Rethinking how to present client case reports
The EMDR Association regularly puts on CPD webinars and it was a pleasure to attend (albeit not in real time) Kim Etherington’s “Narrative approaches to case studies: Bridging practice and research” event in September. I wanted to learn something about how case studies are presented and utilise that knowledge in my role as editor of ETQ.
Kim and I met for a chat prior to her presentation. She is Professor Emerita of Narrative and Life Story research at Bristol University and has researched and published extensively in the area of qualitative and narrative inquiry. John McLeod, in his comprehensive book ‘Case Study Research’ (2010) described Kim’s book “Narrative Approaches to Working with Adult Male Survivors of Child Sexual Abuse: The Clients’, the Counsellor’s and the Researcher’s Story” as ‘the most completely realised narrative case study of therapy experience that is currently available’ (p.193). Kim’s collaborative approach to case studies is different to the traditional medical/psychological view of what a case study is, and how it should be presented.
Clinical case reports are the oldest form of communication amongst medical practitioners. In a selective review of the history of the case report (Nissen & Wynn, 2014) the earliest reports date from an Egyptian antiquity papyrus about 1600BC, long before Hippocrates was writing his case histories around 400BC. Physicians focused on describing their findings objectively, but this began to change when Galen put pen to paper (around 200AD) and included his thought processes, doubts and descriptions of his working day.
In the intervening two centuries case reports have been used to inform and entertain as well as being used as a tool for self-aggrandisement. The latter function was taken to the extreme by Sigmund Freud who not only included objective details of his patients, but also detailed and elaborate descriptions of his thoughts, reflections and hypotheses. In addition, he broke with tradition and included his patients’ own accounts of their therapy. Nissen and Wynn (2014) conclude that “Freud’s case studies, with their literary style, prepared the field again for the inclusion of the narrative, both with regard to form and content” (p4). Even so, there was a trend in the 20th century to reduce the authors to observers and to structurally constrain the text. Kim quoted a psychoanalyst, Mahoney, who criticised these ways of conducting case studies saying, “a radically different approach to case study inquiry in counselling and psychotherapy needs to be found if therapy case studies are to have any chance of being regarded as sources of reliable evidence about what actually happens in therapy”.
Case reports are a form of exploratory research. They can help generate new ideas that might then be tested by other methods. Traditionally, psychologists’ case reports have tended to ape those of their medical colleagues and Prof. Etherington argued eloquently that this is neither necessary nor particularly helpful. She proposes a reflexive, egalitarian approach where knowledge is co-constructed and both voices are heard: therapist/researcher and client/participant; that we need to show transparently how we discover what we discover through the use of reflexivity; and that we need to hold in mind the power issues inherent in our roles. We need to include ourselves because we actively shape the direction of therapy as practitioners and as researchers, and outcomes are inevitably shaped by our beliefs about how the world exists, which in turn influence what we consider to be valid knowledge.
Kim highlighted that case reports can fulfil several functions (see below) from the formative to developing theory and to contributing to the public understanding of our professions.
What functions do case studies perform?
- Document, evaluate and disseminate new approaches
- Contribute to the public understanding of our professions
- Develop theory
- Highlight neglected issues in practice such as boundaries, spirituality, addiction
- Expand and enhance results from large scale studies
- Assess competency and learning during training
During the course of the webinar we learned about the discipline of narrative inquiry as a “means for systematically gathering, analysing and re-presenting peoples’ stories of their lived experiences, as told by them”. The stories that arise and that we use in case studies are reconstructions of a person’s experience. “They do not represent ‘life as lived’ rather they are our re-presentations of those lives as told to us”. Narrative inquiry aims to capture personal and human dimensions of experience over time, taking into account the connection between individual experience and context, both personal and cultural.
The purpose of this webinar was to demonstrate how the principles of narrative inquiry can be applied to our practice so that we can most faithfully re-present our client’s stories. So often it seems we attempt to corral the stories and therapy process into a neat order when in fact we might do better to value the messiness, complexity, and contradictions of experienced life as told to us. If we wish to re-present our clients’ stories and the therapy process with integrity, we should perhaps consider more transparent means than that of the “composite client”. This device seems to me to suggest that an individual’s experience is insufficient and that demonstrating protocol and process in a linear fashion is more important than what really happened. It also seems to sidestep important moral and ethical considerations which are considered below.
Moral and ethical considerations
Consent is paramount but this is not just about the client agreeing to being written about, it is about the client being informed sufficiently about things that matter to them so that they can make an informed decision. Kim led a reflexive exercise where we were asked to imagine being invited to take part in a research project and tell our stories about our experience of being an EMDR client. She asked us to write down the issues that this raised for us. We wanted to know what was the purpose, would we be heard and not distorted, how the work would be disseminated and how confidentiality would be preserved, and much more. All these issues are relevant when writing a case study and can be operationalised when it is considered as a collaborative venture.
Kim talked about collaboration as being a “reciprocal process whereby each party educates the other”. She suggests that researchers (therapists) share the ownership of the data (stories) with our participants, and that by doing so it will undermine the power of the dominant paradigm – i. e. that professionals are the experts. Collaboration is essentially the democratisation of knowledge, and it embraces many ways of knowing, including the complexity of many and different realities. By presenting therapy as it happened and by including the therapist’s part in the conversation, readers will be able to observe the relational aspect of the therapy and see how meaning is made and “stories are shaped through dialogue and co-construction”.
In the last part of the webinar Kim presented an example of narrative case study research, highlighting the delicately told stories of a client who received counselling from a drugs project. Her final words were a powerful statement of meaning-making and evaluation:
“I do know if I hadn’t been going to [the Project], quite possibly, by now, if I wasn’t dead, I’d be dying, because of the harm I was doing to my body. And even if it hadn’t been as dramatic as that, [the Project] has saved the NHS a lot of money because I’m not going to the hospital and taking up a bed, and taking up resources and taking up ambulance spaces and things like that”.
Since attending Kim’s webinar I have challenged myself to read case reports in a more critical way. I now wonder about consent and about what the client thinks of how their story has been re-presented. I wonder about the author and what informs their world view. I wonder what the purpose of the report is, and about what has been left out and why? I also want to challenge myself and the readers of ETQ, to write a case report, prospectively and collaboratively, to present EMDR therapy in the client’s words as it actually happened, and not as the textbooks say it should.
Etherington, R. K. (2000). Narrative approaches to working with adult male survivors of child sexual abuse: The clients’, the counsellor’s and the researcher’s story. London: Jessica Kingsley Publishers.
Mahone, P. J (1996). Freud’s Dora: A psychoanalytic, historical, and textual study. New Haven, CT: Yale University Press
Mcleod, J. (2010). Case study research in counselling and psychotherapy. London: Sage.
Nissen, T., & Wynn, R. (2014). The history of case report: A selective review. JRSM Open, 5(4)doi:10.1177/2054270414523410