Case Study in Psychotherapy Research Paper

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‘Case study’ typically refers to the investigation of the onset and course of a disorder on the basis of personal reports. Frequently used synonyms are case study methodology, case study research, case report, and case description. The acronym ‘N 1’ also pertains to case studies. Case study terminology is applied in an array of very different methodological approaches, ranging from nonstructured explorations to experimental testing of single-case hypotheses.

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Description, documentation, and evaluation of a particular therapy are elements of ‘controlled practice’ (Petermann and Muller 2001), which in turn is based on patient-centered assessments made throughout the duration of therapy and on a well-organized documentation system. This approach allows for continuing control and optimization of the treatment process.

1. Example Of A Case Study Within ‘Controlled Practice’

At the outset of therapy the psychotherapist questions the patient in such areas as biography, current life situation, known problems, former experiences with psychotherapy, and the demand for therapy. The therapist documents answers by recording audiotapes and taking notes. A structured clinical interview for the purpose of classifying the disorder forms the foundation of the diagnosis. The client’s current problems and therapeutic aims are organized in what is called a functional analysis. The therapist devises a written plan for the therapy detailing, for example, time frame and partial goals. The patient and therapist then sign a contract outlining rules and guidelines to remain in effect throughout the therapy. Prior to the actual onset of therapy, psychotherapist and patient negotiate the benchmarks and indicators for a successful outcome, for instance, how frequently undesirable behaviors may occur on a daily basis. Throughout the course of therapy the patient is asked regularly to fill in a brief questionnaire on major outcome variables. Direct observation by the therapist accompanies the written information. Finally, all collected documents, including the final interview, are summarized, discussed, and reviewed in cooperation with the patient. The psychotherapist’s appraisal of the intervention and its outcome is based on comparisons of several case studies, thus allowing for continuous improvement in clinical decision making.




2. Single-Case: Different Methodological Approaches

Yin (1994) distinguishes between descriptive, exploratory, and explanatory case studies. Typically, in case studies questions concerning the ‘why’ and ‘how’ dominate over questions that address the ‘what,’ ‘who,’ and ‘where.’

2.1 Descriptive Case Studies

Descriptive case studies contain descriptions of individual cases but dispense with interpretation. Indications for psychotherapy, the course of therapy, and its outcomes are summarized in descriptive case studies in a verbal format—case reports—which have important documentation and communication functions for therapists. The lucidity of descriptive case studies, in contrast to abstract theory, makes them particularly useful in psychotherapy education. A variant of the descriptive case study yields a detailed description of the therapeutic process. Documentation of crucial outcome parameters is a necessary condition for process monitoring and has practical implications for optimization of therapy. If documentation is kept in the foreground of therapy reporting, treatment integrity can be better controlled. ‘Treatment integrity’ refers to the degree to which actual therapeutic work is concordant with the therapeutic method chosen (e.g., psychoanalysis, behavioral therapy). The more precisely the method of treatment can be defined, for example as a manual, the more exactly the degree of concordance can be assessed.

2.2 Explanatory Case Studies

Explanatory case studies attempt to explain observable therapy-induced changes in behavior. Critical life events in the patient’s biography and experimentally varied factors may serve as explanations. In general, planned (prospective) case studies must be distinguished from unplanned (mostly retrospective) case studies. Planned case studies require a clear design, standardized and replicable data collection, and statistical methods of analysis. These studies are timeconsuming and labor-intensive and consequently are not used very often. This type of process research addresses the decisive procedural mechanisms in effect during psychotherapy. Experimental designs are strictly controlled types of prospective analysis allowing for comparisons between suggested causes in a systematic manner.

2.3 Exploratory Case Studies

Exploratory case studies are used to receive one’s first impression and to generate hypotheses. Data are collected in interviews or from biographical material. Hypotheses are derived from data of the individual by developing a model of the causal and sustaining factors pertinent to a particular individual’s behavior (‘functional behavior analysis,’ see Behavior Analysis, Applied ). Functional analyzes may be classified as exploratory or explanatory case studies. They contain descriptions of the patient’s problem(s) and statements concerning factors that trigger and maintain problem behavior(s).

3. History Of The Single-Case Methodology

In the early days of modern psychology, when Edward Bradford Titchener, William James, and Wilhelm Wundt rose to prominence, single-case analysis was a well-respected research strategy. Not uncommonly the researchers chose themselves as the subjects for investigation. Introspection and single-case experiments largely dominated psychological research in those pioneering times. The German philosopher Karl Jaspers introduced a special form of case study, called Biografik (biographic), which focused primarily on the course of individuals’ lives. With the introduction of what were considered more objective data sources and analytical methods, introspection and single-case experiments—and, as a consequence, the single-case approach—were sidelined and eventually replaced. The reasons were many (Danzinger 1990). Psychology as a new field of research had to gain ground and hold out against well-established traditional disciplines such as medicine, physics, and biology. The decision to adopt an experimental methodology was made in the hope of enhancing the reputation of psychological research. The questionnaire as an economic data collection tool was also making inroads into psychology. This methodology, adopted from the social sciences, allowed for the collection and analysis of large, standardized samples. Experiments could now be carried out involving substantial numbers of people.

The case study underwent a renaissance in the 1960s and 1970s. Awareness had arisen in psychotherapy research that certain questions could no longer be answered properly using group-based studies. Zubin (1950) had blamed the dire situation in clinical research on the lack of appropriate statistical tools for single cases, and called for the individual to be viewed as a distinctive universe. Kiesler (1966) complained about the absence of adequate research strategies in clinical psychology. He also challenged certain myths, including the ‘patient uniformity assumption’ (i.e., at the outset of therapy patients tend to be similar rather than different from one another) and the ‘therapy uniformity assumption’ (i.e., therapists treat individuals uniformly rather than variably).

New methods for the collection and analysis of data were developed in the 1960s. Goal-attainment scaling (Kiresuk and Sherman 1968), for example, opened up the possibility of collecting data that reflected individually defined outcomes. Innovations in statistics (e.g., Markoff chains and ARIMA models) now allowed for the analysis of data sampled from repeated measurements. Once again the case study was on its way to reclaim its reputation as a scientifically sound and respected methodology.

4. Single-Case And Psychotherapy Research

Eysenck’s (1952) provocative conclusion linking positive outcomes in the treatment of neurosis to spontaneous remissions sparked fervent clinical research seeking to prove the effectiveness of different treatments. The ‘Dodo Verdict’ (so called from the Dodo in Alice in Wonderland ), according to which all therapies are equally successful, concluded the first phase of psychotherapy research. This view came under scrutiny during the second phase, when more differentiated analyzes were employed and differences in the indications for psychotherapy could be found for certain disorders. At the end of the second phase, knowledge of the actual mechanisms at work during different psychological therapies was still poor, a fact that eventually led to the third phase of clinical research, known as microanalysis. In microanalysis the interaction between therapist and patient became the primary focus. In an analogy to the use of a microscope, crucial moments during the therapy sessions were scanned with ‘high methodological resolution’ in order to uncover the crucial therapeutic mechanisms at work.

Gradually clinical practice research moved from a primary focus on outcomes to the model of process research. With each increase in the ‘microscopic’ resolution of details, single-case methodology gained in significance. Yet despite the fact that the theoretical rationale behind single-case study methodology was widely accepted in the 1980s, its impact on clinical practice remained limited. Not surprisingly, experts concluded: ‘At present, clinical research has little or no influence on clinical practice’ (Barlow 1981, p. 147).

5. Criticism Of Single-Case Methodology

Single-case methodology has always drawn criticism from different quarters. Some investigators felt that the presentation of qualitative case studies was too arbitrary; others have remained skeptical of the methodology in its entirety. Several problem areas with regard to case study research must be addressed:

(a) objectivity in the collection of data,

(b) degree of rigor in attempts to prove cause and effect, and

(c) interpretation and generalizability of outcomes.

Case studies in clinical research usually deal with personal experiences (e.g., quality of life, well-being), which can be evaluated solely by means of self-reports. However, assessment of self-reported experience is problematic since any subjective report automatically compromises an assessment’s validity. On the other hand, standardized measures are of limited use when tapping into a patient’s subjective appraisals. This problem of control in clinical practice remains unresolved.

The validity of causality statements depends primarily on the degree to which contextual factors in data collection remain constant. Causal relationships are determined by testing hypotheses while excluding factors that may serve as alternative explanations. It is a classical problem of empirical research, however, that alternative influences can never be ruled out entirely in data analysis. While controlling for several potentially confounding variables increases internal validity on the one hand, it limits the generalizability of findings on the other. This problem is reflected in research terminology: the term ‘proof ’ is avoided, while ‘evidence’ or ‘tendency’ are preferred, thus allowing for case-specific statements about a treatment’s effectiveness while avoiding statements of more general applicability.

Given these factors, the following prerequisites must be met in order to appraise the quality of a case study:

(a) Only validated or previously tested assessment tools should be employed,

(b) The decision to use prospective vs. retrospective data collection must be explained, and

(c) It must be decided to what extent contextual factors need to be controlled.

The accuracy of statements will increase with the precision and replicability of the data analysis as well as with the amount of detail provided on factors that may compromise findings.

6. Integrating Case Study And Evidence-Based Clinical Practice

Legal and economic considerations increasingly require therapists to provide documentation of their interventions. Scientific evaluation is increasingly less limited to demonstrating the efficacy of certain therapeutic strategies and now must also show the effectiveness of the process of clinical practice as a whole. The optimization of therapy serves both economic and humanitarian goals, as it is of utilitarian value for both patients and society in its entirety. In future the case study approach will form an integral part of what is known as ‘evidence-based practice.’ Particular difficulties include the problem of objectivity with regard to data collection and analysis, pressure on therapists to organize their interventions, and the integration of results with daily clinical practice. These demands on clinical practice control can only be met if data are analyzed in an exact and economical fashion. Recent software innovations may accelerate this trend.

References:

  1. Barlow D H 1981 On the relation of clinical research to clinical practice. Current issues, new directions. Journal of Consulting and Clinical Psychology 43: 147–55
  2. Danzinger K 1990 Constructing the Subject. Historical Origins of Psychological Research. Cambridge University Press, New York
  3. Eysenck H J 1952 The effects of psychotherapy: An evaluation. Journal of Consulting Psychology 16: 319–24
  4. Kiesler D J 1966 Some myths of psychotherapy research and the search for a paradigm. Psychological Bulletin 65: 110–36
  5. Kiresuk T J, Sherman R E 1968 Goal attainment scaling. A general method for evaluating comprehensive community mental health programs. Community Mental Health Journal 4: 443–53
  6. Petermann F, Muller J M 2001 Clinical Psychology and Single Case Evidence. A Practical Approach to Treatment Planning and Evaluation. Wiley, Chichester, UK
  7. Yin R K 1994 Case Study Research. Design and Methods. Sage Publications, Thousand Oaks, California
  8. Zubin J 1950 Symposium on statistics for the clinician. Journal of Clinical Psychology 6: 1–6
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