SOMATIC EXPERIENCING Case Study Protocol

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					     SOMATIC EXPERIENCING:
     Writing an SE case study

     M. Laurie Leitch, PhD, Director, FHE Research Program                   1-08

     The FHE is interested in encouraging faculty, students, and SEPs to conduct both
     quantitative outcome studies as well as case studies. Both can contribute to our need
     for an evidence-based practice. This set of guidelines is intended to help orient
     practitioners to the clinical case study. The guidelines will first provide some
     information about case studies in general. Second, a suggested format or protocol that
     is specific to SE is presented that can be used to write up a case study for publication.
     In section 3 human subjects protections are discussed. These protections are
     necessary to consider whenever clinical material will be presented for public
     audiences. A sample consent form is attached as well as journals that publish
     qualitative research, including case studies. Two single case study journal articles are
     referenced as examples of case studies of clinical treatment.

I.   Case Studies:

     In a case study the emphasis is on what, specifically, can be learned from the single case. A
     clinical case is chosen because it is believed that understanding that case may lead to a
     better understanding of either the methodology being used (in this case, SE) or to better
     theorizing about other cases that are similar (e.g., sexual abuse survivors). It is also
     possible to study a number of cases jointly (referred to as a collective case study) when
     there is interest in a specific phenomenon (e.g., domestic violence, veterans) and its
     responsiveness to a treatment intervention such as SE.

     Case study is sometimes viewed as a small step which is useful in contributing to broader
     theory building about why a clinical intervention works. However, beyond their role in
     theorizing, case studies have a major benefit of providing rich, descriptive information that
     deepens and enriches the kind of information obtained in larger-scale quantitative studies.

     Another benefit of clinical case studies is that they can be carried out and written up by
     clinicians who are not researchers. Quantitative studies are often daunting to clinicians who
     do not have extensive knowledge of research instruments and statistical analysis. A case
     study, focused as it is on creating a holistic narrative, requires neither and, yet, can
     contribute to building the evidence base of the intervention being used.

     The purpose of the case study shapes the way the analysis or inquiry is conducted. The
     Research Program is interested in case studies which help illuminate the ways in which
     particular clients/patients respond to SE and the treatment benefits of SE with a client. The
     next section discusses the SE case study.




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II.   SE Case Studies

      An SE case study can focus on one session and the SE interventions used and outcomes of
      the interventions (less likely to be published) or it can follow a client receiving SE over
      time (e.g., 3 sessions, 8 sessions, etc.), referred to as a longitudinal case study. In either
      case the focus is on the clinician’s choicepoints during the sessions, the rationale for the
      choices made, and the client’s responses.

      For example, in describing the use of SE interventions over a 6 session treatment process it
      would be important to discuss such choices as:
          How is the client initially introduced to somatic awareness?
          How does the clinician determine the client’s readiness for somatic interventions?
          At what point does the clinician shift from tracking sensations in general to
             resourcing and why?
          At what point is the decision made to begin incorporating traumatic material and
             sensations? And, why?
          How are cognitions and emotions addressed/utilized in the case being presented?

      Because somatic interventions are new to most clinicians in the broader clinical community
      it is important to fully explain such skills as titration and pendulation in terms non-somatic
      clinicians can understand. It is also important to give some information about the
      neuroscience underlying SE (biological basis of trauma, role of the ANS, etc).

      In a longitudinal case study (LCS), the emphasis is on the progression of the SE work over
      time. For example, in a longer term LCS there would most likely be a discussion of
      coupling dynamics and restoration of defensive responses, whereas, in a single session or
      briefer work the basic SE skills would be discussed.

      Because SE is relatively new to clinicians outside the somatic “world,” published case
      studies are an important way for the broader clinical community to learn what SE is and the
      way it is used in clinical work. For those SE practitioners who also draw upon other
      modalities (CBT, EMDR, etc.) a case study can describe when and why SE is woven into a
      session).

      SE Case Study Protocol:

         Single Session Format- The primary goal of the single session or brief treatment (2-4
         sessions) case study is to discuss the way the five basic skills (Grounding, Tracking,
         Resourcing, Titration, and Pendulation) of SE are utilized during a session.




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   FORMAT for Single Session and Brief Treatment write-up

   1. Relevant literature: Brief discussion of literature relevant to your case. This can
   include somatic literature, neuroscience literature, symptom literature related to the
   client’s presenting problem, and literature about treatment outcomes of other forms of
   intervention with this type of presenting problem (EMDR, CBT).

   2. Theory base: Brief description of SE and rationale for using it
   with the selected case (discuss biological basis of trauma).

   3. Case presentation: Relevant demographics on the client that can include gender, age,
   ethnicity, economic status, urban/rural/suburban, health history, life events overview.
   Included would be any demographics that shape the client’s life.
   NOTE: Some identifying information should be altered to prevent identification.

   3. Presenting problem and brief history: including physical
    and psychological symptoms (intensity and duration).

   4. Assessment and Case Conceptualization: Discussion of goals for each session as they
   pertain to the client’s history and presenting complaints, the way the 5 basic skills were
   used, and the response of the client.
       For example:
                            1. Goals for sessions 1-2: psychoeducation about the biology of
                                trauma and preliminary introduction to tracking, grounding,
                                and resourcing. Goal was to, for example, motivate the client
                                for the somatic work, reduce anxiety associated with sensory
                                awareness, etc.)
                            2. Goals for sessions 3-5: work with small increments of
                                traumatic material/sensation alternated with resourcing until
                                activation levels are within the normal window of arousal and
                                presenting symptoms of XYZ were diminished or eliminated.
                                Here you would also discuss the somatic goals (relaxed
                                breathing, decreased heartrate, less contraction in
                                musculature, etc.)

   4. Discussion of Course of Treatment, session outcomes and implications for similar
      cases.

   5. Complicating Factors: Challenges that arose during the treatment and a discussion
      of how they were handled.

6. Treatment Implications: Summary of SE relevance with this client. Here is where you
        would discuss the benefits of working somatically with this type of client.




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               FORMAT for Longitudinal Case Study Write-up

               Follow steps 1-3 above

               4. Discussion of treatment goals. Include discussion about orienting response, coupling
               dynamics, and restoration of defensive responses, where relevant.


               5. Discussion of session summaries that describe key SE interventions and the client
               responses. Clinical choice-points can be discussed and rationale for the various SE
               interventions used can be presented.

               6. Discussion of outcomes.

               7. Summary of SE relevance with this client.

The only difference in the case study in treatment that has more sessions is that there is likely to be
discussion of orienting response, restoration of defensive responses, coupling dynamics, and
syndromal patterns. These may be used in briefer treatment as well, in which case they would be
added into the discussion.

See the two clinical case study articles (EMDR outcome studies of treatment of a single case)
referenced at the end of this protocol to see how the various case study components were written up.

   III.    Human Subjects Protections

           A case study can be written up for publication with the identity of the client masked in such
           a way that no one could identify the client. However, even if it is not possible to identify
           the client from a case write-up, it is respectful to discuss your intent to write-up the case
           study and ask the client’s permission and have him/her sign a form consenting.

           You may also want to ask the client to review a draft of the write-up so that you can
           incorporate any additional information the client may add. At a minimum you may want to
           show the client the descriptive information about him/her to be sure the client feels his/her
           identity is protected.

           All notes pertaining to the case study should be kept either in the client’s file in a locked
           file cabinet or in a separate file in a locked file cabinet. It is important to protect the identity
           of your client by not including his/her name on loose papers or other materials being used
           to write-up the case study.

           When referring to the case study you should, of course, have another name that you use
           when discussing the case study with colleagues or in presentations.

           NOTE: This is only a suggested case study protocol. You may want to include other



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            dimensions (e.g. SIBAM) that you feel best describe your work. In addition, a clinician can
collect assessment data on symptoms, PTSD, resiliency, etc. prior to beginning treatment, after
treatment and at a 3-6 month follow-up in order to add a quantitative dimension to the study.


       Two articles that are case studies of a clinical treatment process with single cases:

           Madrid, A., Skolek, S., & Shapiro, F. (2006). Repairing failures in bonding through
           EMDR. Clinical Case Studies. Vol. 5, No.4:271-286.

           Fernandez, I. & Faretta, E. (2007). Eye Movement Desensitization and Reprocessing in the
           treatment of panic disorder and Agoraphobia. Clinical Case Studies. Vol.6, No. 1: 44-63.




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