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ABSTRACT
I. INTRODUCTION
1. A Brief History
The case study research method is defined as "an empirical inquiry that
investigates a contemporary phenomenon within its real-life context, when
the boundaries between phenomenon and context are not clearly evident,
and in which multiple sources of evidence are used" (Yin, 1984, p. 23). Thus,
case study methodology uses in-depth examination of single and/or multiple
case studies, which provides a systematic way of approaching the problem,
collecting and analyzing the data, and reporting the results.
(2) Case study methodology can be used to test a scientific theory. This is a
heated discussion in epistemology. As we have shown above, many critics of
the case study methodology think that the study of a small number of cases
cannot offer a basis for the reliability and generality of findings and thus, in
testing a theory.
(3) When no other cases are available (i.e., critical and/or unusual cases), the
researcher is limited to case study methodology (i.e., single-case design). If
the objective is similar to that described at point 4, case study should be the
choice research methodology.
Case study is not useful in testing a theory based on verification, and then
arguing that the theory is validated. Generally, the choice for or against case
study methodology depends on the problem we have to solve. If the problem
implies knowledge based on sampling logics, case study methodology should
be avoided.
a. The research should start with the problem - the study question. The
problem can be defined as a discrepancy between an initial state (what he
have) and a final state (what we want to have). A rigorous problem will define
precisely the initial state and will specify clearly the objectives. A serious
problem is one in which the discrepancy between the initial and final states is
approachable by current methodology. For example, if my proposed final
state is to eliminate all mental disorders in the next two years, this will not be
considered a serious problem considering current knowledge in clinical
psychology and medicine.
b. The objectives and/or the hypotheses should be made clear (if they exist).
c. The next step involves defining the unit of analysis and than data
collection. It must be made clear that data collection can be guided by either
quantitative and/or qualitative methods. Data can come for various sources
and depending on the problem and objectives, it can be collected
qualitatively (e.g., by interview) and/or quantitatively (e.g., numerically).
e. In the next step, logic is used to link our results to our objectives and/or
hypotheses. This is where people who use case study methodology make
most mistakes (e.g., generalize when it is not the case). Therefore, it is
fundamental to binocularly integrate the logics and the design of the study to
avoid such errors.
II. APPLICATIONS
Case Study in Research (adapted after David & McMahon: "Clinical strategies
in cognitive behavioral therapy; a case analysis" published in the Romanian
Journal of Cognitive and Behavioral Psychotherapies, vol. 1, no. 1, September
2001, pp. 71-86; see also David, 2003; David et al., 2004; David, 2006a;
2006b). The case of "Dana" is a classic one in the Romanian clinical
literature; this is why it is presented based on its previous publications,
although the context is new (i.e., case study methodology).
1. The Problem
1.1. Introduction
Many people find the distinction among "Behavior Therapy (BT)", "Cognitive
Therapy (CT)", "Cognitive Behavior Modification (CBM)", and "Rational
Emotive Behavior Therapy (REBT)" confused and confusing (Dobson, 2001;
Lazarus, personal communication). We believe that the time has come to stop
elaborating on details regarding the various schools and systems of cognitive
behavior therapy/therapies (CBT), and (1) to focus on the science and theory
of cognitive behavior therapy; (2) to discuss treatments of choice for specific
conditions; (3) to focus on what is and what is not empirically supported; and
(4) to develop really good manuals so that experimentally oriented clinicians
can endeavor to test, repudiate or replicate particular claims and findings. We
think that all these goals can be accomplished under the umbrella of
cognitive science. Cognitive science attempts to understand the basic
mechanisms governing human mind, basic mechanisms that are important in
understanding behavior studies by other clinical and social sciences.
Cognitive science studies the foundation on which many other social and
clinical/psychological sciences stand (Anderson, 1990).
1.2. Cognitive science and emotional problems; A brief presentation (see also
David, 2003; David et al., 2004)
Following the previous distinction between hot and cold cognitions, according
to the appraisal theory of emotions, emotional problems will only appear in
cases 1 (distorted representation/negatively appraised) and 2 (non-distorted
representation / negatively appraised). In case 1 (distorted representation /
negatively appraised), if one changes the distorted representations (e.g., "He
hates me") into an accurate one (e.g., "He does not hate me"), one may end
up changing the negative emotion (anxiety) into a positive one (happiness).
However, the individual may still be prone to emotional problems because
the tendency to make negative appraisals (e.g., "It is awful that he hates
me") is still present. If one changes the negative appraisal (e.g., "It is awful
that he hates me") into a less personally relevant one (e.g., "It is bad that he
hates me but I can stand it"), it is probable to change the dysfunctional
emotion (anxiety) into a functional but still negative one (concern; for the
distinction between functional and dysfunctional emotions see Ellis, 1994). A
strategy that will change both distorted representation and negative
appraisal seems to be a better choice. In case 2 (non-distorted
representation/negatively appraised), the choice seems to be the change of
negative appraisal that would generate a positive (happiness) or negative
(concern) functional emotion. Another possibility is to change a non-distorted
representation (e.g., "He really hates me") into a positively distorted one (i.e.,
positive illusion: "His negative comments are a way of communicating that
he considers me a strong and reasonable person"). However, as in the first
case, in the second situation we may change both representation and
negative appraisal.
Dana is a 28 years-old physician, mother of one, who lives with her husband,
and who has been working full-time as a fellow in gastro-enterology for the
past 3 years.
Chief Complaint. Dana sought psychological treatment for panic attacks and
generalized anxiety at the end of and the beginning of 2000 (18 sessions).
Two months before treatment she had had three panic attacks and feared
having another one. She also reported: "Since about 1991, I have been
feeling nervous and excessively anxious about my life (e.g., "my future job as
a physician"), my relationships (e.g., "with colleagues and my husband") and
my significant activities (e.g., "my school performance, my doctorate"), but
right now I am much more concerned about the recent panic attacks".
History of Present Illness. In 1991, Dana moved away from home, far from
her overprotective parents, to study medicine at a prestigious university.
Starting then she began feeling helpless and she reported attacks of
excessive anxiety and "worry about everything" (emotional symptoms).
These emotional states were often associated with muscular tension, feelings
of weakness, fatigue, and sleep disturbance (physiological symptoms). She
always found it difficult to control these physical symptoms and,
consequently, she started avoiding activities that required physical effort
(behavior symptoms). She thought that her symptoms would affect her
performance at work and her value as a competent human being (cognitive
symptoms); consequently, she often felt helpless, with low self-esteem. Her
GP and then a psychiatrist prescribed her Buspar (Buspirona) (in 1993). After
several months of medical treatment, she gave it up, as it had reduced
symptoms less than she expected. The first panic attack occurred while she
was preparing for her doctoral exam about two months before our first
meeting (1999). About one month later she had another attack. At the time
of the second attack she was at home cleaning her apartment. The third
panic attack occurred just one week before our first meeting, while she was
home alone, preparing a paper for a scientific congress. Her panic symptoms
included the following: Emotional symptoms: intense fear of loosing control,
helplessness and discomfort; Cognitive symptoms: believing that she was
going to die, had heart problems, and that she was going to faint and
collapse; Behavioral symptoms: avoiding physical effort and looking for safe
places in case she fainted; Physiological symptoms: palpitations, trembling,
and chest pains. She consulted a psychiatrist regarding these symptoms, and
was prescribed XANAX just two months before our first meeting.
The major stressors in Dana's life were mainly social. She was an
overprotected child, and being far from home and from the protection of her
parents during training in medical school was the first major stressor that
might have precipitated her generalized anxiety (1991). Moreover, before
getting married (she got married in1998), Dana had hoped that her husband
would be a real support for her. She believed that he could help her to
overcome her anxiety and her "worries about everything". Unfortunately, her
husband's job was highly demanding. He was an assistant professor and a
researcher often working hard late at nights and on weekends. He was not
very involved in the household and in their child's education (the birth of
Dana's son was another stressor and opportunity for her to worry about:
"Considering that I am so busy, how will I have enough time for my son?").
Consequently, she felt overwhelmed by her life as wife, mother, physician,
and student, doing her full-time job as physician, cleaning the apartment,
cooking, taking care of her son, and preparing for her exams doctoral exams.
These were the conditions in which her first panic attacks developed (1999).
Personal and Social History. Dana was an only child. She described her father
as very rigid, controlling and concerned with the future of his daughter.
Because of his authoritative attitude she had been afraid to argue with him
or ask something from him (the same thing is true even now as an adult). She
described her mother as a warm person, highly concerned with the education
and the future of her daughter. Dana remembered that during kindergarten,
primary and secondary school she had been overprotected by her parents but
that she had not liked that attitude at all. For example, every morning they
left her at school and in the afternoon they picked her up. Because of this,
she had no opportunity to have friends and/or be with her colleagues. She
described herself as a girl (and now a woman) with very poor social and
assertiveness skills both at home and in other social situations. During high
school she started preparation for medical school. Both parents wanted her to
attend medical school. They allowed her to have a boyfriend (the relationship
was not very intense); however, they were only allowed to meet at her home
or go out for several hours in the afternoon. After starting medical school
(1991), Dana had to move to another town. During the first year (she was 18)
her parents visited regularly. They did not want her to live in a dorm with her
colleagues, so they rented an apartment where she could learn without being
disturbed by others. During her first year in medical school she started
experiencing intense signs of generalized anxiety and some symptoms of
subclinical depression. She felt alone, helpless, and started to worry about
everything (but not about the separation from her parents - this was one of
the reasons why we did not consider a diagnosis of separation anxiety!).
During her second year of study (1993) she decided to see a general
practitioner and a psychiatrist who prescribed her Buspar (Buspirona). After
several months she gave up treatment because the symptoms of generalized
anxiety persisted. Despite these symptoms she graduated medical school
successfully in 1997 and started working as a fellow in gastro-enterology. She
met her husband around the same. She described him as very bright, strong
and mature man, 15 years older than she was. They fell in love and got
married in 1998. They live in the same town where she graduated medical
school. After one year of marriage their son was born. In 1998 she started a
doctoral program in medicine. During their second year of marriage (1999)
she experienced her first panic attack. I (DD) met her in 1999 after she had
experienced three panic attacks. Beside psychotherapy, Dana took
medication (XANAX) prescribed by her psychiatrist.
Medical history. Dana had no medical problems which could influenced her
psychological functioning or the treatment process.
Mental Status Check. The patient was fully oriented with an anxious mood.
D. Strengths and assets. Dana is a bright person with a good physical health.
She loves medicine and she is very disciplined. She wants the best for her
and her family and consequently, no effort is to high to attain these goals.
She has lived with generalized anxiety for almost 7 years. The coping
mechanisms she employed during these years were: avoiding problems,
avoiding physical exercise and studying hard.
2.3. Treatment plan; A cognitive therapy perspective (by Dr. Daniel David)
A. Problems list: (1) Dana's panic attacks; (2) general feeling of worry about
everything (generalized anxiety and subclinical depression); (3) relationship
with her husband concerning the support he might offer to her (4) low
selfesteem and social and assertiveness skills.
B. Treatment goals: (1) to reduce panic attacks (including panic about panic);
(2) to reduce negative distorted thinking with impact on generalized anxiety
and subclinical depression; (3) to build assertiveness and problem solving
skills in order to improve the relationship with her husband and her ability of
solving practical problem; (4) increase social skills with impact on her
dependent personality traits.
C. Treatment plan. The treatment plan was to first reduce Dana's panic
attacks (including panic about panic) and then her generalized anxiety and
subclinical depression. We also planned to work on her assertiveness, self-
esteem, and social skills. Finally, some practical problems were approached
and a relapse prevention program was introduced.
1. The patient was taught a distraction technique for panic attacks (e.g., to
describe in detail all the objects in the room). This technique: (a) would
counter Dana's belief that she had no control over her anxiety; (b) be a useful
symptom management technique when it was difficult to challenge automatic
thoughts; and (c) be a potent demonstration of the cognitive model of
anxiety to which Dana was initially quite reluctant. She was then introduced
to voluntary hyperventilation technique. This was useful in modifying her
catastrophic interpretations of the bodily sensations she experienced during
panic attack. Controlled breathing was also introduced with the purpose of
reducing hyperventilation.
2. The patient was taught standard cognitive restructuring and behavioral
techniques for her automatic thoughts, catastrophic interpretations, and later
for her core beliefs. We also focused on changing hot cognitions by working
at different levels of abstraction. These techniques allowed Dana to
understand maladaptive thoughts and assumptions and thus significantly
reduced anxious and panic symptoms, subclinical depression, and some of
the dependent traits.
Outcome. Dana's therapy extended over 18 sessions. Six months after the
end of therapy, Dana had no recurrence of panic attacks or symptoms of
subclinical depression. However, some symptoms of generalized anxiety
persisted but they did not meet the DSM IV criteria for generalized anxiety
disorder. Dana's assertiveness and social skills improved significantly and had
a positive impact on her relationships (including with husband and parents)
and on the reduction of dependent personality characteristics. All these
results are operationalized in a single case experiment design: multiple
baselines across symptoms.
2.5. The treatment plan; An REBT strategy (by Dr. James McMahon).
An REBT treatment regimen was put into place, the process of intervention
was commented upon and acceptable to both patient and therapist. Several
issues were emphasized to her namely, that the idea was to be better not get
better, that two primary aspects on the neurotic continuum of thinking-
feeling were her tendency to exaggerate (awfulizing) and to avoid negative
emotions, thereby giving her temporary comfort but long-term misery (low
frustration tolerance). Also it was discussed with Dana how her problems
seemed to be related to demandigness oriented to her own person (e.g., "I
have to do everything at high standards") and others (e.g., "Others have to
help me"). If these demands are not attained, then she moves into self-
downing (e.g., I am weak), awfulizing (e.g., "It is awful") and low frustration
tolerance (e.g., "I cannot stand it"). Session 2-4 went to the heart of panic.
Checked was the secondary problem (panic about panic) and the irrational
beliefs involved (e.g., "I have to be in control otherwise it is awful and I
cannot stand it"; DEM, AWF and LFT). The primary emotional problem was
then focused upon (where we identified others DEM, AWF, LFT and SD).
Session 5-7 stressed self-worth issues related to generalized anxiety and
subclinical depression (e.g., stubborn refusal to judge herself, examining her
roles and how to judge them through the who/what process, rational-emotive
imagery in which she perceived herself to be in control of her own life and
that she was in charge, and disputation of other irrational beliefs). Sessions
8-12 involved further restructuring of IBs into adaptive alternatives (at
different levels of abstraction) and how to distinguish beliefs from feelings
about beliefs. She kept a log of the type of empirical, logical and pragmatic
disputations. Session 13-18 involved dealing with issues of dependency
throughout her life, looking for alternative conceptions. Some practical
problems were approached, and revisiting panic and anxiety situations was
undertaken to preclude regression.
Outcomes. Dana reported in the last session that she was free of panic
attacks, that she could distinguish rational from irrational beliefs, and that
she generally felt happy and liked herself. Regarding her own goals, she
indicated that she was generally happy but busy with her family and work,
that she judged that she could head off panic attacks in the future, and that
she was assertively negotiating home duties with her husband. The patient
and the therapist judged that she achieved good results therapeutically and
as a person.
2.6. Discussion
2.6.1. Comment upon the cognitive therapy strategy (by Dr. James
McMahon).
The work of Dr. Daniel David was generally masterful: good diagnosis, good
interventions, and the goals were attained. He used all available CBT
techniques that were appropriate by distinguishing automatic thoughts vs.
core beliefs vs. evaluative cognitions. However, I would mention that the
distinction between core beliefs (cold cognitions) and evaluative cognitions
(hot cognitions) is not always clear in cognitive therapy, although here, Dr.
David made it very clear. Also, many cognitive therapists prefer to work only
at the level of distorted cold cognitions, both surface and deep, rather than
at both cold cognitions and evaluative beliefs. In that case, the patients may
feel better but not get better. For example, they may feel better because the
activating events (e.g., "It is not true that she laughs at me") are not
dangerous, but the individual still may be prone to emotional problems
because the tendency to make negative appraisals (e.g., "It is awful when she
laughs at me") of activating events incongruent with their goals (e.g., "She
really laugh at me") is still present. However, here, Dr. David approached
correctly both types of cognitions. If there were one negative aspect, that
would be that therapy did not get to the person. Rather, therapy dealt with
symptoms, and then their causes and cure. While achieving personhood in CT
can be inferred, it can only be inferred as one of the several schemas since
the theory purports to be empirical and so deals with piece-by-piece
examples of pathology. Contradistinction, REBT theory clearly tries to
achieve fundamental philosophical change and so is person driven.
I think that Dr. McMahon's elegant REBT is really elegant: great clinical
approach! Unlike me, Dr. McMahon attacked evaluative cognitions directly. I
myself would approach evaluative cognitions, but after a careful challenging
of automatic thoughts and core beliefs. My general criticism to Dr. McMahon's
approach would be that by directly changing evaluative cognitions and
assuming that distortions are real (e.g., "Let us suppose that you are indeed
not able to work at high standards; How does this make you weak and
inadequate as a person?" or "How is this awful?", etc.) one may change a
dysfunctional emotion (anxiety) into a negative functional emotion (concern)
because automatic thoughts (e.g., "I will not be able to prepare my
presentation") and deep cold cognitions are not directly disputed in the
elegant REBT. I know that Dr. McMahon might suggest that by changing
evaluations one indirectly changes distortions too, and indeed, one may
invoke some corpus of research which supports this hypothesis (Dryden,
Ferguson, & Clark, 1989 but see Bond & Dryden, 2001). However, sometimes
distortions may gain functional autonomy from the evaluative cognitions (see
Allport's concept of "functional autonomy"); in this case the change of
evaluative cognitions might not be accompanied by a change in the
distortions. Consequently, the client may feel better (e.g., "concern" rather
than "anxious") but not achieve the best results (e.g., "relaxed", "calm" or
even "happy"). On the other hand, as Ellis repeatedly mentions, (Ellis, 1994),
not all patients may benefit directly from elegant REBT. However, in our case
the patient seems to be in a positive emotional state and thus, Dr. McMahon's
direct disputation of IBs also seemed to change cognitive distortions (i.e.,
elegant REBT). If that had not happen, I suppose that Dr. McMahon would
have forcefully disputed the distortions too (i.e., inelegant REBT). The
difference between our approaches seems to be in terms of strategy. I
started with automatic thought, core beliefs and then evaluative cognitions.
With bright clients, Dr. McMahon seems to prefer starting with evaluative
cognitions and then maybe working on distortions, if necessary (I know that if
the change of irrational beliefs was not accompanied by a change in
distorted cold cognitions, Dr. McMahon would directly examine automatic
thoughts and other distortions - personal communication). I would like to see
some research evaluating concurrently these two different cognitive
strategies. I assume that their efficacy may differ depending on the clinical
condition (e.g., the type of psychopathology, the type of client).
III. DISCUSSIONS
After a short history, this paper briefly and critically presented the
fundamentals of case study methodology. We have then exemplified, by
using the case of "Dana" from our previous publications, how it can be
employed in clinical practice. We hope that the message to take home after
reading this article is clear. Case study methodology is not rigorous or less
rigorous per se. It becomes rigorous or less rigorous depending on the type of
knowledge we want to generate in order to solve specific problems. This is
true for all the research methods. The problems which case study is best fit to
solve are those related to exploratory studies (i.e., generating new theories),
to critical, and unusual cases. It is less fit to test a theory although, if
conditions for falsifiability are met, it can be implemented with this purpose
as well. When used appropriately, case study methodology is very rigorous,
comparable with any other research method. By appropriate we mean two
things: (1) adequate to the problem it is intended to solve; and (2)
implemented at high standards in terms of internal constraints and steps that
need to be followed.
[Reference]
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[Author Affiliation]
Daniel DAVID*
* Corresponding author:
Email: danieldavid@psychology.ro
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