Week 11

Question 1

Role of case studies in the development of theory and

practice in counselling and psychotherapy

Answer 1

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

Question 2

The distinctive contribution of case-based knowledge

Answer 2

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

Question 3

Limitations of standard case study reporting

Answer 3

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

Question 4

Systematic single case studies

Answer 4

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?

Question 5

Aims of case study research Focus on four sets of questions that may be addressed through analysis of case material:

Answer 5

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?

Question 6

Why use systematic case studies?

Answer 6

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

Question 7

Rethinking causality

Answer 7

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

Question 8

Rationale for case studies

Answer 8

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)

Question 9

Advantages of case study methods

Answer 9

Developing a critical perspective

Flexibility

Analysing and reporting innovative practice

Learning from unusual cases

Integration into training and practice

Question 10

Criteria for selecting cases for research

Answer 10

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

Question 11

Three Key Questions in Systematic Case Studies

Answer 11

(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?

Question 12

Research steps in systematic case studies

Answer 12

1. Assemble a rich case record
   Multiple data sources, qualitative/quantitative
2. Outcome analysis
   Analyse and interpret outcome data
3. Change process analysis
   Organise and interpret evidence that counselling contributed to client change (including how counselling helped)
4. Critical reflection
   Critically evaluate alternative explanations

Question 13

Types of systematic case studies

Answer 13

Pragmatic case studies

Hermeneutic single case efficacy design (HSCED) studies

Narrative case studies

Question 14

Pragmatic case studies - Fishman’s template

Answer 14

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

Question 15

Narrative case research

Answer 15

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

Question 16

The Narrative Assessment Interview

Answer 16

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

Question 17

NAI protocol

Answer 17

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

Question 18

HSCED

Answer 18

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

Question 19

HSCED key features

Answer 19

Three features required to ensure inferences are
convincing:

1. rich case study record with multiple data sources
2. one or more pieces of supporting / positive evidence (affirmative case) linking therapy to observed client change
3. 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

Question 20

HSCED overview

Answer 20

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

Question 21

HSCED phases

Answer 21

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

Question 22

Assemble Rich Case Record

Answer 22

1. Basic descriptive information (demographics, diagnoses,
   problems, therapy approach)
2. Quantitative outcome measures: one or more (preferably related to theoretical model or client issues)
3. Weekly or fortnightly outcome measure (e.g., Personal Questionnaire or CORE-10)
4. Change Interview (qualitative; can be done by counsellor but better someone else; e.g., students help each other)
5. Helpful Aspects of Therapy (HAT) form (client; significant
   events)
6. Records of counselling sessions (tapes, therapist process notes)

Question 23

Plausibility criteria for interpreting good

outcome

Answer 23

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:

Question 24

Evidence that the client has changed:

Answer 24

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

Question 25

Evidence that it was therapy that helped:

Answer 25

Clients themselves report that therapy helped

Describe plausible links to therapy experience

They mention aspects of therapy that didn’t help

Question 26

Evidence that the person did not change

Answer 26

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

Question 27

No evidence that it was therapy that helped:

Answer 27

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

Question 28

Factors to consider when developing a

‘sceptic’ interpretation of a case

Answer 28

1. Non-improvement
2. Statistical artefacts
3. Relational artefacts
4. Apparent changes are a result of client expectations or wishful thinking
5. Self-correction
6. Apparent changes due to extratherapy events
7. Psychobiological factors
8. Apparent changes can be attributed to reactive effects of research - they just had attention paid to them

Question 29

Factors to consider when examining links

between therapy process and outcome

Answer 29

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