A Single Case Experiment Design Investigating Wisdom Enhancement to Augment CBT Outcomes for Depression in Post-Stroke Populations
Phase: NA
Conditions: Post-stroke Depression
Sponsor: University of East Anglia

 
 
Evaluation of the Wisdom Enhancement Timeline Approach for Post-Stroke Depression Using a 
Single-Case Experimental Design 
Ercan Hassan¹ᵃ, Dr Fergus Gracey¹, Dr Joshua Blake¹ 
Date: 26/03/2024 
This study will aim to answer the question: Does enhancing wisdom through the timeline technique 
improve mood in post-stroke depressed individuals? Additionally, it will examine whether enhancing 
wisdom restores identity continuity and improves self-esteem. 
It is hypothesised that wisdom will improve first, followed by gains in identity clarity or self-esteem, 
as structured self-reflection fosters agency and self-worth. Finally, mood regulation is expected to 
improve last, aligning with findings that emotional stabilisation follows meaning-making and self-
affirmation rather than occurring simultaneously (Beaumont, 2009). 
Methods 
Design 
A single-case experimental multiple-baseline design (MBD) will be adopted. Following Christ’s (2007) 
recommendations, the study will pre-specify hypotheses, predetermine baseline durations, and 
randomise allocation via Random.org. Participants will be assigned to baseline durations of 2, 3, or 4 
weeks, with non-concurrent intervention introduction to enhance flexibility. The independent 
variable will be the intervention, and the dependent variables will be mood, wisdom, identity, and 
self-esteem, measured repeatedly. Blinding will not be implemented due to feasibility constraints. 
Although stability is generally recommended before intervention, Krasny-Pacini and Evans (2018) 
suggest that five baseline data points are sufficient to distinguish natural fluctuations from 
intervention effects. Replication will be built into the multiple-baseline design, with each participant 
serving as an independent test of the intervention’s effects. Initially, a one-month follow-up review 
will be planned; however, this may be omitted if time does not permit. 
Participants 
Three participants will be recruited, meeting SCED standards (Epstein et al., 2021; Kratochwill et al., 
2013) through local stroke services. Inclusion criteria will require adults with post-stroke depression 
(PSD) who can provide informed consent and engage in therapy. Exclusion criteria will include severe 
cognitive or mental health impairments, medical instability, substance dependency, concurrent 
psychological treatment, participation in clinical trials, or newly prescribed psychotropic medication 
that has not yet stabilised. Participants who start psychotropic medication during the trial will remain 
eligible, as SCED analysis can account for medication-related changes. 
NHS clinical teams will identify eligible participants, seeking permission for the researcher to contact 
them, while the author will conduct eligibility assessments and deliver the intervention. After the 
baseline phase, participants will attend six weekly sessions, either in person at a hospital or online 
via video conference. 
Measures 
Participants will receive a measure pack containing all measures, along with questions on medication 
use and adverse events. 
Idiographic Visual Analogue Scale 
The primary outcome will be assessed using a Visual Analogue Scale (VAS), a widely used measure 

 
 
for tracking subjective experiences in clinical research (McCormack et al., 1988). Participants will rate 
their agreement with four daily statements on vertically presented 10 cm scales, with higher scores 
indicating stronger agreement. VAS items will be aligned with the research questions and reviewed 
for relevance by individuals with lived stroke experience via the university’s Personal and Public 
Involvement (PPI) database. 
The four VAS items will be: 
1. Today, my mood is good (VAS_mood) 
2. Today, I feel able to accept the person I am/Today, I feel like I am adapting to life after my 
stroke (identity; VAS_ID) 
3. Today, I feel good about myself (self-esteem; VAS_SE) 
4. Today, I feel that I can use the wisdom of my life to help me deal with my current problems 
(VAS_wisdom) 
Standardised Measure 
The Patient Health Questionnaire (PHQ-9; Kroenke et al., 2001) will assess pre–post clinical mood 
changes. This nine-item tool (scoring 0–27) reliably detects clinically significant depression and is 
validated for PSD screening across diverse demographic groups with minimal somatic symptom 
confounding (Blake et al., 2025; Katzan et al., 2021). 
Intervention 
Laidlaw’s (2021) Wisdom Enhancement Timeline will be delivered in six structured, manualised 
sessions (Table 1), guiding participants through autobiographical reflection using a visual timeline of 
meaningful life events. To ensure accessibility and relevance, the manual will be reviewed for 
comprehensibility by individuals with lived stroke experience via the university’s PPI panel. 
Fidelity will be monitored through recorded sessions and assessed using the Revised Cognitive 
Therapy Scale (CTS-R; James et al., 2001), which evaluates therapeutic quality and adherence to the 
CBT framework. Ratings will be conducted by a Clinical Psychologist supervising the author, ensuring 
competence and consistency in intervention delivery. 
Table 1. Overview of the Intervention Sessions and Key Objectives 
Session Focus 
Key Activities 
1 
Information gathering, rapport-
building and goal setting 
Assess individual difficulties, set client-focused goals 
2 
Psychoeducation on stroke impact 
and introduction to the timeline 
Discuss changes in identity, mood and self-esteem; 
introduce the concept of wisdom and the timeline 
intervention 
3 
Reflected on timeline events 
Reflect on complex life events, promote resilience, 
meaning-making, self-compassion, and self-
acceptance 
4–5 
Active change methods 
Explore past coping strategies and identify 
significance in events of regret 

 
 
Session Focus 
Key Activities 
6 
Review and consolidation 
Reflect on learning, review new perspectives 
Ethical Statement 
The study will adhere to the Ethical Principles of Psychologists and Code of Conduct set by the BABCP 
and BPS. Ethical approval will be granted by the South Yorkshire Research Ethics Committee 
(24/YH/0055) and the UK Health Research Authority. The study will be registered on ClinicalTrials.gov 
(NCT06451965). 
Analysis 
Both single-case visual and statistical techniques will be used following best practices (Harrington & 
Velicer, 2015; Manolov & Moeyaert, 2017). Visual analysis will assess phase variability using a ±25% 
stability envelope (Lane & Gast, 2014). Higher percentages will indicate greater stability, and lower 
percentages will reflect greater variability. 
To assess whether VAS ratings during the intervention phase are higher than baseline, Tau-U (Parker 
et al., 2011) will be implemented. It will account for baseline trends, effect sizes, and phase non-
overlap. Resistant to autocorrelation, Tau-U provides strong statistical power in small datasets 
(Parker et al., 2014). Interpretations will follow Vannest and Ninci's (2015) guidelines, with baseline 
corrections applied as needed to prevent inflated effect sizes. 
Piecewise regression (Center et al., 1985) will complement Tau-U findings by quantifying change over 
time within each phase. Level and slope changes will be examined, estimating the breakpoint for 
outcome improvements. This approach will model level shifts and gradual trends while considering 
data variability and abrupt changes (Tate & Perdices, 2018). 
To address autocorrelation, lag-1 autocorrelation will be assessed, and if detected, Generalised Least 
Squares (GLS) regression with an AR(1) structure will be applied (Somer et al., 2022). 
Reliable change in PHQ-9 will be measured via the Reliable Change Index (RCI; Jacobson & Truax, 
1991), with Cronbach’s α = 0.79 (De Man-Van Ginkel et al., 2012) and a stroke sample SD of 5.1 
(Strong et al., 2021). Clinically Significant Change (CSC) will not be determined due to limited non-
clinical-normative data for stroke populations. Given concerns about the comparability of PHQ-9 
scores between stroke and non-stroke populations (Blake et al., 2025), data from other populations 
will not be considered. Instead, a cut-off of 10 will be applied to approximate clinically meaningful 
change, based on validated studies (De Man-Van Ginkel et al., 2012; Negeri et al., 2021; Williams et 
al., 2005).