Is psychotherapy fundamentally threatened, with the demise of published case studies, to become neither an art and/ nor a science?

Twenty-five years ago, when this European Journal of Psychotherapy and Counselling (EJPC) was established, we published case studies together with commentaries. Then, this was also a mainstay of other journals in our field – but not now. So how has this come about and what are the consequences?

The Greek letter psi (taken to mean: life, soul, heart) gave rise to such words as ‘psychotherapy’, ‘psychoanalysis’, ‘psychology’, and ‘psychiatry’. Indeed, this Greek letter is used as the logo for our journal (though the EJPC deliberately has a flattened version in an attempt to represent both the Greek and, through the menorah, Hebraic influences on European thought).

Importantly with the Greeks comes phusus/physis to represent the natural, what comes out of itself and where force would usually be inappropriate. But here’s the rub: When the journal was initiated case studies could be published on being anonymised. There was no requirement, unlike now, to have the permission of the client/patient. Yet for many of us we consider that what we may write in a paper if seen by clients could be detrimental to them. This concern is not just during therapy but afterwards as many of us assume that ex-clients may return to working with us.

A popular suggestion as to how to work round this is for authors to construct composite client cases (Duffy, 2010). Yet there are at least two problems here:

First there is an argument that the author of the paper should get permission from all those clients making up the composite case study even though, as with an actual single case, the author has changed identifying aspects. Secondly, and of particular significance here, the author can construct the composite case to tell a story to fit the theory being proposed. But this is forced and not phusis – it does not come out of itself. Aren’t such practices examples of the ‘allegiance effect’ (see for example Winter, 2010) par excellence?

It has been argued that those, such as Freud, have also misused case studies (Willemsen et al., 2017), whilst simultaneously and not unrelatedly getting the Goethe Prize for Literature. They have done this by writing about their work with clients, to demonstrate their theories rather than their theories coming out of their case studies without force. It could be argued that such dangers are even more prescient with fictitious case studies.

I have been involved in arguing that actual case studies are part of psychotherapy’s traditional way of conducting research (Greenwood & Loewenthal, 2005a, 2005b). We take our clients in the form of case studies to our supervisors, and we sometimes give case study papers to closed groups in our specific training and professional institutions. However, if we are to influence our future practices such case studies need to be able to be published to influence our broader culture.

Several years ago I found the following a useful classification of different types of research: ‘exploratory’, ‘descriptive’ and ‘causal’ (Selltiz et al., 1965) and many still do (for example, Sreejesh et al., 2014). Case study is the bedrock of ‘exploratory’ and ‘descriptive’. This is helpful to those where there is not enough explicit knowledge to theorise and those who think our work is much to do with tacit knowledge, enigmatic signifiers, etc. Furthermore, if we undertake case studies as our research, then they are also helpful both to such therapists as those who consider we need to reinvent psychotherapy with each client and those who consider phenomenology to be vital to our work. For such therapists, we hopefully can remain more open to new possibilities in what emerges in the between and facilitate clients by encouraging description rather than explanation, albeit through different psychotherapeutic cultural traditions.

Yet causal research is in direct contrast to such exploratory and descriptive research, particularly with its associated ‘evidence-based practices’ and ‘empirically supported treatments’. The EJPC was one of the first journals to publish causal research and continues to do so, but now there is the concern that we are getting to where it is perhaps wrongly being considered as the only knowledge base. This cultural development, which can be considered as part of an attack on thought, is exacerbated through the demise of actual case studies. Are we, unless we act, in danger of further stunting and distorting our psychotherapeutic capacities, particularly for trainees less exposed to our traditional case study research?

Unlike causal research, when we consider a case, often preferably through exploring what was actually said, we can come across aspects that are new to our existing personal knowledge and those of our modality. In this way, we can be alive to our clients, ourselves and our profession. It is as Blanchot (1992) writes in The Infinite Conversation not to attempt to force those tangential aspects that arise and do not fit into our theories into a new synthesis with our existing ideas. Rather, again to return to notions of Greek justice, that are still predominant in our judicial system, evaluative criteria come from the situation itself and are not to be pre-imposed.

However, the European legislation on General Data Protection Regulations (1978), which post Brexit the U.K. has so far adopted wholesale, gives individuals the rights over their own story/data. Hence, the new rights of our clients to give permission for writing about them in case studies. This may be laudable and many would consider overdue, yet given the problems stated that this poses for many psychotherapists can anything acceptable be done to make our work and future more open to possibilities whilst also safeguarding our clients rights?

Psychologists have devised approaches that might help in their attempts to scientifically standardise procedures. They both write about case study method (Yin, 2012) and use what might be seen as a form of systematising composite case study as phenomenological research for example Empirical Phenomenology Research (Giorgi, 2009), Interpretative Phenomenological Analysis (Smith & Flowers, 2021). But, as well as these approaches showing proven effectiveness in some aspects, phenomenology is research and it can be argued that adding ‘research’ to phenomenology is at best a misnomer and a worse a distortion particularly for those who see psychotherapeutic research as increasing possibilities rather than attempting generalisations.

Might one solution be for our professional bodies and training organisations to ask all clients before commencing therapy if they would sign a participant consent form? Here, we would have stated something to the effect that we consider all the psychotherapy we provide as being psychotherapeutic research to the advancement of our [named] modality .[which could, and might have to name a more specific research area].and therefore potential for publication. Hence, in order not to interrupt the therapeutic process we therefore ask that each participant consent at the start of therapy for their counselling/psychotherapy/psychoanalysis/etc to be considered for any potential research publications. There would be further caveats along such lines as: ‘You are free not to be part of such research in which case you will still be provided with the same therapeutic service’. And ‘I am aware that should I agree for my therapy to be part of such research that I am free to withdraw this permission at any point. I also understand that the information I provide will be treated in confidence by my counsellor/psychotherapist/psychoanalyst and that my identity will be protected, including others identifying me by my story, in the publication’. There could be, as with most research bodies consent forms, a further addition,

Please note: if you have a concern about any aspect of your research participation please raise this with the counsellor/psychotherapist/psychoanalyst. However if you wish to contact an independent party please contact … . There will be many discussions, including variations, of such wording.

However, it is considered that something along these lines needs urgently to be initiated by our professional bodies and training organisations for both our clinical members and trainees. It is suggested here that we need to be able to bring to the mainstream aspects of our work including, for example, the tacit as well as explicit knowledge through real case studies not only to a private but public discourse, including to other modalities, that can influence our future. Then, we can return to developing psychotherapy both as an art and a science. Otherwise, are we in grave danger of psychotherapy being neither and instead potentially being more, perhaps inextricably, exposed to either normative theoretical gurus and/or pseudo-science.

Before introducing the papers for this issue I would like first to thank their authors as named below, the book reviewers Catherine Llewellyn, Antony McSherry, Matt Whitely and the following for their invaluable help in preparing this issue: Yvonne Bergmans, Jung Jin Choi, Rafaell Eshkol, Bob Knight, Robbie Lockwood, Luci Monica, Sally Parsloe, Jennifer O’Donnell, Anna Oldershaw, Teri Pichot, and Jean Wells. Also my particular thanks for the work of our Assistant Editor Miranda Kersley who has more than held, with her sterling work, the EJPC so effectively together over many issues (in many senses!) and will soon be leaving for pastures anew.

Our first paper shows the effective use of fictitious case studies, entitled Narrative Therapy in a post-pandemic world: A fictional case study of a client living with depression by Ashley Morgan. Here the author using Narrative Therapy, considers how a fictitious case might use this therapeutic framework to reframe and re-author a client’s experience. This is an important and topical paper for, as the author states, With the psychosocial legacy of Covid-19 predicted to be far reaching, opportunities exist for providers of counselling and psychotherapy to review the availability of therapeutic modalities that acknowledge the role and impact of social inequality and oppression on the lives of our clients. As one of the reviewers comments, ‘Thank you for this worthwhile read’.

Our second paper is Touching the depths of suffering with others: the nature of witnessing with survivors of torture by Isabella Mighetto. This Interpretative Phenomenological Analysis was underpinned by intersubjectivity and psychoanalytic social theory. The findings explore the significance of engaging in affective relationships of political solidarity against the backdrop of what is seen as the structural disavowal of the ‘hostile environment’ in the UK context. As one of the reviewers comments “This is an important and very well written piece of work . [exploring]. what it means to ‘witness’ as professionals whose role is to co-journey as a human without the expectation of pathologizing or ‘fixing’”.

Our next article is Thera-poiesis: An exploration of the work of resonant images in found poetry to create newness in counsellingby Sarah Penwarden. In this paper, the author drawing on Bachelard calls her approach ‘thera-poiesis’. In listening to bereaved clients, the author ‘paid attention to resonant images in their talk, wrote these as found poetry, and offered this poetry to each participant’. The author argues ‘that one engine of change in counselling may be the generative potential of language itself, and the artful replication of resonant images in particular’. As one reviewer comments ‘Thank you for this very interesting piece on rescued speech poetry in therapy.‘

Our following paper is The Implementation of Solution-Focused Brief Therapy (SFBT) as a Solution for Handling Psychological Anxiety in Facing the COVID-19 Outbreak by Teuku Fadhl. Here, the author argues for the importance of a Solution-Focused Brief Therapy (SFBT) approach in dealing with individuals to find solutions both after and during the occurrence of psychological anxiety. This study uses comparative analysis, which refers to various relevant literature between SFBT and psychological anxiety, especially in the COVID-19 outbreak. The results indicate that there is a significant correlation between theories, both basic assumptions and concepts related to the SFBT intervention process, in an effort to help individuals find solutions to problems that are or will be experienced.

As one reviewer comments, ‘I appreciate the researcher(s)’s effort to bring in an international context in understanding a possibility to implement SFBT as a solution for handling psychological anxiety in facing the COVID-19’.

Our penultimate paper is: Schema Focused and Mentalization Based Therapy – An Integrative Proposal by Or Spivak. Here, the author notes that Schema Focused Therapy (SFT) is regarded as an integrative theory of therapy, which includes aspects of various different therapeutic approaches, but does not stress mentalization. Similarly mentalization does not stress SFT. Hence, the author suggests an assimilation of mentalization into SFT, where causes of impaired mentalization are collected from SFT, and practical implications are discussed. As one reviewer comments, ‘I like this paper because in some ways it speaks of the change process in therapy, what the process is and how it can be adapted depending on the needs and presentations of the client. It can also be useful to note to commonalities between therapeutic approaches such as those drawn by this paper between psychodynamic theory and ST’.

Our final paper in this issue of the EJPC is: Encountering Older Adults in Psychotherapy: The Lived Experience of Therapists working with Older Adults in Ireland by Agapi Kapeloni. The findings from this research suggest that psychotherapy with older adults is a different and challenging experience for therapists, compared to work with clients in younger age ranges. The author importantly concludes that ‘in order to cope with and effectively work with older adults, a commitment to personal development regarding one’s own ageing and mortality is necessary … ’. As one reviewer comments ‘… a good paper that provides insight in to a research area that has not been addressed until now’.

So there we have it: a range of practice, theory, and research processes which we hope are neither resulting from ‘normative theoretical gurus and/nor pseudo-science’. But for us to return to having actual single published case studies let’s hope we can find a way without having to wait for what might at last for some, if the U.K. were to revisit the European legislation on General Data Protection Regulations, could be the long awaited Brexit Dividend’!

Disclosure statement

No potential conflict of interest was reported by the author(s).