CASE STUDY METHODOLOGY: FUNDAMENTALS

AND CRITICAL ANALYSIS

From:
Cognitie, Creier, Comportament
Date:
June 1, 2007
Author:
David, Daniel
More results for:
APPLICATION OF REBT AND SELF ESTEEM publication:["Cognitie Creier
Comportament"]

http://www.highbeam.com/doc/1P3-
1336338121.html
ABSTRACT

This article presents the fundamentals of case study methodology. After a

brief history, the presentation is based on a critical analysis to understand
the role and the place of case study methodology in scientific research. Thus,
both the advantages and the limits of this research method are discussed
and the step-by- step procedure is presented and then exemplified in a
clinical context.

KEYWORDS: case study research.

I. INTRODUCTION

1. A Brief History

The history of case study methodology as a scientific research procedure is

marked by periods of ups and downs. The earliest use of this form of
research can be related to psychophysics and medicine. In the United States,
this methodology was most closely associated with the University of Chicago.
In 1935, there was a public dispute between Columbia University
professionals, who were championing the "scientific methods" (i.e.,
experiment), and the "Chicago School" (Tellis, 1997). The outcome seemed to
be in favor of Columbia University and consequently the use of case study
methodology as a scientific research method declined (Tellis, 1997).

However, in the 1960s, researchers were becoming concerned with the

limitations of quantitative methods. Hence there was a renewed interest in
case study, although the case study methodology is not a pure qualitative or
quantitative method (Tellis, 1997).

Indeed, a quick PsycInfo based scientometric analysis confirms this history.

From 1806 to 1969 about 1319 articles dealing with "case study" and about
11171 articles dealing with "experiment" were published; the ratio is about 1
to 9. From 1960 to present, about 23151 articles dealing with "case study"
and about 46069 articles dealing with "experiment" have been published; the
ratio is about 1 to 2, which proves an increased interest in this methodology
in the psychological field.

The case study research method is defined as "an empirical inquiry that
investigates a contemporary phenomenon within its real-life context, when
the boundaries between phenomenon and context are not clearly evident,
and in which multiple sources of evidence are used" (Yin, 1984, p. 23). Thus,
case study methodology uses in-depth examination of single and/or multiple
case studies, which provides a systematic way of approaching the problem,
collecting and analyzing the data, and reporting the results.

Many proponents of case study methodology argue that it is a

comprehensive method usable for a large spectrum of problems (Yin, 1994).
On the other side, its critics argue that the study of a small number of cases
can offer no support for establishing reliability or generality of findings. Other
critics believe that the intense exposure to study of the case biases the
findings and that case study research can be use only as an exploratory tool
(see Susan, 1997).

The present article discusses the fundamentals of case study methodology.

We will not go into details, which can be found in many handbooks on this
topic. Rather, we will present the fundamentals in a critical manner so that
we can understand the condition of validity of the case study methodology in
scientific research, beyond the positions of its fervent supporters and critics.

2. When to use case study?

The aim of scientific research is to produce knowledge that can be used to

solve various problems, either theoretical or practical. Therefore, the use of
case study methodology as a scientific research tool will be determined by
the type of knowledge needed to solve a target problem. More precisely, a
case analysis methodology is rigorous and acceptable in scientific research
provided it meets the aims of the research. A review of the literature
suggests the following conditions in which case study methodology is
indicated in research.

(1) Case study methodology can be used as an exploratory methodology

helping to generate scientific theories. A scientific theory is an organized
system of propositions embedding knowledge. Some of these theories have
a descriptive role, while others have an explanatory and predictive role. As an
organized system of propositions, a theory also has a role in organizing our
knowledge about various phenomena.

(2) Case study methodology can be used to test a scientific theory. This is a
heated discussion in epistemology. As we have shown above, many critics of
the case study methodology think that the study of a small number of cases
cannot offer a basis for the reliability and generality of findings and thus, in
testing a theory.

The proponents of case study methodology (e.g., Yin, 1994) defend it by

arguing that (1) the generalization of results is made to the theory not to
populations; and (2) case study methodology provides generality by
replication rather than sampling logic. Typically, a theory is tested based on
two procedures: verification (i.e., trying to find examples congruent with its
predictions) and falsification (i.e., trying to find counter-examples to its
predictions). In our opinion, case study methodology can be used to test a
theory in the second case only. According to Karl Popper,
falsification/falsifiability is the most rigorous method to test a scientific
theory. Falsifiability implies that for an assertion to be falsifiable it must be
logically possible to make an observation that would show the assertion to be
false. Thus, if only one observation does not fit with the assertion, it will
invalidate the theory, which should be either dismissed or revised. Case study
methodology is very much appropriate to rigorously identifying and analyzing
such crucial observations. Having said that, we remind our readers the Quine-
Duhem thesis, which argues that each theory is tested in conjunction with a
number of auxiliary hypotheses. If a prediction is falsified, this could mean
that there is something wrong with the conjunction between the theory and
the auxiliary hypotheses rather than the theory is false (Greenwood, 1989).
Thus, Quine argues that a scientist is never forced to reject a theory in the
face of recalcitrant data; the theory can be preserved by the modification of
the auxiliary hypotheses (Greenwood, 1989). In the case of verification,
replication (e.g., by including multiple case studies) provides indeed support
for generality but because the cases are not in the same framework (i.e., the
same context and time) as in sampling logics, the probability of error is
increased. To make a long story short, in theory, case study methodology can
be used to test a theory by following a falsification rather than a verification
logic; however, in practice it is hard to meet this condition for the reason
briefly discussed above.

(1) Case study methodology can be used to exemplify an already validated

theory. This is very important for didactical reasons and for reinforcing an
already validated theory because this condition can also be conceptualized as
an effort to further test the theory following the falsification logic described
above.

(2) Case study methodology should be involved in research when knowledge

is intended to be used and refers to the investigated case studies only.
Indeed, case study methodology uses in-depth examination of single and/or
multiple case studies, and thus, it provides a systematic way of rigorously
understanding these cases.

(3) When no other cases are available (i.e., critical and/or unusual cases), the
researcher is limited to case study methodology (i.e., single-case design). If
the objective is similar to that described at point 4, case study should be the
choice research methodology.

3. When to avoid using case study?

Case study is not useful in testing a theory based on verification, and then
arguing that the theory is validated. Generally, the choice for or against case
study methodology depends on the problem we have to solve. If the problem
implies knowledge based on sampling logics, case study methodology should
be avoided.

4. Case Study Step-by-Step

There are several components of a good case analysis methodology:

a. The research should start with the problem - the study question. The
problem can be defined as a discrepancy between an initial state (what he
have) and a final state (what we want to have). A rigorous problem will define
precisely the initial state and will specify clearly the objectives. A serious
problem is one in which the discrepancy between the initial and final states is
approachable by current methodology. For example, if my proposed final
state is to eliminate all mental disorders in the next two years, this will not be
considered a serious problem considering current knowledge in clinical
psychology and medicine.

b. The objectives and/or the hypotheses should be made clear (if they exist).

c. The next step involves defining the unit of analysis and than data
collection. It must be made clear that data collection can be guided by either
quantitative and/or qualitative methods. Data can come for various sources
and depending on the problem and objectives, it can be collected
qualitatively (e.g., by interview) and/or quantitatively (e.g., numerically).

d. Once collected, the data is analyzed quantitatively and/or qualitatively. If it

was collected qualitatively (e.g., by interview) it can be analyzed either
qualitatively (e.g., thematic analysis) or quantitatively (e.g., frequency). If
data was collected quantitatively (numerical) it can be analyzed
quantitatively, either inferentially or descriptively.

e. In the next step, logic is used to link our results to our objectives and/or
hypotheses. This is where people who use case study methodology make
most mistakes (e.g., generalize when it is not the case). Therefore, it is
fundamental to binocularly integrate the logics and the design of the study to
avoid such errors.

f. Finally, based on the aspects discussed at point "e", conclusions and

discussions should interpret the findings in the particular context and in the
larger context of the scientific literature on the topic.

Having presented the fundamentals of case study methodology let us now

try to exemplify its use in clinical practice. Based on the above presentation,
we use case study methodology to: (1) exemplify an already validated theory
(with didactical purposes) and (2) to further test this theory based on the
falsification principle; more precisely, if the theory is to be invalidated we
expect no success in the treatment of this clinical case.

II. APPLICATIONS
Case Study in Research (adapted after David & McMahon: "Clinical strategies
in cognitive behavioral therapy; a case analysis" published in the Romanian
Journal of Cognitive and Behavioral Psychotherapies, vol. 1, no. 1, September
2001, pp. 71-86; see also David, 2003; David et al., 2004; David, 2006a;
2006b). The case of "Dana" is a classic one in the Romanian clinical
literature; this is why it is presented based on its previous publications,
although the context is new (i.e., case study methodology).

1. The Problem

1.1. Introduction

Many people find the distinction among "Behavior Therapy (BT)", "Cognitive
Therapy (CT)", "Cognitive Behavior Modification (CBM)", and "Rational
Emotive Behavior Therapy (REBT)" confused and confusing (Dobson, 2001;
Lazarus, personal communication). We believe that the time has come to stop
elaborating on details regarding the various schools and systems of cognitive
behavior therapy/therapies (CBT), and (1) to focus on the science and theory
of cognitive behavior therapy; (2) to discuss treatments of choice for specific
conditions; (3) to focus on what is and what is not empirically supported; and
(4) to develop really good manuals so that experimentally oriented clinicians
can endeavor to test, repudiate or replicate particular claims and findings. We
think that all these goals can be accomplished under the umbrella of
cognitive science. Cognitive science attempts to understand the basic
mechanisms governing human mind, basic mechanisms that are important in
understanding behavior studies by other clinical and social sciences.
Cognitive science studies the foundation on which many other social and
clinical/psychological sciences stand (Anderson, 1990).

We believe that cognitive science could be a setting for theoretical

integration within CBT (see also, Ingram & Siegel, 2001). A well-integrated
CBT should easily support different therapeutic strategies in a coherent
theoretical framework. In my opinion, even if there is a strong premise for a
coherent theoretical framework in CBT, an artificial division is maintained
because of the confusion among assumptions/paradigms, theories/models,
and clinical practice debates in CBT. A paradigm is a general pool of
constructs and assumptions for understanding a domain, but it is not tightly
enough organized to represent a predictive theory (Anderson, 1983).
Although at this level we could find incompatible differences among different
schools of CBT, we do not have the tools that would allow us decide which
one is right and which one is wrong. The paradigm is not a level of
conceptualization for disputation or integration. A theory provides a
predictive deductive system, while a model is the application of the theory
to a specific phenomenon. It is at this level of theories and models that we
argue for a coherent science of CBT, based on empirical evidence. Practice
refers to the application of therapeutic strategies and techniques.
Strategies and techniques should be numerous, different and theory driven
so we can check for their efficacy under different conditions.
Our basic argument is that CBT should be driven by cognitive science theory
in clinical research and theory, case conceptualization, and empirically
validated treatments of choice for specific conditions. In the next section of
this article, we discuss (1) some brief considerations on cognitive science and
the theory of emotions, with implications for theoretical integration within
CBT; (2) a case conceptualization based on the theoretical considerations;
and (3) a CT strategy and an elegant REBT strategy to change the target
cognitions in order to change the emotional difficulties. The inelegant REBT
(see Ellis, 1994 for details about the distinction between elegant and
inelegant REBT) seems to be similar with CT so that such a comparison
becomes redundant. Pros and Cons for each strategy are briefly mentioned.

1.2. Cognitive science and emotional problems; A brief presentation (see also
David, 2003; David et al., 2004)

Any analysis of cognitions should take into account a fundamental distinction

between "knowing" and "appraising" (Wessler, 1982). Abelson and Rosenberg
(1958) use the term "hot" and "cold" cognitions to make the distinction
between appraisal (hot) and knowing (cold). According to Lazarus and Smith
(1988) cold cognitions refer to how people develop representations of the
relevant circumstances (i.e., about activating events). Such circumstances
are often analyzed in terms of surface cognitions (easy to access consciously)
and deep cognitions (more difficult to access consciously). Surface cognitions
refer for example to inferences and attributions, while deep cognitions refer
to schemas and other meaning-based representations (for details see
Anderson, 1990; Lazarus, 1991). Hot cognitions refer to how people further
process cold cognitions. They can be more or less abstract (e.g., "It is awful
when my wife does not listen to me" versus "It is awful when people do not
listen to me"). The terms appraisal or evaluative (hot) cognitions are used to
define the processing of cold cognitions and their relevance for personal well-
being (for details see Ellis, 1994; Lazarus, 1991). Consequently, during a
specific activating event, there are different possibilities regarding the
relationship between cold and hot cognitions related to the activating event:

(1) distorted representations of the activating event/negatively appraised;

(2) non-distorted representation/negatively appraised;

(3) distorted representations/non-negatively appraised;

(4) non-distorted representations/non-negatively appraised.

According to Lazarus (1991) and the appraisal theory of emotions, although

cold cognitions contribute to appraisal, only appraisal results in emotions.
Some previous influential research programs showed that cold cognitions
(i.e., attributions, inferences) were strongly related to emotions (e.g.,
Schachter & Singer, 1962; Weiner, 1985). However, according to more recent
developments in cognitive psychology, cold cognitions are relevant to
emotions because they contribute to the data we evaluate with respect to
adaptive significance. Now it is generally accepted that as long as the cold
cognitions remain unevaluated, they are not sufficient to produce emotions
(Lazarus & Smith, 1988; Lazarus, 1991; Smith, Haynes, Lazarus, & Pope,
1993).

Following the previous distinction between hot and cold cognitions, according
to the appraisal theory of emotions, emotional problems will only appear in
cases 1 (distorted representation/negatively appraised) and 2 (non-distorted
representation / negatively appraised). In case 1 (distorted representation /
negatively appraised), if one changes the distorted representations (e.g., "He
hates me") into an accurate one (e.g., "He does not hate me"), one may end
up changing the negative emotion (anxiety) into a positive one (happiness).
However, the individual may still be prone to emotional problems because
the tendency to make negative appraisals (e.g., "It is awful that he hates
me") is still present. If one changes the negative appraisal (e.g., "It is awful
that he hates me") into a less personally relevant one (e.g., "It is bad that he
hates me but I can stand it"), it is probable to change the dysfunctional
emotion (anxiety) into a functional but still negative one (concern; for the
distinction between functional and dysfunctional emotions see Ellis, 1994). A
strategy that will change both distorted representation and negative
appraisal seems to be a better choice. In case 2 (non-distorted
representation/negatively appraised), the choice seems to be the change of
negative appraisal that would generate a positive (happiness) or negative
(concern) functional emotion. Another possibility is to change a non-distorted
representation (e.g., "He really hates me") into a positively distorted one (i.e.,
positive illusion: "His negative comments are a way of communicating that
he considers me a strong and reasonable person"). However, as in the first
case, in the second situation we may change both representation and
negative appraisal.

We believe that a clinical case conceptualization based on cognitive science

should take into account both processes: cold cognitions and hot cognitions.
Although this idea is generally accepted in the clinical literature, Wessler and
Wessler (1980) note that in CBT we do not always clearly differentiate cold
from hot cognitions. Moreover, this distinction is opaque in practice (Wessler,
1982). For example, in REBT both cold cognitions and hot cognitions are
mentioned, but the clinical conceptualization is focused on evaluative/hot
cognitions (irrational beliefs). Cognitive therapy focuses mainly on cold
cognitions, both of surface and deeper level. Even if Beck (1976) argues the
certain schemata involve evaluations and that schemata are similar in
breadth to Ellis's irrational beliefs (DeRubeis, Tang, & Beck, 2001), CT case
conceptualization and interventions are more focused on cold cognitions
(e.g., inferences, attributions, automatic thoughts) rather than on evaluative
beliefs. Generally, CT focuses more on cold cognitions, that is, facts that can
be empirically validated, while REBT focuses more on the hot cognitions, that
is, evaluative cognitions (Dobson, 2001). Because clinical intervention is
driven by case conceptualization often not involving a clear distinction
between hot and cold cognitions, many artificial misunderstandings appear.
We believe that case conceptualization should be theory driven, and that it
should take into account both cold and hot cognitions. This way, CT and
REBT techniques could be seen as different therapeutic strategies in a
coherent theoretical and clinical framework. Within this framework, the
pseudo-problem of CT versus REBT can be replaced by a discussion on
strategies of choice to change different types of cognitions.

2. Clinical case; History, clinical conceptualizations and treatment

2.1. Case History

Dana is a 28 years-old physician, mother of one, who lives with her husband,
and who has been working full-time as a fellow in gastro-enterology for the
past 3 years.

Chief Complaint. Dana sought psychological treatment for panic attacks and
generalized anxiety at the end of and the beginning of 2000 (18 sessions).
Two months before treatment she had had three panic attacks and feared
having another one. She also reported: "Since about 1991, I have been
feeling nervous and excessively anxious about my life (e.g., "my future job as
a physician"), my relationships (e.g., "with colleagues and my husband") and
my significant activities (e.g., "my school performance, my doctorate"), but
right now I am much more concerned about the recent panic attacks".

History of Present Illness. In 1991, Dana moved away from home, far from
her overprotective parents, to study medicine at a prestigious university.
Starting then she began feeling helpless and she reported attacks of
excessive anxiety and "worry about everything" (emotional symptoms).
These emotional states were often associated with muscular tension, feelings
of weakness, fatigue, and sleep disturbance (physiological symptoms). She
always found it difficult to control these physical symptoms and,
consequently, she started avoiding activities that required physical effort
(behavior symptoms). She thought that her symptoms would affect her
performance at work and her value as a competent human being (cognitive
symptoms); consequently, she often felt helpless, with low self-esteem. Her
GP and then a psychiatrist prescribed her Buspar (Buspirona) (in 1993). After
several months of medical treatment, she gave it up, as it had reduced
symptoms less than she expected. The first panic attack occurred while she
was preparing for her doctoral exam about two months before our first
meeting (1999). About one month later she had another attack. At the time
of the second attack she was at home cleaning her apartment. The third
panic attack occurred just one week before our first meeting, while she was
home alone, preparing a paper for a scientific congress. Her panic symptoms
included the following: Emotional symptoms: intense fear of loosing control,
helplessness and discomfort; Cognitive symptoms: believing that she was
going to die, had heart problems, and that she was going to faint and
collapse; Behavioral symptoms: avoiding physical effort and looking for safe
places in case she fainted; Physiological symptoms: palpitations, trembling,
and chest pains. She consulted a psychiatrist regarding these symptoms, and
was prescribed XANAX just two months before our first meeting.

The major stressors in Dana's life were mainly social. She was an
overprotected child, and being far from home and from the protection of her
parents during training in medical school was the first major stressor that
might have precipitated her generalized anxiety (1991). Moreover, before
getting married (she got married in1998), Dana had hoped that her husband
would be a real support for her. She believed that he could help her to
overcome her anxiety and her "worries about everything". Unfortunately, her
husband's job was highly demanding. He was an assistant professor and a
researcher often working hard late at nights and on weekends. He was not
very involved in the household and in their child's education (the birth of
Dana's son was another stressor and opportunity for her to worry about:
"Considering that I am so busy, how will I have enough time for my son?").
Consequently, she felt overwhelmed by her life as wife, mother, physician,
and student, doing her full-time job as physician, cleaning the apartment,
cooking, taking care of her son, and preparing for her exams doctoral exams.
These were the conditions in which her first panic attacks developed (1999).

Personal and Social History. Dana was an only child. She described her father
as very rigid, controlling and concerned with the future of his daughter.
Because of his authoritative attitude she had been afraid to argue with him
or ask something from him (the same thing is true even now as an adult). She
described her mother as a warm person, highly concerned with the education
and the future of her daughter. Dana remembered that during kindergarten,
primary and secondary school she had been overprotected by her parents but
that she had not liked that attitude at all. For example, every morning they
left her at school and in the afternoon they picked her up. Because of this,
she had no opportunity to have friends and/or be with her colleagues. She
described herself as a girl (and now a woman) with very poor social and
assertiveness skills both at home and in other social situations. During high
school she started preparation for medical school. Both parents wanted her to
attend medical school. They allowed her to have a boyfriend (the relationship
was not very intense); however, they were only allowed to meet at her home
or go out for several hours in the afternoon. After starting medical school
(1991), Dana had to move to another town. During the first year (she was 18)
her parents visited regularly. They did not want her to live in a dorm with her
colleagues, so they rented an apartment where she could learn without being
disturbed by others. During her first year in medical school she started
experiencing intense signs of generalized anxiety and some symptoms of
subclinical depression. She felt alone, helpless, and started to worry about
everything (but not about the separation from her parents - this was one of
the reasons why we did not consider a diagnosis of separation anxiety!).
During her second year of study (1993) she decided to see a general
practitioner and a psychiatrist who prescribed her Buspar (Buspirona). After
several months she gave up treatment because the symptoms of generalized
anxiety persisted. Despite these symptoms she graduated medical school
successfully in 1997 and started working as a fellow in gastro-enterology. She
met her husband around the same. She described him as very bright, strong
and mature man, 15 years older than she was. They fell in love and got
married in 1998. They live in the same town where she graduated medical
school. After one year of marriage their son was born. In 1998 she started a
doctoral program in medicine. During their second year of marriage (1999)
she experienced her first panic attack. I (DD) met her in 1999 after she had
experienced three panic attacks. Beside psychotherapy, Dana took
medication (XANAX) prescribed by her psychiatrist.
Medical history. Dana had no medical problems which could influenced her
psychological functioning or the treatment process.

Mental Status Check. The patient was fully oriented with an anxious mood.

DSM IV Diagnoses. Axis I: Panic disorder without agoraphobia and generalized

anxiety disorder (subclinical depression - the patient has some symptoms of
depression but she does not meet the full criteria for any depressive
disorder); Axis II: None. The patient does have some dependent personality
traits. However, a careful analysis has revealed that dependent behaviors
seem to be related to the anxiety disorders and that an independent
diagnosis of dependent personality disorder is not justified; Axis III: None;
Axis IV: Inadequate social support, overwhelmed by life circumstances (e.g.,
housing problems, demanding work conditions, educational solicitations);
Axis V: GAF 60 (current -1999-). Best during the past year - 70.

2.2. Case formulation/conceptualization; A cognitive therapy perspective (by

Dr. Daniel David)

A. Precipitants. Dana's separation from her overprotective parents, her lack

of social and assertive skills, and her immersion in a completely new context
(e.g., new town, new colleagues, new requirements) probably precipitated
and then maintained the generalized anxiety and the subclinical depression.
The panic disorder may have been precipitated by lack of support from her
husband and because she felt overwhelmed by her duties. She expected her
husband to support her emotionally. In fact, after getting married, she felt
overwhelmed, and that she had more duties than before. This is when she
experienced her first panic attack.

B. Cross-Sectional of Current Cognitions and Behaviors. Typical of Dana's

current problematic situation was the one related to her first panic attack.
While preparing for her doctoral exam in her room, she had the following
automatic thought: "I will not be able to prepare properly over the next few
days because nobody helps me with my other duties and nobody can give me
more time to prepare for the exam" (surface cold cognition: automatic
thoughts). Emotionally she felt anxious, stopped reading, and jumped out of
her chair. Then she started to experience shortness of breath, chest pain,
palpitations and uncontrollable trembling. At that moment she had another
automatic thought/catastrophic interpretation: "I am sick and I am having a
heart attack" (surface cold cognition: automatic thoughts). Her symptoms
became more intense (panic about panic-secondary emotion) and the world
seemed strange and unreal. Emotionally she felt fear and intense discomfort.
She went out of the room and tried to reach the bathroom to wash her face
with cold water. A second typical situation is illustrated by the second panic
attack. While she was cleaning her apartment she started having palpitations.
Her automatic thought/catastrophic interpretation was: "Not again. I will die
and nobody will take care of my son" (surface cold cognition: automatic
thoughts). Over the next few minutes she developed another panic attack
with palpitations, chest pain and trembling. She tried to reach an armchair (in
case she fainted) and the phone in order to call her husband (she did not call
him). A third situation occurred when she was preparing a paper for a
scientific congress. She thought: "I don't have enough time to prepare a very
good paper. Nobody helps me have more time" (surface cold cognition:
automatic thought). She started having palpitations and almost immediately
thought/made a catastrophic interpretation: "Oh, my God, I am really sick. I
am going to faint and collapse" (surface cognition: automatic thought). Within
a few minutes, she experienced the third panic attack but this time the fear
of losing control or going crazy was stronger. She went into the living room to
be closer to the phone and she sat down in the armchair trying to relax.
Despite assurance by her GP that nothing was wrong with her physical
health, Dana still related her panic and anxiety attacks to an undiagnosed
physical illness. Even though she was open to referral for psychotherapy, she
was not very open to a psychological conceptualization of her problems.

C. Longitudinal View of Cognitions and Behaviors. Dana grew up with very

protective parents. He job was to learn well. Her parents took care of
everything for her. She had plenty of time to organize learning activities.
Consequently, she was a very good student. Three core beliefs (deep cold
cognitions) developed in connection with her past experiences. The first core
belief (schema) refers to competence: "doing everything at high standards".
This deep cold cognition is often appraised: "I have to do everything at high
standards otherwise I am inadequate, unlovable and weak" (hot cognition).
The second core belief refers to both responsibility and control: "If the others
do not support me, I am not able to focus on, to control and succeed in
important things in my life". This deep cold cognition is further appraised:
"Significant people in my life must help me control my environment in order
for me to focus on and to reach my important objectives. If they don't, it is
awful and I can not stand it" (hot cognition). The third core belief is related to
comfort and control and it seems to be linked to secondary emotions (i.e.,
panic about the panic): "If I am helpless and cannot control myself, I and the
others will suffer". It is negatively appraised: "I have to be in control
otherwise it is awful and I cannot stand it" (hot cognition).

D. Strengths and assets. Dana is a bright person with a good physical health.
She loves medicine and she is very disciplined. She wants the best for her
and her family and consequently, no effort is to high to attain these goals.
She has lived with generalized anxiety for almost 7 years. The coping
mechanisms she employed during these years were: avoiding problems,
avoiding physical exercise and studying hard.

E. Working hypothesis. Dana experienced generalized anxiety because her

core beliefs made her interpret a wide range of situations as threatening. Her
separation from her parents and her immersion in a completely new
environment (e.g., new town, new colleagues, higher requirements than in
high-school) probably precipitated the generalized anxiety and the subclinical
depression by activating these core beliefs. Moreover, her lack of
assertiveness and social skills (e.g., dependent personality characteristics)
could have amplified and contributed to anxious and depressive symptoms.
Later, by corroborating this background of generalized anxiety with (1) the
pressures in her life after marriage and (2) the frustrations concerning the
expected support from her husband, the panic attacks developed. Panic
attacks were stimulated by her catastrophic interpretations, which often
generated panic about the panic.

2.3. Treatment plan; A cognitive therapy perspective (by Dr. Daniel David)

A. Problems list: (1) Dana's panic attacks; (2) general feeling of worry about
everything (generalized anxiety and subclinical depression); (3) relationship
with her husband concerning the support he might offer to her (4) low
selfesteem and social and assertiveness skills.

B. Treatment goals: (1) to reduce panic attacks (including panic about panic);
(2) to reduce negative distorted thinking with impact on generalized anxiety
and subclinical depression; (3) to build assertiveness and problem solving
skills in order to improve the relationship with her husband and her ability of
solving practical problem; (4) increase social skills with impact on her
dependent personality traits.

C. Treatment plan. The treatment plan was to first reduce Dana's panic
attacks (including panic about panic) and then her generalized anxiety and
subclinical depression. We also planned to work on her assertiveness, self-
esteem, and social skills. Finally, some practical problems were approached
and a relapse prevention program was introduced.

For panic attacks we used a treatment package involving: (1) cognitive

restructuring techniques (Clark, 1995) to reduce catastrophic interpretations
(automatic thoughts) and (2) hyperventilation/controlled breathing
techniques (Ost, 1987) to explain (partially) and control panic symptoms. A
distraction technique was also used at the beginning of the intervention with
both didactical (cognition versus emotion) and therapeutic (quickly help
symptom management) role. The panic package was then adapted for
generalized anxiety and subclinical depression, and it consisted of: (1)
cognitive restructuring techniques (Beck, 1976; Clark, 1995) to change
automatic thoughts and core beliefs and (2) relaxation techniques (Ost, 1987)
to reduce the chronic arousal. We also focused on changing (at different
levels of abstractions) the evaluative cognitions associated with the core
beliefs. In order to enhance assertiveness and social skills we used
assertiveness training, social and problem solving skills training, to help her
become more self-confident and less dependent. The treatment package was
implemented as follows.

1. The patient was taught a distraction technique for panic attacks (e.g., to
describe in detail all the objects in the room). This technique: (a) would
counter Dana's belief that she had no control over her anxiety; (b) be a useful
symptom management technique when it was difficult to challenge automatic
thoughts; and (c) be a potent demonstration of the cognitive model of
anxiety to which Dana was initially quite reluctant. She was then introduced
to voluntary hyperventilation technique. This was useful in modifying her
catastrophic interpretations of the bodily sensations she experienced during
panic attack. Controlled breathing was also introduced with the purpose of
reducing hyperventilation.
2. The patient was taught standard cognitive restructuring and behavioral
techniques for her automatic thoughts, catastrophic interpretations, and later
for her core beliefs. We also focused on changing hot cognitions by working
at different levels of abstraction. These techniques allowed Dana to
understand maladaptive thoughts and assumptions and thus significantly
reduced anxious and panic symptoms, subclinical depression, and some of
the dependent traits.

3. Dana was taught a relaxation technique and a controlled breathing

technique. The relaxation technique was expected to mainly impact on
generalized anxiety, as it reduces chronic arousal.

4. Assertiveness training and social and problem-solving skills were

introduced in order to improve her interpersonal relationships (particularly
with her husband) and problem solving abilities. These interventions would
also help her be less dependent.

5. A relapse prevention program was introduced at the end of the treatment.

Obstacles. As she was trained as a physician in the bio-medical model, it was

hard to convince Dana about the relationship between cognition and emotion
using a conventional approach. Thus, the rationale of treatment (e.g.,
relationship between cognition and panic attacks) was not forced upon the
patient. Instead, more techniques were used than with other patients to
illustrate this relationship: (1) bibliotherapy - books on psychosomatic
medicine, cognition, and emotion; (2) more examples including literature on
the experiments (cognition-emotion relationship) of Schachter and Singer
(1962). At the end of this educational program the patient was very surprised
about the influence of cognition over emotion and was eager to introduce
these ideas not only in our work but also in her work as gastro-enterologist.

Outcome. Dana's therapy extended over 18 sessions. Six months after the
end of therapy, Dana had no recurrence of panic attacks or symptoms of
subclinical depression. However, some symptoms of generalized anxiety
persisted but they did not meet the DSM IV criteria for generalized anxiety
disorder. Dana's assertiveness and social skills improved significantly and had
a positive impact on her relationships (including with husband and parents)
and on the reduction of dependent personality characteristics. All these
results are operationalized in a single case experiment design: multiple
baselines across symptoms.

2.4. Case Formulation; An REBT perspective (by Dr. James McMahon)

This married medical student, 28, mother of a child, tried medical/psychiatric

interventions without success at first, and, with the realization that she would
become addicted to increased use of medication to ward off anxiety
symptoms, tried psychological intervention latter. When her thoughts turned
to feelings of worry and worthlessness, she panicked and was unable to
believe in herself and her ability to manage herself. These beliefs were put
into place later in life; while she was able to achieve academically through
her life, because she was overprotected, she had few skills that enabled her
to believe in her own general self management. Escaping from rigid
protection, she went on her own into an apartment and she eventually
married. She demanded (demandigness - DEM) that her husband take the
place of her parents to some extent by providing her with support and rules.
He did not. Instead, he cooperated with her in baby making, he went about
his career and he left Dana with her own career as well as with house and
childcare responsibilities. To deal with panic and anxiety, it was
conceptualized that Dana has superior intelligence, that she could make
logical, empirical and pragmatic distinctions/disputations, and that she would
work within rules to change her dependency. She was willing to read and
engage a given/take process of therapy, and she was willing to keep a log of
behavior. A careful analysis revealed many types of cognitive distortions,
both surface and deep (see Dr. David's analysis) and a group of irrational
beliefs (evaluative cognitions) like: (1) demandigness - DEM (e.g., "I have to
do everything at high standards; the others have to help me", etc.); (2)
awfulizing - AWF (e.g., "If I am not in control it is awful"); (3) low-frustration
tolerance -LFT (e.g., "I cannot stand it") and selfdowning - SD (e.g., "I am
weak and inadequate").

2.5. The treatment plan; An REBT strategy (by Dr. James McMahon).

Treatment was conceptually divided into four components: (1) immediate

management of panic through ego anxiety and discomfort anxiety theory
and practice; (2) unconditional self and other acceptance with impact on
generalized anxiety, sublinical depression and dependent characteristics; (3)
practice against regression through logical, empirical, and pragmatic
disputation as well as recognition of irrational beliefs; (4) solving some
practical problems. These four distinctions integrated, it was conceptualized
that Dana could (a) be happy as a person who liked herself, (b) become self-
managed rather than reach out to others to provide management for her, and
(c) that she could work against regression to irrational beliefs with simple
reading and practice. In addition to cognitive restructuring of irrational
beliefs, it was suggested that Dana engage philosophical change by
distinguishing who she was from what roles she played. A distinction between
practical and emotional problems was made and the patient realized the
usefulness of focusing first on the emotional problems and then on the
practical problem. The emotional problems were separated into primary
emotional problems (panic and generalized anxiety) and secondary emotional
problem (panic about panic).

An REBT treatment regimen was put into place, the process of intervention
was commented upon and acceptable to both patient and therapist. Several
issues were emphasized to her namely, that the idea was to be better not get
better, that two primary aspects on the neurotic continuum of thinking-
feeling were her tendency to exaggerate (awfulizing) and to avoid negative
emotions, thereby giving her temporary comfort but long-term misery (low
frustration tolerance). Also it was discussed with Dana how her problems
seemed to be related to demandigness oriented to her own person (e.g., "I
have to do everything at high standards") and others (e.g., "Others have to
help me"). If these demands are not attained, then she moves into self-
downing (e.g., I am weak), awfulizing (e.g., "It is awful") and low frustration
tolerance (e.g., "I cannot stand it"). Session 2-4 went to the heart of panic.
Checked was the secondary problem (panic about panic) and the irrational
beliefs involved (e.g., "I have to be in control otherwise it is awful and I
cannot stand it"; DEM, AWF and LFT). The primary emotional problem was
then focused upon (where we identified others DEM, AWF, LFT and SD).
Session 5-7 stressed self-worth issues related to generalized anxiety and
subclinical depression (e.g., stubborn refusal to judge herself, examining her
roles and how to judge them through the who/what process, rational-emotive
imagery in which she perceived herself to be in control of her own life and
that she was in charge, and disputation of other irrational beliefs). Sessions
8-12 involved further restructuring of IBs into adaptive alternatives (at
different levels of abstraction) and how to distinguish beliefs from feelings
about beliefs. She kept a log of the type of empirical, logical and pragmatic
disputations. Session 13-18 involved dealing with issues of dependency
throughout her life, looking for alternative conceptions. Some practical
problems were approached, and revisiting panic and anxiety situations was
undertaken to preclude regression.

Outcomes. Dana reported in the last session that she was free of panic
attacks, that she could distinguish rational from irrational beliefs, and that
she generally felt happy and liked herself. Regarding her own goals, she
indicated that she was generally happy but busy with her family and work,
that she judged that she could head off panic attacks in the future, and that
she was assertively negotiating home duties with her husband. The patient
and the therapist judged that she achieved good results therapeutically and
as a person.

2.6. Discussion

2.6.1. Comment upon the cognitive therapy strategy (by Dr. James
McMahon).

The work of Dr. Daniel David was generally masterful: good diagnosis, good
interventions, and the goals were attained. He used all available CBT
techniques that were appropriate by distinguishing automatic thoughts vs.
core beliefs vs. evaluative cognitions. However, I would mention that the
distinction between core beliefs (cold cognitions) and evaluative cognitions
(hot cognitions) is not always clear in cognitive therapy, although here, Dr.
David made it very clear. Also, many cognitive therapists prefer to work only
at the level of distorted cold cognitions, both surface and deep, rather than
at both cold cognitions and evaluative beliefs. In that case, the patients may
feel better but not get better. For example, they may feel better because the
activating events (e.g., "It is not true that she laughs at me") are not
dangerous, but the individual still may be prone to emotional problems
because the tendency to make negative appraisals (e.g., "It is awful when she
laughs at me") of activating events incongruent with their goals (e.g., "She
really laugh at me") is still present. However, here, Dr. David approached
correctly both types of cognitions. If there were one negative aspect, that
would be that therapy did not get to the person. Rather, therapy dealt with
symptoms, and then their causes and cure. While achieving personhood in CT
can be inferred, it can only be inferred as one of the several schemas since
the theory purports to be empirical and so deals with piece-by-piece
examples of pathology. Contradistinction, REBT theory clearly tries to
achieve fundamental philosophical change and so is person driven.

2.6.2. Comments upon REBT's strategy (by Dr. Daniel David).

I think that Dr. McMahon's elegant REBT is really elegant: great clinical
approach! Unlike me, Dr. McMahon attacked evaluative cognitions directly. I
myself would approach evaluative cognitions, but after a careful challenging
of automatic thoughts and core beliefs. My general criticism to Dr. McMahon's
approach would be that by directly changing evaluative cognitions and
assuming that distortions are real (e.g., "Let us suppose that you are indeed
not able to work at high standards; How does this make you weak and
inadequate as a person?" or "How is this awful?", etc.) one may change a
dysfunctional emotion (anxiety) into a negative functional emotion (concern)
because automatic thoughts (e.g., "I will not be able to prepare my
presentation") and deep cold cognitions are not directly disputed in the
elegant REBT. I know that Dr. McMahon might suggest that by changing
evaluations one indirectly changes distortions too, and indeed, one may
invoke some corpus of research which supports this hypothesis (Dryden,
Ferguson, & Clark, 1989 but see Bond & Dryden, 2001). However, sometimes
distortions may gain functional autonomy from the evaluative cognitions (see
Allport's concept of "functional autonomy"); in this case the change of
evaluative cognitions might not be accompanied by a change in the
distortions. Consequently, the client may feel better (e.g., "concern" rather
than "anxious") but not achieve the best results (e.g., "relaxed", "calm" or
even "happy"). On the other hand, as Ellis repeatedly mentions, (Ellis, 1994),
not all patients may benefit directly from elegant REBT. However, in our case
the patient seems to be in a positive emotional state and thus, Dr. McMahon's
direct disputation of IBs also seemed to change cognitive distortions (i.e.,
elegant REBT). If that had not happen, I suppose that Dr. McMahon would
have forcefully disputed the distortions too (i.e., inelegant REBT). The
difference between our approaches seems to be in terms of strategy. I
started with automatic thought, core beliefs and then evaluative cognitions.
With bright clients, Dr. McMahon seems to prefer starting with evaluative
cognitions and then maybe working on distortions, if necessary (I know that if
the change of irrational beliefs was not accompanied by a change in
distorted cold cognitions, Dr. McMahon would directly examine automatic
thoughts and other distortions - personal communication). I would like to see
some research evaluating concurrently these two different cognitive
strategies. I assume that their efficacy may differ depending on the clinical
condition (e.g., the type of psychopathology, the type of client).

III. DISCUSSIONS

After a short history, this paper briefly and critically presented the
fundamentals of case study methodology. We have then exemplified, by
using the case of "Dana" from our previous publications, how it can be
employed in clinical practice. We hope that the message to take home after
reading this article is clear. Case study methodology is not rigorous or less
rigorous per se. It becomes rigorous or less rigorous depending on the type of
knowledge we want to generate in order to solve specific problems. This is
true for all the research methods. The problems which case study is best fit to
solve are those related to exploratory studies (i.e., generating new theories),
to critical, and unusual cases. It is less fit to test a theory although, if
conditions for falsifiability are met, it can be implemented with this purpose
as well. When used appropriately, case study methodology is very rigorous,
comparable with any other research method. By appropriate we mean two
things: (1) adequate to the problem it is intended to solve; and (2)
implemented at high standards in terms of internal constraints and steps that
need to be followed.

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[Author Affiliation]

Daniel DAVID*

Department of Psychology, Babes-Bolyai University, Cluj-Napoca, Romania

* Corresponding author:

Email: danieldavid@psychology.ro

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