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McFall raises a number of points in his comments on our chapter describing the treatment of Andy. His primary critiques reflect three themes: (1) it is impossible to draw scientific conclusions of cause and effect for treatment outcome from a case study; (2) it is not known how successful treatment would have been had the therapist made different choices, including about how quickly to start and stop the intervention or how to handle homework noncompliance; and (3) the formulation offered little additional information. We will respond to each in turn.
First, we agree with McFall that one cannot draw scientific conclusions from case studies, but they can be useful for raising hypotheses. This function largely applies to new areas of scientific inquiry, and as such does not describe treatment for social anxiety disorder, which has been extensively researched since it was called “neglected” more than 25 years ago (Liebowitz, Gorman, Fyer, & Klein, 1985). An important purpose of a case report at this stage of scientific inquiry is to help bridge the gap between treatment as reported in randomized controlled trials and what practitioners perceive to be their own realities of practice. Stepping outside the confines of a clinical trial, we sought to describe how a highly expert clinician with a strong scientific orientation applies the research literature to a relatively complex, multi-problem case. The primary purpose was not to demonstrate the efficacy of the treatment, ruling out competing hypotheses for change, but rather to illustrate a scientific approach to clinical work that draws on research on basic psychopathology, nonspecific treatment factors, and clinical trials.
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