Case Study Research in Counselling and Psychotherapy

John McLeod

• Publisher: SAGE Publications Ltd
• Year: 2010
• Print ISBN: 9781849208055, 9781849208048
• eBook ISBN: 9781446241622
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Case-based knowledge forms an essential element of the evidence base for counselling and psychotherapy practice. This book provides the reader with a unique introduction to the conceptual and practical tools required to conduct high quality case study research that is grounded in their own therapy practice or training. Drawing on real-life cases at the heart of counselling and psychotherapy practice, John McLeod makes complex debates and concepts engaging and accessible for the trainees and practitioners at all levels, and from all theoretical orientations. Key topics covered in the book include:

- the role of case studies in the development of theory, practice and policy in counselling and psychotherapy

- strategies for responding to moral and ethical issues in therapy case study research

- practical tools for collecting case data

- ?how-to-do-it? guides for carrying out different types of case study

- team-based case study research for practitioners and students

- questions, issues and challenges that may have been raised for readers through their study.

Concrete examples, points for reflection and discussion, and recommendations for further reading will enable readers to use the book as a basis for carrying out their own case investigation.

All trainees in counselling, psychotherapy and clinical psychology are required to complete case reports, and this is the only textbook to cover the topic in real depth. The book will also be valuable to people who intend to use existing case studies to inform their practice, and it will help experienced practitioners to generate publishable case reports.

1

The role of case studies in the development of theory and practice in counselling and psychotherapy

Counselling and psychotherapy emerged as discrete areas of professional activity in the late 19th and early 20th centuries (Cushman 1995; McLeod 2009). At the time when counselling and psychotherapy were becoming established, research in psychology was almost entirely focused on the laboratory study of processes of memory, attention and learning, and had not reached the stage of examining real-world applied problems. There were few methods available for evaluating the effectiveness of therapy, or exploring the processes that were associated with good or poor outcome therapy. The only option available to Sigmund Freud and other pioneers of psychotherapy who sought to analyse their practice, was to follow the example of the medical profession, and write up their work in the form of detailed clinical case studies. Since that period, case studies have remained a central strand of the knowledge base for counselling and psychotherapy. Case reports have had a significant impact on the field of counselling and psychotherapy in a variety of ways, and an appreciation of the different styles and purposes of case study report is necessary in order to be able to make sense of current debates around this methodological approach. The chapter offers an overview of the various forms of case study knowledge in counselling and psychotherapy that have been developed over the past century.

The use of case study methods in developing a knowledge base for counselling and psychotherapy

Case study methods have been used in counselling and psychotherapy to generate many different kinds of knowledge. Case study reports have contributed to research, theory-building, training, organizational and political change, marketing and public awareness. It is not possible to be a counsellor or psychotherapist, or to be a lay person who is interested in therapy, and not to have been influenced by case study evidence in some way.

Documenting, evaluating and disseminating new approaches to therapy

When an innovative approach to therapy is first developed, it is necessary to be able to provide evidence of how it operates, and how effective it is, in order to persuade colleagues of its potential. At this stage in the development of an approach, it is likely that there are few practitioners actually using the new methods. It is therefore hard to carry out an extensive study, involving many cases. In recent times, it would also be difficult to secure ethical approval to conduct a large-scale study of an unproven method. In these circumstances, the only way to generate convincing evidence of the possible value of a new approach is to publish case study reports. The history of counselling and psychotherapy encompasses many examples of case reports that were highly influential during the formative phase of new treatment approaches. The early development of psychoanalysis, by Sigmund Freud and his colleagues, depended on presentation and discussion of case studies at conferences and seminars, and their eventual publication (Freud 1901, 1909, 1910). The establishment of behaviour therapy as a credible approach was built on a series of case studies by Joseph Wolpe (1958). Likewise the sex therapy of Masters and Johnson (1970) and the use of eye movement desensitization and reprocessing (EMDR) (McCann 1992; Shapiro 1989) also depended on the publication of plausible and persuasive case reports. Typically, the publication of case reports leads to further research, with larger samples, and to the provision of training programmes for practitioners who are convinced by the case evidence and want to learn how to use the new methods.

Contributing to public understanding of counselling and psychotherapy

Counselling and psychotherapy are forms of help that require active commitment on the part of users, who need to attend regular sessions, explore painful areas of personal experience, and put therapeutic learning into practice in everyday life situations. They are also forms of help whose legitimacy cannot be taken for granted within society – there are many critics who deny the basic validity and worth of therapy (Furedi 2004). It has always been essential therefore, to find ways to let members of the general public know about how therapy works. There have been several memorable case studies that have had a significant impact on how the general public makes sense of therapy. In the 1960s, the spirit of client-centred therapy was captured effectively in the best-selling case study Dibs, written by Virginia Axline (1971), who had been a colleague and student of Carl Rogers. In the 1990s, many people became convinced about the value of therapy by reading the case studies in Love’s Executioner, by Irvin Yalom (1989). More recently, the drama and impact of psychotherapy have been disseminated to a wider public through the series of case study books edited by Jeffrey Kottler and Jon Carlson (2002, 2003, 2006, 2008, 2009) and the TV series In Treatment.

The development of theory

Theories of therapy necessarily involve complex sets of propositions that seek to reflect the way different factors interact and unfold over time. One of the most effective ways in which to develop and test theoretical ideas is through analysis of individual cases; it is at the level of the case that the operation of different factors can best be observed. By contrast, research that attempts to analyse what is happening at the level of a single session, or an event within a session, is in danger of either failing to take into account important contextual factors, or of not being able to access sufficient instances of the phenomenon being examined. There are many examples within the counselling and psychotherapy literature of the use of case studies as a means of advancing theoretical understanding. The historical development of psychoanalysis and psychodynamic psychotherapy has been built around discussion of the theoretical implications of detailed case presentations. Within the client-centred/person-centred tradition, Carl Rogers published transcripts of some of his cases, which have served as the basis for further investigation into the process of client-centred/person-centred therapy (Farber et al. 1996). One of the major areas of theoretical debate within the past 30 years has been around the relative contribution to therapy outcome of non-specific or ‘common factors’ (e.g., instillation of hope), as against specific therapeutic techniques (e.g., the use of systematic desensitization). Hill (1989) carried out an analysis of eight cases of brief psychotherapy, focusing on this theoretical question. A recent trend within the use of case analysis as a means of developing theory, has been the practice of comparing good outcome and poor outcome cases, as a strategy for identifying theoretical factors that are associated with effective practice. This approach was used by Watson, Goldman and Greenberg (2007) in the development of a model of the effectiveness of emotion focused therapy (EFT). The work of Bill Stiles and his colleagues, into the assimilation model of therapeutic change, provides a further example of how a new theoretical perspective can be articulated through case analyses (Stiles 2002).

Drawing attention to critical issues and areas of practice

A notable area of application of case study methodology in counselling and psychotherapy has been its use in highlighting issues that have been previously neglected within the professional and research literature. When a practitioner becomes aware of a topic that he or she feels deserves to be taken more seriously by colleagues, one option is to write and publish a ‘personal opinion’ article. However, a more convincing alternative strategy is to write and publish a detailed case example. There are several areas within the therapy field where case studies have been used both to convince sceptical colleagues to give more serious consideration to a particular issue, and to function as a rallying point for like-minded colleagues. Sex in the Therapy Hour: A Case of Professional Incest is a detailed case study of an episode of sexual exploitation of a client (Bates and Brodsky 1989), which had a significant impact on changing the climate of opinion around the serious nature of client–therapist sexual contact. Shouldn’t I Be Feeling Better by Now? Client Views of Therapy, edited by Yvonne Bates (2006), includes several compelling case descriptions of emotional and financial manipulation of clients by their therapists. There have also been collections of case studies by practitioners who wish to draw attention to, and foster debate around, practice issues such as the use of integrative approaches to therapy (Stricker and Gold 2006), the role of spirituality in therapy (Richards and Bergin 1997), counselling people with disabilities (Blotzer and Ruth 1995), combining psychotherapy with drug treatment (Beitman 1991) and therapy with older people (Knight 1992).

Box 1.1

Exploring the counselling and psychotherapy case study evidence base: where to start?

For counselling and psychotherapy practitioners and students who wish to become more research-informed, it is fairly easy to know where to start. Excellent general overviews of current research findings are available in Cooper (2008), Lambert (2004), Timulak (2008) and Tryon (2002), and in the series of research reviews published by the British Association for Counselling and Psychotherapy. More specific searches can be conducted through PsycInfo and other on-line bibliographic search tools. It is harder to access case-based knowledge about counselling and psychotherapy, which is often ignored in systematic reviews. One of the aims of the present book is to draw attention to high-quality ‘exemplar’ therapy case studies. Miller (2004) includes an appendix that lists a large number of therapy case studies. There are two journals that specialize in therapy case study reports: Clinical Case Studies and Pragmatic Case Studies in Psychotherapy. The latter is an on-line journal, and therefore readily accessible. In addition, the Counselling and Psychotherapy Research journal and Psychotherapy Research have published several case studies, and the American Psychological Association (APA) has published edited collections of therapy case studies on a range of topics.

Extending and enhancing the interpretability of large-scale outcome studies

In relation to evaluating the effectiveness of different therapies, it is widely recognized that large-scale randomized controlled studies have a unique value, in being able to demonstrate clear links between specific causal factors (e.g., the type of therapy being provided) and outcomes. However, the meaning of the results obtained from large-scale studies may sometimes be difficult to interpret, because they consist of generalisations over a large number of cases. It can therefore be useful, when conducting a large-scale study, to build in the possibility of carrying out subsequent in-depth single case analyses in order to explore the meaning of any contradictory findings that may emerge. A good example of this use of case study methods has been within the Vanderbilt I study, carried out by Strupp and Hadley (1979), in which the effects of psychotherapy on socially isolated young men were evaluated. In a series of cases studies that were carried out following primary analyses of the outcome data, Strupp (1980 a, b, c, d) compared the process of therapy that occurred in pairs of good outcome and poor outcome cases that were seen by the same therapists. A further example of this use of case study methods can be found within the Sheffield outcome study of the effectiveness of time-limited psychotherapy for people with work-related depression (Shapiro and Firth 1987; Shapiro and Firth-Cozens 1990). The publication of case studies from this project (Firth-Cozens 1992; Parry et al. 1986) made it possible to illustrate and explore in detail the way that therapy was helpful for this client group. An advantage of these ‘research-based’ case studies is that a great deal of information is available on the case. Also, it is possible to determine how typical the case is, in relation to other cases included in the main study. In contrast to the Vanderbilt and Sheffield research programmes, there are many large-scale studies that have yielded results that remain hard to interpret, in the absence of accompanying case analysis. One of the reasons for the enduring influence of these particular programmes of research is that they have provided a combination of group and case analysis which, taken together, offer an opportunity for readers to arrive at a comprehensive, critical understanding of the results that were obtained.

The use of case studies in training

Possibly the most widespread use of case studies has been as a method of illustrating and communicating knowledge and understanding of an approach to therapy to those who are interested in learning how to practise it (Kutash and Wolf 1986; Wedding and Corsini 1979). This use of case study evidence can vary a great deal in its level of complexity and detail; some authors make use of brief case vignettes, while others offer lengthy extracts of case material. A further way in which case studies are used in counselling and psychotherapy training is in the assessment of competence of trainees. In most training courses students are required to submit a case study of their work with a client, as a means of demonstrating their capacity to provide an effective therapeutic relationship, deal with professional and ethical issues arising in the course of the therapy, implement appropriate therapeutic interventions and engage in critical reflection on practice. Case studies are unique, as assessment tools, in enabling examination of the extent to which the student has been able to integrate component elements of competency into a coherent whole.

Box 1.2

Developing competence in case formulation: the practical application of case study skills

Within most approaches to counselling and psychotherapy, it is usual for the therapist to arrive at a case formulation following a period of assessment, or within the first few sessions of therapy (Eells 2007a; Johnstone and Dallos 2006). This formulation typically consists of an analysis of the nature and severity of the client’s problems, the factors that have caused these problems and which currently maintain them, the strengths or limitations of the client and his/her life situation in relation to addressing the problems and the possible therapeutic interventions or strategies that might be of value in helping the client to overcome his or her life difficulties. The formulation may be arrived at through informal personal reflection on the part of the therapist, or may be produced in a more formal manner (e.g., following a standard protocol). The formulation may or may not be explored with the client, and may or may not form the basis for a therapy contract. Although there exist different styles of case formulation, associated with different therapy traditions, there is a growing consensus that accurate and valid formulation plays an important role in therapy. T...

Table of contents

• Cover Page
• Praise for the book
• Title Page
• Copyright
• Dedication
• Contents
• Foreword
• Preface
• Acknowledgements
• 1. The role of case studies in the development of theory and practice in counselling and psychotherapy
• 2. The development of systematic methods and principles for collecting and analysing case material
• 3. The development of systematic methods and principles for collecting and analysing case material
• 4. Moral and ethical issues in therapy case study research
• 5. Collecting and analysing case material: a practitioner and student toolkit
• 6.Documenting everyday therapeutic practice: pragmatic case studies
• 7. Evaluating the effectiveness of therapy: n⁼1 time–series case studies
• 8. Using multiple judges in evaluating the effectiveness of therapy: the hermeneutic single case efficacy design (HSCED)
• 9. Theory-building case studies
• 10 Exploring the meaning of the therapy experience: narrative case research
• 11 Team-based case study research for practitioners and students
• References
• Index