International Counseling

Case Studies Handbook

Roy Moodley, Marguerite Lengyell, Rosa Wu, Uwe P. Gielen

• Publisher: American Counseling Association
• Year: 2015
• Print ISBN: 9781556203350
• eBook ISBN: 9781119098270
• Edition: 1
• Topic: Psychology
• Subtopic: Social Psychology
• Index: Psychology

In this book, designed to increase mental health professionals' global literacy, authors from 33 countries demonstrate multicultural skills and competencies through case studies that illustrate approaches to counseling and psychotherapy in their countries. Following an introductory section on the use of case studies, chapters focus on a cross section of countries in Africa; Australia and Asia; Central, North, and South America; Europe; and the Middle East. Each case describes the client and his or her presenting concerns and includes a culture-sensitive assessment and treatment plan, an analysis and critical reflection of the case, and questions for discussion. The final chapter of the text presents a comparative analysis of the cases.

*Requests for digital versions from ACA can be found on www.wiley.com. *To purchase print copies, please visit the ACA website.

*Reproduction requests for material from books published by ACA should be directed to [email protected]

Part One
Working With Case Studies

Chapter 1
How to Critically Use Globally Discerned Case Studies in Local Contexts

Eunjung Lee

After an initial consultation with a client, some experienced clinicians not only capture a comprehensive picture of the client in context, propose explanatory working hypotheses of the client’s presenting issues, and develop customized treatment plans but they also suggest a prognosis of the case. How can they tell the differences among cases after the intake in terms of prognosis? They often note that, “I learned from experience.” What does that mean? From years of experience meeting different clients as well as reading and listening to other clinicians’ case studies, they develop bit by bit their own inner data files for each unique client in a particular context, which become more elaborate over time, are tested for or against other similar or dissimilar cases, and are validated with successful or unsuccessful outcomes. With time, practice, and intentional professional attention, they develop a frame of reference or organizing principles that identify significant themes in each client’s struggles, what works in similar cases, and how to monitor indicators for desirable changes. This inductive process of clinically based knowledge building is the case study. Documenting this “disciplined inquiry” of practice (Peterson, 1991, cited in Fishman, 2005, p. 1), selecting appropriate interventions from “case-based reasoning” (Fishman, 2005, p. 11), and transferring the cumulated clinical knowledge to similar cases is the case study based practice and training in counseling and psychotherapy. This cumulative clinical knowledge within a clinician is transferrable not only to his or her other cases but also to fellow clinicians’ cases through case conferences, workshops, and/or publications. Therefore, the case study is beyond a clinician’s hunches or personal clinical wisdom. In reality, it is an inductive, cumulative, and systemic inquiry of human existence and sufferings—a scientific, empirical approach (Lee, Mishna, & Brennenstuhl, 2010). The active pursuit of this wealth of clinical knowledge truly is an accountable practice for a service provider and a necessary quality, especially when serving clients with diverse cultural backgrounds in a global world.

Lee et al. (2010) proposed ways to critically evaluate the case study in clinical practice and proposed case study evaluation criteria. By incorporating these criteria as well as other findings from cross-cultural clinical practice research (Lee, 2010; Lee & Bhuyan, 2013; Lee & Horvath, 2013, 2014), I delineate in this chapter ways to use and maximize a case study approach that is situated in a global context for clinicians in their own local community.

Intensive Investigation of a Case Embedded in Real-Life Context

A main purpose of case study is the intensive investigation of the client system/case under study in naturalistic (not controlled) real contexts, while examining multiple variables using multiple sources of evidence with the aim of providing in-depth rich information (Lee et al., 2010). Providing a thick description of the client in context considering ‘‘contextual inclusiveness’’ (Bergen & While, 2000, p. 932) or ‘‘the proximity to reality’’ (Flyvbjerg, 2006, p. 236) then assists mental health practitioners to “conceptually decide to what extent the case as described” (Fishman, 2005, p. 17) can be applicable to their own cases. Although not exhaustive, the following list is a compilation of areas to consider in developing a rich case study description: the case selection, collection points of clinical information, source of clinical information, intervention procedures and ingredients, interpretation of clinical information, and clients’ feedback.

Why is this case selected? The clinicians choose a particular case because it is “typical, extreme/deviant, critical, or pragmatic” (Lee et al., 2010, p. 685) among other cases in their caseloads. This purposeful sampling is referred to as ‘‘information-oriented sampling’’ (Flyvbjerg, 2006, p. 230) to describe the process of maximizing the use of information from the chosen case or ‘‘theoretical sampling’’ (compared with “statistical sampling“) to “choose cases that are likely to replicate or extend the emergent theory or to fill theoretical categories“ (Meyer, 2001, p. 332). Therefore, the selection of the case itself is informative to mental health practitioners and assists them to reflect on the clinicians’ purposeful attention to the case and its underlying cultural and theoretical orientations.

How frequently and over how long a period of time is clinical information collected? One of the great benefits of conducting a case study is an in-depth understanding of the case under study. Accordingly, not only the end product of therapy but also a whole therapy process can be zoomed in and out to monitor the progress and impasses in the clinical processes and, if necessary, to revise the course of the selected intervention. In the description of the case, it is thus important to see whether the clinicians delineate and elaborate the clinical information over time to highlight the clinical processes. The multiple points of clinical data collection then would assist counselors and psychotherapists to make a decision as to whether the interventions caused changes in the case rather than the alternative explanations, such as the changes stemmed from the client’s maturation or else the problem itself faded away (Kazdin, 1981).

What is the source of clinical information? It is crucial to indicate sources of clinical information that lead to a clinician’s clinical working hypothesis and treatment selection. For example, instead of relying solely on a clinician’s observation or a client’s verbal indication, for example, “I am depressed,” multiple sources of clinical evidence can be collected from multiple subjects (e.g., the client and his or her significant others, the clinician), multiple perspectives (e.g., the client‘s in-session report vs. homework report, a clinician‘s observation of the client in individual vs. group sessions), and multiple places (e.g., school, home, therapy sessions). It does not have to be clinicians who contact the multiple subjects and visit multiple places. Rather, clinicians could ask questions pertaining to multiple sources of clinical information, such as the following: “How do you think your partner/children/friends perceive and react to you when you feel depressed?“ (multiple subjects); “You look very down and have little energy today. I notice this month you have often looked this way” (a clinician’s observation); “Am I getting it right? Do you sometimes feel this way at your school/work?” (multiple places); and “Do you feel the same way that this month is getting harder for you?“ (multiple perspectives). In a case study, clinicians may describe these multiple sources of information. If the collected multiple sources of clinical information capture converging changes after the selected intervention, counselors and psychotherapists can have stronger evidence that the changes occurred because of the intervention than if only one source of clinical information is described (Lee et al., 2010).

What are intervention procedures and ingredients? Providing detailed description of the intervention is extremely useful in that it helps mental health practitioners “decide whether the intervention context or content is transferable to their own practice” (Lee et al., 2010, p. 687). Even if some results are less positive, “detailed description can provide information that can lead to altering the intervention” (Lee et al., 2010, p. 687). Gilgun (1994) articulated that clinicians who attempt to replicate interventions described in the case study

often become frustrated and may doubt their own competence when the particular interventions fail when applied to their practice. If the interventions had been “more thoroughly described, practitioners might have been able to decipher the differences between their interventions and those interventions in research reports and subsequently understand why their interventions and evaluations might not replicate published reports.” (p. 374; cited in Lee et al., 2010, p. 687)

Mental health practitioners may ask the following questions to see whether the case study captures detailed description of the selected intervention: Is the target of the intervention/phenomenon of interest similar to my client’s?; How often does the intervention occur? (dosage); What constitutes the intervention? (not the brand name of the selected intervention but ingredients and contents of the intervention); Is this intervention applicable to our setting? (context); and Can I use this intervention for my client? (clinician’s qualifications and training; Lee et al., 2010). The detailed description of the intervention may help counselors and psychotherapists to imagine their selection and use of the intervention for their own cases. This process may increase potential for their preparedness and attunement to the chosen intervention, which would increase their performance competence in delivering the intervention to the clients and possibly bring more positive outcomes.

What is the clinician’s interpretation of clinical information? It is important to make clinicians’ working hypotheses, or interpretations of the collected clinical information, as transparent as possible by illustrating a clear “chain of evidence” between the raw clinical case information and the clinicians’ interpretations (Lee et al., 2010, p. 687). It is similar to differences between data collection and data analysis when conducting research. Comprehensive clinical information of the client in context using various subjects, perspectives, and places over time is like data collection that attempts a strong power and rigor in data. Clarifying the clinicians’ understanding of, working hypotheses of, and critical analysis of the collected clinical information is like the data analysis process and the results section in the documentation of research findings. Clear documentation of the clinicians’ interpretation would help counselors and psychotherapists consider alternative points that they have not thought about from the clinical information described. Or it may help mental health practitioners to reinterpret the raw clinical information and/or develop their own ideas and new perspectives, thus building a clinical knowledge base.

What is the client‘s feedback? Case study researchers argue that subjective data are subject to bias yet provide “the opportunity to develop in-depth and holistic descriptions of the participant’s experience and behaviors, an essential feature of case study research“ (Yin, 1994, p. 686). Therefore, “guidelines specific to evaluating the usefulness of case studies should include whether they convey the subjective experience of subjects” (Gilgun, 1994, p. 376). Case study is an in-depth study about clinicians as much as it is about clients under study. While reflecting clinicians’ cultural values and theoretical orientations, case studies also clarify clinicians’ interpretations of clinical information; clinicians say outwardly who they are in terms of personal and professional identities in many aspects of case study. Therefore, a central reference point as to whether the clinical information is comprehensively and exhaustively collected, whether the intervention is appropriately selected, and whether the clinician’s interpretation is accurately capturing the client’s experiences is the client. Every aspect of case study thus should incorporate the client’s feedback. A case study should report how the client feedback was pursued and reflected in the course of therapy and evaluation of the case study outcome.

Guiding questions that mental health practitioners could ask include the following:

• Do the clinicians clearly document their working hypothesis/critical analysis/interpretations of clinical information?
• Do the clinicians collect and elaborate the clinical information over time to highlight the clinical processes?
• Do the clinicians describe the multiple sources of information (e.g., multiple subjects, multiple perspectives, and multiple places)?
• Do the clinicians note their rationale of choosing the particular case? What does this choice mean in terms of...

Table of contents

• Cover
• Title Page
• Copyright
• Preface
• About the Editors and Contributors
• Acknowledgments
• Part One: Working With Case Studies
• Part Two: Counseling and Psychotherapy in Africa
• Part Three: Counseling and Psychotherapy in Australia and Asia
• Part Four: Counseling and Psychotherapy in Central, North, and South America
• Part Five: Counseling and Psychotherapy in Europe
• Part Six: Counseling and Psychotherapy in the Middle East
• Conclusion
• Index
• Technical Support
• End User License Agreement