Eulàlia Arias-Pujol
Marina Mestres2
Natalia Bachs
M. Teresa Anguera- 1Faculty of Psychology, Education and Sports Sciences Blanquerna, Ramon Llull University, Barcelona, Spain
- 2Carrilet Research and Education Center, Barcelona, Spain
- 3Faculty of Psychology, Institute of Neurosciences, University of Barcelona, Barcelona, Spain
There has been a comprehensive development over the last few years of low intensity intervention programs that are implemented within a user context and that are made up of everyday life activities, and it has been necessary to adapt the necessary methodological channels in order to guarantee an adequate resolution pathway. The mixed method perspective offers a suitable framework, and observational methodology – in itself considered mixed method – is appropriate for studying the implementation and evaluation of low intensity intervention programs, allowing the development of the QUAL-QUAN-QUAL stages that correspond to the connect integration pathway of mixed methods. In this work it was applied to a single case, in a low intensity intervention, retrieving valuable information obtained, but systematizing it and applying quantitizing to the qualitative data that was treated quantitatively in a rigorous manner. The aim was to analyze the psychotherapist-patient interaction in psychoanalytic psychotherapy, in which we sought to identify which of the therapist’s techniques stimulated actions of reciprocal social interaction in the child, and which techniques inhibited non reciprocal social interactions. The observational design was nomothetic, follow-up, and multidimensional. The patient was a 4-year-old boy with a diagnosis of severe autism spectrum disorder. We used an ad hoc observation instrument combining a field format and a category system. Interobserver agreement was analyzed quantitatively by Cohen’s kappa using the free QSEQ5 software program. Polar coordinate analysis was carried out using the free program HOISAN 2.0. Polar coordinate analysis allows us to obtain an inter-relational map of the connections detected between focal behavior established in each case and the different categories. The results provide objective evidence – backed up by the application of polar-coordinate-based data analysis – that within a framework of psychoanalytic psychotherapy, the techniques of “verbalization” and “vocalization” significantly activate reciprocal social interaction behaviors and inhibit non-social reciprocal behaviors in a child with severe autism spectrum disorder with no language. On the other hand, direct gaze promotes the child’s withdrawal. The results are of key importance as they show the therapist behaviors most useful for promoting social interaction in a child with severe autism.
Introduction
It is an undoubtedly complex task to make decisions about the implementation and evaluation of intervention programs which, in any case, should be conditional on the applied methodology. The structural dimensions of the evaluation of a program are established in scientific literature (Chacón et al., 2000; Chacón-Moscoso et al., 2002, 2013, 2014, 2021), and the existing correspondence between these dimensions and methodological quality in the chosen procedural option is extensively relevant.
The broad definition of the aim of intervention program evaluation leads to judgments concerning the value of such programs or of some of their elements (Anguera and Chacón-Moscoso, 2008; Chacón-Moscoso et al., 2013). It has been observed that the intensity of such intervention can be extremely varied depending on the situation, taking into account that it will have considerable bearing on the procedure to be followed. It is precisely for this reason that minimum basic and common aspects have been specified that must be stated in the evaluation report of any program, regardless of its approach (Chacón-Moscoso et al., 2013), and shape a formative and summative evaluation in continual interaction, throughout its phases.
In the last few years, it has been established that the greatest shortcomings in the implementation of intervention programs are procedural, and that some of these have barely been addressed. This is mainly due to the complex nature of the reality, with many superimposed levels, and the fact that individuals or collectives who experience the actions of an intervention program may be heterogeneous. Furthermore, the dynamic of the processes is not uniform, making it difficult to collate data in a way that fulfills the requirements demanded by rigor.
In this sense, we are aware of the need to pay special attention to the implementation and evaluation of bespoke intervention programs for each specific case, aiming for an increased effectiveness in the actions carried out, without disturbing the daily life of the user, as an essential leitmotif. This special attention implies that the intervention itself blends into daily life, searching for an alternative to traditional conventionality. In this study, we focus on a low level of intervention intensity, an expression coined by Anguera (2008, p. 154), in the face of an “incessant increment in cases in which intervention programs are implemented without the imposition of instructions, and in contexts that are natural and/or habitual for the users of the program, taking advantage of activities that are spontaneous and/or everyday for them.” There have been numerous studies over the last few decades that have dealt with the handling of an intervention in the habitual context of a user, with the different programs having very diverse aims (Weil, 1985; Bryant and Bickman, 1996; Lapresa et al., 2020), and with beneficial effects in terms of the ‘normalization’ of the user’s life (Dvoskin and Steadman, 1994; Roustan et al., 2013; Alcover et al., 2019), studying the interaction in the therapeutic conversation (Arias-Pujol and Anguera, 2017, 2020a,2020b; Del Giacco et al., 2020).
In this study we present a low intensity level program – a psychoanalytic psychotherapy intervention for a child with severe autism. It is carried out in a natural context and stems from the child’s predominantly sensory spontaneous behavior, disconnected from social interaction. The therapeutic technique seeks to help children establish connections between their sensory experiences, their emotions, language and thought, following the approach developed by the prestigious Coromines (Coromines, 1991; Viloca, 2011; Farrés et al., 2020). It is a dyadic program based on the verbal and non-verbal communication between the child and the therapist. An adequate evaluation requires the flexibility and scientific rigor of systematic observation from the mixed method perspective.
In Chacón-Moscoso et al. (2021) an adaptation was carried out of the structural dimensions of low intensity level designs when observational methodology is applied (Anguera, 2003). This is characterized as a scientific method that allows for the study of spontaneous behavior in habitual contexts. Its defining elements are the following: (1) delimiting the aim from a prior needs analysis; (2) building the program depending on the theoretical framework and the intervention context; (3) guaranteeing its usability and sufficiency; (4) proposing a suitable design; (5) implementing the actions of the program in such a way as to obtain a diachronic record throughout the recommended monitoring; (6) building a non-standard instrument adapted to the object of study; (7) systemizing the information; (8) controlling data quality; and (9) assessing the program with adequate analysis techniques. It should be highlighted that in the last two decades the mixed method perspective has been developed exponentially, generating an important cross-fertilization process in terms of procedure.
We would like to point out one final aspect to be developed, relating to the fact that we are dealing with a case study. Here we attempt to transform something that has acquired negative connotations in the literature of the last few years into a worthwhile opportunity that makes a rigorous, intensive study of human behavior possible.
Contributions of the mixed method perspective in the evaluation of low intensity programs
The mixed method perspective has had a significant impact all over the world throughout the last few years, awakening an exponential interest and generating an extremely high volume of scientific production. As is widely known, a harsh dialectic was produced over decades between those in favor of qualitative and quantitative approaches. Almost a quarter of a century ago, Newman and Benz (1998), set out to explore the interactive qualitative-quantitative continuum in research. They considered false and without foundation the dichotomy that many other authors have tried to show, by presenting both options as opposing paradigms and refusing to accept that both qualitative and quantitative strategies are always found in any study. Their approach, focusing on the feedback between qualitative and quantitative analysis, can be considered as an accurate forerunner to the current, complex state of the issue (Anguera, 2022), that forces us to be vigilant whilst moving forward.
Observational studies were initially qualitative, proof of which lies in the main works published in the 1970s and 1980s (Weick, 1968; Hutt and Hutt, 1974; Mucchielli, 1974; Anguera, 1979; Martin and Bateson, 1991), whose aim was to capture the reality in a descriptive way just as it was produced – but which our approach challenges – which led to the belief that qualitative methodology fit with the first half of the process, whilst quantitative methodology should be used in the second half of the process (Sánchez-Algarra and Anguera, 2013). Furthermore, in the last few years things have gone a step further, with the consideration that observational methodology was in itself mixed method (Anguera and Hernández-Mendo, 2016; Anguera et al., 2017) – also in indirect observation (Anguera et al., 2018b) –, and proposing a form of quantitizing as an integration path (Anguera et al., 2020).
The specification of quantitizing in observation methodology is founded on Creswell and Plano Clark’s, 2011 contribution (3rd ed., 2011), that we especially value:
There are three ways in which mixing occurs: merging or converging the two datasets by actually bringing them together, connecting the two datasets by having one build on the other, or embedding one dataset within the other so that one type of data provides a supportive role for the other dataset. (p. 7) (the underlining is ours).
This mixing, in the CONNECT option, taken both literally and from a wider perspective (Anguera, 2022), is a strong basis for carrying out a reconsideration of quantitizing that fits very well within observational methodology.
Indeed, in literal terms, “connecting the two datasets by having one build on the other,” would imply that one dataset can give rise to another via its transformation. Such a transformation must guarantee the maintenance of its informative quality, whilst modifying the appearance. From a wider perspective, connecting allows the alternation of the QUAL-QUAN-QUAL stages; this legitimizes the generic mixed method approach, such that a total integration of qualitative and quantitative elements is achieved (Anguera et al., 2020).
The materialization of quantitizing takes place between the first QUAL stage and the QUAN stage (Anguera et al., 2020; Izquierdo and Anguera, 2021), and is accomplished from two fundamental decisions (Anguera, 2017, 2022): (1) establishment of the design dimensions (or response levels, or criteria) (Weick, 1968), that can be deployed in sub-dimensions on different levels; and (2) proposing segmentation criteria of the observed behavior episodes (or textual material, in indirect observation) in observation units (Anguera, 2020, 2021). The two decisions (dimensions and observation units) were developed later, both in direct observation (Anguera, 2017) and indirect observation (Anguera, 2021).
Once these decisions have been taken and the ad hoc observation instrument built, the record is created, made up of qualitative data, and will preferably be structured in the form of a code matrix, with columns containing the dimensions (or, where appropriate, the sub-dimensions of the most molecularized level); with each row of the matrix containing the codes corresponding to the co-occurrence of the different dimensions in each unit of behavior. This matrix is essential for the process of quantitizing the qualitative data.
Once the data matrix has been obtained, its quality must be controlled via one of the concordance/agreement indexes (Blanco-Villaseñor and Anguera, 2000); and once this is done then the quantitative analysis of the systematized qualitative data is possible (and, among others, the analysis of polar coordinates), thus allowing a complete integration between qualitative and quantitative elements.
Taking this reconsideration into account, the innovative form of quantitizing in the implementation and evaluation of low intensity programs implies important methodological benefits (Anguera, 2022). The mixed method greatly vitalizes the collation, management and analysis of information obtained via observation, which previously played a trivial, superficial and incoherent role. An important strengthening of range is achieved from observational methodology (both direct, as in this study, and also indirect), due to it being considered in itself mixed method; hence, in the Introduction we refer to the process of cross-fertilization.
We strongly defend this approach (Anguera, 2022), that has been progressively structured over the last two decades, without evading the attraction of the mixed methods being developed (Sánchez-Algarra and Anguera, 2013; Portell et al., 2015; Chacón-Moscoso et al., 2019; Anguera et al., 2020; Izquierdo and Anguera, 2021); these differing from multi-method studies (Anguera et al., 2018a), constituting an already consolidated culture of research (Anguera et al., in press).
The case study in the evaluation of low intensity programs
The case study has traditionally been considered marginal and with little convening power; in addition to renowned authors such as Gerring (2004, p. 341) stating that “the case study survives in a curious methodological limbo.”
It is generically accepted as a study that is intensive, detailed, in-depth, centered on one “case,” and focusing on “the particular”; and undoubtedly influenced by the context in which it is located and the theoretical framework that covers it (Anguera, 2018). The case study implies an “intensive study of a single unit for the purpose of understanding a larger class of (similar) units … observed at a single point in time or over some delimited period of time” (Gerring, 2004, p. 342), provided that it is carried out with guarantees of suitability (Kuyken et al., 2005; Flinn et al., 2015).
For Stake (1994), the case study does not represent a methodological option, but an object of study option. However, Campbell, in his Foreword to Yin (2014), and the thematic development itself of this author, do openly consider it a research method. There have been many dissonant voices in different publications (Anguera, 2018), and there is no consensus concerning its methodological range, although there is a majority who do not consider it a methodology. Tight (2010, p. 329) asks the following question: “Case study is widely referred to and applied within social research, but its status remains unclear. Is it a method, a methodology, a strategy, a design, an approach, or what?”.
In our view (Anguera, 2018), it is not a methodology, but it is possible to apply diverse methodologies to a single case. Aside from existing typologies (Stake, 1994; Thomas, 2011; Yin, 2014), the logic of the single case is intra-case by nature (Hilliard, 1993) and permits the consideration of a diachronic perspective, whilst at the same time emphasizing the richness of the context in the real world in which the phenomenon is produced.
There is obviously an inherent weakness in the case study, relating to the non-replication of results, which is totally logical according to its own aim. Its focus of attention is found precisely in the opposing situation, focused on the results of one single case which is studied in depth, and is shown in this study. In our view, the strength of a methodology that is appropriate and adapted to the characteristics of the case study and the profile of the case itself compensates for this weakness.
The methodological criticism that the case study has received focuses essentially on the problem of a lack of representativeness; although the case is an individuality with an initial presumption of singularity, which is studied intensively. As Sandelowski states (Sandelowski, 1996, p. 527), “the analyst works to discern what elements comprise the case and, more importantly, the way they come together uniquely to characterize the case,” which suggests that researchers should establish the profile of the case (Anguera, 2018).
The profile of the case we present below corresponds to that of a child with severe autism. The therapist provokes interaction by initiating communicative turns of protoconversation, verbalizing sensations and emotions that the child feels or could feel, and also dramatizing them (Trevarthen and Aitken, 2001; Viloca, 2003; Alcàcer and Viloca, 2014). Unlike other studies in which we narrate the intervention and clinical improvement of the patient (Arias-Pujol et al., 2015a,b), on this occasion we are interested in focusing on the technique used by the therapist. The suitable methodology is systematic observation, this being equipped with design that supports an intensive approach in the study of perceptible behaviors; carrying out continuous recordings throughout the observation sessions, and being able to manage behaviors arising from different dimensions/sub-dimensions, some specific to the therapist’s role and others to the child’s actions. In other words, we transform into a methodological opportunity that which has traditionally been the biggest weakness in case studies.
For their part, Edwards et al. (2004) state that they do not wish to differentiate between qualitative and quantitative approaches in the case study. As Stake (1994, 1995) indicates, the case study can be qualitative (Hilliard, 1993), or quantitative (Kent, 2009), or a combination of both (mixed methods are currently conceived within a continuum between the qualitative and quantitative poles); although he leans more toward a clear qualitative predominance (Stake, 2005). Our proposal, in line with the above, involves taking advantage of the appearance of a third way, that of the aforementioned mixed methods, which places us in a privileged position of integrating qualitative and quantitative elements.
Aim
To analyze, from the mixed methods perspective, a case study consisting of low intensity psychotherapeutic intervention focused on a child with a diagnosis of severe autism who interacts with the psychotherapist; and in which we aim to identify which actions on the part of the therapist stimulate social interaction from the child.
Design
Observational methodology was applied. The observational design is Nomothetic/Follow-up/Multidimensional (N/F/M) (Anguera et al., 2001; Sánchez-Algarra and Anguera, 2013): nomothetic because we studied the interaction between therapist and autistic child, with inter-session follow-up (three sessions) and intra-session follow-up (because each session was recorded continuously from start to finish); and multidimensional since the complexity of the aim required the application of various dimensions that were included in the observation instrument.
Participants
There were two participants:
The patient was a 4-year-old child with a diagnosis of autism spectrum disorder (ASD), according to the clinical criteria of DSM-5 (American Psychiatric Association, 2015), of a severe type according to the results obtained from the ADOS (Autism Diagnostic Observation Schedule; Lord et al., 2000). The child had no language, although did emit sounds and some syllables forming echolalia.
The therapist was a clinical psychologist with training and experience in psychoanalytic psychotherapy with children.
In accordance with the principles of the Declaration of Helsinki and the Ethical Code of the General Council of the Official College of Psychologists of Spain, the child and the child’s family were informed that they were being filmed. They were shown the location of the video cameras, which were positioned discretely to minimize reactivity bias. Written informed consent was also obtained from the parents of the minor.
Program intervention plan
The psychotherapeutic intervention was designed for a child with severe ASD. It consisted of 20 weekly sessions of 45 min in length, and was focused on stimulating reciprocal social interaction in the child, arising from the relationship. We adapted the psychoanalytic technique described by Coromines that promotes a process of differentiation and of interest in the “Other” via a shared emotional experience between therapist and patient (Viloca, 2003; Farrés et al., 2020). The sessions took place in Carrilet Treatment Center (Barcelona, Spain), attached to the educational and therapeutic center.
Instruments
Recording instrument
All the sessions were filmed using a video camera installed in the therapy office of the Carrilet Treatment Center attached to the Educational and Therapeutic Center where the child was schooled.
Observation instrument
We used an ad hoc observation instrument, as a field format modality combined with category systems, adapted by Bachs and Arias-Pujol (Bachs, 2019) from a previous study (Arias-Pujol et al., 2015b) and recoded for this new study. The instrument has two dimensions for the child: reciprocal social interaction (RSI) and non-reciprocal social interaction (N_RSI) and 12 for the therapist (see Table 1).
Table 1. Observation instrument of ASD child and psychotherapist in psychoanalytic psychotherapy.
With the aim of studying the therapist-patient relationship, the sessions were broken down into units, with the adoption of a primary dialogic criterion, and a secondary criterion that differentiated verbal, vocalized and non-verbal behavior in the transcript (Anguera, 2020). Table 2 shows some fragments of the coded clinical material from sessions 9, 16, and 20.
Table 2. Fragments of the coded clinical material.
Procedure
Inter observer agreement
The inter observer agreement was calculated via Cohen’s kappa coefficient (κ) (Cohen, 1960). Data quality control was performed using the free program GSEQ. An agreement of 85.6% was obtained in the codification of the child’s behavior and of 90.4% in that of the therapist, values considered “almost perfect” according to the criteria of Landis and Koch (1977) and Bachs (2019).
Data analysis
Analysis of polar coordinate
The aim is to apply the analytical technique of polar coordinate analysis, seeking a possible relationship of activation/inhibition between the behaviors of the therapist and the child that will be quantitatively calculated from the qualitative recordings carried out initially at three different points of the intervention, plotting them via vectors.
Polar coordinate analysis allows us to obtain an inter-relational map of the connections detected between the different categories. It is a robust analytical technique developed by Sackett (1980) that is based on the sequentiality of the qualitative records obtained. The focal behavior – located in the center of each of the ‘maps’ that will be created – must be identified in each analysis, and is proposed depending on the desired aim and the conditioned behaviors; these being all those about which we want to know whether there is an associative relationship with the focal behavior. The associative relationships between the focal behavior and each one of the conditioned behaviors incorporate two perspectives: prospective (from the focal behavior forwards) and retrospective (from the focal behavior backwards). We should clarify that we are not referring to a classical retrospective perspective, but to the genuine retrospectivity proposed by Anguera (1997), which has since been consolidated. The calculation required to apply the prospective and retrospective perspectives generates a huge volume of partial results, and Sackett (1980) knew how to exploit the possibilities of the Zsum parameter proposed by Cochran (1954) as an important data reducer. The calculation of the prospective and retrospective Zsum values, in accordance with Sackett’s approach (Sackett, 1980), allows us to obtain the values that correspond to the length of the vector and its angle, which can be graphically represented. The vector angle (that will correspond to one of the quadrants I, II, III, and IV), allows us to interpret the nature of the relationship that exists between the focal behavior and the respective conditioned behavior, while from the length of the vector we can interpret the intensity of said relationship depending on statistic significance.
We have presented all these calculations systematized in our case study (see Table 3), in such a way that the conditioned behaviors appear for each focal behavior; and for each conditioned behavior information is presented, correspondent to the quadrant in which the vector is found: prospective and retrospective values of the Zsum, ratio, length of vector (that is crucial for knowing its significance, since if it is > 1.96 it is significant, and if it is > 2.58 it is very significant), significance, and vector angle.
Table 3. Table of parameters corresponding to the analysis of polar coordinates, with the focal behavior “Verbalizes,” “Vocalizes,” “Verbal imitation,” “Nonverbal imitation,” “Stimulates,” “FEXT,” and “GA” as the center of the analysis and all the others as conditional of sessions 9, 16, and 20.
Polar coordinate analysis was carried out using the free program HOISAN 2.0 (Hernández-Mendo et al., 2012), and additionally R (Rodríguez-Medina et al., 2022) in order to obtain a graphic optimization in the vector representation.
In this case study, the focal behaviors were selected from the therapist’s highest frequency categories or dimensions (see Table 1). The analysis was carried out with seven focal behaviors: “Verbalization,” “Vocalization,” “Stimulation” (combining all the categories of each dimension); “Verbal imitation,” “Non-verbal imitation,” “Facial expression” and “Gaze.” In terms of conditioned behaviors, the child’s 28 categories were included from the observation instrument, excluding the codes SAP (sentence approximation) and VD (verbal demand) due to low frequency.
For the analysis, the behaviors of the therapist and the child were recorded in the first 20 min of sessions 9, 16, and 20.
Descriptive study of clinically favorable behaviors
From the results obtained in the polar coordinate analysis, the conditioned behaviors (the child’s actions) were selected, that were significantly activated or inhibited prospectively. They were grouped by dimensions of reciprocal social interaction (RSI) or non-reciprocal social interaction (N_RSI).
The dimension “Reciprocal social interaction” consists of the categories: Instrumentalized Demand (I), Non-verbal demand (NVD), Vocal demand (VOCD), Active response (AF), No active response (NAF), Moves closer (APRO), Moves away (DPB), Brief Physical Contact (BPC), Maintained Physical Contact (MPC), Child Shows (SH), Child Draws (DRA), Word Approximation (WA), Word (WO), Gaze (EC), Vocal-verbal Imitation (VI), Non-verbal imitation (NVI), Facial Expression Rejection (FEXR), Facial Expression Joy (FEXJ). The dimension “Non-reciprocal social interaction” consists of the categories: Motor Stereotypes (MS), Vocal Stereotypes (VS), Visual Stereotypes (VIS), Erratic Behavior (EB), Auto Sensory (SA), Functional Intent (INT), Gaze (AGO), Blank Stare (BS), Solitary Play (SP), Normal Actions (NA). The following categories were excluded: NA, referring to normal actions in relation with the therapeutic framework without a sensory purpose, and INT, referring to actions with objects appropriate to the purpose for which they were created.
For each of the therapist’s focal behaviors the percentage of RSI and N_RSI behaviors that were activated and inhibited was calculated. The fact that one of the therapist’s focal behaviors activated RSI behaviors and inhibited N_RSI behaviors was considered clinically favorable. The chi-squared test was used to determine whether the clinically favorable behaviors activated by the therapist were statistically significant, (p < 0.05).
Results and discussion
In the sections below, we describe the relationships detected between interventions by the therapist and the child’s behaviors using polar coordinate analysis and a descriptive study of clinically favorable behaviors.
Analysis of polar coordinate
Significant results were obtained in activation/inhibition relationships between all the therapist’s and the child’s behaviors.
Table 3 show the level of significance of the focal behavior “Verbalizes,” “Vocalizes,” “Verbal imitation,” “Non-verbal imitation,” “Stimulates,” “FEXT,” “GA” as the main analysis of sessions 9, 16, and 20.
Figures 1–4 shows the significant vectors for all the focal behaviors in each of the therapist’s seven actions.
Figure 1. Graphic representation of the significant (purple) and very significant (red) vectors obtained in the polar coordinate analysis. Focal behavior “Verbalizes” as the center of the analysis and all the others as conditional of sessions 9, 16, and 20 (from left to right). Focal behavior “Vocalizes” as the center of the analysis and all the others as conditional of sessions 9, 16, and 20 (from left to right).
Figure 2. Graphic representation of the significant (purple) and very significant (red) vectors obtained in the polar coordinate analysis. Focal behavior “Verbal imitation” as the center of the analysis and all the others as conditional of sessions 9, 16, and 20 (from left to right). Focal behavior “Non-verbal imitation” as the center of the analysis and all the others as conditional of sessions 9, 16, and 20 (from left to right).
Figure 3. Graphic representation of the significant (purple) and very significant (red) vectors obtained in the polar coordinate analysis. Focal behavior “Stimulates” as the center of the analysis and all the others as conditional of sessions 9, 16, and 20 (from left to right). Focal behavior “Facial expression” as the center of the analysis and all the others as conditional of sessions 9, 16, and 20 (from left to right).
Figure 4. Graphic representation of the significant (purple) and very significant (red) vectors obtained in the polar coordinate analysis. Focal behavior “Gaze” as the center of the analysis and all the others as conditional of sessions 9, 16, and 20 (from left to right).
Descriptive study of clinically favorable behaviors
Table 4 shows the type and percentage of behaviors that prospectively activated or inhibited each of the therapist’s dimensions.
Table 4. Type and percentage of behaviors that prospectively activated or inhibited each of the therapist’s dimensions.
In the analysis of the child’s clinically favorable behaviors, the therapist’s verbalization was related with 78.9% of clinically favorable behaviors (χ2 = 6.53; df = 1; p = 0.01) and vocalization with 76.5% (χ2 = 5.87; df = 1; p = 0.02). Of the therapist’s imitation behaviors, verbal imitation was related with 53.3% (χ2 = 0; df = 1; p = 1) and non-verbal also with 53.3% (χ2 = 0.13; df = 1; p = 0.71). Similarly, stimulation with 54.5% (χ2 = 0.10; df = 1; p = 0.74) and facial expression with 71.4% (χ2 = 1.59; df = 1; p = 0.20), while gaze produced 38.1% of clinically unfavorable behaviors (χ2 = 0.5; df = 1; p = 0.47).
In this single case study, we have applied an approach that allows observational methodology and mixed methods as the main analysis (Anguera et al., 2017).
Systematic and meta-analysis reviews show that although child psychoanalytic psychotherapy evidence is increasing, high quality research is needed in order to better understand the effectiveness of such interventions (Midgley and Kennedy, 2011; Abbass et al., 2013; Midgley et al., 2017; Target, 2018). However, there are currently very few centers that systematically evaluate the results of psychoanalytic interventions (Arias-Pujol, 2020). Researchers and therapists, aware of the complexity of each person and the singularity of each psychopathological expression, continue to search for what works and for whom (Fonagy et al., 2016). Recent studies suggest a need to carry out process research in order to identify predictive interaction structures in child psychotherapy (Halfon et al., 2020). At present, different methods and methodologies can be applied, with mixed method methodology representing a new and potentially useful approach for evaluating low level psychoanalytic interventions (Arias-Pujol and Anguera, 2020b).
In the present study, by using a mixed method, we aimed to identify which of the therapist’s techniques elucidated clinically favorable behaviors in a child with severe autism, specifically those that promoted RSI actions and inhibited non-RSI actions. From all of them, verbalization and vocalization by the therapist produced significant clinically favorable behaviors, whereas direct gaze promoted the child’s withdrawal.
Specifically, “Verbalization” (formed by VDE, VOH, VAN, VREM, VSUP, INT) consists of describing a behavior or an object, offering help, anticipating actions happening in the near future, remembering aloud, encouraging or repeating what the child says in a similar way to promote certain dialogue. It is used to bring the child closer to the process of symbolization, following Coromines’ aforementioned psycho-pedagogic technique (Coromines, 1991; Viloca, 1998, 2003; Farrés et al., 2020).
Results show that verbalization activates different behaviors of the RSI dimension related to producing a vocal demand (VOCD), the response to a demand (AF, NAF), proxemic behavior (APRO), eye contact (EC), physical contact (BPC); and in joint attention and also protoconversation behaviors (WA, WO). On the other hand, it inhibits stereotypes (MS, VS, EM, EV, MSI), erratic behavior (EB) and solitary play.
On balance, verbalization is shown to produce significant clinically favorable behaviors in the child, suggesting that this technique is appropriate for activating resources of the child’s RSI dimension. It is of key relevance that verbalization prospectively activates the categories “word” (WO) and “word approximation” (WA), as the child in the study is non-verbal. Results suggest that verbalization promotes language and communication, which are also important in developing the symbolization process.
“Vocalization” is the technique used when the therapist seeks interaction by using exclamations, singing, laughing or encouraging the child to express himself/herself vocally. It has been suggested as especially useful for children with verbal communication difficulties. Results show that use of the “Vocalization” (consisting of EE, SI, L, PF) activates behaviors of vocal and non-vocal demand (I, VOCD); and response to the demand (AF), proxemic behaviors (APRO, DPB), eye contact (EC) and word approximation (WA). It also inhibits the attentive gaze at the object (AGO), the verbal stereotype (VS) and solitary play (SP). Therefore, according to our results, “Vocalization” is an appropriate technique for activating interaction.
Imitation involves mirroring the child’s actions. It has been described as a technique that allows the child to see “outside” in a specific way what should be mentally represented “inside” (Farrés et al., 2020). In this type of intervention, verbal and non-verbal imitation is not used as a way of modeling the child’s behavior but as a way of making contact with the child. Within the framework of mirror neurons theory, the results of a previous study by our group suggest that the systematic use of significant imitation in psychoanalytic psychotherapy with autistic children improves their RSI capacity (Arias-Pujol et al., 2015b).
The present results show that verbal imitation, consisting of VIT, activates the actions of instrumentalization (I), non-verbal demand (NVD), word approximation (WA) and lack of response to the demand (NAF), approximation (APRO) and brief physical contact (BPC). It also inhibits sensory action (SA) and solitary play (SP).
Non-verbal imitation, consisting of NVIT, activates actions of no response to the demand (NAF), drawing (DRA), eye contact (EC) and distancing behavior (DPB). There were some moments when the child appeared to enjoy a kind of dance with music with the therapist. For example, while the child was moving drawing or repeating sounds (ti-ti-ti-ti) he/she gazed with curiosity at how the therapist repeated it. Moreover, non-verbal imitation prospectively inhibited erratic behavior (EB), an attentive gaze at the object (AGO) and the action of solitary play (SP).
However, the behaviors were not statistically significant in the analysis of clinically favorable responses in the child. We believe that these results differ from those of the previous study because on that occasion the use of verbal and non-verbal imitation by the therapist was applied systematically and not depending on the child’s spontaneous behavior.
Stimulation (consisting of SDA, SSH, SDB, SPRO) is used when the child is disconnected from the relationship and the therapist tries to seek his/her attention by giving or showing an object, directing the child’s attention toward something or toward him/herself, or proposing an activity. Results show that “stimulation” activates instrumentalized and vocal demand (I, VOCD), response to the demand (AF, NAF), distancing proxemic behavior (DPB) and the child’s non-verbal imitation (NVI). It also inhibits the attentive gaze at the object (AGO), the blank stare (BS) and solitary play (SP). However, stimulation did not produce statistically significant clinically favorable behaviors. These results suggest that stimulating the child when he/she is very disconnected from the relationship can be more intrusive than verbalizations or vocalizations, and does not always promote reciprocal social interaction.
Dramatization of an emotion consisting of FEXT means making faces or moving the arms and torso, expressing oneself through the body (Viloca, 2003; Farrés, 2014). Results show that it activates behaviors of the RSI dimension. Specifically, in sessions 9 and 16 it activates the instrumentalized and vocal demand (I, VOCD), response to the demand (AF), approximation and distance proxemic behavior (APRO, DPB), the use of words (WO) and the child’s non-verbal imitation (NVI); and prospectively inhibits, in session 20, sensory action (SA) and the attentive gaze at the object (AGO). However, the results did not achieve significance as clinically favorable behaviors.
Finally, direct gaze (consisting of GA) refers to when the therapist is observing the child, allowing him/her to express himself/herself freely. Despite the child’s tendency to disconnect and avoid closeness and physical contact with the therapist, the GA activates the child’s behavior of word approximation (WA), facial expression (FAEX) and of moving close to or away from the therapist (APRO, DPB). Likewise, it inhibits the attentive gaze at the object (AGO), the blank stare (BS) and solitary play (SP). Overall, direct gaze promotes significant withdrawal behaviors, which are not clinically favorable. This result is in line with previous studies suggesting the extreme sensitivity shown by children with autism to small breaks in the therapeutic partnership (Goodman et al., 2017).
Conclusion
This study shows how observational methodology, and specifically the use of mixed methods, can be useful for the evaluation of a low intensity intervention program. The greatest advantage is that the mixed method perspective allows us to capture the reality just as it happens, systemize it, guarantee its quality and treat it quantitatively in a rigorous way.
From a clinical perspective, our results provide objective evidence – backed up by the application of polar-coordinate-based data analysis – that within a framework of psychoanalytic psychotherapy of a child with severe ASD and no language, the therapeutic techniques of “verbalization” and “vocalization” significantly activate reciprocal social interaction behaviors and inhibit non-social reciprocal behaviors. On the other hand, direct gaze promotes child withdrawal. The results are of key importance as they show the therapist behaviors most useful for promoting social interaction in a child with severe autism.
Data availability statement
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
Ethics statement
Written informed consent was obtained from the individual(s), and minor(s)’ legal guardian/next of kin, for the publication of any potentially identifiable images or data included in this article.
Author contributions
EA-P and MTA contributed to conception and design of the study. MTA conducted the method section and polar coordinate analysis. JM performed the descriptive analysis. EA-P, MM, and JM performed the interpretation of the data. NB adapted and validated the observational instrument. All authors contributed to manuscript revision, read, and approved the submitted version.
Funding
MTA gratefully acknowledges the support of a Spanish government subproject Integration ways between qualitative and quantitative data, multiple case development, and synthesis review as main axis for an innovative future in physical activity and sports research (PGC2018-098742-B-C31) (2019-2021) (Ministerio de Ciencia, Innovación y Universidades/AgenciaEstatal de Investigación/Fondo Europeo de Desarrollo Regional), that is part of the coordinated project New approach of research in physical activity and sport from mixed methods perspective (NARPAS_MM) (SPGC201800 × 098742CV0). In addition, MTA thanks for the support of the Generalitat de Catalunya Research Group, GRUP DE RECERCA I INNOVACIÓ EN DISSENYS (GRID). Tecnología i aplicació multimedia i digital als dissenys observacionals (Grant number: 2017 SGR 1405). Finally, we also acknowledge support from Ramon Llull University (PGRiD of FPCEE Blanquerna).
Acknowledgments
We thank our colleagues in Carrilet for their help and suggestions, especially Elena Fieschi, Cristina Castelló, Anna Soldevila, and Elisabet Sánchez-Caroz, for their commitment and generosity. We also thank the child and his/her family, without whom this study would not have been possible.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
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Keywords: mixed methods, case study, polar coordinate analysis, CONNECT, autism, psychoanalytic psychotherapy
Citation: Arias-Pujol E, Mestres M, Miralbell J, Bachs N and Anguera MT (2022) Implementation and evaluation in low intensity intervention programs from the CONNECT perspective of mixed methods: Application in a case of an autistic child. Front. Psychol. 13:998658. doi: 10.3389/fpsyg.2022.998658
Received: 20 July 2022; Accepted: 30 August 2022;
Published: 13 October 2022.
Edited by:
Fco. Pablo Holgado-Tello, National University of Distance Education (UNED), SpainReviewed by:
Miguel Pic, South Ural State University, RussiaJosé Ángel Martínez-Huertas, Universidad Nacional de Educación a Distancia, Spain
Copyright © 2022 Arias-Pujol, Mestres, Miralbell, Bachs and Anguera. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Eulàlia Arias-Pujol, eulaliaap@blanquerna.url.edu