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Case-based knowledge forms an essential element of the evidence base for counselling and psychotherapy practice. This book provides the reader with a unique introduction to the conceptual and practical tools required to conduct high quality case study research that is grounded in their own therapy practice or training. Drawing on real-life cases at the heart of counselling and psychotherapy practice, John McLeod makes complex debates and concepts engaging and accessible for the trainees and practitioners at all levels, and from all theoretical orientations. Key topics covered in the book include: the role of case studies in the development of theory, practice and policy in counselling and psychotherapy; strategies for responding to moral and ethical issues in therapy case study research; practical tools for collecting case data; ‘how-to-do-it’ guides for carrying out different types of case study; team-based case study research for practitioners and students; questions, issues and challenges that may have been raised for readers through their study.

Concrete examples, points for reflection and discussion, and recommendations for further reading will enable readers to use the book as a basis for carrying out their own case investigation.

All trainees in counselling, psychotherapy and clinical psychology are required to complete case reports, and this is the only textbook to cover the topic in real depth. The book will also be valuable to people who intend to use existing case studies to inform their practice, and it will help experienced practitioners to generate publishable case reports.

Moral and Ethical Issues in Therapy Case Study Research

By: John McLeod
In: Case Study Research: In Counselling and Psychotherapy
Chapter DOI: https:// doi. org/10.4135/9781446287897.n4
Subject: Counseling and Psychotherapy
Keywords: clients ; counseling research ; identity ; persons ; publications
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the physician takes upon himself duties not only towards the individual patient but towards science as well; and his duties towards science mean ultimately nothing else than his duties towards the many other patients who are suffering or will some day suffer from the same disorder. Thus it becomes the physician's duty to publish what he believes he knows of the causes and structure of hysteria, and it becomes a disgraceful act of cowardice to neglect doing so, as long as he can avoid causing direct personal injury to the single patient involved. (Freud 1901: 8)

Case studies involve a higher degree of moral risk than other research methodologies. When a client in a large-scale therapy study, such as a randomized trial, completes a questionnaire, he or she provides a set of disparate bits of personal information, which cannot readily be connected into a meaningful picture of the person's life because of the absence of an underlying storyline or social context. In addition, in studies with large samples the researcher has no particular interest in individual participants, and will usually report findings in terms of average scores across the group as a whole. In large scale studies, individuals are not recognizable or identifiable. Their friends, colleagues and families are not recognizable either–any statements that the participant makes about significant others is buried in anonymous statistical data. Moreover, if a participant reads the report of the study, he or she is very unlikely to learn anything about himself or herself, or to find out how the researcher interpreted his or her own individual problems and coping strategies. All of these factors are different in case study research. For a client in a case study, his or her life is being examined. More than this, it is the most troubling, embarrassing or shameful aspects of that life that are being most closely scrutinized. In the account of that life that [Page 55] may be published in a case study, it is not only the person that may be identifiable, but also information about their family members and other acquaintances. In reading the case study, the client may be confronted with personal truths and experiences that they might prefer to lay aside. Worse, they may be confronted with what they regard as distortions of their personal truth. Finally, they may discover what their therapist really thought about them. All of these possibilities are embodied in a document that is in the public domain, and which may be read (and perhaps misunderstood or misrepresented) by anyone, at any time.

The moral and ethical issues associated with counselling and psychotherapy case study research apply mainly to the experience of the client, who is normally the main focus of the study. However, they can also apply to the therapist, whose working practices are being uniquely exposed. And a parallel set of moral and ethical issues arise for case study researchers, who can be faced with crippling moral dilemmas in the process of their investigations.

The aim of this chapter is to examine the moral and ethical issues involved in case study research in counselling and psychotherapy. The chapter begins by outlining the key ethical principles that inform social research, then moves to an exploration of the contours of moral risk that are present within the territory of therapy case study research. The chapter concludes by considering the strategies that can be employed to address these ethical considerations. The underlying assumption that informs the approach taken in this chapter is that ethical research is good research. Attending to ethical and moral issues is not merely a matter of passing the tests set by ethical review boards and committees. Instead, effective attention to ethical issues is a necessary part of creating a moral space in which effective inquiry can take place, in which all participants feel safe enough to make the maximum contribution to knowledge and understanding. Conversely, research that is not sufficiently ethically grounded, may lead to guardedness and a reluctance to share information, on the part of everyone involved.

Basic Moral and Ethical Principles

It is generally accepted, following Beauchamp and Childress (1979), Kitchener (1984) and other authoritative sources, that ethical decision-making in counselling and psychotherapy practice and research should be informed by five moral principles that are fundamental to social life in modern democratic societies: autonomy , non-maleficence , beneficence , justice and fidelity.

[Page 56] Autonomy refers to the right of every individual to freedom of action and freedom of choice, in so far as the pursuit of these freedoms does not interfere with the freedoms of others. In relation to research, this principle implies that a research study is only ethically sound if each person taking part in it has made an autonomous decision (i.e., has not been coerced or induced in any way) to be involved. In practice, this is achieved through the procedure of informed consent.

Non-maleficence refers to the instruction to all helpers or healers that they must ‘above all do no harm’. Beneficence refers to the injunction to promote human welfare. Both these ideas emerge in the requirement in research design that any harm to the client is minimized (non-maleficence), that participants are informed in advance about any possible harm, and that the study should make a positive contribution to the greater good (beneficence), for example by not being trivial or scientifically worthless.

Justice is primarily concerned with the fair distribution of resources and services. Kitchener (1984: 50) argues for the special significance of justice for counselling and psychotherapy in writing that:

psychologists ought to have a commitment to being ‘fair’ that goes beyond that of the ordinary person. To the extent we agree to promote the worth and dignity of each individual, we are required to be concerned with equal treatment for all individuals.

In relation to research, the principle of justice implies that researchers should be mindful of the role of research in working in the interests of oppressed or minority groups.

Fidelity relates to the existence of loyalty, reliability, dependability and action in good faith. Lying, deception and exploitation are all examples of primary breaches of fidelity. The importance in research of maintaining confidentiality in research, and respecting the researcher-participant research contract, reflect the importance of fidelity.

Dilemmas in applying ethical concepts and principles in case study research

Principles of moral action are never straightforward to apply in practice. It is possible to identify a long list of desirable moral qualities and principles, that few people would argue against. It is quite another thing to decide on what is the most morally justifiable course of action in any particular situation. The following examples illustrate some of the potential moral and ethical conflicts that can arise for case study researchers.

[Page 57] A therapist works for several years with a client diagnosed with early onset Alzheimer's disease, and throughout the therapy keeps careful notes, recordings and assessment data. By the end of therapy, the therapist realizes that the data that she has collected constitute a potentially unique account of the role of psychotherapy in enabling a person to adjust to cognitive impairment and other issues associated with dementia. The therapist is faced with the following dilemmas:

Is the client, in the later stages of Alzheimer's, able to give genuine informed consent (the principle of autonomy )?
Does the close relationship between client and therapist mean that the client is being implicitly coerced into agreeing to the therapist's wish to publish ( autonomy )?
How much weight should be given to the therapist's wish to use the case study to argue to make therapy more available to people diagnosed with dementia ( social justice )?
How much weight should be given to the therapist's sense of acting with courage, in pursuing the publication of this case?
Could it harm the relationship between the client and some of his family members to describe his struggles to come to terms with their reactions to the progress of his illness?

A client who has suffered from recurrent depression throughout her life has been recruited to a project based in a university research clinic, that involves collection of comprehensive process and outcome data, leading to inclusion in a case series to be published in book form (so that each case can be reported in detail). The research team at the clinic have carefully explained what is involved, and the client has signed ethical consent forms before the start of therapy, at the end and at follow-up, agreeing that her therapy data could be used within the book, and she has agreed with the researchers how her identity will be disguised. Now, at the final stage of the process, the client has been asked to read and comment on the draft chapter on her experiences. She realizes that:

viewed on paper, the case report is much more revealing than she ever thought it might be ( harm )
she only agreed to go along with the study because it was the only chance to get high-quality therapy without either paying a fortune, or being on a lengthy waiting list, and because she was too depressed to stand up for herself ( autonomy )
what has been written is a compelling and convincing analysis of this particular form of therapy, and it would be a huge blow to the researchers (whom she likes and respects) if it were not to be included in the book ( justice, fidelity ).

How best should these situations be resolved? Note: these scenarios reflect dilemmas where case study researchers have acted with maximum integrity and transparency.

[Page 58] Taken together, these moral concepts represent a comprehensive and complex network of injunctions that informs ethical decision-making in case study research in counselling and psychotherapy. However, they do not, in themselves, provide clear-cut guidance for case study researchers about how to proceed in specific instances. This is because, as in any area of applied ethics, it is necessary to interpret and evaluate the implications of abstract principles in concrete practical situations, by developing ‘case lore’, precedents, examples of good practice and sets of guidelines. Because of the relative neglect of systematic case study methods in counselling and psychotherapy research (and in adjacent areas of research such as psychology), over the past 30 years there has been little work on the specific ethical challenges arising from case study investigations. The following sections of this chapter examine the literature that currently exists in the domain of ethical issues in counselling and psychotherapy case study research, and then provides some preliminary guidelines regarding practical procedures that might be undertaken by case study researchers.

Ethical guidelines from the Pragmatic Case Studies in Psychotherapy journal

Pragmatic Case Studies in Psychotherapy seeks in part to publish systematic and scholarly case studies of psychotherapy. A very important ethical obligation on authors in such publication is protection of the privacy of those clients who are the subjects of the case studies by effectively disguising their identity … The editors expect that an author has taken ‘reasonable steps’ to disguise a client's identity. Consent by the client to the publication of the case study as written is an added plus, but not required. Moreover, even with consent, the author is required to disguise the client's identity in order to reduce any harm that could come to the client because of disclosure of their identity. The issue of how to disguise a client's identity while preserving the important parts of a case's ‘clinical and contextual reality’ is a question that will evolve with experience and will certainly deserve early and ongoing discussion in case-study-method articles in PCSP. Examples of disguise that would not seem to alter context in a major way in many clinical situations is to change the age of a client by a few years (e.g., from 68 to 64); to change the client's ethnic origin from one geographic area to one that is similar (e.g., from one Asian nationality to one that is relatively similar in culture); to change a client's profession (e.g., from lawyer to accountant, both of which are white collar and require similar types of education); and/or to change a client's religion, while retaining the degree of religiosity or spirituality. The decision as to what characteristics to disguise is in part a conceptual decision, based upon separating those factors [Page 59] that are crucial to the clinical reality of the case as opposed to factors that are more peripheral … Other means of protecting confidentiality and reducing potential harm may involve case hybridization where elements of two or three similar cases are combined; publication under an author pseudonym; or posthumous publication a sufficient number of years after the death of the client. Another procedure for enhancing the effectiveness of client disguise involves having the author submit a statement from a colleague in the same geographical area indicating that the information revealed in the case would not be likely to reveal the identity of the client. The advantage is that knowing the geographical area and the base rates of various problems in that area, the likelihood that identity might be deduced would be clearer to a local person than to those who would apply a hypothetical or national standard. (For example, the identity of a case of polygamy in Utah would be a lot harder to deduce than one in Vermont.) … Editorial appraisal of a manuscript will include a thorough examination of the protection of confidentiality in the cases reported in an individual publication. Changes requested in manuscripts may be specifically for reasons of protecting confidentiality. In many clinical contexts, co-workers, co-therapists, and supervisors are also familiar with a case being reported and may provide an additional check on the degree to which the client's identity has been effectively concealed. (For a thorough discussion of the confidentiality issues raised by case study reports, see R.B. Miller (2004), Facing Human Suffering: Psychology and Psychotherapy as Moral Engagement . Washington, DC: APA.)

Research into Ethical Issues in Case Study Research in Counselling and Psychotherapy

Historically, research ethics have been viewed as a topic within the broader fields of moral philosophy and law. Within these domains of inquiry, the advancement of ethical understanding has been built on the analysis of concepts, and working through of the implications of specific cases. In recent years, however, there has been a movement in the direction of supplementing conceptual analysis of ethical issues by carrying out empirical research into the ethical beliefs that people hold, and the ways in which ethical practices are experienced by those who are affected by them. For example, within the area of ethical practice in counselling and psychotherapy, there have been studies of client beliefs around confidentiality and client responses to informed consent procedures. The studies that have been published in relation to ethical issues in case study research in therapy have focused on three questions:

How do clinicians negotiate consent with clients around the publication of case reports?
What is the impact on a client of being a participant in a case study?
What is the impact on a therapist of writing a case study?

The body of research that is summarized below is fragmented, meagre and lacking in methodological rigour. For the most part, the evidence that exists in this area consists of first person accounts or small-scale personal research projects, carried out by therapists who are worried about the moral implications of their publication of client case reports. There is clearly a need for further research into this set of issues. Nevertheless, these studies have a valuable story to tell, which has major implications for those engaged in case study research.

Negotiating Consent

Lipton (1991) carried out a survey of 15 psychoanalytic colleagues, about whether they asked clients for permission before using clinical material for papers or presentations. All of them stated that they would only use case material if the identity of the client could be effectively disguised. Most of them reported that they preferred to use material from cases that were complete. Permission from the client was requested around half of the time, and tended not to be requested where the therapist believed that the client was unlikely to read the professional literature (i.e., would never come across the case study, and was therefore not likely ever to be harmed by it). However, there were many instances where the client's relatives or friends had then read the case study, and informed the client. (Note: this implies that attempts to disguise the identity of the client had not been effective.) Lipton (1991) also found that many psychoanalysts believed that their clients unconsciously wished for their therapist to write about their case (as a sign that the therapist cared deeply about them). Gavey and Braun (1997) carried out a survey of attitudes and practices around informed consent in over 300 counsellors and psychotherapists who had published case study reports, and received 64 replies. Eighty-six per cent of the respondents believed that it was ‘essential in all circumstances’ to seek formal consent to publish material on a client who was currently in therapy, with 25% believing that consent was necessary when a past client was being written about. When asked to respond to a hypothetical scenario about whether a current client being asked for consent would feel able to refuse, over one-third of participants in the survey stated that they believed [Page 61] that it was unlikely that the client would feel free to decline consent. In a study of more than 120 psychoanalysts who had published client case material, Kantrowitz (2006) found a similar lack of consensus over procedures for obtaining consent.

The Impact on the Client

In the survey of psychoanalysts carried out by Lipton (1991), informants reported that, when a case report had been published without client consent but the client had subsequently discovered the paper, clients almost always expressed a negative reaction. These informants believed that this negative response could usually be resolved through further therapy. Lipton (1991) described two examples in his own practice of client responses to case reports for which they had given permission to publish. In each of these cases, the client exhibited a strong negative reaction, shaped by their underlying pattern of psychological difficulty. For one client, the publication triggered feelings about an unreliable father; for the other client, the publication reminded him of his deficiencies, and reinforced his low self-esteem. In both cases, the disturbance caused by the case publication generated material that was worked through in on-going therapy. Lipton (1991) also observed that these clients both re-read the case reports at later periods of personal crisis, which triggered a further round of negative reaction. These findings, from the survey carried out by Lipton (1991), and from his discussion of experiences with his own clients, suggest that, for a client coming to terms with the publication of a case study may require further therapy. This finding underscores the depth of emotional impact of reading a case report, and raises issues around situations in which further therapy may not be available. Kantrowitz (2006) interviewed 11 patients who were not analysts, and 18 patients who were analysts, about their experience of having details of their therapy included in a publication. Reactions ranged from negative (mainly hurt) through to positive (had learned about self through reading the case report). In a review of published accounts of client experiences of reading their case reports, Furlong (2006) similarly found that clients reacted in different ways to reading case reports of their own therapy, on a spectrum from highly positive to highly negative. This review identified several instances where clients sued their therapists following publication of case reports, but were not successful because the court found that the therapist had been acting in good faith in attempting to disguise their client's identity. Furlong (2006) observed that:

[Page 62] Based upon my perusal of anecdotes in the literature pertaining to the negative reactions of patients who believe they have recognized themselves in published articles, what upsets patients is not exclusively, nor even necessarily, what they read about themselves, but what they assess or intuit–directly or indirectly through the material presented–of their analyst's internal life. (Furlong 2006: 760)

The suggestion here is that reading their case study triggers questions for the client about the nature of their therapist's interest in them, and how the therapist thinks about the work. These questions have the effect of leading the client to re-evaluate, and perhaps doubt, the nature of the working relationship or alliance that has existed between their therapist and themselves. Other studies (Graves 1996; Josselson 1996b) have found that case study participants have been deeply affected by personal information that was missing from the case report that had been written about them–details of incidents and experiences that had been hugely significant for them, but which their therapist did not seem to have noticed, or to have considered important enough to write about.

The Impact on the Therapist

It is usual for therapists to engage in considerable emotional turmoil over whether to write about their clients, and what to write (Gabbard 2000). Therapists are concerned about the possible impact on the client of publication, or even of asking about potential publication. They also worry about whether they may be exploiting clients for their own professional advancement and gain. Finally, therapists agonize about the extent to which they are revealing themselves in what they write. Graves (1996: 73) observed that:

the hurdle is the intensely self-revelatory nature involved in my writing about my work as an analyst. This writing exposes, more than I like, my mistakes, blind spots, and other limitations, not only my strengths and capabilities.

Josselson (1996b: 69–70) has described her own experience as a case study author as marked by ‘dread, shame and guilt’:

the dread that I will have harmed someone … guilt … from knowing that I have taken myself out of relationship with my participants … and been talking about them behind their backs and doing so publicly … and shame that I am using these people's lives to exhibit myself, my analytic prowess, my cleverness. I am using them as extensions of my own narcissism and fear being caught, seen in this process.

[Page 63] In contrast to these negative aspects of writing about clients, there are some therapists for whom the experience of publishing case studies is viewed more positively. There are some accounts of therapists looking on such publications as a form of self-supervision. Kantrowitz (2006) interviewed several psychoanalysts who intentionally used published case reports on on-going clients as a therapeutic technique, on the basis that the written word would convey certain therapeutic messages in a particularly powerful manner, and function as a type of ‘transition object’ for clients. These therapists anticipated and relished the negative reactions of their clients to their case reports, as grist to the therapy mill. (Incidentally, Kantrowitz (2006) had some misgivings about the wisdom or effectiveness of this strategy.)

This review of studies of the experiences and attitudes of clients and therapists around the process of producing therapy case studies is necessarily selective, for reasons of space. The literature on this topic is dominated by reports written by psychoanalytically oriented therapists (Gabbard and Williams 2001; Galatzer-Levy 2003). In some respects this psychoanalytic emphasis represents a weakness in the case study ethics literature, since it would clearly be of value to know about how clients and therapists feel about their involvement in other types of therapy case study inquiry. On the other hand, a psychoanalytic perspective is one that is particularly sensitive to the relational dynamics of case study publication, and aspects of this process that may not be readily available to conscious awareness (on the part of both therapist and client).

There are perhaps three central conclusions that can be drawn from the studies that have been discussed. First, these studies have identified multiple dimensions of ethical sensitivity, which are linked in complex ways to the personality and adjustment of clients and therapists, the stage in therapy when the case study is written, and the process of informed consent that has been employed. There is little evidence, from client or therapist accounts, that disguising the identity of the client is sufficient in itself to deal with the ethical issues arising from therapy case-based research. Second, the research suggests that there is a lack of consensus within the professional community about how to handle the ethical implications of case study research. For example, some case study writers believe that informed consent should be essential, while others disagree. Third, when writing a therapy case study, it is necessary to be mindful of the potential impact on the client, as well as the meaning that the study may have for professional readers. As one case study writer put it, the key for him was to focus on ‘keeping the patient as my audience’ (Graves 1996: 78).

Strategies for the Ethical Conduct of Counselling and Psychotherapy Case Study Research

The core ethical issues, in relation to case study research in counselling and psychotherapy, are:

obtaining informed consent from clients, in relation to being a subject of a therapy case study;
maintaining confidentiality;
avoiding harm to case study participants.

The nature of these issues, and the advantages and disadvantages of different strategies for dealing with them, are discussed in the following sections.

Informed Consent

The standard practice in counselling and psychotherapy research is for clients to read an information sheet in advance of taking part in a study, and sign a consent form. The information sheet usually specifies: the aims of the study; what the person is being asked to do, in terms of completing questionnaires, being interviewed, etc.; the possible risks associated with participating in the study; what to do if anything harmful occurs; how the data will be stored, and for how long; how confidentiality will be guaranteed in any research reports; who to contact if there are any problems; who has given ethical approval for the study to take place. The person needs to be given a suitable period of time to make their decision on whether or not to take part, should be provided with an opportunity to ask questions and is given a copy of the informed consent information sheet as a research ‘contract’ to keep for future reference. There should be no inducement or pressure involved in the consent–for example, the person should receive therapy whether or not they agree to take part of the research, they should be free to withdraw from the study at any stage without jeopardizing their therapy and the benefits of taking part must not be exaggerated. In research situations of particular ethical sensitivity, the procedure of process consent is often applied (Grafanaki 1996, 2001). Process consent means that the initial consent is reinforced and revisited at regular intervals. For example, if the study involves recording therapy sessions, the therapist may ask for permission to record at the start of every session, and remind the client [Page 65] that the recorder may be turned off at any stage. A further example of process consent (also referred to as rolling consent or provisional consent ; Simons 2009: 103) would be to make recordings, and then ask for additional consent at the end of therapy to use them for research purposes (on the grounds that the person will have no idea at the start of therapy what the recordings might include), or to ask the client to delete sections of interview or session transcripts that he or she does not want to be included in the research data.

In relation to case study research, the procedure of obtaining informed consent generates a number of critical ethical issues:

1 When should consent be sought? Winship (2007) makes a useful distinction between prospective case studies (where the study is planned before therapy commences) and reflective case studies (where the idea for the case study only emerges during therapy, or following termination). In relation to prospective studies, the practice of process consent, where the person agrees in principle, at a pre-therapy meeting, to take part in a case study (by allowing data to be collected), while knowing that final agreement will take place later, once the therapy is complete, is ethically sound. In this situation, maximum autonomy is offered to the participant–he or she has as much control as possible over what is happening. The implication here is that best practice in case study research involves routinely using a consent procedure with all new clients, even if only a few of them will eventually be written up as published cases. In relation to reflective case studies, the action of seeking consent during therapy is more ethically problematic, because the client is in a less autonomous position, in the sense that they have developed a relationship of trust with a therapist, and may wish to please the therapist by agreeing to take part in the study, or fear rejection by the therapist if they decline. Seeking consent after the completion of therapy is also ethically problematic, because the very act of contacting the client may cause harm, by restimulating memories of the therapy, or being viewed as holding out the possibility of a different type of relationship with the therapist. Careful consideration therefore needs to be given to alleviating the risks associated with seeking research consent during therapy, or after therapy has been completed. A compromise position may be to ask for consent at the final session, for permission to make contact at a later date for a further discussion around taking part in case study. Another factor to take into consideration, if consent is sought during therapy, is the nature of the new contract. Does it merely consist of proceeding as before, but with the possibility of using data for a case study? Or does it consist of the introduction into therapy of additional data collection procedures? Clearly, the latter implies a more serious intrusion into the on-going therapy process, with greater possibility for harm.
2 Who should negotiate the consent? In many published case studies, the whole research or inquiry process, including seeking consent-taking, is carried out by the client's therapist. This practice in not ideal, from an ethical perspective. The therapist–client relationship is generally viewed within the profession as being boundaried and ‘special’, with a great deal of caution being expressed over any unavoidable dual relationships. There is a broad consensus that the ideal arrangement is for a therapist to be solely a therapist for the client, and eschew any other type of relationship that may intrude on confidentiality, the process of therapy, etc. Where other relationships are unavoidable (for instance, in small rural communities), therapists find themselves devoting a lot of care and attention to how to handle the boundary issues that emerge (Lazarus and Zur 2002). So, in order to ensure that the client receives the best possible therapy, if a case study is being envisaged, it is helpful if someone else (e.g., a colleague) takes responsibility for the management of the consent process. The other advantage of such an arrangement is that the client then has an independent person to consult, if he or she has any questions or complaints about the research.

Confidentiality

It is standard practice in counselling and psychotherapy research to provide a guarantee to the client that research information will be stored securely, with personal details separate from any participant information. Typically, participants are also told that research data are destroyed within a specified time of completion of the study. It is usual to let research participants know that individuals will not be identifiable in any reports arising from the study, and that any information that is contributed to the study will be used only for research purposes. In some ethically sensitive areas of research (e.g., where the informant may be disclosing information about illegal or abusive behaviour that they have observed), the researcher needs to let the participant know about the conditions under which confidentiality might be limited. All of these confidentiality procedures apply in case study research. However, in case study research there are particular issues around the requirement that individuals will not be identifiable, because of the large amount of detailed personal information that may be included in a case report. In addition, there are issues around the potential identification of people other than the case study subject (e.g., family members or work colleagues). It is possible to address these issues through the use of a number of strategies:

Disguise. Information about the case participant or other people described in the case study can be altered to make it more difficult to identify them. It is relatively straightforward to change details such as name, age, occupation and place of residence. It is somewhat harder to change the details of the person's story so that it is not recognizable. The main difficulty with the use of disguise as a means of ensuring confidentiality is that it is fairly easy to alter information so that general readers will not be able to identify the case participants. It is much harder to achieve a level of disguise that will safeguard the case in respect of readers who are family members, friends or work colleagues. If the case is disguised sufficiently that these significant others would not be able to identify the client, the question is raised about whether what is published can actually claim to be a fair representation of the case.
Deleting information. A further form of disguise is to omit segments of the case material, identified by the client or by an independent consultant, that may be particularly sensitive in terms of confidentiality.
Constructing a composite case. If the researcher has studied several cases of the same type it can be possible to combine features of each case to create a composite case, which accurately reflects the therapy outcome and process that has been studied, while safeguarding the identity of participants.
Using a case series. If a series of cases have been studied, it is possible to write about them in such a way that only a limited amount of information is provided on each individual case participants. In effect, the limited space that is available for reporting each case makes it easier to omit confidentially sensitive information.
Delayed publication. Some therapy case reports have been published only on the death of the client or patient. Clearly, this strategy does not deal with the question of potential confidentiality breaches around the interests of significant others, and in fact may make it harder to address such issues because the client is not available to advise on how best to alter information to protect family members, etc.

On some occasions case study participants may not want their identity to be concealed, because they wish to use the case study to tell their story in an open and transparent manner. In these situations it is essential to support the person in making an informed, reflective choice, based on a realistic appraisal of the potential consequences of publication of a case report in which they can be explicitly identified.

Consideration needs to be given to the decision-making process around the use of disguise or deletion in case study reports. If possible, it is good practice to invite the case participant to indicate the information that he or she would wish to be changed or deleted, and to suggest the kinds of changes that would satisfy them, for example in relation to [Page 68] alterations in age or occupation. If the case participant is not available to engage in this kind of consultation, it can be valuable to use a third party to audit any changes that might be made by the researcher.

Avoiding Harm

There are three main forms of harm that can arise for clients who take part in therapy case study research:

intrusion on the therapy process;
the impact of reading the case report;
negative consequences of breaches of confidentiality.

There are two forms of risk of intrusion on the therapy process. First, there is a generalized risk that may arise when a client agrees to take part in a research programme, and then becomes worried or inhibited throughout the course of therapy by fears around the security of the information that they are providing, or around whether they are being manipulated in some way for research purposes. For the majority of clients, this kind of negative experience can be avoided by offering opportunities to ask questions about the research study, at any stage in the research process. There is evidence that the majority of clients in research studies describe their participation as enhancing the therapy they receive (Marshall et al. 2001). However, it is probable that there is a small minority of clients who are highly sensitive around any kind of research procedure. A second type of intrusion on the therapy process occurs when the therapist alters his or her behaviour as a result of knowing that their work with a client may be published as a case study. This knowledge may motivate the therapist to try harder, and make better use of supervision, which would probably be to the advantage of the client. A more problematic consequence arises if the therapist starts to focus on aspects of the therapy process that they believe may be of particular interest for the case study analysis. For example, if a client engages in some effective dream work in the early stages of therapy, and the therapist decides that the case might be worthy of publication, there may be some pressure exerted on the client to continue to produce dream material, even when the natural course of therapy may have moved into another type of work. In respect of the risk of intrusion arising from a shift in therapist stance, it is essential that the therapist's clinical supervisor should be informed about any case study inquiry that is being undertaken, and should be willing to challenge the therapist on the effect of the case inquiry on the way that he or she might be working with their client.

[Page 69] There is evidence, reviewed earlier in this chapter, that it can be harmful for some clients to read case study reports in which they are featured. From a therapist perspective, it can be argued that the disturbance experienced by a client of reading their case report has potential therapeutic value, in raising issues that had not been sufficiently worked through in the therapy, and which may now be resolved through further therapy. From this perspective, it could be argued that any upset arising from reading a case report is ultimately beneficial, because it leads to the person facing up to personal issues that have previously been avoided. However, this position carries little weight from a moral or ethical point of view. The ethical principle of autonomy implies that any decision to extend or re-enter therapy must be one that the client makes for himself or herself. It is not ethically acceptable to plan a research study around the possibility that participation in the study may result in the need for further treatment. It is not easy to devise ways to deal with this particular ethical dilemma. There are many instances in which clients appear to appreciate reading their case reports, and report that they have benefited from the experience. It does not seem justified, therefore, to devise case study research protocols that eliminate client reading of case reports. Such a policy would, in addition, make it impossible to make use of client collaboration around disguising and other confidentiality procedures. There would appear to be two potentially valuable strategies for dealing with the possibility of negative client reactions to reading their case reports. One strategy would be to give careful consideration to the way that the report is written. In some therapy approaches, such as Narrative Therapy (White and Epston 1990) and Cognitive Analytic Therapy (Ryle and Kerr 2002), clients receive letters from their therapists. There is evidence that clients find these letters helpful. In most instances, these letters include information that might well be part of a case study. It may be useful for research into case study ethics to look at the forms and structures of writing that are most or least likely to be viewed as facilitative (or personally hurtful and destructive) by clients. A second strategy for reducing potential damage associated with reading case reports might be to ensure that the case is audited by an independent reader before being sent to the client, and that the client then has an opportunity to meet with this reader (or that the client actually reads the report in the presence of this independent person). It seems likely that one aspect of the ‘shock’ of reading a case report, for some clients who have agreed to take part in case studies, is that the report represents an unmediated exposure to a different ‘voice’ of the therapist, one that is saying a lot more, saying different things and addressing a different kind of audience. It may be that the involvement of a third party could [Page 70] be a useful way to allow the client to gain some distance from their memories of their therapist's ‘voice-for-me’ and appreciate why the report has been written in a particular way. The provision by the therapist of a covering letter to the client could serve a similar purpose. In situations where the case analysis is conducted by a research team that does not include the therapist, some further considerations may apply. The research team may not know the client well enough to be able to anticipate how the client may respond to reading certain passages. Also, the views and experiences of the therapist may be incorporated in the report, but transformed or edited by the researchers in a manner that may be confusing for the client.

Negative effects of breaches of confidentiality can occur when a case study report is read by people who can identify the client and are influenced by what they have learned about this person. For example, an employer or director of a training programme may discover through a published case study that someone they are employing or considering for acceptance into training has a history of mental health problems, or is gay, lesbian or bisexual. These are factors that may result in a failure to be promoted, or to be accepted into training, depending on the circumstances. These areas of personal information are ones whose disclosure is generally accepted in most societies as being at the discretion of individuals. Unintended disclosure through a case study publication may be directly harmful for the person in terms of income, employment and career development. In other spheres of life unintended disclosure may have repercussions for relationships between family members, or between work colleagues. These risks underscore the requirement for careful handling of disguise and deleting procedures during the process of preparing a case study for dissemination. In considering the issue of unintended disclosure of personal information in case study reports, it is important to keep in mind that the authorship of the report can provide clues to the identity of the client. A reader of a case report may think ‘I know someone who saw that therapist’ or ‘I know someone who attended that counselling centre’, and thereby be sensitized to seeing through the disguise that has been built to defend the identify of the case study client.

The Distinction Between ‘Procedural Ethics’ and ‘Ethics in Practice’

The discussion so far has demonstrated the complexity of ethical issues associated with case study research in counselling and psychotherapy. In [Page 71] seeking to make some sense of this complexity, in terms of identifying guidelines for practice, it is useful to make a distinction between ‘procedural ethics’ and ‘ethics in practice’ (Guillemin and Gillam 2004). Procedural ethics refers to the ethical procedures that are required by institutional ethics committees and boards, in terms of participant information sheets, consent forms and the like. By contrast, ethics in practice, or ‘microethics’, refers to the moment-by-moment ethical decision-making that takes place in interaction with research participants, ‘the difficult, often subtle, and usually unpredictable situations that arise in the practice of doing research’ (Guillemin and Gillam 2004: 262). In counselling and psychotherapy case study research, microethical issues arise when talking with a client about whether they might be willing to be involved in a case study, or about their response to a case study paper that has been written about their therapy. Another example refers to whether or not to ask a client in the first place–is he or she at a point where they could meaningfully say ‘no’? The intricacies of ethics in practice are demonstrated very clearly in the transcripts of discussions between Kim Etherington and two clients, about the basis on which they might want to work together on producing a joint case report (Etherington 2000). It seems reasonable to categorise virtually all of the psychoanalytic and other research and writing on case study ethics, reviewed earlier in this chapter, as being concerned with ethics in practice rather than with formal procedural ethics. The tendency within the psychoanalytic community, responsible for most of this literature, has been to avoid establishing clear-cut procedural rules, and to retain as much of the ethical process as possible within the discretion of the analyst.

From an ‘ethics in practice’ perspective, three main strategies have been suggested as necessary to ensure that morally justifiable decisions are made. First, Etherington (2000) proposes that the process of ethical decision-making should be as collaborative as possible. It is only through an open sharing of all aspects of the decision to publish that the client can feel truly safe and respected. Second, Guillemin and Gillam (2004) propose that researcher reflexivity is a necessary element of microethics–the researcher needs to be aware of his or her own needs and motives, and to pay attention to what is happening during ‘ethically important moments’ when moral choices become crystallized (‘should I push the client a little more to agree, or should I back off?’). Finally, Ellis (2007) argues that the practice of research should be informed by a relational ethics in which the researcher is mindful of the responsibilities that arise from being in relationship with another person. Ellis (2007) shares some compelling stories of her own failure, early in her career, to respect the [Page 72] relationships that she had formed with research informants. From her point of view, in her interactions with these participants, she was acceding to the requirements of the ethics procedures that had been approved by her university. On the other hand, from their point of view , she was betraying friendship ties in the way that she wrote about them. These three characteristics of effective ethics in practice–collaboration, reflexivity and mindfulness of relationships–are not at all easy to separate out from each other, but can be viewed as facets of an essentially person-centred attitude.

Both procedural ethics and ethics in practice are necessary in counselling and psychotherapy case study research. No matter how tightly defined a set of ethical procedures might be, bad things can still happen to clients and therapists, if ethically important moment are not handled well enough. This implies that case study researchers need to be sensitive to the complexities of what can happen around this kind of research. On the other hand, ethics in practice/microethics are ungovernable. There is no way that a body that assumes responsibility for ethical standards, such as a university ethics board, can or should ever accept as an argument that a study will be conducted in an ethically sound manner because the researcher is reflexive and committed to collaboration. It is the duty of the ethics board to ask: ‘How can we know that these virtues are being enacted?’ It is inevitable, therefore, that ethically acceptable case study research should take place within a structure that ensures that potentially vulnerable participants are safeguarded by an externally verifiable set of guidelines.

A final implication of an acknowledgement that case study research is likely to throw up microethical ‘moments’ that are not covered by any formal ethics protocol, is that students undertaking case study research need to be provided with adequate support and supervision, because it would be unreasonable to expect them to possess the experience to handle the type of intricate ethical collaboration exemplified in Etherington (2000). This issue is sensitively explored by Ellis (2007), who is clear that if a relational ethical stance is to exist between student-researcher and participant, it also needs to exist between student-researcher and supervisor.

Guidelines for Ethical Good Practice in Case Study Research in Counselling and Psychotherapy

There are a number of distinctive ethical issues associated with case study research in counselling and psychotherapy that are not explicitly [Page 73] addressed in the existing codes of research ethics that have been published by professional bodies such as the American Psychological Association or the British Association for Counselling and Psychotherapy, or within the author guidelines of relevant journals. The following Ethical Guidelines for Case Study Research in Counselling and Psychotherapy are intended to provide a tentative framework for those involved in case study research.

1 The conduct of all case study research and inquiry in counselling and psychotherapy (including clinical case studies) should adhere to the research ethics codes of the professional groups to which the authors of the case reports are affiliated.
2 Authors of therapy case studies should be transparent about the ethical procedures that have been conducted in relation to their studies, and provide details of these procedures within all case publications.
3 The ethical procedures used within any case study project must always be subject to expert external scrutiny, in the form of an institutional approval committee or board, or an equivalent consultative process.
4 It is advised that, wherever possible, prospective informed consent for in-principle case study participation should be obtained from clients before the commencement of therapy, and then at all further stages of the inquiry cycle up to and including the final release to publish ( process consent ). The person who undertakes the informed consent procedure must not be the therapist conducting the case.
5 In situations where prospective informed consent is not feasible (e.g., decision to conduct a case study made following commencement of therapy) alternative consent procedures must be approved by an appropriate institutional approval committee or board, or an equivalent consultative group, and include the involvement of an independent consultant who will undertake all negotiations with the client.
6 In situations where informed consent is not possible (e.g., the client is not contactable) at least two independent expert consultants should audit all aspects of the inquiry process, as advocates of the client.
7 Good practice in case study research involves providing the client with an opportunity to comment on a draft of the case report, and to stipulate the deletion or disguising of material for confidentiality purposes. Good practice involves encouraging the client to make a personal statement about the case report, to be included in the final published version.
8 Clients must be offered support, from an expert independent consultant as well as the researcher and/or therapist, at the point at which they are invited to comment on the draft report. If possible, this support should continue to be available to the client for a period of 5 years following publication of the study.
9 In case study research where the principal investigator is not the therapist for the case, the therapist should undergo an informed consent and release process similar to that of the client.
10 In case study research where the therapist is the principal investigator, the therapist must engage in clinical supervision or personal therapy with the explicit contracted aim of examining personal factors associated with the case study work, as a means of ameliorating the impact of these factors on (a) the client, (b) bias within the case report and (c) the well-being of the author.

These guidelines are informed by a quasi-judicial approach to case study research (see Chapter 2 ), in advocating various forms of ‘witness protection’ for case study participants. The guidelines that are presented here must be regarded as offering no more than a preliminary effort to construct a template for good practice in this area of therapy research. To establish some future version of these guidelines as an authoritative source of guidance will necessarily involve further discussion and debate within professional associations and the research community, and empirical and conceptual research that subjects these ethical principles to critical test.

Conclusions

The message of this chapter, however, is not merely that personal and professional virtue is a requirement for morally responsible case study research, but that an organized collective approach is necessary. If therapy case study research is to thrive, the profession as a whole needs to be willing to identify the principles and standards of ethical good practice that are to be followed, and to carry out research into the effectiveness of different types of ethical procedure. At the present time, there appears to be a lack of consensus within the professional community regarding what is or is not acceptable in relation to case study research. This vagueness is undermining the case study cause, because it means that individual researchers need to possess high levels of courage, resilience and confidence/competence in order to pursue case study projects. We need to make it morally easier for students, practitioners and new researchers to engage in case study work. Although there are moral and ethical challenges associated with case study research, these issues are arguably less severe than the ethical dilemmas arising from carrying out a randomized trial in which clients may be denied treatment. However, there have been several decades of debate that have hammered out ethical safeguards that enable ‘trialists’ to proceed with confidence. A similar process is necessary in respect of case study methods.

Topics for reflection and discussion

What was the process of consent-giving that I went through, in advance of this study being published? How adequately did that process prepare me for what I am now reading?
What are the statements in the report that jump out at me? What makes these statements so significant for me?
How does this study make me look? What might other people in my life think, if they were to read it?
What do I now think and feel about my therapist?
What have I gained or learned, as a result of this case study?

It is useful to take notes of your reactions to the case study. Once you have completed the task of imaginatively identifying the world of a case study client, reflect on the implications of what you have discovered for yourself as a therapist, and/or as a case study researcher.

2 Imagine that you have carried out a therapy case study, and are now in a position to invite the client to read your draft case report. You have decided to follow the ethical guideline suggested in this chapter, and have asked a colleague to facilitate and support the client through the process of reading and commenting on the report, and making suggestions for ensuring confidentiality. How would you brief the colleague? How would you expect your colleague to approach this task? What training or preparation might your colleague need?
3 Most of the literature around ethical issues associated with case study research has been generated by writers with a psychoanalytic or psychodynamic orientation. How generalizable are the issues and concerns that these writers have identified? Are there different issues and concerns that might arise in behaviourally oriented ‘n=1’ studies, or HSCED studies?
4 Nigel is a senior social worker, who routinely consults with colleagues around decisions about whether to take children into care, the career development of staff in his team and many other issues. Nigel has been in intensive psychoanalytic psychotherapy for two years, mainly to deal with [Page 76] the effect of abusive childhood experiences. As he arrives at the final point of a planned ending to this successful therapy, his therapist wishes to write up the case, and is wondering whether or not to ask Nigel for permission, and then whether or not to ask for his comments on a draft of the paper. What are the main issues here, for both Nigel and his therapist?
5 To what extent might the process of asking clients to approve the publication of case reports eventually result in a largely worthless body of knowledge, owing to the fact that therapists had been inhibited from expressing their true perceptions of clients?
6 It has been argued that attempts to disguise the identity of clients undermines the scientific objectives of research, by supplying readers with false information. Do you agree?

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Garret Counseling > Ethical Dilemmas in Counseling: A Review of Case Studies and the Code – May 26th, 2023

Ethical Dilemmas in Counseling: A Review of Case Studies and the Code – May 26th, 2023

Jan 16, 2023 | Brave Play , Past Event

Presenter: Dr. Ashley Garrett, PhD, LPCS, RPTS, ACS, NCC Date: Friday May 26th, 2023 Time: 10:00am-12:00pm (CST) Location: Garrett Counseling – Jacksonville Cost: $30.00 (Payment link will be emailed once you register) 2.00 NBCC Clock Hours Total (ETHICS)

Workshop Description: Special attention is paid to issues related to fidelity, integrity, justice and rights violations and topics including informed consent, confidentiality, mandated reporting, and HIPAA. Case studies throughout the workshop materials highlight key learning points.

Learning Objectives: Participants will be able to:

Recall at least 3 ethical considerations for Fidelity, Integrity, Justice, & Rights per the ACA Code of Ethics.
Review 2 case studies and demonstrate the ability to use a decision making model to make ethically sound decisions.

Brave Play offers continuing education for mental health professionals that is interactive and experiential. You’ll come away with more knowledge, new skills to enhance your practice, renewed energy, and meaningful connections. In today’s fast-paced world and complex mental health systems, many practitioners feel overwhelmed and experience burnout and other health problems. Our professional training is designed to offer you a safe space with unique opportunities to nourish your personal and professional selves. For information about our speakers visit us here .

*Garrett Counseling has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6763. Programs that do not qualify for NBCC credit are clearly identified. Garrett Counseling is solely responsible for all aspects of the programs NBCC ACEP Provider No. 6763. *Garrett Counseling is approved by APT to provide continuing education. Garrett Counseling maintains responsibility for this program and its content. APT Approved Provider 15-430. *By registering for this event you are giving Brave Play / Garrett Counseling permission to use video and photography for advertisement on all marketing material, including social media. You understand that all of GCC property is being recorded and all common areas have voice and video recordings. By registering and attending you are giving permission to GCC for both voice and video recordings on company property.

Cancellation Policy: If you contact us before the program date, you may exchange for a certificate to attend another program or a tuition refund less a cancellation fee of $10.00. Occasionally, changes are made due to unforeseen circumstances or participant demand. While Garrett Counseling will do everything possible to ensure participant satisfaction, Garrett Counseling’s liability is limited to the tuition fee only. If you cancel, 10 business days before the event, you will receive a full refund. Cancellation must be received in writing and can be faxed to 1-256-217-4162 or emailed to [email protected]. If cancellation is not received in writing, you will be charged the full amount of tuition.