Week 11 Flashcards
Role of case studies in the development of theory and
practice in counselling and psychotherapy
Documenting, evaluating and disseminating new
approaches to therapy
Contributing to public understanding of counselling and
psychotherapy
The development of theory
Drawing attention to critical issues and areas of practice
Extending and enhancing interpretability of large-scale
outcome studies
Use of case studies in training
The distinctive contribution of case-based knowledge
The case study as a form of narrative knowing
The case study as a means of representing complexity
Contextuality as an essential feature of case study research
Describing and analysing practical expertise in action
Limitations of standard case study reporting
It is impossible to recall everything that happened in a
therapy session; inevitable that important information
may have been lost
Writing a retrospective account of a session introduces
the possibility the writer has reconstructed events in line
with own pre-existing assumptions
There is absence of other perspectives
No way of checking whether the interpretation of the
material that has been collected is rigorous, systematic
and comprehensive
Systematic single case studies
Increasingly recognised as having important role of systematic single case studies in counselling and psychotherapy
In particular, the critical role that single case studies having in regard to process and outcome research - is it the same thing leading to good outcomes in all interventions?
Aims of case study research Focus on four sets of questions that may be addressed through analysis of case material:
Outcome questions
How effective has therapy been in this case?
•To what extent can changes observed in client be attributed to therapy
Theory-building questions
•How can process of therapy in this case be understood in theoretical terms?
•Can data base used to test/refine existing theoretical model?
Pragmatic questions
•What strategies/methods did therapist use in this case that contributed to outcome?
•How were therapeutic methods adapted and modified to address needs of specific client?
•What are principles of good practice that can be derived from this case?
Experiential or narrative questions
•What was it like to be the client or therapist in this case?
•What is the story of what happened, from the client or therapist point of view?
Why use systematic case studies?
Why use systematic case studies?
Traditionally, Randomised Controlled Trials (RCT’s) (i.e.
experiments), have been considered the ‘gold standard’
However, criticism of this narrow emphasis on conventional practices used to study efficacy and change in therapy
Particularly in regard to causality - we can learn why the intervention worked in a case study, not in an RCT
Rethinking causality
RCTs provide no method for truly understanding the specific nature of the causal relationship
Although RCTs provide valuable ‘causal’ knowledge at the
group level, RCTs are limited in their ability to capture
idiographic information
In order to fully understand intricacies of causality and the
change process in therapy, pluralistic methods and a shift in paradigm is needed
Systematic case design are suggested as one necessary
complement to RCTs
Rationale for case studies
Access the complexity inherent in the therapy process
Offers longitudinal sensitivity (how change unfold across time is captured by the multiple observations available)
Therapeutic process is embedded in a number of contextual factors -> case study methods enables the influence of context to be more readily investigated
Encompass narrative knowledge (unique story of client is preserved and knowledge gained from narrative)
Advantages of case study methods
Developing a critical perspective
Flexibility
Analysing and reporting innovative practice
Learning from unusual cases
Integration into training and practice
Criteria for selecting cases for research
Where using one case only
Typical cases
Extreme cases
Deviant cases
Influential cases
Innovative cases - If a series of cases are being investigated (modifying an intervention etc)
Similar/matched cases
Different cases
Three Key Questions in Systematic Case Studies
(1) Did the client change substantially over the course of counselling?
(2) If the client changed, did counselling make a substantial contribution?
(3) If the client changed, what brought about those changes?
Research steps in systematic case studies
- Assemble a rich case record
Multiple data sources, qualitative/quantitative - Outcome analysis
Analyse and interpret outcome data - Change process analysis
Organise and interpret evidence that counselling contributed to client change (including how counselling helped) - Critical reflection
Critically evaluate alternative explanations
Types of systematic case studies
Pragmatic case studies
Hermeneutic single case efficacy design (HSCED) studies
Narrative case studies
Pragmatic case studies - Fishman’s template
Fishman (1999)
Template for writing up case studies:
1. Case context and method
2. The client
3. Guiding conception with research and clinical experience support
4. Assessment of client’s problems, goals, strengths and history
5. Formulation and treatment plan
6. Course of therapy
7. Therapy monitoring and use of feedback information
8. Concluding evaluation of the process and outcome of therapy
9. References
Narrative case research
Strategies for constructing a narrative case study
- Writing an autobiographical retrospective account
- Diary or journal entries
- Recordings of therapy sessions
- Artefacts created during therapy or associated with therapy (e.g. letters, poetry, pictures) - enriches their story
- Interviews
The Narrative Assessment Interview
Use to assess self-narrative change in emotion-focused
therapy
Cognitive and developmental researchers suggest that our
capacity to narrate, understand, and integrate our most important life stories may be key to adaptive identity development and establishment of flexible view of self
McAdams & Janis (2004): internalised self-narratives may has much impact on guiding actions and behaviour as
dispositional traits
When therapists help clients construct new self-narrative representations, they are in fact impacting the personality of their clients
NAI protocol
3-step procedure:
(1) Completion of audio-taped baseline interview after Session 1 that asks clients to describe: “how would you
describe yourself?”; “how would someone who knows you
really well describe you?”; “if you could change something
about who you are, what would you change?”
(2) preparation of written summaries of clients response to
initial baseline interview questions
(3) completion of audiotaped semi-structured Narrative
Assessment inquiry asking clients to review baseline NAI
responses, and describe experiences of change and self-
narrative reconstruction at therapy termination
HSCED
Hermeneutic Single-Case Efficacy Design (HSCED) (Elliott) is a naturalistic design for evaluating efficacy in counselling and psychotherapy
Suitable method for making critical claims about causal relationships with new therapies and existing therapeutic interventions with new populations
Design includes strategies that are transparent, systematic and self-reflective enough to enable research to make inferences about therapy efficacy
HSCED key features
Three features required to ensure inferences are
convincing:
- rich case study record with multiple data sources
- one or more pieces of supporting / positive evidence (affirmative case) linking therapy to observed client change
- thorough investigation of alternative explanations (sceptic case) indicating nontherapy explanations are plausible, thus showing insufficiencies in a therapy-based account for client change
Inferences are compiled and subjected to an independent
adjudication process where an overall conclusions I made
about likelihood that therapy was a key influence on client
change
HSCED methodology is interpretive (rather than experimental)
Emphasis thick descriptions in form of rich networks of information rather than design features
Develops probabilistic rather than absolute knowledge claims
Dialectic because there is tension and dialogue between
quantitative and qualitative evidence
HSCED overview
To perform an HSCED study, one needs to:
a) Find an interesting and agreeable client
b) Collect appropriate measures
c) Apply to construct a rich case record
d) Analyse the information to see whether change occurred
e) Establish whether direct evidence linking therapy to client change is present and replicated
f) Analyse evidence for each of the eight nontherapy explanations
g) interpret and weigh the various sets of sometimes conflicting information to determine the overall strength and credibility of each nontherapy explanation
h) Come to an overall conclusion about the likelihood
that therapy was a key influence on client change
HSCED phases
HSCED involved 5 phases: A.Therapy and data collection B.Rich case record development C. Affirmative and sceptic case development D. Adjudication E. Overall conclusions
Assemble Rich Case Record
- Basic descriptive information (demographics, diagnoses,
problems, therapy approach) - Quantitative outcome measures: one or more (preferably related to theoretical model or client issues)
- Weekly or fortnightly outcome measure (e.g., Personal Questionnaire or CORE-10)
- Change Interview (qualitative; can be done by counsellor but better someone else; e.g., students help each other)
- Helpful Aspects of Therapy (HAT) form (client; significant
events) - Records of counselling sessions (tapes, therapist process notes)
Plausibility criteria for interpreting good
outcome
Evidence that the client has changed:
Evidence that it was therapy that helped:
Evidence that the person did not change
No evidence that it was therapy that helped:
Evidence that the client has changed:
Clients note themselves that they have changed
Clients are relatively specific about how they have changed
They report that others have observed them to change
They mention problems that didn’t change
Evidence that it was therapy that helped:
Clients themselves report that therapy helped
Describe plausible links to therapy experience
They mention aspects of therapy that didn’t help
Evidence that the person did not change
Clients note themselves that they did not change
They are specific about how their life is still the same
They seem the same in the therapy session
No evidence that it was therapy that helped:
Clients ascribe changes to events in their life
Give unabashedly positive testimonials, but provide few details about how therapy helped
Changes describe din client’s life could plausibly account for the client’s changes, whether the client sees it that way or not
Factors to consider when developing a
‘sceptic’ interpretation of a case
- Non-improvement
- Statistical artefacts
- Relational artefacts
- Apparent changes are a result of client expectations or wishful thinking
- Self-correction
- Apparent changes due to extratherapy events
- Psychobiological factors
- Apparent changes can be attributed to reactive effects of research - they just had attention paid to them
Factors to consider when examining links
between therapy process and outcome
Retrospective attribution
In post-therapy interviews, client explicitly states that changes were result of therapy. This can be general statement or specific
Process-outcome mapping
Content of post-therapy changes can be linked to specific
events, processes or events in therapy
Within-therapy process-outcome correlation
Specific interventions that are implemented by therapist, or specific therapy events, are linked to client change over the following week
Changes in stable problems
Client has had a longstanding problem and change is observed soon after therapy commences
