case study for cognitive approach

Cognitive Approach in Psychology

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.

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Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

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Cognitive psychology is the scientific study of the mind as an information processor. It concerns how we take in information from the outside world, and how we make sense of that information.

Cognitive psychology studies mental processes, including how people perceive, think, remember, learn, solve problems, and make decisions.

Cognitive psychologists try to build cognitive models of the information processing that occurs inside people’s minds, including perception, attention, language, memory, thinking, and consciousness.

Cognitive psychology became of great importance in the mid-1950s. Several factors were important in this:

• Dissatisfaction with the behaviorist approach in its simple emphasis on external behavior rather than internal processes.
• The development of better experimental methods.
• Comparison between human and computer processing of information . Using computers allowed psychologists to try to understand the complexities of human cognition by comparing it with computers and artificial intelligence.

The emphasis of psychology shifted away from the study of conditioned behavior and psychoanalytical notions about the study of the mind, towards the understanding of human information processing using strict and rigorous laboratory investigation.

Summary Table

Theoretical Assumptions

Mediational processes occur between stimulus and response:

The behaviorist approach only studies external observable (stimulus and response) behavior that can be objectively measured.

They believe that internal behavior cannot be studied because we cannot see what happens in a person’s mind (and therefore cannot objectively measure it).

However, cognitive psychologists consider it essential to examine an organism’s mental processes and how these influence behavior.

Cognitive psychology assumes a mediational process occurs between stimulus/input and response/output. 

These are mediational processes because they mediate (i.e., go-between) between the stimulus and the response. They come after the stimulus and before the response.

Instead of the simple stimulus-response links proposed by behaviorism, the mediational processes of the organism are essential to understand.

Without this understanding, psychologists cannot have a complete understanding of behavior.

The mediational (i.e., mental) event could be memory , perception , attention or problem-solving, etc. 

• Perception : how we process and interpret sensory information.
• Attention : how we selectively focus on certain aspects of our environment.
• Memory : how we encode, store, and retrieve information.
• Language : how we acquire, comprehend, and produce language.
• Problem-solving and decision-making : how we reason, make judgments, and solve problems.
• Schemas : Cognitive psychologists assume that people’s prior knowledge, beliefs, and experiences shape their mental processes. 

For example, the cognitive approach suggests that problem gambling results from maladaptive thinking and faulty cognitions, which both result in illogical errors.

Gamblers misjudge the amount of skill involved with ‘chance’ games, so they are likely to participate with the mindset that the odds are in their favour and that they may have a good chance of winning.

Therefore, cognitive psychologists say that if you want to understand behavior, you must understand these mediational processes.

Psychology should be seen as a science:

This assumption is based on the idea that although not directly observable, the mind can be investigated using objective and rigorous methods, similar to how other sciences study natural phenomena. 

Controlled experiments

The cognitive approach believes that internal mental behavior can be scientifically studied using controlled experiments . It uses the results of its investigations to make inferences about mental processes.  Cognitive psychology uses highly controlled laboratory experiments to avoid the influence of extraneous variables . This allows the researcher to establish a causal relationship between the independent and dependent variables. These controlled experiments are replicable, and the data obtained is objective (not influenced by an individual’s judgment or opinion) and measurable. This gives psychology more credibility.

Operational definitions

Cognitive psychologists develop operational definitions to study mental processes scientifically. These definitions specify how abstract concepts, such as attention or memory, can be measured and quantified (e.g., verbal protocols of thinking aloud). This allows for reliable and replicable research findings.

Falsifiability

Falsifiability in psychology refers to the ability to disprove a theory or hypothesis through empirical observation or experimentation. If a claim is not falsifiable, it is considered unscientific.

Cognitive psychologists aim to develop falsifiable theories and models, meaning they can be tested and potentially disproven by empirical evidence.

This commitment to falsifiability helps to distinguish scientific theories from pseudoscientific or unfalsifiable claims.

Empirical evidence

Cognitive psychologists rely on empirical evidence to support their theories and models. They collect data through various methods, such as experiments, observations, and questionnaires, to test hypotheses and draw conclusions about mental processes.

Cognitive psychologists assume that mental processes are not random but are organized and structured in specific ways. They seek to identify the underlying cognitive structures and processes that enable people to perceive, remember, and think.

Cognitive psychologists have made significant contributions to our understanding of mental processes and have developed various theories and models, such as the multi-store model of memory , the working memory model , and the dual-process theory of thinking.

Humans are information processors:

The idea of information processing was adopted by cognitive psychologists as a model of how human thought works.

The information processing approach is based on several assumptions, including:

• Information is processed by a series of systems : The information processing approach proposes that a series of cognitive systems, such as attention, perception, and memory, process information from the environment. Each system plays a specific role in processing the information and passing it along to the next stage.
• Processing systems transform information : As information passes through these cognitive systems, it is transformed or modified in systematic ways. For example, incoming sensory information may be filtered by attention, encoded into memory, or used to update existing knowledge structures.
• Research aims to specify underlying processes and structures : The primary goal of research within the information processing approach is to identify, describe, and understand the specific cognitive processes and mental structures that underlie various aspects of cognitive performance, such as learning, problem-solving, and decision-making.
• Human information processing resembles computer processing : The information processing approach draws an analogy between human cognition and computer processing. Just as computers take in information, process it according to specific algorithms, and produce outputs, the human mind is thought to engage in similar processes of input, processing, and output.

Computer-Mind Analogy

The computer-brain metaphor, or the information processing approach, is a significant concept in cognitive psychology that likens the human brain’s functioning to that of a computer.

This metaphor suggests that the brain, like a computer, processes information through a series of linear steps, including input, storage, processing, and output.

According to this assumption, when we interact with the environment, we take in information through our senses (input).

This information is then processed by various cognitive systems, such as perception, attention, and memory. These systems work together to make sense of the input, organize it, and store it for later use.

During the processing stage, the mind performs operations on the information, such as encoding, transforming, and combining it with previously stored knowledge. This processing can involve various cognitive processes, such as thinking, reasoning, problem-solving, and decision-making.

The processed information can then be used to generate outputs, such as actions, decisions, or new ideas. These outputs are based on the information that has been processed and the individual’s goals and motivations.

This has led to models showing information flowing through the cognitive system, such as the multi-store memory model.

The information processing approach also assumes that the mind has a limited capacity for processing information, similar to a computer’s memory and processing limitations.

This means that humans can only attend to and process a certain amount of information at a given time, and that cognitive processes can be slowed down or impaired when the mind is overloaded.

The Role of Schemas

A schema is a “packet of information” or cognitive framework that helps us organize and interpret information. It is based on previous experience.

Cognitive psychologists assume that people’s prior knowledge, beliefs, and experiences shape their mental processes. They investigate how these factors influence perception, attention, memory, and thinking.

Schemas help us interpret incoming information quickly and effectively, preventing us from being overwhelmed by the vast amount of information we perceive in our environment.

Schemas can often affect cognitive processing (a mental framework of beliefs and expectations developed from experience). As people age, they become more detailed and sophisticated.

However, it can also lead to distortion of this information as we select and interpret environmental stimuli using schemas that might not be relevant.

This could be the cause of inaccuracies in areas such as eyewitness testimony. It can also explain some errors we make when perceiving optical illusions.

1. Behaviorist Critique

B.F. Skinner criticizes the cognitive approach. He believes that only external stimulus-response behavior should be studied, as this can be scientifically measured.

Therefore, mediation processes (between stimulus and response) do not exist as they cannot be seen and measured.

Behaviorism assumes that people are born a blank slate (tabula rasa) and are not born with cognitive functions like schemas , memory or perception .

Due to its subjective and unscientific nature, Skinner continues to find problems with cognitive research methods, namely introspection (as used by Wilhelm Wundt).

2. Complexity of mental experiences

Mental processes are highly complex and multifaceted, involving a wide range of cognitive, affective, and motivational factors that interact in intricate ways.

The complexity of mental experiences makes it difficult to isolate and study specific mental processes in a controlled manner.

Mental processes are often influenced by individual differences, such as personality, culture, and past experiences, which can introduce variability and confounds in research .

3. Experimental Methods 

While controlled experiments are the gold standard in cognitive psychology research, they may not always capture real-world mental processes’ complexity and ecological validity.

Some mental processes, such as creativity or decision-making in complex situations, may be difficult to study in laboratory settings.

Humanistic psychologist Carl Rogers believes that using laboratory experiments by cognitive psychology has low ecological validity and creates an artificial environment due to the control over variables .

Rogers emphasizes a more holistic approach to understanding behavior.

The cognitive approach uses a very scientific method that is controlled and replicable, so the results are reliable.

However, experiments lack ecological validity because of the artificiality of the tasks and environment, so they might not reflect the way people process information in their everyday lives.

For example, Baddeley (1966) used lists of words to find out the encoding used by LTM.

However, these words had no meaning to the participants, so the way they used their memory in this task was probably very different from what they would have done if the words had meaning for them.

This is a weakness, as the theories might not explain how memory works outside the laboratory.

4. Computer Analogy

The information processing paradigm of cognitive psychology views the minds in terms of a computer when processing information.

However, although there are similarities between the human mind and the operations of a computer (inputs and outputs, storage systems, and the use of a central processor), the computer analogy has been criticized.

For example, the human mind is characterized by consciousness, subjective experience, and self-awareness , which are not present in computers.

Computers do not have feelings, emotions, or a sense of self, which play crucial roles in human cognition and behavior.

The brain-computer metaphor is often used implicitly in neuroscience literature through terms like “sensory computation,” “algorithms,” and “neural codes.” However, it is difficult to identify these concepts in the actual brain.

5. Reductionist

The cognitive approach is reductionist as it does not consider emotions and motivation, which influence the processing of information and memory. For example, according to the Yerkes-Dodson law , anxiety can influence our memory.

Such machine reductionism (simplicity) ignores the influence of human emotion and motivation on the cognitive system and how this may affect our ability to process information.

Early theories of cognitive approach did not always recognize physical ( biological psychology ) and environmental (behaviorist approach) factors in determining behavior.

However, it’s important to note that modern cognitive psychology has evolved to incorporate a more holistic understanding of human cognition and behavior.

1. Importance of cognitive factors versus external events

Cognitive psychology emphasizes the role of internal cognitive processes in shaping emotional experiences, rather than solely focusing on external events.

Beck’s cognitive theory suggests that it is not the external events themselves that lead to depression, but rather the way an individual interprets and processes those events through their negative schemas.

This highlights the importance of addressing cognitive factors in the treatment of depression and other mental health issues.

Social exchange theory (Thibaut & Kelly, 1959) emphasizes that relationships are formed through internal mental processes, such as decision-making, rather than solely based on external factors.

The computer analogy can be applied to this concept, where individuals observe behaviors (input), process the costs and benefits (processing), and then make a decision about the relationship (output).

2. Interdisciplinary approach

While early cognitive psychology may have neglected physical and environmental factors, contemporary cognitive psychology has increasingly integrated insights from other approaches.

Cognitive psychology draws on methods and findings from other scientific disciplines, such as neuroscience , computer science, and linguistics, to inform their understanding of mental processes.

This interdisciplinary approach strengthens the scientific basis of cognitive psychology.

Cognitive psychology has influenced and integrated with many other approaches and areas of study to produce, for example, social learning theory , cognitive neuropsychology, and artificial intelligence (AI).

3. Real World Applications

Another strength is that the research conducted in this area of psychology very often has applications in the real world.

By highlighting the importance of cognitive processing, the cognitive approach can explain mental disorders such as depression.

Beck’s cognitive theory of depression argues that negative schemas about the self, the world, and the future are central to the development and maintenance of depression.

These negative schemas lead to biased processing of information, selective attention to negative aspects of experience, and distorted interpretations of events, which perpetuate the depressive state.

By identifying the role of cognitive processes in mental disorders, cognitive psychology has informed the development of targeted interventions.

Cognitive behavioral therapy aims to modify the maladaptive thought patterns and beliefs that underlie emotional distress, helping individuals to develop more balanced and adaptive ways of thinking.

CBT’s basis is to change how people process their thoughts to make them more rational or positive.

Through techniques such as cognitive restructuring, behavioral experiments, and guided discovery, CBT helps individuals to challenge and change their negative schemas, leading to improvements in mood and functioning.

Cognitive behavioral therapy (CBT) has been very effective in treating depression (Hollon & Beck, 1994), and moderately effective for anxiety problems (Beck, 1993). 

Issues and Debates

Free will vs. determinism.

The cognitive approach’s position is unclear. It argues that cognitive processes are influenced by experiences and schemas, which implies a degree of determinism.

On the other hand, cognitive-behavioral therapy (CBT) operates on the premise that individuals can change their thought patterns, suggesting a capacity for free will.

Nature vs. Nurture

The cognitive approach takes an interactionist view of the debate, acknowledging the influence of both nature and nurture on cognitive processes.

It recognizes that while some cognitive abilities, such as language acquisition, may have an innate component (nature), experiences and learning (nurture) also shape the way information is processed.

Holism vs. Reductionism

The cognitive approach tends to be reductionist in its methodology, as it often studies cognitive processes in isolation.

For example, researchers may focus on memory processes without considering the influence of other cognitive functions or environmental factors.

While this approach allows for more controlled study, it may lack ecological validity, as in real life, cognitive processes typically interact and function simultaneously.

Idiographic vs. Nomothetic

The cognitive approach is primarily nomothetic, as it seeks to establish general principles and theories of information processing that apply to all individuals.

It aims to identify universal patterns and mechanisms of cognition rather than focusing on individual differences.

History of Cognitive Psychology

• Wolfgang Köhler (1925) – Köhler’s book “The Mentality of Apes” challenged the behaviorist view by suggesting that animals could display insightful behavior, leading to the development of Gestalt psychology.
• Norbert Wiener (1948) – Wiener’s book “Cybernetics” introduced concepts such as input and output, which influenced the development of information processing models in cognitive psychology.
• Edward Tolman (1948) – Tolman’s work on cognitive maps in rats demonstrated that animals have an internal representation of their environment, challenging the behaviorist view.
• George Miller (1956) – Miller’s paper “The Magical Number 7 Plus or Minus 2” proposed that short-term memory has a limited capacity of around seven chunks of information, which became a foundational concept in cognitive psychology.
• Allen Newell and Herbert A. Simon (1972) – Newell and Simon developed the General Problem Solver, a computer program that simulated human problem-solving, contributing to the growth of artificial intelligence and cognitive modeling.
• George Miller and Jerome Bruner (1960) – Miller and Bruner established the Center for Cognitive Studies at Harvard, which played a significant role in the development of cognitive psychology as a distinct field.
• Ulric Neisser (1967) – Neisser’s book “Cognitive Psychology” formally established cognitive psychology as a separate area of study, focusing on mental processes such as perception, memory, and thinking.
• Richard Atkinson and Richard Shiffrin (1968) – Atkinson and Shiffrin proposed the Multi-Store Model of memory, which divided memory into sensory, short-term, and long-term stores, becoming a key model in the study of memory.
• Eleanor Rosch’s (1970s) research on natural categories and prototypes, which influenced the study of concept formation and categorization.
• Endel Tulving’s (1972) distinction between episodic and semantic memory, which further developed the understanding of long-term memory.
• Baddeley and Hitch’s (1974) proposal of the Working Memory Model, which expanded on the concept of short-term memory and introduced the idea of a central executive.
• Marvin Minsky’s (1975) framework of frames in artificial intelligence, which influenced the understanding of knowledge representation in cognitive psychology.
• David Rumelhart and Andrew Ortony’s (1977) work on schema theory, which described how knowledge is organized and used for understanding and remembering information.
• Amos Tversky and Daniel Kahneman’s (1970s-80s) research on heuristics and biases in decision making, which led to the development of behavioral economics and the study of judgment and decision-making.
• David Marr’s (1982) computational theory of vision, which provided a framework for understanding visual perception and influenced the field of computational cognitive science.
• The development of connectionism and parallel distributed processing (PDP) models in the 1980s, which provided an alternative to traditional symbolic models of cognitive processes.
• Noam Chomsky’s (1980s) theory of Universal Grammar and the language acquisition device, which influenced the study of language and cognitive development.
• The emergence of cognitive neuroscience in the 1990s, which combined techniques from cognitive psychology, neuroscience, and computer science to study the neural basis of cognitive processes.

Atkinson, R. C., & Shiffrin, R. M. (1968). Chapter: Human memory: A proposed system and its control processes. In Spence, K. W., & Spence, J. T. The psychology of learning and motivation (Volume 2). New York: Academic Press. pp. 89–195.

Baddeley, A. D., & Hitch, G. (1974). Working memory. In G. H. Bower (Ed.), The Psychology of Learning and Motivation: Advances in Research and Theory (Vol. 8, pp. 47-89). Academic Press.

Beck, A. T, & Steer, R. A. (1993). Beck Anxiety Inventory Manual. San Antonio: Harcourt Brace and Company.

Chomsky, N. (1986). Knowledge of Language: Its Nature, Origin, and Use . Praeger.

Gazzaniga, M. S. (Ed.). (1995). The Cognitive Neurosciences. MIT Press.

Hollon, S. D., & Beck, A. T. (1994). Cognitive and cognitive-behavioral therapies. In A. E. Bergin & S.L. Garfield (Eds.), Handbook of psychotherapy and behavior change (pp. 428—466) . New York: Wiley.

Köhler, W. (1925). An aspect of Gestalt psychology. The Pedagogical Seminary and Journal of Genetic Psychology, 32(4) , 691-723.

Marr, D. (1982). Vision: A Computational Investigation into the Human Representation and Processing of Visual Information . W. H. Freeman.

Miller, G. A. (1956). The magical number seven, plus or minus two: some limits on our capacity for processing information. Psychological Review , 63 (2): 81–97.

Minsky, M. (1975). A framework for representing knowledge. In P. H. Winston (Ed.), The Psychology of Computer Vision (pp. 211-277). McGraw-Hill.

Neisser, U (1967). Cognitive psychology . Appleton-Century-Crofts: New York

Newell, A., & Simon, H. (1972). Human problem solving . Prentice-Hall.

Rosch, E. H. (1973). Natural categories. Cognitive Psychology, 4 (3), 328-350.

Rumelhart, D. E., & McClelland, J. L. (1986). Parallel Distributed Processing: Explorations in the Microstructure of Cognition. Volume 1: Foundations. MIT Press.

Rumelhart, D. E., & Ortony, A. (1977). The representation of knowledge in memory. In R. C. Anderson, R. J. Spiro, & W. E. Montague (Eds.), Schooling and the Acquisition of Knowledge (pp. 99-135). Erlbaum.

Tversky, A., & Kahneman, D. (1974). Judgment under uncertainty: Heuristics and biases. Science, 185 (4157), 1124-1131.

Thibaut, J., & Kelley, H. H. (1959). The social psychology of groups . New York: Wiley.

Tolman, E. C., Hall, C. S., & Bretnall, E. P. (1932). A disproof of the law of effect and a substitution of the laws of emphasis, motivation and disruption. Journal of Experimental Psychology, 15(6) , 601.

Tolman E. C. (1948). Cognitive maps in rats and men . Psychological Review. 55, 189–208

Tulving, E. (1972). Episodic and semantic memory. In E. Tulving & W. Donaldson (Eds.), Organization of Memory (pp. 381-403). Academic Press.

Wiener, N. (1948). Cybernetics or control and communication in the animal and the machine . Paris, (Hermann & Cie) & Camb. Mass. (MIT Press).

Further Reading

• Why Your Brain is Not a Computer
• Cognitive Psychology Historial Development

• Abnormal Psychology
• Assessment (IB)
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• Cognitive Psychology
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• Developmental Psychology
• Extended Essay
• General Interest
• Health Psychology
• Human Relationships
• IB Psychology
• IB Psychology HL Extensions
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• Love and Marriage
• Post-Traumatic Stress Disorder
• Prejudice and Discrimination
• Qualitative Research Methods
• Research Methodology
• Revision and Exam Preparation
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• Studies and Theories
• Teaching Ideas

Key Study: HM’s case study (Milner and Scoville, 1957)

Travis Dixon January 29, 2019 Biological Psychology , Cognitive Psychology , Key Studies

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HM’s case study is one of the most famous and important case studies in psychology, especially in cognitive psychology. It was the source of groundbreaking new knowledge on the role of the hippocampus in memory. 

Background Info

“Localization of function in the brain” means that different parts of the brain have different functions. Researchers have discovered this from over 100 years of research into the ways the brain works. One such study was Milner’s case study on Henry Molaison.

The memory problems that HM experienced after the removal of his hippocampus provided new knowledge on the role of the hippocampus in memory formation (image: wikicommons)

At the time of the first study by Milner, HM was 29 years old. He was a mechanic who had suffered from minor epileptic seizures from when he was ten years old and began suffering severe seizures as a teenager. These may have been a result of a bike accident when he was nine. His seizures were getting worse in severity, which resulted in HM being unable to work. Treatment for his epilepsy had been unsuccessful, so at the age of 27 HM (and his family) agreed to undergo a radical surgery that would remove a part of his brain called the hippocampus . Previous research suggested that this could help reduce his seizures, but the impact it had on his memory was unexpected. The Doctor performing the radical surgery believed it was justified because of the seriousness of his seizures and the failures of other methods to treat them.

Methods and Results

In one regard, the surgery was successful as it resulted in HM experiencing less seizures. However, immediately after the surgery, the hospital staff and HM’s family noticed that he was suffering from anterograde amnesia (an inability to form new memories after the time of damage to the brain):

Here are some examples of his memory loss described in the case study:

• He could remember something if he concentrated on it, but if he broke his concentration it was lost.
• After the surgery the family moved houses. They stayed on the same street, but a few blocks away. The family noticed that HM as incapable of remembering the new address, but could remember the old one perfectly well. He could also not find his way home alone.
• He could not find objects around the house, even if they never changed locations and he had used them recently. His mother had to always show him where the lawnmower was in the garage.
• He would do the same jigsaw puzzles or read the same magazines every day, without ever apparently getting bored and realising he had read them before. (HM loved to do crossword puzzles and thought they helped him to remember words).
• He once ate lunch in front of Milner but 30 minutes later was unable to say what he had eaten, or remember even eating any lunch at all.
• When interviewed almost two years after the surgery in 1955, HM gave the date as 1953 and said his age was 27. He talked constantly about events from his childhood and could not remember details of his surgery.

Later testing also showed that he had suffered some partial retrograde amnesia (an inability to recall memories from before the time of damage to the brain). For instance, he could not remember that one of his favourite uncles passed away three years prior to his surgery or any of his time spent in hospital for his surgery. He could, however, remember some unimportant events that occurred just before his admission to the hospital.

Brenda Milner studied HM for almost 50 years – but he never remembered her.

Results continued…

His memories from events prior to 1950 (three years before his surgery), however, were fine. There was also no observable difference to his personality or to his intelligence. In fact, he scored 112 points on his IQ after the surgery, compared with 104 previously. The IQ test suggested that his ability in arithmetic had apparently improved. It seemed that the only behaviour that was affected by the removal of the hippocampus was his memory. HM was described as a kind and gentle person and this did not change after his surgery.

The Star Tracing Task

In a follow up study, Milner designed a task that would test whether or not HMs procedural memory had been affected by the surgery. He was to trace an outline of a star, but he could only see the mirrored reflection. He did this once a day over a period of a few days and Milner observed that he became faster and faster. Each time he performed the task he had no memory of ever having done it before, but his performance kept improving. This is further evidence for localization of function – the hippocampus must play a role in declarative (explicit) memory but not procedural (implicit) memory.

Cognitive psychologists have categorized memories into different types. HM’s study suggests that the hippocampus is essential for explicit (conscious) and declarative memory, but not implicit (unconscious) procedural memory.

Was his memory 100% gone? Another follow-up study

Interestingly, HM showed signs of being able to remember famous people who had only become famous after his surgery, like Lee Harvey Oswald (who assassinated JFK in 1963). (Image: wikicommons)

Another fascinating follow-up study was conducted by two researchers who wanted to see if HM had learned anything about celebrities that became famous after his surgery. At first they tested his knowledge of celebrities from before his surgery, and he knew these just as well as controls. They then showed him two names at a time, one a famous name (e.g. Liza Minelli, Lee Harvey Oswald) and the other was a name randomly taken from the phonebook. He was asked to choose the famous name and he was correct on a significant number of trials (i.e. the statistics tests suggest he wasn’t just guessing). Even more incredible was that he remembered some details about these people when asked why they were famous. For example, he could remember that Lee Harvey Oswald assassinated the president. One explanation given for the memory of these facts is that there was an emotional component. E.g. He liked these people, or the assassination was so violent, that he could remember a few details. 

HM became a hugely important case study for neuro and cognitive Psychologists. He was interviewed and tested by over 100 psychologists during the 53 years after his operation. Directly after his surgery, he lived at home with his parents as he was unable to live independently. He moved to a nursing home in 1980 and stayed there until his death in 2008. HM donated his brain to science and it was sliced into 2,401 thin slices that will be scanned and published electronically.

Critical Thinking Considerations

• How does this case study demonstrate localization of function in the brain? (e.g.c reating new long-term memories; procedural memories; storing and retrieving long term memories; intelligence; personality) ( Application )
• What are the ethical considerations involved in this study? ( Analysis )
• What are the strengths and limitations of this case study? ( Evaluation )
• Why would ongoing studies of HM be important? (Think about memory, neuroplasticity and neurogenesis) ( Analysis/Synthesis/Evaluation )
• How can findings from this case study be used to support and/or challenge the Multi-store Model of Memory? ( Application / Synthesis/Evaluation )

Exam Tips This study can be used for the following topics: Localization – the role of the hippocampus in memory Techniques to study the brain – MRI has been used to find out the exact location and size of damage to HM’s brain Bio and cognitive approach research method s – case study Bio and cognitive approach ethical considerations – anonymity Emotion and cognition – the follow-up study on HM and memories of famous people could be used in an essay to support the idea that emotion affects memory Models of memory – the multi-store model : HM’s study provides evidence for the fact that our memories all aren’t formed and stored in one place but travel from store to store (because his transfer from STS to LTS was damaged – if it was all in one store this specific problem would not occur)

Milner, Brenda. Scoville, William Beecher. “Loss of Recent Memory after Bilateral Hippocampal Lesions”. The Journal of Neurology, Neurosurgery and Psychiatry. 1957; 20: 11 21. (Accessed from web.mit.edu )

The man who couldn’t remember”. nova science now. an interview with brenda corkin . 06.01.2009.       .

  Here’s a good video recreation documentary of HM’s case study…

Travis Dixon is an IB Psychology teacher, author, workshop leader, examiner and IA moderator.

Learn More Psychology

• Cognitive Psychology
• Cognitive Approach

Introduction to the cognitive approach in psychology. Explanation and evaluation of this approach.

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The cognitive approach in psychology is a relatively modern approach to human behaviour that focuses on how we think.

It assumes that our thought processes affect the way in which we behave.

Approaches in Psychology

• Behavioral Approach
• Biological Approach
• Humanistic Approach
• Psychodynamic Approach
• Sociocultural Approach

In contrast, other approaches take other factors into account, such as the biological approach , which acknowledges the influences of genetics and chemical imbalances on our behavior.

• Stimulus (External Factor)
• Response (Human Behavior)

There is some dispute as to who created the cognitive approach, but some sources attribute the term to the 1950s and 1960s, with Ulric Neisser's book Cognitive Psychology , which made allusions of the human mind working in a similar fashion to computers.

The approach came about in part due to the dissatisfaction with the behavioural approach , which focused on our visible behaviour without understanding the internal processes that create it. It is based on the principle that our behaviour is generated by a series of stimuli and responses to these by thought processes.

Comparison to Other Approaches

Cognitive (meaning "knowing") psychologists attempt to create rules and explanations of human behavior and eventually generalise them to everyone's behaviour. The Humanistic Approach opposes this, taking into account individual differences that make us each behave differently. The cognitive approach attempts to apply a scientific approach to human behaviour, which is reductionist in that it doesn't necessarily take into account such differences. However, popular case studies of individual behaviour such as HM have lead cognitive psychology to take into account ideosynchracies of our behaviour. On the other hand, cognitive psychology acknowledges the thought process that goes into our behaviour, and the different moods that we experience that can impact on the way we respond to circumstances.

Key Assumptions

• Human behaviour can be explained as a set of scientific processes.
• Our behaviour can be explained as a series of responses to external stimuli.
• Behaviour is controlled by our own thought processes, as opposed to genetic factors.

Evaluation of the Cognitive Approach

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What Is a Case Study?

Weighing the pros and cons of this method of research

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."

Cognitive Psychology: Experiments & Examples

Cognitive psychology reveals, for example, insights into how we think, reason, learn, remember, produce language and even how illogical our brains are.

Fifty years ago there was a revolution in cognitive psychology which changed the way we think about the mind.

The ‘cognitive revolution’ inspired cognitive psychologists to start thinking of the mind as a kind of organic computer, rather than as an impenetrable black box which would never be understood.

This metaphor has motivated cognitive psychology to investigate the software central to our everyday functioning, opening the way to insights into how we think, reason, learn, remember and produce language.

Here are 10 classic examples of cognitive psychology studies that have helped reveal how thinking works.

1. Cognitive psychology reveals how experts think

Without experts the human race would be sunk.

But what is it about how experts think which lets them achieve breakthroughs which we can all enjoy?

The answer is in how experts think about problems, compared with novices, cognitive psychology reveals.

That’s what Chi et al. (1981) found when they compared how experts and novices represented physics problems.

Novices tended to get stuck thinking about the surface details of the problem whereas experts saw the underlying principles that were operating.

It was partly this deeper, abstract way of approaching problems that made the experts more successful.

2. Short-term memory lasts 15-30 seconds

Short-term memory is a lot shorter than many think, cognitive psychologists find.

In fact it lasts about 15-30 seconds.

We know that because of a classic cognitive psychology study carried out by Lloyd and Margaret Peterson ( Peterson & Peterson, 1959 ).

Participants had to try and remember and recall three-letter strings, like FZX.

When tested, after 3 seconds they could recall 80 percent of them, after 18 seconds, though, they could only remember 10 percent.

That’s how short-term short-term memory is.

3. Cognitive psychology finds people are not logical

People find formal logic extremely difficult to cope with–that’s normal, cognitive psychology finds.

Here’s a quick test for you, and don’t be surprised if your brain overheats:

“You are shown a set of four cards placed on a table, each of which has a number on one side and a coloured patch on the other side. The visible faces of the cards show 3, 8, red and brown. Which card(s) must you turn over in order to test the truth of the proposition that if a card shows an even number on one face, then its opposite face is red?”

The answer is you have to turn over the ‘8’ and the brown card (for an explanation search for “Wason selection task” — even after hearing it, many people still can’t believe this is the correct answer).

If you got it right, then you’re in the minority (or you’ve seen the test before!).

When Wason conducted this classic experiment, less than 10 percent of people got it right (Wason, 1968).

Cognitive psychology finds that our brains are not set up for this kind of formal logic.

4. Example: framing in cognitive psychology

The way you frame a problem, argument or statement can have huge effects on how people perceive it.

For example, think about risk for a moment and the fact that people don’t like to take chances.

They dislike taking chances so much that even the whiff of negativity is enough to send people running for the hills.

That’s what cognitive psychologists Kahneman and Tversky (1981) demonstrated when they asked participants to imagine 600 people were affected by a deadly disease.

There was, they were told, a treatment, but it is risky.

If you decided to use the treatment, here are the odds:

“A 33% chance of saving all 600 people, 66% possibility of saving no one.”

When told this, 72 percent of people thought it was a good bet.

But, when presented the problem this way:

“A 33% chance that no people will die, 66% probability that all 600 will die.”

…the number choosing it dropped to 22 percent.

The beauty of the study is that the outcomes are identical, it’s just the framing that’s different.

Cognitive psychology shows that the way we think is heavily influenced by the terms in which issues are expressed.

5. Attention is like a spotlight

We actually have two sets of eyes — one set real and one virtual, cognitive psychology finds.

We have the real eyes moving around in their sockets, but we also have ‘virtual eyes’ looking around our field of vision, choosing what we pay attention to.

People are using their virtual eyes all the time: for example, when they watch each other using their peripheral vision.

You don’t need to look directly at an attractive stranger to eye them up, you can look ‘out of the corner of your eye’.

Cognitive psychologists have called this the ‘spotlight of attention’ and studies have actually measured its movement.

It means we can notice things in the fraction of a second before our eyes have a chance to reorient.

→ Read on: The Attentional Spotlight

6. The cocktail party effect in cognitive psychology

It’s not just vision which has a kind of spotlight, our hearing is also finely tuned, cognitive psychologists have discovered.

It’s like when you’re at a cocktail party and you can tune out all the voices, except the person you’re talking to.

Or, you can tune out the person you’re talking to and eavesdrop on a more interesting conversation behind.

A beautiful cognitive psychology demonstration of this was carried out in the 1950s by Cherry (1953) .

He found that people could even distinguish the same voice reading two different messages at the same time.

→ Read on: The Cocktail Party Effect

7. Children’s cognitive psychology example

If you take a toy duck and show it to a 12-month-old infant, then put your hand under a cushion, leave the duck there and bring your hand out, the child will only look in your hand, almost never under the cushion.

At this age, children behave as though things they can’t see don’t even exist.

As the famous child psychologist Jean Piaget noted:

“The child’s universe is still only a totality of pictures emerging from nothingness at the moment of action, to return to nothingness at the moment when the action is finished.”

And yet, just six months later, a child will typically look under the cushion, studies in cognitive psychology have found.

It has learnt that things that are hidden from view can continue to exist — this is known as object permanence .

This is just one miracle amongst many in developmental  psychology and cognitive psychology.

8. The McGurk effect in cognitive psychology

The brain is integrating information from all our senses to produce our experience, cognitive psychology shows.

This is brilliantly revealed by the McGurk effect ( McGurk & MacDonald, 1976 ).

Watch the following clip from a BBC documentary to see the effect in full.

You won’t believe it until you see and hear it yourself.

The sensation is quite odd:

9. Implanting false memories

People sometimes think of their memories as being laid down, then later either recalled or forgotten, with little change in the memories themselves between the two.

In fact, cognitive psychology shows that the reality is much more complex and, in some cases, alarming.

One of the most dramatic examples of these studies demonstrated that memories can be changed, or even implanted later, was carried out by Elizabeth Loftus.

In her study, a childhood memory of being lost in a mall was successfully implanted in some people’s mind, despite their families confirming nothing like it had ever happened to them.

Later research in cognitive psychology have found that 50 percent of participants could have a false memory successfully implanted.

→ Read on: Implanting False Memories

10. Why the incompetent don’t know they’re incompetent

There all kinds of cognitive biases operating in the mind, cognitive psychology has found.

The Dunning-Kruger effect , though, is a favourite because it explains why incompetent people don’t know they’re incompetent.

David Dunning and Justin Kruger found in their studies that people who are the most incompetent are the least aware of their own incompetence.

At the other end of the scale, the most competent are most aware of their own shortcomings.

→ Explore more: Cognitive Biases : Why We Make Irrational Decisions

Author: Dr Jeremy Dean

Psychologist, Jeremy Dean, PhD is the founder and author of PsyBlog. He holds a doctorate in psychology from University College London and two other advanced degrees in psychology. He has been writing about scientific research on PsyBlog since 2004. View all posts by Dr Jeremy Dean

Join the free PsyBlog mailing list. No spam, ever.

The Cognitive Approach (To Human Behaviour)

March 10, 2021 - paper 2 psychology in context | approaches to human behaviour.

The Cognitive Approach: Internal Mental Process

Cognitive psychologists attempt to work out what the thought processes are that occur from a behaviour observed, (i.e. they observe behaviour and then try to understand what were the thoughts/motivators of this behaviour). These processes are ‘private’ and cannot be seen, so cognitive psychologists study them  indirectly  by making inferences (going beyond immediate evidence to make assumptions) about what’s going on inside people’s minds on the basis of their behaviour.

The Role Of Schema:

Bartlett war of the ghosts,.

Memory uses schemas to organise things. When we recall an event, our schemas tell us what is  supposed  to happen, however, the schemas might fill in the gaps in our memory ( confabulation ) and even put pressure on our mind to remember things in a way that fits in with the schema, altering details along the way.

Bartlett came up with the idea of “reconstructive memory” during a game of ‘Chinese Whispers’. Bartlett developed a study to illustrate the idea of ‘reconstructive memory’ and ‘schemas.’ He showed 20 students a Native American ghost story titled; War of the Ghosts, which had unusual features (features that would have been ‘uncommon’ in most cultures). He asked them to read it then recall it on a number of occasions after a few hours, days, weeks, years. Bartlett compared the recalled and original story.

War of the Ghosts   Story from Bartlett’s Research: One night two young men from Egulac went down to the river to hunt seals and while they were there it became foggy and calm. Then they heard war-cries, and they thought: “Maybe this is a war-party”. They escaped to the shore, and hid behind a log. Now canoes came up, and they heard the noise of paddles, and saw one canoe coming up to them. There were five men in the canoe, and they said: “What do you think? We wish to take you along. We are going up the river to make war on the people.” One of the young men said,”I have no arrows.” “Arrows are in the canoe,” they said. “I will not go along. I might be killed. My relatives do not know where I have gone. But you,” he said, turning to the other, “may go with them.” So one of the young men went, but the other returned home. And the warriors went on up the river to a town on the other side of Kalama. The people came down to the water and they began to fight, and many were killed. But presently the young man heard one of the warriors say, “Quick, let us go home: that Indian has been hit.” Now he thought: “Oh, they are ghosts.” He did not feel sick, but they said he had been shot. So the canoes went back to Egulac and the young man went ashore to his house and made a fire. And he told everybody and said: “Behold I accompanied the ghosts, and we went to fight. Many of our fellows were killed, and many of those who attacked us were killed. They said I was hit, and I did not feel sick.” He told it all, and then he became quiet. When the sun rose he fell down. Something black came out of his mouth. His face became contorted. The people jumped up and cried. He was dead .

(2) Participants also  confabulated  details, changing unfamiliar parts of the story in line with their schemas: canoes became boats, paddles became oars, hunting seals became fishing.

Theoretical And Computer Models:

Computer   the core assumption of the cognitive approach is that the human mind functions like a computer, that there are similarities regarding the way information is processed. These models use the concepts of a central processing unit (the brain), the concept of  coding  (making information usable) and the use of  stores.

Emergence Of Neuroscience:

Cognitive neuroscience the scientific (and objective) study of the influence of brain structures on mental processes. There is a long history of brain-mapping in psychology, advances in brain imaging techniques (fMRI and PET scans) have meant scientists can observe and describe the neurological basis of mental processes.

The focus of cognitive neuroscience has expanded recently to include the use of computer-generated models that are designed to ‘read’ the brain. This has led to the development of mind mapping techniques known as ‘brain fingerprinting’

The Cognitive Approach Evaluation (AO3):

(1)  POINT:   A strength of the Cognitive Approach  is that it uses lots of scientific methods to measure the main assumptions of the approach.  EXAMPLE/EVIDENCE:  For example,  research investigating the Cognitive Approach uses fMRI, PET scans etc to measure the processes and functions taking part in the human brain.  ELABORATION:  This is a strength because it can be seen that the key concepts of the Cognitive Approach are objectively and scientifically measured adding a degree of validity to the approach.

(1)  POINT:  The Cognitive Approach can be criticised as being deterministic.  EXAMPLE/EXPLAIN:  For example, the approach assumes that we are pre-programmed in a way where we follow cognitive processes/cognitive processes are responsible for our behaviour.  ELABORATION:  This is a weakness because, the Cognitive Approach doesn’t consider the role of genetics/biology in the explanation of human behaviour.

(2)  POINT:  The Cognitive Approach can be criticised as being reductionist.  EXAMPLE/EXPLAIN:  For example, the approach assumes that all our actions and behaviours are as a result of internal-mental processes, thoughts etc .  ELABORATION:  This is a weakness because, the Cognitive Approach can be criticised as being too simplistic, failing to recognise that surely there are an array of factors that impact human behaviour (surely such complex behaviours as those displayed by humans cannot be reduced down to one explanation?)

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The Cognitive Approach

Last updated 5 Sept 2022

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The idea that humans conduct mental processes on incoming information – i.e. human cognition – came to the fore of psychological thought during the mid twentieth century, overlooking the stimulus-response focus of the behaviourist approach. A dominant cognitive approach evolved, advocating that sensory information is manipulated internally prior to responses made – influenced by, for instance, our motivations and beliefs.

Introspection – a subjective method predominantly used by philosophical and psychodynamic approaches – was rejected in favour of experimental methodology to study internal processes scientifically.

The cognitive approach assumes

• The mind actively processes information from our senses (touch, taste etc.).
• Between stimulus and response are complex mental processes, which can be studied scientifically.
• Humans can be seen as data processing systems.
• The workings of a computer and the human mind are alike – they encode and store information, and they have outputs.

The Study of Internal Mental Processes

Using experimental research methods, the cognitive approach studies internal mental processes such as attention, memory and decision-making. For example, an investigation might compare the abilities of groups to memorize a list of words, presenting them either verbally or visually to infer which type of sensory information is easiest to process, and could further investigate whether or not this changes with different word types or individuals.

Theoretical and computer models are proposed to attempt to explain and infer information about mental processes. For example, the Information-Processing Model (Figure 1) describes the mind as if a computer, in terms of the relationship between incoming information to be encoded (from the senses), manipulating this mentally (e.g. storage, a decision), and consequently directing an output (e.g. a behaviour, emotion). An example might be an artist looking at a picturesque landscape, deciding which paint colour suits a given area, before brushing the selected colour onto a canvas.

In recent decades, newer models including Computational and Connectionist models have taken some attention away from the previously dominant information-processing analogy:

• The Computational model similarly compares with a computer, but focuses more on how we structure the process of reaching the behavioural output (i.e. the aim, strategy and action taken), without specifying when/how much information is dealt with.
• The Connectionist model takes a neural line of thought; it looks at the mind as a complex network of neurons, which activate in regular configurations that characterize known associations between stimuli.

The role of Schema

A key concept to the approach is the schema, an internal ‘script’ for how to act or what to expect from a given situation. For example, gender schemas assume how males/females behave and how is best to respond accordingly, e.g. a child may assume that all boys enjoy playing football. Schemas are like stereotypes, and alter mental processing of incoming information; their role in eyewitness testimony can be negative, as what somebody expects to see may distort their memory of was actually witnessed.

Cognitive Neuroscience emergence

This related field became prevalent over the latter half of the twentieth century, incorporating neuroscience techniques such as brain scanning to study the impact of brain structures on cognitive processes.

Evaluation of the cognitive approach

• Models have presented a useful means to help explain internal mental processes
• The approach provides a strong focus on internal mental processes, which behaviourists before did not.
• The experimental methods used by the approach are considered scientific.
• It could be argued that cognitive models over-simplify explanations for complex mental processes.
• The data supporting cognitive theories often come from unrealistic tasks used in laboratory experiments, which puts the ecological validity of theories into question (i.e. whether or not they are truly representative of our normal cognitive patterns).
• Comparing a human mind to a machine or computer is arguably an unsophisticated analogy.
• Cognitive Approach
• Cognitive neuroscience
• Mediating cognitive factors
• Negative self-schemas

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Case Study 1: A 55-Year-Old Woman With Progressive Cognitive, Perceptual, and Motor Impairments

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How Does the Examination Contribute to Our Understanding of Diagnostic Considerations? What Additional Tests or Studies Are Indicated?

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Applying an Integrated Approach to a Case Example: Cognitive Behavioral Therapy and Person Centered Therapy

Cognitive-behavioral therapy (CBT) and Person-Centered Therapy (PCT) have been shown to bring about positive changes in therapy. CBT and PCT, like all single-theory approaches, have limitations. Literature suggests that when the change-producing techniques of CBT and PCT are combined and applied, counseling is more effective (Josefowitz & Myran, 2005; Tursi & Cochran, 2006). In this paper, CBT and PCT are reviewed and then integrated into one approach. A case example is then presented and hypothetical helping sessions are described to demonstrate how the various techniques of the approaches can come together to create positive changes in therapy. A discussion follows that suggests future research and identifies additional resources.

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Pamoja Student Guide to IB Psychology

Chapter 5: cognitive approach to understanding behaviour, chapter outline, 1. the cognitive revolution, 2. research methods of the cognitive approach, 2.1 case studies.

2.2 Experiments

2.3 Observations

2.4 interviews.

2.5 Ethics and Research Methods of the Cognitive Approach

3. Cognitive Processing

3.1 models of memory, 3.2 schema theory, 3.3 thinking and decision-making.

3.4 Assessment Advice

4. Reliability of Cognitive Processes

4.1 reconstructive memory.

4.2 Biases in Thinking and Decision-making

4.3 Assessment Advice

5. Emotion and Cognition

5.1 the influence of emotions on cognitive processes.

5.2 Assessment Advice

6. Cognitive Processing in a Technological (Digital/Modern) World (HL only)

6.1 Assessment Advice

Essential Questions How do psychologists adopting a cognitive approach study behaviour? How is human memory modelled by cognitive psychologists? What are schemas and how do they influence memory? What factors influence our thinking and decision-making? How reliable are our cognitive processes? How do emotions influence our thinking and decision-making? How does digital technology influence cognitive processes? (HL only)

Myths and Misconceptions

Psychologists should only investigate what they can observe.

This was the point of view of psychologists called behaviourists. They believed only direct observable behaviour should be the focus of psychological studies. Psychologists interested in memory and thinking rejected this idea. In this chapter we will examine the contribution of cognitive psychologists to our understanding of human behaviour.

People think logically and make sensible decisions.

Though our biological classification of Homo sapiens comes from Latin meaning ‘the wise human’, our thinking is often illogical and our decisions prone (prone = susceptible, liable, predisposed) to biases. In this chapter we will investigate why our cognitive processes are not always reliable.

Some experiences in our lives are unforgettable.

A common belief is that deeply emotional experiences produce vivid, exact and long-lasting memories. In this chapter, we will read research into whether memories can be imprinted upon the mind so powerfully that they can be recalled in photographic detail.

The historical background to cognitive psychology is behaviourism . Behaviourists argued that only direct observable behaviour should be the focus of investigations into human behaviour. From this viewpoint, psychologists argued that the mind cannot be studied scientifically as the mind cannot be observed directly. By the second half of the 20th century, psychologists interested in memory and thinking rejected this approach. They noted there are many phenomena we cannot directly observe. For example, we cannot observe air but we can infer (infer = to guess that something is correct because of the information that we have) its presence. We can breathe air and see how it moves trees. In a similar way, cognitive psychologists cannot observe mental processes but we can assume mental processes from human behaviour.

Researchers taking a cognitive approach study the mental structures and processes involved in behaviours such as attention, perception, memory, thinking and decision-making, problem-solving and language. Such processes are labelled cognition . While psychologists taking a biological approach study the relationship between the brain and nervous system and human behaviour, cognitive psychologists examine the relationship between cognition and human behaviour. Cognitive psychologists argue they are able to study mental processes by building theoretical models and then testing predictions based on these models. As computers became more widespread, psychologists likened mental processing to the operation of a computer. Information was seen as being inputted through our senses to our brains. This data then underwent mental processing. Behaviour was the output of this system. These ideas were revolutionary and cognitive psychologists produced a huge outpouring of research studies.

Cognitive psychologists use several research methods:

Case studies

Experiments

Observations

Ask Yourself Which research method would be most effective in understanding Malala’s decision to campaign for the education of girls in Pakistan? (See Chapter 1)

Case studies examine correlations between mental processes and behaviour. Case studies sometimes focus on people with unusual mental abilities, or with mental processing problems. They can be longitudinal , which means the investigator studies the person for several years by re-testing or re-interviewing them at regular intervals.

Case studies investigate mental processes of one person or a few people. They provide in-depth information about phenomena that cannot be studied experimentally.

2.2 Experiments (laboratory/field/quasi/natural)

To examine the links between brain activity, mental processing and behaviour, psychologists design laboratory (true) experiments and use brain imaging technology. Though mental processes are not being directly observed, these processes are inferred from the brain activity and the behaviour.

Experiments are useful because they can identify cause-and-effect relationships between two or more variables. Some of the experiments we will study are actually natural or quasi-experiments because the independent variable is often age or gender.

Observation is often part of case studies and experiments. Observation can be quantitative and qualitative, depending on how the data is collected. If the researcher uses a list or grid that involves checking whenever a particular behaviour is exhibited, then the data is quantitative. If the researcher makes notes about the behaviour being observed and then writes down their own thoughts about that behaviour, then the data is qualitative.

Structured interviews comprise a checklist of questions with tick boxes or yes and no answers. Unstructured interviews are similar to a conversation between two people, with a video or sound recorder used to capture the tone of the interviewee’s comments and replies. Interviews can be a mixture of closed questions that need factual answers and other more open-ended questions that allow the interviewee to expand and discuss. Focus group interviews involve the interviewer facilitating a discussion amongst a group of interviewees.

Cognitive psychologists use interviews to supplement other methods, to develop theories and to gain in-depth insight into behaviour. Cognitive testing can sometimes form part of an interview. The interview is used to gain access to the person’s mental processes through conversations about their behaviour and feelings.

2.5 Ethics Consideration of the Cognitive Approach

Psychologists endeavour to consider the following in their research into cognitive processes:

informed consent

right to withdraw

undue stress or harm

As you read about studies conducted by cognitive psychologists, think about the following:

Why are these considerations important?

How did the psychologist resolve any ethical issues? For example, how could the use of deception or stress be justified? Should psychologists undertake a cost/benefit analysis before undertaking research?

Have ethical considerations changed over time?

Memory models provide a framework for an understanding of conceptualizations of human memory processes over time. Examples relevant to the study of memory models include explicit/implicit memory, sensory memory, short-term memory, long-term memory, central executive, phonological loop, episodic buffer, and visuospatial sketchpad.

Source: IB Psychology Guide

James (1890) was the first psychologist to suggest there are two separate types of memory. He called them primary memory and secondary memory. Information is first stored in primary memory. Secondary memory is where the memory stays when it is not being retrieved. Information in primary memory is continuously accessible because it takes an active cognitive process to retrieve information in secondary memory.

Miller (1956) investigated the capacity of short-term information storage. He conducted tests of memory such as repeating a series of digits and found that memory was limited to seven items in most people. Some people could remember nine and some five, but for most seven items was the norm. However, the definition of an item is flexible, and if the information was chunked into seven items, each containing several pieces of information, then the capacity for remembering was extended.

In the 1960s and 1970s, several models of memory were proposed. Early theories like the multi-store model (MSM) focused on storage of information. As computer functions became more complex, so theories of memory as operating as a computer also looked at processing rather than just at capacity and storage. An example of this model is the working memory model (WMM).

To evaluate any model of behaviour a series of questions need to be asked: Are the concepts? Is the model static or dynamic in the way it shows a psychological process? Have studies supported the model?

Keep these questions in mind as we study these models.

The multi-store model (MSM) was first proposed by Atkinson and Shiffrin (1968). Their theory suggests that information flows through three stores. Each store has different capacities and can store information for different durations. Information is first stored in sensory memory for a fraction of a second. This information is then transferred to short-term memory if we attend to and make note of it. Short-term memory has a limited capacity of seven items +/−2. Information is stored in the form of sound for about 30 seconds. This information will then be transferred to long-term memory . When the material is not rehearsed, new information that enters the short-term memory store will displace older information. The information in long-term memory is processed semantically (semantically = by meaning). The capacity of this store may be unlimited.

Ask Yourself Based on your experience, does this model make sense to you?

Strengths of the multi-store model

The multi-store model was an influential theory and prompted a great deal of research into memory. For example, Glanzer and Cunitz (1966) provided evidence that confirmed the model. They did this by conducting studies on the serial position effect using free recall experiments . These experiments involve giving participants a series of twenty or more words to remember and then asking them to recall these words in any order. The results generally fall into a pattern the researchers call the serial position curve. As you can see, participants recalled more of the first words and the last words on the list (see Figure 5.2). This primacy effect showed these first words had been transferred into long-term memory. The recency effect indicates that the last words on the list were also remembered as well as they were still in short-term memory when the participants recalled the words.

Focus on Research

Building on this research, Glanzer and Cunitz (1966) designed experiments to test their Multi-Store Model of Memory (MSM). They aimed to test the hypothesis that there are two distinct storage mechanisms the STM store and the LTM store.

Two repeated measures experiments were conducted. In Experiment I, 240 Army enlisted men were presented with lists of 20 common one-syllable nouns. The presentation rate, the time intervals between one word and the next, varied from 3 to 6 to 9 seconds.

The results indicated that spacing affects the shape of the serial position curve, but the effect is limited to the beginning of the list, not the end. The investigators concluded that this was evidence that the LTM store was distinct from the STM store.

In Experiment II, 46 Army enlisted men were presented with lists of 15 common one-syllable nouns. They were asked to recall the list immediately or after a 10 or 30-second interval in which they performed a distraction task of counting backwards.

Results showed that the recency effect was strongest for immediate recall but declined after that. This variable did not impact the primacy effect. The investigators once again concluded that the results demonstrated the existence of two distinct memory stores.

Weaknesses of the multi-store model

The MSM was criticised as being simplistic. The models did not capture how the different stores interact with each other. For example, the information stored in the LTR could influence what information is judged important by the STM. Baddeley and Hitch (1974) argue that the memory stores are more complex than depicted by the MSM. Craik and Lockhart (1972) point out that rehearsal alone does may not account for the transfer of information from STM to LTM. The type of information being processed and the level at which this information is processed may also influence what information is transferred to the LTM. You can find more information about Craik and Lockhart here .

A further criticism was that many of the studies that support the model lack ecological validity as they rely on random lists of words presented to participants in a laboratory setting.

The working memory model

While the MSM showed that a theoretical model could be effective in investigating cognitive processes there were significant limitations. As a result, some psychologists argued that there must be more than one type of long-term memory store. Shallice and Warrington (1970) undertook a case study of KF who was involved in a motorcycle accident. They found he was still able to form new long-term memories even though his short-term memory capacity was nearly zero. Short-term memory is, according to the MSM, the gateway to long-term memory, so his long-term memory should also have been damaged, at least for events that happened after the accident. As KF could still form new long-term memories, Warrington and Shallice argued there must be another way to access long-term memory other than what is depicted by the MSM.

Building on Atkinson and Shiffrin’s research, Baddeley and Hitch (1974) developed an alternative model of short-term memory which they called the working memory model (see Figure 5.3). They argued that short-term memory is not a static store, but is a complex and dynamic information processor.

The central executive is the most important part of the model, although little is known about how it functions. The central executive monitors and coordinates the operation of the visuo-spatial sketchpad and phonological loop and relays information to long-term memory. The central executive decides which information is attended to and where to send it. Baddeley suggests the central executive acts more like a system which controls attention rather than as a memory store. The central executive enables the working memory system to selectively attend to some stimuli and ignore others. The phonological loop and the visuo-spatial sketchpad are specialised storage systems. See this interview with Baddeley on the functions of the central executive.

The phonological loop is the part of working memory that deals with spoken and written material. It consists of two parts: one is the phonological store, which acts as an inner ear and holds information in a speech-based form for 1–2 seconds. Spoken words enter the store directly. The other part is the articulatory control process . This process converts written words into an articulatory (spoken) code so they can enter the phonological store and it acts like an inner voice rehearsing information from the phonological store. It circulates information round and round like a tape loop. This is how we remember a telephone number we have just heard. We say it aloud or in our minds over and over again and so keep it in our working memory.

The visuo-spatial sketchpad deals with what things look like and how we are in relation to other objects as we move around. If we are asked what our friend looks like, we see a picture of them in our minds. This is our visuo-spatial sketchpad drawing from our long-term memory.

Baddeley (2000) updated the working memory model after it failed to explain the results of various experiments, adding the episodic buffer . The episodic buffer acts as a ‘backup’ store which communicates with both long-term memory and the components of working memory.

Ask Yourself Based on your own experience, does this model make sense to you?

Strengths of the working memory model

The WMM provides a more comprehensive and thorough explanation of memory storage and processing compared to the MSM. Most psychologists now agree that short-term memory is a working memory with processing and filtering powers. The model can be applied to reading and tasks like mental arithmetic and verbal reasoning. The model explains what happens to memory in cases of brain damage.

Experimental studies also support the model by showing that there are separate systems in working memory. Hitch and Baddeley (1976) conducted a dual-task study to find if working memory had more than one process. Their model predicts that two tasks cannot be performed successfully if they use the same component of working memory. On the other hand, if two tasks use different components, they can be carried successfully.

To test this theory, participants were asked to do two tasks at the same time – a task which required them to repeat a list of numbers, and a verbal reasoning task which required them to answer true or false to various questions. The participants could carry out both tasks satisfactorily, and the researchers suggest that this is because each task using a different element of working memory.

This finding was supported by Robbins et al. (1996) who conducted a number of experiments that asked participants to play chess and do another cognitive task at the same time. They found that playing chess involved using the visuo-spatial sketchpad and there was no interference when participants were asked to play chess and repeat words at the same time. However, when participants tried to play chess and tap numbers on a keyboard at the same time, there was interference as the model would predict.

Limitations of the working memory model

Andrés and Van der Linden (2002) examined patients with frontal lobe damage and concluded that not all central executive processes are located there. Evidence indicates there are common brain areas but there are also differences in how different tasks are performed.

There is little direct evidence for how the central executive works and what it does. The capacity of the central executive has never been measured. The working memory model only involves short-term memory, so it is not a comprehensive model.

Finally, the model does not explain changes in processing ability that occur as the result of practice or time.

Cognitive schemas are seen as mental representations that organize our knowledge, beliefs, and expectations. Examples relevant to studying schema processing include but are not limited to: top-down/bottom-up processing; pattern recognition—the matching of a current input to information in memory; effort after meaning—the attempt to match unfamiliar ideas into a familiar framework; stereotyping—a fixed mental representation of a group of individuals.

Bartlett (1932) first introduced schema theory to psychology. A schema can be defined as an internal mental representation that helps us organise and make sense of information. While conducting a series of studies with British students recalling Native American folktales, he noticed the participants often recalled information inaccurately. He found familiar information replaced unfamiliar information as the participants tried to make sense of the story as they recalled it. To account for these findings, Bartlett proposed that people have schemas which can be defined as unconscious mental structures that represent an individual’s experience and knowledge of the world. Schemas are composed of old knowledge. He stated that they are ‘masses of organized past experiences’ (1932: 197–198). These experiences affect a person’s current understanding and memory. For example, going to school helps us to develop a schema of a typical classroom and what you would find in it. Schema processing is automatic and below our level of awareness but as we shall see later in the chapter, biases in thinking and memory can result.

Bartlett (1932) investigated schemas and the constructive nature of remembering. He believed that when people are asked to remember a story they make sense of it in their own way. We use schemas to help us understand the world and we try to fit any new information into these existing schemas. He proposed that memory is a reconstructive process affected by our own culture and expectations.

Bartlett based these ideas on a series of memory exercises. His participants were British male and female undergraduate students in Bartlett's university classes. One study investigated how well a North American folk story called 'War of the Ghosts' could be remembered. The story contained several unusual and strange supernatural elements. To the British participants, parts of this story may have made little sense. Participants read the story and then repeated the story from memory after differing periods (the procedure is called repeated reproduction, which should not be confused with serial reproduction when information is passed from one person to the next). These periods varied from days to years. Bartlett found that the participants changed the story as they tried to remember it. He noted:

The story became more consistent with the participant’s own cultural expectations, that is, names and places were unconsciously changed to fit the norms of British culture. For example, a canoe was recalled as a boat. He called this a process of assimilation .

The story became shorter with each retelling as participants omitted information judged as unimportant. He called this a process of levelling .

Participants changed the order of the story to make sense of it and added details. The overall theme of the story was remembered but unfamiliar elements were changed to match the participant’s culture. This process was called sharpening .

Loftus and Palmer (1974) supported this early work by Bartlett schema and introduced the idea that schemas are susceptible to manipulation by information introduced after an event. They focused on eye-witness testimony and found that changing the verb used when questioning eyewitnesses about a video of a car accident changed how the event was remembered. The different verbs in the questions activated different schemas which then influenced the estimations of speed. For example, the typical schema of cars smashing into one another implies the cars were moving very fast compared to cars contacting each other.

Rumelhart and Norman (1983) wanted to understand the properties of schemas and how they affect memory. They argued that schemas represent all kinds of knowledge including semantic meanings and procedures. Schemas could consist of sub-schemas. For example, a restaurant schema would comprise an ordering schema, an eating schema and a paying schema. They noted that all schema are based on personal experience and are updated to make sense of new information.

Schema theory has also been used to explain cross-cultural differences. For example, Filmore (1975) noted that the English verb to write and the Japanese word kaku are direct translations of each other, but to write in English does not mean the same as it does in Japanese. To the Japanese, kaku can be an image, a sketch or a word or a character. The writing schema in English is broader and includes language. You cannot write an image. Schema theory has been used by psychologists to explain why people from different cultures can misunderstand each other.

Schema theory has been applied to treat people suffering from mood disorders. Beck (1979) argued that faulty cognition can lead to depression, and he devised a schema therapy to correct this faulty thinking in the mind of the sufferer.

Critiques of schema theory have focused on the vagueness of the concept (Cohen 1993). Others say schemas are too rigid and simplistic. For example, Clark (1990) writes that schema theory tries too hard to use a single framework to explain how knowledge is acquired, stored and retrieved.

Despite the limitations outlined above, there is broad support for schema theory.

Tuckey and Brewer (2003) examined how a crime schema influenced the types of details witnesses recalled over several interviews. Some witnesses experienced a delay before the initial interview and some between subsequent interviews. Data showed that, in general, schema-irrelevant memories (memories that neither confirmed nor contradicted the crime schema) were more often forgotten than schema-consistent and schema-inconsistent memories after the initial interview. Delaying the initial interview negatively affected recall at the initial interview, but led to less decay over subsequent interviews.

Witnesses used their schemas to interpret any unclear information and, as a result, made more schema-consistent mistakes and were more likely to report false memories about any ambiguous details.

Thinking involves using information and doing something with it, for example, making a decision. Modern research into thinking and decision- making often refers to rational and intuitive thinking. Examples of thinking and decision- making could be but are not limited to framing, heuristics, loss aversion, and appraisal.

We take thinking for granted but it is complex and an active process. Information is gathered, stored and analysed to make judgements and decisions and to reach conclusions. These cognitive processes are aspects of directed thinking because this type of cognition aims to achieve a goal. Several models of thinking and decision-making have been proposed to understand how we think and make decisions to achieve these goals. We will examine:

Dual processing model

The dual processing model assumes that we think in two ways across several tasks: System 1 thinking and System 2 thinking. System 1 thinking is automatic, quick and requires little effort. Kahneman (2011) describes this as fast thinking. System 1 tends to be our default system of cognition when we are short of time or too tired to give a question a lot of thought. Thinking in this mode operates below our level of conscious awareness and is a more instinctive way of processing information and figuring things out. System 1 relies on feelings, intuition and a toolkit of hidden mental shortcuts to help guide our way through the choices we make, rather than thinking about each one methodically and consciously. Though fast, it is prone to biases. We will explore these biases in the next section on the reliability of cognitive processes. System 2 is more rational, analytical and goal-directed thinking and requires deliberate effort and time. System 2 refers to the processes that kick in when we stop, pay attention and think. Kahneman describes this as slow thinking. Though slow, it is less prone to biases.

One way to contrast these two thinking systems is to examine how we learn to drive a car. At first, a new driver needs to concentrate on each of the actions involved in driving. With more experience and confidence, automatic processing takes over and the driver can talk to a passenger or listen to music. If the weather changes or an emergency arises, the driver can quickly revert to more deliberate driving.

Cognition involves both types of thinking depending on the problem to solve or the decision to make. At times we might make more instinctive and emotional choices and on other occasions, decisions may be less emotional and more analytical.

Table 5.1 summarises some of the differences between the two systems as outlined by Kahneman.

Table 5.2 Differences between System 1 and System 2 thinking

Bonke et al. (2014) aimed to determine if unconscious thought (intuitive and automatic thinking) led to better performance than conscious thought (rational and controlled).

Aims : Determine whether "educated intuition" led doctors to make more accurate estimations about patients' survival probabilities than more deliberate thought.

Type of study : Experiment.

Participants : 86 medical experts and 57 novices selected by purposive sampling from academic and non-academic hospitals and from a university medical centre in the Netherlands between April 2009 and May 2011.

Procedures : The participants were presented with four fictitious medical case histories. The four case histories were presented by a computer in the form of statements and clinical test results. Half of the participants were encouraged to engage in conscious thought for four minutes about the patient's life expectancy. The other half were distracted by performing an anagram task for four minutes. The participants were then asked to estimate the probability that each patient would be alive in 5 years.

Results : There was a significant difference in task performance between the novices and the experts. There was no significant difference in accuracy between the conscious and unconscious thinking conditions.

Conclusion : Unconscious, intuitive thought did not lead to better or worse performance than deliberate, conscious thought.

Algorithms and heuristics

Algorithms can help people solve problems and make decisions. An algorithm is a well-defined process that will produce the right solution or the best decision. Algorithms are an example of System 2 as they require deliberate thinking, logical rules and procedures. Solving a maths problem by using a formula is an example of an algorithm in action. Finding a solution by trial and error is another example as is following a recipe to bake a cake. Follow the steps and you get the right outcome.

Heuristics are mental shortcuts or rules of thumb that generally, but not always, produce the right outcome. Heuristics offer a trade-off between helping us make quick decisions and being occasionally wrong. Some of these easy and quick mental shortcuts are described below.

Representative heuristic

We make decisions based on whether an individual, object or event looks like what we expect it to be.

Imagine this situation:

A stranger tells you about a person from the US who is short, slim and likes to read poetry and then asks you to guess whether the person is more likely to be a professor of classics (Ancient Latin and Greek language and culture) at Harvard or a truck driver. Which would be the better guess?

Like most people, you guessed the Harvard professor. You could make that quick decision because your view of a poetry-lover did not conjure up an image of a truck driver. However, as Nisbett and Ross (1980) pointed out, this representative heuristic leads you to ignore relevant information. At most, there might be 20 classics professors at Harvard and perhaps only half of them like poetry and even less are short and slim. But how many truck drivers are there in the US? Hundreds of thousands. How many are slim and short? Even 10% is a huge number. How many of them like poetry? Maybe only 1%, but that is still more than our slim, short, poetry-loving Harvard professors.

The availability heuristic is used to judge the likelihood of an event based on how easily examples of that event come to mind. Tversky and Kahneman (1974) investigated the availability heuristic by asking a simple question: Are there more words in the English language that start with the letter ‘k’ than words that have ‘k’ as the third letter? As expected, most participants answered words starting with ‘k’ as those words came more readily to mind compared to words like ‘joke’ or ‘bake’.

While the above example is probably only of interest to avid Scrabble players, the availability heuristic can also be at play in our social relationships. Ross and Sicoly (1979) investigated fairness in social relationships when people were engaged in a joint project. The researchers asked different groups of people about how they contributed to a joint project. For example, married participants were asked about shared household and child-rearing duties, academics were asked about how they contributed to the completion of a project and sports people were asked about about their efforts in supporting their team. The results showed that participants were more likely to recall their contributions than the contributions of others.

Ask Yourself Think of group projects you have been involved with. Have you felt you did more of the work than others? Is there a possibility that the available heuristic leads you to make a wrong judgement about how the work was completed?

Fox (2006) aimed to understand how the availability heuristic (or in this case the unavailability of information) influences judgements about the quality of university courses. In this field experiment, sixty-four business students at an American college completed a mid-course evaluation form. They were randomly assigned to two conditions. Half of the participants were asked to list two ways the course could be improved before they provided an overall rating for the course from one to seven with seven being the highest. The other participants were asked to list ten ways the course could be improved before they gave their overall evaluation. The results showed that there was a statistically significant difference between the mean score of 4.92 for the group asked to list two improvements and the mean score of 5.52 for the group asked to list ten improvements. Fox explained this paradoxically (paradoxically = not what is expected) in terms of the availability heuristic. When participants struggled to think of ten ways to improve the course they misinterpreted the difficulty of recalling problems with the course as evidence that there were not so many problems after all.

3.4 Assessment Advice: Cognitive Processing

Human memory is not an exact copy of events, but rather a reconstruction that may be altered over time, through discussions with others or input from the media. Research shows that memory may be changed during storage, processing and retrieval, due to schema processing.

Freud proposed the first psychological theory of memory. According to his psychoanalytic theory, people force themselves to forget painful memories by repressing them into the unconscious . These memories continue to exist but can only be recovered by a psychologist or psychotherapist using hypnosis or dream analysis. Many researchers disagree and believe that recovered memories were created memories of events that never took place. Less controversial is research into the subtle factors that can influence how we recall events. Bartlett (1932) showed how schemas can change how we recall stories and his pioneering studies were supported by Loftus and Palmer (1974) who investigated eyewitness testimony.

‘Reconstruction of automobile destruction: An example of the interaction between language and memory’, is a study by Loftus and Palmer (1974) that investigated the reliability of memory. The study aimed to investigate how information provided after an event influenced a witness’s memory of that event. The researchers changed the verb in a question when asking the witnesses to recall an event. The hypotheses for the study were as follows:

Null hypothesis: Modifying the wording of questions after an event will not influence the accuracy of memory of a witness for that event.

Research hypothesis: Modifying the wording of questions after an event will influence the accuracy of memory of a witness for that event.

Two laboratory experiments made up the study. Both experiments adopted an independent measures design. The IV was the verb used to describe the event. In the first experiment, the DV was the participant’s estimate of speed in miles per hour of the cars involved in the accident and in the second experiment the DV was whether or not the participant believed they saw broken glass at the crash scene.

The researchers used an opportunity sample of 45 college students of the University of Washington for the first part of the study and 150 participants for the second part.

The study had two parts.

First study

In the first study participants were shown seven 5–30 seconds film clips of traffic accidents. The clips were excerpts from safety films made for the education of drivers. After each film participants filled in a questionnaire about the accident. The critical question (IV) here was, ‘About how fast were the cars going when they hit each other?’ Different conditions were used, where the verb was changed to ‘smashed’, ‘collided’, ‘bumped’, ‘hit’ and ‘contacted’. Participants were asked to estimate the speed in miles per hour.

The films were shown in different orders in each condition. This first study was conducted over one-and-a-half hours.

Second study

This study used 150 participants divided into three groups. All participants watched a one-minute film on a multiple-car accident. They then answered some questions about the film. The critical question was, ‘How fast were the cars going when they hit each other?’ The verb was changed to ‘smashed’ in the comparison group. The control group was not asked to estimate the speed.

Results and conclusions

When the critical question had the word ‘smashed’ or ‘collided’ speed estimates were higher than that for the other words. For ‘smashed’ it was 40.8, for ‘collided’ 39.3, while for ‘contacted’ the estimate was 31.8 miles per hour.

According to Loftus and Palmer, the speed estimate was moderated by the verb used to describe the intensity of the crash. The greater the intensity conveyed by the word, the higher the speed estimate to match it. The researchers did note that the estimate could be the result of demand characteristics. Since the participants were unsure of the speed, they offered a figure that they thought would be most suited for the purpose of the study. Again, the choice of verb acted as a cue to make the participant guess what range of speed the researcher might be looking for.

Figure 5.5 Speed estimates for the verbs in Experiment 1

In the second study participants were asked about the speed of the cars and about seeing any broken glass around the scene of the accident. See Table 5.2.

Table 5.3 Response to the question ‘Did you see any broken glass?’

The word ‘smashed’ which employs a more forceful impact, drew more than twice the ‘yes’ responses than when the word ‘hit’ was used.

This result indicates that questions can alter the memory of events and lead to distortions. One initial change in wording can have prolonged effects on memory. Loftus and Palmer offered the reconstructive hypothesis to explain the phenomenon: A person obtains two kinds of information about an event – the first is the information obtained from witnessing the event itself; the second is the information supplied or acquired after the event. If there is some difference between the two sources, integration of information can lead to memory distortions.

How did this study contribute to understanding human behaviour?

The findings of this study have implications for examination of witnesses and how courts should consider eyewitness testimony. Questions that lead a witness to answer in a particular way lessen the accuracy of testimony given by witnesses to crimes. As demonstrated, a single change of word can bring significant changes in how an event is remembered.

4.2 Biases in Thinking and Decision-Making

Humans rely on intuitive thinking and take cognitive shortcuts resulting in a number of well- researched biases.

Human beings are not always rational thinkers. Instead, they rely on intuitive thinking and take cognitive shortcuts. We have already investigated System 1 thinking and the use of heuristics to make decisions that can lead to poor outcomes. Cognitive psychologists have investigated a wide range of cognitive biases, two of which are confirmation bias and illusory correlations.

Confirmation bias is defined as the tendency to seek out information to confirm what you already believe. We unintentionally look for material that supports our opinions and tend to overlook evidence that does not support our viewpoint. When we consider evidence, we tend to interpret it to support our views. Our memories are also affected as we tend to selectively recall information that reinforces our views.

Imagine you are writing an essay on refugees. You believe nations should do all that they can to help these people in need. The tendency will be for you to search for information that supports your view and give lesser weight to any evidence that argues against refugee programmes.

Nickersen (1998) reviewed investigations of the confirmation bias and concluded that it is problematic, pervasive and strong. So powerful is the bias that he was doubtful you can give fair consideration to a belief that opposes your viewpoint. He advises that making people aware of the bias can help guard against it, as can encouraging people to adopt an alternative hypothesis as early as possible in the thinking process.

Ask Yourself When you studied approaches to research you examined the term ‘experimenter bias’. Is this bias related to confirmation bias? Why? Why not?

Hill et al. (2008) investigated the role of confirmation bias in interviewing a suspect to a crime. They designed a study to examine whether an expectation of guilt on the part of the interviewer influenced their behaviour. Sixty-one undergraduate students were asked to make up questions they wanted to ask a person suspected of cheating. Before they wrote their questions, they were either led to believe that the suspect was guilty or that they were innocent. Those participants who had heard that the suspect was guilty formulated more questions that presumed the suspect was guilty than presumed the suspect was innocent. These results indicate that expectations of guilt can have an effect on questioning style.

An illusory correlation is a belief that two things are associated when there is no actual or only a minor association. Imagine a situation where a person concludes Chinese students are better at studying maths because they knew a couple of Chinese students who won an international maths competition. They may be making an illusory correlation. This belief could then be reinforced by the confirmation bias. The person ignores other students from different races who are also good at maths while ignoring Chinese students who are average or poor maths students.

Hamilton and Rose (1980) investigated illusory correlations in the maintenance of social stereotypes in three experiments with seventy-three male and seventy-seven female high school and undergraduate students and adults. In the first experiment, participants read sets of sentences that described different occupations with pairs of adjectives. For example doctors (thoughtful, wealthy), and salesmen (enthusiastic, talkative). Other non-stereotypical traits were included such as boring, clever, demanding and courteous. In the second experiment, the trait adjectives were either consistent with stereotypic beliefs about one of the occupational groups or unrelated to the group’s stereotype; in the third study, traits were either inconsistent with or unrelated to a group’s stereotype. Participants estimated how frequently each of the trait adjectives had described members of each of the occupational groups. Each study revealed systematic biases in the participants’ judgements so that the perceived correlation between traits and occupations was more congruent (congruent = similar to or in agreement with something) with existing stereotypical beliefs than the actual correlation. Findings indicate a cognitive bias in the processing of new information about social groups that are influenced by existing stereotypes.

The study shows an example of stereotypical thinking . Hamilton and Rose (1980) argued that illusionary correlations are triggered when two fairly infrequent situations or events occur together. The observer’s heightened attention to these events results in them being better encoded and remembered. As we know from the availability heuristic the more easily a memory is retrieved, the more it influences our thinking. We tend to overestimate the frequency of these events. For example, if we see a car driven by a young man mount a pavement and narrowly miss hitting a child, we only need to see a young man driving a little erratically a few days later to become convinced that ‘all young people are bad drivers’. Illusory correlations can lead people to remember information that confirms the expected relationship.

Risen et al. (2007) conducted four studies to explore the phenomenon of ‘one-shot’ illusory correlations. These correlations were formed from a single instance of unusual behaviour by a member of a rare group. In Studies 1, 2 and 3, unusual behaviours committed by members of rare groups were processed differently than other types of behaviours. They received more processing time, prompted more attributional thinking, and were more memorable. In Study 4, the authors obtained evidence from two implicit measures of association that one-shot illusory correlations are generalised to other members of a rare group.

The results suggest that one-shot illusory correlations arise because unusual pairings of behaviours and groups uniquely prompt people to consider group membership as the explanation of the unusual behaviour. (i.e. ‘The only reason for this strange behaviour must be that they are members of this particular unusual group’).

4.3 Assessment Advice: Reliability of Cognitive Processes

Psychological and neuroscientific research has revealed that emotion and cognition are intertwined. Memories of emotional events sometimes have a persistence and vividness that other memories seem to lack, but there is evidence that even highly emotional memories may fade over time.

Psychological and neuroscientific research has revealed that emotion and cognition are intertwined. Emotions involve physiological changes like arousal but we may not be fully aware of these biological events. They also involve a subjective feeling of the emotion and associated behaviours. These emotions perform an adaptive function as they shape the experience of events and guide the individual in how to react to events, objects and situations regarding personal relevance and well-being.

To understand how emotions influence cognitive processing this section will focus on memory. In general, emotional episodes tend to be better remembered. We tend to pay close attention to them as they connect us to important people and issues in our lives. These connections increase the strength of the memory. The biological changes associated with emotions also facilitate how memories are consolidated.

Freud’s theory about repression was an early attempt to understand how emotions affected memory. Levinger and Clark (1961) set out to test this theory by looking at the retention of associations to emotionally charged words, such as ‘quarrel’, ‘angry’ and ‘fear’, compared with the retention of associations to neutral words like ‘cow’, ‘tree’ and ‘window’. When participants were asked to give immediate free associations with the words, it took them longer to respond to the emotionally charged words, and their galvanic skin responses were higher. (Galvanic skin response is a method of measuring how the skin conducts electricity, which varies according to its moisture level. Galvanic skin responses are a way of measuring psychological stress or arousal). Immediately after the word association tests, participants were given the words again and asked to remember the associations. They still had difficulty remembering the associations to the emotionally charged words. This study supports Freud’s repression hypothesis.

Brown and Kulik (1977) aimed to test their theory that flashbulb memories are more vivid and more accurate than normal memories. They conducted questionnaires of eighty US participants, forty African Americans and forty Caucasians, between twenty and sixty years old. (Note that there are two types of surveys: interviews and questionnaires. For the purpose of DP psychology, surveys within the qualitative approach will refer to interviews, while surveys within the quantitative approach will refer to questionnaires.) The participants answered questions regarding ten different important events. Nine events were public and most related to assassinations or attempts to kill well-known personalities. The tenth event was of a personal nature. They were asked to recall where they were and what they were doing when they first heard the news of each event. They were also asked to indicate how often they had rehearsed information about each event. The researchers found the assassination of President Kennedy generated the most flashbulb memories, with 90% of participants recalling where they were and what they were doing when they heard the news. Most participants’ personal flashbulb memories related to the death of a parent. They concluded the level of emotional arousal determined whether a memory was a flashbulb one or not and these findings supported their theory.

Subsequently, psychologists have questioned the idea that flashbulb memories are a special category of memory. The challenge for researchers is determining whether these memories as described by participants are accurate.

In order to test the theory of flashbulb memory, Neisser and Harsch (1992) interviewed participants about the 1986 Challenger space shuttle disaster , one day after it happened and again two-and-a-half years later. One day after the event, 21% of participants reported hearing about the disaster on TV. But two-and-a-half years later, 45% reported hearing about it on TV. Their memories of how they knew about the Challenger explosion had changed over time. In the second interview, some of the participants incorrectly reported where they were when they first heard of the disaster. Neisser and Harsch concluded that although flashbulb memories are vivid and long-lasting, they are not always reliable.

Parkin et al. (1982) replicated Levinger and Clark’s study but challenged their conclusion. While Levinger and Clark tested participants immediately after asking them to recall associations, Parkin added a time delay: participants were asked to recall their associations seven days after the original test. They found that emotions did reduce immediate recall, but one week later the associations to the emotionally charged words were remembered better than those relating to the neutral words. These results refuted the theory of repression.

Further research into how emotion can affect cognitive processes has focused on flashbulb memory theory (FMT). Flashbulb memories are defined by Brown and Kulik (1977) as memories of highly charged emotional information. They tend to be more vivid, long-lasting and accurate than other memories. They theorised that these events are maintained in a unique memory store through discussion and rehearsal.

Talarico and Rubin (2003) conducted a study to investigate FMT theory. On 12 September 2001, fifty-four university students recorded their memory of first hearing about the terrorist attacks of September 11th in New York and also their memory of a recent everyday event. This is the first study into flashbulb memory that has used the memory of an everyday event as a control. Participants were interviewed again either one, six or thirty-two weeks later. Consistency for the flashbulb and everyday memories did not differ, in both cases declining over time.

However, self-ratings of vividness, recollection and belief in the accuracy of memory declined only for everyday memories. Initial emotion ratings correlated with a later belief in the accuracy, but not consistency, for these flashbulb memories. Initial emotional ratings also predicted later post-traumatic stress disorder symptoms. The researchers concluded that flashbulb memories are not special in their accuracy, as previously claimed, but only in their perceived accuracy.

In summary, the current view of FMT is that emotions enhance the vividness of the memory and confidence in the reliability of that memory. The true question is not why flashbulb memories are so accurate because they are not, but why people are so confident for so long in the accuracy of their flashbulb memories.

5.2 Assessment Advice: Emotion and Cognition

6. Cognitive Processing in a Technological (Digital/Modern) World

Cognitive process in the technological (digital/modern) world (HL only)

Remarkable advances in technologies in the last few decades have seen a dramatic increase in the distribution and use of information encoded as digital sequences. How this digital world impacts cognitive processes is an HL extension topic. In particular, you will study:

The influence (positive and negative) of technologies (digital/modern) on cognitive processes.

Methods used to study the interaction between technologies and cognitive processes.

How digital technology affects cognitive processes and human interaction is a controversial topic. Both positive and negative effects have been the subject of research. On the positive side, some argue digital technology can enhance cognitive functioning. For example, video gaming can improve perception, mental rotation skills, visual memory, attention, task-switching, multi-tasking and decision-making. On the negative side, some contend that digital technology can lead to distraction, reduced attention spans, a sense of social isolation, scattered thinking and a decline in the ability to think analytically.

Memory has been the focus of several investigations. For example, Sparrow et al. (2011) were interested in how search engines might affect memory. They likened these search engines to external memory sources accessible when information is needed. In this way, digital technology is changing the way information is stored. You may not remember the information, but you do know where you can find that information when necessary.

Sparrow et al. were confident that memory is adapting to new computing and communication technology and they reached this conclusion after a series of experiments. The researchers showed participants trivial pieces of information, for example ‘an ostrich’s eye is bigger than its brain’. These statements were then typed into a computer by the participants. Half the participants believed what they typed would be saved while the other half were informed the information would be lost. Participants who believed the information would be lost recalled more statements than the participants who were told that the information would be saved.

Additional experiments followed the same set of procedures but this time the computer responded either by saying ‘Your entry has been saved’, ‘Your entry has been erased’ or ‘Your entry has been saved to…’ followed by a folder name. Each person was then shown a list of statements and asked two questions: ‘Have you seen this fact before?’, ‘Was this fact saved or deleted?’ or ‘Where was this fact saved?’

When a fact had been flagged as one that the computer erased, participants had a better memory of the fact itself. However, when the computer told them that the fact had been saved and where it had been saved, they more accurately remembered that it had been saved and where it had been saved compared to remembering the fact itself.

Based on these results the researchers challenged simplistic arguments that digital technology is detrimental (detrimental = make something worse) to cognitive processes like memory. Some people argue that knowing where to find information, which is almost immediate with a digital device in our hands, critically evaluating that information, and then using the information in an analytical process is better than having a basic memory of the information. Especially in a learning (school) context, higher order thinking skills can be developed sooner with outsourcing some factual knowledge to ‘search engines’ because the testing of regurgitated factual information takes away time from developing higher order thinking skills.

Ask Yourself Do you think that the potential to ‘outsource’ information to digital devices has a positive or negative effect on cognitive processes? Why? Why not?

With the widespread use of search engines like Google, commentators used the term the ‘Google effect’ to describe the tendency to forget information that can be found readily online. Kaspersky Lab, an internet security company, used the term ‘digital amnesia’ to describe this process and they conducted a survey on their customers to understand the process.

Kaspersky Lab (2015) conducted an internet survey of 6,000 consumers aged from sixteen to over fifty-five. Males and females were equally represented, with 1,000 participants from each of the following countries: the UK, France, Germany, Italy, Spain and Benelux. Participants were asked to recall important telephone numbers. They were also asked how and where they stored information they located online.

An analysis of their data found that:

More than half of adult consumers could recall their home phone number, 53% of parents could recall their children’s phone numbers and 51% their work phone number.

One in three participants reported they were happy to forget or risk forgetting information they can find – or find again – online.

36% of participants reported that they would turn to the internet before trying to remember information.

24% reported they would forget an online fact as soon as they had used it.

The results were consistent across male and female respondents but higher rates of amnesia were prevalent in older age groups. The overall conclusion of the study was that connected devices enrich lives but they can result in digital amnesia.

Video games

How video games affect children and adolescents remains a contested and unresolved issue. Those who oppose video games argue they increase aggressive behaviour, bring social isolation and teach antisocial values. In addition, excessive video-gaming can adversely affect academic performance and lead to poor health. Others argue video gaming can improve cognitive functions including memory, spatial skills, pattern recognition, analysis and decision-making. No consensus has yet emerged from the psychological research.

The following study investigates video gaming and visual working memory (VWM) and argues that gaming can have positive outcomes. VWM is the ability to hold visual information in mind for a brief period. This information is used to navigate the visual world. The storage capacity of VWM is limited.

Blacker et al. (2014) theorised that video games could expand the capacity of VWM. Of interest were action video games as they provide the player with a complex and changing visual environment in which accurate visual memories often decide the player’s success or failure in the game. The hypothesis of the experiment was that exposure to games with rich visual environments over an extensive period would enhance VWM performance compared to games that did not involve rich visual environments.

Thirty-nine male undergraduates with a mean age of 20 were randomly assigned to an action game group or control group. The action game group played video games like ‘Call of Duty’, while the control group played games like ‘Sims’. Both groups played their games for one hour per day for 30 days. After training, the participants’ VWM was tested. Individuals who played on an action game showed significant improvement on measures of VWM capacity compared with those who played the control game. The investigators concluded that exposure to rich visual environments over an extensive period is a distinctive form of training that may allow individuals to extend the capacity of VWM.

Ask Yourself Were you surprised by these results? What are the limitations of this experiment?

Pei-Chi Ho, Szu-Ming Chung and Yi-Hua Lin (2012) investigated how visual cognition could enhance the development of a young child's learning, especially reading and writing. In particular they wanted to determine the extent to which augmented virtual reality technology could enhance creativity and learning.

The investigators developed an enhanced reality teaching tool called GoGoBox . The game was designed to engage a child's interest and stimulate the player's visual abilities, including visual discrimination, visual memory, visual form-constancy and visual closure.

The experimental design involved a pre-test followed by exposure to the GoGoBox followed by a post-test. The investigators used the Motor-Free Visual Perception Test-Revised (MVPT-R) to test the participants before playing the game and then again after 10 hours of playing sessions over five days. Twenty-seven participants were randomly selected from a kindergarten located in Taiwan. Ages ranged from five to six.

The average score on the MVPT-R increased from a pre-test of 59 to a post-test of 64 and was significant at p=<.05. The investigators concluded that digital learning system could enhance young children's cognitive skills.

https://www.euppublishing.com/doi/pdfplus/10.3366/ijhac.2012.0046

6.1 Assessment Advice: Cognitive Processing in a Technological (Digital/Modern) World

Further Reading

The Pamoja Teachers Articles Collection has a range of articles relevant to your study of the cognitive approach to understanding behaviour.

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Atkinson, R.C. and Shiffrin, R.M. (1968). Human memory: A proposal system and its control processes. In Spence, K.W. and Spence, J.T. (Eds.), The psychology of learning and motivation Vol. 2 (pp. 89–195). New York, NY: Academic Press.

Baddeley, A.D. (2000). The episodic buffer: A new component of working memory ? Trends in Cognitive Sciences , 4 , 417–423.

Baddeley, A. and Hitch, G.J. (1974). Working memory. In G.A. Bower (Ed.), Recent Advances in Learning and Motivation, 8 , 47–90. New York, NY: Academic Press.

Bartlett, F.C. (1932). Remembering: A study in experimental and social psychology. Cambridge, England: Cambridge University Press.

Beck, A.T. (1979). Cognitive therapy of depression. New York, NY: Guildford Press.

Blacker, K.J., Curby, K.M., Klobusicky, E. and Chein, J.M. (2014). Effects of action video game training on visual working memory. Journal of Experimental Psychology: Human Perception and Performance, 40 (5), 1992–2004.

Brown, R. and Kulik, J. (1977). Flashbulb memories. Cognition, 5 , 73–99.

Clark, S.R. (1990). Schema Theory and Reading Comprehension. (ERIC Document Reproduction Center, no. ED 325–802).

Cohen, G. (1993). Everyday memory. In G. Cohen, G. Kiss and M. LeVoi (Eds.), Memory: Current Issues (2nd ed., pp. 13–62). Buckingham, England: Open University Press.

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Fox C. (2006). The availability heuristic in the classroom: How soliciting more criticism can boost your course ratings. Judgment and Decision Making , 1 (1), 86–90.

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Kaspersky Lab (2015). The rise and impact of digital amnesia. Retrieved from https://blog.kaspersky.com/files/2015/06/005-Kaspersky-Digital-Amnesia-19.6.15.pdf

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Pei-Chi Ho, Szu-Ming Chung and Yi-Hua Lin (2012). Influences on children's visual cognition capabilities through playing ‘intelligent matrix’ developed by the augmented virtual reality technology, International Journal of Humanities and Arts Computing , Volume 6 Issue 1-2, Page 160-171, ISSN 1753-8548. Available Online Feb 2012].

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• Key learning aims

Introduction

Presenting problem, formulation, course of therapy, financial support, conflicts of interest, ethical statement, key practice points, using targeted cognitive behavioural therapy in clinical work: a case study.

Published online by Cambridge University Press:  14 January 2021

Research shows high levels of complex co-morbidities within psychiatric populations, and there is an increasing need for mental health practitioners to be able to draw on evidence-based psychological interventions, such as cognitive behavioural therapy (CBT), to work with this population effectively. One way CBT may be utilised when working with complexity or co-morbidity is to target treatment at a particular aspect of an individual’s presentation. This study uses a single-case A-B design to illustrate an example of using targeted diagnosis-specific CBT to address symptoms of a specific phobia of stairs in the context of a long-standing co-morbid diagnosis of schizophrenia. Results show the intervention to have been effective, with a change from a severe to mild phobia by the end of intervention. Clinical implications, limitations and areas for future research are discussed.

(1) There are high levels of co-morbid, complex mental health problems within psychiatric populations, and an increasing need for mental health practitioners to be able to work with co-morbidity effectively.

(2) Cognitive behavioural therapy (CBT) remains one of the most well-evidenced psychological interventions with a large amount of research highlighting the effectiveness of diagnosis-specific CBT.

(3) One way evidence-based diagnosis-specific CBT approaches could be utilised when working with more complex co-morbidity may be to target an intervention at a specific set of symptoms.

(4) An example of using a targeted CBT intervention (to tackle a specific phobia of stairs in the context of a long-standing co-morbid diagnosis of schizophrenia and ongoing hallucinations) is presented. The outcomes show significant changes in the specific phobia symptoms, suggesting that CBT can be effectively used in this targeted manner within real-world clinical settings. The impact of co-morbid mental health difficulties on therapeutic process and outcomes are highlighted.

(5) The use of cognitive restructuring techniques was identified as key to engagement and therapeutic process, supporting the importance of including cognitive techniques in the treatment of phobias compared with purely behavioural exposure-based interventions.

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Research suggests that large numbers of individuals experiencing mental health difficulties meet criteria for multiple diagnoses, and thus are presenting with co-morbid difficulties (Kessler et al ., Reference Kessler, Berglund, Demler, Jin, Merikangas and Walters 2005 a; Kessler et al ., Reference Kessler, Chiu, Demler and Walters 2005 b; Nock et al ., Reference Nock, Hwang, Sampson and Kessler 2010 ). This has been found to be true not only for clients presenting with mood and anxiety difficulties, but also with personality difficulties (Lenzenweger et al ., Reference Lenzenweger, Lane, Loranger and Kessler 2007 ) and psychotic presentations (DeVylder et al ., Reference DeVylder, Burnette and Yang 2014 ; Kiran and Chaudhury, Reference Kiran and Chaudhury 2016 ). Thus, it is important for mental health practitioners to be able to work effectively with complex co-morbidities, and there is a need for research which highlights how evidence-based approaches can be implemented with this population.

Cognitive behavioural therapy (CBT) remains one of the most well-evidenced forms of psychological intervention, with a well-established evidence base showing it to be effective when working with varied presentations, including anxiety, mood and psychotic difficulties (Hofmann et al ., Reference Hofmann, Asnaani, Vonk, Sawyer and Fang 2012 ; Jauhar et al ., Reference Jauhar, McKenna, Radua, Fung, Salvador and Laws 2014 ; Trauer et al ., Reference Trauer, Qian, Doyle, Rajaratnam and Cunnington 2015 ). As such, it is critical for CBT to be appropriately utilised in mental health services, including when working with more complex, co-morbid presentations.

One way CBT may be useful when working with co-morbidity is to utilise transdiagnostic CBT approaches, for which there is a rapidly developing evidence base attesting to their effectiveness (Pearl and Norton, Reference Pearl and Norton 2017 ). Alternatively, CBT interventions could be utilised to target a particular aspect of an individual’s presentation, drawing on diagnosis-specific CBT interventions where appropriate. This approach may be especially appropriate where a specific aspect of an individual’s presentation is particularly debilitating or preventing engagement with their treatment more generally. There is a well-established evidence base attesting to the effectiveness of diagnosis-specific CBT interventions, thus utilising a targeted, structured CBT intervention offers one way diagnosis-specific CBT can be effectively utilised when working with complex co-morbidities.

Research has shown that CBT can result in symptom reduction when used in a targeted manner in the context of a wider, complex case (Dudley et al ., Reference Dudley, Dixon and Turkington 2005 ; Kayrouz and Vrklevski, Reference Kayrouz and Vrklevski 2015 ; Williams et al ., Reference Williams, Capozzoli, Buckner and Yusko 2015 ). However, more research replicating these sorts of findings, particularly in real-world settings, would be useful. In particular, research exploring some of the challenges involved in this targeted CBT approach is needed. When working with these complex, multi-faceted presentations, it seems likely that an individual’s co-morbid difficulties may impact on the therapeutic process and outcomes of the targeted CBT intervention. Research exploring this, particularly through drawing on specific clinical examples, would add to the existing literature and is likely to be of use to practitioners. It is this research gap that this study is looking to fill.

This case study describes the clinical treatment of a man presenting with a specific phobia of stairs alongside long-standing difficulties of delusions and auditory hallucinations. This study uses a single-case A-B design and seeks to contribute to the evidence base by detailing an example of how CBT can be used in a targeted manner to tackle a specific set of symptoms within a wider presentation of serious and co-morbid mental health difficulties.

Case introduction

This case study outlines a piece of CBT with Mr A (anonymised), a White British man in his 50s. Mr A lived alone in a ground floor flat, did not work and was moderately socially isolated. Mr A had been referred to the Community Mental Health Team (CMHT) in his early 20s, following experiences of delusions and auditory hallucinations. At that time, he had received a diagnosis of schizophrenia. These psychotic experiences had been ongoing since he received this diagnosis, and had resulted in a number of admissions to in-patient units. Mr A also met criteria for a specific phobia of stairs. The current clinical work began after Mr A was referred by his CMHT care co-ordinator to the Complex Psychological Interventions team for support with the phobia. At the time of treatment, Mr A was still experiencing regular auditory hallucinations and was being prescribed an anti-psychotic medication. He was receiving ongoing support from the CMHT multi-disciplinary team to manage these difficulties in the form of monthly visits from his care co-ordinator.

At assessment, Mr A reported experiencing high levels of anxiety in relation to stairs for 10 years. He reported experiencing anxiety both in relation to climbing and descending stairs, and at assessment could at most climb one stair if necessary. Mr A reported that this was significantly impacting his daily functioning, limiting his ability to do things he used to enjoy (such as go to coffee shops and museums, or go on holiday) and restricting his routine to a point where his social contact was significantly limited.

Mr A reported that these difficulties started following an incident where he fell down a flight of stairs 10 years ago. He reported that he sustained no significant injuries but became increasingly fixated on what could have happened from this fall (particularly, that he could have become permanently disabled). As such, Mr A reported experiencing increasingly high levels of fear when he encountered stairs and began avoiding using stairs as often as possible.

In assessment, Mr A identified a number of key cognitions triggered when encountering stairs, including: ‘I will fall and die if I go on the stairs’, ‘I will fall and become seriously disabled if I go on the stairs’ and ‘If I am disabled, I won’t be able to cope’. He also reported experiencing physical sensations, such as ‘wobbly legs’, ‘racing heart’ and ‘breathing changes’. Mr A reported several behaviours which he used to prevent the above feared responses occurring, including: avoiding stairs, limiting his routine to previously used routes, and holding on to something when using stairs.

Within assessment, some of the wider mental health difficulties that Mr A was experiencing were discussed, including his ongoing auditory hallucinations and low mood related in part to social isolation. However, it was collaboratively agreed to target our work at the specific phobia. As such, the later formulation and intervention work focused exclusively on Mr A’s phobic difficulties.

During assessment, Mr A highlighted his primary concern as the impact his fear of stairs was having on limiting his ability to engage with things that were important to him. Based on this discussion, three therapeutic goals for treatment were collaboratively set:

(1) For Mr A to be able to go up and down seven stairs by the end of treatment.

(2) For Mr A to have increased his confidence in his ability to cope with new stairs to 50% by the end of treatment.

(3) For Mr A to have restarted activities his phobia currently prevented, specifically going to coffee shops and the museum, by the end of treatment.

This case employed a single-case A-B design ( n = 1). The outcome measures were collected at three time points at baseline (A) and session by session during the intervention period (B).

Outcome measures

The primary outcome measure used was the Severity Measure for Specific Phobia – Adult (SMSP-A) (Craske et al ., Reference Craske, Wittchen, Bogels, Stein, Andrews and Lebeu 2013 ). This is a 10-item measure that assesses the severity of specific phobia in adults over the age of 18. Total score was used to represent severity of Mr A’s phobia. This is an emerging measure, and therefore there are limited data regarding its psychometric properties. However, it has been used in a number of studies, where it was found to be a useful measure of symptoms (LeBouthillier and Assmundson, Reference LeBouthillier and Asmundson 2017 ). The measure was collected on a weekly basis. Mr A was encouraged to complete this measure at home at a regular time-point in order to reduce possible measurement confounding variables and to prevent the therapist’s presence biasing findings.

At the time of the case study, no validated measures existed which were applicable to this form of specific phobia (as opposed to spider phobia or agoraphobia), created for adults and were felt to be therapeutically useful. Whilst the Fear Questionnaire was considered (Marks and Mathews, Reference Marks and Mathews 1979 ), this questionnaire is very brief and does not generate detailed information regarding phobia severity. Thus, it was felt that the SMSP-A was the best available measure at the time to track change, with the detailed nature of the measure allowing Mr A and the therapist to explore different facets of the phobia over time.

Singular items on the SMSP-A, items 3 and 6, were used to measure regularity of threat-related cognitions and avoidance of the phobic object. On these items, the client is asked to rate how regularly they have ‘had thoughts of being injured, overcome with fear, or other bad things’ (item 3) and ‘avoided, or did not approach or enter, these situations’ (item 6) on a Likert Scale from 0 to 4 (where 0 is never, and 4 is all of the time).

Additional idiosyncratic measures were collaboratively created by the therapist and Mr A of Mr A’s stair-confidence level and belief in threat-related cognitions. These were quantitative measures, scoring belief and confidence from 0 to 100%, with 0% representing no belief/confidence and 100% representing total belief/confidence. These were created in light of the key role threat-related cognitions and confidence level were hypothesised to play in the maintenance of Mr A’s phobia. These measures were created in the first therapy session as part of the formulation work. As such, no baseline measures could be collected prior to intervention.

The initial focus of therapy was the collaborative development of an idiosyncratic formulation by Mr A and the therapist. The formulation was generated by exploring a recent example of Mr A’s difficulties, and drew on Kirk and Rouf’s ( Reference Kirk, Rouf, Bennett-Levy, Butler, Fennell, Hackmann, Mueller and Westbrook 2004 ) evidence-based model of specific phobia (Fig.  1 ).

Figure 1. Cross-sectional formulation based on Kirk and Rouf ( Reference Kirk, Rouf, Bennett-Levy, Butler, Fennell, Hackmann, Mueller and Westbrook 2004 ) cognitive model of phobia (Kennerly et al ., Reference Kennerley, Kirk and Westbrook 2016 ).

It was hypothesised that Mr A’s difficulties were a result of his beliefs in relation to stairs. These thoughts were posited to have resulted from Mr A’s fall 10 years ago, which had led him to ruminate on and subsequently catastrophically over-estimate the threat level associated with stairs as well as under-estimate his ability to cope. It was hypothesised that Mr A’s interpretations of stairs as threatening and his coping ability as low were maintaining his phobic response (Raes et al ., Reference Raes, Koster, Loeys and De Raedt 2011 ; Shafran et al ., Reference Shafran, Booth and Rachman 1993 ; Thorpe and Salkovskis, Reference Thorpe and Salkovskis 1995 ).

A number of psychological processes were hypothesised to be maintaining Mr A’s catastrophic beliefs over time. Mr A reported ongoing hypervigilance in relation to stairs. It was hypothesised that this hypervigilance was increasing regularity of his phobic responses and subsequently reinforcing his threatening appraisals of stairs via selective attention to phobic triggers (Kirk and Rouf, Reference Kirk, Rouf, Bennett-Levy, Butler, Fennell, Hackmann, Mueller and Westbrook 2004 ; Mogg and Bradley, Reference Mogg and Bradley 2006 ). In addition, Mr A reported subsequently experiencing high levels of anxiety and apprehension, and physical sensations of anxiety (wobbly legs, muscular tension, heart racing, etc.) when encountering stairs. It was hypothesised these unpleasant emotional and physical responses might be reinforcing his belief that stairs were ‘dangerous’ and to be feared.

Finally, Mr A reported coping with these thoughts, feelings and sensations by avoiding stairs wherever possible. If he had to climb stairs, Mr A reported ensuring he held on to something and that he was the only one on the stairs to keep himself safe. These behaviours were formulated as safety-seeking behaviours which, whilst initially alleviating anxiety, prevented Mr A in the long-term from testing his cognitions. It was hypothesised that this may in turn be maintaining Mr A’s difficulties, by preventing updating of his stair-related beliefs (Kennerley et al ., Reference Kennerley, Kirk and Westbrook 2016 ). Mr A reflected that his avoidance of stairs caused a decrease in his confidence in relation to stairs. Mr A and the therapist hypothesised this lowered confidence may be reinforcing his threat-related cognitions and fuelling his hypervigilance (Kennerley et al ., Reference Kennerley, Kirk and Westbrook 2016 ).

It was recognised that some of these maintaining factors were likely to be augmented by Mr A’s co-morbid mental health difficulties. For example, as discussed above, Mr A was moderately socially isolated at the time of treatment, lacking a support network outside of the mental health team and a structured routine. Mr A reflected that this was a result of his psychosis affecting his functioning, and making it more difficult for him to maintain a routine and relationships over time. It was hypothesised that these factors facilitated Mr A’s avoidance, by reducing the necessity of him facing his phobia regularly, and thus may have further entrenched some of his phobic responses. This was held in mind moving into the intervention, as it was appreciated the lack of a robust support system might act as a barrier to treatment.

Treatment orientation

Based on the key role Mr A’s stair-related cognitions appeared to play in his difficulties, a cognitive behavioural approach to treatment was selected as opposed to a habituation-based exposure approach, as informed by NICE guidelines (National Institute for Health and Care Excellence, 2013 ), existing research (Choy et al ., Reference Choy, Fyer and Lipsitz 2007 ; Thng et al ., Reference Thng, Lim-Ashworth, Poh and Lim 2020 ; Wolitzky-Taylor et al ., Reference Wolitzky-Taylor, Horowitz, Powers and Telch 2008 ) and Mr A’s idiosyncratic formulation.

Mr A participated in 11 sessions over 12 weeks (one assessment session and 10 intervention sessions). Throughout the intervention, the therapist was guided by key CBT principles including collaboration and empathy, and utilised core techniques such as guided discovery and Socratic questioning (Kuyken et al., Reference Kuyken, Padesky and Dudley 2017 ). Additionally, homework was used throughout to build on the work done in session.

Sessions 1–2: formulation and psychoeducation

An idiosyncratic formulation was developed in collaboration with Mr A (Fig.  1 ). The accuracy of this formulation was tested out during, and in between, sessions 1 and 2 using in vivo exposure and through Mr A completing thought diaries. Any new insights were added into the formulation until Mr A felt it was an accurate reflection of his experience (Kuyken et al ., Reference Kuyken, Padesky and Dudley 2017 ). Psychoeducation was then completed on the effects of anxiety, with a particular focus on the physiological impact. This information was used to begin cognitive restructuring, particularly focusing on Mr A’s beliefs that the physiological symptoms of anxiety he experienced were indicative of the ‘dangerous’ nature of stairs. In addition, we began to discuss the ‘thinking traps’ associated with anxiety, and identify which of these might apply to Mr A.

Sessions 3–4: cognitive restructuring

Cognitive restructuring was used to update Mr A’s beliefs about the dangers associated with using stairs. This involved reviewing evidence for and against Mr A’s stair-related beliefs, via evidence gathered via collaborative information-gathering (for example, into the mortality rates of death by stairs), surveys (for example, exploring how often other people fell down stairs and how seriously they were injured from this), and reviewing Mr A’s own experiences of stair-use.

Sessions 5–9: behavioural experiments

In vivo behavioural experiments were carried out in session and as homework to test out Mr A’s beliefs in relation to stairs. These primarily focused on testing Mr A’s predictions in relation to what may happen if he reduced his avoidance of stairs and reduced the use of his safety behaviours (see Table  1 for examples). An emphasis was placed on identifying key learning from the experiments and cognitive restructuring from the behavioural experiments. As a CBT approach was being used as opposed to a habituation-based exposure model, a fear hierarchy was not constructed. Instead, the focus was on collaboratively designing experiments which would test out specific idiosyncratic beliefs. These behavioural experiments included consultation with a ‘stair expert’ (a physiotherapist).

Table 1. Examples of behavioural experiments completed in session and as homework

Session 10: relapse management work

Session 10 was spent reflecting on therapeutic process, identifying key learning and what had been most helpful about the intervention. This was then incorporated into a collaboratively written therapeutic blueprint. Mr A highlighted the collaborative approach to therapy, as well as the development of a shared understanding of his difficulties, as key in helping him make positive changes. He reported finding this enabled insight into why he might be struggling, and what he could do to empower himself to overcome his difficulties. In addition, Mr A reported that the incorporation of discursive cognitive restructuring was beneficial prior to engaging in the behavioural experiments, as they introduced enough doubt in relation to his beliefs to allow him to feel more comfortable about engaging with the behavioural experiments.

Impact of co-morbid complexities on the intervention

The context of Mr A’s co-morbid difficulties was noted to impact on the process of the intervention in a number of ways. Mr A’s lack of a robust support network, in part a result of Mr A’s longer standing mental health difficulties, presented some challenges around engagement. Typically, we may hope that a client’s social network would enable the person to engage in treatment, particularly providing support at more challenging aspects of the intervention. Without this, it was noted that more work had to be done on motivating Mr A to remain engaged with the intervention, with particular attention having to be paid to supporting Mr A to generalise learning from the sessions and engage in tasks at home. Furthermore, Mr A’s lack of a varied daily routine meant his organic opportunities to challenge himself around his phobia were limited. As such, Mr A had to actively seek out opportunities to complete homework tasks which presented an additional level of challenge. In addition, the impact of Mr A’s voices on his sleep, as well as his medication, resulted in some cognitive challenges to therapy, including clarity of thought, processing speed and thus his ability to understand concepts being raised. Moreover, his longer-term psychotic experiences appeared to have left Mr A feeling less confident in himself, and thus set-backs in therapy appeared to have a more significant emotional impact than otherwise might be expected.

Throughout the intervention there was a general sense that due to the impact of Mr A’s complex co-morbidities on his life the social and internal resources he held were more limited, which in turn made engaging in therapy more challenging. Thus, there was a need for the therapist to intentionally spend more time building Mr A’s internal motivations for therapy, as well as his confidence and resilience to set-backs, to account for this lack of resources which may have enabled him to do this otherwise. This highlighted the need to consider how co-morbidities might indirectly effect the specific symptoms being targeted through impacting wider functioning and the resources an individual can draw on to engage with this treatment episode. There may be a greater need to focus on engagement when working with these complex cases, as more barriers to engagement may be encountered by this client group with less resources present which enable these to be overcome.

Mr A’s symptoms of specific phobia showed some fluctuation at baseline (phase A). Mr A reported that this accurately reflected how his difficulties could ‘vary from week to week’, depending on encountered triggers. Mr A’s average raw score on the SMSP-A was 32, indicating a severe phobia at baseline (Craske et al ., Reference Braga, Reynolds and Siris 2013 ).

Mr A’s scores on the SMSP-A reduced over the course of therapy, with a reduction from an average score of 32 at baseline to 9 in session 11, indicating a change from a severe to mild phobia (Craske et al ., Reference Craske, Wittchen, Bogels, Stein, Andrews and Lebeu 2013 ) (Fig.  2 ). This suggests that Mr A’s overall phobia symptomology was significantly lower by the end of treatment.

Figure 2. Changes in SMSP-A score throughout treatment.

Reductions were seen on all measure items, with changes of particular note seen on items 3 and 6. A clear reduction was seen on both items, from an average score of 4 at baseline, to 1 in the final session on item 3, and an average score of 3.3 at baseline to 0 in the final session on item 6 (Fig.  3 ). These changes are important given the important role threat-based cognitions and avoidance were hypothesised to play in Mr A’s phobia maintenance (Kirk and Rouf, Reference Kirk, Rouf, Bennett-Levy, Butler, Fennell, Hackmann, Mueller and Westbrook 2004 ). This link between these aspects of Mr A’s presentation and his overall phobia severity is reflected in the comparative changes noted between items 3 and 6, and Mr A’s overall scores on the SMPS-A. In particular, there appears to be a clear parallel between the regularity of Mr A’s threat-cognitions, and his overall phobia symptoms, supporting the key role of these beliefs in his phobia as posited in the original formulation. In addition, this reduction in avoidance reflected in the measure changes is likely to have wider implications for Mr A’s wellbeing than changes in his phobia symptoms alone. In particular, a reduction in avoidance is likely to open up more opportunities for enjoyable activities and social engagement than previously were an option for Mr A. It is likely that this will have a wider impact on Mr A’s wellbeing and may enable improved mood as well as impacting positively on his ongoing psychotic symptoms.

Figure 3. Changes on SMSP-A item 3 (regularity of threat-cognitions) and item 6 (regularity of avoidance) throughout treatment.

Interestingly, a slight spike is seen in symptoms between sessions 4 and 5, followed by a significant reduction in symptoms in session 6. It was hypothesised this might reflect a temporary increase in anxiety following Mr A beginning to engage in the interventive behavioural experiments. It is not unexpected that this might cause an initial increase in anxiety, as the safety behaviour of avoidance had been reduced. However, this seemed to quickly resolve, perhaps reflecting the cognitive restructuring that would have occurred after Mr A engaged in the experiments and did not experience harm.

Changes were also seen on the idiosyncratic measures designed by the therapist and Mr A. In line with changes noted above, a clear reduction in belief of threat-cognitions was seen across sessions, with a decrease from 90% in session 1 to 8% in session 11 (Fig.  4 ). As above, a similar trend can be seen in the reduction of Mr A’s belief in his threat-cognitions, and his overall phobia symptom level. This again is likely to reflect the key role of Mr A’s threat-cognitions within his phobia, as posited in the formulation. Interestingly, however, we do not see a spike in Mr A’s belief levels from sessions 4 to 5, as is seen on his general symptom scores. This may reflect that a change in belief levels alone is not enough to result in symptom change. Rather, this must be combined with a reduction in avoidance and behavioural changes to embed this cognitive learning further. This supports the use of both cognitive restructuring and exposure-based interventions found within CBT treatment of phobias.

Figure 4. Changes in idiosyncratic belief rating of threat-cognitions throughout treatment.

Moreover, Mr A’s self-rated confidence level increased during treatment, from 0% in session 1 to 70% in session 11 (Fig.  5 ). Interestingly, whilst we did not measure this and it was not a treatment goal, Mr A did provide informal feedback that his general self-confidence and self-efficacy had positively increased from this treatment episode. Thus, it appeared the intervention may have had a further reaching impact on Mr A’s general wellbeing as opposed to only specifically impacting on the targeted symptom set.

Figure 5. Changes in idiosyncratic ratings of confidence throughout treatment.

By the end of therapy, Mr A had achieved all his goals. He had managed to climb seven stairs, his confidence had risen to 70% and he was re-engaged in his identified enjoyable activities.

This case study describes a piece of CBT work targeted at symptoms of a specific phobia of stairs in the context of a client with a long-standing co-morbid diagnosis of schizophrenia. Findings showed that the therapeutic approach was effective, with significant reductions seen in overall phobia symptoms, showing a clinically significant change from severe to mild phobia by the end of treatment. These findings cohere with other case studies where significant improvements to targeted symptom sets were seen following CBT treatment despite wider complexity (Dudley et al ., Reference Dudley, Dixon and Turkington 2005 ).

Clinical implications

This study has a number of implications for clinical practice. It not only adds to evidence that CBT interventions can be utilised effectively in this targeted manner, but also gives a detailed example of how this approach can enacted within clinical practice. This piece of work focused exclusively on Mr A’s specific phobia, and as a result a diagnosis-specific treatment approach was followed, which resulted in significant improvements to Mr A’s phobic symptoms. This indicates that diagnosis-specific CBT can be effectively used in a targeted manner within the context of existing co-morbid presentations. It also highlights that formulation and intervention can be useful when deliberately focused only on one aspect of an individual’s wider difficulties without looking to integrate understanding of that symptom set within a more thorough shared formulation. In fact, explicitly focusing on a specific aspect might be experienced as more containing and accessible for clients, particularly if their own experience of their mental health difficulties is that they are complex and overwhelming. Certainly, Mr A reported a desire within our sessions to focus exclusively on his phobia symptoms within this therapeutic episode, expressing that this helped him feel the issue we were tackling was manageable. Thus, this case study highlights one way in which clinicians can consider applying CBT theory when working with complexity and co-morbidity in their practice.

This case study highlighted the reciprocal nature of co-morbid mental health difficulties, and importance of holding this in mind when considering treatment approaches. The context of Mr A’s complex co-morbidities was noted to impact on the process of therapy, particularly around the need for the therapist to adopt a more fundamental role in intentionally building the internal resources necessary to allow meaningful engagement. Moreover, the outcomes of this specific targeted intervention appear to have a more far-reaching impact on Mr A’s general mental wellbeing than just on his phobia, with Mr A indicating his general levels of confidence and self-efficacy had increased within therapy. This highlights how additional complexities can both make targeted CBT treatment approaches more challenging, but also the wider reaching positive impact these approaches can have when carried out successfully. Moreover, it highlights the importance of the therapist holding in mind the wider complex context even when this is not the focus of the treatment, as this will alter how the individual will engage in treatment.

It may be that this targeted clinical approach is particularly appropriate where certain symptoms are impeding a client’s ability to engage more widely in their treatment and preventing general recovery goals being met. Prior to this intervention, Mr A’s phobia was limiting his functioning to a point where he was unable to partake in behavioural activation and social engagement initiatives which were felt to be important for his wider psychological recovery. This targeted intervention enabled changes with regard to a specific symptom set which in turn had wider ripple effects on his recovery journey more widely, and thus whilst a targeted therapeutic intervention might not serve as the whole of a client’s treatment, it may be a useful stepping stone which enables clients to engage with their recovery plan more effectively and reach their goals. Certainly, this coheres with studies showing diagnosis-specific CBT to have transferable effects to co-morbidities that a client may be experiencing (Allen et al ., Reference Allen, White, Barlow, Shear, Gorman and Woods 2010 ; Bauer et al ., Reference Bauer, Wilansky-Traynor and Rector 2012 ; Dudley et al ., Reference Dudley, Dixon and Turkington 2005 ;). Thus, it might be beneficial for clinicians to consider using a targeted intervention where their wider case conceptualisation suggests that a particular set of difficulties may act as a therapeutic barrier for recovery (for example, in a case where a client’s agoraphobia prevents them engaging in behavioural activation that might address their primary presenting symptoms of depression).

This case also highlights the benefits of approaching cases from a multi-disciplinary perspective. It would be difficult to work in the above-described focused therapeutic way if any complex or co-morbid difficulties were not being appropriately held by the wider team around the client, particularly where there are issues of risk. Having the multi-disciplinary structure allowed the therapist to utilise their specific skill set to work most effectively with the client on the identified issue. Thus, this case highlights the usefulness of taking a multi-disciplinary team approach to treatment particularly with complex cases, to provide space for different professionals to focus their work with these clients.

Finally, it was interesting to note that Mr A highlighted the usefulness of cognitive restructuring techniques as enabling him to feel more able to engage in the behavioural experiments that served as a key aspect of the intervention. Certainly, studies have found that whilst in vivo exposure work seems to result in significant symptom changes for phobic presentations, there are high rates of drop-out in exposure-based therapy, and that including cognitive restructuring alongside in vivo exposure can make therapy more tolerable to clients and reduce this rate of drop-out (Botella Arbona et al ., Reference Botella Arbona, Bretón-López, Serrano Zárate, García-Palacios, Quero and Baños Rivera 2014 ; Choy et al ., Reference Choy, Fyer and Lipsitz 2007 ; Foa et al ., Reference Foa, Hembree, Cahill, Rauch, Riggs, Feeny and Yadin 2005 ; Li and Graham, Reference Li and Graham 2020 ; Mattick et al ., Reference Mattick, Peters and Clarke 1989 ). Thus, this study further supports that cognitive restructuring could serve a key role in facilitating engagement within the psychological treatment of specific phobia.

Limitations

It is important to note the limitations of this study. As a single case study, these findings lack replication and thus it is unclear how far findings can be generalised. Further research replicating these findings is needed. In addition, future studies would be strengthened by including a longer, staggered baseline.

It is also important to note that baseline measures were gathered during the assessment period. On the one hand, it is possible this may have confounded scores by contact with the therapist, and thus is a limitation of the design. However, on the other hand, it allowed a shared consensus between the therapist and Mr A on what the main difficulties were and allowed selection of measures that best captured these. Thus, whilst this might have limited the strength of the design somewhat, this was with a trade-off of more idiosyncratically appropriate measures being selected.

Mr A was receiving ongoing input from the multi-disciplinary team during treatment in the form of anti-psychotic medication and monthly visits from his care co-ordinator. As such, it is difficult to delineate the impact of this intervention on Mr A’s phobia symptoms compared with the impact of this wider care. However, Mr A had been receiving input of this type for a number of years without showing progress in his phobia and no changes to Mr A’s medication were made during this therapy episode. Thus, we may tentatively argue that a proportion of Mr A’s improvements are likely to have resulted from the above-described intervention.

Finally, the lack of follow-up data is an important limitation to note. However, this case study nonetheless is an interesting first step highlighting the important role targeted CBT can play in clinical work. Further follow-up research addressing the above identified limitations is needed to build on this.

Reflections

We were aware during assessment of Mr A how complex and long-standing his history of mental health difficulties and interactions with mental health services were. We were mindful of a pull to explore these wider aspects of Mr A’s experiences, and a desire to address those complexities within the current intervention and formulation. It was interesting to reflect that a potential barrier to completing this targeted intervention could therefore have been our own therapeutic curiosity and need to make sense of the whole picture. However, drawing on those core CBT principles of collaborative and shared meaning-making helped maintain our focused approach, as working specifically on the phobic symptoms was identified by Mr A as his primary wish. Ensuring a balance was maintained between remaining targeted in the CBT work, whilst also adapting to any additional challenges raised by the complex context within which the treatment was occurring, was a particularly challenging aspect of this work. Generally, we found working in a multi-disciplinary manner allowed us to maintain focus on how this intervention fitted into Mr A’s wider recovery plan, and thus ensure the targeted approach was maintained. Working as part of the wider multi-disciplinary team enabled us not to take responsibility for Mr A’s recovery plan as a whole, but rather specifically focus our skills on the particular contribution we could most usefully make. It feels like this is particularly effective as an approach for complex clients, with the multi-disciplinary environment enabling different professions to make distinct, useful contributions using their specific skill sets and thus ensure the best overall recovery plan is enacted for the client.

Acknowledgements

We would like to acknowledge Mr A for his hard work and bravery throughout therapy, and thank him for permitting the submission and publication of an anonymised account of his therapy by the research team.

This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

The authors have no conflicts of interest with respect to this publication.

No specific ethical approval was required for this work, as it was an evaluation of a piece of routine clinical practice. Researchers have abided by the Ethical Principles of Psychologists and Code of Conduct as laid out by the British Psychological Society and British Association for Behavioural and Cognitive Psychotherapies. Informed consent was given by Mr A both to participate in therapy, and for this work to be written up and submitted for publication. Identifying details and names have been changed to ensure Mr A’s confidentiality is maintained.

(1) CBT can be effectively utilised to target particular aspects of an individual’s presentation when they are experiencing complex or co-morbid difficulties.

(2) Using targeted CBT might be a particularly useful technique where specific symptom sets are preventing an individual from being able to engage more fully in their treatment or reach recovery goals. Here, using a targeted intervention to first tackle the aspects of an individual’s presentation that might act as therapeutic barriers may enable improvements more generally in the client’s mental health.

(3) This case study highlights the utility of a multi-disciplinary approach in relation to complex cases. Utilising an MDT allows professionals to maximise their specific skill-sets by focusing their input to a client.

(4) The use of cognitive restructuring techniques were experienced as therapeutically beneficial, and enabled the client to engage more confidently in later behavioural experiments. This suggests that including cognitive techniques within phobia treatment, as opposed a pure habituation exposure-based treatment approach, might be clinically useful.

Further reading

Figure 1. Cross-sectional formulation based on Kirk and Rouf (2004) cognitive model of phobia (Kennerly et al ., 2016).

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• Olivia Harris (a1) , Claudia Kustner (a2) , Rachel Paskell (a1) and Chris Hannay (a3)
• DOI: https://doi.org/10.1017/S1754470X20000586

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Case Series in Cognitive Neuropsychology: Promise, Perils and Proper Perspective

Brenda rapp.

Department of Cognitive Science Johns Hopkins University

Schwartz & Dell (2010) advocated for a major role for case series investigations in cognitive neuropsychology. They defined the key features of this approach and presented a number of arguments and examples illustrating the benefits of case series studies and their contribution to computational cognitive neuropsychology. In the Special Issue on “Case Series in Cognitive Neuropsychology” there are six commentaries on Schwartz and Dell (2010) as well as a response to the six commentaries by Dell and Schwartz. In this paper, I provide a brief summary of the key points made in Schwartz and Dell (2010) and I review the promise and perils of case series design as revealed by the six commentaries. I conclude by placing the set of papers within a broader perspective, providing some clarification of the historical record on case series and single case approaches, raising some cautionary notes for case series studies and situating both case series and single case approaches within the larger context of theory development in the cognitive sciences.

Schwartz & Dell (2010) presented a number of arguments and examples in advocating for a major role for case series investigations in cognitive neuropsychology. This Special Issue includes six commentaries on Schwartz and Dell (2010) (referred to as S&D), as well as a response to the six commentaries by Dell and Schwartz (D&S). My goal in this paper is to provide a backdrop for the complete set of papers. I will do so by first providing a brief summary of key points made in S&D, then I will discuss the promise and perils of case series design as revealed by the six commentaries; I will end by attempting to place the discussion within a broader perspective.

Schwartz & Dell (2010)

S&D begin with the premise that cognitive neuropsychology is primarily identified with the single case research approach. They argue that this is a highly limited view of the range of designs that are appropriate within cognitive neuropsychology and propose that the case series approach be promoted as a complement and alternative to the single case approach. They suggest that case series studies have already become increasingly more influential and valuable as interest in individual differences has grown and the application of statistical techniques such as correlation and regression used to exploit these differences has become more widespread.

The defining feature of case series design, as S&D describe it, is the goal of using patterns of co-variance to understand underlying cognitive mechanisms. In service of this goal, S&D describe the case series design as having the following key elements: a sample size suitable for identifying complex trends, the administration of a common set of cognitive tests that is fairly circumscribed (relative to what is common in single case studies) and generally lenient criteria for defining a sample (e.g., broad theoretically based or even clinical and neuroanatomical criteria). The motivation underlying the leniency in selection criteria is that heterogeneity is “deemed welcome and even necessary” (pg. 479) given the centrality of correlational-type analyses. The other major component of the S&D presentation is that case series studies are typically (although presumably not necessarily) associated with the quantitative evaluation of statistical or processing models/computer simulations of the cognitive systems under investigation. That is, case series studies often include a simulation component in which the data from the case series is used to evaluate a hypothesis or set of hypotheses that have been instantiated in a simulation.

S&D emphasize a distinction between the case series approach and other approaches involving multiple brain-damaged individuals. Critically, the case series design is different from group designs that average (or otherwise agglomerate) data across participants because, in the case series approach, individual participant data are still “visible” and readily recoverable. For this reason, the various problems with averaging that have been discussed extensively in the cognitive neuropsychological literature (e.g., McCloskey & Caramazza, 1988 ) do not apply to case series studies. S&D also draw a distinction between case series and what they refer to as “multiple-case” designs in which there is a concatenation of two or more single case studies. For S&D, the fundamental difference between the case series and multiple-case approaches concerns whether or not there is statistical analysis of the variability between multiple factors. S&D argue vigorously for the value of variability, a position which, they claim, stands in contrast with what they refer to as the orthodox approach in cognitive neuropsychology in which variability is seen as unhelpful.

In support of their position, S&D present examples of case studies research. They discuss their own work on lexical access in spoken word production ( Dell et al, 1997 ) in which they examined the relationship between the severity of naming impairment and rates of semantic and nonwords errors. Their finding of a systematic relationship amongst these variables led them to posit that lexical access deficits can be understood by positing disruption to a single global factor within the production system, a proposal they called the “globality assumption”. Another example is based on the work of Lambon Ralph and colleagues with individuals with semantic dementia (e.g., Lambon Ralph, et al, 2007 ). A key observation was the strong co-variation within and across verbal and nonverbal semantic tasks; this was taken as support for the hypothesis of amodal semantic representations. A third example discussed by S&D involves the work of Patterson and colleagues (e.g., Woollams, et al., 2007 ) in which the relationship between semantic impairment and exception word reading (surface dyslexia) was examined (primarily in individuals with semantic dementia). The finding of a strong association between severity of semantic impairment and difficulties in exception word reading was used to support the hypothesis that semantic mediation is required for exception word reading. In turn, this provided support for the PDP triangle theory of reading that posits a division of labor between semantic and phonological pathways to reading.

Each of these lines of behavioral research reviewed by S&D was accompanied by extensive computer simulation work. S&D suggest that the association of case series studies with simulation work is productive (although presumably not required). They imply that the availability of similar behavioral measures for a set of individuals lends itself well to the testing/ fitting of computer simulations of cognitive functions of interest. In the examples that S&D develop, the simulation work was used as a form of “demonstration” of the hypotheses under investigation as well as a source of predictions regarding further data patterns that should be observed. The fit between observed and modeled data was used to argue for the validity of the hypotheses instantiated in the simulations.

S&D go on to address what they correctly perceive as a key concern for case series design: heterogeneity in the set of individuals in a case series. That is, there is concern that individuals in a case series study may differ in ways that are relevant to the conclusions that are drawn. S&D argue that risks posed by heterogeneity are very significantly reduced in case series compared to group studies because the individual patterns are recoverable and aberrant patterns can be identified as outliers (e.g., Fischer-Baum & Rapp, 2012 ). S&D acknowledge that the proper treatment and, in particular, the interpretation of outliers is a complex matter and they discuss various possibilities. These include removing the outliers, using regression to limit heterogeneity and, importantly, the careful examination of the outliers via single case study. The careful study of the outliers via single case study allows investigators to understand the reasons for the observed heterogeneity. One consequence of this understanding may be a reformulation of the original hypothesis.

With regard to the role of single case studies, S&D acknowledge their independent contribution to the field as well as their role as a complement/supplement to case series. They conclude that, while they support an ever more significant role for case series studies in cognitive neuropsychology, the two approaches are complementary in the contributions they make to the study of human cognition.

The authors in this Special Issue all find at least some promising aspects of the case series design. Before describing these, it is worth first noting that Nickels et al. and Olson and Romani do not agree with S&D’s definition of case series itself. In particular, they reject the exclusion of the multiple case approach from the category of case series, arguing that multiple case approaches are often necessary and useful in circumstances similar to those which apply for case series (see also Shallice & Biuatti).

1-Certain types of hypothesis-testing require a case series design

Nickels, Howard & Best (this issue) argue that while certain types hypotheses can be tested with single cases, there are others that require data from multiple cases. While there is not unanimous agreement amongst the authors of this Special Issue with regard to the first claim, there is unanimous support for the second. That is, while there are different views on the role of single case studies in testing/disproving hypotheses, one thing that is clear is that the authors of the Special Issue agree that certain types of interesting hypotheses about cognitive processing do require case series data.

The most obviously relevant hypothesis type involves predictions of the following sort: as X increases (or decreases), Y should increase (or decrease). X and Y may be variables such as severity of naming impairment and rate of semantic and nonword errors ( Dell et al.; 1997 ), severity of semantic impairment and accuracy in reading exception words ( Woollams et al., 2007 ) or severity of sublexical damage and perseveration errors in spelling ( Fischer-Baum & Rapp, 2012 ). Given that the evaluation of these types of predictions requires multiple individuals who show different degrees of X, a case series design involving correlation and regression approaches would seem to be necessary.

Interestingly, Nickels et al. also point out the potentially important role of case series approaches in the evaluation of treatment efficacy. They note that randomized controlled trials suffer from the weaknesses that arise from group studies that engage in data averaging. Nickels et al. discuss how case series can be used profitably used in examining hypotheses related to treatment efficacy (e.g., Best, et al., 2002 ).

Finally, in a position that is not shared by all of the authors (see Nickels et al.), Lambon Ralph, Patterson, & Plaut (this issue) suggest that the case series approach plays an important role in documenting associations more generally. They note that, traditionally, it has been difficult to argue for shared cognitive functions on the basis of associated deficits in single cases, due to the alternative interpretation that the association arises simply from the coincidental neuro-anatomical adjacency of two functions. They argue that the case series design provides for stronger, “more secure” demonstrations of associations than is possible in single case studies.

2-Case series are consistent with “population thinking”

According to Bub (this issue), the tension in the field does not so much concern the issue of whether case series should or should not complement single case studies, but rather it concerns a more fundamental difference regarding assumptions about the basic nature of cognitive systems. Bub suggests that, on the one hand, there is a view that assumes that humans share a common cognitive architecture while, on the other hand, there is a view that assumes diversity in underlying cognitive architectures. He associates the former position with essentialist doctrine dating back to Aristotle, while the latter view he relates to “population thinking” that is prevalent among modern evolutionary biologists. This position assumes “no idealized blueprint underlies diversity and that lawful variation itself should be the goal of theory construction” (p. XX). Bub indicates that the single case approach is commonly associated with those holding the “universality assumption” ( Caramazza, 1986 ), while the case series approach lends itself naturally to the assumptions of population thinking. Furthermore, he seems to imply that, in this regard, case series design is on the leading edge of history.

Consistent with the “population thinking” view, Lambon Ralph et al. explicitly adopt the assumption that there is significant variability in human cognitive architectures (see also Shallice and Buiatti, this issue) and argue that, for this reason, case series should be the method of choice in cognitive neuropsychology. Specifically they claim that the case series design allows for the data reduction necessary to identify underlying central tendencies while, at the same time, providing a means for explaining variability within a population.

3-Case series design permits greater flexibility in selection criteria

Some authors, such as Olson & Romani (this issue) and Nickels, et al., quite explicitly state that selection criteria must be theoretically defined, and that, otherwise, investigators run significant risks of information distortion or loss. In contrast, S&D and Lambon Ralph et al. suggest that because analysis methods used in case series studies do not involve averaging and, therefore, do no obscure single subject results, one can be less concerned about violating assumptions of homogeneity. They propose that, for that reason, sample selection can be done in a more flexible and lenient manner, allowing broad theoretical, clinical and also neuro-anatomical criteria.

Neuro-anatomical selection criteria are of interest to a number of the authors. Interestingly, however, the various authors differ in terms of what they see as the positive outcomes of sample selection according to neuroanatomical criteria. S&D emphasize that studies based neuro-anatomical criteria provide improved understanding of the cognitive functions subserved by specific neural areas, while Lambon Ralph et al. suggest that this approach allows for a better integration of neuro-anatomical findings into cognitive theories. Shallice & Buiatti emphasize that the neuro-anatomically based inclusion approach provides various important benefits precisely because it does not involve behavioral criteria. Among these benefits, the neuro-anatomical approach limits the biasing of outcomes and interpretations that may arise when behavioral criteria used, it also provides opportunities to identify new functional syndromes and to fractionate others and, finally, the finding that certain behavioral patterns (e.g., better performance with animate vs. inanimate objects) are found in one neuroanatomically based group and not another limits the concern that the patterns are based on premorbid abilities and experiences.

4-Uniform behavioral evaluation facilitates testing computational models

None of the authors disputes that neuropsychological data can play an important role in theory building and in testing computational models. The question, therefore, is whether the cognitive neuropsychological data collected in case series has a special role to play in this enterprise. In this regard, S&D, Lambon Ralph et al. and Olson & Romani all refer to the importance of the standardization (or greater uniformity) of the data that is provided by case series studies. Because case series typically involve the administration of a common (relatively limited) set of tasks, similar measures are available for the evaluation and testing of computational models. The availability of the same set of measurements for a group of individuals provides a classical “data set” for model testing.

All of the papers recognize that there are at least some legitimate concerns regarding variability and heterogeneity in a case series. They differ, however, in terms of how serious they think the consequences of heterogeneity are, as well as in terms of how these concerns should be dealt with. In addition, several other concerns, summarized in this section, were expressed in multiple commentaries.

1-Selection criteria can bias outcomes

Both Nickels et al. and Shallice & Buiatti describe the possibility that the criteria used to select participants for the case series may bias the outcomes of the study and the conclusions drawn. Both papers describe examples of this problem and draw attention to the fact that the sample must include the deficit patterns that are necessary to test the hypotheses under consideration. Overly narrow selection criteria for the evaluation of a broad hypothesis will bias the outcomes. While this general point may seem obvious, the problems can often be subtle to discern and, arguably, the case series approach with the volume of cases and data it entails, may make these problems more difficult to detect.

2-Outliers: Finding them, dealing with them, and the consequences of failing to do so

Fundamental to correlation-based analyses and, therefore, to the case series approach is the requirement for variability amongst subjects along at least one of the measurement dimensions. Relatedly, however, are two major concerns: How, amongst the appropriate variability, are outliers to be identified? Once identified what should be done with them?

While many points related to these questions were raised in the commentaries, the crux of the matter was the possibility that consideration of outliers may lead a researcher to different conclusions than would be reached if only the primary trends in the data were considered. The underlying concern is that in case series studies it may be rather easy to ignore outliers, focusing instead on the majority pattern (see below for a related discussion on “What counts as a good fit?”). This concern is illustrated with an example that S&D present from their own work. Based on consideration of outliers, Schwartz et al. (2006) fundamentally changed the conclusions they had reached previously in Dell et al. (1997) regarding the globality assumption according to which there is a common source of error for semantic, nonwords and other errors in word production deficits. Consideration of outlier cases led Schwartz et al (2006) to the conclusion that, contra the globality assumption, spoken word production deficits can arise from differential disruption to specific levels of representation and processing within the production system. This exemplifies the important role of single case studies in “track(ing) down the deviations” (S&D, p. 489) that may be observed in a case series. Most of the other authors in this Special Issue supported this method of dealing with outliers. Essentially it allows researchers to shine a spotlight on outliers and obtain a better understanding of the reasons that differentiate them from the majority pattern. As Nickels et al. indicate, some outliers may turn out to be due merely to confounding factors, while others may represent a serious challenge that requires a different conclusion than one reached on the basis of the majority trend alone.

3-Individual differences: An easy way out?

One way to explain outliers and variability is to attribute them to pre or post-morbid individual differences. With regard to pre-morbid differences, S&D and Lambon Ralph et al. use as an example the Plaut (1997) claim that outliers that violated the majority pattern relating semantic integrity with exception word reading could be explained by positing pre-morbid differences in the reading architectures of the outlier individuals. As Goldrick (this issue)points out, and Lambon Ralph et al. concur, this type of explanation is purely speculative unless it is accompanied by independent evidence of the premorbid differences.

Goldrick also points to a more subtle problem that may arise in computational cognitive neuropsychological work, one that concerns the proper interpretation of post-morbid differences. In using a case series to test a complex hypothesis of a cognitive function, a common approach is to determine if a computational model of the cognitive function can be damaged in ways that will match the individual data points. There may be multiple ways of instantiating damage, for example, different parameters may be adjusted in different ways to generate the best fit to the data. The best-fit solution that is reached is, in essence, an account of the post-morbid differences in terms of the types or loci of disruption. In the work of Dell and colleagues, for example, the patterns of spoken production errors produced by each individual are accounted for by specific values of two parameters of the model. Goldrick points out that, the individual subject solutions that are reached in the process of model fitting do not typically have any independent behavioral motivation. In other words, a model’s attribution of performance patterns to parameters x and y is not typically supported by data (other than the data used in the model fitting) showing that the individual does, in fact, exhibit the features that would be expected from the disruptions “posited” by the simulation (see Olson & Romani for related concerns).

4-Theory testing: What counts as a good fit?

Both Goldrick and Olson & Romani argue that is not enough to show that a computational theory provides a good fit to a case series data set. That is, it is not enough to know that theory can predict X percentage of the variance in the data. Both papers stress that, instead, theory comparison is crucial and that this requires comparing the fit of the data from the case series to alternative theories. For this to work however, it is critical that the theories actually make different predictions regarding the data set being evaluated. To illustrate the importance of this point, Goldrick presents an example based on simulation data showing that determining whether theories actually make different predictions may be a non-trivial matter. Once one has identified theories that do make different predictions, there are different approaches to comparing the fit and parsimony of the alternative theories. Olson & Romani describe a number of these approaches (e.g., minimum description length, bootstrapping and Akaiake’s information Criterion).

Olson & Romani stress the importance in theory evaluation of considering the full range of a theory’s predictions. This requires determining the extent to which the full set of patterns that are predicted by the theory are, in fact, observed and whether or not patterns that are not predicted are not observed. In other words, it is not enough to simply compare the number of cases that are fit well by a theory versus those that are fit poorly; one must ensure that most of the cases are not simply “redundant” and test only a small area of a model’s predicted space of possibilities.

Proper Perspective

1-whoever said that the case series methods were a problem.

While it is difficult to disagree with S&D’s assertion that the cognitive psychology and neuroscience communities identify cognitive neuropsychology with single case studies, it is important to clarify the record in terms of what type of research has actually been carried out, and what has been advocated by leaders in the field.

First, as S&D themselves point out, case series studies have been carried out since quite early in the history of cognitive neuropsychology with papers such as Howard et al., (1984) , Patterson and Hodges (1992) , etc. These types of studies have continued to be steadily produced, although, it is quite true that they have represented a small proportion of papers in cognitive neuropsychology. There are many reasons for this but prominent among them are, most certainly, the difficulties involved in finding multiple relevant cases as well as the various interpretative and other perils that have been identified by the authors in this Special Issue.

Second, it is worthwhile to understand what has been written about single cases and group studies in the seminal papers dealing with this topic. In this regard, McCloskey and Caramazza, (1988) stated: “It is important at the outset to draw a distinction between two senses of the term group study…. Studies in which data are averaged across subjects, or otherwise aggregated in such a way that the performance patterns of individual subjects cannot be recovered from the aggregate results…. It’s this type of group study that we have argued is inappropriate in research with brain damaged patients. …..the term may also be used to refer to studies in which data from multiple cases, each of which maintains its individual identity, are brought to bear on the theoretical questions of interest……. addressing some sorts of theoretical questions requires the consideration of multiple cases (pg. 584).” It seems quite clear from this quote that the case series study is not the type of group study that was seen to be problematic. Furthermore, with regard to the role of single case studies in the broader enterprise of cognitive neuropsychology, in the same paper these authors wrote: “We have certainly never argued that all theoretically meaningful questions in neuropsychology can be answered by considering single-patients studies in isolation (pg. 613)”.

In sum, the promise of case series designs for cognitive neuropsychological investigation are well described in this Special Issue and the history of cognitive neuropsychology provides a record of support for this approach. Perhaps with the increasing and increasingly successful application of case series designs the perceptions of the available methods in cognitive neuropsychology will begin to change both within and outside of the field.

2-The universality assumption: Could the news of its demise by premature?

A bedrock assumption of the cognitive sciences is that humans have cognitive mechanisms that they share (at least at some level of description). This assumption is not incompatible with the existence of individual differences, something about which there is no dispute, even within the cognitive neuropsychology “orthodoxy” (e.g., see Caramazza, 1986 ). Thus the question is not whether or not there are individual differences, but rather whether the range of individual variation is such that it affects a researcher’s ability to test and discriminate between the hypotheses under consideration.

Clearly, an understanding of the nature and extent of individual differences in normal (premorbid) cognitive systems is important for research in cognitive neuropsychology and, for that matter, in all disciplines that deal with cognition: cognitive psychology, cognitive neuroscience, etc. In fact, this type of understanding would seem to be necessary before invoking premorbid variability as a possible explanation for heterogeneity of findings. Therefore, it is surprising that, despite the prevalence of “population thinking”, relatively little work has been done on understanding the extent and nature of individual variability with regard to the types of cognitive mechanisms commonly investigated in cognitive psychology and neuropsychology.

Only once normal variability is understood can we develop means for dealing with pre-morbid differences in cognitive neuropsychology. Given the many the potential sources of variability--measurement error, severity differences, as well as differences in underlying cognitive architecture--a failure to distinguish amongst these on the basis of independent evidence dramatically increases the risk of vacuous speculation. In their reply to the commentaries, D&S suggest that the same parameters manipulated in the modeling of impaired performance can be used for modeling premorbid differences across individuals as well as across items. While this parsimonious approach is certainly appealing, one should be concerned that trying to simultaneously account for pre-morbid individual differences and post-morbid variability within the same parameters allows for a great many degrees of freedom. Independent constraints will be essential for this type of enterprise, and a key component must be a deeper understanding of the range and nature of individual differences in the cognitive systems under investigation. Until we have this understanding, it may well be that the news of the demise of the universality assumption is indeed premature.

3-Case series: The risk of myopia

Although not raised in the commentaries, there may well be a risk that researchers carrying out case series studies will ignore cases outside their own series. Given the elegance of studying a set of individuals who have all been administered the same or very similar tests, there may a temptation to ignore potentially relevant single case reports, or even other case series studies that use different behavioral tasks or that differ in other ways. We can see examples of this in some of the work described in the commentaries. For example, Dell et al. (1997) proposed the globality assumption despite the existence of well-documented single cases in the literature that were at odds with it and then, in revising their position vis à vis the globality assumption, Schwartz et al (2006) focused on evidence from case series studies.

Of course, as several of the papers indicate, methodological and other differences across studies may make the integration of results sometimes difficult, if not impossible, but this is certainly not always or necessarily the case. Furthermore, it is also true that it is always difficult to know how much weight should be given to discrepant findings in terms of making adjustments to a theory, and this problem is not limited to case series studies. However, researchers reporting on single case studies have strong incentives to look to other cases to provide either replication or converging evidence. In contrast, and perhaps counter-intuitively, case series may be at increased risk of developing a narrow view, focused on the methods and results that are specific to a given lab or research group.

4-Scientific progress as multiple constraint satisfaction: Single case studies are not the problem

In their paper in this Special Issue, Lambon Ralph et al. describe one of Eleanor Saffran’s concerns, stating: “to make progress and have an impact, research must accumulate, and her fear was that an endless string of single case studies might be incompatible with such accumulation. They conclude with the following: ”if cognitive neuropsychology is going to make progress, we need a finite number of case series studies, not an infinite number of single cases (p. XX)“. These statements suggest that single case studies, if not incompatible with accumulation of knowledge, at least represent some sort of impediment to progress in research. They further suggest that, in contrast, the case series approach will allow us to reach some endpoint of understanding in finite time. Leaving aside the question of whether there actually is an endpoint to scientific understanding, the statements reflects a surprising view of the role of single case studies within the larger enterprise. In this regard it is important to remember that it was never proposed that single case studies would be single-handedly responsible for progress, it has always been assumed that they would be one piece of a larger and broader deployment of scientific methods (see Caramazza, 1986 ).

It is relatively uncontroversial to assume that progress in understanding human cognition requires bringing to bear a great many (potentially indefinitely many) findings on a problem of interest. Theories are commonly seen as being developed via the pressures exerted by these multiple constraints and there are a great many sources of constraints, include evidence from psychological reaction time experiments, neuropsychological case series, fMRI studies and, also single case studies. Single case studies have long been argued to constitute experiments and, like other experiments they cannot stand alone, but rather contribute to the larger enterprise. Of course, the scientific impact of a particular experiment, set of experiments or a specific method cannot be anticipated. In this regard, however, it is clear that there have been single case studies that have had extraordinary impact. One need only consider the consequences for theories of memory of the Scoville & Milner report on HM (1957), the effect on theories of object recognition of the Goodale and Milner report on DF (1992), and many others, across a wide range of cognitive domains.

Conclusions

It is clear that all of the authors in this Special Issue think that the potential contribution of case series studies is considerable. Whether or not this potential is realized, however, will depend on the same sorts of things that the success of any approach depends on, in the end it comes down to, quite simply, whether or not findings can be used to develop strong and clear logical arguments that serve to advance our understanding of human cognition.

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• What Is a Case Study? | Definition, Examples & Methods

What Is a Case Study? | Definition, Examples & Methods

Published on May 8, 2019 by Shona McCombes . Revised on November 20, 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organization, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research.

A case study research design usually involves qualitative methods , but quantitative methods are sometimes also used. Case studies are good for describing , comparing, evaluating and understanding different aspects of a research problem .

Table of contents

When to do a case study, step 1: select a case, step 2: build a theoretical framework, step 3: collect your data, step 4: describe and analyze the case, other interesting articles.

A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject. It allows you to explore the key characteristics, meanings, and implications of the case.

Case studies are often a good choice in a thesis or dissertation . They keep your project focused and manageable when you don’t have the time or resources to do large-scale research.

You might use just one complex case study where you explore a single subject in depth, or conduct multiple case studies to compare and illuminate different aspects of your research problem.

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Once you have developed your problem statement and research questions , you should be ready to choose the specific case that you want to focus on. A good case study should have the potential to:

• Provide new or unexpected insights into the subject
• Challenge or complicate existing assumptions and theories
• Propose practical courses of action to resolve a problem
• Open up new directions for future research

TipIf your research is more practical in nature and aims to simultaneously investigate an issue as you solve it, consider conducting action research instead.

Unlike quantitative or experimental research , a strong case study does not require a random or representative sample. In fact, case studies often deliberately focus on unusual, neglected, or outlying cases which may shed new light on the research problem.

Example of an outlying case studyIn the 1960s the town of Roseto, Pennsylvania was discovered to have extremely low rates of heart disease compared to the US average. It became an important case study for understanding previously neglected causes of heart disease.

However, you can also choose a more common or representative case to exemplify a particular category, experience or phenomenon.

Example of a representative case studyIn the 1920s, two sociologists used Muncie, Indiana as a case study of a typical American city that supposedly exemplified the changing culture of the US at the time.

While case studies focus more on concrete details than general theories, they should usually have some connection with theory in the field. This way the case study is not just an isolated description, but is integrated into existing knowledge about the topic. It might aim to:

• Exemplify a theory by showing how it explains the case under investigation
• Expand on a theory by uncovering new concepts and ideas that need to be incorporated
• Challenge a theory by exploring an outlier case that doesn’t fit with established assumptions

To ensure that your analysis of the case has a solid academic grounding, you should conduct a literature review of sources related to the topic and develop a theoretical framework . This means identifying key concepts and theories to guide your analysis and interpretation.

There are many different research methods you can use to collect data on your subject. Case studies tend to focus on qualitative data using methods such as interviews , observations , and analysis of primary and secondary sources (e.g., newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data.

Example of a mixed methods case studyFor a case study of a wind farm development in a rural area, you could collect quantitative data on employment rates and business revenue, collect qualitative data on local people’s perceptions and experiences, and analyze local and national media coverage of the development.

The aim is to gain as thorough an understanding as possible of the case and its context.

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In writing up the case study, you need to bring together all the relevant aspects to give as complete a picture as possible of the subject.

How you report your findings depends on the type of research you are doing. Some case studies are structured like a standard scientific paper or thesis , with separate sections or chapters for the methods , results and discussion .

Others are written in a more narrative style, aiming to explore the case from various angles and analyze its meanings and implications (for example, by using textual analysis or discourse analysis ).

In all cases, though, make sure to give contextual details about the case, connect it back to the literature and theory, and discuss how it fits into wider patterns or debates.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

• Normal distribution
• Degrees of freedom
• Null hypothesis
• Discourse analysis
• Control groups
• Mixed methods research
• Non-probability sampling
• Quantitative research
• Ecological validity

Research bias

• Rosenthal effect
• Implicit bias
• Cognitive bias
• Selection bias
• Negativity bias
• Status quo bias

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The Cognitive Approach

The assumption of the cognitive approach is that the mind operates in a similar way to how a computer processes information. This processing takes place in the form of thoughts, and uses cognitive ‘models’. These cognitions include things like memory, perception and problem-solving, and can be studied indirectly through experiments.

Theoretical and computer models: Theoretical models suggest that the mind processes information in a systematic way, for example the multi-store model of memory. Computer models suggest that the mind works like a computer, turning information into a format in which it can be stored (coding).

Schema: Schemas are packages of information relating to various concepts to do with the way the world works. People have schemas relating to all sorts of things, for example gender behaviours, eating, catching the bus, and so on. These develop through experience, starting as very basic in infanthood and getting more complex as the brain develops and more knowledge is gained. Schemas are like mental ‘short cuts’ to help humans make sense of the world more easily. They are useful for this, but can lead to distortions if a person’s expectations do not match up with the reality of what they have seen/experienced.

Cognitive Neuroscience

This refers to the study of how brain structures and biology affect mental processes. Specific brain areas have been found to be associated with particular actions, moods and emotions, which has been tested through brain-scanning techniques. For example, an area of the frontal lobe (Broca’s Area) has been linked with speech production. Specific areas of the brain are active when dealing with different types of memory, and areas such as the parahippocampal gyrus are linked with OCD. This suggests that aspects of people’s though processes have a physical basis.

Evaluation:

• The cognitive approach uses controlled, rigorous scientific procedures, enhancing the credibility of the theories.
• Cognitive approaches have been criticised for reducing human personality and behaviour to the level of a computer, neglecting the role of emotion on actions. This is known as machine reductionism, and is a problem was it does not recognise how much more complex humans are than machines.
• Many concepts in this approach are hard to test, as it considers internal mental processes, which cannot be directly measured. This means it is hard to know how accurate the explanations actually are.

The Biological Approach

This approach assumes that all psychological aspects of a person (their behaviour, personality) has a physical cause located somewhere in the body. This may be determined by genes, biochemistry (levels of hormones and neurotransmitters) and neuroanatomy (brain structure).

Genetics: Twin studies are used to investigate whether personality characteristics are inherited in the same way as physical features. If monozygotic (MZ- identical) twins are found to be more similar in regards to a particular trait than dizygotic (DZ- non-identical) twins, this suggests a genetic influence, as both sets of twins would share an environment but MZs would share 100% of genes, compared to 50% on average for DZs. This rate of similarity is known as a concordance rate.

Genotype and phenotype: Genotype is the particular set of genes a person inherits. Phenotype is the characteristics of an individual, which will be affected by genes and the environment. For example, MZ twins have the same genotype, but will lead different lifestyles, leading to changes in physical appearance and perhaps personality.

Evolution: The process of natural selection explains how changes in an organism happen over time. If a characteristic is helpful to survival (for example, results in better access to food or a greater mate choice/opportunity to mate) then this characteristic becomes ‘naturally selected’, and is passed down to the animal’s offspring. Over time, these characteristics are shared by all of a species, as those animals not suited to their environments die out. This is true for behaviour as well as physical characteristics, for example the preference in males for youthfulness and physical attractiveness in a female partner means that they are more likely to have healthy offspring, to that preference becomes naturally selected.

• The biological approach uses highly scientific methods, such as brain scans and twin studies, which are much less prone to bias than methods such as interviews. Therefore, the assumptions of the biological approach are supported by strong evidence.
• The approach has resulted in the development of effective drug therapies for many psychological disorders, helping sufferers live a more normal life. Therefore, the approach has very useful practical benefits.
• This approach is highly determinist, suggesting that there is little or no free will over behaviour. This could have serious consequences, for example for criminal responsibility, as it could be claimed that a person is not responsible for their actions in committing a serious crime. The criminal justice system does assume that people are able to exercise free will over their behaviour.

The Psychodynamic Approach

The assumption of the psychodynamic approach (the work of Sigmund Freud) is that behaviour can be explained by unconscious thoughts and motivations, and the effect of childhood experiences in shaping personality.

The unconscious: Freud proposed that conscious awareness only makes up a small proportion of the mind. The rest is made up of the unconscious- desires and drives that we are not aware of. Behaviour is motivated by unconscious drives and conflicts between different elements of the personality. The ‘preconscious’ is the part of the mind just below conscious awareness. This is revealed through dreams, which can be interpreted as representing an unconscious conflict which hasn’t been resolved, or a desire that hasn’t been satisfied. This is also shown through ‘Freudian slips’, which seem like mistakes, but are actually insights into desires we are not aware of. Accidentally calling a teacher ‘mum’ instead of ‘miss’ could be interpreted as the student seeing the teacher as a substitute parent figure in their unconscious.

Structure of personality: Freud suggested that there are three ‘parts’ to everyone’s personality, so it is ‘tripartite’. These are:

• Id: Present from birth, this is the ‘pleasure principle’, as it is selfish, motivated by primitive drives (sex and aggression) and demands instant gratification. It is the ‘devil on your shoulder’.
• Ego: This develops at around two years of age, and is the ‘reality principle’. It works to reduce the conflicting demands of the id and superego, and recognises that instant satisfaction of needs is not possible. The ego uses tactics to balance the demands of the other two parts of the personality- these are defence mechanisms. These include repression (pushing unpleasant thoughts down into the unconscious mind), denial (refusing to accept the reality of the situation) and displacement (transferring unpleasant or undesirable thoughts from one source to another).
• Superego: This develops at around five years of age, and is the ‘morality principle’. It is the internalised standards of right and wrong, and represents perfect moral behaviour. It is the ‘angel on your shoulder’.

Psychosexual stages: Freud claimed that children go through stages of development, where the id’s psychic energy is focused on a particular part of the body, so children gain pleasure from using that part of the body. Children progress through the stages, but may become fixated on a particular stage if they are over or under-indulged at that stage. This leads to possible problems in later life. The stages are:

• Oral (0-18 months): id energy focused on mouth, pleasure gained from sucking, chewing, biting and so on. Fixation could lead to smoking, chewing gum, a sarcastic and critical personality…
• Anal (18 months-3 years): id energy focused on anus, pleasure gained from withholding and expelling faeces. Fixation could lead to anal retentive (overly neat, organised and uptight) or anal expulsive (thoughtless and disorganised)
• Phallic (3-5 years): id energy focused on genitals. The child experiences Oedipus (boys) or Electra (girls) complex, where a sexual desire develops for the opposite-sex parent and the child identifies with the same-sex parents to reduce the resulting anxiety and resolve the complex. Fixation could lead to the phallic personality which is reckless and self-obsessed.
• Latency (5 years-puberty): id energy is dormant.
• Genital (puberty onwards): id energy focused on genitals, pleasure gained from sexual practices. Fixation could lead to difficulty forming heterosexual relationships.
• Freud’s ideas have had a huge influence on psychology, and concepts such as the unconscious are accepted as true today. This shows the value of his ideas in explaining personality.
• Freud’s theories were based on case studies of individuals, which were very subjective- Freud himself used his patients as evidence, and other cases were reported to him by his supporters. This evidence may be unreliable and invalid, so weakening the theory.
• Much of Freud’s theory cannot be directly tested, for example unconscious conflicts, the psychosexual stages, the role or repression and so on. This makes the theory unscientific, as the concepts cannot be falsified.

Case Examples

Examples of recommended interventions in the treatment of depression across the lifespan.

Children/Adolescents

A 15-year-old Puerto Rican female

The adolescent was previously diagnosed with major depressive disorder and treated intermittently with supportive psychotherapy and antidepressants. Her more recent episodes related to her parents’ marital problems and her academic/social difficulties at school. She was treated using cognitive-behavioral therapy (CBT).

Chafey, M.I.J., Bernal, G., & Rossello, J. (2009). Clinical Case Study: CBT for Depression in A Puerto Rican Adolescent. Challenges and Variability in Treatment Response. Depression and Anxiety , 26, 98-103.  https://doi.org/10.1002/da.20457

Sam, a 15-year-old adolescent

Sam was team captain of his soccer team, but an unexpected fight with another teammate prompted his parents to meet with a clinical psychologist. Sam was diagnosed with major depressive disorder after showing an increase in symptoms over the previous three months. Several recent challenges in his family and romantic life led the therapist to recommend interpersonal psychotherapy for adolescents (IPT-A).

Hall, E.B., & Mufson, L. (2009). Interpersonal Psychotherapy for Depressed Adolescents (IPT-A): A Case Illustration. Journal of Clinical Child & Adolescent Psychology, 38 (4), 582-593. https://doi.org/10.1080/15374410902976338

© Society of Clinical Child and Adolescent Psychology (Div. 53) APA, https://sccap53.org/, reprinted by permission of Taylor & Francis Ltd, http://www.tandfonline.com on behalf of the Society of Clinical Child and Adolescent Psychology (Div. 53) APA.

General Adults

Mark, a 43-year-old male

Mark had a history of depression and sought treatment after his second marriage ended. His depression was characterized as being “controlled by a pattern of interpersonal avoidance.” The behavior/activation therapist asked Mark to complete an activity record to help steer the treatment sessions.

Dimidjian, S., Martell, C.R., Addis, M.E., & Herman-Dunn, R. (2008). Chapter 8: Behavioral activation for depression. In D.H. Barlow (Ed.) Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed., pp. 343-362). New York: Guilford Press.

Reprinted with permission from Guilford Press.

Denise, a 59-year-old widow

Denise is described as having “nonchronic depression” which appeared most recently at the onset of her husband’s diagnosis with brain cancer. Her symptoms were loneliness, difficulty coping with daily life, and sadness. Treatment included filling out a weekly activity log and identifying/reconstructing automatic thoughts.

Young, J.E., Rygh, J.L., Weinberger, A.D., & Beck, A.T. (2008). Chapter 6: Cognitive therapy for depression. In D.H. Barlow (Ed.) Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed., pp. 278-287). New York, NY: Guilford Press.

Nancy, a 25-year-old single, white female

Nancy described herself as being “trapped by her relationships.” Her intake interview confirmed symptoms of major depressive disorder and the clinician recommended cognitive-behavioral therapy. 

Persons, J.B., Davidson, J. & Tompkins, M.A. (2001). A Case Example: Nancy. In Essential Components of Cognitive-Behavior Therapy For Depression (pp. 205-242). Washington, D.C.: American Psychological Association. http://dx.doi.org/10.1037/10389-007

While APA owns the rights to this text, some exhibits are property of the San Francisco Bay Area Center for Cognitive Therapy, which has granted the APA permission for use.

Luke, a 34-year-old male graduate student

Luke is described as having treatment-resistant depression and while not suicidal, hoped that a fatal illness would take his life or that he would just disappear. His treatment involved mindfulness-based cognitive therapy, which helps participants become aware of and recharacterize their overwhelming negative thoughts. It involves regular practice of mindfulness techniques and exercises as one component of therapy.

Sipe, W.E.B., & Eisendrath, S.J. (2014). Chapter 3 — Mindfulness-Based Cognitive Therapy For Treatment-Resistant Depression. In R.A. Baer (Ed.), Mindfulness-Based Treatment Approaches (2nd ed., pp. 66-70). San Diego: Academic Press.

Reprinted with permission from Elsevier.

Sara, a 35-year-old married female

Sara was referred to treatment after having a stillbirth. Sara showed symptoms of grief, or complicated bereavement, and was diagnosed with major depression, recurrent. The clinician recommended interpersonal psychotherapy (IPT) for a duration of 12 weeks.

Bleiberg, K.L., & Markowitz, J.C. (2008). Chapter 7: Interpersonal psychotherapy for depression. In D.H. Barlow (Ed.) Clinical handbook of psychological disorders: a treatment manual (4th ed., pp. 315-323). New York, NY: Guilford Press.

Peggy, a 52-year-old white, Italian-American widow

Peggy had a history of chronic depression, which flared during her husband’s illness and ultimate death. Guilt was a driving factor of her depressive symptoms, which lasted six months after his death. The clinician treated Peggy with psychodynamic therapy over a period of two years.

Bishop, J., & Lane , R.C. (2003). Psychodynamic Treatment of a Case of Grief Superimposed On Melancholia. Clinical Case Studies , 2(1), 3-19. https://doi.org/10.1177/1534650102239085

Several case examples of supportive therapy

Winston, A., Rosenthal, R.N., & Pinsker, H. (2004). Introduction to Supportive Psychotherapy . Arlington, VA : American Psychiatric Publishing.

Older Adults

Several case examples of interpersonal psychotherapy & pharmacotherapy

Miller, M. D., Wolfson, L., Frank, E., Cornes, C., Silberman, R., Ehrenpreis, L.…Reynolds, C. F., III. (1998). Using Interpersonal Psychotherapy (IPT) in a Combined Psychotherapy/Medication Research Protocol with Depressed Elders: A Descriptive Report With Case Vignettes. Journal of Psychotherapy Practice and Research , 7(1), 47-55.

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Cognitive Behaviour Therapy Case Studies

• Mike Thomas - University of Chester, UK
• Mandy Drake - University of Chester, UK
• Description

This distinctive practical format is ideal in showing how to put the principles of CBT and stepped care into effect. As well as echoing postgraduate level training, it provides an insight into the experiences the trainee will encounter in real-world practice. Each chapter addresses a specific client condition and covers initial referral, presentation and assessment, case formulation, treatment interventions, evaluation of CBT strategies and discharge planning. Specific presenting problems covered include:

- First onset and chronic Depression

- Social Phobia

- Obsessive-Compulsive Disorder

- Generalised Anxiety Disorder (GAD)

- Chronic Bulimia Nervosa and Anorexia nervosa

- Alcohol Addiction

- Personality Disorder

'This text is more than a cook book representation of CBT - it shows how some real-world creative work can be done'. - Michael Worrell, Consultant Clinical Psychologist & Programme Director CBT Training Programmes, CNWL Foundation Trust and Royal Holloway University of London

The contributors describe therapy experiences with people with problems ranging from depression and specific anxiety problems to personality disorder, and offer reflections on progress, as well as learning exercises and tips for clinical practice. 

Great resource for use in skills sessions. Provides more in-depth case studies that we can use across a number of courses.

This book helped my studetns explore real case and debate real solutions.

Excellent case studies for teaching, diverse range of clients and issues.

This is a good book for students to be aware of, when looking at the interventions for working with people with mental health problems.

This is an excellent text book, it gives a step by step guide for lecturers and students alike and is a must for every CBT practitioner.

Great text with well illustrated case examples for a range of different disorders.

As a lecturer I have found it's material useful in case discussions, formulations and role plays for students.

This is a good book. Being a researcher myself in the writings of case studies according to the CBT framework, I find this book essential for my students for they will be able to grasp not only the basics of how to write a CBT case study, but also to comprehend the elements which such research is constituted by

This is an excellent resource. Professor Thomas' in-depth knowledge of CBT enables him to present realistic case-studies. The introductory chapters provide a contemporary view of CBT before we are provided with detailed and varied case histories. I particularly liked the addition of a critique of each case study.

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A mediation approach in resting-state connectivity between the medial prefrontal cortex and anterior cingulate in mild cognitive impairment

Affiliations.

• 1 International Research Center for Neurointelligence (WPI-IRCN), UTIAS, The University of Tokyo, Tokyo, Japan.
• 2 Department of Neurology, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
• 3 Department of Psychiatry, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
• 4 Institute of Public Health, College of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan.
• 5 International Health Program, College of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan.
• 6 Graduate Institute of Medicine, Yuan Ze University, Building 3 R3705, 135 Yuan-Tung Road, Zhongli District, Taoyuan City, 32003, Taiwan.
• 7 Department of Neurology, Cardinal Tien Hospital, New Taipei City, Taiwan.
• 8 Institute of Neuroscience, National Yang Ming Chiao Tung University, Taipei City, Taiwan.
• 9 Department of Medical Research, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
• 10 Graduate Institute of Medicine, Yuan Ze University, Building 3 R3705, 135 Yuan-Tung Road, Zhongli District, Taoyuan City, 32003, Taiwan. [email protected].
• PMID: 39078432
• PMCID: PMC11289021
• DOI: 10.1007/s40520-024-02805-8

Mild cognitive impairment (MCI) is recognized as the prodromal phase of dementia, a condition that can be either maintained or reversed through timely medical interventions to prevent cognitive decline. Considerable studies using functional magnetic resonance imaging (fMRI) have indicated that altered activity in the medial prefrontal cortex (mPFC) serves as an indicator of various cognitive stages of aging. However, the impacts of intrinsic functional connectivity in the mPFC as a mediator on cognitive performance in individuals with and without MCI have not been fully understood. In this study, we recruited 42 MCI patients and 57 healthy controls, assessing their cognitive abilities and functional brain connectivity patterns through neuropsychological evaluations and resting-state fMRI, respectively. The MCI patients exhibited poorer performance on multiple neuropsychological tests compared to the healthy controls. At the neural level, functional connectivity between the mPFC and the anterior cingulate cortex (ACC) was significantly weaker in the MCI group and correlated with multiple neuropsychological test scores. The result of the mediation analysis further demonstrated that functional connectivity between the mPFC and ACC notably mediated the relationship between the MCI and semantic fluency performance. These findings suggest that altered mPFC-ACC connectivity may have a plausible causal influence on cognitive decline and provide implications for early identifications of neurodegenerative diseases and precise monitoring of disease progression.

Keywords: Anterior cingulate cortex (ACC); Medial prefrontal cortex (mPFC); Mild cognitive impairment (MCI); Resting-state connectivity; Semantic fluency.

© 2024. The Author(s).

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Conflict of interest statement

The authors declared no potential conflict of interest concerning the research, authorship, and/or publication of this article.

Neuropsychological evaluations in the HC…

Neuropsychological evaluations in the HC and MCI groups. Differences in neurocognitive tests between…

mPFC-specified functional connectivity in the…

mPFC-specified functional connectivity in the HC and MCI groups. For the within-group analyses,…

Regressions of functional connectivity against…

Regressions of functional connectivity against neuropsychological evaluations. Strengths of mPFC-ACC functional connectivity were…

Mediation analysis results. The path…

Mediation analysis results. The path diagram in panel A shows the group label…

• Burns A, Zaudig M (2002) Mild cognitive impairment in older people. Lancet 360:1963–1965. 10.1016/S0140-6736(02)11920-9 10.1016/S0140-6736(02)11920-9 - DOI - PubMed
• Gauthier S, Reisberg B, Zaudig M et al (2006) Mild cognitive impairment. Lancet 367:1262–1270. 10.1016/S0140-6736(06)68542-5 10.1016/S0140-6736(06)68542-5 - DOI - PubMed
• Petersen RC, Smith GE, Waring SC et al (1999) Mild cognitive impairment: clinical characterization and outcome. Arch Neurol 56:303–308. 10.1001/archneur.56.3.303 10.1001/archneur.56.3.303 - DOI - PubMed
• Gillis C, Mirzaei F, Potashman M et al (2019) The incidence of mild cognitive impairment: a systematic review and data synthesis. Alzheimer’s Dement: Diagn, Assess Dis Monitoring 11:248–256. 10.1016/j.dadm.2019.01.00410.1016/j.dadm.2019.01.004 - DOI - PMC - PubMed
• Ganguli M, Dodge HH, Shen C et al (2004) Mild cognitive impairment, amnestic type: an epidemiologic study. Neurology 63:115–121. 10.1212/01.wnl.0000132523.27540.81 10.1212/01.wnl.0000132523.27540.81 - DOI - PubMed
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Integrating pharmacotherapy and psychotherapy in the treatment of late-onset psychosis.

Late-onset psychosis is a mental health condition marked by the emergence of psychotic symptoms such as delusions and hallucinations in individuals typically aged 60 years and older. This condition, which is distinct from early-onset psychosis, presents unique clinical challenges and considerations due to the aging population it affects. Epidemiologically, late-onset psychosis is less common than its early-onset counterpart but carries significant implications for patient care and management, making its study and understanding crucial for effective treatment [1] .

Diagnosing late-onset psychosis is complicated by the need to differentiate it from other neurodegenerative disorders, delirium, and substance-induced psychosis. Advanced imaging techniques, such as MRIs, are often employed when neurological symptoms suggest an organic cause, although routine screening is generally not recommended due to its minimal diagnostic yield [2] . Age-specific criteria are also important, with cases arising between ages 40 and 60 classified as late-onset schizophrenia and those occurring after age 60 termed very-late-onset schizophrenia-like psychosis [3] .

Current treatment protocols advocate for the integration of pharmacotherapy and psychotherapy to manage the complexities of late-onset psychosis. Pharmacotherapy typically involves antipsychotic medications to alleviate symptoms, while psychotherapy provides cognitive and behavioral strategies to improve mental health management. Although the empirical evidence supporting this combined approach is still evolving, integrating these treatments has shown promise in enhancing overall outcomes and reducing symptom recurrence [4] [5] .

Despite the potential benefits, combining pharmacotherapy and psychotherapy in treating late-onset psychosis remains a topic of debate among researchers and clinicians. Some argue that this integration may not always be efficient or effective, given the dominance of the medical model favoring biological explanations and treatments [6] . Nonetheless, ongoing research and case studies highlight the importance of a nuanced, individualized approach to care, emphasizing the need for further studies to refine and optimize treatment strategies for this vulnerable population [7] .

Late-onset psychosis is a condition characterized by the emergence of psychotic symptoms such as delusions and hallucinations in individuals typically aged 60 years and older. This condition is distinct from early-onset psychosis and often presents unique clinical challenges and considerations. Epidemiological data indicate that late-onset psychosis is less common than its early-onset counterpart, but it carries significant implications for patient care and management.

The clinical presentation of late-onset psychosis often includes symptoms similar to those seen in schizophrenia, but with some distinctions in the context of aging. The etiology is multifactorial, involving genetic, neurobiological, and environmental factors. Notably, individuals with the APOE-ε4 allele may require more intensive monitoring and additional interventions as they age, although these findings need further replication in clinical studies [1] [2] .

From a diagnostic perspective, it is crucial to differentiate late-onset psychosis from other neurodegenerative disorders, delirium, substance-induced psychosis, and the effects of prescribed medications and illicit drugs [1] . Advanced imaging techniques, such as MRIs, are often employed when focal neurological findings suggest an organic cause for psychotic symptoms, although routine screening in first-episode psychosis patients is generally not recommended due to minimal diagnostic yield [3] .

Current treatment approaches emphasize a combination of pharmacotherapy and psychotherapy, although the empirical evidence supporting this integration is still evolving. The medical model often favors biological explanations within a diathesis-stress framework, which has led to debates about the validity of diagnoses and the effectiveness of targeted pharmacological treatments [4] . Consequently, there is a need for more elaborate research on comorbid physical conditions and their clinical influence on late-onset psychosis [1] [2] .

Diagnostic Challenges and Considerations

Diagnosing late-onset psychosis presents several unique challenges compared to diagnosing psychotic disorders in younger populations. Firstly, it is crucial to differentiate between primary psychotic disorders and psychotic symptoms that may be secondary to medical or neurological conditions, medications, or illicit drugs [3] . This differentiation is critical because the etiologies for psychosis in late life differ significantly from those in younger individuals, with a greater incidence of secondary causes such as neurodegenerative disorders and other comorbid medical conditions [1] [3] .

Although the DSM-5 and ICD classification systems do not provide a formal definition of ‘psychosis,’ they list psychotic features, including delusions, hallucinations, disorganized thinking (speech), grossly disorganized motor behavior (including catatonia), and negative symptoms [3] . The World Health Organization has also updated the ICD-11 to distinguish more clearly between primary psychotic disorders and other causes by renaming ‘F2 Schizophrenia, schizotypal, and delusional disorders’ to ‘Schizophrenia spectrum and other primary psychotic disorders’ [3] .

Late-onset psychosis is often associated with higher morbidity and mortality rates than early-onset psychosis, complicating the diagnostic process [1] . The condition requires careful consideration of differential diagnoses, including neurodegenerative disorders characterized by delirium, substance-induced psychosis, and the effects of prescribed medications [1] . Regular imaging, such as MRIs, may be used in patients with focal neurological findings suggestive of an organic cause for psychotic symptoms, although routine screening is generally not recommended due to minimal diagnostic yield and clinical usefulness [3] .

Additionally, clinical studies have proposed various age cutoffs to define late-onset psychosis. A consensus has been reached that cases with onset between ages 40 and 60 should be termed late-onset schizophrenia, while those occurring after age 60 should be classified as very-late-onset schizophrenia-like psychosis [5] . This distinction is crucial for appropriate diagnosis and treatment planning, as different age groups may present with different clinical features and treatment responses [6] .

Interplay Between Pharmacotherapy and Psychotherapy

Integrating pharmacotherapy and psychotherapy in the treatment of late-onset psychosis has been a topic of significant clinical interest. Both treatment modalities offer unique benefits, and their interplay can provide a comprehensive approach to managing the complexities of this condition. While pharmacotherapy primarily targets the biological underpinnings of psychosis, psychotherapy addresses cognitive, behavioral, and emotional aspects, often enhancing the overall effectiveness of treatment.

Complementary Roles

Pharmacotherapy typically involves the use of antipsychotic medications to manage symptoms such as delusions and hallucinations. However, evidence suggests that psychotherapy can be an effective standalone treatment for certain patients, especially those who may not require immediate pharmacological intervention [7] . Psychotherapy offers cognitive and behavioral mechanisms that help individuals manage their mental health through lifestyle changes and cognitive strategies, fostering a better understanding of oneself and others.

Combined Treatment Efficacy

Although it is common clinical practice to combine pharmacotherapy with psychotherapy, the effectiveness of this integrative approach has been debated. Some researchers argue that combining these treatments has not shown significant efficacy in practice and may represent an inefficient use of mental health resources [8] . A critical review of several articles indicates flawed empirical evidence supporting the integration of these modalities, suggesting a dominance of the medical model that favors biological explanations and treatments [4] .

Practical Considerations

When pharmacotherapy and psychotherapy are integrated, the collaboration between two clinicians—one providing medication and the other delivering therapy—adds layers of complexity to treatment [4] . Courses designed for psychiatry residents often review the literature, discuss various treatment models, and outline the skills required for effective collaborative care [4] .

Despite the complexities, combined treatment is often warranted in cases of chronic depression, psychosocial issues, intrapsychic conflict, and co-occurring disorders [9] . Poor adherence to pharmacotherapy may also necessitate combined treatment, with psychotherapy focusing on improving treatment adherence and addressing underlying psychosocial factors [9] .

Evidence and Outcomes

Research indicates that immediate antipsychotic treatment following the onset of psychosis may be associated with poorer long-term outcomes, highlighting the need for a nuanced approach that includes psychosocial treatments like psychotherapy [7] . For patients with partial responses to single treatment modalities, combined treatments have shown potential in enhancing overall outcomes and reducing the recurrence of depression and other symptoms [9] .

Evidence-Based Treatment Protocols and Guidelines

Evidence-based treatment protocols for late-onset psychosis emphasize the importance of integrating both pharmacotherapy and psychotherapy to optimize patient outcomes. Cognitive Behavioral Therapy for psychosis (CBTp) is widely recommended in international treatment guidelines, although these recommendations are predominantly based on studies conducted in community settings [10] . The approach for inpatient settings remains less well-defined, highlighting the need for systematic reviews to explore the potential size and scope of existing literature and to identify ongoing or planned research [10] .

Combining pharmacotherapy and psychotherapy is common clinical practice for managing complex cases, including those with late-onset psychosis. While pharmacotherapy, particularly antipsychotic medications, is a cornerstone of treatment, these medications are not curative but effective in reducing and controlling many symptoms [11] . Guidelines suggest starting with the lowest effective dosage to minimize side effects while achieving short-term efficacy [2] .

Psychotherapy plays a crucial role in promoting recovery by offering cognitive and behavioral strategies to help individuals manage their mental health. These interventions can include psychoeducation, coping skills training, and providing a dialogical space for patients to navigate changes and understand their diagnosis [7] . However, the literature underscores the importance of flexibility within fidelity, allowing practitioners to tailor their approaches based on individual patient needs rather than rigidly adhering to protocols [12] .

Combined treatment may be particularly beneficial for patients who have experienced partial responses to single treatment modalities, those with chronic depression, interpersonal problems, or co-occurring disorders [9] . Despite some debate on the efficiency of combining treatments, evidence supports the integrative approach for conditions such as major depressive disorder and anxiety disorders [8] .

For caregivers and families, continuous support alongside patient-oriented interventions is recommended to improve treatment adherence and outcomes [2] . The integration of pharmacotherapy and psychotherapy often involves collaboration between multiple clinicians, which adds complexity to the treatment process [4] . Further research, particularly involving larger and more diverse samples, is needed to refine treatment approaches and ensure their effectiveness across different populations and settings [2] .

Case Studies

Case study 1: paraphrenia in older adults.

A notable case fitting the concept of “paraphrenia,” a chronic psychotic disorder emerging in old age, demonstrates the practical application of combined pharmacotherapy and psychotherapy. The therapeutic goals for this case included establishing a therapeutic bond, validating the patient’s emotions, titrating antipsychotics according to tolerance and response, coordinating with neurologists for anti-dementia drug prescriptions, and working with social services to provide social support. Furthermore, legal institutions were informed with the patient’s knowledge to consider protective measures. This case highlighted several teaching points, such as the differential diagnosis for “late-onset” psychosis, which includes conditions like delirium, drugs, disease, dementia, depression, and delusional disorder or schizophrenia spectrum disorders. The specific clinical features of late-onset psychosis are often not considered in current international diagnostic criteria, and organic factors may significantly influence its presentation [2] [6] .

Case Study 2: Integration of Psychotherapy and Pharmacotherapy

In another case, the integration of psychotherapy and pharmacotherapy was explored in a postgraduate course for third-year psychiatry residents. This course reviewed the literature and various treatment models, focusing on the technical skills and issues in collaborative care. However, a critical review of three articles revealed flawed empirical evidence supporting the integration, noting that the dominance of the medical model favors biology within a diathesis-stress framework. Despite the common clinical practice of combining these treatments, some researchers argue it has not been proven effective and may be an inefficient use of limited mental health resources. Nonetheless, the course aimed to equip residents with a comprehensive understanding of the complexities involved in collaborative treatment models [4] [8] .

Case Study 3: Treatment of Moderate to Severe Major Depressive Disorder

A further case examined the utility of combining psychotherapy and pharmacotherapy in treating moderate to severe major depressive disorder. Indications for combined treatment included chronic forms of depression, psychosocial issues, intrapsychic conflict, interpersonal problems, or co-occurring Axis II disorders. Patients with a history of partial response to single treatment modalities or poor adherence to pharmacotherapy might benefit from an integrated approach. Discussing the use of combined treatment with patients was also emphasized, as this method could improve treatment adherence and overall outcomes [9] .

Future Directions

The future of integrating pharmacotherapy and psychotherapy in the treatment of late-onset psychosis hinges on several promising avenues for research and clinical practice improvements. One of the foremost goals is to enhance the efficacy of both therapeutic modalities through structured discussions and collaborative treatment models [4] . Such discussions are crucial in group therapy settings, milieu environments, and with individuals who may be reluctant to openly address interpersonal issues. Vignettes from group sessions illustrate the benefits of integrating medication discussions to advance group processes, thereby highlighting the importance of collaborative treatment approaches [4] .

Future research should focus on larger sample sizes and multi-country consortia to develop a more comprehensive understanding of late-onset psychosis [2] . Unified operational definitions for diagnosis and standardized treatment protocols will be instrumental in elaborating the clinical characteristics of this condition. Additionally, there is a need for slow titration of antipsychotics, monitored closely for tolerance and response, to achieve optimal therapeutic outcomes [2] [6] .

Another critical area for future investigation is the coordinated evaluation of anti-dementia drugs in conjunction with neurologists, aiming to tailor treatments more precisely to individual patient needs [6] . Collaborating with social services to devise effective strategies for social support, and involving legal institutions to consider protective measures when necessary, are also key components that warrant further exploration [6] .

Furthermore, developing training programs for psychiatric residents and other mental health professionals can enhance the integration of psychotherapy and pharmacotherapy. Such programs should focus on reviewing existing literature, discussing various treatment models, and refining the technical skills required for effective collaborative care [4] . By fostering these interdisciplinary collaborations, we can better address the complex needs of patients with late-onset psychosis and improve their overall treatment outcomes.

Integrating pharmacotherapy and psychotherapy in the treatment of late-onset psychosis offers a comprehensive approach to managing this complex condition. This research highlights the necessity of combining antipsychotic medications with cognitive and behavioral strategies to address both the biological and psychosocial aspects of the disorder. Diagnostic challenges, including differentiating late-onset psychosis from other neurodegenerative disorders and substance-induced psychosis, underscore the importance of a nuanced and individualized treatment plan [1] [4] .

The findings suggest that this integrated approach can enhance patient outcomes, reduce symptom recurrence, and improve overall mental health management. By leveraging the strengths of both pharmacological and psychotherapeutic interventions, clinicians can provide more effective and holistic care for elderly patients experiencing psychosis. Continued research and refinement of these integrated treatment strategies are essential to optimize care for this vulnerable population, ensuring that advancements in both fields are utilized to their fullest potential [2] [3] .

Navneet Iqbal, MD

About The Author

Dr. Navneet Iqbal, MD is a distinguished psychiatrist specializing in Geriatric and Forensic Psychiatry. She completed her Geriatric Psychiatry fellowship at Stanford University School of Medicine, where she honed her expertise in addressing complex mental health issues in older adults. Currently, Dr. Iqbal serves at Napa State Hospital, where she integrates advanced pharmacotherapy and psychotherapy techniques in her practice. Her research focuses on innovative treatment modalities for late-onset psychosis, aiming to improve patient outcomes through a holistic approach. Dr. Iqbal is dedicated to advancing the field of psychiatry through continuous learning and evidence-based practices.

[1] García-Baamonde, M. E., Marchena-Giráldez, C., Garcia-Baamonde, J. L., & Benítez-Borrego, S. (2022). Impact of sleep deprivation on academic performance in health sciences students . Journal of Personalized Medicine, 12(3), Article 381. https://doi.org/10.3390/jpm12030381  

[2] Kim, K., Jeon, H. J., Myung, W., Suh, S. W., Seong, S. J., Hwang, J. Y., Ryu, J. I., & Park, S.-C. (2022, March). Clinical approaches to late-onset psychosis . Journal of Personalized Medicine, 12(3), Article 381. https://doi.org/10.3390/jpm12030381  

[3] Tampi, R. R., Young, J., Hoq, R., Resnick, K., & Tampi, D. J. (2019, October 16). Psychotic disorders in late life: A narrative review. Therapeutic Advances in Psychopharmacology , 9 , Article 2045125319882798. https://doi.org/10.1177/2045125319882798  

[4] Sparks, J., Duncan, B. L., & Miller, S. D. (2008). Integrating psychotherapy and pharmacotherapy. Journal of Family Psychotherapy, 17 (3), 83-108. http://dx.doi.org/10.1300/J085v17n03_05

[5] Howard, R., Rabins, P. V., Seeman, M. V., & Jeste, D. V. (2000). Late-onset schizophrenia and very-late-onset schizophrenia-like psychosis: An international consensus. American Journal of Psychiatry, 157 (2), 172-178. https://doi.org/10.1176/appi.ajp.157.2.172

[6] Gracia-García, P., González-Maiso, Á., & Romance-Aladren, M. (2017). Diagnostic and therapeutical challenges of late-onset psychosis. Journal of Psychology and Cognition, 2 (4), 218-220. https://doi.org/10.35841/psychology-cognition.2.4.218-220

[7] Faith, L. A., Hillis-Mascia, J. D., & Wiesepape, C. N. (2024). How does individual psychotherapy promote recovery for persons with psychosis? A systematic review of qualitative studies to understand the patient’s experience. Behavioral Sciences, 14 (6), Article 460. https://doi.org/10.3390/bs14060460

[8] Kuzma, J. M., & Black, D. W. (2004). Integrating pharmacotherapy and psychotherapy in the management of anxiety disorders. Current Psychiatry Reports, 6 (4), 268-273. https://doi.org/10.1007/s11920-004-0076-y

[9] Busch, F. N. (2020, January 30). Integrating psychotherapy and psychopharmacology in the treatment of major depressive disorder. Psychiatric Times, 37 (1). https://www.psychiatrictimes.com/view/integrating-psychotherapy-and-psychopharmacology-treatment-major-depressive-disorder

[10] Jacobsen, P., Hodkinson, K., Peters, E., & Chadwick, P. (2018). A systematic scoping review of psychological therapies for psychosis within acute psychiatric inpatient settings. British Journal of Psychiatry, 213 (2), 490-497. https://doi.org/10.1192/bjp.2018.106  

[11] Better Health Channel. (n.d.). Antipsychotic medications. State Government of Victoria. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/antipsychotic-medications

[12] Cook, S. C., Schwartz, A. C., & Kaslow, N. J. (2017). Evidence-based psychotherapy: Advantages and challenges. Neurotherapeutics, 14 (3), 537-545. https://doi.org/10.1007/s13311-017-0549-4  

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