2.2 The Case Study

A case study is a detailed description of a person’s life and psychological problems. It describes the person’s history, present circumstances, and symptoms. It may also include speculation about why the problems developed, and it may describe the person’s treatment (Yin, 2013; Lee, Mishna, & Brennenstuhl, 2010).

case study A detailed account of a person’s life and psychological problems.

Case study, Hollywood style Case studies often find their way into the arts or media and capture the public’s attention. Unfortunately, as this movie poster of The Three Faces of Eve illustrates, the studies may be trivialized or sensationalized in those ventures.

In his famous case study of Little Hans (1909), Sigmund Freud discusses a 4-year-old boy who developed a fear of horses. Freud gathered his material from detailed letters sent to him by Hans’s father, a physician who had attended lectures on psychoanalysis, and from his own limited interviews with the child. Freud’s study runs 140 pages in his Collected Papers, so only key excerpts are presented here.

BETWEEN THE LINES

All About Freud

Freud’s parents often favored Sigmund over his siblings.

Freud’s fee for one session of therapy was $20.

For almost 40 years, Freud treated patients 10 hours per day, 5 or 6 days per week.

Freud’s four sisters died in Nazi concentration camps.

Freud was nominated for the Nobel Prize in 12 different years, but never won.

In 1929, the Nobel Committee for Medicine hired a consultant who concluded that Freud’s work was of no scientific value.

(Nobel Media, 2014; Cherry, 2010; Hess, 2009; Gay, 2006, 1999; Jacobs, 2003)

One day while Hans was in the street he was seized with an attack of morbid anxiety…. [Hans’s father wrote:] “He began to cry and asked to be taken home…. In the evening he grew visibly frightened; he cried and could not be separated from his mother…. [When taken for a walk the next day] again he began to cry, did not want to start, and was frightened…. On the way back from Schönbrunn he said to his mother, after much internal struggling: ‘I was afraid a horse would bite me.’ … In the evening he … had another attack similar to that of the previous evening….”

But the beginnings of this psychological situation go back further still…. The first reports of Hans date from a period when he was not quite three years old. At that time, by means of various remarks and questions, he was showing a quite peculiarly lively interest in that portion of his body which he used to describe as his “widdler” [his word for penis]….

When he was three and a half his mother found him with his hand to his penis. She threatened him in these words: “If you do that, I shall send for Dr. A. to cut off your widdler. And then what’ll you widdle with?” … This was the occasion of his acquiring [a] “castration complex.” …

[At the age of four, Hans entered] a state of intensified sexual excitement, the object of which was his mother. The intensity of this excitement was shown by … two attempts at seducing his mother. [One such attempt, occurring just before the outbreak of his anxiety, was described by his father:] “This morning Hans was given his usual daily bath by his mother and afterwards dried and powdered. As his mother was powdering round his penis and taking care not to touch it, Hans said: ‘Why don’t you put your finger there?’ … “

… The father and son visited me during my consulting hours…. Certain details which I now learnt—to the effect that [Hans] was particularly bothered by what horses wear in front of their eyes and by the black round their mouths—were certainly not to be explained from what we knew. But as I saw the two of them sitting in front of me and at the same time heard Hans’s description of his anxiety-horses, a further piece of the solution shot through my mind…. I asked Hans jokingly whether his horses wore eyeglasses, to which he replied that they did not. I then asked him whether his father wore eyeglasses, to which, against all the evidence, he once more said no. Finally I asked him whether by “the black round the mouth” he meant a moustache; and I then disclosed to him that he was afraid of his father, precisely because he was so fond of his mother. It must be, I told him, that he thought his father was angry with him on that account; but this was not so, his father was fond of him in spite of it, and he might admit everything to him without any fear. Long before he was in the world, I went on, I had known that a little Hans would come who would be so fond of his mother that he would be bound to feel afraid of his father because of it….

By enlightening Hans on this subject I had cleared away his most powerful resistance…. [T]he little patient summoned up courage to describe the details of his phobia, and soon began to take an active share in the conduct of the analysis.

33

… It was only then that we learnt [that Hans] was not only afraid of horses biting him—he was soon silent upon that point—but also of carts, of furniture-vans, and of buses …, of horses that started moving, of horses that looked big and heavy, and of horses that drove quickly. The meaning of these specifications was explained by Hans himself: he was afraid of horses falling down, and consequently incorporated in his phobia everything that seemed likely to facilitate their falling down.

It was at this stage of the analysis that he recalled the event, insignificant in itself, which immediately preceded the outbreak of the illness and may no doubt be regarded as the exciting cause of the outbreak. He went for a walk with his mother, and saw a bus-horse fall down and kick about with its feet. This made a great impression on him. He was terrified, and thought the horse was dead; and from that time on he thought that all horses would fall down. His father pointed out to him that when he saw the horse fall down he must have thought of him, his father, and have wished that he might fall down in the same way and be dead. Hans did not dispute this interpretation…. From that time forward his behavior to his father was unconstrained and fearless, and in fact a trifle overbearing.

It is especially interesting … to observe the way in which the transformation of Hans’s libido into anxiety was projected on to the principal object of his phobia, on to horses. Horses interested him the most of all the large animals; playing at horses was his favorite game with the older children. I had a suspicion—and this was confirmed by Hans’s father when I asked him—that the first person who had served Hans as a horse must have been his father…. When repression had set in and brought a revulsion of feeling along with it, horses, which had till then been associated with so much pleasure, were necessarily turned into objects of fear.

[Hans later reported] two concluding phantasies, with which his recovery was rounded off. One of them, that of [a] plumber giving him a new and … bigger widdler, was … a triumphant wish-phantasy, and with it he overcame his fear of castration…. His other phantasy, which confessed to the wish to be married to his mother and to have many children by her … corrected that portion of those thoughts which was entirely unacceptable; for, instead of killing his father, it made him innocuous by promoting him to a marriage with Hans’s grandmother. With this phantasy both the illness and the analysis came to an appropriate end.

(Freud, 1909)

Most clinicians take notes and keep records in the course of treating their patients, and some, like Freud, further organize such notes into a formal case study to be shared with other professionals. The clues offered by a case study may help a clinician better understand or treat the person under discussion (Yin, 2013; Stricker & Trierweiler, 1995). In addition, case studies may play nomothetic roles that go far beyond the individual clinical case.

How Are Case Studies Helpful?

Case studies can be a source of new ideas about behavior and “open the way for discoveries” (Bolgar, 1965). Freud’s theory of psychoanalysis was based mainly on the patients he saw in private practice. He pored over their case studies, such as the one he wrote about Little Hans, to find what he believed to be broad psychological processes and principles of development. In addition, a case study may offer tentative support for a theory. Freud used case studies in this way as well, regarding them as evidence for the accuracy of his ideas. Conversely, case studies may serve to challenge a theory’s assumptions (Yin, 2013; Elms, 2007).

34

Case studies may also show the value of new therapeutic techniques or unique applications of existing techniques. The psychoanalytic principle that says patients may benefit from discussing their problems and discovering underlying psychological causes, for example, has roots in the famous case study of Anna O., presented by Freud’s collaborator Josef Breuer, a case you will read about in Chapter 3. Similarly, Freud believed that the case study of Little Hans demonstrated the therapeutic potential of a verbal approach for children as well as for adults.

Finally, case studies may offer opportunities to study unusual problems that do not occur often enough to permit a large number of observations (Goodwin & Goodwin, 2012). For years, information about dissociative identity disorder (previously called multiple personality disorder) was based almost exclusively on case studies, such as a famous case popularly referred to as The Three Faces of Eve, a clinical account of Chris Sizemore, a woman who displayed three alternating personalities, each having a separate set of memories, preferences, and personal habits (Thigpen & Cleckley, 1957).

What Are the Limitations of Case Studies?

Case studies also have limitations (Yin, 2013; Girden & Kabacoff, 2011). First, they are reported by biased observers, that is, by therapists who have a personal stake in seeing their treatments succeed. These therapists must choose what to include in a case study, and their choices may at times be self-serving. Second, case studies rely on subjective evidence. Is a client’s problem really caused by the events that the therapist or client says are responsible? After all, those are only a fraction of the events that may be contributing to the situation. When investigators are able to rule out all possible causes except one, a study is said to have internal accuracy, or internal validity (Jackson, 2012). Obviously, case studies rate low on that score.

Why do case studies and other anecdotal offerings influence people so much, often more than systematic research does?

internal validity The accuracy with which a study can pinpoint one factor as the cause of a phenomenon.

Another problem with case studies is that they provide little basis for generalization. Even if we agree that Little Hans developed a dread of horses because he was terrified of castration and feared his father, how can we be confident that other people’s phobias are rooted in the same kinds of causes? Events or treatments that seem important in one case may be of no help at all in efforts to understand or treat others. When the findings of an investigation can be generalized beyond the immediate study, the investigation is said to have external accuracy, or external validity (Jackson, 2012). Case studies rate low on external validity, too (Goodwin & Goodwin, 2012).

external validity The degree to which the results of a study may be generalized beyond that study.

Does mental dysfunctioning run in families? One of the most celebrated case studies in abnormal psychology is a study of identical quadruplets dubbed the “Genain” sisters by researchers (after the Greek term for “dire birth”). All of the sisters developed schizophrenia in their twenties.

The limitations of the case study are largely addressed by two other methods of investigation: the correlational method and the experimental method. These methods do not offer the rich detail that makes case studies so interesting, but they do help investigators draw broad conclusions about abnormality in the population at large. Thus they are now the preferred methods of clinical investigation.

Three features of the correlational and experimental methods enable clinical investigators to gain general, or nomothetic, insights: (1) The researchers typically observe many individuals (see MindTech below). That way, they can collect enough information, or data, to support a conclusion. (2) The researchers apply procedures uniformly. Other researchers can thus repeat, or replicate, a particular study to see whether it consistently gives the same findings. (3) The researchers use statistical tests to analyze the results of a study. These tests can help indicate whether broad conclusions are justified.

35

MindTech

A Researcher’s Paradise?

Two of the biggest problems for researchers are finding enough participants for their studies and obtaining a sufficient range of participants. Until recent years, undergraduates were the most common participants in behavioral research—even clinical research (Gosling, 2011). This was largely a matter of convenience. Undergraduates are, after all, just down the hall, often in need of money, and typically interested in joining research studies. Moreover, at many universities, undergraduates are required to participate in research studies.

On the downside, undergraduates are a pretty homogeneous group whose behaviors and emotions do not always generalize to other groups in society (Phillips, 2011). Thus, it is probably good that the face of research recruitment is now changing. More and more researchers are turning to social networking sites—Facebook, Twitter, Tumblr, Instagram, and others—and their ready-tobe-studied users (Kosinski, Stillwell, & Graepel, 2013; Phillips, 2011). These sites provide an enormous pool of potential participants. Facebook, for example, has 1 billion monthly visitors and Twitter has 300 million (eBizMBA, 2014). And the sites’ users are diverse—persons of all races, ages, incomes, and education levels (Pew Research, 2013).

One recent study demonstrates the power and potential of social media participant pools (Kosinski et al., 2013). In this investigation, 58,000 Facebook subscribers allowed the researchers access to their list of “likes,” and the subscribers further filled out online personality tests. The study found that information about a participant’s likes could predict with considerable accuracy his or her personality traits, level of happiness, use of addictive substances, and level of intelligence, among other variables. Similarly, other social media site studies have tested various psychological theories “about relationships, identity, self-esteem, popularity, collective action, race, and political engagement” (Rosenbloom, 2007).

What a great resource, right? Not so fast. The studies above asked social media users whether they were willing to participate, but in a number of other studies, the users do not know that their posted information is being examined and tested. Inasmuch as posted information is publicly available, some researchers believe it is ethical to study that information without informing users that they are indeed being studied.

Can an argument be made that ethical standards regarding Internet use should be different from those applied in other areas of life?

Facebook and most other social media sites do not have policies prohibiting scholars from studying user profiles without permission (Rosenbloom, 2007). In contrast, the Institutional Review Boards at many research institutes have concluded that postings on social networking sites should be considered private, and they require researchers at their institutions to obtain explicit permission from social media users when network information is being examined. While this technology-driven question of what’s public and what’s private is under debate, it is probably best that posters follow a new version of that most sacred rule of consumerism—”poster beware.”