case study in counseling

Writing a Counselling Case Study

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

Before You Start Writing a Case Study

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

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

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

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

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

Selecting the Client

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

Opening the Case Study

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

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

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Describing the Client’s Counselling Journey

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

Theory-Based Case Studies

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

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

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

Supervision-Based Case Studies

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

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

Closing Your Case Study

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

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Case conceptualization: Key to highly effective counseling

By Jon Sperry and Len Sperry

December 2020

I n their first session, the counseling intern learned that Jane’s son had been diagnosed with brain cancer. The therapist then elicited the client’s thoughts and feelings about her son’s diagnosis. Jane expressed feelings of guilt and the thought that if she had done more about the early symptoms, this never would have happened to her son. Hearing this guilt producing thought, the intern spent much of the remaining session disputing it. As the session ended, the client was more despondent.  

After processing this session in supervision, the intern was no longer surprised that Jane had not kept a follow-up appointment. The initial session had occurred near the end of the intern’s second week, and she had been eager to practice cognitive disputation, which she believed was appropriate in this case. In answer to the supervisor’s question of why she had concluded this, the intern responded that “it felt right.”

The supervisor was not surprised by this response because the intern had not developed a case conceptualization. With one, the intern could have anticipated the importance of immediately establishing an effective and collaborative therapeutic alliance and gently processing Jane’s emotional distress sufficiently before dealing with her guilt-producing thought.

This failure to develop an adequate and appropriate case conceptualization is not just a shortcoming of trainees, however. It is also common enough among experienced counselors.

What is case conceptualization?

Basically, a case conceptualization is a process and cognitive map for understanding and explaining a client’s presenting issues and for guiding the counseling process. Case conceptualizations provide counselors with a coherent plan for focusing treatment interventions, including the therapeutic alliance, to increase the likelihood of achieving treatment goals.

We will use the definition from our integrated case conceptualization model to operationalize the term for the purposes of explaining how to utilize this process. Case conceptualization is a method and clinical strategy for obtaining and organizing information about a client, understanding and explaining the client’s situation and maladaptive patterns, guiding and focusing treatment, anticipating challenges and roadblocks, and preparing for successful termination.

We believe that case conceptualization is the most important counseling competency besides developing a strong therapeutic alliance. If our belief is correct, why is this competency taught so infrequently in graduate training programs, and why do counselors-in-training struggle to develop this skill? We think that case conceptualization can be taught in graduate training programs and that counselors in the field can develop this competency through ongoing training and deliberate practice.

This article will articulate one method for practicing case conceptualization.

The eight P’s

We use and teach the eight P’s format of case conceptualization because it is brief, quick to learn and easy to use. Students and counselors in the community who have taken our workshops say that the step-by-step format helps guide them in forming a mental picture — a cognitive map — of the client. They say that it also aids them in making decisions about treatment and writing an initial evaluation report.

The format is based on eight elements for articulating and explaining the nature and origins of the client’s presentation and subsequent treatment. These elements are described in terms of eight P’s: presentation, predisposition (including culture), precipitants, protective factors and strengths, pattern, perpetuants, (treatment) plan, and prognosis.

Presentation

Presentation refers to a description of the nature and severity of the client’s clinical presentation. Typically, this includes symptoms, personal concerns and interpersonal conflicts.

Four of the P’s — predisposition, precipitants, pattern and perpetuants — provide a clinically useful explanation for the client’s presenting concern.

Predisposition

Predisposition refers to all factors that render an individual vulnerable to a clinical condition. Predisposing factors usually involve biological, psychological, social and cultural factors.

This statement is influenced by the counselor’s theoretical orientation. The theoretical model espouses a system for understanding the cause of suffering, the development of personality traits, and a process for how change and healing can occur in counseling. We will use a biopsychosocial model in this article because it is the most common model used by mental health providers. The model incorporates a holistic understanding of the client.

Biological: Biological factors include genetic, familial, temperament and medical factors, such as family history of a mental or substance disorder, or a cardiovascular condition such as hypertension.

Psychological: Psychological factors might include dysfunctional beliefs involving inadequacy, perfectionism or overdependence, which further predispose the individual to a medical condition such as coronary artery disease. Psychological factors might also involve limited or exaggerated social skills such as a lack of friendship skills, unassertiveness or overaggressiveness.

Social: Social factors could include early childhood losses, inconsistent parenting style, an overly enmeshed or disengaged family environment, and family values such as competitiveness or criticalness. Financial stressors can further exacerbate a client’s clinical presentations. The “social” element in the biopsychosocial model includes cultural factors. We separate these factors out, however.

Cultural: Of the many cultural factors, three are particularly important in developing effective case conceptualizations: level of acculturation, acculturative stress and acculturation-specific stress. Acculturation is the process of adapting to a culture different from one’s initial culture. Adapting to another culture tends to be stressful, and this is called acculturative stress. Such adaptation is reflected in levels of acculturation that range from low to high.

Generally, clients with a lower level of acculturation experience more distress than those with a higher level of acculturation. Disparity in acculturation levels within a family is noted in conflicts over expectations for language usage, career plans, and adherence to the family’s food choices and rituals. Acculturative stress differs from acculturation-specific stresses such as discrimination, second-language competence and microaggressions.

Precipitants

Precipitants refer to physical, psychological and social stressors that may be causative or coincide with the onset of symptoms or relational conflict. These may include physical stressors such as trauma, pain, medication side effects or withdrawal from an addictive substance. Common psychological stressors involve losses, rejections or disappointments that undermine a sense of personal competence. Social stressors may involve losses or rejections that undermine an individual’s social support and status. Included are the illness, death or hospitalization of a significant other, job demotion, the loss of Social Security disability payments and so on.

Protective factors and strengths

Protective factors are factors that decrease the likelihood of developing a clinical condition. Examples include coping skills, a positive support system, a secure attachment style and the experience of leaving an abusive relationship. It is useful to think of protective factors as being the mirror opposite of risk factors (i.e., factors that increase the likelihood of developing a clinical condition). Some examples of risk factors are early trauma, self-defeating beliefs, abusive relationships, self-harm and suicidal ideation.

Related to protective factors are strengths. These are psychological processes that consistently enable individuals to think and act in ways that benefit themselves and others. Examples of strengths include mindfulness, self-control, resilience and self-confidence. Because professional counseling emphasizes strengths and protective factors, counselors should feel supported in identifying and incorporating these elements in their case conceptualizations.

Pattern (maladaptive)

Pattern refers to the predictable and consistent style or manner in which an individual thinks, feels, acts, copes, and defends the self both in stressful and nonstressful circumstances. It reflects the individual’s baseline functioning. Pattern has physical (e.g., a sedentary and coronary-prone lifestyle), psychological (e.g., dependent personality style or disorder) and social features (e.g., collusion in a relative’s marital problems). Pattern also includes the individual’s functional strengths, which counterbalance dysfunction.

Perpetuants

Perpetuants refer to processes through which an individual’s pattern is reinforced and confirmed by both the individual and the individual’s environment. These processes may be physical, such as impaired immunity or habituation to an addictive substance; psychological, such as losing hope or fearing the consequences of getting well; or social, such as colluding family members or agencies that foster constrained dysfunctional behavior rather than recovery and growth. Sometimes precipitating factors continue and become perpetuants.

Plan (treatment)

Plan refers to a planned treatment intervention, including treatment goals, strategy and methods. It includes clinical decision-making considerations and ethical considerations.

Prognosis refers to the individual’s expected response to treatment. This forecast is based on the mix of risk factors and protective factors, client strengths and readiness for change, and the counselor’s experience and expertise in effecting therapeutic change.  

Case example

To illustrate this process, we will provide a case vignette to help you practice and then apply the case to our eight P’s format. Ready? Let’s give it a shot.

Joyce is a 35-year-old Ph.D. student at an online university. She is white, identifies as heterosexual and reports that she has never been in a love relationship. She is self-referred and is seeking counseling to reduce her chronic anxiety and social anxiety. She recently started a new job at a bookstore — a stressor that brought her to counseling. She reports feeling very anxious when speaking in her online classes and in social settings. She is worried that she will not be able to manage her anxiety at her new job because she will be in a managerial role.

Joyce reports that she has been highly anxious since childhood. She denies past psychological or psychiatric treatment of any kind but reports that she has recently read several self-help books on anxiety. She also manages her stress by spending time with her close friend from class, spending time with her two dogs, drawing and painting. She appears to be highly motivated for counseling and states that her goals for therapy are “to manage and reduce my anxiety, increase my confidence and eventually get in a romantic relationship.”

Joyce describes her childhood as lonely and herself as “an introvert seeking to be an extrovert.” She states that her parents were successful lawyers who valued success, achievement and public recognition. They were highly critical of Joyce when she would struggle with academics or act shy in social situations. As an only child, she often played alone and would spend her free time reading or drawing by herself.

When asked how she views herself and others, Joyce says, “I often don’t feel like I’m good enough and don’t belong. I usually expect people to be self-centered, critical and judgmental.”

Case conceptualization outline

We suggest developing a case conceptualization with an outline of key phrases for each of the eight P’s. Here is what these phrases might look like for Joyce’s case. These phrases are then woven together into sentences that make up a case conceptualization statement that can be imported into your initial evaluation report.

Presentation: Generalized anxiety symptoms and social anxiety

Precipitant: New job and concerns about managing her anxiety

Pattern (maladaptive): Avoids cl oseness to avoid perceived harm

Predisposition:

• Biological: Paternal history of anxiety
• Psychological: Views herself as inadequate and others as critical; deficits in assertiveness skills, self-soothing skills and relational skills
• Social: Few friends, a history of social anxiety, and parents who were highly successful and critical
• Cultural: No acculturative stress or cultural stressors but from upper-middle-class socioeconomic status, so from privileged background — access to services and resources

Perpetuants: Small support system; believes that she is not competent at work

Protective factors/strengths: Compassionate, creative coping, determined, hardworking, has access to various resources, motivated for counseling

Plan (treatment): Supportive and strengths-based counseling, thought testing, self-monitoring, mindfulness practice, downward arrow technique, coping and relationship skills training, referral for group counseling

Prognosis: Good, given her motivation for treatment and the extent to which her strengths and protective factors are integrated into treatment

Case conceptualization statement

Joyce presents with generalized anxiety symptoms and social anxiety (presentation) . A recent triggering event includes her new job at a local bookstore — she is concerned that she will make errors and will have high levels of anxiety (precipitant) . She presents with an avoidant personality — or attachment — style and typically avoids close relationships. She has one close friend and has never been in a love relationship. She typically moves away from others to avoid being criticized, judged or rejected (pattern) . Some perpetuating factors include her small support system and her belief that she is not competent at work (perpetuants) .

Some of her protective factors and strengths include that she is compassionate, uses art and music to cope with stress, is determined and hardworking, and is collaborative in the therapeutic relationship. Protective factors include that she has a close friend from school, has access to university services such as counseling services and student clubs and organizations, is motivated to engage in counseling, and has health insurance (strengths & protective factors) .

The following biopsychosocial factors attempt to explain Joyce’s anxiety symptoms and avoidant personality style: a paternal history of anxiety (biological) ; she views herself as inadequate and others as critical and judgmental, and she struggles with deficits in assertiveness skills, self-soothing skills and relational skills (psychological) ; she has few friends, a history of social anxiety and parents who were highly successful and critical toward her (social) . Given Joyce’s upper-middle-class upbringing, she was born into a life of opportunity and privilege, so her entitlement of life going in a preferred and comfortable path may also explain her challenges with managing life stress (cultural) .

Besides facilitating a highly supportive, empathic and encouraging counseling relationship, treatment will include psychoeducation skills training to develop assertiveness skills, self-soothing skills and relational skills. These skills will be implemented through modeling, in-session rehearsal and role-play. Her challenges with relationship skills and interpersonal patterns will also be addressed with a referral to a therapy group at the university counseling center. Joyce’s negative self-talk, interpersonal avoidance and anxiety symptoms will be addressed with Socratic questioning, thought testing, self-monitoring, mindfulness practice and the downward arrow technique (plan-treatment) .

The outcome of therapy with Joyce is judged to be good, given her motivation for treatment, if her strengths and protective factors are integrated into the treatment process (prognosis) .

Notice how the treatment plan is targeted at the presenting symptoms and pattern dynamics of Joyce’s case. Each of the eight P’s was identified in the case conceptualization, and you can see the flow of each element and its interconnections to the other elements.

Tips for writing effective case conceptualizations

1) Seek consultation or supervision with a peer or supervisor for feedback on your case conceptualizations. Often, another perspective will help you understand the various elements (eight P’s) that you are trying to conceptualize.

2) Be flexible with your hypotheses and therapeutic guesses when piecing together case conceptualizations. Sometimes your hunches will be accurate, and sometimes you will be way off the mark.

3) Consider asking the client how they would explain their presenting problem. We begin with a question such as, “How might you explain the (symptoms, conflict, etc.) you are experiencing?” The client’s perspective may reveal important predisposing factors and cultural influences as well as their expectations for treatment.

4) Be OK with being imperfect or being completely wrong. This process takes practice, feedback and supervision.

5) After each initial intake or assessment, jot down the presenting dynamics and make some guesses of the cause or etiology of them.

6) Have a solid understanding of at least one theoretical model. Read some of the seminal textbooks or watch counseling theory videos to help you gain a comprehensive assessment of a specific theory. Knowing the foundational ideas of at least one theory will help with your conceptual map of piecing together the information that you’ve gathered about a client.

We realize that putting together case conceptualizations can be a challenge, particularly in the beginning. We hope you will find that this approach works for you. Best wishes!

For more information and ways of learning and using this approach to case conceptualization, check out the recently published second edition of our book, Case Conceptualization: Mastering This Competency With Ease and Confidence .

Jon Sperry is an associate professor of clinical mental health counseling at Lynn University in Florida. He teaches, writes about and researches case conceptualization and conducts workshops on it worldwide. Contact him at [email protected] or visit his website at drjonsperry.com .

Len Sperry is a professor of counselor education at Florida Atlantic University and a fellow of the American Counseling Association. He has long advocated for counselors learning and using case conceptualization, and his research team has completed eight studies on it. Contact him at [email protected] .

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

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How to Write a Case Conceptualization: 10 Examples (+ PDF)

Such understanding can be developed by reading relevant records, meeting with clients face to face, and using assessments such as a mental status examination.

As you proceed, you are forming a guiding concept of who this client is, how they became who they are, and where their personal journey might be heading.

Such a guiding concept, which will shape any needed interventions, is called a case conceptualization, and we will examine various examples in this article.

Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with detailed insight into positive Cognitive-Behavioral Therapy (CBT) and give you the tools to apply it in your therapy or coaching.

This Article Contains:

What is a case conceptualization or formulation, 4 things to include in your case formulation, a helpful example & model, 3 samples of case formulations, 6 templates and worksheets for counselors, relevant resources from positivepsychology.com, a take-home message.

In psychology and related fields, a case conceptualization summarizes the key facts and findings from an evaluation to provide guidance for recommendations.

This is typically the evaluation of an individual, although you can extend the concept of case conceptualization to summarizing findings about a group or organization.

Based on the case conceptualization, recommendations can be made to improve a client’s self-care , mental status, job performance, etc (Sperry & Sperry, 2020).

• Summary of the client’s identifying information, referral questions, and timeline of important events or factors in their life . A timeline can be especially helpful in understanding how the client’s strengths and limitations have evolved.
• Statement of the client’s core strengths . Identifying core strengths in the client’s life should help guide any recommendations, including how strengths might be used to offset limitations.
• Statement concerning a client’s limitations or weaknesses . This will also help guide any recommendations. If a weakness is worth mentioning in a case conceptualization, it is worth writing a recommendation about it.

Note: As with mental status examinations , observations in this context concerning weaknesses are not value judgments, about whether the client is a good person, etc. The observations are clinical judgments meant to guide recommendations.

• A summary of how the strengths, limitations, and other key information about a client inform diagnosis and prognosis .

You should briefly clarify how you arrived at a given diagnosis. For example, why do you believe a personality disorder is primary, rather than a major depressive disorder?

Many clinicians provide diagnoses in formal psychiatric terms, per the International Classification of Diseases (ICD-10) or Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Some clinicians will state a diagnosis in less formal terms that do not coincide exactly with ICD-10 or DSM-5 codes. What is arguably more important is that a diagnostic impression, formal or not, gives a clear sense of who the person is and the support they need to reach their goals.

Prognosis is a forecast about whether the client’s condition can be expected to improve, worsen, or remain stable. Prognosis can be difficult, as it often depends on unforeseeable factors. However, this should not keep you from offering a conservative opinion on a client’s expected course, provided treatment recommendations are followed.

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Based on the pointers for writing a case conceptualization above, an example for summarizing an adolescent case (in this instance, a counseling case for relieving depression and improving social skills) might read as follows.

Background and referral information

This is a 15-year-old Haitian–American youth, referred by his mother for concerns about self-isolation, depression, and poor social skills. He reportedly moved with his mother to the United States three years ago.

He reportedly misses his life and friends in Haiti. The mother states he has had difficulty adjusting socially in the United States, especially with peers. He has become increasingly self-isolating, appears sad and irritable, and has started to refuse to go to school.

His mother is very supportive and aware of his emotional–behavioral needs. The youth has been enrolled in a social skills group at school and has attended three sessions, with some reported benefit. He is agreeable to start individual counseling. He reportedly does well in school academically when he applies himself.

Limitations

Behavioral form completed by his mother shows elevated depression scale (T score = 80). There is a milder elevation on the inattention scale (T score = 60), which suggests depression is more acute than inattention and might drive it.

He is also elevated on a scale measuring social skills and involvement (T score = 65). Here too, it is reasonable to assume that depression is driving social isolation and difficulty relating to peers, especially since while living in Haiti, he was reportedly quite social with peers.

Diagnostic impressions, treatment guidance, prognosis

This youth’s history, presentation on interview, and results of emotional–behavioral forms suggest some difficulty with depression, likely contributing to social isolation. As he has no prior reported history of depression, this is most likely a reaction to missing his former home and difficulty adjusting to his new school and peers.

Treatments should include individual counseling with an evidence-based approach such as Cognitive-Behavioral Therapy (CBT). His counselor should consider emotional processing and social skills building as well.

Prognosis is favorable, with anticipated benefit apparent within 12 sessions of CBT.

How to write a case conceptualization: An outline

The following outline is necessarily general. It can be modified as needed, with points excluded or added, depending on the case.

• Client’s gender, age, level of education, vocational status, marital status
• Referred by whom, why, and for what type of service (e.g., testing, counseling, coaching)
• In the spirit of strengths-based assessment, consider listing the client’s strengths first, before any limitations.
• Consider the full range of positive factors supporting the client.
• Physical health
• Family support
• Financial resources
• Capacity to work
• Resilience or other positive personality traits
• Emotional stability
• Cognitive strengths, per history and testing
• The client’s limitations or relative weaknesses should be described in a way that highlights those most needing attention or treatment.
• Medical conditions affecting daily functioning
• Lack of family or other social support
• Limited financial resources
• Inability to find or hold suitable employment
• Substance abuse or dependence
• Proneness to interpersonal conflict
• Emotional–behavioral problems, including anxious or depressive symptoms
• Cognitive deficits, per history and testing
• Diagnoses that are warranted can be given in either DSM-5 or ICD-10 terms.
• There can be more than one diagnosis given. If that’s the case, consider describing these in terms of primary diagnosis, secondary diagnosis, etc.
• The primary diagnosis should best encompass the client’s key symptoms or traits, best explain their behavior, or most need treatment.
• Take care to avoid over-assigning multiple and potentially overlapping diagnoses.

When writing a case conceptualization, always keep in mind the timeline of significant events or factors in the examinee’s life.

• Decide which events or factors are significant enough to include in a case conceptualization.
• When these points are placed in a timeline, they help you understand how the person has evolved to become who they are now.
• A good timeline can also help you understand which factors in a person’s life might be causative for others. For example, if a person has suffered a frontal head injury in the past year, this might help explain their changeable moods, presence of depressive disorder, etc.

Sample #1: Conceptualization for CBT case

This is a 35-year-old Caucasian man referred by his physician for treatment of generalized anxiety.

Strengths/supports in his case include willingness to engage in treatment, high average intelligence per recent cognitive testing, supportive family, and regular physical exercise (running).

Limiting factors include relatively low stress coping skills, frequent migraines (likely stress related), and relative social isolation (partly due to some anxiety about social skills).

The client’s presentation on interview and review of medical/psychiatric records show a history of chronic worry, including frequent worries about his wife’s health and his finances. He meets criteria for DSM-5 generalized anxiety disorder. He has also described occasional panic-type episodes, which do not currently meet full criteria for panic disorder but could develop into such without preventive therapy.

Treatments should include CBT for generalized anxiety, including keeping a worry journal; regular assessment of anxiety levels with Penn State Worry Questionnaire and/or Beck Anxiety Inventory; cognitive restructuring around negative beliefs that reinforce anxiety; and practice of relaxation techniques, such as progressive muscle relaxation and diaphragmatic breathing .

Prognosis is good, given the evidence for efficacy of CBT for anxiety disorders generally (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012).

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Sample #2: Conceptualization for DBT case

This 51-year-old Haitian–American woman is self-referred for depressive symptoms, including reported moods of “rage,” “sadness,” and “emptiness.” She says that many of her difficulties involve family, friends, and coworkers who regularly “disrespect” her and “plot against her behind her back.”

Her current psychiatrist has diagnosed her with personality disorder with borderline features, but she doubts the accuracy of this diagnosis.

Strengths/supports include a willingness to engage in treatment, highly developed and marketable computer programming skills, and engagement in leisure activities such as playing backgammon with friends.

Limiting factors include low stress coping skills, mild difficulties with attention and recent memory (likely due in part to depressive affect), and a tendency to self-medicate with alcohol when feeling depressed.

The client’s presentation on interview, review of medical/psychiatric records, and results of MMPI-2 personality inventory corroborate her psychiatrist’s diagnosis of borderline personality disorder.

The diagnosis is supported by a longstanding history of unstable identity, volatile personal relationships with fear of being abandoned, feelings of emptiness, reactive depressive disorder with suicidal gestures, and lack of insight into interpersonal difficulties that have resulted in her often stressed and depressive state.

Treatments should emphasize a DBT group that her psychiatrist has encouraged her to attend but to which she has not yet gone. There should also be regular individual counseling emphasizing DBT skills including mindfulness or present moment focus, building interpersonal skills, emotional regulation, and distress tolerance. There should be a counseling element for limiting alcohol use. Cognitive exercises are also recommended.

Of note, DBT is the only evidence-based treatment for borderline personality disorder (May, Richardi, & Barth, 2016). Prognosis is guardedly optimistic, provided she engages in both group and individual DBT treatments on a weekly basis, and these treatments continue without interruption for at least three months, with refresher sessions as needed.

Sample #3: Conceptualization in a family therapy case

This 45-year-old African-American woman was initially referred for individual therapy for “rapid mood swings” and a tendency to become embroiled in family conflicts. Several sessions of family therapy also appear indicated, and her psychiatrist concurs.

The client’s husband (50 years old) and son (25 years old, living with parents) were interviewed separately and together. When interviewed separately, her husband and son each indicated the client’s alcohol intake was “out of control,” and that she was consuming about six alcoholic beverages throughout the day, sometimes more.

Her husband and son each said the client was often too tired for household duties by the evening and often had rapid shifts in mood from happy to angry to “crying in her room.”

On individual interview, the client stated that her husband and son were each drinking about as much as she, that neither ever offered to help her with household duties, and that her son appeared unable to keep a job, which left him home most of the day, making demands on her for meals, etc.

On interview with the three family members, each acknowledged that the instances above were occurring at home, although father and son tended to blame most of the problems, including son’s difficulty maintaining employment, on the client and her drinking.

Strengths/supports in the family include a willingness of each member to engage in family sessions, awareness of supportive resources such as assistance for son’s job search, and a willingness by all to examine and reduce alcohol use by all family members as needed.

Limiting factors in this case include apparent tendency of all household members to drink to some excess, lack of insight by one or more family members as to how alcohol consumption is contributing to communication and other problems in the household, and a tendency by husband and son to make this client the family scapegoat.

The family dynamic can be conceptualized in this case through a DBT lens.

From this perspective, problems develop within the family when the environment is experienced by one or more members as invalidating and unsupportive. DBT skills with a nonjudgmental focus, active listening to others, reflecting each other’s feelings, and tolerance of distress in the moment should help to develop an environment that supports all family members and facilitates effective communication.

It appears that all family members in this case would benefit from engaging in the above DBT skills, to support and communicate with one another.

Prognosis is guardedly optimistic if family will engage in therapy with DBT elements for at least six sessions (with refresher sessions as needed).

Introduction to case conceptualization – Thomas Field

The following worksheets can be used for case conceptualization and planning.

• Case Conceptualization Worksheet: Individual Counseling helps counselors develop a case conceptualization for individual clients.
• Case Conceptualization Worksheet: Couples Counseling helps counselors develop a case conceptualization for couples.
• Case Conceptualization Worksheet: Family Counseling helps counselors develop a case conceptualization for families.
• Case Conceptualization and Action Plan: Individual Counseling helps clients facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
• Case Conceptualization and Action Plan: Couples Counseling helps couples facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
• Case Conceptualization and Action Plan: Family Counseling helps families facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.

17 Science-Based Ways To Apply Positive CBT

These 17 Positive CBT & Cognitive Therapy Exercises [PDF] include our top-rated, ready-made templates for helping others develop more helpful thoughts and behaviors in response to challenges, while broadening the scope of traditional CBT.

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The following resources can be found in the Positive Psychology Toolkit© , and their full versions can be accessed by a subscription.

Analyzing Strengths Use in Different Life Domains can help clients understand their notable strengths and which strengths can be used to more advantage in new contexts.

Family Strength Spotting is another relevant resource. Each family member fills out a worksheet detailing notable strengths of other family members. In reviewing all worksheets, each family member can gain a greater appreciation for other members’ strengths, note common or unique strengths, and determine how best to use these combined strengths to achieve family goals.

Four Front Assessment is another resource designed to help counselors conceptualize a case based on a client’s personal and environmental strengths and weaknesses. The idea behind this tool is that environmental factors in the broad sense, such as a supportive/unsupportive family, are too often overlooked in conceptualizing a case.

If you’re looking for more science-based ways to help others through CBT, check out this collection of 17 validated positive CBT tools for practitioners. Use them to help others overcome unhelpful thoughts and feelings and develop more positive behaviors.

In helping professions, success in working with clients depends first and foremost on how well you understand them.

This understanding is crystallized in a case conceptualization.

Case conceptualization helps answer key questions. Who is this client? How did they become who they are? What supports do they need to reach their goals?

The conceptualization itself depends on gathering all pertinent data on a given case, through record review, interview, behavioral observation, questionnaires completed by the client, etc.

Once the data is assembled, the counselor, coach, or other involved professional can focus on enumerating the client’s strengths, weaknesses, and limitations.

It is also often helpful to put the client’s strengths and limitations in a timeline so you can see how they have evolved and which factors might have contributed to the emergence of others.

Based on this in-depth understanding of the client, you can then tailor specific recommendations for enhancing their strengths, overcoming their weaknesses, and reaching their particular goals.

We hope you have enjoyed this discussion of how to conceptualize cases in the helping professions and that you will find some tools for doing so useful.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

• Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research , 36 (5), 427–440.
• May, J. M., Richardi, T. M., & Barth, K. S. (2016). Dialectical behavior therapy as treatment for borderline personality disorder. The Mental Health Clinician , 6 (2), 62–67.
• Sperry, L., & Sperry, J. (2020).  Case conceptualization: Mastering this competency with ease and confidence . Routledge.

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

Greta kaluzeviciute.

Department of Psychosocial and Psychoanalytic Studies, University of Essex, Wivenhoe Park, Colchester, CO4 3SQ UK

Associated Data

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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 ​ (Table1 1 ).

Key concept: systematic case study

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 ​ Table2 2 ).

How can Case Study Evaluation-tool (CaSE) be used in psychotherapy research and practice?

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 ​ (Table3 3 ).

Key concept: evidence-based practice (EBP)

‘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. ​ Fig.1 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. ​ Fig.2 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 ​ (Table4 4 ).

Key concept: practice-based evidence (PBE)

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. ​ Fig.3. 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. ​ Fig.4 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 ​ (Table5 5 ).

Key concept: research appraisal tool

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 ​ (Tables6, 6 , ​ ,7 7 and ​ and8 8 ).

CASP (Critical Appraisal Skills Programme-tool)

JBI (Joanna Briggs Institute-tool)

ETQS (Evaluation Tool for Qualitative Studies)

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 ​ Table9 9 for detailed descriptions of each component).

Comparing the relevance of JBI (Joanna Briggs Institute), CASP (Critical Appraisal Skills Program) and ETQS (Evaluation Tool for Qualitative Studies) for appraising components specific to systematic case studies

The evaluation criteria for each tool in Table ​ Table9 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 ​ Table10 10 demonstrates how each tool should be used (i.e. recommended reviewer responses to checklists and questionnaires).

Recommended reviewer responses to JBI (Joanna Briggs Institute), CASP (Critical Appraisal Skills Program) and ETQS (Evaluation Tool for Qualitative Studies)

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 ​ (Table10). 10 ). Systematic case studies can vary significantly in their formulation and purpose. The methodological, theoretical and clinical components outlined in Table ​ Table9 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 ​ Table9. 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 ​ (Table11 11 ).

Case Study Evaluation-tool (CaSE) checklist for essential components in systematic case studies. Recommended responses: Yes, No, unclear or not applicable

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 ​ (Table12 12 ).

Key concept: purpose–based systematic case studies

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 ​ Table13 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.

Case Study Evaluation-tool (CaSE) purpose-based evaluative framework for systematic case studies. Recommended responses: open-ended questionnaire

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 ​ (Table13). 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 ​ Table14. 14 . Based on the core questions associated with the six purpose-based systematic case study types in Table ​ Table13(1 13 (1 to 6), the purpose of Lunn et al.’s ( 2016 ) case was identified as critical (testing an existing theoretical suggestion).

Using Case Study Evaluation-tool (CaSE): Lunn et al. ( 2016 )’s case ‘ Psychoanalytic psychotherapy with a client with bulimia nervosa ’

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 ​ Table13(2) 13 (2) on descriptive cases. If the reviewed cases do not align with the questions in Table ​ Table13(2), 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 ​ Table14 14 .

Along with CaSE Purpose - based Evaluative Framework (Table ​ (Table13), 13 ), the paper also developed CaSE Checklist for Essential Components in Systematic Case Studies (Table ​ (Table12). 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 ​ Table14. 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.

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.

Author’s contributions

GK is the sole author of the manuscript. The author(s) read and approved the final 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].

Availability of data and materials

Declarations.

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Case Examples

I would not exchange or trade the honor and privilege I have had helping individuals, couples and families since 1987. Along this journey, I experienced many situations of success and seeing people grow and share their positive outcomes.

Below you will find a sample of cases where a client has given me permission to share their experience. Identifying information has been changed to protect confidentiality.

Dr. Chen is a good therapist.  He has helped me clarify perceptions that have blocked my growth and development.  I have been able to resolve the feelings that have grown from the misperceptions.  In counseling, I have learned new attitudes and language to help improve my marriage and family relationships.  The barriers I have built up over the years are being removed.  This process takes a long time, but I think it has moved at an appropriate pace.  Other counselors have taken much longer to help me even begin the healing process.  I have made great progress while working with Dr. Chen.

Dear Dr. Chen,

I am writing to express my appreciation for your knowledge and understanding in helping us deal with our teenager’s issues. We were very distraught when we learned about our child’s problems. As with any parent, we were concerned for our child and feared for the worst. We didn’t know what to expect or how to help our child.

Your extensive knowledge and expertise helped us understand what was going on and provided comfort and reassurance. Your expertise and ability to relate to our situation helped us get through a very difficult time.

Thank you for the competence and calm demeanor you displayed as you helped reassure us during this critical time. I firmly believe that others facing similar problems would greatly benefit from your services.

Thanks again, Bruce L.

After suffering with trichotillomania for 15 years, I felt trapped by my constant urges to pull my hair.  3 weeks after seeking professional help from you, I was able to greatly reduce the amount I pulled my hair.  By using the tools I learned in therapy, I can go several days at a time without pulling and am continually improving.

Thank you! Kelsey

Alcoholic Alan

Not long ago a client (Alan) came in seeking help for drug and alcohol abuse. He was in his mid 30’s and had been using marijuana, cocaine and methamphetamine since his late teenage years. He started drinking alcohol before he was a teenager.

Alan finished high school and began working in retail. He changed jobs or was fired every couple years but was able to work his way up into a manager position. He was married and had three children. His drinking had a negative impact on his family and occasionally he yelled at his wife and kids. Often he spent time by himself at home watching T.V. or surfing on the Internet.

He wasn’t very satisfied at work and occasionally got into arguments with his assistant manager.  During therapy, it became evident that Alan used drugs and alcohol to cover up his feelings of anger, frustration and at times low self-esteem.

He was able to learn new coping skills and reduce his use of drugs and alcohol. His marriage improved and he enjoyed his kids more. Even his relationship with his assistant manager improved.

Co-dependent Cathy

Cathy had been married for 14 years to her high school sweetheart. Things started out good but as their family grew to four children the first five years, their marital relationship gradually deteriorated. Her husband, a sales manager traveled almost every week. When he was home, he tended to ignore her and the kids.

Cathy would occupy herself with housework, church duties and helping neighbors and other relatives. Most people thought Cathy had a good marriage, but inside she felt empty and trapped.

Feelings of frustration and anger would occasionally rise to the surface, but most of the time she just kept it all inside.

When Cathy started therapy, she had just discovered her husband had an addiction to pornography. She was surprised, hurt, angry and didn’t know whether she wanted to stay in the marriage or leave. She was concerned about the kids.

The therapy focused on a pattern of behavior called co-dependency. Cathy discovered that her husband was in many ways like her father, who was an alcoholic. She tried to control her family growing up and now she was trying to control her husband.

Gradually Cathy developed a healthy mental separation from her husband and as she began to get healthy, her husband admitted he had a problem with pornography and decided to get help himself.

Anxious Ann

Ann was in her late 20’s and had been working in a secretarial position since graduating from high school. She was nervous and anxious most of the time. She rarely dated but desperately wanted to get married.

However, Ann was afraid to socialize and had few friends. Most evenings she would read a book at home or talk on the phone to her parents or other relatives.

By the time Ann came to therapy, she had begun to have panic attacks and at times she thought she might die. Therapy began by exploring why Ann was not dating. It was discovered that she had been sexually abused by a baby sitter when she was 7 years old. This abuse continued over a two year period. She had never told her parents. Later she was also sexually abused by an uncle.

Ann had strong feelings of anger toward men but also wanted to develop a relationship with a man and eventually get married. Her feelings of ambivalence had developed into anxiety which lead her to isolate and avoid men.

During therapy Ann was able to work through the trauma of the two different periods of sexual abuse. Her anxiety disappeared and then therapy focused on helping her develop appropriate social skills. Ann began dating and recently became engaged.

Depressed Donna

Donna was in her mid 40’s, a typical mother of 4 children, married for over 16 years and active in the community and church.}

She had her first depression with the birth of her first child, and her family doctor prescribed an anti-depressant.

Her husband was supportive and made a decent income, yet money always seemed tight. It was a challenge taking each of the four children to music lessons, dance, football practice and the like, not to mention all the church activities.

Donna never felt like there was any time for herself. In fact, if she did take time to do something she enjoyed, she felt guilty.

She tried to talk to her church leader once, but that didn’t seem to help. She knew there were other women who were depressed and taking medication, but she still felt like no one understood what she was going through.

When she finally came to therapy, she felt hopeless but wanted to change her life. In therapy, she learned to develop some positive thinking skills, not just think happy thoughts, but really challenge some of her long held beliefs that kept her from finding the peace and happiness she knew she had always sought.

She began to enjoy life more and her husband even commented how much happier she seemed. The best compliment was from one of her children who said “mommy, you don’t seem like you’re mad at me anymore”. Donna almost cried. The mixture of joy and sadness she had; joy that she could connect better to her husband and children, and sadness that she hadn’t sought help sooner.

Career Confusion

Tom was in his late 40’s and ready for a new challenge in his life. He had worked in the computer industry for over 20 years and was recently let go from one of the major computer companies.

He first got into the computer industry because it was exciting and new developments were happening all the time. But over the years he became upset by the lack of loyalty that large companies showed their employees.

This was the third time he was a “victim” of a downsizing and he was ready to bail out of computers. But he didn’t have a clue what to do.

When Tom came to career counseling, the first question he asked was “What else am I good at?” He took a battery of assessments and found that he had natural abilities in the science and technology areas. The more he explored, the more interested he became in fixing scientific devices. He enrolled in a course designed to help technicians fix medical devices.

During this course he met another entrepreneur and together they developed a business plan. Tom had found a new challenge and was ready to move forward.

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What Is a Case Study?

Weighing the pros and cons of this method of research

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

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

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

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

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

At a Glance

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

What Are the Benefits and Limitations of Case Studies?

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

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

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

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

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

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

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

Case Study Examples

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

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

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

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

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

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

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

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

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

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

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

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

Section 1: A Case History

This section will have the following structure and content:

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

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

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

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

Section 2: Treatment Plan

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

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

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

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

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

Need More Tips?

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

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

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

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

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

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

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

Case Study Research Method in Psychology

Saul McLeod, PhD

Editor-in-Chief for Simply Psychology

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

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

Learn about our Editorial Process

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

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

On This Page:

Case studies are in-depth investigations of a person, group, event, or community. Typically, data is gathered from various sources using several methods (e.g., observations & interviews).

The case study research method originated in clinical medicine (the case history, i.e., the patient’s personal history). In psychology, case studies are often confined to the study of a particular individual.

The information is mainly biographical and relates to events in the individual’s past (i.e., retrospective), as well as to significant events that are currently occurring in his or her everyday life.

The case study is not a research method, but researchers select methods of data collection and analysis that will generate material suitable for case studies.

Freud (1909a, 1909b) conducted very detailed investigations into the private lives of his patients in an attempt to both understand and help them overcome their illnesses.

This makes it clear that the case study is a method that should only be used by a psychologist, therapist, or psychiatrist, i.e., someone with a professional qualification.

There is an ethical issue of competence. Only someone qualified to diagnose and treat a person can conduct a formal case study relating to atypical (i.e., abnormal) behavior or atypical development.

 Famous Case Studies

• Anna O – One of the most famous case studies, documenting psychoanalyst Josef Breuer’s treatment of “Anna O” (real name Bertha Pappenheim) for hysteria in the late 1800s using early psychoanalytic theory.
• Little Hans – A child psychoanalysis case study published by Sigmund Freud in 1909 analyzing his five-year-old patient Herbert Graf’s house phobia as related to the Oedipus complex.
• Bruce/Brenda – Gender identity case of the boy (Bruce) whose botched circumcision led psychologist John Money to advise gender reassignment and raise him as a girl (Brenda) in the 1960s.
• Genie Wiley – Linguistics/psychological development case of the victim of extreme isolation abuse who was studied in 1970s California for effects of early language deprivation on acquiring speech later in life.
• Phineas Gage – One of the most famous neuropsychology case studies analyzes personality changes in railroad worker Phineas Gage after an 1848 brain injury involving a tamping iron piercing his skull.

Clinical Case Studies

• Studying the effectiveness of psychotherapy approaches with an individual patient
• Assessing and treating mental illnesses like depression, anxiety disorders, PTSD
• Neuropsychological cases investigating brain injuries or disorders

Child Psychology Case Studies

• Studying psychological development from birth through adolescence
• Cases of learning disabilities, autism spectrum disorders, ADHD
• Effects of trauma, abuse, deprivation on development

Types of Case Studies

• Explanatory case studies : Used to explore causation in order to find underlying principles. Helpful for doing qualitative analysis to explain presumed causal links.
• Exploratory case studies : Used to explore situations where an intervention being evaluated has no clear set of outcomes. It helps define questions and hypotheses for future research.
• Descriptive case studies : Describe an intervention or phenomenon and the real-life context in which it occurred. It is helpful for illustrating certain topics within an evaluation.
• Multiple-case studies : Used to explore differences between cases and replicate findings across cases. Helpful for comparing and contrasting specific cases.
• Intrinsic : Used to gain a better understanding of a particular case. Helpful for capturing the complexity of a single case.
• Collective : Used to explore a general phenomenon using multiple case studies. Helpful for jointly studying a group of cases in order to inquire into the phenomenon.

Where Do You Find Data for a Case Study?

There are several places to find data for a case study. The key is to gather data from multiple sources to get a complete picture of the case and corroborate facts or findings through triangulation of evidence. Most of this information is likely qualitative (i.e., verbal description rather than measurement), but the psychologist might also collect numerical data.

1. Primary sources

• Interviews – Interviewing key people related to the case to get their perspectives and insights. The interview is an extremely effective procedure for obtaining information about an individual, and it may be used to collect comments from the person’s friends, parents, employer, workmates, and others who have a good knowledge of the person, as well as to obtain facts from the person him or herself.
• Observations – Observing behaviors, interactions, processes, etc., related to the case as they unfold in real-time.
• Documents & Records – Reviewing private documents, diaries, public records, correspondence, meeting minutes, etc., relevant to the case.

2. Secondary sources

• News/Media – News coverage of events related to the case study.
• Academic articles – Journal articles, dissertations etc. that discuss the case.
• Government reports – Official data and records related to the case context.
• Books/films – Books, documentaries or films discussing the case.

3. Archival records

Searching historical archives, museum collections and databases to find relevant documents, visual/audio records related to the case history and context.

Public archives like newspapers, organizational records, photographic collections could all include potentially relevant pieces of information to shed light on attitudes, cultural perspectives, common practices and historical contexts related to psychology.

4. Organizational records

Organizational records offer the advantage of often having large datasets collected over time that can reveal or confirm psychological insights.

Of course, privacy and ethical concerns regarding confidential data must be navigated carefully.

However, with proper protocols, organizational records can provide invaluable context and empirical depth to qualitative case studies exploring the intersection of psychology and organizations.

• Organizational/industrial psychology research : Organizational records like employee surveys, turnover/retention data, policies, incident reports etc. may provide insight into topics like job satisfaction, workplace culture and dynamics, leadership issues, employee behaviors etc.
• Clinical psychology : Therapists/hospitals may grant access to anonymized medical records to study aspects like assessments, diagnoses, treatment plans etc. This could shed light on clinical practices.
• School psychology : Studies could utilize anonymized student records like test scores, grades, disciplinary issues, and counseling referrals to study child development, learning barriers, effectiveness of support programs, and more.

How do I Write a Case Study in Psychology?

Follow specified case study guidelines provided by a journal or your psychology tutor. General components of clinical case studies include: background, symptoms, assessments, diagnosis, treatment, and outcomes. Interpreting the information means the researcher decides what to include or leave out. A good case study should always clarify which information is the factual description and which is an inference or the researcher’s opinion.

1. Introduction

• Provide background on the case context and why it is of interest, presenting background information like demographics, relevant history, and presenting problem.
• Compare briefly to similar published cases if applicable. Clearly state the focus/importance of the case.

2. Case Presentation

• Describe the presenting problem in detail, including symptoms, duration,and impact on daily life.
• Include client demographics like age and gender, information about social relationships, and mental health history.
• Describe all physical, emotional, and/or sensory symptoms reported by the client.
• Use patient quotes to describe the initial complaint verbatim. Follow with full-sentence summaries of relevant history details gathered, including key components that led to a working diagnosis.
• Summarize clinical exam results, namely orthopedic/neurological tests, imaging, lab tests, etc. Note actual results rather than subjective conclusions. Provide images if clearly reproducible/anonymized.
• Clearly state the working diagnosis or clinical impression before transitioning to management.

3. Management and Outcome

• Indicate the total duration of care and number of treatments given over what timeframe. Use specific names/descriptions for any therapies/interventions applied.
• Present the results of the intervention,including any quantitative or qualitative data collected.
• For outcomes, utilize visual analog scales for pain, medication usage logs, etc., if possible. Include patient self-reports of improvement/worsening of symptoms. Note the reason for discharge/end of care.

4. Discussion

• Analyze the case, exploring contributing factors, limitations of the study, and connections to existing research.
• Analyze the effectiveness of the intervention,considering factors like participant adherence, limitations of the study, and potential alternative explanations for the results.
• Identify any questions raised in the case analysis and relate insights to established theories and current research if applicable. Avoid definitive claims about physiological explanations.
• Offer clinical implications, and suggest future research directions.

5. Additional Items

• Thank specific assistants for writing support only. No patient acknowledgments.
• References should directly support any key claims or quotes included.
• Use tables/figures/images only if substantially informative. Include permissions and legends/explanatory notes.
• Provides detailed (rich qualitative) information.
• Provides insight for further research.
• Permitting investigation of otherwise impractical (or unethical) situations.

Case studies allow a researcher to investigate a topic in far more detail than might be possible if they were trying to deal with a large number of research participants (nomothetic approach) with the aim of ‘averaging’.

Because of their in-depth, multi-sided approach, case studies often shed light on aspects of human thinking and behavior that would be unethical or impractical to study in other ways.

Research that only looks into the measurable aspects of human behavior is not likely to give us insights into the subjective dimension of experience, which is important to psychoanalytic and humanistic psychologists.

Case studies are often used in exploratory research. They can help us generate new ideas (that might be tested by other methods). They are an important way of illustrating theories and can help show how different aspects of a person’s life are related to each other.

The method is, therefore, important for psychologists who adopt a holistic point of view (i.e., humanistic psychologists ).

Limitations

• Lacking scientific rigor and providing little basis for generalization of results to the wider population.
• Researchers’ own subjective feelings may influence the case study (researcher bias).
• Difficult to replicate.
• Time-consuming and expensive.
• The volume of data, together with the time restrictions in place, impacted the depth of analysis that was possible within the available resources.

Because a case study deals with only one person/event/group, we can never be sure if the case study investigated is representative of the wider body of “similar” instances. This means the conclusions drawn from a particular case may not be transferable to other settings.

Because case studies are based on the analysis of qualitative (i.e., descriptive) data , a lot depends on the psychologist’s interpretation of the information she has acquired.

This means that there is a lot of scope for Anna O , and it could be that the subjective opinions of the psychologist intrude in the assessment of what the data means.

For example, Freud has been criticized for producing case studies in which the information was sometimes distorted to fit particular behavioral theories (e.g., Little Hans ).

This is also true of Money’s interpretation of the Bruce/Brenda case study (Diamond, 1997) when he ignored evidence that went against his theory.

Breuer, J., & Freud, S. (1895).  Studies on hysteria . Standard Edition 2: London.

Curtiss, S. (1981). Genie: The case of a modern wild child .

Diamond, M., & Sigmundson, K. (1997). Sex Reassignment at Birth: Long-term Review and Clinical Implications. Archives of Pediatrics & Adolescent Medicine , 151(3), 298-304

Freud, S. (1909a). Analysis of a phobia of a five year old boy. In The Pelican Freud Library (1977), Vol 8, Case Histories 1, pages 169-306

Freud, S. (1909b). Bemerkungen über einen Fall von Zwangsneurose (Der “Rattenmann”). Jb. psychoanal. psychopathol. Forsch ., I, p. 357-421; GW, VII, p. 379-463; Notes upon a case of obsessional neurosis, SE , 10: 151-318.

Harlow J. M. (1848). Passage of an iron rod through the head.  Boston Medical and Surgical Journal, 39 , 389–393.

Harlow, J. M. (1868).  Recovery from the Passage of an Iron Bar through the Head .  Publications of the Massachusetts Medical Society. 2  (3), 327-347.

Money, J., & Ehrhardt, A. A. (1972).  Man & Woman, Boy & Girl : The Differentiation and Dimorphism of Gender Identity from Conception to Maturity. Baltimore, Maryland: Johns Hopkins University Press.

Money, J., & Tucker, P. (1975). Sexual signatures: On being a man or a woman.

Further Information

• Case Study Approach
• Case Study Method
• Enhancing the Quality of Case Studies in Health Services Research
• “We do things together” A case study of “couplehood” in dementia
• Using mixed methods for evaluating an integrative approach to cancer care: a case study

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How to write counseling case studies

• Jan 31, 2021
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As a psychotherapy or counseling student, you are very likely to come across such written assignments as counseling case studies . As this is a very particular type of academic assignment, we created this guide to help you write psychotherapy case studies as a professional. 

A counseling case study is basically a simulation of your future work as a counselor. You have got a case about a person who has some psychological or mental challenges. You are provided with a description of the situation, the client’s complaints, behavior, some environmental factors like family, work, ethnic, cultural, and socio-economic factors, and you need to present your opinion about the situation and a tentative treatment plan. 

So essentially, you need to imagine yourself as a psychotherapist who works with this client and knows how to treat him. Therefore in your paper, you cannot just write irrelevant information such as definitions of mental diseases, history of counseling, or other side digressions just to fill up the required word count. This approach may work for many types of essays, but not for counseling case studies.  When writing case studies on psychotherapy, you need to be very on point. 

Your paper should contain three basic sections:

• Your analysis about the client’s situation;
• Diagnosis or summary/interpretation of the client’s problem from a particular theoretical standpoint or from an integrative perspective
• Interventions that might help the client based on your analysis. 

Your counseling case study should contain the analysis of the client's situation, assessment or diagnosis, and treatment plan containing proposed interventions and reflection on the therapeutic process. 

Keep in mind that the basic principle of academic paper writing is: KNOW WHAT YOU WRITE . That means know what you are required to write (make sure you understand the assignment and read the case carefully) and have the background knowledge about the theory and practice of psychotherapy, general counseling theories or a specific theory, and therapeutic techniques and interventions. 

For some people, such an assignment may seem overwhelming as you are not a working counselor yet and you are not sure how to tackle the client’s problem. But do not panic, just follow the steps below to produce a high-quality counseling case study. 

1.    Read your assignment and the case description carefully

Clarify all the terms you encounter in the case.  Make sure you know what theory of psychotherapy you are expected to follow in your diagnosis and treatment plan. If no theoretical approach is mentioned in your assignment, check if you have covered any particular theories in your classes.

If you are not sure what a theory of psychotherapy is, it’s a particular approach to interpret psychological and mental problems. The first theory of psychotherapy was psychoanalysis developed by Sigmund Freud. Its theoretical foundation relied on distinguishing three parts of the mind: ego, superego, and id; recognizing the role of the subconscious with its instincts and drives in psychological conflicts; interpreting maladaptive behavior through the lens of ego defenses; recognizing the role of early childhood experiences, particularly childhood traumas, in the pathophysiology of mental problems.  Later, many other theories of counseling were developed, such as Adlerian, existential, humanistic and person-centered, behavior (BT), cognitive-behavior therapy (CBT), Gestalt therapy, reality, feminist, narrative, solution-focused brief therapy, family systems therapy , and many others. So if earlier in the class, you covered humanistic counseling, you can use the humanistic theoretical approach in your case analysis (unless, of course, your assignment clearly states what theory you need to follow). 

2.    Review the textbook chapters on that theory paying attention to particular approaches to diagnosis and therapeutic techniques.

Theory is important as different theoretical frameworks interpret the same situation in a different way. For example, the same symptoms could be interpreted as defenses caused by childhood trauma in psychoanalysis, malfunctioning behavioral patterns in Behavior therapy, dysfunctional cognitive schemes in CBT, unfinished business in Gestalt, destructive environmental factors in feminist therapy, being stuck in a pattern of living a problem-saturated story in narrative therapy, and so on. 

3.    Re-read the case again paying attention to special terms

and see if you now understand the meaning of these terms after studying the literature. 

4.    Read additional resources (optional)

If you still have doubts about the case and how to proceed with it, you might need additional resources, either provided by your teacher or found on the Internet. If you have a specific psychotherapeutic theory to follow for your case, you can google “assessment and treatment in [your theory]” and search for books, worksheets, or articles. 

5.    Summarize the client’s situation in the case.

In this stage, we start writing up the draft of the case analysis. Describe the gist of the client’s problem as he sees it and as you can grasp from the description of his behavior, thoughts, and feelings in the case. If you can locate it in the case, summarize his family situation, relationships, the family of origins, and work relations . Also, note if any sociocultural factors, like race, religion, ethnicity, gender, income level, sexual orientation, or neighborhood , may have impacted the client and his significant relations. Note if the client has previously done efforts to deal with his problems and what these efforts were. 

6.    Formulate a diagnosis for the client.

This section will often require you to provide a diagnosis according to DSM diagnostic criteria or formulate a problem according to the conventions of your counseling theory. Some theoretical frameworks, like Narrative or Feminist therapy, do not make diagnoses in working with clients as they view clinical diagnosis as a pathologizing, discriminatory and condescending practice that skews power balance in favor of the therapist. So if you are writing the case study within one of these paradigms, you will not have to provide a diagnosis for the client. However, you will still have to make a sort of assessment. While diagnosis involves identifying specific mental disorders based on patterns of symptoms, for assessment , you need to point out the client’s main problem and identify the main factors of the client’s life that you think might be contributing to this problem.

If you need to provide the diagnosis according to DSM-V manual, pay attention to the Differential diagnosis section for each disorder description. If the client’s symptoms initially look like major depressive disorder, you can consult the differential diagnosis section in the major depressive disorder chapter to see if there are alternative explanations fitting the client’s symptoms. Thus, for major depressive disorder, the alternatives may be substance/medication-induced depressive or bipolar disorder, mood disorder due to another medical condition, ADHD, adjustment disorder with depressed mood, and sadness. Check the diagnostic criteria for all these disorders to find which one fits better. Some of the assignments will require you to spell out how many symptoms fit the criteria of the disorders, and name these symptoms.

7.    Outline the developmental context of the problem.

Write how the client’s problem developed over time. Consider if early childhood experiences, the family of origin, or family structure may have contributed to this problem. Has a similar problem been experienced by some family member before? Have environmental and socio-economic factors , like income level, race, ethnicity, religion, sex, sexual orientation, or any others, contributed to the development of the problem?  How do these developmental factors interact with the current stressors and conflicts to shape the client’s worldview? Does the client have social support or safety net to rely on? In some theoretical approaches, you will also have to identify the client’s pathogenic or irrational beliefs about himself (like BT and CBT), maladaptive styles of functioning (Gestalt, psychoanalysis), or internalized dysfunctional cultural narratives (narrative and feminist therapies). 

8.    Propose interventions and techniques that might benefit the client.

If you follow a specific theory, this assignment is not that hard. Just go to the textbook chapter of your theory, check the techniques and interventions, and choose the ones that are appropriate for your situation. But do not just mechanically copy the list of techniques from the textbook. Imagine yourself sitting with the client and having a counseling session with them. Where would you start? If you are at loss, remember that almost all theories start with establishing a contact, creating a therapeutic relationship with the client. You might start by explaining your role and responsibilities, the client’s rights and the process of therapy, and getting informed consent from the client. Listen to his story attentively and respectfully, learn reflective listening , suspend judgment about the client, show empathy . These are basic things that almost all therapists irrespective of their theoretical orientation and client’s problem, use. To these, you will add specific techniques from your theoretical approach or techniques that are normally used for similar problems. 

9.    Add reflections on the therapeutic process.

This section is not required in all case studies, but it’s often present since you need to be aware of this aspect as a future therapist. Here, write what you think about the client. Does she and her problems engage you emotionally? How might your feelings help or hinder the therapeutic process? Is there room for countertransference (when a client’s problem triggers an emotional response from you connected with your previous experience or your own problem). How might this client perceive you? How might her feelings help or hinder the therapeutic process? What challenges you might face while working with the client? What traits of your personality or any previous experience might help you establish trust and connection? 

Final thoughts

This is the general outline of all counseling case studies. The requirements might vary from case to case, but these steps are pretty much essential for a solid analysis of a client’s situation in a therapeutic setting. All these steps might seem overwhelming to you, but do not despair. To be successful, it is essential to understand the requirements and the case, have knowledge about your theory and counseling approach, and then use your brains to reflect on the given case using common sense, knowledge from the textbook, and your imagination of how you would work with a person presented in the case. As you see, in this paper there is not much room for paraphrasing or filling the space with irrelevant information. Everything must be very to the point. The only place where you can use some rewriting is the DSM diagnosis section, ONLY if the teacher asks you to note down all the symptoms that fit the diagnosis. Then you can take those symptoms from the diagnostic criteria of the disorder and slightly paraphrase them. The rest of the paper is your own reflection about the case, the client, and the ways to help him . If you feel intimidated, do not worry. Just start doing these cases, and you will get better with time. 

If you feel that you need professional help from a research assistant with good experience in counseling case studies, you’re at the right place. Check our prices for custom written counseling case studies and make your order here , it takes just a few minutes. 

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Methodology

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

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

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

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

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

Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Research bias

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

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Counselling Case Study: Working with Grief

Grief is a complex and individual process. There are a number of well documented stages to the grief process such as numbness, guilt, despair, panic and acceptance to name a few. The order in which these stages are experienced and the intensity and duration of each stage will be different for each individual.

It is therefore understandable that an eclectic counselling approach to grief can be beneficial in allowing for the flexibility needed to work with individuals through various stages of the grief process. The following case study is a practical application of a variety of counselling approaches to one client and her experience of grief.

The client’s name is Joan. Joan sought counselling to deal with the unexpected loss of her daughter in a car accident. She received counselling about 2 weeks after her daughter’s death and continued with the counselling process over a period of 8 months.

The key features of Joan’s grief were her feelings of guilt and despair. In these areas, the counsellor worked mainly from a Person-Centered approach (PCT). The counsellor also utilised some techniques from Solution-Focussed Therapy (SFT) and Cognitive-Behaviour Therapy (CBT). A brief analysis of the case study and application of the various techniques are provided below.

Case Information

Joan is a semi-retired accountant, maintaining contract work with a few long-term clients to support herself in retirement. Joan is a divorcee, who lives on her own, in her family home. She is a mother of 2 children, Kirsten and Mathew, aged in their mid 20s. Joan has a supportive network of family and friends, including her sister, father, children, and friends from her gardening club.

Joan’s relatively steady life was overturned with the sudden death of her daughter, Kirsten. Kirsten was 24 when she died from head injuries caused during a car accident. She was admitted to hospital in a coma. Joan spent several anxious days with Kirsten, before she passed away.

In the days that followed, Joan arranged her daughter’s funeral and affairs and deferred her work commitments. Joan described this as a whirlwind period, where she operated in a mechanical way. She was completely absorbed in the organisation of Kirsten’s funeral and pushed aside her feelings of grief. Joan said that she found some security in the numbness that filled her during that time.

After a couple of weeks, however, Joan became concerned that she was not coping as she couldn’t move on from these feelings. People had commented that she should try to carry on as usual, however her numbness persisted and she couldn’t motivate herself to “carry on” as if nothing had happened.

Joan thought that there must have been something wrong with her and it was this fear that led her to counselling some weeks after her daughter’s funeral.

For ease of writing, the professional counsellor in this case will be referred to as “C”.

The Initial Stages

(Numbness) In the first session, Joan appeared somewhat vague and tired. She seemed focussed on describing the details of the funeral, the family members who attended and her concern about her daughter not having a will. “C” observed that Joan’s behaviour reflected a need to be in control of the situation and was a useful coping strategy for Joan at this time. “C” used PCT to build an empathetic understanding of Joan’s experience. She did not attempt to move Joan towards experiencing her grief, but trusted that Joan would reach this stage in her own time.

Joan began discussing the rapid way in which the whole event had occurred and the numbness that she was feeling. “C” used paraphrases and encouragers to assist Joan to express herself. “Everything has happened so quickly that you haven’t had time to absorb it all, is that right Joan?” “Yes”, Joan replied, “I’ve hardly had time to miss my little girl.” “You miss her,” responded “C”.

With this encourager, Joan began to cry and express her grief. Joan cried for some time whilst “C” sat with her in silence. At one point Joan apologised for her crying. “C” responded “It seems that you have a lot to cry about Joan. It shows me how much you loved your daughter.”

In the first session, Person-Centered therapy and Active Listening techniques enabled “C” to be guided by Joan’s readiness to express her feelings. The encouragers and reflection of feeling used, demonstrated to Joan that “C” understood her and allowed Joan to experience her feelings of grief, rather than to keep them at arms length.

Whilst “C” could have indicated to Joan that she was avoiding her grief, “C” instead trusted in Joan’s ability to express her grief in her own time. If Joan had not expressed her grief in this session, “C” would not have pressed the issue, although she may have encouraged Joan to have a further session within a few days.

(Grief and Despair) The following sessions were characterised by further experiences of grief and despair. Joan had found that her grief was no longer avoidable and her days were mostly filled with mourning. Joan abandoned her daily routines such as grooming, making meals and other basic self-care practices.

Joan’s disheveled appearance at the counselling sessions were concerning. At this point, “C” became more directive and suggested that Joan might have someone live-in with her for a while. Whilst “C” was encouraged by Joan’s regular adherence to the counselling sessions, she felt that Joan may need some extra support at home.

Joan contacted her sister Kerrie, who was available to stay with her for a month. Kerrie proved to be good support for Joan and provided her with gentle, yet insistent encouragement to face the everyday challenges.

Over several weeks of counselling, Joan had moved further into stages of despair and guilt. She described her life as being swallowed by a black hole and felt that she would never get over her daughter’s death. She felt that every day dragged by with no release from the pain. She had difficulty getting out of her bed in the morning and was constantly tired from lack of solid sleep.

“C” continued to employ PCT to allow Joan to explore and express her feelings and thoughts about her daughter’s death. Joan focussed heavily on her pain and seemed to stay with these feelings for a long time. “C” observed that Joan’s thoughts did not seem to be focused; she quickly moved from one topic to the next. “C” used summarising skills to help Joan highlight the key recurring issues from her thoughts.

“C” continued to trust that Joan would move through her feelings of grief in her own time. “C” did however experience some frustration with Joan’s continual despair. “C” sought the counsel of a colleague, who advised her to maintain her faith in Joan’s ability to grow and heal and reminded “C” of how the resolution of grief can often be a long-term process. The colleague also suggested some role-play techniques that “C” could use to work on Joan’s experience of her feelings.

(Guilt) Guilty feelings about her inability to prevent her daughter’s death were also of concern for Joan. “C” avoided telling Joan that she was not responsible for Kirsten’s car accident, and encouraged Joan to explore her guilt. In many instances grieving people feel guilt in relation to their loss. Often they will be told that they are not at fault, by well meaning people. The concern for counsellors is that grieving people are feeling guilty and will benefit more from expressing their guilt.

Dismissing guilty feelings won’t stop the grieving person from feeling blame and may lead to the increase of these feelings. “C” realised that Joan’s guilt was a means of expressing how fervently she wished to have her daughter with her still. “C” invited Joan to express her sorrow and guilt to Kirsten in a role play activity.

Afterwards, “C” encouraged Joan to debrief and talk about the effect of the activity. Joan was able to acknowledge the depth of her love and concern for Kirsten. “C” supported Joan by offering encouraging feedback. “C” was particularly taken with the extent of love and devotion that Joan displayed towards her daughter.

Joan left the session a little lighter for the experience. She said that she had been able to release some of her guilt and that she felt her despair ease a little. After two months of counselling, both Joan and “C” recognised this as a small breakthrough of acceptance.

Middle Stages

Joan’s grief and despair continued into the middle phase of the counselling sessions. Her emotions came in waves, rather than the constant fog of despair that had characterised her earlier sessions. “C” was continuing to utilise PCT with Joan to explore her issues. Joan expressed a readiness to establish goals during this stage. “C” implemented some CBT techniques for this purpose.

(Feelings of Panic) Kerrie had been encouraging Joan to take on small, everyday tasks such as walking to the shops, or posting the mail, in order to get out of the house for a while. Joan said she had done these tasks reluctantly as she was concerned about trying to “put on a brave face” in public.

Joan related a particular incident where she was at the local shop. She explained that when picking items from the shelves, she had selected her daughter’s favourite brand of biscuits. Feelings of panic had come over her as she realised that she no longer needed to buy the item, but she couldn’t bring herself to return the item to the shelf. In this state, she left all her purchases in the shop and walked straight home.

This incident had increased Joan’s anxiety about her ability to cope and accept her daughter’s death. In the session, “C” validated Joan’s experiences as being normal and a legitimate part of her grieving. As a part of the CBT process, “C” clarified and identified the causes and effects of Joan’s feelings of panic. These were as follows:

A realisation that her daughter was absent in her everyday life A rejection of awareness that her daughter was absent in her everyday life Conflicting emotions about acceptance of daughter’s absence

• Causing anxiety
• Causing a belief that she will never be able to accept her daughter’s loss
• Causing a fear of losing control in public places

“C” and Joan discussed the nature of the anxious feelings, and Joan’s associated beliefs and fears. Together they devised a number of goals, including (1) the development of new beliefs, (2) relaxation and (3) taking it one step at a time – otherwise referred to as a graded-task assignment.

Joan’s new beliefs included:

• It is normal to want my daughter back
• I am normal to grieve for and miss my daughter
• It doesn’t matter if I cry in public
• Time will help me to heal

She kept notes in a personal journal about when she used these new beliefs. The journal writing was also a process that allowed her to identify other problematic beliefs and thoughts. Once identified, she developed more appropriate and accepting beliefs.

In preparation of taking it one step at a time, Joan and “C” devised some relaxation techniques for Joan to use when she felt a sudden onset of panicky or anxious emotions. Joan had used imagery before and found that an effective method of relaxation. Joan was to imagine a warm, white light surrounding her whenever she felt even slightly anxious. They also devised some imagery to help Joan continue to experience the overwhelming nature of her grief.

Joan often referred to her feelings as a fog, and so “C” encouraged her to imagine sitting in a fog, which was black, thick and impenetrable. Little by little, she suggested that Joan should try to make the fog thin out with her mind. (It is important to note that this imagery was to be used at times when Joan felt bogged down in despair, but not during her anxious moments).

Joan was to record her practice of her relaxing imagery (white light) and to note her responses to the technique. She also recorded the times she used her despairing imagery (black fog) and the extent to which she was able to thin the fog with her mind. The purpose of the exercise was to increase her relaxation and to give her an image of her despair and a means to control it as time went on.

The ‘one step at a time’ goal consisted of Joan taking small steps towards running errands and taking on more of her everyday responsibilities. Her tasks involved the following:

• Plan meals for week
• Write a grocery list
• Go shopping with Kerrie.

Using her relaxation imagery, Joan completed the following graded tasks:

• Imagine walking around the shops
• Drive with Kerrie to the shop and stay in the car
• Walk with Kerrie to the shop door
• Walk with Kerrie around the shop for 10 minutes approximately
• Start to purchase a small number of items
• Complete an entire grocery shopping task

Each week, Joan completed a harder task. It took her only 4 weeks to complete a full shopping trip, although she experienced several occasions of feeling overwhelmed. Each time this occurred she gripped the shopping trolley and imagined the white light. Kerrie encouraged her to breathe deeply and relax. A couple of times, they left the shop (abandoned the trolley) when Joan felt she could not cope. They came back the following day to complete the shopping.

The important thing for Joan was to accept the times when she could not cope. Kerrie proved to be a supportive role model for Joan, helping her to accept her reduced ability to cope by offering encouraging comments and faith that Joan would heal.

Joan applied the graded-task technique to other areas of her life. “C” observed Joan’s increasing attention to self-care and other routines of everyday living.

Final Stages

(Acceptance) Joan’s increasing acceptance of the loss of Kirsten became more obvious with the passing of time. By dealing thoroughly with her despair and grief, she naturally moved on with her life and mourned less and less. After six months, the rewards for both “C” and Joan were evident in her long term improvement and growth.

Joan’s ability to develop goals for herself was greatly improved, as was her motivation. Joan was living independently again and without Kerrie around, she took on more responsibility and began to make plans for her life without Kirsten. Joan’s plans included a number of support mechanisms, as well as long-term goals for herself.

Joan had taken to visiting her daughter’s grave on a monthly basis. During her intense despair, she had been unwilling to venture to the cemetary. Due to her increasing acceptance, she was more inclined to visit and found the visits to be a sad, yet calming experience. The visits allowed her the opportunity to tell Kirsten the things she had left unsaid, and to update her daughter about her life, as she would have when Kirsten was alive. Joan found the visits kept Kirsten’s spirit and memory alive within her.

In these stages, “C” continued using PCT, and incorporated SFT to assist Joan to define her goals. “C” complemented Joan on her inventive ways of honoring her daughter’s memory. “C” was encouraged to see that Joan was actively seeking personal ways to express her grief.

Together, they worked to build Joan’s miracle picture. Joan expressed an interest to honor Kirsten’s life, by writing a book. Joan wanted to combine her own and Kirsten’s journals to recount the significance of her life and death. The process would also be a means to resolve her grief and offer a parting gift to her daughter.

Joan’s miracle picture included redefining her life goals to determine what was important for her. Kirsten’s death, whilst painful, had also brought growth and changes with it, and Joan was increasingly inclined to shed parts of her life that no longer held meaning for her. She threw out material things such as old furniture, files and boxes of junk and mentally discarded the maintenance of acquaintances that she no longer felt obliged to remain in contact with.

She renewed her bonds with close friends and family. Kirsten’s death allowed her family to grow closer to one another. Joan was buoyed by the love and support of these few, special people during her long months of despair.

Joan accepted that she would never completely ‘get over’ Kirsten’s death and that that was okay. Counselling assisted her to realise that her daughter would remain a part of her forever. She made a pledge to herself that she would continue to learn ways to live with Kirsten’s absence. Her journal writings and the possibility of publishing a book for Kirsten, would provide her with some therapeutic means of coping and expressing her grief. Joan would also draw from the support of her family and friends in times of need, particularly around the times of Kirsten’s birthday and the anniversary of her death.

End of Session

The case study has illustrated some of the stages that clients may experience due to the loss of a loved one. It has also attempted to demonstrate the way in which PCT lent itself to the complex and individual experience of Joan. The key issue from the PCT perspective was “C’s” respect for Joan to grieve and grow to acceptance in her own way and time.

CBT was applied to changing Joan’s negative thoughts about her ability to cope with her daughter’s loss and the fear of losing control of her emotions in public places. The imagery was a technique that Joan had prior experience with and was therefore ideal for her. Another client, may prefer other relaxation methods. It is important to identify strategies that the client is comfortable with.

Graded task assignments, journal writing, role plays, homework and other practical strategies such as developing support networks are also invaluable CBT techniques. Timing is important when introducing strategies, and the client should not be pushed into solutions before they are ready to accept them. Wherever possible, the counsellor should consult with the client about their ideas for, and their suitability to, particular techniques.

Once the client is ready to focus on solutions to their problems, SFT can be an invaluable tool for identifying the client’s goals through development of the miracle picture. The use of SFT has been briefly presented in the case of Joan, to illustrate its effectiveness in drawing out the plans and goals that Joan aspired to.

Author: Jane Barry

Related Case Studies: A Case of Grief and Loss ,  A Person Centred Approach to Grief and Loss , A Case of Acceptance and Letting Go

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Descriptive Research and Case Studies

Learning objectives.

• Explain the importance and uses of descriptive research, especially case studies, in studying abnormal behavior

Types of Research Methods

There are many research methods available to psychologists in their efforts to understand, describe, and explain behavior and the cognitive and biological processes that underlie it. Some methods rely on observational techniques. Other approaches involve interactions between the researcher and the individuals who are being studied—ranging from a series of simple questions; to extensive, in-depth interviews; to well-controlled experiments.

The three main categories of psychological research are descriptive, correlational, and experimental research. Research studies that do not test specific relationships between variables are called descriptive, or qualitative, studies . These studies are used to describe general or specific behaviors and attributes that are observed and measured. In the early stages of research, it might be difficult to form a hypothesis, especially when there is not any existing literature in the area. In these situations designing an experiment would be premature, as the question of interest is not yet clearly defined as a hypothesis. Often a researcher will begin with a non-experimental approach, such as a descriptive study, to gather more information about the topic before designing an experiment or correlational study to address a specific hypothesis. Descriptive research is distinct from correlational research , in which psychologists formally test whether a relationship exists between two or more variables. Experimental research goes a step further beyond descriptive and correlational research and randomly assigns people to different conditions, using hypothesis testing to make inferences about how these conditions affect behavior. It aims to determine if one variable directly impacts and causes another. Correlational and experimental research both typically use hypothesis testing, whereas descriptive research does not.

Each of these research methods has unique strengths and weaknesses, and each method may only be appropriate for certain types of research questions. For example, studies that rely primarily on observation produce incredible amounts of information, but the ability to apply this information to the larger population is somewhat limited because of small sample sizes. Survey research, on the other hand, allows researchers to easily collect data from relatively large samples. While surveys allow results to be generalized to the larger population more easily, the information that can be collected on any given survey is somewhat limited and subject to problems associated with any type of self-reported data. Some researchers conduct archival research by using existing records. While existing records can be a fairly inexpensive way to collect data that can provide insight into a number of research questions, researchers using this approach have no control on how or what kind of data was collected.

Correlational research can find a relationship between two variables, but the only way a researcher can claim that the relationship between the variables is cause and effect is to perform an experiment. In experimental research, which will be discussed later, there is a tremendous amount of control over variables of interest. While performing an experiment is a powerful approach, experiments are often conducted in very artificial settings, which calls into question the validity of experimental findings with regard to how they would apply in real-world settings. In addition, many of the questions that psychologists would like to answer cannot be pursued through experimental research because of ethical concerns.

The three main types of descriptive studies are case studies, naturalistic observation, and surveys.

Clinical or Case Studies

Psychologists can use a detailed description of one person or a small group based on careful observation.  Case studies  are intensive studies of individuals and have commonly been seen as a fruitful way to come up with hypotheses and generate theories. Case studies add descriptive richness. Case studies are also useful for formulating concepts, which are an important aspect of theory construction. Through fine-grained knowledge and description, case studies can fully specify the causal mechanisms in a way that may be harder in a large study.

Sigmund Freud   developed  many theories from case studies (Anna O., Little Hans, Wolf Man, Dora, etc.). F or example, he conducted a case study of a man, nicknamed “Rat Man,”  in which he claimed that this patient had been cured by psychoanalysis.  T he nickname derives from the fact that among the patient’s many compulsions, he had an obsession with nightmarish fantasies about rats. 

Today, more commonly, case studies reflect an up-close, in-depth, and detailed examination of an individual’s course of treatment. Case studies typically include a complete history of the subject’s background and response to treatment. From the particular client’s experience in therapy, the therapist’s goal is to provide information that may help other therapists who treat similar clients.

Case studies are generally a single-case design, but can also be a multiple-case design, where replication instead of sampling is the criterion for inclusion. Like other research methodologies within psychology, the case study must produce valid and reliable results in order to be useful for the development of future research. Distinct advantages and disadvantages are associated with the case study in psychology.

A commonly described limit of case studies is that they do not lend themselves to generalizability . The other issue is that the case study is subject to the bias of the researcher in terms of how the case is written, and that cases are chosen because they are consistent with the researcher’s preconceived notions, resulting in biased research. Another common problem in case study research is that of reconciling conflicting interpretations of the same case history.

Despite these limitations, there are advantages to using case studies. One major advantage of the case study in psychology is the potential for the development of novel hypotheses of the  cause of abnormal behavior   for later testing. Second, the case study can provide detailed descriptions of specific and rare cases and help us study unusual conditions that occur too infrequently to study with large sample sizes. The major disadvantage is that case studies cannot be used to determine causation, as is the case in experimental research, where the factors or variables hypothesized to play a causal role are manipulated or controlled by the researcher. 

Link to Learning: Famous Case Studies

Some well-known case studies that related to abnormal psychology include the following:

• Harlow— Phineas Gage
• Breuer & Freud (1895)— Anna O.
• Cleckley’s case studies: on psychopathy ( The Mask of Sanity ) (1941) and multiple personality disorder ( The Three Faces of Eve ) (1957)
• Freud and  Little Hans
• Freud and the  Rat Man
• John Money and the  John/Joan case
• Genie (feral child)
• Piaget’s studies
• Rosenthal’s book on the  murder of Kitty Genovese
• Washoe (sign language)
• Patient H.M.

Naturalistic Observation

If you want to understand how behavior occurs, one of the best ways to gain information is to simply observe the behavior in its natural context. However, people might change their behavior in unexpected ways if they know they are being observed. How do researchers obtain accurate information when people tend to hide their natural behavior? As an example, imagine that your professor asks everyone in your class to raise their hand if they always wash their hands after using the restroom. Chances are that almost everyone in the classroom will raise their hand, but do you think hand washing after every trip to the restroom is really that universal?

This is very similar to the phenomenon mentioned earlier in this module: many individuals do not feel comfortable answering a question honestly. But if we are committed to finding out the facts about handwashing, we have other options available to us.

Suppose we send a researcher to a school playground to observe how aggressive or socially anxious children interact with peers. Will our observer blend into the playground environment by wearing a white lab coat, sitting with a clipboard, and staring at the swings? We want our researcher to be inconspicuous and unobtrusively positioned—perhaps pretending to be a school monitor while secretly recording the relevant information. This type of observational study is called naturalistic observation : observing behavior in its natural setting. To better understand peer exclusion, Suzanne Fanger collaborated with colleagues at the University of Texas to observe the behavior of preschool children on a playground. How did the observers remain inconspicuous over the duration of the study? They equipped a few of the children with wireless microphones (which the children quickly forgot about) and observed while taking notes from a distance. Also, the children in that particular preschool (a “laboratory preschool”) were accustomed to having observers on the playground (Fanger, Frankel, & Hazen, 2012).

It is critical that the observer be as unobtrusive and as inconspicuous as possible: when people know they are being watched, they are less likely to behave naturally. For example, psychologists have spent weeks observing the behavior of homeless people on the streets, in train stations, and bus terminals. They try to ensure that their naturalistic observations are unobtrusive, so as to minimize interference with the behavior they observe. Nevertheless, the presence of the observer may distort the behavior that is observed, and this must be taken into consideration (Figure 1).

The greatest benefit of naturalistic observation is the validity, or accuracy, of information collected unobtrusively in a natural setting. Having individuals behave as they normally would in a given situation means that we have a higher degree of ecological validity, or realism, than we might achieve with other research approaches. Therefore, our ability to generalize the findings of the research to real-world situations is enhanced. If done correctly, we need not worry about people modifying their behavior simply because they are being observed. Sometimes, people may assume that reality programs give us a glimpse into authentic human behavior. However, the principle of inconspicuous observation is violated as reality stars are followed by camera crews and are interviewed on camera for personal confessionals. Given that environment, we must doubt how natural and realistic their behaviors are.

The major downside of naturalistic observation is that they are often difficult to set up and control. Although something as simple as observation may seem like it would be a part of all research methods, participant observation is a distinct methodology that involves the researcher embedding themselves into a group in order to study its dynamics. For example, Festinger, Riecken, and Shacter (1956) were very interested in the psychology of a particular cult. However, this cult was very secretive and wouldn’t grant interviews to outside members. So, in order to study these people, Festinger and his colleagues pretended to be cult members, allowing them access to the behavior and psychology of the cult. Despite this example, it should be noted that the people being observed in a participant observation study usually know that the researcher is there to study them. [1]

Another potential problem in observational research is observer bias . Generally, people who act as observers are closely involved in the research project and may unconsciously skew their observations to fit their research goals or expectations. To protect against this type of bias, researchers should have clear criteria established for the types of behaviors recorded and how those behaviors should be classified. In addition, researchers often compare observations of the same event by multiple observers, in order to test inter-rater reliability : a measure of reliability that assesses the consistency of observations by different observers.

Often, psychologists develop surveys as a means of gathering data. Surveys are lists of questions to be answered by research participants, and can be delivered as paper-and-pencil questionnaires, administered electronically, or conducted verbally (Figure 3). Generally, the survey itself can be completed in a short time, and the ease of administering a survey makes it easy to collect data from a large number of people.

Surveys allow researchers to gather data from larger samples than may be afforded by other research methods . A sample is a subset of individuals selected from a population , which is the overall group of individuals that the researchers are interested in. Researchers study the sample and seek to generalize their findings to the population.

There is both strength and weakness in surveys when compared to case studies. By using surveys, we can collect information from a larger sample of people. A larger sample is better able to reflect the actual diversity of the population, thus allowing better generalizability. Therefore, if our sample is sufficiently large and diverse, we can assume that the data we collect from the survey can be generalized to the larger population with more certainty than the information collected through a case study. However, given the greater number of people involved, we are not able to collect the same depth of information on each person that would be collected in a case study.

Another potential weakness of surveys is something we touched on earlier in this module: people do not always give accurate responses. They may lie, misremember, or answer questions in a way that they think makes them look good. For example, people may report drinking less alcohol than is actually the case.

Any number of research questions can be answered through the use of surveys. One real-world example is the research conducted by Jenkins, Ruppel, Kizer, Yehl, and Griffin (2012) about the backlash against the U.S. Arab-American community following the terrorist attacks of September 11, 2001. Jenkins and colleagues wanted to determine to what extent these negative attitudes toward Arab-Americans still existed nearly a decade after the attacks occurred. In one study, 140 research participants filled out a survey with 10 questions, including questions asking directly about the participant’s overt prejudicial attitudes toward people of various ethnicities. The survey also asked indirect questions about how likely the participant would be to interact with a person of a given ethnicity in a variety of settings (such as, “How likely do you think it is that you would introduce yourself to a person of Arab-American descent?”). The results of the research suggested that participants were unwilling to report prejudicial attitudes toward any ethnic group. However, there were significant differences between their pattern of responses to questions about social interaction with Arab-Americans compared to other ethnic groups: they indicated less willingness for social interaction with Arab-Americans compared to the other ethnic groups. This suggested that the participants harbored subtle forms of prejudice against Arab-Americans, despite their assertions that this was not the case (Jenkins et al., 2012).

Think it Over

Research has shown that parental depressive symptoms are linked to a number of negative child outcomes. A classmate of yours is interested in  the associations between parental depressive symptoms and actual child behaviors in everyday life [2] because this associations remains largely unknown. After reading this section, what do you think is the best way to better understand such associations? Which method might result in the most valid data?

clinical or case study:  observational research study focusing on one or a few people

correlational research:  tests whether a relationship exists between two or more variables

descriptive research:  research studies that do not test specific relationships between variables; they are used to describe general or specific behaviors and attributes that are observed and measured

experimental research:  tests a hypothesis to determine cause-and-effect relationships

generalizability:  inferring that the results for a sample apply to the larger population

inter-rater reliability:  measure of agreement among observers on how they record and classify a particular event

naturalistic observation:  observation of behavior in its natural setting

observer bias:  when observations may be skewed to align with observer expectations

population:  overall group of individuals that the researchers are interested in

sample:  subset of individuals selected from the larger population

survey:  list of questions to be answered by research participants—given as paper-and-pencil questionnaires, administered electronically, or conducted verbally—allowing researchers to collect data from a large number of people

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• Descriptive Research.  Provided by : Boundless.  Located at :  https://www.boundless.com/psychology/textbooks/boundless-psychology-textbook/researching-psychology-2/types-of-research-studies-27/descriptive-research-124-12659/ .  License :  CC BY-SA: Attribution-ShareAlike
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• Research Designs.  Authored by : Christie Napa Scollon.  Provided by : Singapore Management University.  Located at :  https://nobaproject.com/modules/research-designs#reference-6 .  Project : The Noba Project.  License :  CC BY-NC-SA: Attribution-NonCommercial-ShareAlike
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• Scollon, C. N. (2020). Research designs. In R. Biswas-Diener & E. Diener (Eds), Noba textbook series: Psychology. Champaign, IL: DEF publishers. Retrieved from http://noba.to/acxb2thy ↵
• Slatcher, R. B., & Trentacosta, C. J. (2011). A naturalistic observation study of the links between parental depressive symptoms and preschoolers' behaviors in everyday life. Journal of family psychology : JFP : journal of the Division of Family Psychology of the American Psychological Association (Division 43), 25(3), 444–448. https://doi.org/10.1037/a0023728 ↵

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988 Lifeline

Independent Analysis, Innovative Ideas

The Lifeline and 988

On July 16, 2022, the 988 Lifeline transitioned away from the National Suicide Prevention Line reached through a 10-digit number to the three-digit 988 Lifeline. It is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and administered by Vibrant Emotional Health (Vibrant).

When people call, text, or chat with the 988 Lifeline, they are connected to trained crisis counselors who are part of the existing 988 Lifeline network, made up of over 200 local crisis centers. These crisis counselors are trained to provide free and confidential emotional support and crisis counseling to people in suicidal crisis or emotional distress and connect them to resources. These services are available 24 hours a day, seven days a week, across the United States.

The previous 988 Lifeline phone number (1-800-273-8255) will always remain available to people in emotional distress or suicidal crisis.

The 988 Lifeline’s network of over 200 crisis centers has been in operation since 2005 and has been proven to be effective. Trained crisis counselors listen, provide support, and connect callers to resources when appropriate.

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Answer the call!

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Psychology and French and Francophone studies major gains clinical experience through APEX fellowship

Anna Chapman ’25, a French and Francophone studies and psychology major at The College of Wooster, attended an internship fair at the College to learn about various summer opportunities that would give her a chance to put her psychology knowledge to use. There, she learned about the opportunity to take part in an APEX fellowship at The Counseling Center of Wayne and Holmes County. Throughout the summer, Chapman learned about careers in mental health, shadowed case managers, offered collaborative solutions to clients’ problems, helped transport clients, and learned about suicide prevention and mental health programs that could assist the community. This experiential learning opportunity gave Chapman an inside look at the field of mental healthcare, helping her realize that she wants to attend graduate school to pursue a career in clinical psychology and counseling.  

“My internship helped me experience new things and challenges that led me to explore new perspectives, ideas, and interests. This experience also gave me the opportunity to explore different careers related to psychology and helped me to realize different aspects of jobs or careers I might be interested in.” —Anna Chapman ’25

Q: How did you learn about the opportunity for your APEX fellowship? 

Chapman: I learned about my internship through one of the College’s internship fairs during the spring semester. This internship was perfect for me because I am a psychology major, and I wanted to learn more about careers I could do with a psychology degree.  

Q: What interests you most about the work you did? 

Chapman: I loved getting to know the case managers I shadowed and worked with. They were my mentors and taught me a lot about different mental health disorders and how to help someone who struggles with depression or anxiety. I liked getting to see the progress that clients made despite some of the struggles they faced. Some of the things I did during my internship were to shadow case managers and collaborate on different solutions for problems clients faced. I also helped transport clients to and from appointments at the counseling center and attended a variety of meetings to talk about client care and different coalitions about suicide prevention and mental health.  

Q: Who was your fellowship mentor and how did they help you to succeed in this position? 

Chapman: My fellowship mentor was Grit Herzmann, associate professor of psychology and department chair of neuroscience. She always helped me navigate my thoughts and feelings about my internship through thoughtful and thought-provoking questions. These questions helped me reflect on my time at my internship and helped me to constantly ask myself questions to think about my strengths in the mental health field and what career I would like to pursue in the future.  

Q: How has the internship helped you to see what’s next for you?  

Chapman: My internship helped me experience new things and challenges that led me to explore new perspectives, ideas, and interests. Before this internship, I was still unsure of what kind of career in psychology I wanted. Looking ahead in the future, this internship made me come to the conclusion that I would like to pursue graduate school to gain more education in psychology to be a licensed professional clinical counselor or pursue a doctorate in clinical psychology.  

Posted in Experiential Learning on August 10, 2024.

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Related areas of study.

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• Open access
• Published: 13 September 2024

Adherence of healthcare providers to Enhanced Adherence Counseling (EAC) intervention protocol in West Amhara Public Health Facilities, Northwest Ethiopia, 2023: mixed method evaluation

• Amare Belete 1   na1 ,
• Getachew Teshale 2   na1 ,
• Andualem Yalew 2 ,
• Endalkachew Delie 2 ,
• Gebrie Getu 3 &
• Asmamaw Atnafu 2  

BMC Infectious Diseases volume  24 , Article number:  977 ( 2024 ) Cite this article

Metrics details

In Ethiopia, there were an estimated 670,906 people living with the Human Immune Virus (HIV). Implementing an HIV test and treat strategy and rapid scale-up of anti-retroviral treatment (ART) provided health facilities increased the number of the number of people living with HIV/AIDS. In the same way, the expansion of viral load monitoring in these health facilities and poor adherence to ART increase the number of high-viral load (HVL) patients. To alleviate this problem, the World Health Organization (WHO) recommended EAC intervention for HVL patients. Therefore, the aim of this research was to determine the level of healthcare providers’ adherence to the EAC intervention protocol and explore barriers and facilitators of the intervention in West Amhara, Northwest Ethiopia.

Descriptive cross-sectional study design with concurrent mixed-method evaluation was employed. The adherence dimension, with its sub-dimensions of content, coverage, frequency, and duration of the EAC intervention, was used with sixteen indicators. A total of 20 high-case-load public health facilities and 173 HVL patients were included in our study. Quantitative data was entered into Epi Info and exported to SPSS version 25 for analysis. Descriptive statistics are analyzed in terms of frequencies, percentages, variances, and means and presented as narrations, frequency tables, graphs, and charts. Qualitative data were transcribed, translated, coded, and analyzed thematically using Open Code version 4.0 software. The qualitative findings were used to triangulate the quantitative findings.

The average adherence level of health care providers (HCPs) to the EAC intervention protocol was 55.3%, from which content, coverage, frequency, and duration of the intervention contributed 70.3%, 86.3%, 36.9%, and 27.7%, respectively. Most of the intervention contents were delivered during the session, but none of the providers developed a patient adherence plan at the end of the session. All HVL patients were linked and enrolled in the EAC intervention. But only 6% of them were tested for repeat VL.

The average adherence level of HCPs to the EAC intervention protocol was very inadequate. The main gap identified was difficulties in completing the EAC intervention sessions based on schedules. Implementing adherence improvement strategies, assigning an adequate number of EAC providers in ART and Prevention of Mother-to-Child Transmission (PMTCT) clinics, and allowing sufficient time during EAC sessions are important.

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Introduction

In Ethiopia, there were an estimated 670,906 people living with HIV, with an incidence rate of 36,990 per year among all ages and sexes. Although the age-standardized AIDS mortality rate declined very fast after 2005, nearly 20,000 AIDS-related deaths were predicted in 2023/24 in Ethiopia [ 1 ].

Implementing HIV test and treat strategy and rapid scale-up of ART providing health facilities led to large number of people living with HIV on ART [ 2 , 3 ]. The expansion of viral load monitoring in these health facilities, in turn, led to the detection of an increased number of HVL patients. Poor adherence is also another reason to increase the number of HVL patients [ 3 , 4 , 5 , 6 ]. As a solution, WHO has recommended EAC intervention for HVL patients and [ 7 ] following this WHO recommendation, countries has adopted and implemented EAC intervention.

EAC is a structured and targeted adherence counseling intervention for HVL patients after the client has been on ART for at least 6 months and before they are diagnosed with treatment failure. It includes assessing the adherence rate, exploring barriers, and supporting HVL patients to find solutions [ 4 , 7 ]. EAC intervention is given for all HVL patients monthly for 3–6 months to identify adherence barriers [ 4 ]. HVL patients should have at least 3 months’ good adherence record to repeat the VL test. A repeated VL test result > 1000 copies/ml is one of the indicators to switch an HIV patient from 1st line ART to 2nd or 3rd line ART in EAC, but HIV patients with a repeated VL test result of £1000 copies/ml will be discharged from EAC intervention and stay at 1st line ART (Fig.  1 ).

Algorithm of VL monitoring and EAC intervention [ 4 ]

Based on WHO recommendations, Ethiopia has implemented EAC interventions since 2017 [ 4 ]. Studies conducted in West Gojjam [ 8 ] and North Wollo [ 9 ] Ethiopia showed only 51.73% and 60.4% viral re-suppression was achieved after EAC sessions respectively. Both findings were lower than the WHO minimum target [ 3 ].

Studies suggest that the content of an intervention is its active ingredient as it primarily determines implementation success or failure. These studies noted that the inability to deliver the content of an intervention affects the extent to which full implementation is attained [ 10 , 11 , 12 ]. Programs are less effective when study participants do not receive the intended contents [ 13 ].In addition to the content of the intervention, the coverage of the intervention services has an effect on attaining the program’s expected results. An epidemiological study in Ethiopia showed that around 51% of HVL patients had defaulted on their EAC intervention before their repeated VL testing [ 14 ]. Incomplete delivery and poor coverage makes the intervention ineffective [ 15 ].Although the EAC implementation guidelines recommended that all HVL patients receive their EAC sessions on a monthly basis, they didn’t attend due to different challenges like the inaccessibility of health facilities, current peace and security problems in the country, and the limited number of EAC rooms [ 16 ]. EAC is designed to provide it services for 3 months, after which a HVL patients are being on ART regimen or switched to next regimen [ 4 ].But studies showed that the median time to start the first EAC session after HVL detection was 8 weeks, 33.2% of participants started the first EAC session 4–8 weeks after HVL detection, and around 13% of HVL patients did not start EAC sessions up to 3 months [ 9 ]. The same study in Ethiopia showed that only 46.8% of HVL patients completed EAC sessions within the recommended time duration, and 27.2% completed EAC sessions after 6 months of initiation of EAC sessions [ 9 ].

Therefore, this evaluation study determined the level of healthcare providers’ adherence to the EAC intervention protocol and program design in terms of intervention content, frequency, coverage, and duration and explored the intervention barriers and facilitators (Fig.  2 ).

Conceptual framework for implementation fidelity of EAC intervention in West Amhara public health facilities, Northwest Ethiopia Adapted from Carroll et al. [ 10 ] and Hasson [ 54 ]

Methods and materials

Evaluation area and period.

This evaluation study was conducted in 20 public HFs in West Amhara, Ethiopia, from February to July 2023. West Amhara includes seven town administrations: Debark, Gondar, Debre-Tabor, Bahir Dar, Injibara, Finote Selam, Debre-Markos, and eight zones: North Gondar, Central Gondar, South Gondar, West Gondar, West Gojjam, Awi, and East Gojjam. Based on a population estimation of 2021/22, it had a total population of 13,889,807 [ 17 ]. One hundred seventy-eight (178) public health facilities have been providing ART services in West Amhara in 2022/23.

Evaluation design and method

Descriptive cross-sectional study design with concurrent mixed method evaluation was employed. This study design aims to measure and describe healthcare providers’ adherence to EAC intervention protocol accurately and systematically and for better understanding of the intervention gaps. Using mixed method approach provides complimentary and more comprehensive evidences and for better understanding of EAC intervention. It can increase confidence and validity of the findings.

Variables and measurement

After discussion and reaching consensus with stakeholders, adherence dimension with its sub dimensions of content, coverage, frequency and duration of EAC intervention with sixteen indicators were used. Indicators for each sub dimensions were adopted from Ethiopia national EAC intervention guideline, routine monthly key performance indicator (KPI) as well as from other WHO, CDC, PEPFAR and ICAP documets [ 4 , 18 , 19 , 20 , 21 ]. Sub dimensions and indicators also wieghted based on their level of importance for the program and stakeholders’ agreement. Accordingly, a total of 16 indicators were used in the four sub-dimensions.

Content indicators

Number of EAC sessions for which patient adherence rate was assessed.

Number of EAC sessions for which patient adherence barriers were assessed.

Number of EAC sessions with EAC provider motivated and assisted HVL patients to identify solutions for their challenges.

Number of EAC sessions with patient adherence plan was prepared.

Coverage indicators

Percentage of HVL patients initiated first EAC session.

Percentage of HVL patients received second EAC session.

Percentage of HVL patients received third EAC session.

Percentage of HVL patients tested for repeat VL.

Frequency indicators19

Percentage of HVL patients who got 2nd EAC session one month after first EAC session.

Percentage of HVL patients who got 3rd EAC session one month after second EAC session.

Percentage of HVL patients who tested for repeat VL one month after third EAC session.

Duration indicators

Time to first EAC session in days from VL result received.

Time to second EAC session in days from first EAC session.

Time to third EAC session in days from second EAC session.

Time to repeat VL collection in days from third EAC session.

EAC session duration in minutes during direct EAC session observation.

Populations and sampling

In Amhara region, there were 178 ART providing health facilities. Thus, based on sampling manual for facility surveys recommendation [ 22 ] and feasibility issues of the study, we took 11% of the health facilities and these facilities were selected purposively; based on their relative high-case-load. Since all HVL patients enrolled in the EAC intervention in the selected health facilities during our study period were only 173, census was done for all cases (Table  1 ).

Besides, EAC providers, ART focal persons, EAC registrations and selected patients’ chart in the selected public health facilities were also our study population. Based on USAID recommendation [ 23 ], we conducted 32 randomly selected EAC session observations from 14 purposively selected public HFs. The health facilities used for observation were selected based on their relative performance on ART program (4, 4, 5 low, high and averagely performed facilities) and their performance status was obtained from their routine performance reports. The numbers of observation sessions were determined by the level saturation.

A total of 23 in-depth interviews with randomly selected HVL patients and 20 key informant interviews with purposively selected individuals (ART focal) from each selected health facilities were also conducted.

Data collection tool and field work

HVL patients’ charts and EAC register (logbooks) extraction tools, observation checklists, in-depth interview and KII tools adopted from EAC intervention guideline and other related literatures [ 4 , 24 , 25 ]. These tools were translated to Amharic (local language) and retranslated to English to check its consistency and validity for easily understanding. A senior research expert was involved during the tool adaptation and translation (mentioned in the acknowledgment) process.

We recruited four bachelor degree holder data collectors and two MSc holder supervisors and provided two days training. Both quantitative and qualitative data were collected simultaneously analyzed separately and integrated in result and discussion section.

Data management and analysis

Quantitative data were checked daily for its consistency and completeness, entered into Epi Info and exported to SPSS version 25 for analysis. Descriptive statistics like frequency distribution, central tendency and dispersion analysis was conducted and findings presented in terms of narrations, frequency tables, percentages, means, graphs and charts. Qualitative data were transcribed, translated, coded and analyzed schematically by using Open Code version 4.0 software. The qualitative findings were used to triangulate the quantitative results.

Matrix of analysis and judgment

The matrix of analysis and judgment were developed with full involvement of stakeholders. The weight of sub-dimensions under adherence dimension and the respective indicators were given depending on their level of relevance and stakeholders’ consensus. The sum of all sub-dimensions was attributed to the adherence of the program. Therefore, by convention the stakeholders gave the weight for content 30%, frequency 25%, coverage 20% and duration 25%.Finally, the healthcare providers’ adherence was judged by the average score of these sub-dimensions and we categorized it as very adequate(95–100%), adequate (80–94%), inadequate (60–79%) and very inadequate (< 60% ) [ 26 , 27 , 28 ].

A total of 173 HVL patients’ EAC follow up forms and 21 EAC logbook reviews, 32 direct EAC session observations, 23 in-depth interviews and 21 key informant interviews were done. Six hospitals and fifteen health centers were included in our study. From 173 HVL patients whose document reviewed, 84 (49%) were females and 89 (51%) were males, 150 (87%) were on 1st line and 23 (13%) were on 2nd line ART drugs, 79 (45.7%) had VL count between 1,001 and 10,000 copies/ml and 94 (54.3%) were above 10,000 copies/ml when they enrolled to EAC. All HVL participants had no documented mental illness. Most of HVL patients 133 (76.9%) were tested for their viral load due to their annual schedule and almost all patients’ test was done and ART started with in the same health facility. Majority 140 (80.9%) of HVL participants’ first VL test result was in the range of 1,001 to 50,000 viruses per cubic centimeter. While the remaining 17 (9.8%) and 16 (9.2%) of HVL participants’ first VL test result was in the range 50,001 to 100,000 and greater than 100,000 viruses per cubic centimeter respectively.

Content of EAC intervention

Among 32 direct observation EAC sessions, none of the healthcare provides developed or assisted to develop patient adherence plan for HVL participants at end of the session and only 59.4% (19) of the healthcare providers asked and assessed about the storage of patients’ ARV drugs (Table  2 ).

Health care workers counseled me on different issues like avoiding alcohol, timely taking ARV medicationsby using phone alarming, storing ARV drugs in dry places, using condom during intercourse and eating timely balanced diet. To tell the truth, I can not totally avoid alcohol. This is really challengig even I tried many times. [43 years old male RVI patient ]

Our observation finding also revealed that none of the observed EAC sessions adherence plan were prepared. The average content of EAC intervention was 70.3% and it was judged as adequate (Table  3 ).

Coverage of EAC intervention

All HVL patients included in our study were linked and enrolled to EAC intervention. Among these, 164 (94.8%) received first EAC intervention, 146 (84.4%) received second EAC intervention and 107 (61.8%) received EAC intervention for the third time. Seven HVL patients’ viral load test result were received during our data collection period and six of them were below 50 copies per ml while the remaining one was > 1,000 copies per ml. Nine participants in six HFs did not receive any EAC session within the three months.

About 39 charts had no EAC follow up forms and there was no EAC session recorded for 20 (11.6%) HVL patients’ charts despite EAC form were attached. There was no EAC session registered in EAC logbooks for nine (5%) of HVL patients. Numbers of EAC sessions registered in EAC follow up forms and EAC logbooks were also different (Table  4 ).

Among the HVL patients who tested for repeat VL test after completing the three EAC sessions, 6 (60%) had undetectable VL result and remained in their first line ART but one result remained HVL and not yet switched to 2nd line regimen. The remaining three tests were not returned to the HFs from viral load testing laboratories. Among all 173 HVL patients, only 10 (6%) were tested for repeat VL and163 (94%) didn’t complete EAC sessions.

Qualitative findings suggest that poor patient adherence, HVL patients’ workload and distance from health facilities are some of the challenges for EAC intervention.

I have been working in private organization. Working environment in the organization is very busy throughout the day. Because of this, frequently, coming to my follow up hospital to receive EAC session as well as medication refill was difficult for me. For example, I was on field last month and I did not receive last month EAC session but I took medication from other nearby health facility.

(37 years old male RVI patient).

The coverage of EAC intervention was measured by five indicators and it was 86.3% which was judged as adequate (Table  5 ).

Frequency of EAC intervention

Mean time between EAC session one and EAC session two was 33.94 days while from EAC two to EAC three was 31.57 days. The mean time to complete three EAC session (from EAC one to repeat VL collection) was 84 days (Table  6 ).

Over burdening with other activities and poor adherence of patients to EAC intervention are some of the barriers to conduct regular EAC session schedules and ARV refill.

“ I have received adequate counseling in the first month of EAC session but , sometimes , there are things that come in and affect me to take EAC sessions monthly and regularly. For example , the EAC session had strict schedule , when I went for social reasons in my parents and relatives for few days , I missed the sessions. I knew this would really lead to high viral load test results”. (42 years old female RVI patients).

Poor commitment of some HVL patients for adjustable and minor reasons were also considered as other barriers to conduct the session based on schedule.

“From my observation , some HVL patients were not truly committed to their counseling session due to different easily adjustable and very minor reasons. Receiving counseling session is lifesaving and the benefit is more than anything else. They did know this but simply they gave less attention. We will work focusing on these patients”. [31 years HCP serving in ART clinic for more than 7 years]

Overall, only 36.9% EAC intervention sessions were conducted based on their schedule and this was judged as very inadequate based on our judgment parameter (Table  7 ).

Duration of EAC intervention

Based on our research findings, Turnaround Time (TaT) for 1st VL was 16 days while mean time to start first EAC after receiving HVL result was 16.3 days which was late from the recommended time (7days). Despite late engagement to EAC first session after receiving HVL result, the mean time to complete three EAC sessions was 84 days which (Table  8 ).

More than half of HVL patients 95 (54.9%) at 1st EAC session received their 1st EAC session within recommended period (within 7 days) but only 28.3% and 26% of HVL patients were received their 2nd and 3rd EAC sessionsbased on recommended time (within 1 month) respectively. About one-fifth of HVL patients have started EAC sessions after more than one month of HVL result received. Similarly, 10% of HVL patients didn’t start EAC session up to 2 months.

In addition, mean time in minutes took for one EAC session during our session observation was 23 min (ranged from 9 to 59 min). EAC providers could not be able to give EAC sessions according to the protocol due to workload. A key informat intereview also revealed this:

At this health facility, we are working as EAC providers as well as ART refillers, we have to counsel new ART clients, those who were lost to follow up and those with poor adherence. This leaves very little time for HVL patients’ EAC session. [27 years old male HCP with 5 years work experience

Our finding showed that EAC session was given according to the standard duration for only 27.7% HVL patients (Table  9 ).

Based on the above four adherence sub-dimensions measured, the average adherance level of HCPs to the EAC intervention protocol was 55.3%, from which content, coverage, frequency, and duration of the intervention contributed 70.3%, 86.3%, 36.9%, and 27.7%, respectively, and were judged as very inadequate.

This study determined the adherence of EAC providers to the intervention protocol and explored barriers and facilitators of the intervention. Accordingly, the average adherence level of HCPs to the EAC intervention protocol was 55.3%. Our observation findings revealed that most of the EAC intervention contents were delivered to the target beneficiaries. The finding was in line with EAC intervention protocol expectations [ 7 , 29 ]. But it was less than a similar study in Indonesia [ 30 ]. His difference may be due to the fact that the fact that our data collection method was direct observation of EAC sessions, while the Indonesian study used self-reports of participants, which increased the intended results. This evidence was supported by Hanssen et al. [ 31 ]ho found that observational measures are more reliable and have higher validity than self-reports by implementers or participants.

Our session observation and chart review also showed that preparing the next adherence plan for HVL patients was not implemented in all study health facilities. However, the EAC intervention protocol recommends that HVL patients receive all the core contents of the of the EAC session. Similarly, studies suggest that the content of an intervention is its active ingredient, as it primarily determines implementation success or failure. These studies noted that the inability to deliver the content of an intervention affects the extent to which full implementation is attained [ 10 , 11 , 12 ].In addition, we found that some study health facilities did not document some performed activities properly in EAC follow-up charts and EAC logbooks.

All HVL patients were linked and enrolled to EAC intervention. The finding was similar to a study in Nigeria [ 32 ] where 100% HVL patients were linked to EAC sessions. The finding was alsohigher than a study in Uganda [ 33 ]. The difference may be due to the fact that our study includes facilities found in urban sites while the Ugandian study was in rural health facilities, which is characterized by transport inaccessibility to attend the EAC sessions. It was also greater than studies conducted in Zimbabwe [ 34 ], Uganda [ 35 ], Kenya [ 36 ], Nigeria [ 37 ] and Lesotho [ 38 ].

Among those HVL patients who enrolled in EAC intervention, 94.7% of HVL patients received their first EAC session. This EAC intervention coverage was in line with the EAC intervention protocol, which stated that it is satisfactory if more than 80% of HVL patients receive the first EAC session. In our study, the coverage of the EAC intervention was found to be greater than in other studies in Uganda [ 39 ], Uganda [ 40 ], Zimbabwe [ 34 ], India [ 41 ], Swaziland [ 42 ] and Lesotho [ 43 ]. The reason for this variation might be due to the measurement difference where some studies took one EAC session, some others took two EAC sessions, and the and the other remaining studies took three EAC sessions to calculate EAC intervention coverage.

Most HVL patients who were eligible for EAC intervention sessions two and three got the session, and the findings were greater than the study findings in Uganda [ 40 ], Zambiya [ 44 ], Zimbabwe [ 34 ], Swaziland [ 45 ] and India [ 41 ]. But, it was lower than study in Zimbabwe [ 34 ] and in Kenya [ 36 ]. Those who did not receive any EAC session in our study was 5.2% and this was lower than a study in Swaziland [ 42 ], Zimbabwe [ 34 ], Uganda [ 33 ] and Lesotho [ 43 ]. The reason for this variation might be due to measurement differences, and the EAC intervention got more attention recently in our study than in earlier other studies. Our qualitative findings also revealed that HVL patrients were challenged to be fully engaged in the EAC sessions due to an inconvenient schedule, difficulty avoiding alcohol consumption, and fear of stigma. This finding was supported by other previous studies [ 46 ].

The proportion of HVL patients that completed EAC sessions and achieved VL re-suppression following EAC in our study was better than the protocol set by WHO and a study in North Wollo zone of Ethiopia [ 9 ]. The difference could be because our study didn’t include children where as the Wollo study included children. Children are known to have low VL resuppression. Our finding was also greater than a study in Lesotho [ 38 ], four West african countries [ 47 ], meta analysis studies [ 48 ] and Kenya [ 36 ].

Findings from the qualitative analysis showed that HVL patients’ work-related problems and the far distance from their house to health facilities were some barriers to attending EAC sessions. Similarly, it was very difficult for EAC providers, adherence case managers, and adherence supporters to address the socio-economic constraints of HVL patients. They had linked a few clients, especially vulnerable children, to some projects such as ANPPCAN for nutritional support, but these institutions cannot take on all the clients due to resource constraints. This finding was supported by a qualitative study done in Uganda [ 49 ].

Our study showed only one third of HVL patients received three EAC sessions on a monthly basis. This finding was lower than a recommendation set by the intervention protocol, which stated that all HVL patients have to receive their EAC sessions on a monthly basis. Our finding was also lower than a study in Nairob [ 36 ]. This might be because in Kenya providers used phone alarms to remind the session schedules.

Participants reported that there were barriers like disclosing their HIV positive status to others and social and family-related barriers that negatively affected taking their EAC sessions monthly and regularly. Despite this, our key informant said that some HVL patients were not committed to their EAC session follow-up for adjustable and minor reasons. Findings from the qualitative analysis also justified the fact that the majority of HVL patients reasoned that the monthly visits of health facilities for EAC sessions usually resulted in stigma against to them.

Only one fourth of EAC sessions were delivered for recommenended duration. EAC sessions took place for a very short duration (mean of 23 min) despite to EAC intervention protocol which states that one EAC session has to be given for at least 30–45 min. Our finding was also less than a study conducted in New York [ 50 ] but greater than a study in South Africa [ 51 ]. Increasing the length of time for each sessions may increase the adherance rate and was supported by a randomized controlled trial study in New York [ 50 ], where each additional counseling hour was associated with a 20% increase in post-counseling adherence rate.

In our study, the time to start EAC sessions after the HVL result was received was late as compared to the intervention protocol. However, our finding was better than a study conducted in Lesotho [ 38 ]. About one-fifth of HVL patients have started EAC sessions after more than one month of HVL results. Similarly, 10% of HVL patients didn’t start an EAC session for up to 2 months. But this finding was better than a study in northern Wollo, Ethiopia [ 9 ]. The difference might be due to the fact that in some of our study sites, the CDC started to send an alarm to the targets’ cell phones to remind them of the session schedules.

Despite the fact that over two-thirds of HVL patients started the third EAC session, only 6% of them completed the recommended three repeat VL tests within the protocol time frame. This finding was less than studies done in northern Wollo, Ethiopia [ 9 ], Nigeria [ 37 ] and south Africa [ 52 ]. The reason for our lower finding could be that the study period in our study was only three months, whereas in other studies it was longer.

In our study, we found that the mean time from the third EAC session to the repeat VL was earlier than the protocol. This finding was also slightly earlier than the study in the north Wollo zone of Ethiopia [ 9 ]. Our finding indicated that only around one-third of HVL patients gave samples for repeat VL tests in accordance with the protocol within 30 days. This finding was lower than a study in Tanzania [ 53 ]. After having three consecutive good adherences to EAC sessions, the repeat VL has to be tested to check whether the first HVL is suppressed or not. The recommendation in the protocol stated that this repeat VL sample has to be collected within 30 days after the third EAC session given.

Our qualitative finding indicated that providers’ workload was found to be a barrier to attending the sessions. They reported that they were overwhelmed with workload and may not be able to give EAC sessions according to the intervention protocol.

Our document review clearly showed the registerees were incomplete, which implies that they did not review client records very thoroughly and often sent HVL patients by refilling their ARV only but missed conducting the sessions.

Strength and limitation of the evaluation

This study was done using a mixed-methods approach and multiple data sources like in-depth interviews, key informant interviews, document reviews, and observation of EAC sessions, which increased the validity of the findings. The study also included multiple health facilities with the maximum effort to address high-case-load facilities in the region. However, the study is descriptive, which couldn’t show a cause-and-effect relationship and unable to infer for the general population. Hawthorne effect during observation, which may increase the observation findings, was also the other limitation.

The overall adherence level of HCPs to the EAC intervention protocol was 55.3%, which was judged to be very inadequate. The main gap identified was difficulties in completing the EAC intervention sessions based on schedules. The findings also showed that a lack of transport fees, a lack of EAC session rooms, HVL patients work and social-related issues, a lack of commitment of HVL patients to the schedule, and an inadequate number of EAC providers in ART and PMTCT clinics were the barriers to poor adherence.

The regional health bureau shall implement adherence improvement strategies like providing ongoing monitoring and feedback, training, and follow-up for EAC providers and supporting their work. Health facilities have to assign an adequate number of EAC providers in ART and PMTCT clinics and create suitable rooms for counseling sessions, and HCPs should allow sufficient time during EAC sessions to explore individual-level barriers and facilitators.

Data availability

Data is provided within the manuscript or supplementary information files.

Abbreviations

Acquired Immune Deficiency Syndrome

African Network for the Prevention and Protection against Child Abuse and Neglect

Antiretroviral Therapy

Antiretroviral

Centers for Disease Control and Prevention

Enhanced Adherence Counseling

Health Center

Health Facility

Human Immunodeficiency Virus

High Viral Load

People Living with Human Immunodeficiency Virus

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Acknowledgements

We are very grateful to University of Gondar for its technical support. We would also like to thank all health facilities included in our study all participants for their information and commitment. We would like to give our deepest gratitude to Professor Amsalu Feleke for their comments, suggestions and help to improve our research quality and finally our appreciation extended to the data collectors for their unreserved contribution.

There is no specific fund for this research work.

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Amare Belete and Getachew Teshale have equal contribution.

Authors and Affiliations

Gondar Branch Office, Amhara Regional Health Bureau, CDC project, Gondar, Ethiopia

Amare Belete

Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

Getachew Teshale, Andualem Yalew, Endalkachew Delie & Asmamaw Atnafu

Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

Gebrie Getu

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All authors contributed to the preparation of the manuscript. AB and GT designed the study, wrote proposal, collected and analyzed the data. AY, ED, GG and AA revised the analysis. AB and GT prepared the manuscript. All authors approved the manuscript.

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Correspondence to Getachew Teshale .

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Ethical clearance was obtained from the Institutional Review Board (IRB) of the University of Gondar, College of Medicine and Health Sciences, Institute of Public Health (ref. №: IPH/2119/2014). After a brief explanation of the study objective and purpose, informed consent was obtained from each participant. Participants were also informed that participation is voluntary, and they had the right to withdraw from the study at any time during the data collection. Furthermore, all data obtained from participants were kept confidential and used for this study only. The study was also conducted according to Helsinki declarations.

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Belete, A., Teshale, G., Yalew, A. et al. Adherence of healthcare providers to Enhanced Adherence Counseling (EAC) intervention protocol in West Amhara Public Health Facilities, Northwest Ethiopia, 2023: mixed method evaluation. BMC Infect Dis 24 , 977 (2024). https://doi.org/10.1186/s12879-024-09888-8

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Received : 02 January 2024

Accepted : 05 September 2024

Published : 13 September 2024

DOI : https://doi.org/10.1186/s12879-024-09888-8

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