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Commentary: critical reflections on the ethical and professional considerations in writing about clients.

From the standpoint of a journal editor and researcher, this commentary critically reflects on some of the primary notions addressed in the 4 featured articles of the special section, discussing areas of agreement and divergence, As a way of further exploring these ethical and professional concerns, the contentious issue of using school children as case studies in publications and in graduate counseling courses is briefly examined.


The subject under discussion in this special section is unmistakably an important yet delicate one. In this commentary, my intent is to first examine, mainly from the perspective of a journal editor and researcher, some of the key recommendations posited in the featured articles. Second, I touch on the use of student case studies as instructional narratives and in scholarly publications. Before my closing remarks, I describe my experience as a journal editor dealing with clinical case studies in manuscripts submitted for publication. Sample editorial suggestions are included as well.

Articles in the Special Section

In their entirety, the articles competently speak to the multifarious ethical issues surrounding the various applications of case studies, including their use in preservice and in-service training of counseling professionals, research design, and scholarly publications. As the contributors point out, there are no definitive profession-wide guidelines to follow, and the manner in which one openly recounts case studies requires considerable ethical reflection. The potential value and harm of using clients' stories in public venues must be cautiously weighed. The articles by Duffy (2010) and Sperry and Pies (2010) offered comprehensive and insightful ethical discussions, accompanied by valuable recommendations for best practice. Shifting from the general to the specific, Kantrowitz (2010) narrowed her discussion to psychoanalytic case studies, aptly reviewing the advantages of and the hazards of disguising identities in this therapeutic context. Similarly, Bridges (2010) centered in on the challenges of seeking consent from psychotherapy clients to use their clinical stories in professional publications. The authors, to varying degrees of success, provided helpful ethical guidelines relevant to many counseling and mental health settings.

Even though these authors eruditely addressed the ethical topic and its broad contours, for those journal editors, counselor educators, publication authors, and researchers who need a tighter delineation of the ethical topography, many unanswered questions remain. For example, assuming that appropriate permissions and safeguards are in place to ensure client confidentiality, does best practice evidence support the use of disguised clinical cases and/or composites of similar clients? Informed opinions were expressed, but on the issue of when and why one approach was preferred over the others, author consensus was lacking. For example, Bridges (2010) indicated, "There may be no satisfactory way to reconcile the needs of the profession while protecting clients" (p. 103). Kantrowitz (2010) added, "There are no easy answers about how to write, when to write, or who and what to write about. Simple rules will not work" (p. 133). Perhaps, because the ethical concerns can be so nuanced when using case studies in publications and elsewhere, the contributors seemed to advocate for an "individualization policy." In other words, I gather from the four articles that the decision on what ethical strategy to follow, after weighing intersecting and diverging factors and in consultation with other professionals, should be made on a case-by-case basis. In response, I wonder if this individualized approach sacrifices methodological rigor for ethical sensitivity.

More specifically, whereas Sperry and Pies (2010) suggested using composite clinical cases only in relevant situations, Duffy (2010) seemed to prefer this ethical strategy over others. Furthermore, the ethical options presented in each article protect psychotherapy clients' and study participants' identities; however, they may not be altogether practical in other professional and scholarly settings. It is interesting that the contributors failed to address the reliability and validity concerns that arise when presenting modified case studies to wider audiences. When scholarly authorities are discussing altered or composite client narratives (e.g., to illustrate a therapeutic concept or mental disorder), it seems to some preservice and in-service counselors/therapists that these "fictionalized" case studies can be regarded as supplementary evidence. If interventions/treatments are devised based on case studies that lack consistency, generalizability, and ecological validity, can therapists still ensure their efficacy? Are research conclusions gleaned from investigations using composite case studies anything more than equivocal?

In medical studies, patient data are carefully vetted and aggregated while ensuring patient confidentially. With the appropriate protections in place, medical school professors discuss individual patient cases with their students, but good science does not allow them to make treatment generalizations to other patients with like symptomatology. Regrettably, many counseling studies and case presentations are rife with high levels of subjectivity, lack standardized procedures for data collection, and strict methodological controls. Client data are limited in their applicability to even similar participant groups. If professional ethics with regard to using client case studies are situationally mediated, should the conclusions drawn from such unreliable personal data be reported in graduate school classrooms or scholarly journals?

Those readers who use case studies as classroom exemplars, or as instructive vignettes in scholarly publications, or who conduct research deploying methods that involve case studies or portrait analyses ought to consider the scientific credibility of their ethical decision making. Perhaps more individualization on how to ethically report case studies is not called for; instead, additional standardization and rigor are necessary. I admit, the processes and procedures to achieve this aim will be difficult to elucidate, and the obstacles to widespread implementation are numerous. Nonetheless, at a minimum, it is advisable to report on authentic case studies, modifying as little as possible the client's story and context. This will require professionals and researchers to obtain explicit written consent from clients. A consent protocol could be developed that plainly summarizes why, how, and when the client's information will be used. Clients ought to read and endorse the case study before it is publicly released. If they desire to amend the case study in a way that obviously changes essential aspects and diminishes the narrative's validity, the user would be wise not to publish it. Within reason, the vignette should include carefully worded behavioral descriptions, avoiding "therapeutic" comments and interpretations that could be misunderstood by an underinformed audience. I now briefly turn to a serious omission in the ethical discussion of case studies.

Further Discussion on Case Studies

Student Stories as Case Studies

There are multiple resources that address the notion of "meaningful consent" and the publication of adult counseling clients' personal vignettes (e.g., Clifft, 1986; Patterson, 1999; Pope & Vasquez, 2007; Stiles, 2007; also, see special section articles in this issue). However, the use of case studies within educational counseling settings has received virtually no professional attention. For instance, unlike the articles discussed earlier, wide-ranging school counseling ethical and legal texts provide little guidance on how to address this case study issue (Remley, Hermann, & Huey, 2003; Stone, 2005). As a result, I cautiously veer into this area as a way to expand the conversation to "students as clients."

For the ,obvious reasons, when working with students in a counseling capacity, the utmost ethical and legal sensitivity is required. Ethical standards developed for mental health settings do not fully apply to school personnel. It is essential to obtain written parental/guardian, and if possible, student consent when providing most counseling-related services (e.g., individual, group, and peer counseling). To use students as case studies for non-school-related purposes adds another layer of ethical and legal complexity. It is especially challenging to discern the most ethical course of action when students openly publicize their lives on Internet sites (e.g.,, disclose personal information in classrooms, and in other nonconfidential situations. If the student candidly discloses information in public settings, is it reasonable to assume that it can be reshared without consent in a case study?

From my perspective, composite student cases drawn from the literature and school practice are appropriate to discuss for educational and training purposes in graduate counseling and school psychology programs. If one uses real student cases for teaching purposes, no identifying student data (e.g., student name, school, or school district name) should be reported. School personnel should consider Sperry and Pies's (2010) guidelines for seeking permission, disguising the client identities, and developing a composite case. However, the nonidentifying information (i.e., the student's narrative in behavioral terms) presented to the public must not be embellished, distorted, or invented. Beyond these recommendations, school-based counseling personnel--in consultation with their school district's attorney, administrators, and other relevant stakeholders--should develop a clear policy as to when, where, and how student case studies can be disclosed to a wider audience. Sample case studies that are policy informed should be distributed to all educators during school in-services. Obviously, these school-based suggestions are only preliminary; far more professional discussion is needed.

A Journal Editor's View of Case Studies

As indicated earlier, case studies are presented in many journal articles that I consider for publication. Anecdotal evidence suggests a variety of ways editors address the ethical issues related to use of client narratives. Some editors apparently insist that all case material requires documentation of written client permission before a manuscript can be reviewed. This has not been my policy, however. Editors, in my view, must respect the professional integrity of submitting authors. Unless I believe the reported case studies are unclear, poorly described, or misinterpreted, I assume the author has accurately portrayed and discussed the client's story in an ethical manner. Rarely do I question the author, because most case studies presented in manuscripts are well written and the client's identity so well disguised that it is virtually impossible to trace the source of the information and check its reliability.

Other than trusting authors' careful attention to general ethical principles, how can editors be assured that the case presentation is an authentic depiction of the client's story and that all client safeguards have been properly applied? Although I have had no serious concerns over client privacy and legal liability issues, it is advisable to provide manuscript contributors with at least some case study presentation guidelines. For example, rigorous methodological standards should be elucidated when contributors/authors use case studies as objective evidence for a particular concept, practice, theory, and so on. In this situation, the author should provide detailed information about how the case study was collected. The reliability and validity of the data need to be included. Moreover, as suggested earlier, a consent protocol could be devised and submitted along with the manuscript if the case studies are to be used as research data. On the other hand, if case studies are disguised composites of many clients and are to be used as client exemplars or for instructional purposes, it seems overly burdensome to ask manuscript writers to document the ways client confidentiality was protected. In short, how case studies are used in the publication should probably govern what ethical standards need to be applied.

Concluding Remarks

This special issue has advanced an important conversation and broached new areas related to case study ethics. The guidelines presented in these articles are generally apropos for most mental health professionals and clients; however, I am concerned that the authors' foci and their recommendations for practice are not entirely amenable to school-based mental health professionals and their enormous client base. Case studies are a vital component in school counselor and school psychologist preparation programs. How the authors' positions and guidelines pertain to the educational milieu should be the focus for further dialogue. Finally, when the publication of client case studies is involved, I am not convinced that the psychotherapeutic/counseling profession should move in the direction of more context-specific ethics. Rather, to increase the reliability and validity of reported client data, the profession needs to adopt a more stringent position, standardizing ethical procedures and processes.


Bridges, N. A. (2010). Clinical writing about clients: Seeking consent and negotiating the impact on clients and their treatments. Counseling and Values, 54, 103-116.

Clifft, M. A. (1986). Writing about psychiatric patients: Guidelines for disguising case material. Bulletin of the Menninger Clinic: A Journal for the Mental Health Professions, 50, 1-13.

Duffy, M. (2010). Writing about clients: Developing composite case material and its rationale. Counseling and Values, 54, 135-153.

Kantrowitz, J. L. (2010). Using disguised clinical case material. Counseling and Values, 54, 117-134.

Patterson, A. (1999). The publication of case studies and confidentiality: An ethical predicament. Psychiatric Bulletin, 23, 562-564.

Pope, K. S., & Vasquez, M J. T. (2007). Ethics in psychotherapy and counseling: A practical guide (3rd ed.). New York, NY: Wiley.

Remley, T. P., Jr., Hermann, M. A., & Huey, W. C. (Eds.). (2003). Ethical and legal issues in school counseling (2nd ed.). Alexandria, VA: American School Counselor Association.

Sperry, L., & Pies, R. (2010). Writing about clients: Ethical considerations and options. Counseling and Values, 54, 88-102.

Stiles, W. B. (2007). Theory-building case studies of counselling and psychotherapy. Counselling and Psychotherapy Research, 7, 122-127.

Stone, C. B. (2005). School counseling principles: Ethics and law. Alexandria, VA: American School Counselor Association.

Christopher A. Sink, Department of Counselor Education, Seattle Pacific University. Correspondence concerning this article should be addressed to Christopher A. Sink, Department of Counselor Education, Seattle Pacific University, 3307 Third Avenue West, Seattle, WA 98119-1907 (e- mail:
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Title Annotation:Special Section: Writing About Clients: Ethical and Professional Issues in Clinical Case Reports
Author:Sink, Christopher A.
Publication:Counseling and Values
Article Type:Viewpoint essay
Geographic Code:1USA
Date:Apr 1, 2010
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