Theory-building case studies of counselling and psychotherapy
WILLIAM B. STILES
Miami University, Ohio, USA
In addition to their potential for healing, psychotherapy and counselling offer extraordinary opportunities to observe human
experience and behaviour. I suggest practitioners have expertise in and daily access to the phenomena that theories of
counselling and psychotherapy seek to explain. Practitioners’ clinical experience can be accumulated and shared through
theory-building case study research
. This article summarizes the logic of theory-building case studies and offers practical
suggestions for conducting case study research.
Case studies, theory-building, research methods
Anyone who has practiced psychotherapy or counsel-
ling realises that, in addition to its potential for
healing, it is an extraordinary opportunity to observe
human experience and behaviour. Practitioners reg-
ularly see aspects of people that others seldom or
never see. They gain new and useful understandings
about human feeling, thinking, communication and
relationships that can improve theory and practice.
Many practitioners feel they lack the expertise or
resources to conduct research. Research stereotypes
suggest it requires laboratories, large numbers of
participants and sophistication in measurement and
statistics. I disagree. I suggest that practitioners have
expertise in and daily access to precisely the sorts of
phenomena that theories of counselling and psy-
chotherapy seek to explain. This paper describes one
way in which practitioners’ clinical experience can be
accumulated and shared through publication. I call it
theory-building case study research.
Theory is important
Theories are ideas about the world conveyed in
words, numbers, diagrams or other signs. My main
interest here is in the theories that practitioners use in
treating clients, such as person-centred, psychoana-
lytic, cognitive-behavioural and gestalt theories, along
with many others. Each of these offers a set of
assumptions and principles about the nature and
sources of psychological problems, and about ap-
proaches and interventions to address them. These
principles are the intellectual tools that guide practi-
tioners’ day-to-day and minute-to-minute clinical
Theories need work
Theories of counselling and psychotherapy don’t
provide complete descriptions of or exact specifica-
tions for moment-to-moment interventions. Practi-
tioners who use them have to interpret what is
happening and adapt what they do to emerging
circumstances, the state of the client and the relation-
ship (Stiles et al., 1998). Some practitioners identify
themselves with one theory, but many amend or
combine theories at least some of the time. Rather
than adhering to a pure version of what they have
read, they are privately engaging in theory building.
And this is precisely my point! These clinicians have
made empirical observations on relevant case material
that have led to modifications or elaborations of
theory. Their observations could be incorporated into
the explicit theory to improve others’ understanding.
If your best practice requires you to amend a theory or
combine theories, you may have something to con-
Unique features of cases can inform theory
The theories we build in counselling and psychother-
apy are meant to encompass more than is ever
encountered in a single case. Each case includes
details not shared with other cases, and a good
clinical theory helps practitioners understand them.
Turning this around, unique features of cases can
show where theories need to grow. Unlike statistical
Correspondence: Department of Psychology, Miami University, Oxford, OH 45056, USA. E-mail: firstname.lastname@example.org
Counselling and Psychotherapy Research
, June 2007; 7(2): 122 127
1473-3145 (print)/1746-1405 (online) – 2007 British Association for Counselling and Psychotherapy
hypothesis testing, where unique features are often
regarded as error, case studies can use them to inform
theory (Rosenwald, 1988; Stiles, 2005).
I think this point is the one made by the parable of
the blind men and the elephant. The man who felt its
side said the elephant was like a wall; the man who
felt its tusk, like a spear; the man who felt its trunk,
like a snake; and so forth. Each inference was
different, but all were at least partly justified and all
described the same animal. Although the blind men in
the parable failed to listen to each other, the point is
that the elephant (i.e., counselling and psychother-
apy) has many aspects.
An adequate theory has to incorporate the distinct
features of each case as well as the common features.
If you restrict yourself to the themes that are common
across cases, you will overlook the most interesting
parts. Each case tells us something new, and new
observations are always valuable, whether they con-
firm previous theory or add something unexpected.
Research provides quality control on theory
The researcher’s task is to make systematic observa-
tions and describe them in ways that are accurate and
relevant to the theory. The goal is for theory to
correspond to observation and practice to describe
the world accurately. If the theoretical description and
the clinical observation don’t match, then something
needs adjusting. Either the observations were some-
how misleading or inaccurately described, or the
theory needs to be modified.
So, the researcher’s task is to make and check
observations (and re-check observations) and, when
necessary, adjust the theory so that it corresponds
better with the observations. In this process, failures
are as important as successes. Observations that show
where the theory doesn’t work can be as scientifically
important as observations that show where the
theory does work.
Hypothesis testing versus case study
Both hypothesis testing and case study research can
be used to build theories, and both can provide
scientific quality control on theory. In contrast to
hypothesis testing, however, case studies address
many theoretical issues in the same study rather
than focusing on only one or a few.
The familiar statistical hypothesis testing strategy is
to derive one statement from a theory and compare
that statement with many observations. That is, we
test a hypothesis by seeing if it holds across cases. If
the observations tend to correspond to the statement,
then people’s confidence in the statement is substan-
tially increased. We say the hypothesis was confirmed,
or at least that the null hypothesis was rejected. This
yields a small increment of confidence in the theory as
The case study strategy is to compare each of many
theoretically-based statements with one or a few
observations. This is achieved by describing the case in
theoretical terms. Each case is different and may
address different aspects of theory. At issue is the
correspondence of theory and observation how
well the theory describes details of the case. Because
each detail may be observed only once, the change in
confidence in any one theoretical statement is small.
However, there are lots of details, and each can be
described in theoretical terms. Because many state-
ments are examined, the gain in confidence in the
theory may be as large as that from a statistical
hypothesis testing study (Campbell, 1979). The key is
multiple points of contact between the case and the
theory; this is accomplished through rich case descrip-
tions and detailed links between theory and case
Observations permeate theories
In any scientific research, observations change the-
ories. They may confirm or disconfirm or strengthen
or weaken the theory. More constructively, the
changes may involve extending, elaborating, refining,
modifying or qualifying the theory. Theoretical ideas
change to fit the observations.
To describe how observations change theories, I like
to say that the observations
(Stiles, 1993, 2003). This is a diffusion metaphor; I
picture particles of observation spreading through the
theoretical interstices. Aspects of the new observa-
tions actually enter and become part of the theory.
For example, the theory may be explained differently,
using words that accommodate the new observations
along with the previous ones. Or the new observa-
tions may be used as illustrations.
Through research, then, observations accumulate
in theories. New observations permeate the theory
while earlier thinking and results are retained. The
diffusion metaphor offers an alternative to the brick
wall metaphor for how science is cumulative. That
is, understanding grows not by stacking fact upon
fact, but by infusing observations that expand the
Thus, a theory is not a fixed formula but a growing
and changing way of understanding. This is a flexible
view of theory from the perspective of theorists who
may change it or practitioners who must adapt it,
rather than from the perspective of students who
have to read and memorise a static version of what
other people have said.
How to do theory-building case studies
If I have convinced you to consider adding your clinical
observations to building a theory, how would you go
about it? There is no single correct method for doing
case studies. If the procedures were fully prescribed,
the activity would be a laboratory exercise, not
research. The point of any research is to find new
ways to examine an idea, new ways to make
observations that check the accuracy of a theory. In
Theory-building case studies
this section, I do not give step-by-step instructions but
instead advance some broad considerations and
Familiarity with the theory and courage to change it
For your new observations to permeate a theory, you
need to know the theory. You must be able to put
your observations in the context of what has gone
before. You must know what is new and what
converges with others’ observations. What are the
logical implications of making the changes you want
to make? What aspects of the theory do your clinical
observations agree or disagree with? Thus, you need
to do background reading about the theory and
previous research on the theory. Online search facil-
ities now make this possible for anyone, although
access to a university library helps. Authors of journal
articles are usually happy to send free copies to
In addition to familiarity with the theory and
research, you will need the courage to change the
theory and make adjustments in light of your own
observations. You must be confident and brave
enough to comment on which aspects of the theory
seem to fit your observations and which must be
amended. Simultaneously, however, you must be
humble enough to accept the possibility that your
own observations and thinking are mistaken.
Selecting a case
Good cases are ones that have taught you something
new, interesting or theoretically relevant. On the
other hand, probably every case can teach something,
although you may not know what it will teach until
you have finished the study. In contrast to statistical
hypothesis testing studies, case studies do not require
representative sampling. An unusual case can be as
informative as a typical case (if any case is typical). The
main requirement is to be explicit in your report about
your reasons for deciding to write about a particular
Rich case record
A prerequisite for a case study of a counselling or
psychotherapy client is a rich collection of information
about the client and the treatment. Elliott (2002) has
provided a valuable list of such sources, which I have
. Basic facts about client and practitioner: includ-
ing demographic information, diagnoses, pre-
senting problems and treatment approach or
. Recordings of treatment sessions: verbatim tran-
scriptions of audio or video recordings are a
particularly strong source for grounding your
inferences. Practitioners’ process notes may also
be useful, although these have been filtered
through the practitioner’s attention and memory
and so may be considered less trustworthy.
. Session-by-session assessments: repeated mea-
surement of the client’s problems, goals and
symptoms, together with evaluations of sessions
and the strength of the client practitioner
relationship can help track process and progress.
In Appendix 1, I list a few of the many available
. Outcome assessments: treatment outcome has
both descriptive qualitative (how the client
changed) and quantitative (how much the client
changed) aspects, and measures of both are
helpful. In addition to sources listed in Appendix
1, see the information sheet on outcome mea-
surement by Roth (2006).
. Post-treatment interviews: sometimes clients can
be interviewed after they have finished treat-
ment, to gather their impressions.
. Other personal documents can be useful: for
example, personal journals or diaries, poetry,
artwork, letters or e-mail messages.
There are no firm rules about what information must
be used. Useful studies may sometimes be based on
only one or a few of the sources listed here. The point
of a rich case record is to permit multiple links to
theory, facilitate trustworthy inferences and provide a
source of evidence for presentation to your readers.
Analysing case study materials
There are many ways to go about qualitative analysis
of case materials, but it may be useful to think of the
work in three phases:
. Gaining familiarity: this includes listening to or
watching recordings, reading transcripts and
reviewing other available materials. Typically,
researchers review case materials many times,
perhaps taking different perspectives or asking
different questions and making notes about the
case and their thoughts. There is value in system-
atically attending to each item (e.g., each
passage in a transcript) and temporarily suspend-
ing judgment about whether it is important.
. Selecting and focusing: the goal of this phase is
to decide what the focus of the study will be. It
also includes selecting materials (e.g., passages
in a transcript) that are relevant to the focal
theoretical topic or theme.
. Interpreting: this conceptual analysis phase re-
quires explicit linking of observations to theore-
tical concepts and ideas, and making sense of
what has happened in terms of the theory.
Much research in counselling and psychotherapy is
collaborative. If you do not already have colleagues
interested in case study research, it may be worth
looking for others who can help, perhaps some with
relevant research experience or access to university or
W. B. Stiles
online library facilities. It is valuable some would say
essential to involve multiple people in observing and
reporting. Each can independently read transcripts,
listen to recordings and generally become familiar
with case materials. Having more than one person
considering the material can inject new ideas into
your understanding of the case and smooth the rough
edges of your interpretations. Consensus among
multiple observers can help make the product more
convincing to others. It may also be more fun to have
Apply the case to the theory rather than the theory to
Theory-building case studies are meant to change the
theory, not just to provide an understanding of the
case. Of course, applying the theory to the case is an
essential first step in theory-building seeing how the
theory corresponds to the new observations. But
investigators then must turn the observations back
on the theory in order to improve it. This is a major
difference between clinical case studies and theory-
building case studies. This is why investigators must
have familiarity with the theory and the confidence to
modify it to extend its scope, to change its
expression and so forth.
I think many case studies miss this distinction. They
may adhere to previous theory and ignore observa-
tions that fail to fit. They may cite authority rather
than observation what Freud thought, for example,
rather than what actually happened.
Of course, a respectful attitude towards theory has
a place in clinical applications. We often fail to
appreciate phenomena the theories point to, so
crediting the theory or esteemed theorists above our
own initial impressions may open us to things we had
overlooked. However, case studies that merely apply
theories, without putting them at risk of alteration, do
not make a scientific contribution.
How to report theory-building case studies
A first step in learning to report case studies is to
see how others have done it. In Appendix 2, I list
some journals that publish case studies in counsel-
ling and psychotherapy. For some recent case
studies that I’ve been involved in, building a
developmental theory of psychological change that
we call the assimilation model, see Brinegar et al.
(2006), Humphreys et al. (2005), Osatuke et al.
(2005) and Stiles et al. (2006).
Some writing tips
In this section, I list a few suggestions for writing
journal articles about theory-building case studies. For
another list, see the instructions to authors on the
website of the online journal
Pragmatic Case Studies
(URL listed in Appendix 2).
. Pick the one or two most interesting things you
have learned from the case and write about
those. Do not attempt to say everything you
know about the case.
. Begin with the main point of the study, stating
the main theoretical topic, the fact that it is a
theory-building case study and a phrase about
the nature of the case.
. Very early in the Introduction, summarise the
relevant parts of the theory (not the whole
theory!). Incorporate (and explain that you are
incorporating) any changes you have made to
the theory as a result of this case study. The point
of this Introduction is quickly to provide your
readers with the best possible conceptual frame-
work for understanding what you did and what
you observed, including your additions to the
framework. Do not make readers start back
where you started.
. Selectively review other research about your
main topic, linking what others have said with
your current understanding. How would you
explain their observations?
. Depending on the journal you intend to submit
your report to, you may need to explain briefly
what is meant by a theory-building case study.
. At the end of the Introduction, summarise the
purpose and design of your study and your
reasons for writing about this case.
. In the Method section, describe the client, the
therapist, the treatment, the co-investigators
(including yourself), any measures you used and
your procedures (including how you gathered
the data and how you and your co-investigators
dealt with the material and came to your
interpretations), in that order.
. Case studies require particular sensitivity to
ethical issues of anonymity and informed con-
sent (see discussion of research ethics by Bond,
2004). This can be briefly described in your
description of the client or the procedure.
. In the Results section, the central goal is to link
observations with theoretical concepts. Make
multiple points of contact between observation
and theory! Clinical theories are rich and de-
tailed, and the case material should be compared
to the theory in many ways, not just in one way.
Interpretations the theoretical points you
make should be grounded in observations.
This can be accomplished by presenting verbatim
passages from sessions or interviews or other
sorts of records. Show readers why you made
. In reporting results, state your theoretical inter-
pretation first and then describe the evidence
that led you to it. For example, state the
conceptual conclusion of your paragraph in the
initial sentence. Begin each section with the main
point of that section. Do not ask readers to keep
all the pieces of evidence in mind, waiting until
Theory-building case studies
the end of the paragraph or the section to learn
. In your Discussion, focus on the theoretical
contribution what you have learned, how
you have supported or changed the theory.
Acknowledge limitations. Note that criteria
for evaluating qualitative work are somewhat
different from criteria for evaluating statistical
hypothesis testing studies (e.g., Elliott et al.,
1999; Stiles, 1993, 2003).
Case studies don’t yield conclusions: Generality is
carried by the theory
As discussed earlier, a case study cannot yield much
confidence in any one sentence. Another way to say
this is: case studies do not yield one-sentence
conclusions. By the same token, case studies typically
do not test hypotheses or answer simple research
questions. Hypotheses and questions narrow the
study to a single statement, and case studies typically
don’t change confidence in single statements very
This lack of hypotheses and conclusions can make
case studies profoundly puzzling to people used to
hypothesis testing research. There is no one-sentence
generalisation that captures your results. When some-
one asks what you found, there is no sentence to
summarise it. You may have to explain how to
generalise from case study research when you talk
In theory-building case studies, the only way to
generalise is through the theory. The theory typically
includes a description of what it applies to. To the
extent that the theory has a logical structure,
observations on one part of the theory affect other
parts of the theory too. If the theory does a good job
explaining the many details of your case, this lends
confidence that it will explain other people’s cases as
well. Observations on different cases and different
aspects of cases strengthen the whole theory
because the theory states how different aspects of
counselling and psychotherapy are related to each
other. Logical internal consistency and generality are
some of the main reasons for having a theory in the
Persistence is essential for successful scholarly pub-
lication. If you are offered a chance to revise and
resubmit, do so. If one journal rejects your manu-
script, consider revising and submitting it to another
journal. If you are not experienced in journal publica-
tion, take the editor’s letter to a more experienced
colleague and ask for an interpretation. Take the
revisions seriously. Consider reviewers as representa-
tive readers; if they did not understand what you
meant, then many other readers won’t either. If you
want to be understood (and why else would you be
writing?), then criticism is just what you need. As you
revise, prepare a cover letter than describes what you
have done. If you do not agree with some of the
suggestions, then use the cover letter to explain your
reasons (but don’t send the letter until you have made
all of the revisions you feel you can make).
Theories are tools that practitioners use and that can
be improved by practitioners’ observations. Practi-
tioners of counselling and psychotherapy routinely
witness people’s pain, struggle, courage and joy in a
depth and detail rarely possible in psychological
laboratories or daily life. Theory-building case study
research, I think, offers a way in which these rich and
valuable observations, and the understandings they
engender, can be accumulated and shared to improve
I thank Carol Humphreys, James Mosher, Katerine
Osatuke, Darren Del Castillo, Jonathan Fishman,
Jacob Goldsmith, Corrine Hoener and Hugo Shielke
for comments on drafts of this article.
Bond, T. (2004).
Ethical guidelines for researching counselling and
. Rugby, UK: British Association for Counselling
Brinegar, M. G., Salvi, L. M., Stiles, W. B., & Greenberg, L. S. (2006).
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(2005). The assimilation of anger in a case of dissociative identity
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Appendix 1: Standard measures of session
impact, alliance, symptoms and outcome
Symptoms and outcome
Barkham, M., Mellor-Clark, J., Connell, J. & Cahill, J. (2006). A core
approach to practice-based evidence: A brief history of the
origins and applications of the CORE-OM and CORE system.
Counselling and Psychotherapy Research
Lambert, M. J., Morton, J. J., Hatﬁeld, D., Harmon, C., Hamilton, S.,
Reid, R. C. et al. (2004).
Administration and scoring manual for
the Outcome Questionnaire (OQ-45.2).
Orem, UT: American
Professional Credentialing Services.
Individualised measure of target complaints
Phillips, J. P. N. (1986). Shapiro Personal Questionnaire and
generalized personal questionnaire techniques: A repeated
measures individualized outcome measurement. In L. S. Green-
berg & W. M. Pinsof (Eds),
The psychotherapeutic process: A
(pp. 557 589). New York: Guilford.
Evaluation of session impact
Elliott, R. & Wexler, M. M. (1994). Measuring the impact of
treatment sessions: The Session Impacts Scale.
, 166 174.
Stiles, W. B., Reynolds, S., Hardy, G. E., Rees, A., Barkham, M. &
Shapiro, D. A. (1994). Evaluation and description of psychother-
apy sessions by clients using the Session Evaluation Questionnaire
and the Session Impacts Scale.
Journal of Counseling Psychology
, 175 185.
The client practitioner relationship or alliance
Agnew-Davies, R., Stiles, W. B., Hardy, G. E., Barkham, M. &
Shapiro, D. A. (1998). Alliance structure assessed by the Agnew
Relationship Measure (ARM).
British Journal of Clinical Psychol-
, 155 172.
Horvath, A. O. & Greenberg, L. S. (1989). Development and
validation of the Working Alliance Inventory.
Journal of Counsel-
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Client perceptions of significant treatment events
Llewelyn, S. P. (1988). Psychological therapy as viewed by clients
British Journal of Clinical Psychology
Change process interview protocol
Elliott, R., Slatick, E. & Urman, M. (2001). Qualitative change
process research on psychotherapy: Alternative strategies. In J.
Frommer & D. L. Rennie (Eds),
research: Methods and methodology
(pp. 69 111). Lengerich,
Germany: Pabst Science Publishers.
Appendix 2: Journals that publish case
Where should you submit your case study manu-
script? One journal to consider is the BACP research
Counselling and Psychotherapy Research.
Other possible outlets include the following (the
case studies published in these journals are not
exclusively theory-building case studies):
tered and Experiential Psychotherapies
Psychology and Psychotherapy:
Theory, Research, and Practice
Journal of Clinical Psychology: In Session
special issues that include five or six case studies
dealing with a common topic.
Pragmatic Case Studies in Psychotherapy
online journal that specialises in case studies (see
http://pcsp.libraries.rutgers.edu/index.php). It is fo-
cused mainly on accumulating a database of cases
with standard information, however, rather than on
theory-building. The instructions for authors are
particularly thorough (see http://pcsp.libraries.rutgers.
Theory-building case studies