women are twice as likely as men to have GAD (ADDA, 2016). Anxiety can cause stress
that is unequal to the proportion of the event that results in restlessness, increased worry,
withdrawal from activities or isolation, and fear; in addition, to the effected thoughts and
behaviors, people with anxiety can also experience physical symptoms such as nausea, increased
heart rate, trembling, sweating and headaches (Timberland Knolls, 2016). Anxiety can be treated
with medications such as Selective Serotonin Reuptake Inhibitors, many forms of psychotherapy,
and self care practices (Timberland Knolls, 2016.)
For the purpose of this project we used Mindfulness Meditation as our chosen
intervention. This would fall under a self-care practice form of treatment. This is something that
an individual can do on their own with some guidance from music or a phone application or in a
group setting led by an instructor. “Meditation is a family of mental exercises that generally
involve sitting quietly and comfortably while focusing on some simple internal or external
stimulus, such as a word, one's breathing pattern, or a visual object. In relaxation, the individual
engages in a number of mental, and sometimes physical, activities. In meditation, the person is
physically still and has a much narrower focus of attention” (Anxieties.com, 2003).
We chose this intervention because there is evidence-based research showing that
meditation can help reduce levels of anxiety. Many substance abuse and mental health care
facilities incorporate meditation into their treatment plans. Using meditation as an intervention
for the subject’s anxiety might allow her to feel more centered and calm while helping her to
3. develop new ways to manage her anxious feelings that are not as distressing mentally,
physically, or emotionally.
Background Information and Purpose of Project:
The purpose of this project was to reduce the levels of anxiety that the subject
experiences. We used a single study case design to focus on the self-change project for a member
of our group who experiences many symptoms of Generalized Anxiety Disorder. The subject is a
25 year-old caucasian female. She started having anxiety when she was twelve years old and has
been using therapy and medication intermittently from the age of twelve through college. The
subject has many stressors in her busy life which often lead to the anxious feelings we hoped to
reduce through our meditation intervention. She has a full-time graduate level course load, a
time-consuming internship, and obligations to her family and as a wife. This year the subject is
experiencing an added stressor which is the pressure of upcoming graduation and deciding what
she will do after graduation. The subject has support from her close friends, husband, and family
but is interested in finding a new way to manage her anxiety on her own using mindfulness. We
explored several self-care activities that we could use for the intervention for this project such as
yoga, exercise, and healthy dieting. We decided on Mindfulness Meditation because it was
feasible to do with the subject’s busy schedule. Mindfulness Meditation is an intervention being
used in treatment facilities around the world. It is something that all team members were aware
of but we were interested in finding out if using an online meditation video would be effective in
reducing the anxiety levels of a team member.
Description of Methods:
There are several types of single-case designs. For our project, we chose to use the AB
design where “A” represents a baseline time-period and “B” represents an intervention time
4. period. Our case took place over the course of the month of October. For the first two weeks in
October, October 2 - 15, we took consistent baseline measures of anxiety without implementing
any intervention. For the last two weeks in October, October 16 - 29, we implemented a
Mindfulness Meditation intervention and continued to take anxiety measures. This allowed us a
brief period of time after the intervention phase to analyze the data and review the results of our
case. The team chose to use three types of anxiety measures to collect data in both the baseline
and intervention periods. The first is a Distress Thermometer (see Appendix A). It is a
subjective, self-report measure that was used daily to report the level of anxiety reached for that
particular day. The second measure was the DASS 21 (see Appendix A). This is a 21-item,
evidence-based scale that measures levels of depression, anxiety, and stress. It was self-
administered at the end of each week of both baseline and intervention phases. The third measure
used was the GAD-7, a 7-item evidence based scale that measures anxiety only (see Appendix
A). It was self-administered once at the end of the baseline phase and once at the end of the
intervention phase. All measurements were taken by the subject in the late-afternoon or evening
time of the day. The intervention that the team selected for this case was Mindfulness
Meditation. During the intervention phase, the subject viewed a Jon-Kabat Zinn-style guided
Mindfulness Meditation video (Panagotacos, 2012). The intervention was implemented three
times a week on Mondays, Wednesdays, and Fridays; therefore, the subject experienced the
intervention a total of six times throughout the intervention phase of the study. The video was
fifteen minutes long and viewed by the subject in the mornings before she began her day.
Project Timeline and Measurements:
Baseline Phase (A): Week 1: Oct 2 - 8 Week 2: Oct 9 - 15
5. Intervention Phase (B) Week 3: Oct 16 - 22 Week 4: Oct 23 - 29
Measurements Used: Daily: Distress Thermometer Weekly: DASS 21 Every-Other Week: GAD-7
Rationale for Methods:
The research team selected the AB single-case design due to constraints on the time-
frame and budget of our project. AB is the most basic single-case design; findings from the study
can be clearly communicated and easily replicated (Royse, Thyer, & Padgett, 2016). In order to
maintain a healthy balance between our school, field, and home lives, we decided to perform our
study over the month of October. In looking at this four week time-period, we opted to take
baseline measures for two weeks and intervention measures for two weeks. According to our
textbook, 5-10 data points are generally need to establish a trend (Royse, Thyer, & Padgett,
2016). Spending two weeks collecting baseline data allowed us to get 14 daily measures, 2
weekly measures, and 1 two-week measure; therefore, we could establish a definite baseline
trend by using daily measures. The intervention period mirrored the baseline phase in time and
measures. Making both phases equal in all respects ensured that they are easily comparable,
having the same amount of data points over the same amount of time (Royse, Thyer, & Padgett,
2016).
The team selected three measurement tools based on the idea triangulation, or that adding
more measurements increases validity (Royse, Thyer, & Padgett, 2016). In addition, all measures
were given at different intervals throughout the phases, allowing different perspectives. All
measurements were self-administered and self-reported by the subject. This is for a number of
reasons. Firstly, all measurements that the team selected were designed to be taken directly by
clients. Secondly, the construct of anxiety is subjective and dependent on the person who is
6. experiencing it (Kaplowitz, 2012). This means that how one experiences anxiety differs from
how another may experience it; therefore, it can be difficult for an evaluator to assess a subject’s
anxiety level from basic observation (Kaplowitz, 2012). Anxiety can be externally assessed by
looking at one’s biological functions such as heart rate and muscle tension (Pluess, Conrad, &
Wilhelm, 2009). In order to determine these things, however, medical equipment and technology
are necessities (Pluess, Conrad, & Wilhelm, 2009). Our team had neither the budget for nor
access to such equipment. Thirdly, these self-administered measurements are relatively simple
and quick to administer and score; this type of measurement fit well within our time-frame.
The Distress Thermometer was created by the National Comprehensive Cancer Network
(2016). We chose to use it as our daily measure because it is simple, easy to read, and provides
an accurate data point for the level of distress one is feeling on a given day. We chose the DASS
21 for our weekly measure because it assesses not only anxiety but also stress and depression
(Gomez, 2016). It is not meant to be a diagnostic tool but is used for assessing severity and
monitoring changes in these three constructs. It is also meant to be used in conjunction with
other evaluations and scales (Gomez, 2016). It was useful for our study because it isolated
feelings of anxiety from general stress or depressive feelings allowing our group to focus solely
on the assessment of anxiety. It has been found to have a high degree of validity (Henry &
Crawford, 2005). The GAD - 7 is an assessment tool that measures anxiety only. It covers
symptoms from the previous two weeks, making it perfect for our end-of-baseline and end-of-
intervention time periods. It also has been shown to be a valid measurement tool (Spitzer, et al.,
2006).
The intervention, a Jon-Kabat Zinn-style guided Mindfulness Meditation video, is fifteen
minutes long and was accessed for free on YouTube.com (see Appendix B). In addition to this
7. intervention fitting within the budget constraints of our study, it is also friendly to those who
have never tried meditation before. People may shy away from trying meditation because they
are daunted by the amount of time it takes or by being unsure of the steps to take during
meditation (Dienstmann, 2015). In this video, Dr. Panagotacos gently guides through different
phases of mindfulness meditation, and fifteen minutes is a very manageable time (2012). The
intervention was implemented in the morning before the subject left her house for work or
school. The intervention was administered three days a week, all during weekdays, so as not to
become overwhelming to the subject but to still become a regular part of her schedule.
Results of Project:
1. Distress Thermometer (DT)
The line graph for the Distress Thermometer (DT) contains daily ratings from October
2nd to October 29th. There is somewhat visual significance to the data when analyzing the
graph. Before the subject began implementing the intervention on October 17th, the anxiety level
8. of the subject is sporadic with different levels of high and moderate anxiety. However, anxiety
levels during the intervention were more steady and averaged to about a level 3.
2. DASS-21
The line graph for DASS-21 shows a steady decrease in levels for depression (Score-D),
anxiety (Score-A), and stress (Score-S). The level for depression is significantly lower than
anxiety and stress throughout the four weeks. The levels for anxiety and stress with the
intervention are significantly lower than the levels before the intervention.
3. GAD-7
GAD-7 Data
Date Time
Practitioner or
Self-Administered Score Interpretation
9. October 15 3:40 PM Self-Administered 11/21 Moderate Anxiety
October 29 1:40 PM Self-Administered 8/21 Mild Anxiety
The data for GAD-7 shows that the level of anxiety decreased from October 15th to
October 29th by three points. The subject’s level went from Moderate Anxiety to Mild Anxiety.
Interpretation of Results:
According to the DT, the subject’s anxiety level without the intervention fluctuates
between high levels and moderate levels. With the high levels of anxiety within the first two
weeks, it appears that the subject experiences extreme changes in anxiety regularly. Once the
subject begins the intervention, the level of anxiety begins to steady at a mild/moderate level and
is at a level four or lower. From these results, it can be interpreted that the subject has responded
well to the intervention. It is evident by the levels of anxiety that begin to steady and lower.
The results of DASS-21 and GAD-7 also support the data of DT which show that
Mindfulness Meditation helps decrease the subject’s anxiety levels. According to DASS-21, both
of the subject’s anxiety and stress levels decreased significantly with the intervention, and the
anxiety level, according to GAD-7, lowered from “Moderate Anxiety” to “Mild Anxiety.” With
the results from DASS-21 and GAD-7, it helps validate the effectiveness of the intervention to
decrease anxiety.
From this evaluation, Mindful Meditation helped decrease the subject’s anxiety and stress
level within the four week period. The single-case study is a good preliminary for a more
vigorous research where a bigger sample and extended length of study would be recommended
in order to generalize the results to an actual population.
Limitations:
10. With a single-case study, there are a few limitations to be mindful of when interpreting
results. First of all, the time-frame of the evaluation is an important factor to consider. Data for
DASS-21 and GAD-7 were taken less frequently than DT throughout the four week period. With
the time limitation, the effectiveness of the intervention cannot be directly correlated with the
improvement of the subject’s anxiety level. However, with three measurement tools, the
connection between the intervention and anxiety level is more solidified.
Second, the implementation of the Mindfulness Meditation intervention and measurement
tools should be analyzed to prove the validity of the evaluation. Both intervention and
measurements were both administered and collected by the subject. The quality of the
intervention is dependent on the level of the subject’s compliance. With the testing and retesting
of DASS-21, the subject became familiar with the questions and may not have answered the
questions objectively.
Third, the the data for DT was attempted to be consistently taken at the end of each day;
however, there were days when data was recorded the day after. After a night of sleep, whether
good or bad, and just passage of time can have an impact or change the subject’s anxiety level.
With this being said, an inconsistency of data collection can skew the soundness of the subject’s
rating.
Lastly, there is a possibility of regression toward the mean that threatens the internal
validity of the evaluation. The subject is a graduate student of social work who has several
projects, midterms, quizzes, and papers. On top of classwork, subject is also has an internship
that she works at for two to three days per week. Depending on subject’s workload, the pressures
of the demands of school and work can affect her anxiety level throughout the day and the
11. anxiety level at the moment she is rating or answering questions from DT, DASS-21, and GAD-
7.
Summary of Project as Conclusion:
The purpose of our single-case design self-change project was to help the subject reduce
her levels of anxiety. We decided to use an online guided Mindfulness Meditation video as our
intervention. We used three different measurements to determine the subjects level of anxiety.
The measures used were the Distress Thermometer, DASS 21, and the GAD-7. We took
measurements for two weeks before implementing the intervention and then continued
measurements for the two weeks that the subject was implementing the Mindfulness Meditation
intervention into her life. The subject utilized the Distress Thermometer every day throughout
the baseline and intervention period. She did the GAD-7 twice, and the DASS 21 four times
throughout. We used an AB design design where “A” represented the 2 week baseline time-
period and “B” represented the two week intervention time period. The results of our study
showed that on all three measurements, the subject’s level of anxiety decreased with the
implementation of the meditation intervention. Her anxiety was moderate to high before the
intervention and after intervention she showed significantly lower levels of anxiety. This leads us
to believe that the intervention of meditation was successful in reducing the anxiety in the
subject.
Although the client’s levels of anxiety were reduced during the time she was doing the
meditation intervention, it is not possible to say that her reduced anxiety can be fully credited to
the intervention. There are other possibilities for the reduction such as times that papers and
projects were due at school, different stressors at home, and different tasks at her internship
could have all contributed to the change in her levels of anxiety.
12. Resources:
ADAA. (2016, August.) Facts & statistics. Anxiety and Depression Association of America.
Retrieved November 1, 2016 from https://www.adaa.org/about-adaa/press-room/facts-statistics
Anxieties.com. (2003). Meditation. Pathway Systems: Anxieties.com. Retreived November 1,
2016 from http://www.anxieties.com/133/gad-step2c#.V-P6jjvhr9o
Dienstmann, G. (25 May, 2015). 10 reasons why people don’t meditate. Positive Psychology
Program. Retrieved October 29, 2016 from https://positivepsychologyprogram.com/10-reasons-
why-people-dont-meditate/
Gomez, F. (2016). A guide to the Depression, Anxiety, and Stress Scale. Retreived on October
29, 2016 from
https://www.cesphn.org.au/images/mental_health/Frequently_Used/Outcome_Tools/Dass21.pdf
Henry, J., & Crawford, J. (2005). The short-form version of the Depression Anxiety Stress Scales
(DASS 21): Construct validity and normative data in a large non-clinical sample. The British
Journal of Clinical Psychology. Retrieved October 29, 2016 from
http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.712.5643&rep=rep1&type=pdf
Kaplowitz, S. (28 August, 2012). What anxiety can look like in the body. GoodTherapy.org.
Retrieved October 28, 2016 from http://www.goodtherapy.org/blog/what-anxiety-can-look-like-
in-the-body-0828124
Lovibond, S.H. & Lovibond, P.F. (1995). Manual for the Depression Anxiety Stress Scales.
(2nd. Ed.) Sydney: Psychology Foundation.
NCCN. (2016). NCCN distress thermometer and problem list for patients. National
Comprehensive Cancer Network. Retrived October 2, 2016 from
https://www.nccn.org/patients/resources/life_with_cancer/pdf/nccn_distress_thermometer.pdf
13. Panagotacos, V. (27 November, 2012). Mindfulness meditation - Quick 15 min stress relief
version. Youtube. Retrieved October 2, 2016 from
https://www.youtube.com/watch?v=8v45WSuAeYI
Pluess, M., Conrad, A., & Wilhelm, F. (28 March, 2008). Muscle tension in generalized anxiety
disorder: A critical review of the literature. Journal of Anxiety Disorders. Retrieved October 29,
2016 from
http://www.philosonic.com/michaelpluess_construction/Files/Pluess_2009_Muscle%20Tension
%20in%20Generalized%20Anxiety%20Disorder%20-
%20A%20Critical%20Review%20of%20the%20Literature.pdf
Royse, D., Thyer, B., & Padgett, D. (2016). Program evaluation: An introduction to an
evidence-based approach. Boston, MA: Cengage Learning.
Spitzer, R.L., Kroenke, K., Williams, J.B., & Lowe, B. (May 22, 2006). A brief measure for
assessing generalized anxiety disorder: The GAD-7. PubMed. Retrevied October 29, 2016 from
https://www.ncbi.nlm.nih.gov/pubmed/16717171
Timberline Knolls. (2016). Anxiety symptoms and effects. Timberline Knolls Residential
Treatment Facility. Retrieved October 31, 2016 from http://www.timberlineknolls.com/mood-
personality/anxiety/signs-effects/
14. Appendix A - Measurement Tools
Clinical Distress Thermometer-
NCCN. (2016). NCCN distress thermometer and problem list for patients. National Comprehensive Cancer
Network.
15. DASS 21-
Lovibond,S.H. & Lovibond,P.F. (1995). Manual for the Depression Anxiety Stress Scales. (2nd. Ed.) Sydney:
Psychology Foundation.
16. GAD 7 -
Spitzer, R.L., Kroenke, K., Williams, J.B., & Lowe, B. (May 22, 2006). A brief measure for assessing generalized
anxiety disorder: The GAD-7.
17. Appendix B - Intervention
Transcription of audio of Mindfulness Meditation Video
https://www.youtube.com/watch?v=8v45WSuAeYI
