psychotherapy case study approach

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Doing Research in Counselling and Psychotherapy

Student resources, carrying out a systematic case study.

The key messages of this chapter are:

• case study analysis makes a distinctive contribution to the evidence base for counselling and psychotherapy
• case studies are ethically sensitive, so need to be carried out with care and sensitivity
• it is important to be aware of how different types of research question require different case study approaches.

The following sources are intended to help you to explore issues covered in the chapter in more depth.

Methodological issues and challenges associated with case study research

Flyvbjerg, B. (2006). Five misunderstandings about case-study research . Qualitative Inquiry, 12 , 219 – 245. 

Essential reading – a highly influential paper that clarifies the value of case study methods

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

The rationale for the pragmatic case study approach

Foster, L.H. (2010). A best kept secret: single-subject research design in counseling.  Counseling Outcome Research and Evaluation,  1, 30 – 39

An accessible and informative introduction to n=1 single subject case study methodology  

McLeod, J. (2013). Increasing the rigor of case study evidence in therapy research.  Pragmatic Case Studies in Psychotherapy, 9 , 382 – 402

Explores further possibilities around the development of case study methodology

Different types of therapy case study

Bloch-Elkouby, S., Eubanks, C. F., Knopf, L., Gorman, B. S., & Muran, J. C. (2019). The difficult task of assessing and interpreting treatment deterioration: an evidence-based case study.  Frontiers in Psychology , 10, 1180. 

Systematic case study that combines qualitative and quantitative information to explore a theoretically-significant case of apparent client deterioration. Case was drawn from dataset of a larger study

Brezinka, V., Mailänder, V., & Walitza, S. (2020). Obsessive compulsive disorder in very young children–a case series from a specialized outpatient clinic.  BMC Psychiatry , 20(1), 1 – 8. 

Example of how a series of n=1 case studies can be used

Faber, J., & Lee, E. (2020). Cognitive-Behavioral Therapy for a refugee mother with depression and anxiety.  Clinical Case Studies , 19(4), 239 – 257.

A hybrid theory-building/pragmatic case study that seeks to develop new understanding of therapy in situations of client-therapist cultural difference. Clinical Case Studies is a major source of case study evidence – this study is a typical example of the kind of work that it publishes  

Gray, M.A. & Stiles, W.B. (2011). Employing a case study in building an Assimilation Theory account of Generalized Anxiety Disorder and its treatment with Cognitive-Behavioral Therapy. Pragmatic Case Studies in Psychotherapy , 7(4), 529 – 557

An example of a theory-building case study focused on the development of the assimilation model of change 

Kramer, U. (2009).  Between manualized treatments and principle-guided psychotherapy: illustration in the case of Caroline.  Pragmatic Case Studies in Psychotherapy , 5(2), 45 – 51

A pragmatic case study that also seeks to address important theoretical issues associated with the use of exposure techniques in CBT

McLeod, J. (2013). Transactional Analysis psychotherapy with a woman suffering from Multiple Sclerosis: a systematic case study.  Transactional Analysis Journal,  43 , 212 – 223.

A hybrid case study – mainly aims to develop a theory of therapy in long-term health conditions, but also includes elements of pragmatic, narrative and HSCED approaches. Good example of the use of the Client Change Interview in case study research

Powell, M.L. and Newgent, R.A. (2010) Improving the empirical credibility of cinematherapy: a single-subject interrupted time-series design.  Counseling Outcome Research  
 and Evaluation , 1, 40 – 49. 

Example of a series of n=1 case studies

Stige, S. H., & Halvorsen, M. S. (2018). From cumulative strain to available resources: a narrative case study of the potential effects of new trauma exposure on recovery.  Illness, Crisis & Loss , 26(4), 270 – 292. 

A narrative case study based on client interviews

Kellett, S., & Stockton, D. (2021). Treatment of obsessive morbid jealousy with cognitive analytic therapy: a mixed-methods quasi-experimental case study.  British Journal of Guidance & Counselling , 1 – 19. 

Example of an n=1 case study of a single case. Useful demonstration of how this approach can be used to study non-behavioural therapy

Wendt, D. C., & Gone, J. P. (2016). Integrating professional and indigenous therapies: An urban American Indian narrative clinical case study.  The Counseling Psychologist , 44(5), 695 – 729. 

A narrative case study based on client interviews 

Werbart, A., Annevall, A., & Hillblom, J. (2019). Successful and less successful psychotherapies compared: three therapists and their six contrasting cases. Frontiers in Psychology . DOI: 10.3389/fpsyg.2019.00816.                  

Combined narrative, theory-building and cross-case analysis, based on interviews with client and therapist dyads

Widdowson, M. (2012). TA treatment of depression: A hermeneutic single-case efficacy design study-case three: 'Tom'.  International Journal of Transactional Analysis Research , 3(2), 15 – 27. 

Example of an HSCED study that also includes elements of theory-building. Supplementary information on journal website includes full details of the Change Interview and judges’ case analyses. This open access journal has also published many other richly-described HSCED studies

Issues and possibilities associated with quasi-judicial methodology

Bohart, A.C., Tallman, K.L., Byock, G.and Mackrill, T. (2011). The “Research Jury” Method: The application of the jury trial model to evaluating the validity of descriptive and causal statements about psychotherapy process and outcome.  Pragmatic Case Studies in Psychotherapy, 7 (1) ,101 – 144. 

Miller, R.B. (2011). Real Clinical Trials (RCT) – Panels of Psychological Inquiry for Transforming anecdotal data into clinical facts and validated judgments: introduction to a pilot test with the Case of “Anna”.  Pragmatic Case Studies in Psychotherapy, 7(1), 6 – 36. 

Stephen, S. and Elliott, R. (2011). Developing the Adjudicated Case Study Method.  Pragmatic Case Studies in Psychotherapy, 7(1), 230 – 224.

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What Is a Case Study?

Weighing the pros and cons of this method of research

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

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

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

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

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

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

At a Glance

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

What Are the Benefits and Limitations of Case Studies?

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

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

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

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

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

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

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

Case Study Examples

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

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

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

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

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

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

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

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

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

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

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

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

Section 1: A Case History

This section will have the following structure and content:

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

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

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

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

Section 2: Treatment Plan

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

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

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

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

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

Need More Tips?

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

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

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

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

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

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

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

How to Write a Case Study

Note 1 : For illustrative purposes the below is written for a therapy comprised of a single individual in the therapist role and a single individual in the client role. If you are writing a case study about a couple, family, or group, perhaps with a co-therapist, the structure as described below is the same, there is just an expansion of the individuals in the client role and/or the therapist role.   

Note 2 : Most of the case studies already published in PCSP have been written by the therapist in the case. However, an alternative is for others to join the therapist or for others alone to function as authors, using direct observations of the sessions, videotapes, transcripts, detailed clinical notes, and/or interviews with the therapist as the data for the case study. Two examples in PCSP of others joining the author to write the case study can be found at : https://pcsp.nationalregister.org/index.php/pcsp/article/view/936/2334 https://pcsp.nationalregister.org/index.php/pcsp/article/view/1915/3340

Note 3 : Almost all of the case studies already published in PCSP have been written about actual, although disguised, cases, and this is highly desirable. However, there have been instances in which for various reasons, such as special confidentiality concerns, a composite, hybrid case has been employed. Such an example can be found at: https://pcsp.nationalregister.org/index.php/pcsp/article/view/2112/3511    

Note 4 : The below are guidelines -- not rigid rules -- for how to write a case study for PCSP. 

CONCEPTUAL BACKGROUND OF A PRAGMATIC CASE STUDY IN PSYCHOTHERAPY

          The Pragmatic Case Studies in Psychotherapy  ( PCSP ) journal was founded in 2005 on a vision of publishing psychotherapy case studies that is centered in Donald Peterson’s (1991) disciplined inquiry model of best practice across applied psychology, including psychotherapy (also see Fishman, 2013).

          In the Peterson model, the therapist begins with a focus on the Client and his or her presenting problems (component A). In this context, the therapist selects a general Guiding Conception (component B) with accompanying Clinical Experience and Research Support (component C). The therapist then conducts a comprehensive Assessment (component D), including history, personality, living situation, symptoms and other problems, diagnosis, and strengths. Applying the Guiding Conception to the Assessment data next yields an individualized Formulation and Treatment Plan (component E). The Case Formulation and Treatment Plan are thus a mini-version of the Guiding Conception as personalized for the individual client.  

          The Treatment Plan is implemented during the Course of Therapy (component F). This clinical process is consistently subjected to Therapy Monitoring  (component G), generating feedback loops. If the therapy is not proceeding well possible changes in earlier steps (via component H) might be needed—e.g., reviewing the client’s characteristics and the “chemistry” between the Client and the therapist (component A); collecting more and/or reinterpreting the Assessment data (component D); and/or revising the Case Formulation and/or the Treatment Plan (component E). 

          If the Therapy Monitoring (component H) results in showing that the client has been successful and/or that the therapist and client agree that further therapy will not be productive, therapy is terminated and a Concluding Evaluation (component L) is conducted. This can yield feedback for either confirming—via assimilation—the original Guiding Conception (component J), or revising that theory through accommodation (component K). 

The Narrative Nature of the Psychotherapy Case Study

          Note that therapy involves the development of a highly emotionally and meaningful relationship and interactions over time between two persons, one in a therapist role providing help and one who in a client role receiving help. The resulting case study capturing these events should thus read in part like a richly detailed story about what happens when these two people meet.  

Three Parts

As a summary, the therapy documented in Figure 1 proceeds in three parts:

(a)  preparing for intervention  (components A-E, headings 1-5);

(b)  intervention  (components F-I, headings 6 and 7); and

(c)  outcome evaluation  (components J-L, heading 8).  

SPECIFIC GUIDELINES

             In line with the above, PCSP  is interested in manuscripts that describe the process and outcome of one or more clinical cases. Detailed description of the patient, presenting problem(s), conceptualization of the clinical challenges, and the course of treatment are necessary.  PCSP  expects a comprehensive presentation of all aspects of the case(s) reported, as reflected in headings 1-11 in Figure 1. 

             Note that deviations from the headings are allowed if they are conceptually based. An example is Shapiro’s (2023) case of “Keo,” in which sections 4, 5, and 6 are combined as they emerged from the initial contact with Keo because, in Shapiro’s words,  “In the existential therapy model, the therapist approaches the client with a very open mind, not wanting to allow preconceptions to interfere with the process of relationship-building and the client telling their story in their own way.” ( https://pcsp.nationalregister.org/index.php/pcsp/article/view/2127/3524 , p. 5).     

            Each of the eight main sections in a  PCSP  case study is addressed below, followed by three guidelines that apply to all eight sections. 1. Case Context and Method

          This section is a short introduction to the reader about you, your background and clinical experience, and how you approach your clinical work. This should be brief and factual. Typical items include:

(a) Who you are;  

(b) How long have you practiced;

(c) In what settings with what populations have you worked;

(d) What training experiences and supervision have you had; and

(e) The way(s) in which you ensured confidentiality in your case study ( required ). This is typically done by disguising the client’s identity, in accordance with section 4.07 of the  Ethical Principles of Psychologists and Code of Conduct  of the American Psychological Association:

4.07 Use of Confidential Information for Didactic or Other Purposes Psychologists do not disclose in their writings, lectures, or other public media, confidential, personally identifiable information concerning their clients/patients, students, research participants, organizational clients, or other recipients of their services that they obtained during the course of their work, unless (1) they take reasonable steps to disguise the person or organization, (2) the person or organization has consented in writing, or (3) there is legal authorization for doing so. ( https://www.apa.org/ethics/code ).

2. The Client

          This section should consist of a concise description of the client with selected details. The goal is to introduce the reader to the client as a person so they can keep this image of the person  in mind as the reader continues through the case study. Some details about the client can include:

(a) cultural status,

(c) gender,

(d) education/work background and status, 

(e) marital status,

(f) parental status   

(f) life circumstances, and

(g) presenting problems and, if relevant, diagnosis(es).

          Note  that this Client section is not a clinical assessment (this is below in section 4, Assessment). Rather, The Client section is a short description that places the patient in the context of their life, physical surrounds, and individuals with whom they must often interact.  

3. Guiding Conception with Research and Clinical Experience Support

          This section should inform the reader about:

(a) the type of clinical problem area(s) the client is presenting with and the relevant theoretical and clinical literature describing these problems. (The specific details and context of the client’s problems are presented in section 4, Assessment, described below.)    

(b) your theoretical approach to understanding others in general and, more specifically, to the problem area(s) being addressed;

(c) how your theoretical approach is translated into therapy; and

(d) your roadmap to the clinical work that needs to be done.

           This Guiding Conception section provides the reader a context for understanding you as a therapist and how you work with the problem area(s) involved. This section should include references to important books and journal articles—including past case study articles—that you have found important over the years and have influenced how you approach and do psychotherapy. This section alerts the readers to general aspects of the client and their entire life that you will utilize in making your Assessment (section 4 below) of the client’s problems; your Case Formulation and Treatment Plan (section 5 below); and your conduct of Therapy (section 6 below).   

4. A ssessment of the Client’s Problems, Goals, Strengths, and History

          This section should provide the reader with a systematic understanding of the client, including:

(a) their presenting problem(s);

(b) other problems and challenges;

(c) relevant diagnoses, keeping in mind both the strengths and limitations of diagnostic categories;  

(d) personality and character issues;   

(e) their initial stated goals for  treatment;

(f) previous therapy;  

(g) relevant aspects of their life history (personal development, family issues and       events, and educational and work history);

(h) multicultural issues capturing the larger socio-cultural context of the case,       including information about the client’s gender, sexual orientation, race, ethnicity,       religion, socioeconomic class, etc.; and

(i) their strengths as well as limitations.

          This section should present the methods and results of any quantitative assessment or other measurement tools you collected at intake, during therapy, at termination, and/or at follow-up.   

5. F ormulation and Treatment Plan

(a) This section should provide the reader with your conceptualization of what—in clinical theory terms—the client’s problems and issues are and how you planned to address them. Understanding of an individual, the conceptualization of their problems, and the goals of treatment can change over time.

(b) Provide the initial Case Formulation and Treatment Plan of the case in this section.

(c) In section 6 below, Course of Therapy, describe any changes that occurred in the Assessment, in the Case Formulation, and in the Treatment Plan as the treatment progressed.  

6. C ourse of Therapy

             This is the main section of the case study and should provide a detailed description of the process of the psychotherapy that occurred.

(a) Note that a very important way to capture the richness, subtlety, power, emotional and experiential nature, and relational dynamics of the therapy is through the use of selected transcript excerpts. Specifically, sample transcripts of the verbal exchange between patient and therapist should be utilized liberally to provide the concrete details of the clinical process, including at important points—such as points of client insight, of client obstacles, of client corrective emotional experiences, of ruptures and repairs in the therapeutic relationship, of therapist insight, crucial therapist choice points, and so forth.

(b) Descriptions of the therapy can be organized by: (i) by Session; (ii) by Blocks of Sessions; and/or (iii) by Phases (Sessions grouped into substantive Phases).  

          The goal is to provide the reader with a rich experiential sense of the client and the process of doing psychotherapy with this client. Some questions to think and write about: 

(a) How did the client present themselves?

(b) What sort of therapeutic relationship was established?

(c) How did the client react to different comments or interventions you made? (d) How did the therapeutic relationship change over time? (e) How did you adjust your style or word choice in light of the client’s behavior or reactions? (f) How did you bring up or introduce important issues that the client might have been avoiding?

             Keep in mind the role and importance of other voices and influences in the therapy, such as a spouse, other family members, a boss, employees, colleagues, and friends.  

7. T herapy Monitoring and Use of Feedback Information

          This section should describe how the patient’s problems and behaviors were assessed over the course of therapy and how the process of therapy was monitored.

(a) Were quantitative treatment monitoring tools (such as the OQ-45 inventory ( https://www.oqmeasures.com/oq-45-2/ ) employed in each session, in selected sessions, and/or at the beginning and end of treatment and at follow-up?

(b) Were the psychotherapy sessions recorded or videotaped?

(c) What type of clinical notes were made?

(d) How was the supervision of the therapy handled?  

8. Concluding Evaluation of the Therapy's Process and Outcome

            This section should be a summary of the process and outcome of the treatment, using both qualitative and, ideally, quantitative data.

(a) What changes, if any, occurred?

(b) Were the goals set in the treatment plan met?

(c) How satisfied was the patient with the journey and its outcome?

(d) How, in general terms, did the process go?

(e) What comments and interventions seemed the most helpful? Least helpful?

Overall Guidelines Across the Eight Areas

(a) Be systematic, properly covering each of sections 1-8 and their interrelationships, ensuring a common structure with other pragmatic case studies.

(b) Clearly differentiate description from theory. 

(c) Remember that the goal of a pragmatic case study is primarily to describe and interpret what happened in this particular case as a basic unit of knowledge in the field—not primarily to illustrate or confirm a theory, strategy, or procedure per se.

GENERAL GUIDELINES

Page Length

          Manuscripts are to be typed double-spaced, following the APA Publication Manual. The  format for pragmatic case studies allows a good deal of flexibility in page length. In terms of total pages independent of references, tables, figures, and appendices, PCSP manuscripts  typically range between 35 and 90 pages. In terms of a 35-page manuscript, the first 8 sections might be distributed something like as follows (this is just an example, not a rigid requirement):

• Case Context and Method, 1 ½ pages.
• The client, ½ page. 
• Guiding Conception with Research and Clinical Experience Support, 4 pages.
• Assessment of the Client’s Problems, Goals, Strengths, and History, 5 pages.
• Formulation and Treatment Plan, 4 pages.
• Course of the Therapy, 15 pages.
• Therapy Monitoring and Use of Feedback Information, 1 page.
• Concluding Evaluation of the Therapy’s Process and Outcome, 4 pages.

Note: Additional pages would be devoted to relevant references, tables, and figures.

Quantitative Data

            The use of relevant quantitative data for assessment of problems, for monitoring therapy, and for outcome at termination and, if relevant, at follow-up is highly desirable. Almost all the case studies published in  PCSP  provide examples of the use of relevant quantitative data. 

            Note that if prospective quantitative measures are not collected, an option is to employ retrospective quantitative assessment. In this method, the client is asked at the end of therapy or at follow-up to complete quantitative measures a number of times with different mind sets, e.g., how they were feeling, thinking, and/or behaving at the beginning of therapy, at the end of therapy, and at follow-up. While not directly comparable to a prospective quantitative, such  retrospective quantitative assessment can provide a useful additional perspective on the outcome of the therapy as subjctively viewed by client. 

Description Versus Theory

            Pay careful attention to the distinction between the description of clinical phenomena in ordinary language versus the interpretation of those phenomena in theoretical language, indicated by the use of technical theoretical jargon. Particularly, the Assessment and Course of therapy sections should contain a good deal of clinical description, such that the clinical phenomena of the client and the therapy could reasonably be interpreted from a different theoretical point of view.  The use of technical, theoretical “jargon” terms when needed should be explained, knowing that not every reader is deeply knowledgeable about the theoretical orientation being employed by the author. Overall, the goal of a pragmatic case study is primarily to describe and interpret what happened in a particular case as a basic unit of knowledge in the field—not primarily to confirm a theory, strategy, and/or procedure per se. Rather the goal is to show how a theory, strategy, and/or procedure functioned in a particular case setting.

Scholarship

          Present your material so as to include references to relevant books, journal articles, and web sites—including past case study articles—so that your work is connected to the relevant scholarly and research literature.

A Checklist of Questions to be Answered About Your PCSP Manuscript  

• Do you have separate sections with all the 8 headings in Figure 1?
• Do each of the headings follow the Specific Guidelines associated with them?
• Is the manuscript length between 35 and 90 pages (double-spaced; before references, tables, figures, and appendices)?
• If there is quantitative data (which is desirable), is it fully presented?
• Do you carefully distinguish between clinical description and clinical interpretation?
• Are there references to the relevant scholarly and research literature?
• Have you looked at sample cases from the journal as models?

Sample Cases

            The published case studies in PCSP offer many examples of the variety of types of properly written case studies that, while varying in a number of ways, all follow the common structure outlined in Figure 1 and the specific and general guidelines outlined above. Sample cases can be found on the Home Page of this  PCSP journal .  

          An instructive example of a case study published in PCSP  is the case of “Caroline” by Ueli Kramer (2009;  https://pcsp.nationalregister.org/index.php/pcsp/article/view/966/2366 ). An outline of the case illustrating the above headings is presented in Table 4 of Fishman (2013; https://pcsp.nationalregister.org/index.php/pcsp/article/view/1833/3256 ).   

Fishman, D.B. (2013). The pragmatic case study method for creating rigorous and systematic,                  practitioner-friendly research.   Pragmatic Case Studies in Psychotherapy , 9 (4), Article 2, 403-425.              Available: https://pcsp.nationalregister.org/index.php/pcsp/article/view/1833

Kramer, U. (2009). Individualizing exposure therapy for PTSD: The case of Caroline. Pragmatic Case            Studies in Psychotherapy , 5(2), Article 1, 1-24. Available:                 https://pcsp.nationalregister.org/index.php/pcsp/article/view/966/2366

Peterson, D.R. (1991).  Connection and disconnection of research and practice in the education of            professional psychologists. American Psychologist, 46 , 422-429.

Shapiro, J.L. (2023). Existential psychotherapy in a deep cultural context: The case of “Keo.” Pragmatic            Case Studies in Psychotherapy , 19 (1), Article 1, 1-32. Available:                        https://pcsp.nationalregister.org/index.php/pcsp/article/view/2127/3524

Psychology: Research and Review

• Open access
• Published: 19 March 2021

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

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

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

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

Introduction

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

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

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

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

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

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

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

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

The common approach: evidence-based practice.

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

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

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

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

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

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

Internal validity

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

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

The alternative approach: practice-based evidence

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

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

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

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

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

External validity

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

A third way approach to validity and evidence

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

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

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

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

What is a research tool.

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

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

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

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

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

Comparing different qualitative tools

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

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

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

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

Using CASP, JBI and ETQS for systematic case study appraisal

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

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

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

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

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

Developing purpose-oriented evaluation criteria for systematic case studies

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

CaSE checklist for essential components in systematic case studies

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

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

CaSE purpose-based evaluative framework for systematic case studies

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

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

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

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

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

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

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

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

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

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

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

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

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

Concluding comments

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

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

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

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

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

Availability of data and materials

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Acknowledgments

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

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

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

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What is preventing psychotherapy case studies from having a greater impact on evidence-based practice, and how to address the challenges?

1. introduction.

Case studies are an essential part of evidence-based practice (EBP) because they provide a type of evidence for clinical practice that cannot be provided by other types of research. Case studies demonstrate how (not just which) change processes operate to achieve positive outcome, and how these processes can be influenced within the context of an individual treatment. Even in cases with positive outcome there are many barriers and resistances that can be documented in a case study and that are very helpful for practitioners to learn about. Case studies are also very well suited to demonstrate individualized, qualitative, and non-symptomatic changes through psychotherapy ( 1 ). In this sense, case studies contribute to the emergence of the personalized approach to treatment outcome. Through the focus on a single patient, case studies contain insights and knowledge in a format and at a level that is coherent with the practitioner's way of thinking. Clinical reasoning and case conceptualization are always about “thinking in cases” ( 2 , 3 ). The key element here is particularization, not generalization: while efficacy studies demonstrate whether interventions work on average in a group, case studies demonstrate how they work with individual patients through a detailed description of therapeutic microprocesses. This is lost if case study approaches are not built into the fabric of EBP. However, there are several obstacles that are currently preventing case study research from having a greater impact on EBP.

2. The persuasiveness issue

Although case-based research complements other types of research in unique ways, it is often considered inferior to sample-based research. Efficacy studies apply a very straightforward and simple causal logic which consists of checking whether the same cause (under sufficiently similar conditions) produces the same effect. If a cause and an effect regularly follow each other (for instance in a sample of patients) it can be deduced that the cause (for instance a psychological intervention) creates an effect (for instance symptom reduction). Moreover, statistical significance testing provides efficacy studies with a clear binary criterion for determining the evidential value of psychological interventions. For these reasons, Cartwright ( 4 ) calls this type of studies “clinchers”: if the assumptions are met, the conclusion can be deduced with certainty. This makes them very persuasive for researchers, policy makers and the general public. At the same time, efficacy studies have limited value for clinical practice and cannot be the sole source of EBP ( 4 ). As pointed out in the introduction, other types of research evidence, including case studies, should be considered in the context of EBP. However, these other types of evidence have a less straightforward causal logic and have less clear criteria for determining the evidential value of interventions. In case study research, causality is situated in a complex psychological process that takes place at the level of the unique case, and case studies (at best) provide evidence that makes a case for a conclusion. Case studies never allow to deduce with certainty a clear yes/no answer to the question what works. Cartwright calls this type of research “vouchers”: in contrast to “clinchers,” they can only speak for a conclusion ( 4 ). This makes them less persuasive.

The persuasiveness issue cannot be solved by trying to emulate “clinchers.” What can improve their credibility is increasing the visibility of the strengths and impact of case study research, and increasing the awareness about new developments in the field. At the methodological level, specific approaches to rigorous data collection and data analysis for case studies have been developed ( 5 , 6 ); quality criteria to improve the evidential value of clinical case studies have been proposed ( 7 , 8 ). Moreover, methods to generalize by comparing and aggregating case studies are available and used ( 9 , 10 ). Others have argued that the use of data from psychotherapy trials for conducting individual-focused case studies can “improve the yield” of painstakingly collected data, but also increase the impact of research on practice ( 11 ). The difference between sample-selection and case-selection has been highlighted as a crucial parameter in the process of generalization ( 12 ). At the epistemological level, Stake ( 13 ) introduced the concept of naturalistic generalization to describe knowledge that is gained through personal or vicarious experiences, for instance by reading case studies. Moreover, the concept of statistical generalization, which is so important for EBP based on efficacy studies, must be complemented with the concept of analytic generalization ( 14 ) which underpins the use of case studies for theory building ( 15 ). In the past, it has often been suggested that case studies are only useful for generating descriptions of and hypothesis about phenomena that are not well understood (“context of discovery”). However, these recent methodological and epistemological developments have shown that case studies can also contribute to the “context of justification.” That is, under the right conditions, they can provide rigorous tests of theory and therapeutic technique ( 16 , 17 ).

3. The lack of framework issue

Within the community of case study “producers” and case study “users” (researchers, trainers, trainees, students, practitioners, policy makers), there is a lack of a shared framework of criteria to assess the quality of case studies. This problem can be situated at different levels. At the level of ethics, there are inconsistencies in the policies used by psychotherapy training institutions, universities and publishers that oversee the ethical aspects of case study research. Ethical committees within academic or clinical institutions often struggle to evaluate project applications that involve case study research, either because they don't see its scientific merit (see Section 2), or because their experience with the evaluation of sample-based studies is unhelpful when it comes to assessing the ethical intricacies of a case study project. At the level of the methodology, there are no tools to evaluate the quality of case studies. Existing frameworks and tools for evaluating the quality of research evidence (e.g., GRADE) categorize case studies as “low-quality evidence.” This is because these tools apply the criteria for efficacy studies to case reports. As a consequence, policy-makers undervalue the importance of case studies in the development of EBP. Organizations that promote and support EBP, such as the Joanna Briggs Institute and the Critical Appraisal Skills Programme, have developed checklists for rating the quality of qualitative research and case reports. However, these tools are developed for medical research, and they are diagnosis-oriented. Moreover, these tools and checklist operate on the basis of a categorical difference between qualitative and quantitative research, whereas case studies often take the form of mixed-method research.

The lack of framework issue can be addressed by developing ethics, methodology, and epistemology consensual frameworks for case study research. The general criteria for good science (objectivity and generalization) need to be adapted to case study research, in which the focus is on the individual and in which context plays a central role. In the field of social sciences, much work has been done on developing the methodological and epistemological principles that underpin case study research ( 14 ). This literature needs to be explored for relevant concepts and frameworks. Truijens et al. ( 18 ) argue that a precondition for EBP is the development of a theory of evidence that is clear on what should be evidenced to be useful and valid for psychological interventions. An important step toward the development of a framework is Kaluzeviciute's ( 19 ) Case Study Evaluation-tool (CaSE), the first tool that offers a framework and a checklist to evaluate the evidential value of case studies in the field of psychotherapy. This tool needs to be completed, disseminated, and implemented more broadly.

4. The accessibility issue

Case studies remain difficult to access by researchers, trainers, practitioners, and policy-makers. For case studies to have an impact on EBP, they should be easily accessible through searchable digital databases. However, current databases that are most often used for the development of EBP like Science Citation Index, PubMed and PsycInfo, do not allow to search the field of case study research efficiently. Case studies are often difficult to find with regular search terms, which makes it difficult to find relevant (sets of) case studies. Practitioners who want to look up case studies that can inform their work are not able to systematically identify relevant case studies. As a result, experiences and insights from clinical practice are insufficiently transformed into knowledge that can be shared and taught and, in a sense, each practitioner must discover the richness of clinical work anew. Practitioners write case studies in the context of their training and for professional development, but almost none of this work is available to other practitioners or for researchers ( 20 ). Training institutions have archives of case studies in the form of doctoral theses that are not cataloged and classified, and therefore not accessible.

The accessibility issue can be addressed by increasing the visibility of existing case study research and by making case studies more easily accessible. Practitioners need to be able to access case study research via different platforms and in different formats, for instance journals articles, online database of vignettes… A coordinated effort is needed to map available case study resources, for instance in the archives of training institutions. Several initiatives have been taken in the past. The Ulm Textbank ( 21 ) and the Psychoanalytic Research Consortium ( 22 ) are collections of recorded and transcribed therapy sessions that provide a rich resource for case study research. Miller (in 2004) and Iwakabe (in 2005) laid the foundation for building a searchable database of case studies. Their initiatives inspired a network of researchers from Ghent University, Université catholique de Louvain, and the University of Essex to create the Single Case Archive ( www.singlecasearchive.com ), an online searchable database of +3,400 published case studies that can be used by researchers, trainers, practitioners, and students. In the context of the Single Case Archive project, the first comprehensive review of case studies was published ( 23 ).

5. Discussion

The research-practice gap in the field of psychotherapy has been described as a lack of integration between the findings disseminated by researchers and the decisions made in the consulting room by therapists ( 19 ). This gap has negative consequences for the application of research findings in mental health services as well as on the development of research—supported psychological treatments. Case studies are an important means to reduce this gap because they provide templates of how to integrate basic research and knowledge into applied work at the individual case level. Reducing the research-practice gap should not be a matter of promoting the systematic uptake of research findings and other evidence-based practices into routine practice (top-down implementation). Rather, therapists should be engaged as learners that learn from their own and others' experiences and that learn from sharing and reflective on these experiences. The flexible case study research approach is a means to stimulate, support, and improve these learning processes, while considering different learning styles. For that reason, the above-mentioned obstacles need to be addressed urgently.

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John Sommers-Flanagan

A short existential case example from counseling and psychotherapy theories . . ..

Each chapter in Counseling and Psychotherapy Theories in Context and Practice includes at least two case vignettes. These vignettes are brief, but designed to articulate how clinicians can use specific theories to formulate cases and engage in therapeutic interactions. The following case is excerpted from the Existential Theory and Therapy chapter.

This post is part of a series of free posts available to professors and students in counseling and psychology who are teaching and learning about theories of counseling and psychotherapy. It, as well as the recommended video clip at the end, can be used for discussion purposes and/or to supplement course content.

Vignette II: Using Confrontation and Visualization to Increase Personal Responsibility and Explore Deeper Feelings

In this case, a Native American counselor-in-training is working with an 18-year-old Latina female. The client has agreed to attend counseling to work on her anger and disruptive behaviors within a residential vocational training setting. Her behaviors are progressively costing her freedom at the residential setting and contributing to the possibility of her being sent home. The client says she would like to stay in the program and complete her training, but her behaviors seem to say otherwise.

Client: Yeah, I got in trouble again yesterday. I was just walking on the grass and some “ho” told me to get on the sidewalk so I flipped her off and staff saw. So I got a ticket. That’s so bogus.

Counselor: You sound like you’re not happy about getting in trouble, but you also think the ticket was stupid.

Client: It was stupid. I was just being who I am. All the women in my family are like this. We just don’t take shit.

Counselor: We’ve talked about this before. You just don’t take shit.

Client: Right.

Counselor: Can I be straight with you right now? Can I give you a little shit?

Client: Yeah, I guess. In here it’s different.

Counselor: On the one hand you tell me and everybody that you want to stay here and graduate. On the other hand, you’re not even willing to follow the rules and walk on the sidewalk instead of the grass. What do you make of that?

Client: Like I’ve been saying, I do my own thing and don’t follow anyone’s orders.

Counselor: But you want to finish your vocational training. What is it for you to walk on the sidewalk? That’s not taking any shit. All you’re doing is giving yourself trouble.

Client: I know I get myself trouble. That’s why I need help. I do want to stay here.

Counselor: What would it be like for you then . . . to just walk on the sidewalk and follow the rules?

Client: That’s weak brown-nosing bullshit.

Counselor: Then will you explore that with me? Are you strong enough to look very hard right now with me at what this being weak shit is all about?

Client: Yeah. I’m strong enough. What do you want me to do?

Counselor: Okay then. Let’s really get serious about this. Relax in your chair and imagine yourself walking on the grass and someone asks you to get on the sidewalk and then you just see yourself smiling and saying, “Oh yeah, sure.” And then you see yourself apologize. You say, “Sorry about that. My bad. You’re right. Thanks.” What does that bring up for you.

Client: Goddamn it! It just makes me feel like shit. Like I’m f-ing weak. I hate that.

In this counseling scenario the client is conceptualized as using expansive and angry behaviors to compensate for inner feelings of weakness and vulnerability. The counselor uses the client’s language to gently confront the discrepancy between what the client wants and her behaviors. As you can see from the preceding dialogue, this confrontation (and the counselor’s use of an interpersonal challenge) gets the client to look seriously at what her discrepant behavior is all about. This cooperation wouldn’t be possible without the earlier development of a therapy alliance . . . an alliance that seemed deepened by the fact that the client saw the counselor as another Brown Woman. After the confrontation and cooperation, the counselor shifts into a visualization activity designed to focus and vivify the client’s feelings. This process enabled the young Latina woman to begin understanding in greater depth why cooperating with rules triggered intense feelings of weakness. In addition, the client was able to begin articulating the meaning of feeling “weak” and how that meaning permeated and impacted her life.

To check out a 4+ minute existential counseling video clip go to: https://www.youtube.com/watch?v=jiirtIKcIeM

This clip is taken from our Counseling and Psychotherapy Theories 2 DVD set. The 2 DVD set is available through Psychotherapy.net: http://www.psychotherapy.net/video/counseling-psychotherapy-theories and Amazon: http://www.amazon.com/Counseling-Psychotherapy-Theories-Context-Practice/dp/1118402537/ref=asap_bc?ie=UTF8

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2 thoughts on “a short existential case example from counseling and psychotherapy theories . . .”.

Beautiful example of “process” work, staying with the client’s existential experience. Yes, it works.

Thanks Nadine! I hope all is well for you and your chickens:)

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The place to click if you want to learn about psychotherapy, counseling, or whatever john sf is thinking about..

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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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Kathleen Wheeler, PhD, PMHNP-BC, APRN, FAAN

A case study companion to the leading textbook on psychotherapy for advanced practice psychiatric nurses

Case Study Approach to Psychotherapy for Advanced Practice Psychiatric Nurses is a case study companion to the groundbreaking and award-winning textbook Psychotherapy for the Advanced Practice Psychiatric Nurse , edited by Kathleen Wheeler. Designed for both the novice and experienced advanced practice psychiatric nurse, it provides complementary content and activities to help students and professionals master the art and science of conducting psychotherapy.

The case studies address a wide range of diverse theoretical approaches and varied client problems and psychiatric diagnoses. Each chapter follows a consistent format to allow for comparison, beginning with the author's personal experience, providing the reader with the understanding of how various theoretical orientations were chosen. This is followed by background on philosophy and key concepts, as well as mental health and psychopathology, therapeutic goals, assessment perspectives, and therapeutic interventions. The chapter then presents background on the client and a selection of verbatim transcript segments from the beginning, middle, and final phase of therapy. The therapeutic process is illustrated by client–therapist dialogues, which are supplemented with process commentaries that explain the rationale for the interventions. A final commentary on the case is presented to enhance the reader's clinical reasoning skills.

Key Features:

• Augments the groundbreaking Psychotherapy for the Advanced Practice Psychiatric Nurse
• Features case studies that address a range of theoretical approaches and varied client problems and psychiatric diagnoses
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• Includes reflection questions to help the reader apply the material to their personal lives and offer guidelines for continuing to work with the theoretical orientation
• Purchase includes digital access for use on most mobile devices or computers

Contributors

Acknowledgments

Chapter 1. Psychodynamic Psychotherapy: Healing Attachment Wounds

Chapter 2. Gestalt Psychotherapy: A Client with a Conversion Disorder

Chapter 3. Person-Centered Therapy: A Client with Postpartum Depression

Chapter 4. Existential Psychotherapy: An Older Adult Client at a Crossroad

Chapter 5. Humanistic and Psychoanalytic Play Therapy: A Child with Attention-Deficit/Hyperactivity Obsessive-Compulsive Disorders

Chapter 6. Group Therapy: Stages of Group Development

Chapter 7. Family Therapy: A Family Over Time

Chapter 8. Cognitive Behavioral Therapy: A Grieving Client

Chapter 9. Manualized Cognitive Behavioral Therapy: An Adolescent with Anxiety and Depression

Chapter 10. Dialectical Behavior Therapy: A Client with Complex Trauma

Chapter 11. Interpersonal Psychotherapy: A Client with Complicated Bereavement

Chapter 12. Motivational Interviewing: A Client with Depression

Chapter 13. Harm Reduction Psychotherapy: A Client with a Substance Use Disorder

Chapter 14. Eye Movement Desensitization and Reprocessing Therapy: Healing Trauma

Chapter 15. Trauma Resiliency Model®: A Client with Chronic Trauma

Candice Knight, PhD, EdD, APN, PMHCNS-BC, PMHNP-BC, is an associate professor and director of the Psychiatric-Mental Health Nurse Practitioner Program at New York University College of Nursing in New York City, New York.

Kathleen Wheeler, PhD, PMHNP-BC, APRN, FAAN , is an advanced practice psychiatric nurse and a professor and director of the PMHNP program at Fairfield University Egan School of Nursing and Health Studies in Fairfield, Connecticut.

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Person-Centered Therapy Case Study: Examples and Analysis

Introduction

Welcome to The Knowledge Nest's in-depth exploration of person-centered therapy case study examples and analysis. We aim to provide you with comprehensive insights into the therapeutic approach, techniques, and outcomes associated with person-centered counseling. Through real-life case scenarios, we demonstrate the effectiveness of this humanistic and client-centered approach in fostering personal growth and facilitating positive change.

Understanding Person-Centered Therapy

Person-centered therapy, also known as client-centered therapy or Rogerian therapy, is a compassionate and empathetic therapeutic approach developed by the influential psychologist Carl Rogers. This person-centered approach recognizes the profound significance of the therapeutic relationship, placing the individual at the center of the therapeutic process.

Unlike traditional approaches that impose solutions or interpretations on clients, person-centered therapy emphasizes the innate human capacity to move towards growth and self-actualization. By providing a supportive and non-judgmental environment, therapists aim to enhance clients' self-awareness, self-acceptance, and self-discovery. This holistic approach has proven to be particularly effective in addressing a wide range of mental health concerns, empowering individuals to overcome challenges and achieve personal well-being.

Case Study Examples

Case study 1: overcoming social anxiety.

In this case study, we explore how person-centered therapy helped Sarah, a young woman struggling with severe social anxiety, regain her confidence and navigate social interactions. Through the establishment of a strong therapeutic alliance, her therapist cultivated a safe space for Sarah to explore her fears, challenge negative self-perceptions, and develop effective coping strategies. Through the person-centered approach, Sarah experienced significant improvements, enabling her to participate more actively in social situations and regain a sense of belonging.

Case Study 2: Healing from Trauma

John, a military veteran suffering from PTSD, found solace and healing through person-centered therapy. This case study delves into the profound transformation John experienced as he worked collaboratively with his therapist to process unresolved trauma. By providing unconditional positive regard, empathetic listening, and genuine empathy, the therapist created an environment where John felt safe to explore his traumatic experiences. With time, he was able to develop healthier coping mechanisms, embrace self-compassion, and rebuild a sense of purpose.

Case Study 3: Enhancing Self-Esteem

In this case study, we examine Lisa's journey towards building self-esteem and self-worth. Through person-centered therapy, her therapist empowered Lisa to identify and challenge deeply ingrained negative self-beliefs that inhibited her personal growth. By offering non-directive support, active listening, and reflective feedback, the therapist enabled Lisa to develop a more positive self-concept, fostering increased self-esteem, and self-empowerment.

Analysis of Person-Centered Therapy

The therapeutic relationship.

Person-centered therapy places profound importance on the therapeutic relationship as the foundation for positive change. The therapist cultivates an atmosphere of trust, respect, and authenticity, enabling the individual to feel heard and valued. By providing unconditional positive regard, therapists create a non-judgmental space where clients can freely explore their thoughts, emotions, and experiences.

Client-Centered Approach

The client-centered approach encourages individuals to take an active role in their therapeutic journey. The therapist acts as a facilitator, guiding clients towards self-discovery and personal growth. By allowing clients to set the agenda and directing the focus of sessions, the person-centered approach acknowledges the unique needs and perspectives of each individual.

Empowering Self-Awareness and Growth

Person-centered therapy seeks to unlock individuals' innate capacity for self-awareness and personal growth. Through empathic understanding, therapists support clients in gaining insight into their emotions, thoughts, and needs. This heightened self-awareness helps individuals develop healthier coping mechanisms, make meaningful choices, and move towards a more fulfilling life.

Person-centered therapy, as exemplified through the case studies presented, offers a powerful and transformative path towards holistic well-being and personal growth. The Knowledge Nest is committed to providing a platform for sharing knowledge, experiences, and resources related to person-centered counseling. Together, we strive to facilitate positive change, empower individuals, and create a more compassionate and understanding society.

Explore more case studies and resources on person-centered therapy at The Knowledge Nest to discover the profound impact of this therapeutic approach.

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Ambitious federal study failed to curb opioid deaths, NIH announces

By Lev Facher June 16, 2024

I n 2019, amid an ever-worsening drug crisis, the federal government launched a research study with an ambitious goal: to lower opioid overdoses in participating communities by 40% using evidence-based interventions like distributing naloxone and providing access to addiction medications.

But communities that implemented the public health strategies did not see a statistically significant reduction in opioid overdose deaths, according to data published Sunday in the New England Journal of Medicine . 

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Given the study’s simple premise — that helping communities use proven strategies could help prevent deaths — the results came as a surprise. But its leaders warn against making too much of the disappointing data, citing the fast-changing drug supply and, critically, the backdrop of the Covid-19 pandemic.  

“We started this study in January of 2020, and guess what happened in March of 2020?” Redonna Chandler, the National Institute on Drug Abuse official who directed the research project. “And while our communities continued working in the background, we weren’t able to get into hospitals. We weren’t able to get into jails. We weren’t able to get into a lot of the places and spaces where we wanted to implement our evidence-based practices.” 

Related: How the U.S. is sabotaging its best tools to prevent deaths in the opioid epidemic

In fact, of the hundreds of individual interventions that communities had planned to use as part of the study, just 38% had been implemented by the start of the year that data was analyzed, according to the NEJM analysis.

The National Institutes of Health launched the initiative, known as the HEALing Communities Study — short for Helping End Addiction Long-term — in April 2018. It awarded $344 million to participating communities, using funds that Congress had appropriated for substance use research the previous year. 

“Now is the time to channel the efforts of the scientific community to deliver effective — and sustainable — solutions to this formidable public health challenge,” several top NIH officials, including then-Director Francis Collins and NIDA Director Nora Volkow, wrote in 2018 when the project kicked off. 

The study focused on 67 communities across Massachusetts, New York, Kentucky, and Ohio. Roughly half were picked to implement their overdose-prevention strategies beginning in 2020; the rest put their strategies into place beginning in 2022, following the comparison period between the two groups. 

Interventions included increasing access to medications like methadone and buprenorphine by reducing restrictions, supporting health care providers, and working with jails and prisons. It also included education surrounding opioid prescribing, and bolstering the distribution of naloxone , a medication used to reverse opioid overdoses. 

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During the comparison period, the communities that put their strategies into place sooner experienced 47.2 opioid-related overdose deaths per 100,000 people; the communities that hadn’t begun experienced 51.7. Despite a nearly 10% lower death rate in communities that had implemented their strategies, however, the results fell short of statistical significance. 

In statements, federal health officials cast the study as at least a partial victory. While the interventions did not meaningfully reduce overdose deaths, the officials argued, they set the stage for future action and created a framework to help hard-hit communities choose new policy approaches and begin to implement them, with the hope that with more time and without Covid-19, deaths would fall.  

Volkow, the NIDA director, said that increasing use of stimulants like methamphetamine and cocaine, and the proliferation of fentanyl, mean society must “continue developing new tools and approaches” for preventing overdose deaths. Miriam Delphin-Rittmon, the administrator of the Substance Abuse and Mental Health Services Administration, said the study “recognizes there is no quick fix.” 

And in an interview, Chandler, the director of the study, stressed that the results should not challenge what research has long demonstrated: There is a “mountain of evidence,” she said, supporting the belief that tools like naloxone, medications for opioid use disorder, and safer prescribing techniques, save lives. The challenge, Chandler said, lies in implementation — not the strategies themselves. 

The study released Sunday, she said, “doesn’t negate, in any way, the evidence that suggests the strengths of those interventions.”

STAT’s coverage of chronic health issues is supported by a grant from  Bloomberg Philanthropies . Our financial supporters  are not involved in any decisions about our journalism.

About the Author Reprints

Addiction Reporter

Lev Facher covers the U.S. addiction and overdose crisis.

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