Clinical Psychology

The Mask of Sanity(Cleckley, 1964) provided
detailed accounts of the lives of psychopaths.
Cases in Behavior Modification(Ullman &
Krasner, 1965) demonstrated the efficacy
of behavioral treatments with single cases.
Nothing will ever likely supplant the case
study as a way of helping clinicians to understand
that unique patient who sits there before them.
As Allport (1961) so compellingly argued, indivi-
duals must be studied individually. Case studies
have been especially useful for (a) providing
descriptions of rare or unusual phenomena or
novel, distinctive methods of interviewing,

assessing, or treating patients; (b) disconfirming

“universally”known or accepted information; and

(c) generating testable hypotheses (Kazdin, 2003)

(see Box 4-2).

There is, of course, a downside to case study

methods. For example, it is difficult to use individ-

ual cases to develop universal laws or behavioral

principles that apply to everyone. Likewise, one

case study cannot lead to cause–effect conclusions

because clinicians are not able to control important

variables that have operated in that case. For exam-

ple, one patient may benefit enormously from psy-

chodynamic therapy for reasons that have less to do

with the therapy method than with the personality

BOX4-2 Clinical Applications: Generating Hypotheses from Therapy

Karl was an unmarried veteran referred to a Veterans

Administration outpatient clinic. It did not take long

for the therapist to realize that Karl’s problems were

not of the typical variety. Karl was a bit anxious or, at

times, depressed, but his main problem seemed to be a

near total lack of interpersonal and social skills. He had

no job, and he lived off his small government pension

along with whatever support his mother could provide.

Aside from his mother, with whom he lived, he rarely

interacted with anyone except perhaps to buy cigar-

ettes or get change from a disinterested bus driver. He

certainly had no friends.

Therapy, then, became not an insight-oriented,

uncovering process but a teaching process. The goals

became teaching Karl to find work, enabling him to

attend night school to learn a trade, and inculcating at

least a few basic social skills. The focus was on how to

find a job, keep a job, talk with others, and gain their

interest. Hour after hour was spent on these tasks

during the therapy.

But progress was slow. It was not that Karl failed

to understand or was totally disinterested or even

loath to try out newly learned skills. The difficulty was

that even when Karl attempted a new behavior and

was successful, that success seemed to have little effect

on his subsequent behavior. This was strange indeed.

Psychologists quickly learn that reinforcement

strengthens the likelihood of the reinforced behavior

in the future, given similar conditions. But not so with

Karl. Reinforcement seemed to do little to raise his

expectancies that the behavior would work again.

Karl almost seemed to want to be the singular excep-

tion to a prime rule of learning theory—that rein-

forcement enhances habit strength!

The therapist and his consultants puzzled over this

for months. For example, after applying for a job and

getting it, Karl’s confidence did not increase at all.

Instead, he attributed his success to luck, not to his

own efforts. Several other similar episodes followed.

After much urging by the therapist, Karl asked a

female coworker for a date. She accepted. But again,

Karl merely remarked on his good luck.

Eventually, the therapist decided that perhaps

Karl believed that the occurrence of reinforcement was

outside his personal control. If so, the inability of suc-

cess to increase his confidence began to make sense.

He was not responding in defiance of learning theory.

Instead, the therapist’s conceptualization had been

incomplete. Reinforcement will“stamp in”a behavior,

but only when that behavior is seen as causally related

to the subsequent reinforcement. Karl believed chance

rather than personal skill was operative. And under

chance conditions, reinforcement carries no implica-

tions for the future. Thus, the riddle of Karl’s behavior

seemed to have been solved. Or at the very least, an

important hypothesis had been formulated. In fact, a

great deal of empirical research lay ahead. Only after

several years of empirical research could the utility of

the chance-versus-skill hypothesis be verified. This gen-

eral research field came to be referred to asinternal–

external control(Rotter, 1966), orlocus of control.

RESEARCH METHODS IN CLINICAL PSYCHOLOGY 99