case study psychotherapy

Pragmatic Case Studies in Psychotherapy

PCSP is a peer reviewed, open-access journal and database. It provides innovative, quantitative and qualitative knowledge about psychotherapy process and outcome. PCSP is published by the National Register of Health Service Psychologists.

January, 2024 -- see our newest case, "The Commitment of a Lifetime": The Role of Emotionally Focused Couple Therapy in Strengthening Attachment Bonds and Improving Relationship Health in Later-Life Couples—The Teletherapy Case of "Alice" and "Steve."

Click on the upper left button for the “Newest Case" or the button labeled "Current."   Click on "CE Exams On Case Studies" below for an Exam on the current issue's case study and on past issues' case studies.  

The Case Studies

Autism spectrum, cognitive difficulties, medical conditions, obsessive compulsive, personality disorders, psychosis/schizophrenia, trauma/ptsd, specific features in case studies, methodology of case studies, approaches and theories in case studies, ce exams on case studies.

January 23, 2024 -- FROM THE EDITOR  

ANNOUNCING THE PUBLICATION OF OUR 67th ISSUE (Vol. 20, Module 1)  

"The Commitment of a Lifetime": The Role of Emotionally Focused Couple Therapy in Strengthening Attachment Bonds and Improving Relationship Health in Later-Life Couples --The Teletherapy Case of "Alice" and "Steve"  

*** Drew Mendelson, Rutgers University-New Brunswick, NJ    

Commentaries 

*** Karen Skean and Elisabeth Brown, Rutgers University-New Brunswick, NJ   

*** Shalonda Kelly, Rutgers University-New Brunswick, NJ 

EDITOR'S NOTE

A healthy marriage is a crucial protective factor for adapting to the challenges of late life. Emotionally Focused Couple Therapy (EFCT) for couples is an attachment-based model of psychotherapy that emphasizes here-and-now processing of emotion in a safe holding environment; enhanced understanding of the patterned interactions between self and other; and a non-pathologizing, growth-oriented approach toward couples’ difficulties.   This case study examines the benefits of EFCT for addressing issues specific to late life, including existential concerns such as aging, illness, and mortality; caregiving burdens and stress; cumulative relational trauma over the lifespan; and forgiveness and healing from emotional injuries.   Specifically, this case study involves a 20-session, teletherapy treatment of a couple named “Alice” and “Steve,” aged 74 and 75, respectively, with Steve suffering from advanced Parkinson’s Disease. The couple presented with hopelessness and resentment about their caregiving situation, unresolved traumas from early childhood fueling their relationship’s sore spots, and unprocessed grief and fears concerning losses at the end stage of life.   The EFCT-guided treatment focused on promoting transformational and corrective experiences of secure attachment bonding and was importantly successful in resolving their presenting problems.

*** For a Table of Contents and pdf links to the articles, click on the upper left button labeled "Newest Case" or the button labeled "Current."  

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Case Study Research in Counselling and Psychotherapy

• John McLeod - University of Oslo, Norway
• Description

- the role of case studies in the development of theory, practice and policy in counselling and psychotherapy

- strategies for responding to moral and ethical issues in therapy case study research

- practical tools for collecting case data

- 'how-to-do-it' guides for carrying out different types of case study

- team-based case study research for practitioners and students

- questions, issues and challenges that may have been raised for readers through their study.

Concrete examples, points for reflection and discussion, and recommendations for further reading will enable readers to use the book as a basis for carrying out their own case investigation.

See what’s new to this edition by selecting the Features tab on this page. Should you need additional information or have questions regarding the HEOA information provided for this title, including what is new to this edition, please email [email protected] . Please include your name, contact information, and the name of the title for which you would like more information. For information on the HEOA, please go to http://ed.gov/policy/highered/leg/hea08/index.html .

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This text offers students the opportunity to grasp the importance of using case studies to inform research and is recommended for our students taking an Introduction to Evidence based practice in counselling module

An excellent textbook with clear guidelines to help students understand the importance of developing consistent methods for gathering evidence as they work with cases. The role of case studies for students as they learn about the different theories is essential for them to grasp a practical understanding of applications. This book covers the knowledge of writing case reports in a clear and comprehensive way.

John McLeod is and probably always will be the author we recommend when talking about evidence based practice. His other texts in Doing Counselling Research and Qualitative Research are seminal in this context. This text fills the gap around working with case studies in research, and is very relevant as this is an area that most counsellors will need to be familiar with. The book is well written and if possible makes the subject even more approachable and interesting. Our third year students are now recommended to read this title in relation to all of the third year professional level study modules, as it offers so the opportunity to become familiar with research methodologies and language.

An excellent book which helps people understand the ethics and processes involved in a case study approach. Some very useful examples contained within the book which makes the subject understandable. It has provided me with the motivation to consider applying this in my own practice.

Part of the beauty of this book is the accessibility of the author; as he brings the reader through an exciting, interesting, pragmatic and richly informed account of living qualitative research in action. The book considers; pragmatic, n=1, HSCED, theory-building adn one of my personal favourites - narrative approaches. This book is a required resource for anyone interested in qualitative research or therapy practice. A gem.

A thorough and rigorous review of the latest developments in case study research. Important reading for all counselling and psychotherapy research students, and practitioners who want to write up their clinical work.

This is a useful book, that makes a considered case for the the use of Case Studies for effective research as well as a developmental method for students.

Excellent book, which fills a gap in the current literature; especially useful in clinical psychology training where alternatives to n=1 empirical case studies are not widely accepted.

this has everything that you need for researching

This book has been useful in thinking about revalidation the Social Work degree and its themes will take a more central part in the revalidated degree from 2011-12 onwards.

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Sample materials & chapters.

Foreword by Daniel B. Fishman, Ph.D., Rutgers University

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• March 15, 2024 | VOL. 77, NO. 1 CURRENT ISSUE pp.1-42

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Recovery in First-Episode Psychosis: A Case Study of Metacognitive Reflection and Insight Therapy (MERIT)

• Bethany L. Leonhardt , Psy.D. ,
• Kristen Ratliff , M.S. ,
• Jenifer L. Vohs , Ph.D.

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Despite historically pessimistic views from both the professional community and lay public, research is emerging that recovery from psychosis is possible. Recovery has evolved to include not only a reduction in symptoms and return to functioning, but a sense of agency and connection to meaningful roles in life. The development of a more comprehensive conceptualization of recovery has particular importance in the treatment of first-episode psychosis, because early intervention may avoid some of the prolonged dysfunction that may make recovery difficult. As the mental health field moves to intervene early in the course of psychosis and to support recovery for individuals with severe mental illness, it is essential to develop and assess interventions that may promote a more comprehensive recovery. This case illustration offers an account of a type of integrative psychotherapy that may assist individuals in achieving recovery: metacognitive reflection and insight therapy (MERIT).

Despite early pessimism about the chronicity and course of schizophrenia spectrum disorders in psychiatry, there has been a shift in discussion in research, treatment, and policy suggesting that recovery from severe mental illness is possible. Various factors have contributed to this shift, including long-term outcomes studies that show a heterogeneous course for those with schizophrenia spectrum disorders ( 1 ), as well as a shift in the conceptualization of recovery in serious mental illness. Due to a grassroots movement of activists and scholars embracing a broadened view of recovery, recovery now includes a process of regaining autonomy over one’s life and a return to meaningful life roles, even in the face of persisting symptoms or difficulties ( 2 , 3 ). This aspect of recovery is called many things, including recovery as process and subjective recovery. Included in this definition of recovery is that individuals see themselves as more than a mental health patient, feel empowered to make decisions about their lives and health care, and can participate in aspects of their community that are meaningful to them ( 2 ).

This broadened view of recovery has several implications for interventions offered to individuals with schizophrenia spectrum disorders. In particular, with a recent emphasis on intervening early in the course of illness, or first-episode psychosis (FEP), a broadened view of recovery has implications for the types of interventions offered in FEP clinics. The literature to date has shown that early intervention in FEP is related to a range of improved outcomes ( 4 ), yet these outcomes are often more objectively defined, such as symptom remission, use of acute services, and level of functioning. While these outcomes are important, it remains unanswered how early intervention can assist individuals with FEP to attain subjective recovery.

One promising intervention that may assist in promoting recovery in FEP is metacognitive reflection and insight therapy (MERIT; 5 ). MERIT is an integrative psychotherapy that targets metacognition. Metacognition refers to a range of cognitive activities that allow one to form complex, flexible accounts of one’s own life, as well as of significant others, and to use this knowledge to respond to a range of psychosocial problems ( 6 ). Deficits in metacognition have been found to exist in schizophrenia spectrum disorders ( 7 , 8 ), to be stable ( 9 ), and to be present across all phases of illness, including FEP ( 10 ). Promoting metacognition may assist persons in moving toward subjective recovery because it may be necessary to think in a sophisticated way about oneself to obtain this type of recovery. For example, thinking flexibly and coherently about oneself may allow one to see oneself as more than a mental health patient, to identify a range of passions and life roles that would make one’s life fulfilling, and to be able to respond flexibly to psychosocial distress.

There is some evidence to suggest that higher metacognition is related to an improved sense of subjective recovery in those with schizophrenia spectrum disorders ( 11 ), and offering interventions such as MERIT that specifically target metacognition may assist in promoting recovery. In fact, in a sample of individuals with prolonged psychosis, metacognitively oriented psychotherapy was found to assist in forming a coherent sense of self and to ultimately promote recovery ( 12 ). Additionally, case studies have been reported examining the use of MERIT as an intervention to target and promote insight in FEP ( 13 , 14 ). The following case builds upon this work to illustrate the use of MERIT as an intervention promoting recovery in FEP.

Presenting Problem and Client Background

The client for this case will be referred to as Grohl. All identifying information has been altered to protect his confidentiality. Grohl is a single male in his early to mid-20s who was diagnosed as having schizophrenia two years prior to his engagement in therapy. He grew up as the eldest of three children in a middle-class family and reported no developmental concerns or delays. Grohl described himself as having many friends during his childhood and reported he was involved in extracurricular activities and performed well in school. Prior to his diagnosis of schizophrenia, he had no other mental health diagnoses or mental health treatment. He was a talented artist and was active in his high school’s art community. He and his parents noted a change after high school in which Grohl became less social and struggled academically in his college classes. Immediately after high school, Grohl relocated from living with his family of origin to living with his grandfather in a different city in the same state. He had limited contact with his family of origin during that time and began to experience a change in his level of psychosocial functioning: socially withdrawing, failing to keep jobs, and eventually dropping out of school. Grohl’s grandfather struggled with substance abuse during this time and was actively using substances while Grohl lived with him. Grohl and his parents reported that there were often verbal and physical fights as a result of Grohl’s grandfather’s substance use and overall this was a tumultuous time for Grohl. Grohl’s own substance use included occasional marijuana and alcohol in high school, and he reported drinking alcohol several times per week while living with his grandfather. He had legal charges related to an arrest for underage drinking.

During the onset of Grohl’s illness, he began to believe a range of persecutory delusions that often centered on his physical health, stating that others were poisoning him and noting strange physical sensations that he believed were a result of the poison he was administered. His grandfather took him to a behavioral health center where Grohl was diagnosed as having schizophrenia and an oral second-generation antipsychotic was prescribed, which he took intermittently. Grohl lived with his grandfather and occasionally sought medical assistance for physical sensations for one-and-a-half years before he visited emergency rooms in several states, attempting to convince hospital staff that he was being poisoned and requesting medical attention. Grohl would leave the emergency room before care could be administered. He was eventually detained by the police due to erratic behavior and was transferred to an inpatient hospital close to his parents’ residence. It was following this hospitalization that Grohl was linked to the early psychosis clinic. While on the inpatient unit, Grohl was involuntarily committed due to his refusal to take medications and his attempts to leave the unit against medical advice. He began receiving an injection of paliperidone palmitate. Grohl eventually moved to a supported living environment and attended an outpatient clinic, receiving case management and medication services for six months before agreeing to psychotherapy. He remained on a stable dose of his medications during the duration of the therapy presented below, and he received services from a multidisciplinary team, including case management and supported employment services. In addition, because of Grohl’s somatic complaints, he received care at several primary and specialty care clinics to evaluate his health. He received a diagnosis of gastroesophageal reflux disease and was treated for this condition. He received no other medical diagnoses.

When Grohl began therapy, he was primarily experiencing negative symptoms. He experienced thought blocking, prolonged response latency, anhedonia, and flat affect. He described that his mind was “empty” and noted that he spent much of his day lying in his bed. Grohl was unemployed at the time and saw his family once per week when his parents picked him up for a family Sunday dinner. He had no other social contact. He endorsed avolition, noting that despite being bored much of the time he was not motivated to engage in any behaviors that he used to find enjoyable, such as creating art, spending time in Internet forums, or spending time with his friends. Grohl was quiet, rarely made eye contact, and often came to his psychotherapy session appearing disheveled.

Case Conceptualization

Grohl’s deficits in metacognition were assessed with the Metacognition Assessment Scale-Abbreviated (MAS-A; 15 ), which is an adaptation of the original MAS ( 16 ) and includes four domains of metacognition: self-reflectivity, awareness of others, decentration, and mastery. Each part of the scale is hierarchical, with higher scores representing increased capacity to perform the complex mental tasks of each domain. Self-reflectivity refers to the ability to acknowledge and identify internal states and to ultimately form flexible understandings of oneself and one’s unique life events over time. Grohl initially had low self-reflectivity. Although he was able to distinguish a range of cognitive operations, he was unable to name a nuanced range of emotions or recognize that his thoughts were fallible, giving him a score of 3 out of 9 on the self-reflectivity scale. For example, Grohl remained convinced that he was being poisoned by an unnamed entity and remained adamant that he had holes in his head that were causing discomfort in his body. Awareness of others refers to the ability to consider other people’s internal states and to make guesses about their intentions. Grohl also scored low in this capacity. He recognized that others had their own internal states but was unable to name a range of emotions significant others in his life might experience and struggled to guess their intentions. He was evaluated at a 3 out of a possible score of 7 on this subscale of the MAS-A. Decentration refers to the ability to recognize that one is not the center of all activities and that other people have differing, valid opinions separate from one’s own. Grohl tended to view events as being connected to him, often believing that others wished him harm, and failed to consider that others in his life had lives outside of his. He scored 0 out of 3 on this scale. Finally, mastery refers to the ability to use knowledge about oneself to respond in increasingly complex ways to psychological problems. Grohl initially came to therapy without a clear psychological problem, often stating that something had gone wrong in his life but attributing that distress to the malicious, unnamed individuals who he believed were causing his physical sensations. Thus, his score on mastery was a 1.5 out of 9.0 because he did not meet the criteria of articulating a plausible psychological problem.

Course of Treatment

The therapy described below refers to an 18-month period of weekly individual psychotherapy utilizing MERIT. MERIT is an integrative psychotherapy with eight core elements incorporated into each session. These elements can be used along with a range of therapeutic approaches and offer therapists a method of building upon existing skills and conceptualizations and employing a flexible framework that centers on increasing the client’s metacognitive capacity ( 17 ). Each of these elements is briefly defined below, along with a description of how that element was addressed in Grohl’s psychotherapy.

Element 1: The Preeminent Role of the Client’s Agenda

This element refers to, first and foremost, establishing what the client wants from the session that day. Agendas are often not clearly articulated, and it is possible for clients to have multiple, and at times conflicting, agendas at once. For example, a client could wish that a therapist agree that he or she is a victim of a jealous neighbor or may want the therapist to view him or her as independent and capable. Attending to these agendas requires that therapists be curious about and attentive to the ways in which the client’s desires pull for a reaction in a session, whether it is to be viewed a certain way or for the therapist to take a certain action.

Initially, Grohl’s agenda appeared to be to convince the therapist that he did not have a mental illness and to get her to agree with his belief that others were causing his physical symptoms through attacks on him in his sleep. Grohl often was adversarial with his psychiatrist, asserting that he did not have schizophrenia and noting his anger at being forced to take medications he did not believe he needed. The therapist responded to these agendas with curiosity about Grohl’s physical symptoms and attempted to gather a timeline and narrative episodes surrounding the onset of these symptoms. When Grohl would directly ask the therapist to align with him against his psychiatrist by asking whether she agreed that he did not have schizophrenia but was the victim of a conspiracy, she responded by reflecting on the dynamics of Grohl’s agenda and with curiosity about what her agreement would mean to him. The therapist would then request more information about Grohl’s experience to better understand what he was experiencing. It seemed important to the therapist that she remain open to and curious about Grohl’s agenda rather than attempting to promote her own agenda (such as improving insight or adherence to treatment). The therapist’s openness seemed to allow Grohl to move at a pace with which he was comfortable, which ultimately seemed to promote trust and further exploration of Grohl’s life story. However, at times moving at Grohl’s pace was difficult, and often the treatment team would experience impatience or anxiety as Grohl continued to attempt to get body scans or other medical procedures to address his somatic experiences.

Element 2: Introduction of the Therapist’s Thoughts as Dialogue

This element refers to the therapist offering his or her own reflections and reactions throughout the session to promote dialogue. The therapist’s mental contents are fodder for reflection and not presented as fact or a more accurate view of reality but to encourage the client to react to the therapist’s reflections so the two can think together about them.

The therapist initially achieved this element with Grohl by stating her confusion about the claims he was asserting regarding his physical sensations. As Grohl provided more information and reflected upon the events surrounding the onset of these sensations, it occurred to the therapist that Grohl often experienced these strange sensations when he felt unsafe. He reported that the sensations began while living with his grandfather, who was unpredictable and often verbally and physically abusive to Grohl, including attacking him in his sleep. Since then, Grohl had moved into a supported living home with individuals with psychiatric needs in a neighborhood in the city that was known for being unsafe. Grohl often reported being most bothered by these physical symptoms when he was around others living in the home, and he reported that he did not experience these symptoms at his parents’ home. The therapist responded to Grohl by offering reflections such as “When you share these stories, it makes me wonder if you felt threatened,” and, “I have a thought that you felt unsafe staying with your grandfather.” The therapist would then invite Grohl to comment on her reflections.

Element 3: Eliciting Narrative Episodes

The third element of MERIT emphasizes the importance of eliciting narrative episodes to assist clients in developing a storied sense of their lives over time. This element was particularly important with Grohl and was challenging in the beginning due to his barren account of his life. Grohl described his life as being successful and positive until the physical sensations began, to which he attributed all his dissatisfaction with his current circumstances. The therapist elicited narratives by asking for more details about the onset of his physical symptoms and attempting to gather information about where he was living and with whom he was interacting. Eventually, she began to compile a timeline of Grohl’s life. He often responded to the therapist’s inquiries by stating that he could not remember his life. By revisiting the few narratives he could offer, Grohl eventually was able to provide more details to these narratives and slowly, narratives of other times arose. A richer picture of his life emerged, including his account of the abuse he endured while living with his grandfather, his sense of having failed at becoming an independent adult, his social discomfort in high school, and his remembering of his love and dedication to art. With this richer picture of his life, Grohl’s account of having experienced a perfect life prior to the onset of physical symptoms was challenged and evolved into a rich, storied sense of his unique life, including his challenges and triumphs. This richer version of Grohl’s life often caused him pain and discomfort, as he grappled with a sense of loss of dreams he previously had for himself and struggled with acceptance of painful interactions with significant others. Likewise, this process was difficult at times for the therapist as she watched Grohl struggle with painful aspects of his life and continued to encourage him to reflect and explore potentially distressing narratives. Despite the discomfort that often accompanied the increased reflectivity, Grohl appeared better able to make sense of his life. Exploring narratives seemed to allow Grohl to finally come to terms with experiencing psychiatric difficulties as well as to see himself as a full being and not only a psychiatric patient.

Element 4: The Psychological Problem

The fourth element refers to assisting clients in forming a plausible, mutually agreed upon psychological problem. The psychological problem often emerges from the understanding of the client’s agenda and narratives and may include a range of difficulties not restricted to a mental disorder. Examples of these difficulties could include struggling to connect with others in an adaptive manner or difficulty in understanding the intentions of others and thus navigating interactions.

Initially, Grohl struggled to form a plausible psychological problem and focused on implausible explanations for the distress he was experiencing. He often stated that others were poisoning him or performing operations on him while he was sleeping, leaving no trace of surgical scars when he woke. These expressions often left the therapist in a difficult position, because she could not join Grohl in these explanations of his difficulties. However, through exploration of the development of these physical sensations and the narratives he offered, Grohl began to articulate a psychological problem that something had gone wrong in his life and that he had gotten off track. He considered factors that could have influenced the course of his life, expanding these factors from his suspicions of others to include his decreased self-esteem caused by perceived failures, such as of losing jobs, dropping out of college, and new difficulties in connecting with others. Grohl’s understanding of his psychological problem continued to evolve as he discussed various narrative episodes in his life and considered what had changed. He began to acknowledge difficulties occurring earlier in his life and in particular reflected on the impact of his grandfather’s abuse. He described themes of feeling unsafe, struggling to perceive the intentions of others, and feeling left behind in life, as his peers and siblings established their autonomy in young adulthood in ways in which Grohl felt he should but was unable.

Element 5: Reflecting on Interpersonal Processes

This element requires attention to and reflection on the interpersonal dynamics occurring within the therapy sessions by both the therapist and client. This element was difficult with Grohl, who would struggle to describe his reactions to the therapist. He seemed initially unsure of the therapist and her intentions and would state that he was not sure what to talk about during the sessions. Grohl often noted surprise at having talked through the entire session.

Another significant interpersonal process in Grohl’s psychotherapy was seen in his attempts to convince his therapist that he did not have a mental illness and should not have to be in treatment. At times he would experience the therapist’s curiosity as challenging the legitimacy of what he was experiencing and would offer statements attempting to legitimize his experiences, such as “This isn’t all in my head” and “There is something seriously wrong with my body, and I’m afraid I’m going to die.” At times he perceived his therapist as being on his side and would attempt to recruit her help in procuring a body scan that would “prove” the damage he was sure was happening to his body. The therapist described her experience during these moments as feeling pulled in different directions by Grohl, and she would invite him to reflect on how he perceived her during these moments as well and to react to her reflections.

Element 6: Reflecting on the Process of Therapy Within and Across Sessions

In practicing element 6, the therapist invites feedback from the client on how the session has gone each time as well as to reflect on the therapy process as a whole. In MERIT, the process of therapy is viewed as an opportunity for reflection and dialogue about the connection between two individuals over time and how this connection can evolve. Initially, Grohl described that sessions went well but also noted his discomfort in knowing what to talk about. As he reflected on more of his life and developed a conceptualization of his psychological problem, Grohl would describe that he was thinking about his life differently as a result of therapy. He noted that these reflections were at times painful, particularly when describing memories of his earliest experiences of psychosis and traumatic interactions with his grandfather. The therapist would often observe a change in Grohl in the sessions following exploration of his relationship with his grandfather. Specifically, Grohl tended to describe his grandfather in an overwhelmingly positive manner in the sessions following his disclosure of painful moments with him. The therapist would note this change between sessions and explore with Grohl his ambivalence about his relationship with his grandfather and about discussing and reflecting on painful moments in his life.

Element 7: Stimulating Reflectivity of Self and Others

One of the hallmarks of MERIT is the stimulation of reflective activity at the appropriate level of metacognition. This stimulation requires the therapist to continuously assess clients’ current level of metacognitive capacity to reflect on the internal states of themselves and others. The therapist then offers interventions at that level or attempts to assist them to the next highest level through scaffolding. Offering interventions that are either too metacognitively complex or simple is viewed as ineffective as the client is being asked to reflect at a level that does not match his or her current capacity. Of note, metacognitive capacity is dynamic and changes between sessions and often even within sessions ( 18 ), so to effectively perform this element, therapists must frequently assess the client’s metacognitive capacity.

In this case, the therapist first needed to intervene to provide a scaffold for Grohl to express a range of nuanced emotions, as Grohl could describe a range of cognitive operations but could not identify how he was feeling in various narratives. The therapist performed this intervention by inviting Grohl to describe the circumstances around the beginning of his physical symptoms. This encouragement led him to describe narrative episodes that, while initially barren, gave some material for Grohl and the therapist to reflect upon. The therapist would stimulate self-reflectivity by asking Grohl to describe his reactions to events in these narratives and the various feelings within his body during those moments. The therapist would offer labels for emotions and at times would describe her own guesses about how she might feel if she were experiencing the narrative Grohl described, exploring how those guesses fit or did not fit for Grohl, fine-tuning his understanding of how he was feeling. During the exploration of these initial barren narratives, Grohl began offering narratives from earlier periods in his life, and more details emerged, particularly his complicated and traumatic interactions with his grandfather. As Grohl developed his ability to reflect on a range of emotions, the therapist also began to scaffold the fallibility of thoughts, assisting Grohl in exploring how his thoughts had changed over time. He was most able to do this when thinking about events in the past, and he struggled to recognize that his current thoughts were also fallible. To address this, the therapist would invite Grohl to reflect on his certainty within the moment and how that differed from times in the past when his thoughts had changed. Ultimately, as Grohl began reflecting on his life in more detail and began to integrate the circumstances of significant points of his life, he developed a more complex understanding of himself and the psychosocial events he had experienced.

When Grohl began to offer narrative episodes that included significant others in his life, the therapist targeted his ability to understand the internal states of other people. Grohl initially struggled to recognize a range of nuanced emotion in others. As he developed the capacity to describe his own nuanced emotional states, he began to consider the emotional states of others. When Grohl considered his family dynamics, the therapist would often stimulate reflectivity of others by asking Grohl how he thought his parents viewed or reacted to significant events. He began to articulate, and form guesses about how certain events, such as the onset of his illness, had affected others in his family. As Grohl considered the impact his relationship with his grandfather had upon him, he was receptive to interventions that invited him to reflect upon aspects of his grandfather’s life that may have influenced his grandfather’s behavior. Grohl began to think flexibly about an individual who had caused him much pain and developed some hypotheses about what may have influenced his grandfather’s behavior.

Element 8: Stimulating Psychological Mastery

The eighth and final element of MERIT requires the therapist to offer interventions to stimulate metacognitive mastery, or the use of knowledge of self and others to respond to psychological distress. Similar to stimulating reflectivity of self and others at the correct metacognitive level, mastery interventions also must be tailored to the metacognitive capacity of the client. Stimulation of mastery includes assisting clients to form a plausible psychological problem and then to develop increasingly complex ways to master the problem. Interventions become more complex as they include the knowledge gained in reflection about self and others to navigate difficulties in life.

For Grohl, the therapist first began to stimulate mastery by offering interventions to promote reflectivity about what his plausible psychological problem might be. As discussed in the fourth element, Grohl initially struggled to articulate a problem that was plausible, but through exploration of the onset of his physical problems, he was eventually able to describe that his life had gotten off track and to acknowledge his difficulty in assessing others’ intentions and interacting successfully. As Grohl became more reflective of significant moments in his past, he began to describe the fulfillment he found while creating art. He began to create again and engaged this part of himself, eventually even agreeing to do contracted pieces of art as he had in the past. Being paid to create caused Grohl great anxiety initially, as he wondered whether he would perform to his past abilities and feared he might disappoint those who were paying him. However, he was successful with his first few pieces, and this success improved his self-esteem and sense of agency over aspects of his life.

As Grohl began to gain self-confidence and continued to reflect on the change he noticed in his life’s trajectory, his explanation of his psychological problem again evolved. He began to describe narratives he had previously not mentioned and acknowledged experiencing psychotic symptoms, which he had formerly denied. What emerged was a more complex understanding of the unique life circumstances that had led him to experience a high level of stress and a sense of being lost. He reflected on his history of being anxious as a child and as a rebellious teenager, and he noted how he had often overcompensated for his insecurity by acting out while in high school. Grohl abandoned the narrative that he had previously stated, that all was perfect in his life prior to his physical sensations and described a childhood of uncertainty that included moments of strength and happiness. Describing the moments of happiness led him to conclude that it was important to connect more with his family of origin and with the passions he had, including art.

Clinical Outcomes

Significantly, Grohl appears to have made gains in his personal recovery. At the beginning of therapy, he was unemployed and isolated, and much of his focus (including interactions with his family) was on his physical experiences. Within two years of starting therapy, Grohl’s life looked considerably different. He has been employed for 18 months at one job and recently added a second job. He has reconnected with his family members and sees them several times every week. He has reestablished an old friendship and begun two new ones. He engages with his community by creating murals for the church he attends and taking other offers to generate art. Additionally, he lives independently in an apartment, has bought a car, has gotten a pet, and has other accomplishments that seem to illustrate a dynamic life. As Anthony ( 19 ) points out, the meaning of recovery for each individual is deeply personal, and thus Grohl’s own subjective sense of recovery is the best marker for whether or not he is in recovery from his severe mental illness. Grohl describes in therapy sessions that he has an improved quality of life, expressing that while he still feels anxious and unsure about taking chances on his future, he feels more fulfilled with his current life than he did two years ago. He articulates an improved sense of self-esteem and appears to experience himself as an agent, even making decisions about his mental health care and how and when he will engage in it. He seems to rely less on his parents to make decisions for him, although he considers their advice. Grohl is actively pursuing higher education opportunities and has been reflecting on what type of career he would like. He is planning to start college within the next year.

Thus, while this case has results similar to other case studies using MERIT for patients with FEP, such as an increase in insight and decrease in symptoms ( 14 ), Grohl’s case also illustrates the movement from being dominated by a mental health condition to living a more fulfilling and enriched life in recovery. While this case occurred within clinical practice and thus other contributing and confounding factors cannot be ruled out, it seems likely that the use of MERIT promoted Grohl’s recovery. We posit that MERIT promotes recovery for two reasons: first, each of its elements supports the core values of recovery, and second, metacognitive capacity may be necessary to achieve many of the subjective elements of recovery.

By starting with the first of these two assertions, that the eight elements of MERIT support the tenets of recovery, we see that elements 1, 4, 5, 6, 7, and 8 all position the client as an agent with an agenda, a mind for dialogue, and an active participant in care, thus encouraging self-direction. Element 1, or the preeminent role of the client’s agenda, places importance on understanding what the client wants in a given moment, creating a therapeutic environment with multiple pathways to recovery, tailored to what is important to the individual and allowing for self-direction. MERIT promotes an open stance, in which the therapist does not operate as an expert but rather as a consultant, serving as a guide to explore the content of one’s own mind. The MERIT therapist does not merely mirror the client, but in addition to providing reflections of the client’s mind, actively offers his or her own thoughts to discuss and react to within the therapy encounter (elements 2 and 5). MERIT also supports recovery through the therapist’s interest in the client’s story and life before and after illness, helping the client recapture a sense of self rather than just focusing on symptom relief or eradication of unhealthy thoughts and behaviors (element 3). Thus, all eight elements of MERIT support the core values of recovery.

Turning to the second assertion, MERIT may assist persons in the types of sense-making that are necessary to achieve subjective recovery. For example, having a storied sense of one’s life as having good moments as well as challenges aligns with the recovery tenets of seeing oneself as more than a mental health patient, feeling empowered to make decisions about one’s life, and ultimately recapturing a sense of self. By contrast, having significant metacognitive deficits may make achieving subjective elements of recovery difficult if one is struggling to identify one’s own hopes and dreams and to understand and respond to psychological challenges. Thus, it may be that by promoting metacognitive capacity through the eight elements of MERIT, therapists are able to assist clients in forming flexible, coherent understandings of themselves, others, and their unique challenges in life and begin to respond to them.

Significantly, Grohl made gains on each of the four metacognition subscales. Grohl began to describe and recognize a range of nuanced emotions; began to view his thoughts as fallible and thus changeable; believed that his expectations were not always reality; and began to integrate his thoughts, feelings, and behaviors when thinking about specific narrative episodes of his life. Thus, Grohl moved from a 3 to a 6.5 on self-reflectivity. He also began to see other people as having rich internal experiences and began to make guesses about their intentions using unique information about them, thus moving from a 3 to a 5 on awareness of others. Grohl initially scored a 0 on decentration, as he thought all others were somehow tied to a conspiracy against him. He developed a different view, however, and was able to see others as having their own lives separate from him, and he even began to consider that other people have valid but differing opinions from him, placing him at 1.5 on the scale. Finally, Grohl developed a plausible psychological problem and began to use behavioral strategies, such as engaging in artistic endeavors, to manage his distress, moving him from a 1.5 to a 5 on the mastery scale.

Although case studies provide in-depth examinations of an individual’s experience, they have limitations. The findings from this case study may not be generalizable to other individuals. More work is needed with individuals of differing demographic characteristics and phases of illness to assess the generalizability of these findings. Additionally, other factors external to Grohl’s psychotherapy may have had an impact on his ability to recover, including other services he received, such as medication management and supported employment services. Despite these limitations and given the larger body of literature and the findings of this case, MERIT appears to be a promising intervention that may help promote recovery for patients with FEP.

The authors report no financial relationships with commercial interests.

1 Harding CM, Brooks GW, Ashikaga T, et al. : The Vermont longitudinal study of persons with severe mental illness, I: methodology, study sample, and overall status 32 years later . Am J Psychiatry 1987 ; 144:718–726 Crossref , Medline ,  Google Scholar

2 Davidson L, Roe D : Recovery from versus recovery in serious mental illness: one strategy for lessening confusion plaguing recovery . J Mental Health 2007 ; 16:459–470 Crossref ,  Google Scholar

3 Silverstein SM, Bellack AS : A scientific agenda for the concept of recovery as it applies to schizophrenia . Clin Psychol Rev 2008 ; 28:1108–1124 Crossref , Medline ,  Google Scholar

4 Dixon LB, Goldman HH, Bennett ME, et al. : Implementing coordinated specialty care for early psychosis: the RAISE Connection Program . Psychiatr Serv 2015 ; 66:691–698 Crossref , Medline ,  Google Scholar

5 Van Donkersgoed RJM, De Jong S, Van der Gaag M, et al. : A manual-based individual therapy to improve metacognition in schizophrenia: protocol of a multi-center RCT . BMC Psychiatry 2014 ; 14:27–45 Crossref , Medline ,  Google Scholar

6 Lysaker PH, Vohs JL, Ballard R, et al. : Metacognition, self-reflection and recovery in schizophrenia . Future Neurol 2013 ; 8:103–115 Crossref ,  Google Scholar

7 Hasson-Ohayon I, Avidan-Msika M, Mashiach-Eizenberg M, et al. : Metacognitive and social cognition approaches to understanding the impact of schizophrenia on social quality of life . Schizophr Res 2015 ; 161:386–391 Crossref , Medline ,  Google Scholar

8 Lysaker PH, Leonhardt BL, Brüne M, et al. : Capacities for theory of mind, metacognition, and neurocognitive function are independently related to emotional recognition in schizophrenia . Psychiatry Res 2014 ; 219:79–85 Crossref , Medline ,  Google Scholar

9 Hamm JA, Renard SB, Fogley RL, et al. : Metacognition and social cognition in schizophrenia: stability and relationship to concurrent and prospective symptom assessments . J Clin Psychol 2012 ; 68:1303–1312 Crossref , Medline ,  Google Scholar

10 Vohs JL, Lysaker PH, Francis MM, et al. : Metacognition, social cognition, and symptoms in patients with first episode and prolonged psychoses . Schizophr Res 2014 ; 153:54–59 Crossref , Medline ,  Google Scholar

11 Kukla M, Lysaker PH, Salyers MP : Do persons with schizophrenia who have better metacognitive capacity also have a stronger subjective experience of recovery? Psychiatry Res 2013 ; 209:381–385 Crossref , Medline ,  Google Scholar

12 Bargenquast R, Schweitzer RD : Enhancing sense of recovery and self-reflectivity in people with schizophrenia: a pilot study of Metacognitive Narrative Psychotherapy . Psychol Psychother 2014 ; 87:338–356 Crossref , Medline ,  Google Scholar

13 Hillis JD, Leonhardt BL, Vohs JL, et al. : Metacognitive reflective and insight therapy for people in early phase of a schizophrenia spectrum disorder . J Clin Psychol 2015 ; 71:125–135 Crossref , Medline ,  Google Scholar

14 Leonhardt BL, Benson K, George S, et al. : Targeting insight in first episode psychosis: a case study of metacognitive reflective insight therapy (MERIT) . J Contemp Psychother 2016 ; 46:207–216 Crossref ,  Google Scholar

15 Lysaker PH, Leonhardt BL, Pijnenborg M, et al. : Metacognition in schizophrenia spectrum disorders: methods of assessment and associations with neurocognition, symptoms, cognitive style and function .  Isr J Psychiatry Relat Sci   2014 ; 51:54–61 Medline ,  Google Scholar

16 Semerari A, Carcione A, Dimaggio G, et al. : How to evaluate metacognitive function in psychotherapy? The metacognition assessment scale and its applications . Clin Psychol Psychother 2003 ; 10:238–261 Crossref ,  Google Scholar

17 Lysaker PH, Buck KD, Leonhardt B, et al. : Metacognitively focused psychotherapy for persons with schizophrenia: eight core elements that define practice ; in Metacognition and Social Cognition in Schizophrenia . Edited by Lysaker PH, Dimaggio G, Brune M . New York, Elsevier, 2014 Crossref ,  Google Scholar

18 Lysaker PH, Buck KD, Ringer JM : The recovery of metacognitive capacity in schizophrenia across 32 months of individual psychotherapy: a case study . Psychother Res 2007 ; 17:713–720 Crossref ,  Google Scholar

19 Anthony WA : Recovery from mental illness: the guiding vision of the mental health service system in the 1990s . Psychosoc Rehabil J 1993 ; 16:11–23 Crossref ,  Google Scholar

• A Recovery-Oriented Approach: Application of Metacognitive Reflection and Insight Therapy (MERIT) for Youth with Clinical High Risk (CHR) for Psychosis 15 April 2024 | Behavioral Sciences, Vol. 14, No. 4
• Metacognition as a Transdiagnostic Determinant of Recovery in Schizotypy and Schizophrenia Spectrum Disorders 17 April 2024 | Behavioral Sciences, Vol. 14, No. 4
• Metacognitive Reflection and Insight Therapy (MERIT) Delivered Virtually During the COVID-19 Pandemic: An Illustration of Two Cases 10 August 2022 | Journal of Contemporary Psychotherapy, Vol. 53, No. 1
• Metacognitive Reflection and Insight Therapy with a Patient with Low Medication Adherence: The Interplay Between Personal, Functional and Clinical Recovery 13 September 2022 | Journal of Contemporary Psychotherapy, Vol. 53, No. 1
• A Guide for the Implementation of Group-Based Metacognitive Reflection and Insight Therapy (MERITg) 16 September 2022 | Journal of Contemporary Psychotherapy, Vol. 53, No. 1
• Recovery-Focused Metacognitive Interpersonal Therapy (MIT) for Adolescents with First-Episode Psychosis 22 September 2022 | Journal of Contemporary Psychotherapy, Vol. 53, No. 1
• The Phenomenological Perspective and Metacognitive Psychotherapy in Addressing Psychosis 26 April 2023
• Addressing Schizotypy in Metacognitive Reflection and Insight Therapy 10 October 2023
• The Recovery Process for Individuals With Schizophrenia in the Context of Evidence-Based Psychotherapy and Rehabilitation European Psychologist, Vol. 26, No. 2
• Trauma and Personal Recovery in Serious Mental Illness: A Case Report of Integrative Psychotherapy 19 February 2020 | Journal of Psychosocial Rehabilitation and Mental Health, Vol. 7, No. 1
• Metacognitive function and fragmentation in schizophrenia: Relationship to cognition, self-experience and developing treatments Schizophrenia Research: Cognition, Vol. 19
• <p>Metacognitive Reflection and Insight Therapy: A Recovery-Oriented Treatment Approach for Psychosis</p> 1 April 2020 | Psychology Research and Behavior Management, Vol. Volume 13
• Metacognitive deficits and social functioning in schizophrenia across symptom profiles: A latent class analysis 27 March 2019 | Journal of Experimental Psychopathology, Vol. 10, No. 1
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• Paul H. Lysaker , Ph.D.
• Promoting recovery from severe mental illness: Implications from research on metacognition and metacognitive reflection and insight therapy World Journal of Psychiatry, Vol. 8, No. 1

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What Is a Case Study?

Weighing the pros and cons of this method of research

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

Where do you find data for a case study, how do i write a psychology case study.

A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in many different fields, including psychology, medicine, education, anthropology, political science, and social work.

The point of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.

While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, we got you—here are some rules of APA format to reference.  

At a Glance

A case study, or an in-depth study of a person, group, or event, can be a useful research tool when used wisely. In many cases, case studies are best used in situations where it would be difficult or impossible for you to conduct an experiment. They are helpful for looking at unique situations and allow researchers to gather a lot of˜ information about a specific individual or group of people. However, it's important to be cautious of any bias we draw from them as they are highly subjective.

What Are the Benefits and Limitations of Case Studies?

A case study can have its strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.

One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult or impossible to replicate in a lab. Some other benefits of a case study:

• Allows researchers to capture information on the 'how,' 'what,' and 'why,' of something that's implemented
• Gives researchers the chance to collect information on why one strategy might be chosen over another
• Permits researchers to develop hypotheses that can be explored in experimental research

On the other hand, a case study can have some drawbacks:

• It cannot necessarily be generalized to the larger population
• Cannot demonstrate cause and effect
• It may not be scientifically rigorous
• It can lead to bias

Researchers may choose to perform a case study if they want to explore a unique or recently discovered phenomenon. Through their insights, researchers develop additional ideas and study questions that might be explored in future studies.

It's important to remember that the insights from case studies cannot be used to determine cause-and-effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.

Case Study Examples

There have been a number of notable case studies in the history of psychology. Much of  Freud's work and theories were developed through individual case studies. Some great examples of case studies in psychology include:

• Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
• Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
• Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language learning was possible, even after missing critical periods for language development. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.

Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse denied her the opportunity to learn a language at critical points in her development.

This is clearly not something researchers could ethically replicate, but conducting a case study on Genie allowed researchers to study phenomena that are otherwise impossible to reproduce.

There are a few different types of case studies that psychologists and other researchers might use:

• Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those who live there.
• Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
• Explanatory case studies : These   are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
• Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
• Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
• Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic case study can contribute to the development of a psychological theory.

The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.

The type of case study that psychology researchers use depends on the unique characteristics of the situation and the case itself.

There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:

• Archival records : Census records, survey records, and name lists are examples of archival records.
• Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
• Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
• Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
• Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
• Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.

If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines you need to follow. If you are writing your case study for a professional publication, check with the publisher for their specific guidelines for submitting a case study.

Here is a general outline of what should be included in a case study.

Section 1: A Case History

This section will have the following structure and content:

Background information : The first section of your paper will present your client's background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals, and coping skills and weaknesses.

Description of the presenting problem : In the next section of your case study, you will describe the problem or symptoms that the client presented with.

Describe any physical, emotional, or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.

Section 2: Treatment Plan

This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.

• Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
• Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
• Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
• Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.

This section of a case study should also include information about the treatment goals, process, and outcomes.

When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research. 

In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?

Need More Tips?

Here are a few additional pointers to keep in mind when formatting your case study:

• Never refer to the subject of your case study as "the client." Instead, use their name or a pseudonym.
• Read examples of case studies to gain an idea about the style and format.
• Remember to use APA format when citing references .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach .  BMC Med Res Methodol . 2011;11:100.

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100

Gagnon, Yves-Chantal.  The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Psychology: Research and Review

• Open access
• Published: 19 March 2021

Appraising psychotherapy case studies in practice-based evidence: introducing Case Study Evaluation-tool (CaSE)

• Greta Kaluzeviciute   ORCID: orcid.org/0000-0003-1197-177X 1  

Psicologia: Reflexão e Crítica volume  34 , Article number:  9 ( 2021 ) Cite this article

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Systematic case studies are often placed at the low end of evidence-based practice (EBP) due to lack of critical appraisal. This paper seeks to attend to this research gap by introducing a novel Case Study Evaluation-tool (CaSE). First, issues around knowledge generation and validity are assessed in both EBP and practice-based evidence (PBE) paradigms. Although systematic case studies are more aligned with PBE paradigm, the paper argues for a complimentary, third way approach between the two paradigms and their ‘exemplary’ methodologies: case studies and randomised controlled trials (RCTs). Second, the paper argues that all forms of research can produce ‘valid evidence’ but the validity itself needs to be assessed against each specific research method and purpose. Existing appraisal tools for qualitative research (JBI, CASP, ETQS) are shown to have limited relevance for the appraisal of systematic case studies through a comparative tool assessment. Third, the paper develops purpose-oriented evaluation criteria for systematic case studies through CaSE Checklist for Essential Components in Systematic Case Studies and CaSE Purpose-based Evaluative Framework for Systematic Case Studies. The checklist approach aids reviewers in assessing the presence or absence of essential case study components (internal validity). The framework approach aims to assess the effectiveness of each case against its set out research objectives and aims (external validity), based on different systematic case study purposes in psychotherapy. Finally, the paper demonstrates the application of the tool with a case example and notes further research trajectories for the development of CaSE tool.

Introduction

Due to growing demands of evidence-based practice, standardised research assessment and appraisal tools have become common in healthcare and clinical treatment (Hannes, Lockwood, & Pearson, 2010 ; Hartling, Chisholm, Thomson, & Dryden, 2012 ; Katrak, Bialocerkowski, Massy-Westropp, Kumar, & Grimmer, 2004 ). This allows researchers to critically appraise research findings on the basis of their validity, results, and usefulness (Hill & Spittlehouse, 2003 ). Despite the upsurge of critical appraisal in qualitative research (Williams, Boylan, & Nunan, 2019 ), there are no assessment or appraisal tools designed for psychotherapy case studies.

Although not without controversies (Michels, 2000 ), case studies remain central to the investigation of psychotherapy processes (Midgley, 2006 ; Willemsen, Della Rosa, & Kegerreis, 2017 ). This is particularly true of systematic case studies, the most common form of case study in contemporary psychotherapy research (Davison & Lazarus, 2007 ; McLeod & Elliott, 2011 ).

Unlike the classic clinical case study, systematic cases usually involve a team of researchers, who gather data from multiple different sources (e.g., questionnaires, observations by the therapist, interviews, statistical findings, clinical assessment, etc.), and involve a rigorous data triangulation process to assess whether the data from different sources converge (McLeod, 2010 ). Since systematic case studies are methodologically pluralistic, they have a greater interest in situating patients within the study of a broader population than clinical case studies (Iwakabe & Gazzola, 2009 ). Systematic case studies are considered to be an accessible method for developing research evidence-base in psychotherapy (Widdowson, 2011 ), especially since they correct some of the methodological limitations (e.g. lack of ‘third party’ perspectives and bias in data analysis) inherent to classic clinical case studies (Iwakabe & Gazzola, 2009 ). They have been used for the purposes of clinical training (Tuckett, 2008 ), outcome assessment (Hilliard, 1993 ), development of clinical techniques (Almond, 2004 ) and meta-analysis of qualitative findings (Timulak, 2009 ). All these developments signal a revived interest in the case study method, but also point to the obvious lack of a research assessment tool suitable for case studies in psychotherapy (Table 1 ).

To attend to this research gap, this paper first reviews issues around the conceptualisation of validity within the paradigms of evidence-based practice (EBP) and practice-based evidence (PBE). Although case studies are often positioned at the low end of EBP (Aveline, 2005 ), the paper suggests that systematic cases are a valuable form of evidence, capable of complimenting large-scale studies such as randomised controlled trials (RCTs). However, there remains a difficulty in assessing the quality and relevance of case study findings to broader psychotherapy research.

As a way forward, the paper introduces a novel Case Study Evaluation-tool (CaSE) in the form of CaSE Purpose - based Evaluative Framework for Systematic Case Studies and CaSE Checklist for Essential Components in Systematic Case Studies . The long-term development of CaSE would contribute to psychotherapy research and practice in three ways.

Given the significance of methodological pluralism and diverse research aims in systematic case studies, CaSE will not seek to prescribe explicit case study writing guidelines, which has already been done by numerous authors (McLeod, 2010 ; Meganck, Inslegers, Krivzov, & Notaerts, 2017 ; Willemsen et al., 2017 ). Instead, CaSE will enable the retrospective assessment of systematic case study findings and their relevance (or lack thereof) to broader psychotherapy research and practice. However, there is no reason to assume that CaSE cannot be used prospectively (i.e. producing systematic case studies in accordance to CaSE evaluative framework, as per point 3 in Table 2 ).

The development of a research assessment or appraisal tool is a lengthy, ongoing process (Long & Godfrey, 2004 ). It is particularly challenging to develop a comprehensive purpose - oriented evaluative framework, suitable for the assessment of diverse methodologies, aims and outcomes. As such, this paper should be treated as an introduction to the broader development of CaSE tool. It will introduce the rationale behind CaSE and lay out its main approach to evidence and evaluation, with further development in mind. A case example from the Single Case Archive (SCA) ( https://singlecasearchive.com ) will be used to demonstrate the application of the tool ‘in action’. The paper notes further research trajectories and discusses some of the limitations around the use of the tool.

Separating the wheat from the chaff: what is and is not evidence in psychotherapy (and who gets to decide?)

The common approach: evidence-based practice.

In the last two decades, psychotherapy has become increasingly centred around the idea of an evidence-based practice (EBP). Initially introduced in medicine, EBP has been defined as ‘conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’ (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996 ). EBP revolves around efficacy research: it seeks to examine whether a specific intervention has a causal (in this case, measurable) effect on clinical populations (Barkham & Mellor-Clark, 2003 ). From a conceptual standpoint, Sackett and colleagues defined EBP as a paradigm that is inclusive of many methodologies, so long as they contribute towards clinical decision-making process and accumulation of best currently available evidence in any given set of circumstances (Gabbay & le May, 2011 ). Similarly, the American Psychological Association (APA, 2010 ) has recently issued calls for evidence-based systematic case studies in order to produce standardised measures for evaluating process and outcome data across different therapeutic modalities.

However, given EBP’s focus on establishing cause-and-effect relationships (Rosqvist, Thomas, & Truax, 2011 ), it is unsurprising that qualitative research is generally not considered to be ‘gold standard’ or ‘efficacious’ within this paradigm (Aveline, 2005 ; Cartwright & Hardie, 2012 ; Edwards, 2013 ; Edwards, Dattilio, & Bromley, 2004 ; Longhofer, Floersch, & Hartmann, 2017 ). Qualitative methods like systematic case studies maintain an appreciation for context, complexity and meaning making. Therefore, instead of measuring regularly occurring causal relations (as in quantitative studies), the focus is on studying complex social phenomena (e.g. relationships, events, experiences, feelings, etc.) (Erickson, 2012 ; Maxwell, 2004 ). Edwards ( 2013 ) points out that, although context-based research in systematic case studies is the bedrock of psychotherapy theory and practice, it has also become shrouded by an unfortunate ideological description: ‘anecdotal’ case studies (i.e. unscientific narratives lacking evidence, as opposed to ‘gold standard’ evidence, a term often used to describe the RCT method and the therapeutic modalities supported by it), leading to a further need for advocacy in and defence of the unique epistemic process involved in case study research (Fishman, Messer, Edwards, & Dattilio, 2017 ).

The EBP paradigm prioritises the quantitative approach to causality, most notably through its focus on high generalisability and the ability to deal with bias through randomisation process. These conditions are associated with randomised controlled trials (RCTs) but are limited (or, as some argue, impossible) in qualitative research methods such as the case study (Margison et al., 2000 ) (Table 3 ).

‘Evidence’ from an EBP standpoint hovers over the epistemological assumption of procedural objectivity : knowledge can be generated in a standardised, non-erroneous way, thus producing objective (i.e. with minimised bias) data. This can be achieved by anyone, as long as they are able to perform the methodological procedure (e.g. RCT) appropriately, in a ‘clearly defined and accepted process that assists with knowledge production’ (Douglas, 2004 , p. 131). If there is a well-outlined quantitative form for knowledge production, the same outcome should be achieved regardless of who processes or interprets the information. For example, researchers using Cochrane Review assess the strength of evidence using meticulously controlled and scrupulous techniques; in turn, this minimises individual judgment and creates unanimity of outcomes across different groups of people (Gabbay & le May, 2011 ). The typical process of knowledge generation (through employing RCTs and procedural objectivity) in EBP is demonstrated in Fig. 1 .

Typical knowledge generation process in evidence–based practice (EBP)

In EBP, the concept of validity remains somewhat controversial, with many critics stating that it limits rather than strengthens knowledge generation (Berg, 2019 ; Berg & Slaattelid, 2017 ; Lilienfeld, Ritschel, Lynn, Cautin, & Latzman, 2013 ). This is because efficacy research relies on internal validity . At a general level, this concept refers to the congruence between the research study and the research findings (i.e. the research findings were not influenced by anything external to the study, such as confounding variables, methodological errors and bias); at a more specific level, internal validity determines the extent to which a study establishes a reliable causal relationship between an independent variable (e.g. treatment) and independent variable (outcome or effect) (Margison et al., 2000 ). This approach to validity is demonstrated in Fig. 2 .

Internal validity

Social scientists have argued that there is a trade-off between research rigour and generalisability: the more specific the sample and the more rigorously defined the intervention, the outcome is likely to be less applicable to everyday, routine practice. As such, there remains a tension between employing procedural objectivity which increases the rigour of research outcomes and applying such outcomes to routine psychotherapy practice where scientific standards of evidence are not uniform.

According to McLeod ( 2002 ), inability to address questions that are most relevant for practitioners contributed to a deepening research–practice divide in psychotherapy. Studies investigating how practitioners make clinical decisions and the kinds of evidence they refer to show that there is a strong preference for knowledge that is not generated procedurally, i.e. knowledge that encompasses concrete clinical situations, experiences and techniques. A study by Stewart and Chambless ( 2007 ) sought to assess how a larger population of clinicians (under APA, from varying clinical schools of thought and independent practices, sample size 591) make treatment decisions in private practice. The study found that large-scale statistical data was not the primary source of information sought by clinicians. The most important influences were identified as past clinical experiences and clinical expertise ( M = 5.62). Treatment materials based on clinical case observations and theory ( M = 4.72) were used almost as frequently as psychotherapy outcome research findings ( M = 4.80) (i.e. evidence-based research). These numbers are likely to fluctuate across different forms of psychotherapy; however, they are indicative of the need for research about routine clinical settings that does not isolate or generalise the effect of an intervention but examines the variations in psychotherapy processes.

The alternative approach: practice-based evidence

In an attempt to dissolve or lessen the research–practice divide, an alternative paradigm of practice-based evidence (PBE) has been suggested (Barkham & Mellor-Clark, 2003 ; Fox, 2003 ; Green & Latchford, 2012 ; Iwakabe & Gazzola, 2009 ; Laska, Motulsky, Wertz, Morrow, & Ponterotto, 2014 ; Margison et al., 2000 ). PBE represents a shift in how we think about evidence and knowledge generation in psychotherapy. PBE treats research as a local and contingent process (at least initially), which means it focuses on variations (e.g. in patient symptoms) and complexities (e.g. of clinical setting) in the studied phenomena (Fox, 2003 ). Moreover, research and theory-building are seen as complementary rather than detached activities from clinical practice. That is to say, PBE seeks to examine how and which treatments can be improved in everyday clinical practice by flagging up clinically salient issues and developing clinical techniques (Barkham & Mellor-Clark, 2003 ). For this reason, PBE is concerned with the effectiveness of research findings: it evaluates how well interventions work in real-world settings (Rosqvist et al., 2011 ). Therefore, although it is not unlikely for RCTs to be used in order to generate practice-informed evidence (Horn & Gassaway, 2007 ), qualitative methods like the systematic case study are seen as ideal for demonstrating the effectiveness of therapeutic interventions with individual patients (van Hennik, 2020 ) (Table 4 ).

PBE’s epistemological approach to ‘evidence’ may be understood through the process of concordant objectivity (Douglas, 2004 ): ‘Instead of seeking to eliminate individual judgment, … [concordant objectivity] checks to see whether the individual judgments of people in fact do agree’ (p. 462). This does not mean that anyone can contribute to the evaluation process like in procedural objectivity, where the main criterion is following a set quantitative protocol or knowing how to operate a specific research design. Concordant objectivity requires that there is a set of competent observers who are closely familiar with the studied phenomenon (e.g. researchers and practitioners who are familiar with depression from a variety of therapeutic approaches).

Systematic case studies are a good example of PBE ‘in action’: they allow for the examination of detailed unfolding of events in psychotherapy practice, making it the most pragmatic and practice-oriented form of psychotherapy research (Fishman, 1999 , 2005 ). Furthermore, systematic case studies approach evidence and results through concordant objectivity (Douglas, 2004 ) by involving a team of researchers and rigorous data triangulation processes (McLeod, 2010 ). This means that, although systematic case studies remain focused on particular clinical situations and detailed subjective experiences (similar to classic clinical case studies; see Iwakabe & Gazzola, 2009 ), they still involve a series of validity checks and considerations on how findings from a single systematic case pertain to broader psychotherapy research (Fishman, 2005 ). The typical process of knowledge generation (through employing systematic case studies and concordant objectivity) in PBE is demonstrated in Fig. 3 . The figure exemplifies a bidirectional approach to research and practice, which includes the development of research-supported psychological treatments (through systematic reviews of existing evidence) as well as the perspectives of clinical practitioners in the research process (through the study of local and contingent patient and/or treatment processes) (Teachman et al., 2012 ; Westen, Novotny, & Thompson-Brenner, 2004 ).

Typical knowledge generation process in practice-based evidence (PBE)

From a PBE standpoint, external validity is a desirable research condition: it measures extent to which the impact of interventions apply to real patients and therapists in everyday clinical settings. As such, external validity is not based on the strength of causal relationships between treatment interventions and outcomes (as in internal validity); instead, the use of specific therapeutic techniques and problem-solving decisions are considered to be important for generalising findings onto routine clinical practice (even if the findings are explicated from a single case study; see Aveline, 2005 ). This approach to validity is demonstrated in Fig. 4 .

External validity

Since effectiveness research is less focused on limiting the context of the studied phenomenon (indeed, explicating the context is often one of the research aims), there is more potential for confounding factors (e.g. bias and uncontrolled variables) which in turn can reduce the study’s internal validity (Barkham & Mellor-Clark, 2003 ). This is also an important challenge for research appraisal. Douglas ( 2004 ) argues that appraising research in terms of its effectiveness may produce significant disagreements or group illusions, since what might work for some practitioners may not work for others: ‘It cannot guarantee that values are not influencing or supplanting reasoning; the observers may have shared values that cause them to all disregard important aspects of an event’ (Douglas, 2004 , p. 462). Douglas further proposes that an interactive approach to objectivity may be employed as a more complex process in debating the evidential quality of a research study: it requires a discussion among observers and evaluators in the form of peer-review, scientific discourse, as well as research appraisal tools and instruments. While these processes of rigour are also applied in EBP, there appears to be much more space for debate, disagreement and interpretation in PBE’s approach to research evaluation, partly because the evaluation criteria themselves are subject of methodological debate and are often employed in different ways by researchers (Williams et al., 2019 ). This issue will be addressed more explicitly again in relation to CaSE development (‘Developing purpose-oriented evaluation criteria for systematic case studies’ section).

A third way approach to validity and evidence

The research–practice divide shows us that there may be something significant in establishing complementarity between EBP and PBE rather than treating them as mutually exclusive forms of research (Fishman et al., 2017 ). For one, EBP is not a sufficient condition for delivering research relevant to practice settings (Bower, 2003 ). While RCTs can demonstrate that an intervention works on average in a group, clinicians who are facing individual patients need to answer a different question: how can I make therapy work with this particular case ? (Cartwright & Hardie, 2012 ). Systematic case studies are ideal for filling this gap: they contain descriptions of microprocesses (e.g. patient symptoms, therapeutic relationships, therapist attitudes) in psychotherapy practice that are often overlooked in large-scale RCTs (Iwakabe & Gazzola, 2009 ). In particular, systematic case studies describing the use of specific interventions with less researched psychological conditions (e.g. childhood depression or complex post-traumatic stress disorder) can deepen practitioners’ understanding of effective clinical techniques before the results of large-scale outcome studies are disseminated.

Secondly, establishing a working relationship between systematic case studies and RCTs will contribute towards a more pragmatic understanding of validity in psychotherapy research. Indeed, the very tension and so-called trade-off between internal and external validity is based on the assumption that research methods are designed on an either/or basis; either they provide a sufficiently rigorous study design or they produce findings that can be applied to real-life practice. Jimenez-Buedo and Miller ( 2010 ) call this assumption into question: in their view, if a study is not internally valid, then ‘little, or rather nothing, can be said of the outside world’ (p. 302). In this sense, internal validity may be seen as a pre-requisite for any form of applied research and its external validity, but it need not be constrained to the quantitative approach of causality. For example, Levitt, Motulsky, Wertz, Morrow, and Ponterotto ( 2017 ) argue that, what is typically conceptualised as internal validity, is, in fact, a much broader construct, involving the assessment of how the research method (whether qualitative or quantitative) is best suited for the research goal, and whether it obtains the relevant conclusions. Similarly, Truijens, Cornelis, Desmet, and De Smet ( 2019 ) suggest that we should think about validity in a broader epistemic sense—not just in terms of psychometric measures, but also in terms of the research design, procedure, goals (research questions), approaches to inquiry (paradigms, epistemological assumptions), etc.

The overarching argument from research cited above is that all forms of research—qualitative and quantitative—can produce ‘valid evidence’ but the validity itself needs to be assessed against each specific research method and purpose. For example, RCTs are accompanied with a variety of clearly outlined appraisal tools and instruments such as CASP (Critical Appraisal Skills Programme) that are well suited for the assessment of RCT validity and their implications for EBP. Systematic case studies (or case studies more generally) currently have no appraisal tools in any discipline. The next section evaluates whether existing qualitative research appraisal tools are relevant for systematic case studies in psychotherapy and specifies the missing evaluative criteria.

The relevance of existing appraisal tools for qualitative research to systematic case studies in psychotherapy

What is a research tool.

Currently, there are several research appraisal tools, checklists and frameworks for qualitative studies. It is important to note that tools, checklists and frameworks are not equivalent to one another but actually refer to different approaches to appraising the validity of a research study. As such, it is erroneous to assume that all forms of qualitative appraisal feature the same aims and methods (Hannes et al., 2010 ; Williams et al., 2019 ).

Generally, research assessment falls into two categories: checklists and frameworks . Checklist approaches are often contrasted with quantitative research, since the focus is on assessing the internal validity of research (i.e. researcher’s independence from the study). This involves the assessment of bias in sampling, participant recruitment, data collection and analysis. Framework approaches to research appraisal, on the other hand, revolve around traditional qualitative concepts such as transparency, reflexivity, dependability and transferability (Williams et al., 2019 ). Framework approaches to appraisal are often challenging to use because they depend on the reviewer’s familiarisation and interpretation of the qualitative concepts.

Because of these different approaches, there is some ambiguity in terminology, particularly between research appraisal instruments and research appraisal tools . These terms are often used interchangeably in appraisal literature (Williams et al., 2019 ). In this paper, research appraisal tool is defined as a method-specific (i.e. it identifies a specific research method or component) form of appraisal that draws from both checklist and framework approaches. Furthermore, a research appraisal tool seeks to inform decision making in EBP or PBE paradigms and provides explicit definitions of the tool’s evaluative framework (thus minimising—but by no means eliminating—the reviewers’ interpretation of the tool). This definition will be applied to CaSE (Table 5 ).

In contrast, research appraisal instruments are generally seen as a broader form of appraisal in the sense that they may evaluate a variety of methods (i.e. they are non-method specific or they do not target a particular research component), and are aimed at checking whether the research findings and/or the study design contain specific elements (e.g. the aims of research, the rationale behind design methodology, participant recruitment strategies, etc.).

There is often an implicit difference in audience between appraisal tools and instruments. Research appraisal instruments are often aimed at researchers who want to assess the strength of their study; however, the process of appraisal may not be made explicit in the study itself (besides mentioning that the tool was used to appraise the study). Research appraisal tools are aimed at researchers who wish to explicitly demonstrate the evidential quality of the study to the readers (which is particularly common in RCTs). All forms of appraisal used in the comparative exercise below are defined as ‘tools’, even though they have different appraisal approaches and aims.

Comparing different qualitative tools

Hannes et al. ( 2010 ) identified CASP (Critical Appraisal Skills Programme-tool), JBI (Joanna Briggs Institute-tool) and ETQS (Evaluation Tool for Qualitative Studies) as the most frequently used critical appraisal tools by qualitative researchers. All three instruments are available online and are free of charge, which means that any researcher or reviewer can readily utilise CASP, JBI or ETQS evaluative frameworks to their research. Furthermore, all three instruments were developed within the context of organisational, institutional or consortium support (Tables 6 , 7 and 8 ).

It is important to note that neither of the three tools is specific to systematic case studies or psychotherapy case studies (which would include not only systematic but also experimental and clinical cases). This means that using CASP, JBI or ETQS for case study appraisal may come at a cost of overlooking elements and components specific to the systematic case study method.

Based on Hannes et al. ( 2010 ) comparative study of qualitative appraisal tools as well as the different evaluation criteria explicated in CASP, JBI and ETQS evaluative frameworks, I assessed how well each of the three tools is attuned to the methodological , clinical and theoretical aspects of systematic case studies in psychotherapy. The latter components were based on case study guidelines featured in the journal of Pragmatic Case Studies in Psychotherapy as well as components commonly used by published systematic case studies across a variety of other psychotherapy journals (e.g. Psychotherapy Research , Research In Psychotherapy : Psychopathology Process And Outcome , etc.) (see Table 9 for detailed descriptions of each component).

The evaluation criteria for each tool in Table 9 follows Joanna Briggs Institute (JBI) ( 2017a , 2017b ); Critical Appraisal Skills Programme (CASP) ( 2018 ); and ETQS Questionnaire (first published in 2004 but revised continuously since). Table 10 demonstrates how each tool should be used (i.e. recommended reviewer responses to checklists and questionnaires).

Using CASP, JBI and ETQS for systematic case study appraisal

Although JBI, CASP and ETQS were all developed to appraise qualitative research, it is evident from the above comparison that there are significant differences between the three tools. For example, JBI and ETQS are well suited to assess researcher’s interpretations (Hannes et al. ( 2010 ) defined this as interpretive validity , a subcategory of internal validity ): the researcher’s ability to portray, understand and reflect on the research participants’ experiences, thoughts, viewpoints and intentions. JBI has an explicit requirement for participant voices to be clearly represented, whereas ETQS involves a set of questions about key characteristics of events, persons, times and settings that are relevant to the study. Furthermore, both JBI and ETQS seek to assess the researcher’s influence on the research, with ETQS particularly focusing on the evaluation of reflexivity (the researcher’s personal influence on the interpretation and collection of data). These elements are absent or addressed to a lesser extent in the CASP tool.

The appraisal of transferability of findings (what this paper previously referred to as external validity ) is addressed only by ETQS and CASP. Both tools have detailed questions about the value of research to practice and policy as well as its transferability to other populations and settings. Methodological research aspects are also extensively addressed by CASP and ETQS, but less so by JBI (which relies predominantly on congruity between research methodology and objectives without any particular assessment criteria for other data sources and/or data collection methods). Finally, the evaluation of theoretical aspects (referred to by Hannes et al. ( 2010 ) as theoretical validity ) is addressed only by JBI and ETQS; there are no assessment criteria for theoretical framework in CASP.

Given these differences, it is unsurprising that CASP, JBI and ETQS have limited relevance for systematic case studies in psychotherapy. First, it is evident that neither of the three tools has specific evaluative criteria for the clinical component of systematic case studies. Although JBI and ETQS feature some relevant questions about participants and their context, the conceptualisation of patients (and/or clients) in psychotherapy involves other kinds of data elements (e.g. diagnostic tools and questionnaires as well as therapist observations) that go beyond the usual participant data. Furthermore, much of the clinical data is intertwined with the therapist’s clinical decision-making and thinking style (Kaluzeviciute & Willemsen, 2020 ). As such, there is a need to appraise patient data and therapist interpretations not only on a separate basis, but also as two forms of knowledge that are deeply intertwined in the case narrative.

Secondly, since systematic case studies involve various forms of data, there is a need to appraise how these data converge (or how different methods complement one another in the case context) and how they can be transferred or applied in broader psychotherapy research and practice. These systematic case study components are attended to a degree by CASP (which is particularly attentive of methodological components) and ETQS (particularly specific criteria for research transferability onto policy and practice). These components are not addressed or less explicitly addressed by JBI. Overall, neither of the tools is attuned to all methodological, theoretical and clinical components of the systematic case study. Specifically, there are no clear evaluation criteria for the description of research teams (i.e. different data analysts and/or clinicians); the suitability of the systematic case study method; the description of patient’s clinical assessment; the use of other methods or data sources; the general data about therapeutic progress.

Finally, there is something to be said about the recommended reviewer responses (Table 10 ). Systematic case studies can vary significantly in their formulation and purpose. The methodological, theoretical and clinical components outlined in Table 9 follow guidelines made by case study journals; however, these are recommendations, not ‘set in stone’ case templates. For this reason, the straightforward checklist approaches adopted by JBI and CASP may be difficult to use for case study researchers and those reviewing case study research. The ETQS open-ended questionnaire approach suggested by Long and Godfrey ( 2004 ) enables a comprehensive, detailed and purpose-oriented assessment, suitable for the evaluation of systematic case studies. That said, there remains a challenge of ensuring that there is less space for the interpretation of evaluative criteria (Williams et al., 2019 ). The combination of checklist and framework approaches would, therefore, provide a more stable appraisal process across different reviewers.

Developing purpose-oriented evaluation criteria for systematic case studies

The starting point in developing evaluation criteria for Case Study Evaluation-tool (CaSE) is addressing the significance of pluralism in systematic case studies. Unlike RCTs, systematic case studies are pluralistic in the sense that they employ divergent practices in methodological procedures ( research process ), and they may include significantly different research aims and purpose ( the end - goal ) (Kaluzeviciute & Willemsen, 2020 ). While some systematic case studies will have an explicit intention to conceptualise and situate a single patient’s experiences and symptoms within a broader clinical population, others will focus on the exploration of phenomena as they emerge from the data. It is therefore important that CaSE is positioned within a purpose - oriented evaluative framework , suitable for the assessment of what each systematic case is good for (rather than determining an absolute measure of ‘good’ and ‘bad’ systematic case studies). This approach to evidence and appraisal is in line with the PBE paradigm. PBE emphasises the study of clinical complexities and variations through local and contingent settings (e.g. single case studies) and promotes methodological pluralism (Barkham & Mellor-Clark, 2003 ).

CaSE checklist for essential components in systematic case studies

In order to conceptualise purpose-oriented appraisal questions, we must first look at what unites and differentiates systematic case studies in psychotherapy. The commonly used theoretical, clinical and methodological systematic case study components were identified earlier in Table 9 . These components will be seen as essential and common to most systematic case studies in CaSE evaluative criteria. If these essential components are missing in a systematic case study, then it may be implied there is a lack of information, which in turn diminishes the evidential quality of the case. As such, the checklist serves as a tool for checking whether a case study is, indeed, systematic (as opposed to experimental or clinical; see Iwakabe & Gazzola, 2009 for further differentiation between methodologically distinct case study types) and should be used before CaSE Purpose - based Evaluative Framework for Systematic Case Studie s (which is designed for the appraisal of different purposes common to systematic case studies).

As noted earlier in the paper, checklist approaches to appraisal are useful when evaluating the presence or absence of specific information in a research study. This approach can be used to appraise essential components in systematic case studies, as shown below. From a pragmatic point view (Levitt et al., 2017 ; Truijens et al., 2019 ), CaSE Checklist for Essential Components in Systematic Case Studies can be seen as a way to ensure the internal validity of systematic case study: the reviewer is assessing whether sufficient information is provided about the case design, procedure, approaches to inquiry, etc., and whether they are relevant to the researcher’s objectives and conclusions (Table 11 ).

CaSE purpose-based evaluative framework for systematic case studies

Identifying differences between systematic case studies means identifying the different purposes systematic case studies have in psychotherapy. Based on the earlier work by social scientist Yin ( 1984 , 1993 ), we can differentiate between exploratory (hypothesis generating, indicating a beginning phase of research), descriptive (particularising case data as it emerges) and representative (a case that is typical of a broader clinical population, referred to as the ‘explanatory case’ by Yin) cases.

Another increasingly significant strand of systematic case studies is transferable (aggregating and transferring case study findings) cases. These cases are based on the process of meta-synthesis (Iwakabe & Gazzola, 2009 ): by examining processes and outcomes in many different case studies dealing with similar clinical issues, researchers can identify common themes and inferences. In this way, single case studies that have relatively little impact on clinical practice, research or health care policy (in the sense that they capture psychotherapy processes rather than produce generalisable claims as in Yin’s representative case studies) can contribute to the generation of a wider knowledge base in psychotherapy (Iwakabe, 2003 , 2005 ). However, there is an ongoing issue of assessing the evidential quality of such transferable cases. According to Duncan and Sparks ( 2020 ), although meta-synthesis and meta-analysis are considered to be ‘gold standard’ for assessing interventions across disparate studies in psychotherapy, they often contain case studies with significant research limitations, inappropriate interpretations and insufficient information. It is therefore important to have a research appraisal process in place for selecting transferable case studies.

Two other types of systematic case study research include: critical (testing and/or confirming existing theories) cases, which are described as an excellent method for falsifying existing theoretical concepts and testing whether therapeutic interventions work in practice with concrete patients (Kaluzeviciute, 2021 ), and unique (going beyond the ‘typical’ cases and demonstrating deviations) cases (Merriam, 1998 ). These two systematic case study types are often seen as less valuable for psychotherapy research given that unique/falsificatory findings are difficult to generalise. But it is clear that practitioners and researchers in our field seek out context-specific data, as well as detailed information on the effectiveness of therapeutic techniques in single cases (Stiles, 2007 ) (Table 12 ).

Each purpose-based case study contributes to PBE in different ways. Representative cases provide qualitatively rich, in-depth data about a clinical phenomenon within its particular context. This offers other clinicians and researchers access to a ‘closed world’ (Mackrill & Iwakabe, 2013 ) containing a wide range of attributes about a conceptual type (e.g. clinical condition or therapeutic technique). Descriptive cases generally seek to demonstrate a realistic snapshot of therapeutic processes, including complex dynamics in therapeutic relationships, and instances of therapeutic failure (Maggio, Molgora, & Oasi, 2019 ). Data in descriptive cases should be presented in a transparent manner (e.g. if there are issues in standardising patient responses to a self-report questionnaire, this should be made explicit). Descriptive cases are commonly used in psychotherapy training and supervision. Unique cases are relevant for both clinicians and researchers: they often contain novel treatment approaches and/or introduce new diagnostic considerations about patients who deviate from the clinical population. Critical cases demonstrate the application of psychological theories ‘in action’ with particular patients; as such, they are relevant to clinicians, researchers and policymakers (Mackrill & Iwakabe, 2013 ). Exploratory cases bring new insight and observations into clinical practice and research. This is particularly useful when comparing (or introducing) different clinical approaches and techniques (Trad & Raine, 1994 ). Findings from exploratory cases often include future research suggestions. Finally, transferable cases provide one solution to the generalisation issue in psychotherapy research through the previously mentioned process of meta-synthesis. Grouped together, transferable cases can contribute to theory building and development, as well as higher levels of abstraction about a chosen area of psychotherapy research (Iwakabe & Gazzola, 2009 ).

With this plurality in mind, it is evident that CaSE has a challenging task of appraising research components that are distinct across six different types of purpose-based systematic case studies. The purpose-specific evaluative criteria in Table 13 was developed in close consultation with epistemological literature associated with each type of case study, including: Yin’s ( 1984 , 1993 ) work on establishing the typicality of representative cases; Duncan and Sparks’ ( 2020 ) and Iwakabe and Gazzola’s ( 2009 ) case selection criteria for meta-synthesis and meta-analysis; Stake’s ( 1995 , 2010 ) research on particularising case narratives; Merriam’s ( 1998 ) guidelines on distinctive attributes of unique case studies; Kennedy’s ( 1979 ) epistemological rules for generalising from case studies; Mahrer’s ( 1988 ) discovery oriented case study approach; and Edelson’s ( 1986 ) guidelines for rigorous hypothesis generation in case studies.

Research on epistemic issues in case writing (Kaluzeviciute, 2021 ) and different forms of scientific thinking in psychoanalytic case studies (Kaluzeviciute & Willemsen, 2020 ) was also utilised to identify case study components that would help improve therapist clinical decision-making and reflexivity.

For the analysis of more complex research components (e.g. the degree of therapist reflexivity), the purpose-based evaluation will utilise a framework approach, in line with comprehensive and open-ended reviewer responses in ETQS (Evaluation Tool for Qualitative Studies) (Long & Godfrey, 2004 ) (Table 13 ). That is to say, the evaluation here is not so much about the presence or absence of information (as in the checklist approach) but the degree to which the information helps the case with its unique purpose, whether it is generalisability or typicality. Therefore, although the purpose-oriented evaluation criteria below encompasses comprehensive questions at a considerable level of generality (in the sense that not all components may be required or relevant for each case study), it nevertheless seeks to engage with each type of purpose-based systematic case study on an individual basis (attending to research or clinical components that are unique to each of type of case study).

It is important to note that, as this is an introductory paper to CaSE, the evaluative framework is still preliminary: it involves some of the core questions that pertain to the nature of all six purpose-based systematic case studies. However, there is a need to develop a more comprehensive and detailed CaSE appraisal framework for each purpose-based systematic case study in the future.

Using CaSE on published systematic case studies in psychotherapy: an example

To illustrate the use of CaSE Purpose - based Evaluative Framework for Systematic Case Studies , a case study by Lunn, Daniel, and Poulsen ( 2016 ) titled ‘ Psychoanalytic Psychotherapy With a Client With Bulimia Nervosa ’ was selected from the Single Case Archive (SCA) and analysed in Table 14 . Based on the core questions associated with the six purpose-based systematic case study types in Table 13 (1 to 6), the purpose of Lunn et al.’s ( 2016 ) case was identified as critical (testing an existing theoretical suggestion).

Sometimes, case study authors will explicitly define the purpose of their case in the form of research objectives (as was the case in Lunn et al.’s study); this helps identifying which purpose-based questions are most relevant for the evaluation of the case. However, some case studies will require comprehensive analysis in order to identify their purpose (or multiple purposes). As such, it is recommended that CaSE reviewers first assess the degree and manner in which information about the studied phenomenon, patient data, clinical discourse and research are presented before deciding on the case purpose.

Although each purpose-based systematic case study will contribute to different strands of psychotherapy (theory, practice, training, etc.) and focus on different forms of data (e.g. theory testing vs extensive clinical descriptions), the overarching aim across all systematic case studies in psychotherapy is to study local and contingent processes, such as variations in patient symptoms and complexities of the clinical setting. The comprehensive framework approach will therefore allow reviewers to assess the degree of external validity in systematic case studies (Barkham & Mellor-Clark, 2003 ). Furthermore, assessing the case against its purpose will let reviewers determine whether the case achieves its set goals (research objectives and aims). The example below shows that Lunn et al.’s ( 2016 ) case is successful in functioning as a critical case as the authors provide relevant, high-quality information about their tested therapeutic conditions.

Finally, it is also possible to use CaSE to gather specific type of systematic case studies for one’s research, practice, training, etc. For example, a CaSE reviewer might want to identify as many descriptive case studies focusing on negative therapeutic relationships as possible for their clinical supervision. The reviewer will therefore only need to refer to CaSE questions in Table 13 (2) on descriptive cases. If the reviewed cases do not align with the questions in Table 13 (2), then they are not suitable for the CaSE reviewer who is looking for “know-how” knowledge and detailed clinical narratives.

Concluding comments

This paper introduces a novel Case Study Evaluation-tool (CaSE) for systematic case studies in psychotherapy. Unlike most appraisal tools in EBP, CaSE is positioned within purpose-oriented evaluation criteria, in line with the PBE paradigm. CaSE enables reviewers to assess what each systematic case is good for (rather than determining an absolute measure of ‘good’ and ‘bad’ systematic case studies). In order to explicate a purpose-based evaluative framework, six different systematic case study purposes in psychotherapy have been identified: representative cases (purpose: typicality), descriptive cases (purpose: particularity), unique cases (purpose: deviation), critical cases (purpose: falsification/confirmation), exploratory cases (purpose: hypothesis generation) and transferable cases (purpose: generalisability). Each case was linked with an existing epistemological network, such as Iwakabe and Gazzola’s ( 2009 ) work on case selection criteria for meta-synthesis. The framework approach includes core questions specific to each purpose-based case study (Table 13 (1–6)). The aim is to assess the external validity and effectiveness of each case study against its set out research objectives and aims. Reviewers are required to perform a comprehensive and open-ended data analysis, as shown in the example in Table 14 .

Along with CaSE Purpose - based Evaluative Framework (Table 13 ), the paper also developed CaSE Checklist for Essential Components in Systematic Case Studies (Table 12 ). The checklist approach is meant to aid reviewers in assessing the presence or absence of essential case study components, such as the rationale behind choosing the case study method and description of patient’s history. If essential components are missing in a systematic case study, then it may be implied that there is a lack of information, which in turn diminishes the evidential quality of the case. Following broader definitions of validity set out by Levitt et al. ( 2017 ) and Truijens et al. ( 2019 ), it could be argued that the checklist approach allows for the assessment of (non-quantitative) internal validity in systematic case studies: does the researcher provide sufficient information about the case study design, rationale, research objectives, epistemological/philosophical paradigms, assessment procedures, data analysis, etc., to account for their research conclusions?

It is important to note that this paper is set as an introduction to CaSE; by extension, it is also set as an introduction to research evaluation and appraisal processes for case study researchers in psychotherapy. As such, it was important to provide a step-by-step epistemological rationale and process behind the development of CaSE evaluative framework and checklist. However, this also means that further research needs to be conducted in order to develop the tool. While CaSE Purpose - based Evaluative Framework involves some of the core questions that pertain to the nature of all six purpose-based systematic case studies, there is a need to develop individual and comprehensive CaSE evaluative frameworks for each of the purpose-based systematic case studies in the future. This line of research is likely to enhance CaSE target audience: clinicians interested in reviewing highly particular clinical narratives will attend to descriptive case study appraisal frameworks; researchers working with qualitative meta-synthesis will find transferable case study appraisal frameworks most relevant to their work; while teachers on psychotherapy and counselling modules may seek out unique case study appraisal frameworks.

Furthermore, although CaSE Checklist for Essential Components in Systematic Case Studies and CaSE Purpose - based Evaluative Framework for Systematic Case Studies are presented in a comprehensive, detailed manner, with definitions and examples that would enable reviewers to have a good grasp of the appraisal process, it is likely that different reviewers may have different interpretations or ideas of what might be ‘substantial’ case study data. This, in part, is due to the methodologically pluralistic nature of the case study genre itself; what is relevant for one case study may not be relevant for another, and vice-versa. To aid with the review process, future research on CaSE should include a comprehensive paper on using the tool. This paper should involve evaluation examples with all six purpose-based systematic case studies, as well as a ‘search’ exercise (using CaSE to assess the relevance of case studies for one’s research, practice, training, etc.).

Finally, further research needs to be developed on how (and, indeed, whether) systematic case studies should be reviewed with specific ‘grades’ or ‘assessments’ that go beyond the qualitative examination in Table 14 . This would be particularly significant for the processes of qualitative meta-synthesis and meta-analysis. These research developments will further enhance CaSE tool, and, in turn, enable psychotherapy researchers to appraise their findings within clear, purpose-based evaluative criteria appropriate for systematic case studies.

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Almond, R. (2004). “I Can Do It (All) Myself”: Clinical technique with defensive narcissistic self–sufficiency. Psychoanalytic Psychology , 21 (3), 371–384. https://doi.org/10.1037/0736-9735.21.3.371 .

Article   Google Scholar  

American Psychological Association (2010). Evidence–based case study. Retrieved from https://www.apa.org/pubs/journals/pst/evidence–based–case–study.

Google Scholar  

Aveline, M. (2005). Clinical case studies: Their place in evidence–based practice. Psychodynamic Practice: Individuals, Groups and Organisations , 11 (2), 133–152. https://doi.org/10.1080/14753630500108174 .

Barkham, M., & Mellor-Clark, J. (2003). Bridging evidence-based practice and practice-based evidence: Developing a rigorous and relevant knowledge for the psychological therapies. Clinical Psychology & Psychotherapy , 10 (6), 319–327. https://doi.org/10.1002/cpp.379 .

Berg, H. (2019). How does evidence–based practice in psychology work? – As an ethical demarcation. Philosophical Psychology , 32 (6), 853–873. https://doi.org/10.1080/09515089.2019.1632424 .

Berg, H., & Slaattelid, R. (2017). Facts and values in psychotherapy—A critique of the empirical reduction of psychotherapy within evidence-based practice. Journal of Evaluation in Clinical Practice , 23 (5), 1075–1080. https://doi.org/10.1111/jep.12739 .

Article   PubMed   Google Scholar  

Bower, P. (2003). Efficacy in evidence-based practice. Clinical Psychology and Psychotherapy , 10 (6), 328–336. https://doi.org/10.1002/cpp.380 .

Cartwright, N., & Hardie, J. (2012). What are RCTs good for? In N. Cartwright, & J. Hardie (Eds.), Evidence–based policy: A practical guide to doing it better . Oxford University Press. https://doi.org/10.1093/acprof:osobl/9780199841608.003.0008 .

Critical Appraisal Skills Programme (CASP). (2018). Qualitative checklist. Retrieved from https://casp–uk.net/wp–content/uploads/2018/01/CASP–Qualitative–Checklist–2018.pdf .

Davison, G. C., & Lazarus, A. A. (2007). Clinical case studies are important in the science and practice of psychotherapy. In S. O. Lilienfeld, & W. T. O’Donohue (Eds.), The great ideas of clinical science: 17 principles that every mental health professional should understand , (pp. 149–162). Routledge/Taylor & Francis Group.

Douglas, H. (2004). The irreducible complexity of objectivity. Synthese , 138 (3), 453–473. https://doi.org/10.1023/B:SYNT.0000016451.18182.91 .

Duncan, B. L., & Sparks, J. A. (2020). When meta–analysis misleads: A critical case study of a meta–analysis of client feedback. Psychological Services , 17 (4), 487–496. https://doi.org/10.1037/ser0000398 .

Edelson, M. (1986). Causal explanation in science and in psychoanalysis—Implications for writing a case study. Psychoanalytic Study of Child , 41 (1), 89–127. https://doi.org/10.1080/00797308.1986.11823452 .

Edwards, D. J. A. (2013). Collaborative versus adversarial stances in scientific discourse: Implications for the role of systematic case studies in the development of evidence–based practice in psychotherapy. Pragmatic Case Studies in Psychotherapy , 3 (1), 6–34.

Edwards, D. J. A., Dattilio, F. M., & Bromley, D. B. (2004). Developing evidence–based practice: The role of case–based research. Professional Psychology: Research and Practice , 35 (6), 589–597. https://doi.org/10.1037/0735-7028.35.6.589 .

Erickson, F. (2012). Comments on causality in qualitative inquiry. Qualitative Inquiry , 18 (8), 686–688. https://doi.org/10.1177/1077800412454834 .

Fishman, D. B. (1999). The case for pragmatic psychology . New York University Press.

Fishman, D. B. (2005). Editor’s introduction to PCSP––From single case to database: A new method for enhancing psychotherapy practice. Pragmatic Case Studies in Psychotherapy , 1 (1), 1–50.

Fishman, D. B., Messer, S. B., Edwards, D. J. A., & Dattilio, F. M. (Eds.) (2017). Case studies within psychotherapy trials: Integrating qualitative and quantitative methods . Oxford University Press.

Fox, N. J. (2003). Practice–based evidence: Towards collaborative and transgressive research. Sociology , 37 (1), 81–102. https://doi.org/10.1177/0038038503037001388 .

Gabbay, J., & le May, A. (2011). Practice–based evidence for healthcare: Clinical mindlines . Routledge.

Green, L. W., & Latchford, G. (2012). Maximising the benefits of psychotherapy: A practice–based evidence approach . Wiley–Blackwell. https://doi.org/10.1002/9781119967590 .

Hannes, K., Lockwood, C., & Pearson, A. (2010). A comparative analysis of three online appraisal instruments’ ability to assess validity in qualitative research. Qualitative Health Research , 20 (12), 1736–1743. https://doi.org/10.1177/1049732310378656 .

Hartling, L., Chisholm, A., Thomson, D., & Dryden, D. M. (2012). A descriptive analysis of overviews of reviews published between 2000 and 2011. PLoS One , 7 (11), e49667. https://doi.org/10.1371/journal.pone.0049667 .

Article   PubMed   PubMed Central   Google Scholar  

Hill, A., & Spittlehouse, C. (2003). What is critical appraisal? Evidence–Based Medicine , 3 (2), 1–8.

Hilliard, R. B. (1993). Single–case methodology in psychotherapy process and outcome research. Journal of Consulting and Clinical Psychology , 61 (3), 373–380. https://doi.org/10.1037/0022-006X.61.3.373 .

Horn, S. D., & Gassaway, J. (2007). Practice–based evidence study design for comparative effectiveness research. Medical Care , 45 (10), S50–S57. https://doi.org/10.1097/MLR.0b013e318070c07b .

Iwakabe, S. (2003, May). Common change events in stages of psychotherapy: A qualitative analysis of case reports. In Paper presented at the 19th Annual Conference of the Society for Exploration of Psychotherapy Integration, New York .

Iwakabe, S. (2005). Pragmatic meta–analysis of case studies. Annual Progress of Family Psychology , 23 , 154–169.

Iwakabe, S., & Gazzola, N. (2009). From single–case studies to practice–based knowledge: Aggregating and synthesizing case studies. Psychotherapy Research , 19 (4-5), 601–611. https://doi.org/10.1080/10503300802688494 .

Jimenez-Buedo, M., & Miller, L. (2010). Why a Trade–Off? The relationship between the external and internal validity of experiments. THEORIA: An International Journal for Theory History and Foundations of Science , 25 (3), 301–321.

Joanna Briggs Institute (JBI). (2017a). Critical appraisal checklist for qualitative research. Retrieved from https://joannabriggs.org/sites/default/files/2019–05/JBI_Critical_Appraisal–Checklist_for_Qualitative_Research2017_0.pdf

Joanna Briggs Institute (JBI). (2017b). Checklist for case reports. Retrieved from https://joannabriggs.org/sites/default/files/2019–05/JBI_Critical_Appraisal–Checklist_for_Case_Reports2017_0.pdf

Kaluzeviciute, G. (2021). Validity, Evidence and Appraisal in Systematic Psychotherapy Case Studies . Paper presented at the Research Forum of Department of Psychosocial and Psychoanalytic Studies, University of Essex, Colchester, UK. https://doi.org/10.13140/RG.2.2.33502.15683  

Kaluzeviciute, G., & Willemsen, J. (2020). Scientific thinking styles: The different ways of thinking in psychoanalytic case studies. The International Journal of Psychoanalysis , 101 (5), 900–922. https://doi.org/10.1080/00207578.2020.1796491 .

Katrak, P., Bialocerkowski, A. E., Massy-Westropp, N., Kumar, S. V. S., & Grimmer, K. (2004). A systematic review of the content of critical appraisal tools. BMC Medical Research Methodology , 4 (1), 22. https://doi.org/10.1186/1471-2288-4-22 .

Kennedy, M. M. (1979). Generalising from single case studies. Evaluation Quarterly , 3 (4), 661–678. https://doi.org/10.1177/0193841X7900300409 .

Laska, K. M., Gurman, A. S., & Wampold, B. E. (2014). Expanding the lens of evidence–based practice in psychotherapy: A common factors perspective. Psychotherapy , 51 (4), 467–481. https://doi.org/10.1037/a0034332 .

Levitt, H. M., Motulsky, S. L., Wertz, F. J., Morrow, S. L., & Ponterotto, J. G. (2017). Recommendations for designing and reviewing qualitative research in psychology: Promoting methodological integrity. Qualitative Psychology , 4 (1), 2–22. https://doi.org/10.1037/qup0000082 .

Lilienfeld, S. O., Ritschel, L. A., Lynn, S. J., Cautin, R. L., & Latzman, R. D. (2013). Why many clinical psychologists are resistant to evidence–based practice: root causes and constructive remedies. Clinical Psychology Review , 33 (7), 883–900. https://doi.org/10.1016/j.cpr.2012.09.008 .

Long, A. F., & Godfrey, M. (2004). An evaluation tool to assess the quality of qualitative research studies. International Journal of Social Research Methodology , 7 (2), 181–196. https://doi.org/10.1080/1364557032000045302 .

Longhofer, J., Floersch, J., & Hartmann, E. A. (2017). Case for the case study: How and why they matter. Clinical Social Work Journal , 45 (3), 189–200. https://doi.org/10.1007/s10615-017-0631-8 .

Lunn, S., Daniel, S. I. F., & Poulsen, S. (2016). Psychoanalytic psychotherapy with a client with bulimia nervosa. Psychotherapy , 53 (2), 206–215. https://doi.org/10.1037/pst0000052 .

Mackrill, T., & Iwakabe, S. (2013). Making a case for case studies in psychotherapy training: A small step towards establishing an empirical basis for psychotherapy training. Counselling Psychotherapy Quarterly , 26 (3–4), 250–266. https://doi.org/10.1080/09515070.2013.832148 .

Maggio, S., Molgora, S., & Oasi, O. (2019). Analyzing psychotherapeutic failures: A research on the variables involved in the treatment with an individual setting of 29 cases. Frontiers in Psychology , 10 , 1250. https://doi.org/10.3389/fpsyg.2019.01250 .

Mahrer, A. R. (1988). Discovery–oriented psychotherapy research: Rationale, aims, and methods. American Psychologist , 43 (9), 694–702. https://doi.org/10.1037/0003-066X.43.9.694 .

Margison, F. B., et al. (2000). Measurement and psychotherapy: Evidence–based practice and practice–based evidence. British Journal of Psychiatry , 177 (2), 123–130. https://doi.org/10.1192/bjp.177.2.123 .

Maxwell, J. A. (2004). Causal explanation, qualitative research, and scientific inquiry in education. Educational Researcher , 33 (2), 3–11. https://doi.org/10.3102/0013189X033002003 .

McLeod, J. (2002). Case studies and practitioner research: Building knowledge through systematic inquiry into individual cases. Counselling and Psychotherapy Research: Linking research with practice , 2 (4), 264–268. https://doi.org/10.1080/14733140212331384755 .

McLeod, J. (2010). Case study research in counselling and psychotherapy . SAGE Publications. https://doi.org/10.4135/9781446287897 .

McLeod, J., & Elliott, R. (2011). Systematic case study research: A practice–oriented introduction to building an evidence base for counselling and psychotherapy. Counselling and Psychotherapy Research , 11 (1), 1–10. https://doi.org/10.1080/14733145.2011.548954 .

Meganck, R., Inslegers, R., Krivzov, J., & Notaerts, L. (2017). Beyond clinical case studies in psychoanalysis: A review of psychoanalytic empirical single case studies published in ISI–ranked journals. Frontiers in Psychology , 8 , 1749. https://doi.org/10.3389/fpsyg.2017.01749 .

Merriam, S. B. (1998). Qualitative research and case study applications in education . Jossey–Bass Publishers.

Michels, R. (2000). The case history. Journal of the American Psychoanalytic Association , 48 (2), 355–375. https://doi.org/10.1177/00030651000480021201 .

Midgley, N. (2006). Re–reading “Little Hans”: Freud’s case study and the question of competing paradigms in psychoanalysis. Journal of the American Psychoanalytic Association , 54 (2), 537–559. https://doi.org/10.1177/00030651060540021601 .

Rosqvist, J., Thomas, J. C., & Truax, P. (2011). Effectiveness versus efficacy studies. In J. C. Thomas, & M. Hersen (Eds.), Understanding research in clinical and counseling psychology , (pp. 319–354). Routledge/Taylor & Francis Group.

Sackett, D. L., Rosenberg, W. M., Gray, J. A. M., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn’t. BMJ , 312 (7023), 71–72. https://doi.org/10.1136/bmj.312.7023.71 .

Stake, R. E. (1995). The art of case study research . SAGE Publications.

Stake, R. E. (2010). Qualitative research: Studying how things work . The Guilford Press.

Stewart, R. E., & Chambless, D. L. (2007). Does psychotherapy research inform treatment decisions in private practice? Journal of Clinical Psychology , 63 (3), 267–281. https://doi.org/10.1002/jclp.20347 .

Stiles, W. B. (2007). Theory–building case studies of counselling and psychotherapy. Counselling and Psychotherapy Research , 7 (2), 122–127. https://doi.org/10.1080/14733140701356742 .

Teachman, B. A., Drabick, D. A., Hershenberg, R., Vivian, D., Wolfe, B. E., & Goldfried, M. R. (2012). Bridging the gap between clinical research and clinical practice: introduction to the special section. Psychotherapy , 49 (2), 97–100. https://doi.org/10.1037/a0027346 .

Thorne, S., Jensen, L., Kearney, M. H., Noblit, G., & Sandelowski, M. (2004). Qualitative metasynthesis: Reflections on methodological orientation and ideological agenda. Qualitative Health Research , 14 (10), 1342–1365. https://doi.org/10.1177/1049732304269888 .

Timulak, L. (2009). Meta–analysis of qualitative studies: A tool for reviewing qualitative research findings in psychotherapy. Psychotherapy Research , 19 (4–5), 591–600. https://doi.org/10.1080/10503300802477989 .

Trad, P. V., & Raine, M. J. (1994). A prospective interpretation of unconscious processes during psychoanalytic psychotherapy. Psychoanalytic Psychology , 11 (1), 77–100. https://doi.org/10.1037/h0079522 .

Truijens, F., Cornelis, S., Desmet, M., & De Smet, M. (2019). Validity beyond measurement: Why psychometric validity is insufficient for valid psychotherapy research. Frontiers in Psychology , 10 . https://doi.org/10.3389/fpsyg.2019.00532 .

Tuckett, D. (Ed.) (2008). The new library of psychoanalysis. Psychoanalysis comparable and incomparable: The evolution of a method to describe and compare psychoanalytic approaches . Routledge/Taylor & Francis Group. https://doi.org/10.4324/9780203932551 .

van Hennik, R. (2020). Practice based evidence based practice, part II: Navigating complexity and validity from within. Journal of Family Therapy , 43 (1), 27–45. https://doi.org/10.1111/1467-6427.12291 .

Westen, D., Novotny, C. M., & Thompson-Brenner, H. (2004). The empirical status of empirically supported psychotherapies: Assumptions, findings, and reporting in controlled clinical trials. Psychological Bulletin , 130 (4), 631–663. https://doi.org/10.1037/0033-2909.130.4.631 .

Widdowson, M. (2011). Case study research methodology. International Journal of Transactional Analysis Research & Practice , 2 (1). https://doi.org/10.29044/v2i1p25 .

Willemsen, J., Della Rosa, E., & Kegerreis, S. (2017). Clinical case studies in psychoanalytic and psychodynamic treatment. Frontiers in Psychology , 8 (108). https://doi.org/10.3389/fpsyg.2017.00108 .

Williams, V., Boylan, A., & Nunan, D. (2019). Critical appraisal of qualitative research: Necessity, partialities and the issue of bias. BMJ Evidence–Based Medicine . https://doi.org/10.1136/bmjebm-2018-111132 .

Yin, R. K. (1984). Case study research: Design and methods . SAGE Publications.

Yin, R. K. (1993). Applications of case study research . SAGE Publications.

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Acknowledgments

I would like to thank Prof Jochem Willemsen (Faculty of Psychology and Educational Sciences, Université catholique de Louvain-la-Neuve), Prof Wayne Martin (School of Philosophy and Art History, University of Essex), Dr Femke Truijens (Institute of Psychology, Erasmus University Rotterdam) and the reviewers of Psicologia: Reflexão e Crítica / Psychology : Research and Review for their feedback, insight and contributions to the manuscript.

Arts and Humanities Research Council (AHRC) and Consortium for Humanities and the Arts South-East England (CHASE) Doctoral Training Partnership, Award Number [AH/L50 3861/1].

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Kaluzeviciute, G. Appraising psychotherapy case studies in practice-based evidence: introducing Case Study Evaluation-tool (CaSE). Psicol. Refl. Crít. 34 , 9 (2021). https://doi.org/10.1186/s41155-021-00175-y

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Clinical Case Studies in Psychoanalytic and Psychodynamic Treatment

This manuscript provides a review of the clinical case study within the field of psychoanalytic and psychodynamic treatment. The method has been contested for methodological reasons and because it would contribute to theoretical pluralism in the field. We summarize how the case study method is being applied in different schools of psychoanalysis, and we clarify the unique strengths of this method and areas for improvement. Finally, based on the literature and on our own experience with case study research, we come to formulate nine guidelines for future case study authors: (1) basic information to include, (2) clarification of the motivation to select a particular patient, (3) information about informed consent and disguise, (4) patient background and context of referral or self-referral, (5) patient's narrative, therapist's observations and interpretations, (6) interpretative heuristics, (7) reflexivity and counter-transference, (8) leaving room for interpretation, and (9) answering the research question, and comparison with other cases.

Introduction

Psychoanalysis has always been, according to its inventor, both a research endeavor and a therapeutic endeavor. Furthermore it is clear from Freud's autobiography that he prioritized the research aspect; he did not become a doctor because he wished to cure people in ill health (Freud, 2001 [1925] ). His invention of the psychoanalytic approach to therapy, involving the patient lying down and associating freely, served a research purpose as much as a therapeutic purpose. Through free association, he would be able to gain unique insight in the human mind. Next, he had to find a format to report on his findings, and this would be the case study. The case study method already existed in medicine (Forrester, 2016 ), but Freud adjusted it considerably. Case studies in medical settings were more like case files, in which the patient was described or reduced to a number of medical categories: the patient became a case of some particular ailment (Forrester, 2016 ). In Freud's hands, the case study developed into Kranken Geschichten in which the current pathology of the patient is related to the whole of his life, sometimes even over generations.

Although Freud's case studies have demonstrably provided data for generations of research by analysts (Midgley, 2006a ) and various scholars (Pletsch, 1982 ; Sealey, 2011 ; Damousi et al., 2015 ), the method of the case study has become very controversial. According to Midgley ( 2006b ), objections against the case study method can be grouped into three arguments. First there is the data problem: case studies provide no objective clinical data (Widlöcher, 1994 ), they only report on what went right and disregard any confusion or mistakes (Spence, 2001 ). Second, there is the data analysis problem: the way in which the observations of the case study are analyzed lack validity; case studies confirm what we already know (Spence, 2001 ). Some go even so far to say that they are purely subjective: Michels calls case studies the “crystallization of the analyst's countertransference” (Michels, 2000 , p. 373). Thirdly, there is the generalizability problem: it is not possible to gain generalizable insight from case studies. Reading, writing and presenting case studies has been described as being a group ritual to affirm analysts in their professional identity, rather than a research method (Widlöcher, 1994 ).

These criticisms stand in contrast to the respect gained by the case study method in the last two decades. Since the 1990s there has been an increasing number of psychoanalytic and psychodynamic clinical case study and empirical case studies being published in scientific journals (Desmet et al., 2013 ; Cornelis et al., in press ). It has also been signaled that the case study method is being revived more broadly in the social sciences. In the most recent, fifth edition of his seminal book on case study research, Yinn ( 2014 ) includes a figure showing the steady increase of the frequency with which the term “case study research” appears in published books in the period from 1980 to 2008.

KEY CONCEPT 1

Clinical case study.

A clinical case study is a narrative report by the therapist of what happened during a therapy together with the therapist's interpretations of what happened. It is possible that certain (semi)-structured assessment instruments, such as a questionnaire or a diagnostic interview are included in clinical case studies, yet it is still the therapist that uses these, interprets and discusses them.

KEY CONCEPT 2

Empirical case studies.

In an empirical case study data are gathered from different sources (e.g., self-report, observation,…) and there is a research team involved in the analyses of the data. This study can take place either in a naturalistic setting (systematic case study) or in a controlled experimental environment (single-case experiment).

In addition to the controversy about the case study method, psychoanalysis has developed into a fragmented discipline. The different psychoanalytic schools share Freud's idea of the unconscious mind, but they focus on different aspects in his theoretical work. Some of the schools still operate under the wings of the International Psychoanalytic Association, while others have established their own global association. Each school is linked to one or several key psychoanalysts who have developed their own version of psychoanalysis. Each psychoanalytic school has a different set of theories but there are also differences in the training of new psychoanalysts and in the therapeutic techniques that are applied by its proponents.

Based on this heterogeneity of perspectives in psychoanalysis, a research group around the Single Case Archive investigated the current status of case study research in psychoanalysis (Willemsen et al., 2015a ). They were particularly interested to know more about the output and methodology of case studies within the different psychoanalytic schools.

KEY CONCEPT 3

Single case archive.

The Single Case Archive is an online archive of published clinical and empirical case studies in the field of psychotherapy ( http://www.singlecasearchive.com ). The objective of this archive is to facilitate the study of case studies for research, clinical, and teaching purposes. The online search engine allows the identification of sets of cases in function of specific clinical or research questions.

Our survey among case study authors about their psychoanalytic school

In order to investigate and compare case studies from different psychoanalytic schools, we first had to find a way of identifying to which school the case studies belonged. This is very difficult to judge straightforwardly on the basis of the published case study: the fact that someone cites Winnicott or makes transference interpretations doesn't place him or her firmly within a particular psychoanalytic school. The best approach was to ask the authors themselves. Therefore, we contacted all case study authors included in the Single Case Archive (since the time of our original study in 2013, the archive has expanded). We sent emails and letters in different languages to 445 authors and received 200 replies (45% response rate). We asked them the following question: “ At the time you were working on this specific case, to which psychoanalytic school(s) did you feel most attached? ” Each author was given 10 options: (1) Self Psychology (1.a Theory of Heinz Kohut, 1.b Post-Kohutian Theories, 1.c Intersubjective psychoanalysis), (2) Relational psychoanalysis, (3) Interpersonal psychoanalysis, (4) Object relational psychoanalysis (4.a Theory of Melanie Klein, 4.b Theory of Donald W. Winnicott, 4.c Theory of Wilfred R. Bion, 4.d Theory of Otto F. Kernberg), (5) Ego psychology (or) “Classic psychoanalysis” (5.a Theories of Sigmund Freud, 5.b Ego psychology, 5.c Post-Ego psychology), (6) Lacanian psychoanalysis, (7) Jungian psychoanalysis, (8) National Psychological Association for Psychoanalysis (NPAP) related theory, (9) Modern psychoanalysis related to the Boston or New York Graduate School of Psychoanalysis (BGSP/NYGSP), (10) Other. Respondents could indicate one or more options.

Analysis of the responses indicated that the two oldest schools in psychoanalysis, Object-relations psychoanalysis and Ego psychology, dominate the field in relation to case studies that are published in scientific journals. More than three quarters of all case study authors (77%) reported these schools of thought to be the ones with which they considered themselves most affiliated. Three more recent schools were also well-represented among case studies: Self Psychology, Relational Psychoanalysis, and Interpersonal Psychoanalysis. Lacanian Psychoanalysis, Jungian Psychoanalysis, NPAP related Theory and Modern Psychoanalysis related to the BGSP/NYGSP were only rarely mentioned by case study authors as their school of thought. This does not mean that clinicians or researchers within these latter schools do not write any case studies. It only means that they publish few case studies in the scientific journals included in ISI-ranked journals indexed in Web of Science. But they might have their own journals in which they publish clinical material.

Our survey demonstrated that the majority of case study authors (59%) feel attached to more than one psychoanalytic school. This was in fact one of the surprising findings in our study. It seems that theoretical pluralism is more rule than exception among case study authors. There were some differences between the psychoanalytic schools though in terms of pluralism. Case study authors who feel attached to Self Psychology and Interpersonal Psychoanalysis are the most pluralistic: 92 and 86%, respectively also affiliate with one or more other psychoanalytic schools. Case study authors who feel attached to Object Relations Psychoanalysis are the “purest” group: only 69% of them affiliate with one or more other psychoanalytic schools.

KEY CONCEPT 4

Theoretical pluralism.

A situation in which several, potentially contradicting, theories coexist. It is sometimes interpreted as a sign of the immaturity of a science, under the assumption that a mature science should arrive at one single coherent truth. Others see theoretical pluralism as unavoidable for any applied discipline, as each theory can highlight only part of reality.

Psychoanalytic pluralism and the case study method

We were not really surprised to find that Object Relations psychoanalysis and Ego psychology were the most dominant schools in the field of psychoanalytic case studies, as they are very present in European, Latin-American and North-American psychoanalytic institutes. We were more surprised to find such a high degree of pluralism among these case study authors, given the fact that disputes between analysts from different schools can be quite ardent (Green, 2005 ; Summers, 2008 ). Others have compared the situation of psychoanalytic schools with the Tower of Babel (Steiner, 1994 ).

It has been argued that the case study method contributes to the degree of theoretical pluralism within psychoanalysis. The reason for this is situated in the reasoning style at the basis of case study research (Chiesa, 2010 ; Fonagy, 2015 ). The author of a psychoanalytic case study makes a number of observations about the patient within the context of the treatment, and then moves to a conclusion about the patient's psychodynamics in general. The conclusion he or she arrives at inductively gains its “truth value” from the number and quality of observations it is based on. This style of reasoning in case study research is very similar to how clinicians reason in general. Clinicians look for patterns within patients and across patients. If they make similar observations in different patients, or if other psychoanalysts make similar observations in their patients, the weight of the conclusion becomes greater and greater. The problem with this reasoning style is that one can never arrive at definite conclusions: even if a conclusion is based on a large number of observations, it is always possible that the next observation disconfirms the conclusion. Therefore, it could be said, it is impossible to attain “true” knowledge.

The above argument is basically similar to objections against any kind of qualitative research. To this, we argue with Rustin ( 2003 ) that there is not one science and no hierarchy of research methods. Each method comes with strengths and weaknesses, and what one gains in terms of control and certainty in a conventional experimental setup is lost in terms of external validity and clinical applicability. Numerous researchers have pleaded for the case study approach as one method among a whole range of research methods in the field of psychoanalysis (Rustin, 2003 ; Luyten et al., 2006 ; Midgley, 2006b ; Colombo and Michels, 2007 ; Vanheule, 2009 ; Hinshelwood, 2013 ). Leuzinger-Bohleber makes a distinction between clinical research and extra-clinical research (Leuzinger-Bohleber, 2015 ). Clinical research is the idiographic type of research conducted by a psychoanalyst who is working with a patient. Unconscious phantasies and conflicts are symbolized and put into words at different levels of abstraction. This understanding then molds the perception of the analyst in subsequent clinical situations; even though the basic psychoanalytic attitude of “not knowing” is maintained. The clinical case study is clinical research par excellence . Extra-clinical research consists in the application of different methodologies developed in the natural and human sciences, to the study of the unconscious mind. Leuzinger-Bohleber refers to empirical psychotherapy research, experimental research, literature, cultural studies, etc. We believe that the clinical case study method should step up and claim its place in psychoanalytic research, although we agree that the method should be developed further. This paper and a number of others such as Midgley ( 2006b ) should facilitate this methodological improvement. The clinical research method is very well-suited to address any research question related to the description of phenomena and sequences in psychotherapy (e.g., manifestation and evolution of symptoms and therapeutic relationship over time). It is not suitable for questions related to causality and outcome.

We also want to point out that there is a new evolution in the field of psychotherapy case study research, which consists in the development of methodologies for meta-studies of clinical case studies (Iwakabe and Gazzola, 2009 ). The evolution builds on the broader tendency in the field of qualitative research to work toward integration or synthesis of qualitative findings (Finfgeld, 2003 ; Zimmer, 2006 ). The first studies which use this methodology have been published recently: Widdowson ( 2016 ) developed a treatment manual for depression, Rabinovich ( 2016 ) studied the integration of behavioral and psychoanalytic treatment interventions, and Willemsen et al. ( 2015b ) investigated patterns of transference in perversion. The rich variety of research aims demonstrates the potential of these meta-studies of case studies.

KEY CONCEPT 5

Meta-studies of clinical case studies.

A meta-study of clinical case studies is a research approach in which findings from cases are aggregated and more general patterns in psychotherapeutic processes are described. Several methodologies for meta-studies have been described, including cross-case analysis of raw data, meta-analysis, meta-synthesis, case comparisons, and review studies in general.

Lack of basic information in psychoanalytic case studies

The second research question of our study (Willemsen et al., 2015a ) concerned the methodological, patient, therapist, and treatment characteristics of published psychoanalytic case studies. All studies included in the Single Case Archive are screened by means of a coding sheet for basic information, the Inventory of Basic Information in Single Cases (IBISC). The IBISC was designed to assess the presence of basic information on patient (e.g., age, gender, reasons to consult), therapist (e.g., age, gender, level of experience), treatment (e.g., duration, frequency, outcome), and the methodology (e.g., therapy notes or audio recoding of sessions). The IBISC coding revealed that a lot of basic information is simply missing in psychoanalytic case studies (Desmet et al., 2013 ). Patient information is fairly well-reported, but information about therapist, treatment and methodology are often totally absent. Training and years of experience are not mentioned in 84 and 94% of the cases, respectively. The setting of the treatment is not mentioned in 61% of the case studies. In 80% of the cases, it was not mentioned whether the writing of the case studies was on the basis of therapy notes, or audiotapes. In 91% of the cases, it was not mentioned whether informed consent was obtained.

Using variables on which we had more comprehensive information, we compared basic information of case studies from different psychoanalytic schools. This gave us a more detailed insight in the type of case studies that have been generated within each psychoanalytic school, and into the difference between these schools in terms of the kind of case study they generate. We found only minimal differences. Case studies in Relational Psychoanalysis stand out because they involve older patients and longer treatments. Case studies in Interpersonal Psychoanalysis tend to involve young, female patients and male therapists. Case study authors from both these schools tend to report on intensive psychoanalysis in terms of session frequency. But for the rest, it seems that the publication of case studies throughout the different psychoanalytic schools has intensified quite recently.

Guidelines for writing clinical case studies

One of the main problems in using psychoanalytic case studies for research purposes is the enormous variability in quality of reporting and inconsistency in the provision of basic information about the case. This prevents the reader from contextualizing the case study and it obstructs the comparison of one case study with another. There have been attempts to provide guidelines for the writing of case studies, especially in the context of analytic training within the American Psychoanalytic Association (Klumpner and Frank, 1991 ; Bernstein, 2008 ). However, these guidelines were never enforced for case study authors by the editors from the main psychoanalytic journals. Therefore, the impact of these guidelines on the field of case study research has remained limited.

Here at the end of our focused review, we would like to provide guidelines for future case study authors. Our guidelines are based on the literature and on our experience with reading, writing, and doing research with clinical case studies. We will include fragments of existing case studies to clarify our guidelines. These guidelines do not provide a structure or framework for the case study; they set out basic principles about what should be included in a case study.

Basic information

First of all, we think that a clinical case study needs to contain basic information about the patient, the therapist, the treatment, and the research method. In relation to the patient , it is relevant to report on gender, age (or an age range in which to situate the patient), and ethnicity or cultural background. The reader needs to know these characteristics in order to orientate themselves as to who the patient is and what brings them to therapy. In relation to the therapist , it is important to provide information about professional training, level of professional experience, and theoretical orientation. Tuckett ( 2008 ) emphasizes the importance for clinicians to be explicit about the theory they are using and about their way of practicing. It is not sufficient to state membership of a particular group or school, because most groups have a wide range of different ways of practicing. In relation to the treatment itself, it is important to be explicit about the kind of setting, the duration of treatment, the frequency of sessions, and details about separate sequences in the treatment (diagnostic phase, follow-up etc.). These are essential features to share, especially at a time when public sector mental health treatment is being subjected to tight time restrictions and particular ways of practising are favored over others. For example short-term psychotherapies are being implemented in public services for social and economic reasons. While case studies carried out in the public sector can give us information on those short-term therapies, private practice can offer details about the patient's progress on a long-term basis. Moreover, it is important to report whether the treatment is completed. To our astonishment, there are a considerable number of published case studies on therapies that were not finished (Desmet et al., 2013 ). As Freud ( 2001 [1909] , p. 132) already advised, it is best to wait till completion of the treatment before one starts to work on a case study. Finally, in relation to the research method , it is crucial to mention which type of data were collected (therapy notes taken after each session, audio-recordings, questionnaires, etc.), whether informed consent was given, and in what way the treatment was supervised. Clinicians who would like to have help with checking whether they included all necessary basic information case use the Inventory for Basic Information in Single Cases (IBISC), which is freely available on http://www.singlecasearchive.com/resources .

Motivation to select a particular patient

First of all, it is crucial to know what the motivation for writing about a particular case comes from. Some of the following questions should be kept in mind and made explicit from the beginning of the case presentation. Why is it interesting to look at this case? What is it about this case or the psychotherapist's work that can contribute to the already existing knowledge or technique?

“This treatment resulted in the amelioration of his [obsessive-compulsive] symptoms, which remained stable eight years after treatment ended. Because the standard of care in such cases has become largely behavioral and pharmacological, I will discuss some questions about our current understanding of obsessive-compulsive phenomena that are raised by this case, and some of the factors that likely contributed to the success of psychoanalytic treatment for this child (McGehee, 2005 , p. 213–214).”

This quotation refers to a case that has been selected on the basis of its successful outcome. The author is then interested to find out what made this case successful.

Informed consent and disguise

As regulations on privacy and ethics are becoming tighter, psychotherapists find themselves with a real problem in deciding what is publishable and what is not. Winship ( 2007 ) points out that there is a potential negative effect of research overregulation as clinicians may be discouraged from reporting ordinary and everyday findings from their clinical practice. But he also offers very good guidelines for approaching the issue of informed consent. A good practice is asking for consent either at the start of the treatment or after completion of the treatment: preferably not during treatment. It is inadvisable to complete the case study before the treatment has ended. It is also advisable that the process of negotiating consent with the patient is reported in the case study.

“To be sure that Belle's anonymity was preserved, I contacted her while writing this book and told her it would not be published without her complete approval. To do this, I asked if she would review every word of every draft. She has (Stoller, 1986 , p. 217).”

In relation to disguise, one has to strike a balance between thin and thick disguise. Gabbard ( 2000 ) suggests different useful approaches to disguising the identity of the patient.

Patient background and context of referral or self-referral

It is important to include relevant facts about the patient's childhood, family history, siblings, any trauma or losses and relationship history (social and romantic) and the current context of the patient's life (family, working, financial). The context of referral is also key to understanding how and why the patient has come to therapy. Was the patient encouraged to come or had wanted to come? Has there been a recent crisis which prompted the intervention or an on-going problem which the patient had wanted to address for some time?

“Michael was one of the youngest children in his family of origin. He had older brothers and sisters who had been received into care before his birth. His parents separated before he was born. There had been some history of violence between them and Michael was received into care on a place of safety order when he was an infant because his mother had been unable to show consistent care toward him (Lykins Trevatt, 1999 , p. 267).”

Patient's narrative, therapist's observations, and interpretations

A case study should contain detailed accounts of key moments or central topics, such as a literal transcription of an interaction between patient and therapist, the narration of a dream, a detailed account of associations, etc. This will increase the fidelity of the case studied, especially when both patient's and therapist's speech are reported as carefully as possible.

“Martha spoke in a high-pitched voice which sounded even more tense than usual. She explained that her best friend's mum had shouted at her for being so withdrawn; this made her angry and left her feeling that she wanted to leave their home for good. I told Martha that she often tried to undo her bad feelings by acting quickly on her instincts, as she did not feel able to hold her feelings in her mind and bring them to her therapy to think about with me. Martha nodded but it was not clear whether she could really think about what I just said to her. She then said that she was being held in the hospital until a new foster placement could be found. “In the meantime,” she said in a pleased tone, “I have to be under constant supervision” (Della Rosa, 2015 , p. 168).”

In this example, observations of nonverbal behavior and tonality are also included, which helps to render a lively picture of the interaction.

Interpretative heuristics

In which frame of reference is the writer operating? It is important to know what theories are guiding the therapist's thinking and what strategies he employs in order to deal with the clinical situation he is encountering. Tuckett ( 1993 ) writes about the importance of knowing what “explanatory model” is used by the therapist in order to make sense of the patient and to relate his own thinking to a wider public for the purpose of research. This idea is also supported by Colombo and Michels ( 2007 ) who believe that making theoretical orientations as explicit as possible would make the case studies intelligible and more easily employed by the research community. This can be done by the therapists explaining why they have interpreted a particular situation in the way they have. For example, Kegerreis in her paper on time and lateness (2013) stresses throughout how she is working within the object-relations framework and looking out for the patient's use of projective mechanisms.

“She was 10 minutes late. Smiling rather smugly to herself she told me that the wood supplied for her new floor had been wrongly cut. The suppliers were supposed to come and collect it and hadn't done so, so she had told them she was going to sell it to a friend, and they are now all anxious and in a hurry to get it. I said she now feels as if she has become more powerful, able to get a response. She agrees, grinning more, telling me she does have friends who would want it, that it was not just a ploy. She said she had found it easier to get up today but was still late. I wondered if she had a sense of what the lateness was about. She said it was trying to fit too much in. She had been held up by discussing the disposal of rubble with her neighbors. I said I thought there was a link here with the story about the wood. In that she had turned the situation around. She had something that just didn't work, had a need for something, but it was turned around into something that was the suppliers' problem. They were made to feel the urgency and the need. Maybe when she is late here she is turning it around, so it is me who is to be uncertain and waiting, not her waiting for her time to come. We maybe learn here something of her early object relationships, in which being in need is felt to be unbearable, might lead to an awful awareness of lack and therefore has to be exported into someone else. One could go further and surmise that in her early experience she felt teased and exploited by the person who has the power to withhold what you need (Kegerreis, 2013 , p. 458).”

There can be no doubt reading this extract about the theoretical framework which is being used by the therapist.

Reflexivity and counter-transference

A good case study contains a high degree of reflexivity, whereby the therapist is able to show his feelings and reactions to the patient's communication in the session and an ability to think about it later with hindsight, by himself or in supervision. This reflexivity needs to show the pattern of the therapist's thinking and how this is related to his school of thought and to his counter-transferential experiences. How has the counter-transference been dealt with in a professional context? One can also consider whether the treatment has been influenced by supervision or discussion with colleagues.

“Recently for a period of a few days I found I was doing bad work. I made mistakes in respect of each one of my patients. The difficulty was in myself and it was partly personal but chiefly associated with a climax that I had reached in my relation to one particular psychotic (research) patient. The difficulty cleared up when I had what is sometimes called a ‘healing’ dream. […] Whatever other interpretations might be made in respect of this dream the result of my having dreamed it and remembered it was that I was able to take up this analysis again and even to heal the harm done to it by my irritability which had its origin in a reactive anxiety of a quality that was appropriate to my contact with a patient with no body (Winnicott, 1949 , p. 70).”

Leaving room for interpretation

A case study is the therapist's perspective on what happened. A case study becomes richer if the author can acknowledge aspects of the story that remain unclear to him. This means that not every bit of reported clinical material should be interpreted and fitted within the framework of the research. There should be some loose ends. Britton and Steiner ( 1994 ) refer to the use of interpretations where there is no room for doubt as “soul murder.” A level of uncertainty and confusion make a case study scientifically fruitful (Colombo and Michels, 2007 ). The writer can include with hindsight what he thinks he has not considered during the treatment and what he thinks could have changed the course for the treatment if he had been aware or included other aspects. This can be seen as an encouragement to continue to be curious and maintain an open research mind.

Answering the research question, and comparison with other cases

As in any research report, the author has to answer the research question and relate the findings to the existing literature. Of particular interest is the comparison with other similar cases. Through comparing, aggregating, and contrasting case studies, one can discover to what degree and under what conditions, the findings are valid. In other words, the comparison of cases is the start of a process of generalization of knowledge.

“Although based on a single case study, the results of my research appear to concur with the few case studies already in the field. In reviewing the literature on adolescent bereavement, it was the case studies that had particular resonance with my own work, and offered some of the most illuminating accounts of adolescent bereavement. Of special significance was Laufer's ( 1966 ) case study that described the narcissistic identifications of ‘Michael’, a patient whose mother had died in adolescence. Both Laufer's research and my own were conducted using the clinical setting as a basis and so are reflective of day-to-day psychotherapy practice (Keenan, 2014 , p. 33).”

As Yinn ( 2014 ) has argued for the social sciences, the case study method is the method of choice when one wants to study a phenomenon in context, especially when the boundaries between the phenomenon and the context are fussy. We are convinced that the same is true for case study methodology in the fields of psychoanalysis and psychotherapy. The current focused review has positioned the research method within these fields, and has given a number of guidelines for future case study researchers. The authors are fully aware that giving guidelines is a very tricky business, because while it can channel and stimulate research efforts it can as well-limit creativity and originality in research. Moreover, guidelines for good research change over time and have to be negotiated over and over again in the literature. A similar dilemma is often pondered when it comes to qualitative research (Tracy, 2010 ). However, our first impetus for providing these guidelines is pedagogical. The three authors of this piece are experienced psychotherapists who also work in academia. A lot of our students are interested in doing case study research with their own patients, but they struggle with the methodology. Our second impetus is to improve the scientific credibility of the case study method. Our guidelines for what to include in the written account of a case study, should contribute to the improvement of the quality of the case study literature. The next step in the field of case study research is to increase the accessibility of case studies for researchers, students and practitioners, and to develop methods for comparing or synthesizing case studies. As we have described above, efforts in that direction are being undertaken within the context of the Single Case Archive.

Author contributions

JW has written paragraphs 1–4; ER and JW have written paragraph 5 together; SK has contributed to paragraph 5 and revised the whole manuscript.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

• Bernstein S. B. (2008). Writing about the psychoanalytic process . Psychoanal. Inq. 28 , 433–449. 10.1080/0735516908022126694 [ CrossRef ] [ Google Scholar ]
• Britton R., Steiner J. (1994). Interpretation: selected fact or overvalued idea? Int. J. Psychoanal. 75 , 1069–1078. [ PubMed ] [ Google Scholar ]
• Chiesa M. (2010). Research and psychoanalysis: still time to bridge the great divide? Psychoanal. Psychnol. 27 , 99–114. 10.1037/a0019413 [ CrossRef ] [ Google Scholar ]
• Colombo D., Michels R. (2007). Can (should) case reports be written for research use? Psychoanal. Inq. 27 , 640–649. 10.1080/07351690701468256 [ CrossRef ] [ Google Scholar ]
• Cornelis S., Desmet M., Meganck R., Cauwe J., Inslegers R., Willemsen J., et al. (in press). Interaction between obsessional symptoms interpersonal dynamics: an empirical single case study . Psychoanal. Psychnol. 10.1037/pap0000078 [ CrossRef ] [ Google Scholar ]
• Damousi J., Lang B., Sutton K. (2015). Case Studies and the Dissemination of Knowledge . New York, NY: Routledge. [ Google Scholar ]
• Della Rosa E. (2015). The problem of knowledge in psychotherapy with an adolescent girl: reflections on a patient's difficulty in thinking and issues of therapeutic technique . J. Child Psychother. 41 , 162–178. 10.1080/0075417X.2015.1048125 [ CrossRef ] [ Google Scholar ]
• Desmet M., Meganck R., Seybert C., Willemsen J., Van Camp I., Geerardyn F., et al.. (2013). Psychoanalytic single cases published in ISI-ranked journals: the construction of an online archive . Psychother. Psychosom. 82 , 120–121. 10.1159/000342019 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Finfgeld D. L. (2003). Metasynthesis: the state of the art – so far . Qual. Health Res. 13 , 893–904. 10.1177/1049732303253462 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Fonagy P. (2015). Research issues in psychoanalysis , in An Open Door Review of Outcome and Process Studies in Psychoanalysis, 3rd Edn. , eds Leuzinger-Bohleber M., Kächele H. (London: International Psychoanalytic Association; ), 42–60. [ Google Scholar ]
• Forrester J. (2016). Thinking in Cases . Cambridge: Polity. [ Google Scholar ]
• Freud S. (2001 [1909]). Analysis of a Phobia in a Five-Year-Old Boy, 10th Standard Edn. London: Vintage Books. [ Google Scholar ]
• Freud S. (2001 [1925]). An Autobiographical Study, 20th Standard Edn. London: Vintage Books. [ Google Scholar ]
• Gabbard G. O. (2000). Disguise or consent: problems and recommendations concerning the publication and presentation of clinical material . Int. J. Psychoanal. 81 , 1071–1086. 10.1516/0020757001600426 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Green A. (2005). The illusion of common ground and mythical pluralism . Int. J. Psychoanal. 86 , 627–632. [ PubMed ] [ Google Scholar ]
• Hinshelwood R. D. (2013). Research on the Couch . London: Routledge. [ Google Scholar ]
• Iwakabe S., Gazzola N. (2009). From single-case studies to practice-based knowledge: aggregating and synthesizing case studies . Psychother. Res. 19 , 601–611. 10.1080/10503300802688494 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Keenan A. (2014). Parental loss in early adolescence and its subsequent impact on adolescent development . J. Child Psychother. 40 , 20–35. 10.1080/0075417X.2014.883130 [ CrossRef ] [ Google Scholar ]
• Kegerreis S. (2013). “When I can come on time I'll be ready to finish”: meanings of lateness in psychoanalytic psychotherapy . Br. J. Psychother. 29 , 449–465. 10.1111/bjp.12053 [ CrossRef ] [ Google Scholar ]
• Laufer M. (1966). Object loss in adolescence . Psychoanal. Study Child 31 , 269–293. [ PubMed ] [ Google Scholar ]
• Leuzinger-Bohleber M. (2015). Development of a plurality during the one hundred year old history of research of psychoanalysis , in An Open Door Review of Outcome and Process Studies in Psychoanalysis, 3rd Edn. , eds Leuzinger-Bohleber M., Kächele H. (London: International Psychoanalytic Association; ), 18–32. [ Google Scholar ]
• Klumpner G. H., Frank A. (1991). On methods of reporting clinical material . J. Am. Psychoanal. Assoc. 39 , 537–551. 10.1177/000306519103900211 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Luyten P., Blatt S. J., Corveleyn J. (2006). Minding the gap between positivism and hermeneutics in psychoanalytic research . J. Am. Psychoanal. Assoc. 54 , 571–610. 10.1177/00030651060540021301 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Lykins Trevatt D. (1999). An account of a little boy's attempt to recover from the trauma of abuse . J. Child Psychother. 25 , 267–287. 10.1080/00754179908260293 [ CrossRef ] [ Google Scholar ]
• McGehee R. H. (2005). Child psychoanalysis and obsessive-compulsive symptoms: the treatment of a ten-year-old boy . J. Am. Psychoanal. Assoc. 53 , 213–237. 10.1177/00030651050530011301 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Michels R. (2000). The case history . J. Am. Psychoanal. Assoc. 48 , 355–411. 10.1177/00030651000480021201 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Midgley N. (2006a). Re-reading “Little Hans”: Freud's case study and the question of competing paradigms in psychoanalysis . J. Am. Psychoanal. Assoc. 54 , 537–559. 10.1177/00030651060540021601 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Midgley N. (2006b). The “inseparable bond between cure and research”: clinical case study as a method of psychoanalytic inquiry . J. Child Psychother. 32 , 122–147. 10.1080/00754170600780273 [ CrossRef ] [ Google Scholar ]
• Pletsch C. E. (1982). Freud's case studies and the locus of psychoanalytic knowledge . Dynamis 2 , 263–297. [ PubMed ] [ Google Scholar ]
• Rabinovich M. (2016). Psychodynamic emotional regulation in view of Wolpe's desensitization model . Am. J. Psychol. 129 , 65–79. 10.5406/amerjpsyc.129.1.0065 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Rustin M. (2003). Research in the consulting room . J. Child Psychother. 29 , 137–145. 10.1080/0075417031000138415 [ CrossRef ] [ Google Scholar ]
• Sealey A. (2011). The strange case of the Freudian case history: the role of long case histories in the development of psychoanalysis . Hist. Human Sci. 24 , 36–50. 10.1177/0952695110383460 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Spence D. P. (2001). Dangers of anecdotal reports . J. Clin. Psychol. 57 , 37–41. 10.1002/1097-4679(200101)57:1<37::AID-JCLP5>3.0.CO;2-S [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Steiner R. (1994). “The tower of Babel” or “After Babel in contemporary psychoanalysis”? – Some historical and theoretical notes on the linguistic and cultural strategies implied by the foundation of the International Journal of Psycho-Analysis, and on its Relevance today . Int. J. Psychoanal. 75 , 883–901. [ PubMed ] [ Google Scholar ]
• Stoller R. J. (1986). Sexual Excitement: Dynamics of Erotic Life . London: Maresfield Library. [ Google Scholar ]
• Summers F. (2008). Theoretical insularity and the crisis of psychoanalysis . Psychoanal. Psychnol. 25 , 413–424. 10.1037/0736-9735.25.3.413 [ CrossRef ] [ Google Scholar ]
• Tracy S. J. (2010). Qualitative quality: eight “big tent” criteria for excellent qualitative research . Qual. Inq. 16 , 837–851. 10.1177/1077800410383121 [ CrossRef ] [ Google Scholar ]
• Tuckett D. (1993). Some thoughts on the presentation and discussion of the clinical material of psychoanalysis . Int. J. Psychoanal. 74 , 1175–1190. [ PubMed ] [ Google Scholar ]
• Tuckett D. (2008). Psychoanalysis Comparable and Incomparable: The Evolution of a Method to Describe and Compare Psychoanalytic Approaches . New York, NY: Routledge. [ Google Scholar ]
• Vanheule S. (2009). Psychotherapy and research: a relation that needs to be reinvented . Br. J. Psychother. 25 , 91–109. 10.1111/j.1752-0118.2008.01103.x [ CrossRef ] [ Google Scholar ]
• Widdowson M. (2016). Transactional Analysis for Depression: A Step-by-step Treatment Manual . Abingdon: Routledge. [ Google Scholar ]
• Widlöcher D. (1994). A case is not a fact . Int. J. Psychoanal. 75 , 1233–1244. [ PubMed ] [ Google Scholar ]
• Willemsen J., Cornelis S., Geerardyn F. M., Desmet M., Meganck R., Inslegers R., et al.. (2015a). Theoretical pluralism in psychoanalytic case studies . Front. Psychol. 6 :1466. 10.3389/fpsyg.2015.01466 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Willemsen J., Inslegers R., Meganck R., Geerardyn F., Desmet M., Vanheule S. (2015b). A metasynthesis of published case studies through Lacan's L-schema: transference in perversion . Int. J. Psychoanal. 96 , 773–795. 10.1111/1745-8315.12179 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Winnicott D. W. (1949). Hate in the counter-transference . Int. J. Psychoanal. 30 , 69–74. [ Google Scholar ]
• Winship G. (2007). The ethics of reflective research in single case study inquiry . Perspect. Psychiatr. Care 43 , 174–182. 10.1111/j.1744-6163.2007.00132.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Yinn R. K. (2014). Case Study Research: Design and Methods . Thousand Oaks, CA: Sage. [ Google Scholar ]
• Zimmer L. (2006). Qualitative meta-synthesis: a question of dialoguing with texts . J. Adv. Nurs. 53 , 311–318. 10.1111/j.1365-2648.2006.03721.x [ PubMed ] [ CrossRef ] [ Google Scholar ]

Writing a Counselling Case Study

As a counselling student, you may feel daunted when faced with writing your first counselling case study. Most training courses that qualify you as a counsellor or psychotherapist require you to complete case studies.

Before You Start Writing a Case Study

However good your case study, you won’t pass if you don’t meet the criteria set by your awarding body. So before you start writing, always check this, making sure that you have understood what is required.

For example, the ABC Level 4 Diploma in Therapeutic Counselling requires you to write two case studies as part of your external portfolio, to meet the following criteria:

• 4.2 Analyse the application of your own theoretical approach to your work with one client over a minimum of six sessions.
• 4.3 Evaluate the application of your own theoretical approach to your work with this client over a minimum of six sessions.
• 5.1 Analyse the learning gained from a minimum of two supervision sessions in relation to your work with one client.
• 5.2 Evaluate how this learning informed your work with this client over a minimum of two counselling sessions.

If you don’t meet these criteria exactly – for example, if you didn’t choose a client who you’d seen for enough sessions, if you described only one (rather than two) supervision sessions, or if you used the same client for both case studies – then you would get referred.

Check whether any more information is available on what your awarding body is looking for – e.g. ABC publishes regular ‘counselling exam summaries’ on its website; these provide valuable information on where recent students have gone wrong.

Selecting the Client

When you reflect on all the clients you have seen during training, you will no doubt realise that some clients are better suited to specific case studies than others. For example, you might have a client to whom you could easily apply your theoretical approach, and another where you gained real breakthroughs following your learning in supervision. These are good ones to choose.

Opening the Case Study

It’s usual to start your case study with a ‘pen portrait’ of the client – e.g. giving their age, gender and presenting issue. You might also like to describe how they seemed (in terms of both what they said and their body language) as they first entered the counselling room and during contracting.

If your agency uses assessment tools (e.g. CORE-10, WEMWBS, GAD-7, PHQ-9 etc.), you could say what your client scored at the start of therapy.

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Writing a Case Study: 5 Tips

Describing the Client’s Counselling Journey

This is the part of the case study that varies greatly depending on what is required by the awarding body. Two common types of case study look at application of theory, and application of learning from supervision. Other possible types might examine ethics or self-awareness.

Theory-Based Case Studies

If you were doing the ABC Diploma mentioned above, then 4.1 would require you to break down the key concepts of the theoretical approach and examine each part in detail as it relates to practice. For example, in the case of congruence, you would need to explain why and how you used it with the client, and the result of this.

Meanwhile, 4.2 – the second part of this theory-based case study – would require you to assess the value and effectiveness of all the key concepts as you applied them to the same client, substantiating this with specific reasons. For example, you would continue with how effective and important congruence was in terms of the theoretical approach in practice, supporting this with reasoning.

In both, it would be important to structure the case study chronologically – that is, showing the flow of the counselling through at least six sessions rather than using the key concepts as headings.

Supervision-Based Case Studies

When writing supervision-based case studies (as required by ABC in their criteria 5.1 and 5.2, for example), it can be useful to use David Kolb’s learning cycle, which breaks down learning into four elements: concrete experience, reflective observation, abstract conceptualisation and active experimentation.

Rory Lees-Oakes has written a detailed guide on writing supervision case studies – entitled How to Analyse Supervision Case Studies. This is available to members of the Counselling Study Resource (CSR).

Closing Your Case Study

In conclusion, you could explain how the course of sessions ended, giving the client’s closing score (if applicable). You could also reflect on your own learning, and how you might approach things differently in future.

Henry Gustav Molaison: The Curious Case of Patient H.M. 

Erin Heaning

Clinical Safety Strategist at Bristol Myers Squibb

Psychology Graduate, Princeton University

Erin Heaning, a holder of a BA (Hons) in Psychology from Princeton University, has experienced as a research assistant at the Princeton Baby Lab.

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Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

On This Page:

Henry Gustav Molaison, known as Patient H.M., is a landmark case study in psychology. After a surgery to alleviate severe epilepsy, which removed large portions of his hippocampus , he was left with anterograde amnesia , unable to form new explicit memories , thus offering crucial insights into the role of the hippocampus in memory formation.

• Henry Gustav Molaison (often referred to as H.M.) is a famous case of anterograde and retrograde amnesia in psychology.
• H. M. underwent brain surgery to remove his hippocampus and amygdala to control his seizures. As a result of his surgery, H.M.’s seizures decreased, but he could no longer form new memories or remember the prior 11 years of his life.
• He lost his ability to form many types of new memories (anterograde amnesia), such as new facts or faces, and the surgery also caused retrograde amnesia as he was able to recall childhood events but lost the ability to recall experiences a few years before his surgery.
• The case of H.M. and his life-long participation in studies gave researchers valuable insight into how memory functions and is organized in the brain. He is considered one of the most studied medical and psychological history cases.

Who is H.M.?

Henry Gustav Molaison, or “H.M” as he is commonly referred to by psychology and neuroscience textbooks, lost his memory on an operating table in 1953.

For years before his neurosurgery, H.M. suffered from epileptic seizures believed to be caused by a bicycle accident that occurred in his childhood. The seizures started out as minor at age ten, but they developed in severity when H.M. was a teenager.

Continuing to worsen in severity throughout his young adulthood, H.M. was eventually too disabled to work. Throughout this period, treatments continued to turn out unsuccessful, and epilepsy proved a major handicap and strain on H.M.’s quality of life.

And so, at age 27, H.M. agreed to undergo a radical surgery that would involve removing a part of his brain called the hippocampus — the region believed to be the source of his epileptic seizures (Squire, 2009).

For epilepsy patients, brain resection surgery refers to removing small portions of brain tissue responsible for causing seizures. Although resection is still a surgical procedure used today to treat epilepsy, the use of lasers and detailed brain scans help ensure valuable brain regions are not impacted.

In 1953, H.M.’s neurosurgeon did not have these tools, nor was he or the rest of the scientific or medical community fully aware of the true function of the hippocampus and its specific role in memory. In one regard, the surgery was successful, as H.M. did, in fact, experience fewer seizures.

However, family and doctors soon noticed he also suffered from severe amnesia, which persisted well past when he should have recovered. In addition to struggling to remember the years leading up to his surgery, H.M. also had gaps in his memory of the 11 years prior.

Furthermore, he lacked the ability to form new memories — causing him to perpetually live an existence of moment-to-moment forgetfulness for decades to come.

In one famous quote, he famously and somberly described his state as “like waking from a dream…. every day is alone in itself” (Squire et al., 2009).

H.M. soon became a major case study of interest for psychologists and neuroscientists who studied his memory deficits and cognitive abilities to better understand the hippocampus and its function.

When H.M. died on December 2, 2008, at the age of 82, he left behind a lifelong legacy of scientific contribution.

Surgical Procedure

Neurosurgeon William Beecher Scoville performed H.M.’s surgery in Hartford, Connecticut, in August 1953 when H.M. was 27 years old.

During the procedure, Scoville removed parts of H.M.’s temporal lobe which refers to the portion of the brain that sits behind both ears and is associated with auditory and memory processing.

More specifically, the surgery involved what was called a “partial medial temporal lobe resection” (Scoville & Milner, 1957). In this resection, Scoville removed 8 cm of brain tissue from the hippocampus — a seahorse-shaped structure located deep in the temporal lobe .

Bilateral resection of the anterior temporal lobe in patient HM.

Further research conducted after this removal showed Scoville also probably destroyed the brain structures known as the “uncus” (theorized to play a role in the sense of smell and forming new memories) and the “amygdala” (theorized to play a crucial role in controlling our emotional responses such as fear and sadness).

As previously mentioned, the removal surgery partially reduced H.M.’s seizures; however, he also lost the ability to form new memories.

At the time, Scoville’s experimental procedure had previously only been performed on patients with psychosis, so H.M. was the first epileptic patient and showed no sign of mental illness. In the original case study of H.M., which is discussed in further detail below, nine of Scoville’s patients from this experimental surgery were described.

However, because these patients had disorders such as schizophrenia, their symptoms were not removed after surgery. In this regard, H.M. was the only patient with “clean” amnesia along with no other apparent mental problems.

H.M’s Amnesia

H.M.’s apparent amnesia after waking from surgery presented in multiple forms. For starters, H.M. suffered from retrograde amnesia for the 11-year period prior to his surgery.

Retrograde describes amnesia, where you can’t recall memories that were formed before the event that caused the amnesia. Important to note, current research theorizes that H.M.’s retrograde amnesia was not actually caused by the loss of his hippocampus, but rather from a combination of antiepileptic drugs and frequent seizures prior to his surgery (Shrader 2012).

In contrast, H.M.’s inability to form new memories after his operation, known as anterograde amnesia, was the result of the loss of the hippocampus.

This meant that H.M. could not learn new words, facts, or faces after his surgery, and he would even forget who he was talking to the moment he walked away.

However, H.M. could perform tasks, and he could even perform those tasks easier after practice. This important finding represented a major scientific discovery when it comes to memory and the hippocampus. The memory that H.M. was missing in his life included the recall of facts, life events, and other experiences.

This type of long-term memory is referred to as “explicit” or “ declarative ” memories and they require conscious thinking.

In contrast, H.M.’s ability to improve in tasks after practice (even if he didn’t recall that practice) showed his “implicit” or “ procedural ” memory remained intact (Scoville & Milner, 1957). This type of long-term memory is unconscious, and examples include riding a bike, brushing your teeth, or typing on a keyboard.

Most importantly, after removing his hippocampus, H.M. lost his explicit memory but not his implicit memory — establishing that implicit memory must be controlled by some other area of the brain and not the hippocampus.

After the severity of the side effects of H.M.’s operation became clear, H.M. was referred to neurosurgeon Dr. Wilder Penfield and neuropsychologist Dr. Brenda Milner of Montreal Neurological Institute (MNI) for further testing.

As discussed, H.M. was not the only patient who underwent this experimental surgery, but he was the only non-psychotic patient with such a degree of memory impairment. As a result, he became a major study and interest for Milner and the rest of the scientific community.

Since Penfield and Milner had already been conducting memory experiments on other patients at the time, they quickly realized H.M.’s “dense amnesia, intact intelligence, and precise neurosurgical lesions made him a perfect experimental subject” (Shrader 2012).

Milner continued to conduct cognitive testing on H.M. for the next fifty years, primarily at the Massachusetts Institute of Technology (MIT). Her longitudinal case study of H.M.’s amnesia quickly became a sensation and is still one of the most widely-cited psychology studies.

In publishing her work, she protected Henry’s identity by first referring to him as the patient H.M. (Shrader 2012).

In the famous “star tracing task,” Milner tested if H.M.’s procedural memory was affected by the removal of the hippocampus during surgery.

In this task, H.M. had to trace an outline of a star, but he could only trace the star based on the mirrored reflection. H.M. then repeated this task once a day over a period of multiple days.

Over the course of these multiple days, Milner observed that H.M. performed the test faster and with fewer errors after continued practice. Although each time he performed the task, he had no memory of having participated in the task before, his performance improved immensely (Shrader 2012).

As this task showed, H.M. had lost his declarative/explicit memory, but his unconscious procedural/implicit memory remained intact. Given the damage to his hippocampus in surgery, researchers concluded from tasks such as these that the hippocampus must play a role in declarative but not procedural memory.

Therefore, procedural memory must be localized somewhere else in the brain and not in the hippocampus.

H.M’s Legacy

Milner’s and hundreds of other researchers’ work with H.M. established fundamental principles about how memory functions and is organized in the brain.

Without the contribution of H.M. in volunteering the study of his mind to science, our knowledge today regarding the separation of memory function in the brain would certainly not be as strong.

Until H.M.’s watershed surgery, it was not known that the hippocampus was essential for making memories and that if we lost this valuable part of our brain, we would be forced to live only in the moment-to-moment constraints of our short-term memory .

Once this was realized, the findings regarding H.M. were widely publicized so that this operation to remove the hippocampus would never be done again (Shrader 2012).

H.M.’s case study represents a historical time period for neuroscience in which most brain research and findings were the result of brain dissections, lesioning certain sections, and seeing how different experimental procedures impacted different patients.

Therefore, it is paramount we recognize the contribution of patients like H.M., who underwent these dangerous operations in the mid-twentieth century and then went on to allow researchers to study them for the rest of their lives.

Even after his death, H.M. donated his brain to science. Researchers then took his unique brain, froze it, and then in a 53-hour procedure, sliced it into 2,401 slices which were then individually photographed and digitized as a three-dimensional map.

Through this map, H.M.’s brain could be preserved for posterity (Wb et al., 2014). As neuroscience researcher Suzanne Corkin once said it best, “H.M. was a pleasant, engaging, docile man with a keen sense of humor, who knew he had a poor memory but accepted his fate.

There was a man behind the data. Henry often told me that he hoped that research into his condition would help others live better lives. He would have been proud to know how much his tragedy has benefitted science and medicine” (Corkin, 2014).

Corkin, S. (2014). Permanent present tense: The man with no memory and what he taught the world. Penguin Books.

Hardt, O., Einarsson, E. Ö., & Nader, K. (2010). A bridge over troubled water: Reconsolidation as a link between cognitive and neuroscientific memory research traditions. Annual Review of Psychology, 61, 141–167.

Scoville, W. B., & Milner, B. (1957). Loss of recent memory after bilateral hippocampal lesions . Journal of neurology, neurosurgery, and psychiatry, 20 (1), 11.

Shrader, J. (2012, January). HM, the man with no memory | Psychology Today. Retrieved from, https://www.psychologytoday.com/us/blog/trouble-in-mind/201201/hm-the-man-no-memory

Squire, L. R. (2009). The legacy of patient H. M. for neuroscience . Neuron, 61 , 6–9.

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