bluuebunny/crossref_metadata_2025 huggingface dataset:
From "Incurable" Schizophrenic to Person in Recovery: A Not So Uncommon Story
Authors: Davidson Larry
Published: April 2014

In this commentary on Bertram Karon’s (2008) case study of Mr. X, I present my perspective from today’s clinical, empirical, political, and sociological perspectives, 40 years after Karon began seeing Mr. X. Within this context, I agree with Karon that he most likely “saved” Mr. X’s life, keeping him from quite probably destructive electro-convulsive treatment (ECT) and possible suicide, and facilitating Mr. X’s return to a full and gratifying social and professional life. In my analysis of Karon’s case study, I identify those elements in his treatment that, from today’s clinical and empirical evidence, seem to have been effective. A number of these can be seen as consistent with today’s model of “assertive community treatment” (ACT), including Karon’s daily engagement with Mr. X in natural, “in vivo” settings (like a diner and Mr. X’s work setting); Karon’s attention to Mr. X’s basic needs (like food and employment); and Karon’s continuing to supportively spend time with Mr. X over quite a while, even when Mr. X did not immediately appear responsive to this. All of these effective ingredients of the treatment do not require psychoanalytic theory for their explanation. Overall, I am led to conclude that Karon’s theoretical, psychoanalytic account of the successful treatment of Mr. X goes beyond the available data, at least the data available to the reader. Much of what Karon describes as effective would also be considered helpful by people with psychotic disorders who have neither been offered nor benefited from psychodynamic insights, and can be accounted for by alternative conceptual frameworks which make fewer theoretical assumptions. I end my commentary with a plea for humility in our attempts to understand the daunting challenge of helping a person “create a livable world” in the face of a condition as complex, dynamic, and seemingly mysterious as schizophrenia.
Targeting Catholic Rituals as Symptoms of Obsessive Compulsive Disorder: A Cognitive-Behavioral and Psychodynamic, Assimilative Integrationist Approach
Authors: Garcia Hector A.
Published: April 2014

“Bridget” was my first cognitive behavioral therapy (CBT) case and assigned to me in my second year of doctoral training as part of a clinical practicum. She was a 21-year-old undergraduate student who presented with depression and obsessive-compulsive disorder (OCD), in which the obsessions were religious in nature and the compulsions were rituals of the Catholic religious tradition, such as crossing and praying. Distinguishing between thoughts and behaviors that would be targeted as symptoms and those that would be retained as bona fide religious beliefs — and thus not viewed as a function of Bridget’s OCD — presented unique ethical and technical challenges. In Phase 1 of treatment I used cognitive-behavioral therapy (CBT) methods to target Bridget’s OCD symptoms. After these obsessions and compulsions had been virtually eliminated using the CBT-oriented treatment, Bridget was eager to pursue other difficulties (such as the impact of her interpersonal style on her relationships with men). At this time I had the opportunity to continue therapy with Bridget in conjunction with a psychoanalytic course I was taking that offered a psychodynamic supervisor. I determined that this Phase 2 arrangement would be in Bridget’s therapeutic interests in light of: (a) the issues with which she was dealing; (b) the fact that Bridget and I had established an excellent working relationship during Phase 1 and Bridget easily agreed to continue therapy with me in the new, less structured, psychodynamically oriented format; and (c) the fact that the new, psychodynamic supervisor was open to my integrating psychodynamic concepts into the CBT approach I had employed in Phase 1. Overall, therapy was conducted weekly during 2 ½ academic years (the client generally took the summers off) for a total of 79 sessions. The therapy results across the two phases present evidence that in the context of the above-mentioned facilitating conditions, the two phases worked smoothly together to help Bridget with the variety of problems she presented.
On the Nature and Treatment of Scrupulosity
Authors: Deacon Brett , Nelson Elizabeth A.
Published: April 2014

Obsessive-compulsive disorder (OCD) focused on religious themes, also known as scrupulosity, is a relatively common but poorly understood form of this disorder. It also presents unique challenges to the therapist who must negotiate the procedures of exposure and response prevention while respecting the patient’s religious beliefs and practices. Garcia (2008) describes the successful treatment of Bridget, a 21-year-old woman with scrupulosity, using cognitive-behavioral therapy. Following resolution of her OCD symptoms, a second treatment phase targeted several more interpersonal problems using an integrated cognitive-behavioral and psychodynamic approach. This commentary reviews the nature of religion in OCD, the utility of functional analysis and case formulation, issues in the delivery of cognitive and behavioral techniques in OCD, working with religious compulsions, and the integration of cognitive-behavior therapy (CBT) and psychodynamic approaches in the second phase of Bridget’s treatment.
New Wine in Old Bottles: The Transdiagnostic Model in the Case of Geoffrey
Authors: Hyer Lee
Published: April 2014

This reaction to the “Case of Geoffrey” by Dr. Jan Mohlman et al. (2008) highlights its use of a state-of-the-art, clinical combination of the transdiagnostic model and empirically supported, cognitive-behavioral therapies in the treatment of an older adult with multiple problems.  I comment on Dr. Mohlman et al.’s creative use of cognitive rehabilitation, as a necessary adjunct to both anxiety and depression in the elderly, and, more generally, on Dr. Mohlman’s et al.’s unerring use of tactics, strategies, and interventions with Geoffrey.  More specifically, I comment on: (1) the context of aging, both as it applies and serves as background to treatment in later life; (2) evidence-based practice of psychological and psychiatric treatments, as necessary for psychotherapy for older adults; (3) common factors of treatment in Dr. Mohlman et al.’s case that address aging-related issues in therapy which require case-specific alterations that they  creatively considered, applied and monitored; and (4) a discussion of what was missing or lacking in Dr. Mohlman et al.’s approach. Their case of Geoffrey should serve as a model for graduate teaching in psychotherapy for older adults.
Balancing Between Empirically-Supported Methods and Individualized Treatment Design in the Case of Geoffrey
Authors: Mohlman Jan , Cedeno Linda A. , Price Rebecca B. , Hekler Eric B. , Yan Grace W. , Fishman Daniel B.
Published: April 2014

This is a response to the commentaries by Dr. Knight (2008) and Dr. Hyer (2008) on “The Case of Geoffrey” (Mohlman et al., 2008). The response focuses on three major themes: the notion of cultural competence in the psychotherapeutic setting; possible risks inherent in and alternatives to the medicalization of mental health treatment for older adults; and the growing use of cognitive remediation in the treatment of psychiatric disorders.  We also address some of the other excellent issues raised by Drs. Knight and Hyer regarding cohort effects in the study of older therapy clients and missing elements in the case of Geoffrey.
Handling Multiple Levels of Data and Multiple Research Questions in an Embedded Case Study: Methodological Challenges
Authors: Edwards David J.A.
Published: April 2014

Hougaard et al. (2008) report an embedded case study in which nine socially phobic clients were treated as part of a therapy program, which incorporated individual and group therapy and which was largely delivered by trainee clinicians. An important focus of the report is on the effectiveness of their treatment model. This commentary draws attention to the size and complexity of the available data, and it suggests ways in which the use of a more explicitly interpretative methodology can draw out additional dimensions of the data and allow a more systematic contribution to be made to the development of clinical theory.
A Novel Group Therapeutic Format in Cognitive Behavioral Treatment for Clients with Social Phobia in a Training Setting: A Case Study of One Treatment Group with Nine Clients
Authors: Hougaard Esben , Madsen Sarah S. , Hansen Line M. , Jensen Mette , Katborg Gro S. , Morsaa Lars , Pedersen Marie , Pedersen Signe M. , Piet Jacob
Published: April 2014

This case study pilot-tests a novel, cognitive behavioral treatment (CBT) program for social phobic clients in an Anxiety Clinic run by the Department of Psychology of the University of Aarhus, Denmark. The core of the program was an intensive therapy group lasting for 5 consecutive days during one week, from 9:00 am to 2:00 pm each day. The group was composed of 9 clients and 8 student therapists in training, who were present throughout the total 25 hours, and two supervising psychologists, who were present during the first 2 hours of each day. Each client was also assigned to one of the student therapists, seeing the therapist for 2-4 individual sessions before the intensive group-week, and 6 weekly 2-hour group sessions after the intensive group experience. The groups were composed of 4 (or 5) clients and 4 students with the students on their own in charge of the therapy. Individual therapy was also provided when clinically indicated after the end of the group therapy. Treatment was evaluated within an embedded case study design with one group and 9 clients via both qualitative information and quantitative measures that assessed the clients’ presenting problems and therapeutic progress over the entire course of therapy and at follow-up. The results show that the intensive group treatment was therapeutically valuable for the clients. Specifically, almost all the clients appreciated the intensive group treatment format, and most achieved fast symptomatic declines over the week. Outcomes of the full treatment program for the whole group were in line with results from studies on psychotherapy for social phobia provided by experienced therapists. The educational value of the program is commented on in the discussion.
Where Does the "Core Clinical Hypotheses" Model Fit Among Models of Integrative Psychotherapy?
Authors: Ingram Barbara Lichner
Published: April 2014

Stricker (2009), Grinfeld (2009), and Lampropoulos (2009) provide three types of commentary on my case of Ms. Q (Ingram, 2009): feedback on my handling of  psychotherapy with this high-functioning client; critical evaluation of my “28 core clinical hypotheses” model; and discussion of where this model fits within four categories of integrative psychotherapy—common factors integration, theoretical integration, assimilative integration, and technical eclecticism. In this response I focus on each topic in turn, and conclude with a discussion of the training of clinical graduate students as integrationally-oriented psychotherapists.
Plan Analysis in Action
Authors: Caspar Franz
Published: April 2014

Kramer (2009) reports a case study of the cognitive-behavioral treatment (CBT) of Posttraumatic Stress Disorder that involved individualizing the therapy to the distinctive aspects of the client’s personality and life circumstances. This individualization process was facilitated by Grawe and Caspar’s "Plan Analysis," which is a model for assessment and treatment planning. In this commentary I discuss the general issues raised by Kramer’s deviation from a strict manualized CBT approach in this case. I also comment on the value of Kramer’s case as a contribution to the Plan Analysis approach by concretizing this model within a detailed, systematic case study.
Prolonged Exposure (PE) for Treatment of Childhood Sexual Abuse-Related PTSD: Do We Need to Augment It?
Authors: Hembree Elizabeth A. , Brinen Aaron P.
Published: April 2014

Kramer's thoughtful and extremely thorough case study of treating Caroline, a survivor of childhood sexual abuse (CSA), raises several important issues. A major assumption underlying Kramer's approach with Caroline's PTSD symptoms is that the Prolonged Exposure (PE) manualized treatment of Foa and her colleagues is a necessary but not sufficient method to address the clinical needs of such a client. Thus Kramer begins his treatment of this client with other clinical components, such as an assessment of Caroline's interpersonal patterns utilizing Caspar'sPlan Analysis method; custom tailoring of his therapeutic relationship with Caroline; imaginative relaxation; cognitive crisis intervention; and interventions to enhance the client's social competence. He then initiates a brief course of in vivo and imaginal exposure, following the procedures in the PE manual. In this commentary, we critically evaluate this major assumption of Kramer's and review data which argue that PE can be sufficient for treating clients like Caroline. Specifically, our commentary considers the following questions: (a) What are the effects of exposure alone versus exposure combined with other treatments for PTSD? (b) Does CSA-related PTSD require additional treatment components other than PE? (c) Is PE intolerable without additional interventions? (d) Why is length of treatment important? and (e) What are some of the issues raised by the manner in which Kramer implemented the PE treatment?
What Can We Learn from Case Studies? More than Most Psychologists Realize
Authors: Westerman Michael A.
Published: April 2014

Stiles (2009) was on target when he argued that theory-building case studies have much more to offer than most psychologists realize. In this analysis of Stiles’ position, I focus on comparisons he drew between theory-building case studies and hypothesis-testing investigations with regard to (a) sensitivity to context, and (b) evaluating theories. Stiles’ suggestion that case studies are context-sensitive whereas hypothesis-testing studies are not misses some of the actual complexity of that issue because some hypothesis-testing studies reflect genuine appreciation of context. I identify specific differences that exist between the two research approaches with respect to sensitivity to context, including particular ways in which case studies are better with respect to this concern. Stiles’ comments about how case studies can contribute to evaluating theories are novel, convincing, and very important. The key point Stiles developed is that case-study research is especially well suited for theory evaluation because it allows investigators to compare observations to the multiple tenets of a theory at the same time, whereas hypothesis-testing studies test single tenets of theories against observations. I illustrate Stiles’ model with an example from a set of case studies of my own on the theory of interpersonal defense.
Evaluating the Philosophies of Theory-Building in Case Studies
Authors: Slife Brent D. , Richardson Michael
Published: April 2014

The purpose of this reply to Stiles’ (2009) article is threefold: identify his particular philosophy of theory-building, expose some of its problems for evaluation, and describe another philosophy of theory-building as a point of comparison. The article begins by describing how Stiles’ philosophical approach to theory-building is ontologically dualist in nature. Dualism is evident in his view of experience, signs, meanings, knowledge, and truth. We point not only to general problems with this dualism but also to specific problems with Stiles’ particular formulation. We then describe a nondualist philosophy in a successful case study movement outside psychology, namely Consumer Reports car ratings. It is only in comparison with such nondualist approaches that we can begin to evaluate Stiles’ proposal and properly serve the important project of case study evaluation.
The Case of Felix: An Example of Gay-Affirmative, Cognitive-Behavioral Therapy
Authors: Glassgold Judith M.
Published: April 2014

Felix, a Gay Latino man, presented with anxiety and panic attacks, which were addressed as symptoms of minority stress and self-stigma. The client’s panic attacks were eliminated and anxiety was reduced by cognitive-behavioral therapy that targeted his concealment of his sexual orientation and that increased his active coping. By facing his fears of the negative impact of self-disclosure of his sexual orientation, Felix improved his mental health and relationships with others. A four-month follow-up interview is described.
Acute Stress Disorder and Forms of Narrative Disruption
Authors: Currier Joseph M.
Published: April 2014

Intervening with persons in the immediate aftermath of potentially traumatic events poses a number challenges for clinicians. Particularly in clinics that serve military personnel or other populations whose livelihoods may depend on regaining functioning efficiently following trauma, there is a need for sensitive and effective psychotherapies for acute stress disorder (ASD), a diagnostic category which attempts to capture maladaptive responses to trauma within the initial four weeks. In this context, Palgi and Ben-Ezra (2010) developed "Back to the Future," a novel treatment for ASD guided by narrative and constructivist understandings of posttraumatic adjustment (e.g., Neimeyer, 2009; White & Epston, 1990). One of the distinctive aspects of Palgi and Ben-Ezra's approach involves a departure from exposure-oriented models of psychotherapy so as not to strengthen the substantive core of the traumatic experience for the survivor -- called the "traumatic nucleus" -- in the early adjustment period. My discussion of Palgi and Ben-Ezra's case of Mr. G and related general issues uses a framework of three common forms of narrative disruption after trauma. Specifically, I first discuss "narrative dominance" as a particular strength of the Back to the Future
The Persecuting God and the Crucified Self: The Case of Olav and the Transformation of His Pathological Self-Image
Authors: Stalsett Gry , Engedal Leif Gunnar , Austad Arne
Published: April 2014

This case study describes the treatment of "Olav," a divorced lawyer in his mid-30's, who, at the time of treatment, had been continuously hospitalized in closed, short-term psychiatric wards for more than seven years with severe treatment-resistant depression, transient psychotic episodes, self-destructive behavior, and suicide attempts. He was about to be admitted to a long-term ward for chronic schizophrenics. A great deal of his psychopathology revolved around his feeling tortured from condemning inner voices of what he called "the Committee" that he believed were the sacred voices of God. The present case study describes Olav's treatment in our institution's "VITA" unit, a 12-week, group-based, residential day-treatment program that explicitly focuses on existential and religious issues. The VITA program includes diary-writing, affect consciousness, and regular group sessions consisting of such activities as mindfulness training; art therapy focusing on drawing or painting internal representations of self, father, mother and God; multiple group experiences; and reflection on existential issues. A standard assessment battery documents Olav's dramatic improvement over the course of treatment and at one-year follow-up.
Psychotherapeutic Change and Spiritual Transformation: The Interaction Effect
Authors: Jones James W.
Published: April 2014

Olav was an extremely difficult, regressed, and religiously preoccupied patient, with a long history of unsuccessful outpatient and inpatient treatment. His case study by Stalsett, Engedal, and Austad (2010) is used here to illustrate the VITA treatment program at the Modum Bad Hospital in Norway. This program uniquely combines contemporary psychoanalytic therapy and a focus on religious and spiritual concerns to produce a remarkably intense 12-week inpatient treatment process. My commentary concentrates on some of the theoretical and practical implications of Olav's case for the psychological study of religion and the clinical treatment of religious patients, and it argues in favor of the VITA approach to dealing with religious and spiritual concerns as opposed to other forms of "religious" or "spiritual" therapy. The case presentation implies that the VITA Program succeeded with Olav where others did not because it explicitly focused on religious and existential issues. I offer some suggestions based on self-psychology why that might be true but also suggest that other factors were at work as well.
Developing a Systematic Procedure for the Assessment of Self-Defining Memories in Psychodynamic Therapy: Promise and Pitfalls
Authors: Moertl Kathrin , Boritz Tali Z. , Bryntwick Emily , Angus Lynne
Published: April 2014

The innovative approach to assessing autobiographical memory narratives that Singer and Bonalume (2010) demonstrate in their case study of Cynthia is an ambitious expression of integrative psychotherapy research. It brings together the rich research findings on self-defining memories derived from laboratory studies and therapy case analyses, and applies these to the multimodal assessment situation in a psychotherapy program. Further, Singer and Bonalume's case of Cynthia is grounded in a truly "common factor" that is essential to most if not all psychotherapies: patient narrative expression. However, the integration of findings across different research studies still needs further elaboration to clarify and explore when they are consistent and when they are inconsistent with one another. In our commentary we critically assess the following issues associated with Singer and Bonalume's narrative memory coding system and its application to the case of Cynthia: (a) the utilization of narrative analyses for the identification of themes; (b) challenges inherent in establishing criteria for the identification of clinically important autobiographical memory narratives in therapy sessions; (c) the degree of integrative processing that takes place in narrative expression; and (d) the process of formulating inferences based on client narrative expression in assessment interviews versus therapy sessions.  The commentary concludes with a discussion of promising future directions for narrative research in psychotherapy.
Toward The Scientific Study of Autobiographical Memory Narratives in Psychotherapy
Authors: Singer Jefferson A. , Bonalume Laura A.
Published: April 2014

In responding to Adler (2010) and Moertl, Boritz, Bryntwick, and Angus (2010), we elaborate three areas of discussion: (1) Defining the autobiographical memory narrative unit; (2) Clarifications regarding our approach to coding narrative memories; and (3) Potential future research.  Our response highlights the importance of a coding system specific to long-term narrative memories, the need to distinguish clearly what is meant by narrative memory, and the value of creating a bridge between the study of narrative memory in psychotherapy and research in cognitive science and personality psychology.
The Unfolding Case Formulation: The Interplay of Description and Inference
Authors: Eells Tracy D.
Published: April 2014

Single subject research (SSR) can complement findings from aggregated group data and contribute uniquely toward the goal of generating and generalizing scientific knowledge in psychology.
What Services and Supports Are Needed to Enable Trauma Survivors to Rebuild Their Lives? Implications of a Systematic Case Study of Cognitive Therapy With a Township Adolescent Girl With PTSD Following Rape
Authors: Payne Charmaine , Edwards David J.A.
Published: April 2014

This systematic clinical case study describes the psychological assessment and treatment with cognitive therapy of Zanele, a Xhosa-speaking adolescent rape survivor with major depressive disorder and posttraumatic stress disorder (PTSD). A case narrative was developed to document the main features of the therapy process and progress was monitored using scales measuring symptoms of depression and PTSD. The narrative documents the operation in a local context of factors that maintain PTSD that have been identified in the international literature and, with the self-report scales, provides evidence for Zanele’s recovery from PTSD and the transportability to this context of an evidence-based psychological treatment. The narrative also documents the lack of safety for young women and girls in a South African township as well as significant limitations in the professional services available: in this case, Zanele was infected with HIV and other sexually transmitted diseases but medical management had not been followed through, and criminal charges against the rapist were dropped, and dropped again even after he had committed another rape on a six-year-old girl. This provides a basis for examining the complementary roles that can be played by psychologists and other professionals in empowering trauma survivors to regain a sense of dignity and control over their lives.
Seeing Beyond the Scars: A Testament to "Anna"
Authors: Podetz Stacy M.
Published: April 2014

The client, Anna, was an 18 year-old young woman who had a six-year history of self-injury, panic attacks, anxiety, disordered eating, and depression. She presented with a unique pattern of cutting in which she would cut when she felt too much and when she did not feel enough. In a sense, Anna existed in a perpetual cycle of emotional regulation through the induction of physical pain. Her thousands of scars are a testament to her deep emotional pain, which are associated with her relationship with her parents. From a psychodynamic perspective, Anna presented as very defended as she often suppressed her emotions, idealized her father, and dissociated during cutting episodes. The therapy primarily focused on maintaining and fostering the therapeutic relationship while using transference and counter-transference issues in order to promote the growth and understanding of her deeply rooted pain. Anna was self-referred and we met weekly for one hour in a college counseling center. Our work together was ongoing and included a total of 25 sessions at the time the case was written. I received individual supervision one hour per week from Andrea Kelly, a licensed Masters level psychologist, and group supervision two hours per week with Andrea and four other Master’s level interns from various colleges and theoretical backgrounds. Andrea, the client Anna, and I were primarily responsible for treatment planning; however, I did receive some guidance from the other graduate interns.
Subjected to Proof: The Advocate's Perspective
Authors: Altman Alexandra Jessup
Published: April 2014

Assuming the role of the "advocate" in the Panel of Psychological Inquiry provided me a unique opportunity to read and examine a master’s thesis case study (Podetz, 2008, 2011) in great depth. The task required a familiarity with current discourse on the presentation of written clinical case material, and an interest in the task of establishing some criteria by which the validity of claims being made could be assessed. This author had first to establish to her own satisfaction, that the case being presented was indeed defensible. Having done so, in conjunction with the case study author, the advocate decided which of the salient points made were ideally suited to oral defense supported by both witness testimony and documentation. Four claims were argued: (1) It is absolutely clear that the patient, “Anna”, presented with a serious psychopathology. (2) It is clear that the therapist/intern provided humanistic, psychodynamically informed therapy to “Anna”. (3) It is highly probable that the treatment resulted in increased health and growth. (4) Ms. Podetz’s premise, that “Anna’s” cutting served a self-regulatory function as it offered relief from the tension of both numbness and excessive anxiety, was valid and critical to the client’s eventual growth. The successful conclusion of the Panel of Inquiry was a rewarding experience for the advocate, but it raised questions about the possible need for elaboration of the meaning  of  the judge’s rulings, as well as the need for an agreed upon vocabulary to describe qualities of character  therapists’ possess which do often influence therapeutic outcomes.
Panel of Psychological Inquiry: The Therapist’s Perspective
Authors: Podetz Stacy M.
Published: April 2014

I agreed to have my master's thesis case study with my client Anna" presented by a case advocate before a Panel of Psychological Inquiry, and to testify and be cross-examined before the Panel about my work. I will contrast my thesis defense on Anna's case study with appearing before the Panel, both in terms of my preparation and the myriad of emotions generated by this experience. My experience of the Psychological Inquiry was guided by my commitment to honor the confidentiality of Anna’s story and our process together, while at the same time participating in a demonstration of a new methodology that might be used generally to examine n depth and to honor the work of clinicians.
Findings of the Panel of Psychological Inquiry Convened at Saint Michael’s College, May 13, 2008: The Case of "Anna"
Authors: Miller Ronald B. , Kessler Marc , Bauer Marion , Howell Sandra , Kreiling Kenneth , Miller Melvin
Published: April 2014

This paper briefly describes the proceedings of the  Panel of Inquiry held May 13, 2008 at Saint Michael’s College on the case of “Anna" (Podetz, 2008, 2011).  It summarizes the advocate's and critic's positions on four claims and one counter-claim. The five judges independently voted to accept all four of the advocate’s claims (by votes of 5-0 or 4-1), and rejected the critic's counter-claim by a vote of 3-2.  The panelists all found the educative and pedagogical aspects of the Panel of Inquiry process commendable, but several raised questions about how this methodology would be accepted by their own research and practice communities.
Developing the Adjudicated Case Study Method
Authors: Stephen Susan , Elliott Robert
Published: April 2014

In this commentary we discuss Miller’s Panel of Psychological Inquiry (PPI) and Bohart’s Research Jury method approaches to the development of the adjudicated case study method, as represented by the papers assembled for this issue of Pragmatic Case Studies in Psychotherapy.  In our view, the case studies presented here demonstrate the rapidly developing potential offered by this approach for psychotherapy research and reveal many parallels to recent research using the Hermeneutic Single Case Efficacy Design (HSCED) model. In our view, each of the three models has taken significant steps forward in adapting particular aspects of the legal process as viable psychotherapy research procedures.  In this commentary we summarize the HSCED method, then take readers through the issues of the sources of the evidence used; ways in which that evidence is tested; claims, burden and standard of proof; and the handling of the adjudication process itself.  We conclude with recommendations for further development of adjudicated case study methods..
The "Individual-Case-Comparison" Method for Systematically Comparing Good-Outcome and Poor-Outcome RCT Clients: Editor's Introduction
Authors: Fishman Daniel B.
Published: April 2014

This issue of PCSP explores a promising approach for bridging the gap in communication and mutual respect between therapy group researchers and therapy practitioners: the "Individual Case-Comparison" (ICC) method. This method consists of systematically comparing good-outcome and poor-outcome cases that have both been drawn from a successful randomized controlled trial (RCT) treatment condition. As such the ICC method adopts a "mixed methods" model that integrates group-based, quantitative results with the case-based results of systematic and contextualized, narrative case studies—viewing both types of knowledge as complementary. To illustrate the ICC method, two pairs of case comparisons between a good-outcome and a poor-outcome client are presented. One pair is drawn from the successful condition of an RCT on Dialectical Behavior Therapy (DBT) for borderline personality disorder; and one pair, from the successful condition of an RCT for Emotion-Focused Therapy (EFT) for depression. In each instance, the comparative analysis incorporates detailed qualitative data from the individual cases along with standardized, quantitative process and outcome measures drawn from the RCT studies—showing the "value added" of a mixed methods model. The issue is capped by a wide-ranging and incisive commentary by the Japanese clinical psychologist Shigeru Iwakabe, who discusses the history, logic, and cultural context of the comparative case study method, together with a critical analysis of the DBT and EFT case studies comparisons.
Contrasting Clients in Dialectical Behavior Therapy for Borderline Personality Disorder: "Marie" and "Dean," Two Cases with Different Alliance Trajectories & Outcomes
Authors: Burckell Lisa A. , McMain Shelley
Published: April 2014

Dialectical Behavior Therapy (DBT; Linehan, 1993a) has garnered a strong evidence base to support its efficacy in treating borderline personality disorder (BPD). Despite this, some clients do not benefit from evidenced-based approaches. There is a recent emphasis on identifying the processes and mechanisms of DBT in order to improve treatment outcomes. This report describes the course of treatment for two individuals who were treated with one-year of standard, outpatient DBT in the context of a randomized control trial. The two clients were selected because (1) both reported poor initial alliances, and (2) they had different outcomes. The first case, "Marie," showed considerable change across a broad range of outcomes whereas the second case, "Dean," made only limited treatment gains. The two cases are contrasted in order to highlight potential factors that may have contributed to the different alliance trajectories and outcomes. We explore several hypotheses to help to explain the relationship between treatment outcome and client characteristics, the therapeutic alliance, the consultation team, and the research context.
A Strengths-Based, Skill-Building, Integrative Approach to Treating Conduct Problems in a 12-Year-Old Boy: Rafael's Story
Authors: Clement Paul W.
Published: April 2014

School administrators suspended Rafael, an adopted, 12-year-old boy being raised by a single mother, following an episode of vandalism. They demanded that he enter psychotherapy in order to return to school. Raphael had a history of acting out, aggressive behavior, angry outbursts, disruptive classroom behavior, destruction of property, fighting, lying, stealing, and being teased by peers about his serious birth defects. The initial task facing the clinician was to make a differential diagnosis including to determine what developmental trajectory the youth was following. The first course of treatment covered 29 sessions. Goal setting, assertiveness training, and training in conflict resolution were the major components of treatment. Based on his mother's ratings, Rafael was clearly improved by the 17th session and greatly improved by termination. Eight months later he returned to treatment because of an episode of stealing. The second course of treatment was for 20 sessions. Rafael and his mother evaluated Rafael at intake and at termination during this second course. Based on their input his treatment outcome was extremely positive, with an effect size of 3.02. The article concludes by describing Rafael's major accomplishments during the eight years since treatment ended as well as his plans for a career.
A Case of Rejection, Redemption, and Resilience: Commentary on the Case of Rafael
Authors: Oades-Sese Geraldine V. , Kitzie Mark
Published: April 2014

Paul Clement (2011) presents a unique case of an adolescent with congenital limb deficiency. He integrates a number of approaches that encompass positive psychology, cognitive restructuring, social problem-solving skills, outcome assessment, and a quantitative evaluation of therapeutic change.  We examine this case using resilience as a theoretical framework with an emphasis on identity formation, self-esteem, coping strategies, and assessment. We provide some comments on the strengths of Clement's approach as well as offer suggestions of additional assessment procedures and interventions that may have been beneficial to Rafael's treatment.
Practice-Based Evidence on the Treatment of Conduct Problems in a Child/Adolescent
Authors: Clement Paul W.
Published: April 2014

In this discussion I respond to two commentaries on a case study of my treatment of Rafael, a 12-year-old boy presenting with conduct problems (Clement, 2011b). My response includes shorter consideration of a variety of specific points raised by the commentators. I also elaborate in some detail on one of the points raised concerning my system for measuring treatment outcomes in routine clinical practice. The approach adapts Goal Attainment Scaling, the Global Assessment Scale/Global Assessment of Functioning, and Smith and Glass's 1977 method of calculating treatment effect sizes (ESs). Finally, I frame my case study as an example of practice-based evidence for the effectiveness of psychotherapy.
A Case Study Investigating Whether the Process of Resolving Interpersonal Problems in Couple Therapy Is Isomorphic to the Process of Resolving Problems in Individual Therapy
Authors: Schielke Hugo J. , Stiles William B. , Cuellar Raven E. , Fishman Jonathan L. , Hoener Corinne , Del Castillo Darren , Dye April K. , Zerubavel Noga , Walker David P. , Greenberg Leslie S.
Published: April 2014

The assimilation model of therapeutic change describes the self as comprised of multiple internal voices (mental states), and tracks the development of understanding and joint action between those voices in successful psychotherapies.
Employing a Case Study in Building an Assimilation Theory Account of Generalized Anxiety Disorder and Its Treatment with Cognitive-Behavioral Therapy
Authors: Gray Michael A. , Stiles William B.
Published: April 2014

This theory-building case study aimed to elaborate an account of anxiety and its treatment within an assimilation model of therapeutic change (e.g., Stiles, 2002). A team consisting of the senior author and two other co-investigators independently reviewed the case of Robert, a 52 year-old man who was successfully treated for generalized anxiety disorder (GAD) in a clinical trial of cognitive behavior therapy (CBT). The team observed the expression of Robert's major voices—the assimilation model’s name for the individual parts of a client’s personality—in the audio record of the client’s in-session dialogue. Prominent among these was a critic voice, described by co-investigators as harsh and derisive toward other aspects of the self. Our work led us to infer that, although the critic voice seemed closely associated with the anxiety that characterized Robert's GAD, it did not produce that anxiety directly through its attacks on his other voices. Rather, the critic voice induced vulnerability to specific, anxiety-arousing external circumstances by derogating Robert's coping skills or exaggerating the threat of specific external circumstances. Robert's anxiety then arose when he encountered those circumstances.
Combining Expressive Writing with an Affect- and Attachment-Focused Psychotherapeutic Approach in the Treatment of a Single-Incident Trauma Survivor: The Case of "Grace"
Authors: Pass Erica R.
Published: April 2014

The idea of using a phase-oriented model in the treatment of trauma is an established one.  The first phase aims to establish safety, stabilization, and trust before moving onto the second phase, which involves more direct and intensive processing of trauma.  The third phase serves to consolidate and integrate the gains made in treatment.  The purpose of this study is to determine whether utilizing a phase-oriented model that combines Accelerated Experiential Dynamic Psychotherapy (AEDP), an affect and attachment-focused experiential treatment, with expressive writing enhanced the treatment of "Grace," a single-incident trauma survivor.  While both AEDP and expressive writing are well developed methods, their combination has not been tried before.  Focusing on a  survivor of a single-incident trauma was chosen to best implement the goal of writing about a concrete traumatic event.  In line with the three-phase approach, the "AEDP-Writing" model first utilizes AEDP to build a secure attachment as well as affect tolerance, setting the stage for deeper exploration of a patient’s traumatic history.  Second, the expressive writing component then builds on this base by directly addressing the traumatic incident and processing it in a deeper and more comprehensive manner.  Finally, utilizing both the AEDP and expressive writing approaches, the third phase involves reflection on the work done, consolidation, and celebration of the patient’s true self state of being.
The Case of Grace: Strategic Rationales Underlying the Therapy Process
Authors: Pass Erica R.
Published: April 2014

This is a response to three commentaries to my case study of "Grace" (Pass, 2012), which utilized an integrative treatment for a survivor of a single traumatic incident. My therapeutic approach (the "AEDP-Writing" model) began with a foundation in Diana Fosha’s Accelerated Experiential Dynamic Psychotherapy (AEDP) and then added Expressive Writing to the treatment in order for Grace to more directly process her trauma. Two of the commentaries are by practitioners and scholars of integrative treatment, Stanley Messer and George Stricker, and the third is by a pair of more empirically-influenced researchers, Kara Harmon and Michael Lambert. In the following response, I consider these thoughtful commentaries and offer my feedback.
Assimilative Integration in the Treatment of Trauma
Authors: Stricker George
Published: April 2014

Erica Pass (2012) presents the case of Grace in which she assimilated Expressive Writing within  an Accelerated Experiential Dynamic Psychotherapy approach to the treatment of a young woman reacting to a simple adult traumatic experience. Although the treatment might have been improved by more attention to the patient's angry feelings and cultural background, it was both creative and successful. The treatment provided a good example of the functioning of a Local Clinical Scientist.
The Case of "Grace"-- A Commentary
Authors: Harmon Kara L. , Lambert Michael J.
Published: April 2014

This commentary focuses on the case of “Grace” treated by Erica Pass (2012) through the use of Accelerated Experiential Dynamic Psychotherapy with writing assignments (the "AEDP-Writing" model) delivered over 40-sessions. Grace was experiencing some PTSD symptoms resulting from a single index trauma and was viewed as having a positive outcome by herself, by her therapist, and by her supervisor. The case study included Grace completing self-report measures at the end of therapy both about her present status at the end of therapy and a retrospective view of her status at the beginning of therapy. The significant limitations of change scores based on such retrospective estimates are discussed as well as the advantages of session-by-session tracking of Grace's mental health and symptomatology as a means of calibrating change over the course of therapy and estimating final treatment status. In addition we discuss fundamental factors for consideration in facilitating trauma-focused treatment for clients with PTSD symptomatology, such as avoidance, approach, and approach-resultant rises in symptomatology, and related recommendations for psychoeducation.
On Tone, Play, and Healing: Commentary on Riordan's Case Studies
Authors: McWilliams Nancy
Published: April 2014

The clinical work reported by Riordan (2012) is discussed, with attention to prosody (tone) and other subjectively inferred aspects of his therapeutic style with narcissistically troubled clients. Consideration is also given to cultural contexts relevant to understanding the reported increase in narcissistic problems in contemporary patients, the personality and genuineness of the therapist as factors in psychological healing, and the role of play and playfulness in reducing the suffering of clients who rely on narcissistic defenses to compensate for a fragile, erratic, or unrealistic sense of self-esteem. The focus throughout is on the less specifiable, more artistic elements of the psychotherapy process.
A Personal Perspective on the Treatment of Three Cases of Narcissistic Vulnerability
Authors: Riordan Robert W.
Published: April 2014

ABSTRACT This article is a response to the commentaries of Nancy McWilliams (2012) and Kenneth Levy (2012) concerning my treatment of three patients—Alex, Brian, and Candace—whose presenting difficulties included a narcissistic personality disturbance and who were treated using Mitchell's (1988) integrated treatment model. In addition to responding to particular points raised by McWilliams' more "artistic" and Levy's more "scientific" perspectives, I provide a more personal context and view of my experience in providing therapy to these three patients.
Editor's Introduction: Combining Pragmatic Case Studies Within a Single Case Experimental Design
Authors: Fishman Daniel
Published: April 2014

The target article in the current issue of PCSP by Fredrik Folke and associates (2012) documents and interprets six case studies of cognitive-behavioral therapy for Body Dysmorphic Disorder. This introduction places the article in a larger methodological context from my perspective as editor of the PCSP journal. I first review five types of case studies identified by McLeod (2010) in his seminal book on case study research. These include the main type of case study employed in PCSP, the Pragmatic Case Study, and four other kinds, including those that focus on theory-building, the adjudication of truth claims, the narrative experience of the participants, and single-case experimental designs. I then discuss the advantages of combining Pragmatic Case Study designs with these other types. The Folke et al. article is an example of a successful such combination, integrating parallel pragmatic case studies within a single-case experimental design structure.
Exposure and Response Prevention in the Treatment of Body Dysmorphic Disorder: A Case Series
Authors: Folke Fredrik , Von Bahr Mari , Assadi-Talaremi Vandad , Ramnero Jonas
Published: April 2014

This case study series investigates the effect of Exposure and Response Prevention in relation to other components present in behavioral therapy for Body Dysmorphic Disorder (BDD). Treatment components were added one at a time in four consecutive phases: (A1) Self-Monitoring; (B) Therapist Contact; (C) Exposure and Response Prevention (ERP); and, (A2) Renewed Self-Monitoring. Client assessment involved (a) a daily self-report diary of BDD symptoms throughout treatment, and (b) periodic completion of standardized self-report measures tapping BDD symptoms and related symptoms of depression and global functioning.  In all, six clients participated in the study. Three clients (Ms. A, Ms. B, and Ms. C) made large or relatively large improvements in their daily self-reported BDD symptoms during the ERP phase. A fourth client (Mr. D) did not make such an improvement during this phase, but made overall progress over the course of treatment. All four of these clients achieved statistically significant improvement over baseline on the standardized BDD measure. One client (Ms. E) dropped out of treatment during the ERP phase, and one (Ms. F) chose not to proceed to the ERP phase after receiving education about it. The results indicate that beneficial effects of treatment occurred during the ERP phase for three of the clients, and thus suggest that this component should, in spite of clients’ almost reflexive, initial skepticism, be considered essential in the behavioral treatment of Body Dysmorphic Disorder. The variety of reactions of the different clients to the treatments is documented and discussed, along with an analysis of the factors that differentiated those clients who found the ERP phase helpful and those who did not.