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Case Study Research in Counselling and Psychotherapy

• John McLeod - University of Oslo, Norway
• Description

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

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

- practical tools for collecting case data

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

- team-based case study research for practitioners and students

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

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

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

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

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

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

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

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

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

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

this has everything that you need for researching

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

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

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

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

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

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

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

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

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

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

Presenting Problem and Client Background

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

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

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

Case Conceptualization

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

Course of Treatment

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

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

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

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

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

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

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

Element 3: Eliciting Narrative Episodes

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

Element 4: The Psychological Problem

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

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

Element 5: Reflecting on Interpersonal Processes

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

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

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

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

Element 7: Stimulating Reflectivity of Self and Others

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

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

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

Element 8: Stimulating Psychological Mastery

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

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

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

Case study definition

Case study, a term which some of you may know from the "Case Study of Vanitas" anime and manga, is a thorough examination of a particular subject, such as a person, group, location, occasion, establishment, phenomena, etc. They are most frequently utilized in research of business, medicine, education and social behaviour. There are a different types of case studies that researchers might use:

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Psychology: Research and Review

• Open access
• Published: 19 March 2021

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

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

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

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

Introduction

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

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

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

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

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

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

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

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

The common approach: evidence-based practice.

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

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

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

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

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

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

Internal validity

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

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

The alternative approach: practice-based evidence

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

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

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

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

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

External validity

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

A third way approach to validity and evidence

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

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

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

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

What is a research tool.

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

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

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

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

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

Comparing different qualitative tools

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

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

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

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

Using CASP, JBI and ETQS for systematic case study appraisal

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

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

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

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

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

Developing purpose-oriented evaluation criteria for systematic case studies

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

CaSE checklist for essential components in systematic case studies

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

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

CaSE purpose-based evaluative framework for systematic case studies

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

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

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

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

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

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

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

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

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

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

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

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

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

Concluding comments

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

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

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

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

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

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Acknowledgments

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

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

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

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What Is a Case Study?

Weighing the pros and cons of this method of research

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

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

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

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

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

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

At a Glance

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

What Are the Benefits and Limitations of Case Studies?

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

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

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

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

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

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

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

Case Study Examples

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

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

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

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

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

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

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

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

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

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

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

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

Section 1: A Case History

This section will have the following structure and content:

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

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

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

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

Section 2: Treatment Plan

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

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

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

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

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

Need More Tips?

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

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

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

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

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

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

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

How to Write a Case Study

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

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

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

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

CONCEPTUAL BACKGROUND OF A PRAGMATIC CASE STUDY IN PSYCHOTHERAPY

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

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

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

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

The Narrative Nature of the Psychotherapy Case Study

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

Three Parts

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

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

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

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

SPECIFIC GUIDELINES

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

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

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

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

(a) Who you are;  

(b) How long have you practiced;

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

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

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

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

2. The Client

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

(a) cultural status,

(c) gender,

(d) education/work background and status, 

(e) marital status,

(f) parental status   

(f) life circumstances, and

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

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

3. Guiding Conception with Research and Clinical Experience Support

          This section should inform the reader about:

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

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

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

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

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

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

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

(a) their presenting problem(s);

(b) other problems and challenges;

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

(d) personality and character issues;   

(e) their initial stated goals for  treatment;

(f) previous therapy;  

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

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

(i) their strengths as well as limitations.

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

5. F ormulation and Treatment Plan

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

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

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

6. C ourse of Therapy

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

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

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

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

(a) How did the client present themselves?

(b) What sort of therapeutic relationship was established?

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

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

7. T herapy Monitoring and Use of Feedback Information

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

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

(b) Were the psychotherapy sessions recorded or videotaped?

(c) What type of clinical notes were made?

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

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

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

(a) What changes, if any, occurred?

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

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

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

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

Overall Guidelines Across the Eight Areas

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

(b) Clearly differentiate description from theory. 

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

GENERAL GUIDELINES

Page Length

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

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

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

Quantitative Data

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

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

Description Versus Theory

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

Scholarship

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

A Checklist of Questions to be Answered About Your PCSP Manuscript  

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

Sample Cases

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

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

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

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

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

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

COMMUNITY CASE STUDY article

Do asymptomatic stec-long-term carriers need to be isolated or decolonized new evidence from a community case study and concepts in favor of an individualized strategy.

• 1 Department of Medicine I, Division of Gastroenterology and Nephrology, University Hospital Schleswig-Holstein, Lübeck, Germany
• 2 Department of Infectious Diseases and Microbiology, University Hospital Schleswig-Holstein, Lübeck, Germany
• 3 Institute for Medical Microbiology, Virology and Hygiene, Department for Infection Prevention and Control, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

Asymptomatic long-term carriers of Shigatoxin producing Escherichia coli (STEC) are regarded as potential source of STEC-transmission. The prevention of outbreaks via onward spread of STEC is a public health priority. Accordingly, health authorities are imposing far-reaching restrictions on asymptomatic STEC carriers in many countries. Various STEC strains may cause severe hemorrhagic colitis complicated by life-threatening hemolytic uremic syndrome (HUS), while many endemic strains have never been associated with HUS. Even though antibiotics are generally discouraged in acute diarrheal STEC infection, decolonization with short-course azithromycin appears effective and safe in long-term shedders of various pathogenic strains. However, most endemic STEC-strains have a low pathogenicity and would most likely neither warrant antibiotic decolonization therapy nor justify social exclusion policies. A risk-adapted individualized strategy might strongly attenuate the socio-economic burden and has recently been proposed by national health authorities in some European countries. This, however, mandates clarification of strain-specific pathogenicity, of the risk of human-to-human infection as well as scientific evidence of social restrictions. Moreover, placebo-controlled prospective interventions on efficacy and safety of, e.g., azithromycin for decolonization in asymptomatic long-term STEC-carriers are reasonable. In the present community case study, we report new observations in long-term shedding of various STEC strains and review the current evidence in favor of risk-adjusted concepts.

Introduction

Food-borne outbreaks of severe hemorrhagic enterocolitis complicated by life-threatening hemolytic uremic syndrom (HUS) are an utterly devastating incident and a major challenge for public health ( 1 , 2 ). The largest outbreak caused 3,816 documented infections in Northern Germany in 2011, including 845 cases of HUS ( 3 ). It was mediated by the Shigatoxin-producing Escherichia coli (STEC) strain O104:H4 and related to the consumption of contaminated sprouts. This strain harbored a phage encoding the highly pathogenic Shigatoxin type 2 (Stx 2) and expressed virulence factors of both the enterohemorrhagic (EHEC) and enteroaggregative (EAggEC) E. coli phenotypes. The latter might have mediated the high rate of prolonged shedding (i.e., >28 days) of viable STEC after recovery from acute diarrhea ( 4 , 5 ). Infection prevention measures like sanitary separation of patients during enterohemorrhagic diarrheal disease are undisputed and essential to prevent human-to-human spread. However, the role of asymptomatic STEC carriers as a potential source of new outbreaks is controversial ( 5 – 8 ). Still, health authorities in most western countries are imposing far-reaching restrictions on STEC carriers. Even lenient measures like separated sanitary facilities exert psychosocial pressure and stigmatization. Ban from work, school or kindergarten might inflict substantial economic burden on the affected families and employers. Therefore, in the case of long-term STEC-shedding decolonization appears highly desirable.

Several case series suggested that antibiotic treatment for asymptomatic STEC-carriage may be an effective and safe eradication method ( 9 , 10 ). In a pilot trial we previously documented that azithromycin was highly effective for the sustained decolonization of post-symptomatic long-term carriers of the highly pathogenic STEC O104:H4 outbreak strain ( 11 ). Antibiotic rehabilitation from long-term STEC carriage could stop both the risk of person-to-person transmission and set aside the social impact of exclusion policies. However, the application of antibiotics to clinically asymptomatic persons always needs appropriate justification. Moreover, antibiotic therapy is commonly discouraged in STEC-disease ( 12 – 14 ), since some reports have raised concerns about an inherent potential of some antibiotics to enhance Stx release and thus HUS development mainly in STEC O157.

Over the past two decades, the increasing use of syndromic multi-pathogen assays in diarrhea that detect Stx or their encoding genes has markedly increased the sporadic detection of colonization with endemic STEC strains independent of clinically overt disease or even outbreaks. This surge in detection raises questions from physicians, institutions, and public health officials about reasonable and practical measures to prevent secondary transmission. STEC is genetically a very heterogeneous and large group. The spectrum of virulence is governed in part by the subtype of Stx expressed (Stx1 or 2), and by additional pathogenicity factors, including genes encoding intestinal adherence. Different E. coli strains have varying pathogenic potential as proposed by the seropathotype concept ( 15 ). Moreover, the risk of long-term shedding with human-to-human transmission and, hence, the benefit from antibiotic decolonization needs strain-specific stratification. Most endemic STEC-strains have a low pathogenicity and have never been reported in the context of outbreaks or the development of HUS [for review: ( 10 , 16 – 19 )]. Most likely, they would neither justify antibiotic decolonization therapy nor substantiate social exclusion stipulations. Return-to-work and return-to-school polices tailored to the virulence of the STEC strain may lessen the personal and socioeconomic burden in conditions of asymptomatic long-term shedding of low-virulence organisms.

Therefore, in asymptomatic long-term STEC carriers an individualized risk-adapted approach appears mandatory. Such strategies were recently advocated by several national health authorities ( Figure 1 ). However, the implementation in daily routine lags behind these recommendations.

Figure 1 . Updated recommendations of German national health authorities (Robert-Koch-Institute) on readmittance to community facilities [adapted from Pörtner et al. ( 20 )].

Context of the community case study–population, programmatic details and core observations

Antibiotic eradication attempts, evidence from post-symptomatic long-term carriers of the highly pathogenic outbreak-related stec o104:h4.

Following the large food-borne outbreak of STEC O104:H4 in Northern Germany in 2011 ( 3 ) a considerable number of patients showed persistent STEC-carriage (i.e., >28 days) after recovery from acute STEC-infection ( 4 , 5 ). The high rate of long-term carriage was attributed to an enteroaggregative phenotype. Interestingly, STEC shedding was found to be promptly terminated by azithromycin administered as meningitis prophylaxis during off-label treatment with eculizumab in severe HUS-cases ( 11 ). Azithromycin is an approved therapy in diarrheal disease caused by enteroaggregative E. coli and was previously reported to reduce Stx-release in vitro ( 21 , 22 ). Therefore, as a proof of principle, we offered a 3-day course of oral azithromycin (500 mg/d) to 15 long-term carriers (> 28 d) who - though now asymptomatic - were restricted in their social or working life. After the 3-day course all had consistently negative stools without any HUS related symptoms ( 11 ). This observation required approval in a greater cohort of long-term carriers of STEC O104:H4.

Accordingly, we treated 27 additional cases, totaling n  = 42 long-term carriers with a history of acute STEC-enterocolitis and/or HUS. They all had completely recovered but – though being asymptomatic – showed persistent fecal STEC shedding beyond day 28 from the onset of diarrheal symptoms. Patients were referred to our outpatient clinic due to their individual burden of social and economic restrictions.

The decolonization protocol is visualized in Figure 2 . Details on microbiologic analysis are presented in the online supplement. Persistent STEC shedding was documented within the last 7 days prior to the decolonization attempt. The core efficiency parameter was the rate of sustained microbiological response vs. rate of relapse/persistence at 2–3 weeks after azithromycin treatment. The safety outcome comprised any clinical or laboratory signs of HUS and/or any other clinical adverse event.

Figure 2 . Treatment protocol for decolonization of STEC-long-term carriers with short course azithromycin.

The median duration from the onset of outbreak-related diarrheal symptoms to the start of decolonization therapy was 60 days (range 30–189, mean duration73.5 ± 39.4 days) in 39 of 42 persons of this cohort. The remaining three individuals, however, did not report a preceding diarrheal episode, but were eventually detected. E.g., one of them was found positive at screening as a household-contact about 10 days after his wife had developed STEC-diarrhea. It is unclear whether he had the same nutritional source of infection as his wife or had acquired a secondary person-to-person infection.

41 (98%) participants were successfully decolonized as confirmed by at least 3 negative stool samples within the subsequent 21 days. The median duration from acute symptom onset until first negative stool following the 3-day azithromycin course was 63 days (range 35–198). However, 1 person showed a relapse/recurrence of STEC-positivity after two samples had been negative. In this individual a second 3-day course of azithromycin was repeated after another 7 weeks of positive stool samples and then lead to prompt and sustained decolonization ( Figure 3 ). None of the subjects demonstrated any HUS-related clinical or laboratory deterioration. There were no adverse events apart from abdominal discomfort in two participants that lasted less than 2 days while continuing azithromycin.

Figure 3 . Line-list STEC O104:H4 cases; blue, time span of documented STEC shedding since symptom onset or first diagnosis until start of decolonization with azithromycin; red, time span until negative stool tests.

In this cohort of O104:H4 long-term carriers, individuals judged that their expected personal benefits from decolonization would far exceed the potential risk of adverse events. Some of them were at risk of losing their jobs after prolonged ban from work. One individual, e.g., was blocked from running his restaurant for weeks, another was suspended from his food-processing job for almost 3 months, one adolescent patient was not allowed to travel abroad as an au-pair and one child was banned from kindergarten for several weeks, which severely restrained its parents’ working life. One married couple first declined a decolonization attempt and then stayed at home for about 6 months awaiting spontaneous decolonization. As shown in the line-list ( Figure 3 ), they continued to be positive after 180 days, but even then, therapy with azithromycin promptly led to sustained decolonization.

Community case series of sporadic asymptomatic long-term carriers of endemic strains

Additionally, we collected sporadic community cases colonized with endemic non-O104:H4, non-O157 STEC over 10 years (2012–2021). All were incidentally detected, and they had no history of gastrointestinal disease or HUS, and none was associated with an outbreak. Therefore, the duration of shedding was undetermined, but all of these subjects had repeatedly been found STEC-positive since ≥28 days. They reported severe social restrictions inflicted by local public health authorities for several weeks or months. Nationwide, we encountered about 50 contacts for counseling initiated either by the colonized individuals, by their general practitioner or via public health office seeking advice for decolonization. We carefully discussed the individual pros and cons to perform a decolonization attempt with azithromycin. Some decided not to undergo a decolonization attempt. In other cases, information on the strain-serotype or the subtyping of Stx-1 vs. 2 were incomplete as such diagnostic workups are regularly not reimbursed by health insurance coverage. Therefore, we here report 21 sporadic asymptomatic long-term STEC-carriers with confirmed endemic non-O104 strains treated with azithromycin. Of these, 10 carried serotype O91:H14, a subtype with H14-flaggelin which has never been associated with STEC-outbreaks or HUS ( 23 ). During the last two decades the fraction of O91 strains has significantly increased, according to the German National Reference Centre for Enteric Bacterial Pathogens run by the Robert-Koch-Institute (RKI) ( 16 ). In 4 subjects we found serogroup O26, 2 harbored O113, and one was found positive for O15, O76, O146, O156, or O181, respectively. Patients decided that their individual burden of exclusion outweighed any potential risk of decolonization treatment. They took full responsibility for their decision to undergo the off-label decolonization attempt according to the above-mentioned protocol, and to perform safety checks. Decolonization was successful in all 21 individuals as determined by the family physician’s report of negative follow-up stool samples. None of them reported any signs of HUS or other significant adverse events.

Pros and cons of antibiotic therapy in STEC-disease and long-term shedding

Evidently, azithromycin is highly effective for the sustained decolonization of asymptomatic long-term STEC O104:H4 carriers as well as asymptomatic long-term shedders of endemic STEC strains. This approach appeared safe, since no HUS-related clinical or laboratory deterioration occurred. In contrast to these findings in asymptomatic long-term carriers, antibiotics are generally discouraged during STEC-related acute bloody diarrhea ( 12 – 14 ). In vitro , Stx production is boosted by sub-inhibitory concentrations of specific antibiotics. Data are available mainly for EHEC O157 and for two classes of antibiotics, the fluoroquinolones and trimethoprim-sulfamethoxazol (TMP/SMZ), which have repeatedly been shown to induce Stx production in vitro . This is plausible, as both antibiotics, targeting DNA-synthesis, induce the bacterial SOS stress response to DNA damage, which is linked to an increase in phage production and toxin release ( 24 – 26 ). Additionally, a retrospective analysis from the US FoodNet surveillance recently reported an augmented risk of HUS among children and adults with O157 diarrhea treated with β-lactams ( 14 ). For other strains, data were conflicting and hardly comparable due to different antibiotics at variable doses and variable susceptibility profiles. Currently, there is no rational to suggest alternative antibiotics without prior testing of antimicrobial resistance. Harm from antibiotic treatment has never been proven through randomized controlled trials, and observational studies suffer from biases such as greater likelihood of antibiotic treatment in patients presenting with more severe illness. During the O104-outbreak in 2011 the use of several antibiotics for concurrent reasons did not deteriorate clinical outcome according to an observational multicenter study ( 27 ).

Azithromycin, an antibiotic of the macrolide family, binds to the 50S subunit of the bacterial ribosome. Azithromycin inhibits protein synthesis including the production and release of Shiga toxin in vitro independent from its bacteriostatic effects ( 21 , 22 , 28 ). In addition, azithromycin has modulating effects on the Stx-induced inflammatory reaction on the vascular endothelium. Whether azithromycin could reduce the duration of diarrhea or protect against the development of HUS in highly pathogenic STEC is an unsolved question. Currently, there is no evidence that antibiotic treatment is harmful once HUS has developed. Studies on animal models showed a drastic reduction in HUS-related mortality. Nonetheless, we have to await the results of an ongoing clinical trial ( ClinicalTrials.gov number, NCT02336516) of azithromycin therapy initiated during established HUS.

Moreover, we found no report on HUS-induction in asymptomatic long-term STEC-carriers receiving antibiotics for concurrent indications ( 10 ). Based on a recent meta-analysis including 10 clinical and 22 in vitro studies, as well as data from the Danish cohort of registered STEC infections, antibiotic treatment with protein and cell-wall synthesis inhibitors can be considered safe in chronic STEC-carriers when specific criteria regarding patient group, serotype and virulence profile are met ( 18 , 29 ). Case reports suggested that antibiotic treatment for asymptomatic STEC-carriage may be a safe eradication method for less virulent strains ( 9 , 10 ). This is confirmed by our present collection of anecdotic endemic cases.

In general, the advantages of antibiotic treatment must always be balanced against the disadvantages of short and long-term interference with the human intestinal microbiome. It is important to consider that the dissemination of plasmide-borne macrolide resistance may reduce the potential benefit of azithromycin for STEC decolonization, and determination of azithromycin MICs should be considered ( 30 ). Other treatment options especially in acute STEC disease, including Stx-receptor analogs, antibodies against LPS, use of probiotics as well as phages and vaccines, have been reviewed elsewhere ( 31 , 32 ). In brief, they did not provide novel successful concepts – neither for acute disease nor in asymptomatic long-term carriage.

Human-to-human transmission

The infectious potential of asymptomatic STEC shedding for human-to-human transmission is unclear. Present knowledge about person-to-person STEC-transmission is predominantly deduced from serogroup O157, a group that mainly affects young children. In childcare settings, secondary cases via human-to-human spread during active diarrhea are frequent and this is advocated as an important mechanism during outbreaks ( 33 ). During the acute diarrheal phase persons appear to be more likely to spread STEC than asymptomatic long-term shedders ( 6 , 7 ). In registries of STEC-O157 cases from England ( n  = 225 children <6 yrs), Scotland ( n  = 2.228 cases over 10 years) and the US secondary cases due to fecal-oral transmission occurred in 10–14% of all cases with confirmed acute enterocolitis. The mean time between onset in primary and secondary cases was about 8 days (range 3–24 days); pathogen transmission from asymptomatic O157-carriers was not observed ( 33 – 35 ). During the O104:H4 outbreak in 2011 only few cases of secondary human-to-human household transmission were reported. Most of them occurred early, i.e., during the acute diarrheal phase of the primary case ( 5 ); the risk of transmission from asymptomatic long-term STEC shedders appeared much lower. In a prospective post-outbreak surveillance in 2011 run by German health authorities in order to detect further infections after the outbreak’s end, 33 post-outbreak cases were recorded based on mandatory reporting from summer until the end of 2011. These post-outbreak cases occurred with decreasing frequency over the 6 months follow-up period and were clinically rather mild. Most of them had previous contact with known outbreak cases or were mediated by laboratory or nosocomial spread but were not related to sprout consumption ( 36 ). Evidently, the pathogenic outbreak strain STEC O104:H4 has the potential to prolong chains of human transmission, with long-term shedding being the most relevant risk factor. Still the number of secondary cases was low (< 1%) compared to the food-borne cases ( n  = 3.816). For endemic non-pathogenic STEC-strains there are no valid data on person-to-person transmission.

Strain specific pathogenicity factors for HUS-development and long-term shedding

Shiga-toxins and the adherence factor intimin (eae) /enterocyte effacement pathogenicity island are the main virulence factors of STEC. They cause the attaching and effacing lesions on infected epithelial cells. Moreover, expression of phage-encoded Stx-subtype 2a, 2c or 2d appears to be responsible for the intestinal vascular damage that characterizes STEC-mediated hemorrhagic enterocolitis and to induce the systemic complications like hemolysis, renal failure and neurologic deterioration seen in HUS. The O104:H4 outbreak strain harbored a phage encoding Stx2a, which is associated with the high rate of HUS observed. Stx-1 expression, in contrast, is in general not associated with HUS. Genomic plasticity and horizontal gene transfer enable the emergence of STEC strains with additionally acquired virulence properties. The Stx gene distribution changed, for example, from only 7% of STEC O26:H11 harboring Stx2 in 1999 to 59% in 2013 ( 37 ). Therefore, it is not possible to predict the emergence of „new‟ highly pathogenic STEC types based solely on the presence of any unspecified Stx or by focusing on a restricted panel of serogroups. Next to molecular strain-typing, whole-genome sequencing, including differentiation of Stx1 and 2 allelic variants, might help to assess the risk inherent to long-term STEC carriage. Further molecular details have been discussed elsewhere ( 15 – 19 , 38 ).

Differential bacterial mechanisms of intestinal adherence and host factors may result in variable shedding dynamics of diverse STEC-strains. In some individuals long-term STEC carriage was documented for up to 1 year. STEC O104:H4, the outbreak strain in Germany in 2011 ( 3 ) expressed virulence factors of enteroaggregative (EAggEC) phenotype attributing to a high rate of persistent STEC-carriage (i.e., >28 days) after recovery from acute STEC-infection ( 4 , 5 ). STEC O157 – another highly pathogenic serogroup which is primarily responsible for outbreaks and severe HUS in children – in contrast, rarely persists for >28 days ( 39 ). For endemic STEC which are incidentally detected in asymptomatic carriers without antecedent diarrheal disease or HUS, the period of shedding is unknown.

Pros and cons of social restriction policies

In many countries worldwide far-reaching restrictions are enunciated by health authorities for those asymptomatic STEC carriers who might constitute a potential risk of infecting other persons or contaminating food items irrespective of the strain. This sounds justified for highly virulent strains shed by persons in food-sensible context. However, in cases of prolonged shedding, social restrictions beyond personal hygiene can be onerous. Exclusion of asymptomatic persons from normal daily life with the risk of losing their jobs imposes a severe economic burden in addition to psychosocial pressure and stigmatization. Given the increased detection rate of endemic STEC, risk-adjusted modifications appear mandatory. In Denmark, subtyping of Stx is routinely integrated into public health strategies since 2015 in order to focus follow-up surveillance to patients infected with high-risk strains ( 18 ). Recently, in Norway and Germany the official rules for re-admittance of STEC-carriers to work, to school or kindergarten were greatly revised by the legal health authorities ( 20 , 40 ). The new recommendations adhere to a strain-specific stratification. In Germany, patients infected with STEC expressing Stx-1 and sporadic cases of asymptomatic colonization with endemic strains, e.g., do not need any further fecal controls and should no longer suffer from restricted daily social interaction ( Figure 1 ). Syndromic PCR panels that do not differentiate between Stx1 and 2, however, provide inadequate information. In our collection of endemic STEC long-term carriers, subjects reported ongoing exclusion policies even though their subtyping indicated no substantial pathogenic threat, mostly before 2020. According to the new national standards, most of them would retrospectively not require any precautionary restraints and therefore would no longer apply for eradication with azithromycin today.

Epidemiologically, all large STEC-outbreaks over the last 50 years were food-borne. Next to contaminated vegetable, products of domestic and wild animals served as STEC-vehicles. Ruminants, especially cattle, are regarded as important sources of food-borne STEC-transmission to humans. STEC strains persisting in cattle for longer periods can serve as gene reservoirs that supply E. coli with virulence factors, thereby generating new potential outbreak strains. Moreover, there are multiple reports from all over the world showing a considerable prevalence of plasmid-borne antimicrobial (multidrug) resistance of various STEC strains in domestic and even in hunted wildlife animals. This clearly precludes benefit from the broad use of antibiotics to prevent outbreaks. Given the globalization of food chains and human travel, resistance patterns in far distant regions might well have relevance on public health elsewhere, nowadays. The O104:H4 outbreak in 2011, e.g., was mediated by contaminated sprouts imported from overseas, and this strain was resistant to ß-lactams (ESBL), tetracycline, streptomycin and trimethoprim/sulfamethoxazole. In contrast, there are no reports on outbreaks that were triggered from asymptomatic human long-term STEC carriers. To the best of our literature search, there is no epidemiologic evidence of any public health benefit from social exclusion policies for asymptomatic long-term STEC-carriers. Public health attempts to reduce the human risk for acquiring STEC infections should therefore mainly address strategies to control persisting STEC strains in the food-chain. Animal carriage of STEC is reduced, e.g., through vaccination and improved farm practices ( 41 ). To decently review the large body of scientific literature concerning this highly relevant veterinary issue is far beyond the scope of this article. In summary, preventing STEC transmission from animals and nutritional environments to humans includes appropriate food preparation, personal hand hygiene, control of environmental contamination, and food and water quality. This might be much more effective than the social exclusion of asymptomatic human carriers of low-virulent strains ( 42 ).

Limitations

The conclusions drawn from this community case study are inevitably subject to some limitations. The German O104-STEC-outbreak in 2011 was one of the largest worldwide, and likewise, our cohort of long-term-carriers decolonized with azithromycin is the largest reported. Still the number of cases in our decolonization cohorts is low to conclude strict recommendations. To overcome the substantial lack of scientific evidence, central registries are needed. They might aim at systematically determining strain-specific risks of human-to-human transmission in asymptomatic long-term carriers as well as benefit vs. harm from social restriction. Finally, antibiotic decolonization approaches need confirmation in prospective controlled studies. This includes a more in depth specification of the optimum follow-up period after decolonization to rule-out relapses.

Recommendation for an individualized risk-adjusted strategy

The above issues endorse the recent concept of an individualized approach that takes strain-specific risks and personal and public threats into account. Molecular strain-profiling in long-term STEC carriage would trigger stringent hygiene measures reserved to high-risk strains and limit unnecessary precautionary measures in low-virulent STEC. This, however, mandates molecular microbiologic diagnostics beyond the routine of simply detecting Stx by ELISA or by PCR ( Figure 1 ). This work-up is still not regularly reimbursed by health insurance policies. On a public health level, such molecular stratification, however, might well be cost-effective.

From a clinical point of view, the previous dogma that antibiotics are absolutely contraindicated in STEC infection needs to be revised. To date, antibiotics should be handled cautiously in patients with acute bloody diarrhea caused by STEC, especially if caused by STEC O157. In long-term shedding of highly virulent STEC, decolonization by a short course of oral azithromycin might offer an appropriate option. Our community case study confirms that a 3-day course is highly effective and safe. Decolonization with azithromycin could shorten the duration of human STEC shedding, and thereby reduce the risk of transmission and the need of prolonged restrictions. The potential benefit is underlined by the evidence of some human-to-human post-outbreak transmissions during the 6 months of national surveillance after the O104:H4 outbreak in 2011 ( 36 ). Asymptomatic carriers of endemic non-virulent STEC strains, in contrast neither need prolonged restrictions, nor fecal follow-up testing, and therefore, do not require antibiotic decolonization treatment ( 20 ). Strain-specific risk stratification allows for a risk-adjusted individual strategy. Together with our eradication approach reserved to high-risk pathogens, this could modify public health surveillance, enable an earlier return to normal life for many long-term carriers, and hence reduce the individual and socioeconomic burden of long-term STEC-carriage.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

Ethical approval was not required for the studies involving humans because community case study, part of it was interventional (with ethical approval), part of it was rather observational (not approved). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

FS: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. SH: Data curation, Investigation, Methodology, Resources, Validation, Writing – review & editing, Conceptualization, Project administration, Writing – original draft. JK: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Resources, Supervision, Validation, Writing – review & editing. JR: Conceptualization, Resources, Supervision, Writing – review & editing. MN: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Resources, Supervision, Validation, Writing – review & editing.

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Conflict of interest

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

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2024.1364664/full#supplementary-material

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24. Safdar, N, Said, A, Gangnon, RE, and Maki, DG. Risk of hemolytic uremic syndrome after antibiotic treatment of Escherichia coli O157: H7 enteritis: a meta-analysis. JAMA . (2002) 288:996–1001. doi: 10.1001/jama.288.8.996

25. McGannon, CM, Fuller, CA, and Weiss, AA. Different classes of antibiotics differentially influence Shiga toxin production. Antimicrob Agents Chemother . (2010) 54:3790–8. doi: 10.1128/AAC.01783-09

26. Kimmitt, PT, Harwood, CR, and Barer, MR. Toxin gene expression by Shiga toxin-producing Escherichia coli : the role of antibiotics and the bacterial SOS response. Emerging Infect Dis . (2000) 6:458–65. doi: 10.3201/eid0605.000503

27. Menne, J, Nitschke, M, Stingele, R, Abu-Tair, M, Beneke, J, Bramstedt, J, et al. Validation of treatment strategies for enterohaemorrhagic Escherichia coli O104:H4 induced haemolytic uraemic syndrome: case-control study. BMJ . (2012) 345:e4565. doi: 10.1136/bmj.e4565

28. Corogeanu, D, Willmes, R, Wolke, M, Plum, G, Utermöhlen, O, and Krönke, M. Therapeutic concentrations of antibiotics inhibit Shiga toxin release from enterohemorrhagic E. coli O104:H4 from the 2011 German outbreak. BMC Microbiol . (2012) 12:160. doi: 10.1186/1471-2180-12-160

29. Gantzhorn Pedersen, M, Hansen, C, Riise, E, Persson, S, and Olsen, KEP. Subtype-specific suppression of Shiga toxin 2 released from Escherichia coli upon exposure to protein synthesis inhibitors. J Clin Microbiol . (2008) 46:2987–91. doi: 10.1128/JCM.00871-08

30. Jost, C, Bidet, P, Carrère, T, Mariani-Kurkdjian, P, and Bonacorsi, S. Susceptibility of enterohaemorrhagic Escherichia coli to azithromycin in France and analysis of resistance mechanisms. J Antimicrob Chemother . (2016) 71:1183–7. doi: 10.1093/jac/dkv477

31. Melton-Celsa, AR, and O’Brien, AD. New therapeutic developments against Shiga toxin-producing Escherichia coli . Microbiol Spectrum . (2014, 2014) 2. doi: 10.1128/microbiolspec.EHEC-0013-2013

32. Rahal, EA, Fadlallah, SM, Nassar, FJ, Kazziand, N, and Matar, GM. Approaches to treatment of emerging Shigatoxin-producing Escherichia coli infections highlighting the O104:H4 serotype. Front Cell Infect Microbiol . (2015) 5:24. doi: 10.3389/fcimb.2015.00024

33. Dabke, G, Le Menach, A, Black, A, Gamblin, J, Palmer, M, Boxall, N, et al. Duration of shedding of Verocytotoxin-producing Escherichia coli in children and risk of transmission in childcare facilities in England. Epidemiol Infect . (2014) 142:327–34. doi: 10.1017/S095026881300109X

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35. Locking, ME, Pollock, KG, Allison, LJ, Rae, L, Hanson, MF, and Cowden, JM. Escherichia coli O157 infection and secondary spread, Scotland, 1999-2008. Emerg Infect Dis . (2011) 17:524–7. doi: 10.3201/eid1703.100167

36. Frank, D, Milde-Busch, A, and Werber, D. Results of surveillance for infections with Shiga toxin-producing Escherichia coli (STEC) of serotype O104:H4 after the large outbreak in Germany, July to December 2011. Euro Surveill . (2014) 19:20760. doi: 10.2807/1560-7917.es2014.19.14.20760

37. Bielaszewska, M, Mellmann, A, Bletz, S, Zhang, W, Köck, R, Kossow, A, et al. Enterohemorrhagic Escherichia coli O26:H11/H-: a new virulent clone emerges in Europe. Clin Infect Dis . (2013) 56:1373–81. doi: 10.1093/cid/cit055

38. Lang, C, Hiller, M, Konrad, R, Fruth, A, and Flieger, A. Whole-genome-based public health surveillance of less common Shiga toxin-producing Escherichia coli Serovars and Untypeable strains identifies four novel O genotypes. J Clin Microbiol . (2019) 57:e00768–19. doi: 10.1128/JCM.00768-19

39. Lucarelli, LI, Alconcher, LF, Arias, V, and Galavotti, J. Duration of fecal shedding of Shiga toxin-producing Escherichia coli among children with hemolytic uremic syndrome. Arch Argent Pediatr . (2021) 119:39–43. doi: 10.5546/aap.2021.eng.39

40. Veneti, L, Lange, H, Brandal, L, Danis, K, and Vold, L. Mapping of control measures to prevent secondary transmission of STEC infections in Europe during 2016 and revision of the national guidelines in Norway. Epidemiol Infect . (2019) 147:e267. doi: 10.1017/S0950268819001614

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Keywords: STEC, EHEC, socio-economic burden, social restrictions, Shigatoxin, HUS, long-term carriage, fecal shedding

Citation: Sayk F, Hauswaldt S, Knobloch JK, Rupp J and Nitschke M (2024) Do asymptomatic STEC-long-term carriers need to be isolated or decolonized? New evidence from a community case study and concepts in favor of an individualized strategy. Front. Public Health . 12:1364664. doi: 10.3389/fpubh.2024.1364664

Received: 02 January 2024; Accepted: 08 April 2024; Published: 17 April 2024.

Reviewed by:

Copyright © 2024 Sayk, Hauswaldt, Knobloch, Rupp and Nitschke. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Friedhelm Sayk, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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New EY US Consulting study: employees overwhelmingly expect empathy in the workplace, but many say it feels disingenuous

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The majority (86%) of employees believe empathetic leadership boosts morale while 87% of employees say empathy is essential to fostering an inclusive environment.

As many employees face downsizings, restructurings and a looming global recession, most say that empathic leadership is a desired attribute but feel it can be disingenuous when not paired with action, according to the 2023 Ernst & Young LLP ( EY US )  Empathy in Business Survey .

The study of more than 1,000 employed US workers examines how empathy affects leaders, employees, and operations in the workplace. The survey follows the initial EY Consulting analysis of empathy in 2021 and finds workers feel that mutual empathy between company leaders and employees leads to increased efficiency (88%), creativity (87%), job satisfaction (87%), idea sharing (86%), innovation (85%) and even company revenue (83%).

“A  transformation’s success  or failure is rooted in human emotions, and this research spotlights just how critical empathy is in leadership,” said  Raj Sharma , EY  Americas Consulting  Vice Chair. “Recent years taught us that leading with empathy is a soft and powerful trait that helps empower employers and employees to collaborate better, and ultimately create a culture of accountability.”

The evolving state of empathy in the workplace

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“Time and again we have found through our research that in order for businesses to successfully transform, they must put humans at the center with empathetic leadership to create transparency and provide employees with psychological safety,” said  Kim Billeter , EY Americas  People Advisory Services  Leader. “Empathy is a powerful force that must be embedded organically into every aspect of an organization, otherwise the inconsistency has a dramatic impact on the overall culture and authenticity of an organization.”

In fact, half (52%) of employees currently believe their company’s efforts to be empathetic toward employees are dishonest ― up from 46% in 2021, and employees increasingly report a lack of follow-through when it comes to company promises (47% compared to 42% in 2021).

To fulfill the authenticity equation, previous EY research indicates offering flexibility is essential. In the 2022 EY US Generation Survey, 92% of employees surveyed across all four workplace generations said that company culture has an impact on their decision to remain with their current  employer.

Lead with empathy  now  to combat the workplace challenges ahead

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“What happens outside of work has a direct impact on how people show up. It’s no longer enough for leaders to think of a person in one dimension – as an employee or as a professional within the organization,” said  Ginnie Carlier , EY Americas Vice Chair – Talent. “Leading with empathy helps move from the transactional and to the transformational Human Value Proposition, where people feel supported both personally and professionally.”

2023 EY Empathy in Business Survey methodology

EY US  commissioned a third-party vendor to conduct the 2023 EY Empathy in Business Survey, following the 2021 Empathy in Business Survey. The survey among 1,012 Americans who are employed, either full-time or part-time, was completed between October 23 and November 6, 2022. At the total level, the study has a margin of error of +/- 3 percentage points at the 95% confidence level.

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

1. introduction.

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

2. The persuasiveness issue

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

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

3. The lack of framework issue

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

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

4. The accessibility issue

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

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

5. Discussion

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

Author contributions

The author confirms being the sole contributor of this work and has approved it for publication.

Conflict of interest

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

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All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.