With the case of “Melissa” in SWT, there is no concern that of a confidentiality breach since the authors report there was never such a person to begin with. Creating a case that is both totally fictitious yet at the same time creditable is a difficult job and the authors are to be commended. From time to time over the years, I have tried to create a teaching case from “scratch” for use in teaching practice courses, presentations and/or articles. It never seemed to work well. Either my fictitious case would look like a disjointed bunch of chaotic symptoms and clouded history with no clear connection to any specific condition to be treated or without being aware of it, I would be drawing on my recollections of some of my actual patients. I concluded that the former was not very practical and with the latter I could not in good conscious claim that any resemblance to actual clients was coincidental since I knew that was not true. Even if no one else would notice and even if my patient never learned I borrowed liberally from their situation, I would know. So I usually endeavored to try to get informed consent from patients to use their material. But that has its difficulties.
Getting an actual patient to give true informed consent meant telling them that I would use their history and material and it may be heard and read by any number of people. Also if truth be told, once it was out there I would have little control over what others did with that information. Many patients if not most would be reluctant to grand permission to have their situations discussed in public even when a pseudonym is used. It’s a dilemma but unless one had consent, it is my position that using patient information even if disguised and even for teaching others raised serious ethical issues. So unless we can find a courageous patient fictitious cases are often the next best thing.
There is however one significant drawback to discussing fictitious cases. While it’s possible to discuss a fictitious case from any number of different clinical orientations there is simply no way for an independent practitioner, the reader or anyone to tell which perspective would work better than the other. There is no actual baseline and there is no real progress to measure because there is no real patient.The case of “Melissa” brings this point home fairly well. We read how Melissa reacts to treatment i.e. her anxiety diminishing after several months of treatment only to have the situation deteriorate when her husband returns from Iraq. But as a factitious case we need to recognize that both the therapist and the patient are really the same. Since the case is so well written and we are intrigued by every turn of events presented as in a good novel and can easily forget that Melissa is a factitious character and exist only in the minds of the authors. All these developments never occurred. As with any fictitious character Melissa is the product of the imagination of the authors. Its like Reality TV. It may look and sound real but it is scripted nonetheless.
Again I am not saying it can’t be useful or educational. We can learn much from such fictitious and scripted case presentations. But without a case real record to examine; actual progress to monitor or a real live patient to give their feedback any number of clinicians can discuss the case from their own orientation or perspective and there is no way to evaluate which approach might be more effective than another. One can often look at the same case from a psychodynamic, cognitive behavioral or any number of other perspectives and come to different conclusions. Any one perspective is no more or less valid than another and it is a reader’s choice. With a real case on the other hand sometimes the approach taken can matter and sometimes the approach taken can be significant. If nothing else some approaches many be more efficient than the others in time and or cost. In real life that could be quite important.
Ideally what is needed especially in this day where evidenced based practice is in such demand and sorely needed is ironically going back to the some of the old masters. Perhaps what we need to encourage is something like that old and famous training video of “Gloria” where such luminaries as Carl Rogers, Fritz Pearls and Al Ellis, each in turn interviewed a single patient. Each therapist presented their conclusions and then the patient herself then gave her feedback as to what she thought was most effective about the style and approach of each therapist. That training tape is a classic and in many ways was far ahead of its time. Of course took a courageous patient to give informed consent to be filmed and have therapy viewed by generations of therapists in training not to mention the courage of Rogers, Pearls and Ellis to put their skills on the line.
But the SWT piece is a step in the right direction. We will follow SWT’s Therapist’s Notebook feature on a regular basis and report on its evolution. Who knows perhaps in time they will present actual patients who have given informed consent.
John A. Riolo, PhD
http://www.insiderlawethics.com/
http://www.youradvocateonline.com/
http://www.psychinsider.com/
http://www.myspace.com/johnriolo
