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Theory-building case studies of counselling and psychotherapy. Counselling and Psychotherapy Research, 7, 122-127



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.
Theory-building case studies of counselling and psychotherapy
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:
Counselling and Psychotherapy Research
, June 2007; 7(2): 122 127
1473-3145 (print)/1746-1405 (online) 2007 British Association for Counselling and Psychotherapy
DOI: 10.1080/14733140701356742
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
a whole.
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
the theory
(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
interested readers.
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
borrowed from:
. 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
the case
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
in Psychotherapy
(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
those interpretations.
. 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
your conclusion.
. 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
to researchers.
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
first place.
Be persistent
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
future practice.
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
and Psychotherapy.
Brinegar, M. G., Salvi, L. M., Stiles, W. B., & Greenberg, L. S. (2006).
Building a meaning bridge: Therapeutic progress from problem
formulation to understanding.
Journal of Counseling Psychology
, 165 180.
Campbell, D. T. (1979). ‘‘Degrees of freedom’’ and the case study.
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(pp. 49 67).
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related fields.
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, 215
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(2005). The assimilation of anger in a case of dissociative identity
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, 121 132.
Osatuke, K., Glick, M. J., Stiles, W. B., Greenberg, L. S., Shapiro, D.
A., & Barkham, M. (2005). Temporal patterns of improvement in
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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
,3 15.
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
research handbook
(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.
Journal of
Counseling Psychology
, 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-
ing Psychology
, 223 233.
Client perceptions of significant treatment events
Llewelyn, S. P. (1988). Psychological therapy as viewed by clients
and therapists.
British Journal of Clinical Psychology
, 223
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),
Qualitative psychotherapy
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 Quarterly
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
is an
online journal that specialises in case studies (see 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
... In this qualitative, theory-building case study (Stiles, 2007), we focused on Hargaden and Sills's (2002) concept of empathic transactions (ETs) as therapeutic interventions. After summarizing the theory of ETs, we introduce the assimilation model (Stiles, 2011), which describes how clients change during successful therapy. ...
... If not, the theory needs to be modified. Qualitative theory-building case studies seek to evaluate and strengthen the theory by examining many aspects of the theory in a particular case rather than testing one hypothesis across many cases (Stiles, 2007(Stiles, , 2017. Although objectivity may be an inappropriate standard for qualitative observations, theory-building qualitative research aims to support its inferences with observable qualitative evidence (e.g., transcripts), and it seeks a shared understanding of the chosen theory. ...
... A theory-building case study is not meant to be generalized. Instead, the generality is provided by the theory (in this case, both ET theory and the assimilation model), and the study serves to increase confidence in the theory (Stiles, 2007(Stiles, , 2017. Any one case study can address only parts of a clinical theory, and the increment in confidence from the Clara case, or any case, is modest. ...
This theory-building case study examined the relational transactional analysis concept of empathic transactions (ETs) developed by Hargaden and Sills. The researchers analyzed the transactions between a 28-year-old woman and her therapist during their 26-session therapy. Client progress was assessed using the Assimilation of Problematic Experiences Sequence (APES) as well as standard symptom intensity inventories. Results were largely consistent with theoretical accounts offered by the concept of ETs in facilitating psychological change. All of the ETs were employed, but five of the ETs—inquiry, confrontation, specification, illustration, and explanation—were particularly useful in this case. Results also pointed to aspects of the theories that need refinement or modification. For example, the sequencing of ETs suggested by Hargaden and Sills was not uniformly confirmed.
... The present study is the first to examine the dynamic bidirectional relationships between mentalization techniques (i.e., therapists' overall adherence to attention control, emotion regulation, and explicit mentalization interventions) and TA in psychodynamic child psychotherapy. An evidence-based case study approach (Stiles, 2007) was adopted by selecting two psychodynamic child therapy cases with different outcomes: a good outcome case that showed significant clinical improvement in symptoms as well as psychosocial functioning and level of mentalization, and a case that showed less improvement in symptoms and no improvement in mentalization. Following Stiles (2007) guidelines on systematic case reports, This document is copyrighted by the American Psychological Association or one of its allied publishers. ...
... An evidence-based case study approach (Stiles, 2007) was adopted by selecting two psychodynamic child therapy cases with different outcomes: a good outcome case that showed significant clinical improvement in symptoms as well as psychosocial functioning and level of mentalization, and a case that showed less improvement in symptoms and no improvement in mentalization. Following Stiles (2007) guidelines on systematic case reports, This document is copyrighted by the American Psychological Association or one of its allied publishers. ...
... Theory-oriented case studies (Stiles, 2007;McLeod, 2013) were used as a supplementary source of information. The case studies were five to ten DIN A4 pages and followed a pre-defined structure. ...
... Interviews 14-16 were deconstructed into meaning units and assigned to categories. Following Stiles (2007Stiles ( , 2009, the meaning units from the case studies were then assigned to the existing categories. In the third phase, memos were used to draw out relationships between the EXPERIENCES TREATING OLDER PEOPLE IN NEED OF CARE 15 categories and formulate higher-order categories called clusters. ...
This study used qualitative methods to explore psychotherapists’ experiences conducting athome psychotherapy with older adults (60+ years) with long-term care needs and depression. We conducted semi-structured interviews with 16 female psychotherapists (26-70 years old) who delivered at-home cognitive behavioral therapy to home-living older adults with longterm care needs and depression. We additionally conducted 10 patient case studies. Using an adaption of the methodology of grounded theory, we iteratively developed a hierarchical model. Results showed that psychotherapists experienced three dilemmas: (1) pushing for change versus acknowledging limitations, (2) providing help versus maintaining boundaries, and (3) being a guest in the patient’s home versus the host of a psychotherapy session. The absence of a shared understanding of therapy and confrontation with patients’ existential suffering intensified the experience of the dilemmas. The dilemmas generated professional self-doubt and negative emotions, which in turn triggered a reflexive process and ultimately participants’ professional development. Participants found a way to integrate drives initially perceived as mutually exclusive, and further developed their professional self-image and therapeutic techniques. We interpret the dilemmas as reflecting difficulty reconciling the “curing” and “caring” treatment paradigms. Practice and support managing the three dilemmas along with reflection on the curing paradigm, views on old age, and fear of existential suffering should be part of qualifications for psychotherapists working with older adults in need of care. Cooperating with other care providers may relieve the pressure on psychotherapists to provide forms of support that could lead to overburden and impede therapeutic progress.
... The two research hypotheses that guided the five research projects were the following: The integrative group intervention i. will increase the postintervention CAAS total and subscale scores of the participants, and ii. will decrease their postintervention scores on the CDDQ. Like Cardoso et al. (2019), I took my cue from Stiles' (2007) notion of theory-building case studies. Stiles (2007) proposes that researchers should draw on related case studies to develop further 'general' theory (and practice) by examining and building on the idiosyncratic characteristics of each case individually and all cases collectively. ...
... Like Cardoso et al. (2019), I took my cue from Stiles' (2007) notion of theory-building case studies. Stiles (2007) proposes that researchers should draw on related case studies to develop further 'general' theory (and practice) by examining and building on the idiosyncratic characteristics of each case individually and all cases collectively. Even research that yields null or 'negative' outcomes tells an important story. ...
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This article reviews the outcomes of five purposely selected group career construction research projects conducted in a developing country context. Thematic data analysis was done on the results of these projects to identify qualitatively the strengths and areas for development (weaknesses) of the approach followed in these projects. The findings demonstrated the value of career constructing in contexts that differed substantially from the context in which the career construction counselling was originally developed. Overall, the quantitative findings in regard to career adaptability revealed that the women benefited more from the intervention than the men. The findings in regard to career decision-making difficulties also uncovered gender differences. The qualitative outcomes revealed that the participants’ psychological self as an autobiographical author benefited more from the intervention than either the social actor or the motivated agent. Future research should focus on the application of group career construction counselling with larger groups, using instruments based on career construction counselling theory developed locally. Moreover, given current developments (including the impact of the Covid-19 pandemic on employment), special emphasis should be placed on research among the unemployed. Keywords: psychological self, integrative group career construction, Global South, unemployment
... For this, I draw on the findings of a qualitative study that explores the nature of experiences of loneliness and solitude (Motta and Larkin 2022) The study follows a growing tradition of phenomenology engaging with qualitative research. In line with what Stiles proposes (Stiles 2007) 1 the study was planned as theory-building qualitative research. In contrast to methods that are hypothesis-testing, which are limited to the confirmation or rejection of a specific statement, exploratory qualitative research can contribute to the very construction and development of a theory. ...
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Loneliness is more complex and multi-faceted than it may appear at first glance. Most of the characterizations that we have of loneliness in the extant literature tend to focus on the absence of other people and on the social, mental, and physical distress that can be caused by this type of absence. Although the experience of absence may be a fundamental and encompassing aspect of loneliness, loneliness may also reflect a deeper, more complex experience. This paper integrates data from a qualitative study on the phenomenology of loneliness with philosophical theories on the self. It argues that there is a connection between the experience of absence and the impossibility to appear in the world and that this may consequentially lead to the disruption of self-experience.
... Theory-building case study research offers the opportunity to examine valuable moments in therapeutic practice and use these observations to further understand and refine both theory and future practice (Stiles, 2007). This study aims to illuminate the in-session transformation of emotions for the individuals and the restructuring of the interactional cycle for the couple in order to demonstrate how this case aligns with the EFT theory. ...
Emotion-focused therapy for couples (EFT-C) is therapy which has a substantial evidence base both for process and outcome studies. However, to date there have been no in-depth empirical case studies that track interactional and emotional transformation in the couple, minute-to-minute, across the entire course of therapy. This case study aimed to observe the interactional transformation and emotional transformation in a couple over 11 sessions of EFT-C therapy. Videos of each session were analyzed using theoretically informed qualitative psychotherapy research. Results showed clients presenting with a negative interactional pattern, which appeared to be composed of two separate but linked cycles. Over the course of treatment, the clients presented with secondary emotions and behaviors including criticism and withdrawal. The individuals within the couple progressed at different rates through the expression of core pain and unmet needs, and after several sessions they were able to give and receive compassion to each other. They also showed signs of beginning to self-soothe more effectively and let go of some pain. The expression of assertive or healthy anger was found to be particularly important for the change in their interaction. Strengths, limitations and ideas for future research are discussed.
... However, Cronbach does not clearly define what a working hypothesis case study is. We will follow the work of Stiles (2003Stiles ( , 2007, Mahrer (1988), and Edelson (1985Edelson ( , 1986 on theory testing case studies in order to define a working hypothesis case study more clearly. In the context of this paper, case studies that propose important new distinctions, discoveries or revisions to existing theories are called working hypothesis case studies. ...
In the fields of psychoanalysis and psychotherapy, case study researchers rarely justify their knowledge claims on formal epistemological grounds. This poses several issues to the case study method. First, without articulating the standards by which our knowledge is being justified, we are potentially enabling the criticism that case studies are mere anecdotal reports and should not be treated as forms of evidence. Second, without the guidance of wider epistemological standards for case study research, we risk falling into arbitrary justifications of other as well as our own case studies. This paper seeks to address these issues by examining and developing epistemic practices in psychoanalytic and psychotherapy case studies. Drawing from different social science resources, the paper describes three epistemological concepts appropriate for case study research: retroductive reasoning, analytic generalization and working hypothesis. The paper demonstrates how each epistemological concept can be used in psychotherapy research and explicates specific methodological guidelines. Social science definitions and principles are applied in a psychotherapy and/or psychoanalytic research context, and further considerations about canons of evidence are provided. The impetus of this paper is to strengthen qualitative research standards, particularly case study research standards, in clinical case study writing.
... Empirical case study research has a rich tradition in the humanistic-experiential paradigm (see Elliott, 2002a;McLeod, 2010;Stiles, 2007). The previous edition of this chapter reviewed case studies establishing efficacy of a HEP therapy as well as theory-building case studies. ...
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We review recent research on humanistic-experiential psychotherapies (HEPs), which include person-centered therapy (PCT), emotion-focused therapy (EFT), gestalt, and psychodrama approaches, along with generic relationship control conditions characterized as supportive or nondirective. A key part of this review is a meta-analysis of 91 studies of the effectiveness/efficacy of HEPs, published between 2009 and 2018, which produced the following results: (1) HEPs were associated with large pre-post client change (d = .86). (2) In controlled studies, clients in HEPs generally showed large gains relative to clients who received no therapy (.88). (3) In comparative outcome studies, HEPs in general were statistically and clinically equivalent in effectiveness to other therapies (-.08). (4) Overall, CBT appeared to have an equivocal advantage over HEPs (-.26). However, these studies were overwhelmingly delivered by CBT researchers in largely non-bona fide versions of HEPs as comparison conditions. Overall, the strongest results were found for EFT, followed by PCT; generic supportive-nondirective approaches were least effective, especially when compared to CBT. HEPs appeared to be most effective with relationship/interpersonal difficulties, self-damaging activities, coping with chronic medical conditions, and psychosis. Findings were more mixed for depression and anxiety. In addition, we offer an updated meta-synthesis of the qualitative outcomes of these therapies, which fell into three main categories: appreciating experiences of self; appreciating experience of self in relationship to others; and changed view of self/others. We also provide narrative reviews of recent qualitative research on helpful and unhelpful factors in HEPs, along with quantitative process-outcome research on HEPs including process-outcome research and work on mediating processes. In an integrative summary we identify a core set of interwoven client change processes involving emotional expression, deepening and transformation, the emergence of new client narratives, and the assimilation of problematic experiences. We conclude with a set of recommendations for research, practice and mental health guideline development. Humanistic-Experiential Psychotherapies Update, p. 2 Content Outline
Generalised anxiety disorder (GAD) is a highly prevalent, chronic and impairing disorder. The aim of this study was to qualitatively describe the transformation in emotional processing across 16 sessions of a successful emotion‐focused therapy (EFT) treatment for GAD. A theoretical framework derived from the EFT model of in‐session emotional transformation proposed by Pascual‐Leone and Greenberg was used as the basis for qualitative analysis. Additionally, the Classification of Affective Meaning States, the Client‐Expressed Arousal Scale‐III and the Client Emotional Productivity Scale‐Revised were utilised by observer–raters to classify moment‐by‐moment shifts in client affective‐meaning states, emotional arousal and emotional productivity. Results supported the emotion transformation model. The client presented in a state of poorly differentiated but highly aroused distress provoked by identifiable interpersonal and intrapersonal triggers. Emotional and behavioural avoidance provoked by fear of pain was evident. Accessing core pain and responding to attendant needs with compassion and protective anger was shown to facilitate the higher order emotional processing states of grief, relief and agency. Implications are proposed, including that addressing core emotional vulnerability may be a critical intervention in the successful treatment of GAD.
Social anxiety disorder (SAD) is characterized by marked and persistent fear in social situations in which one may be exposed and/or anticipates being exposed to external evaluation and in which embarrassment/humiliation may occur. Acceptance and Commitment Therapy (ACT) has been showing promising results in several disorders, including adult SAD. Considering this evidence and given that adolescence is typically the age of onset for SAD, we developed the ACT@TeenSAD, which is a manualized approach to adolescent SAD delivered via videoconference. It encompasses 10 weekly, 90-minute sessions targeting core pathological processes and fostering higher levels of psychological flexibility; it also includes two booster sessions. The current work illustrates the case conceptualization and therapeutic trajectory of a 17-year-old adolescent (Josie; pseudonym) with a 5-year history of SAD that underwent the ACT@TeenSAD. During the course of the intervention, Josie found purpose and learned life skills to cope with adversity, especially in socially relevant situations. This aligns with the pre- to post-intervention progress shown by Josie (using the Reliable Change Index), particularly in measures assessing acceptance, psychological inflexibility, and self-reported social anxiety. Josie’s case study gives preliminary evidence of the acceptability and feasibility of the ACT@TeenSAD, making it a helpful tool for therapists to become familiarized with. The current work also discusses the limitations of the intervention and presents practical challenges and suggestions thought to be useful for therapists.
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Psychotherapy's equivalence paradox refers to clients achieving similar degrees of overall improvement in different treatment approaches, despite the non-equivalent processes. The current intensive qualitative study described and compared how different processes brought about their respective outcomes in one case of client-centred therapy (CCT) and one of cognitive-behaviour therapy (CBT). The assimilation model of psychotherapeutic change was used to compare processes of change and patterns of improvement in these two demographically and diagnostically similar clients, who had equally favourable outcomes on post-treatment measures. We applied the method of assimilation analysis to both therapies, and compared the assimilation account of client change with the theoretical models used in the two treatments.
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This article reviews the development of the CORE‐OM and CORE System from 1995 to 2005 in the context of the need to measure, monitor, and manage the delivery of counselling and the psychological therapies in service of providing best quality care for clients. The origins and philosophy of these tools are summarised and practical aspects of how to use them in routine service settings are set out, including an easy to use look‐up table of differing ways of presenting CORE‐OM scores and their associated meaning. The wider family of CORE outcome measures is briefly outlined to show the relationship between the various versions and how each is designed for a specific purpose. These outcome tools are set within the broader context of the CORE System. In turn, the CORE‐OM and CORE System are placed within the paradigm of practice‐based evidence and examples are provided of how these tools have been applied in routine as well as more traditional evaluative settings. The aim of the present article is two‐fold. The first aim is to provide a background to the origins and development of the CORE‐OM and its role as part of the broader‐based CORE System during the period 1995 to 2005. The second aim is to consider the applications of both the CORE‐OM and CORE System within the context of the developing paradigm of practice‐based evidence up to 2005.
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The assimilation model considers personality as a community of voices, each representing the traces of past experiences. Problematic voices are kept separate by painful emotion, but they may be gradually assimilated into the community in successful psychotherapy. People with dissociative identity disorder may be considered as having multiple subcommunities of voices. For Kristen, a nineteen-year-old therapy client diagnosed with dissociative identity disorder, the process of assimilation proceeded in at least two ways. Assimilation appeared to occur via negotiation among Kristen's various subcommunities (alters). It also occurred simultaneously through dialogue between the discrepant voices within each of the subcommunities. In this paper, Kristen's and her primary alter's changing experiences of anger over a 36 month period of therapy were identified, tracked and discussed using the assimilation model.
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Present stages of development and preliminary validation of a self-report instrument for measuring the quality of alliance, the Working Alliance Inventory (WAI). The measure is based on Bordin's (1980) pantheoretical, tripartite (bonds, goals, and tasks) conceptualizaton of the alliance. Results from 3 studies were used to investigate the instrument's reliability and validity and the relations among the WAI scales. Data suggest that the WAI has adequate reliability. The instrument is reliably correlated with a variety of counselor and client self-reported outcome measures. Nontrivial relations were also observed between the WAI and other relationship indicators. Results are interpreted as preliminary support for the validity of the instrument. Although the results obtained in the reviewed studies are encouraging, the high correlations between the 3 subscales of the inventory bring into question the distinctness of the alliance components. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Clients' evaluations of their sessions were prominent in factor-based indexes of session impact derived from the Session Evaluation Questionnaire (SEQ) and the Session Impacts Scale (SIS) in a large sample ( N = 2,414 sessions with 218 clients). One or both of the SEQ's independent session evaluation indexes, Depth and Smoothness, were highly correlated with SEQ's postsession Positivity and Good Therapist indexes and with the SIS's Understanding, Problem Solving, and Relationship indexes, as well as with single-item global evaluation scales, Good–Bad and Helpful–Hindering. Only the SEQ's postsession Arousal index and the SIS's single-item Unwanted Thoughts index appeared to be primarily descriptive rather than evaluative. The SIS's Hindering Impacts index's items were endorsed infrequently but might usefully flag problematic sessions. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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IntroductionWhy Is Qualitative Research Necessary?What Is Qualitative Research?Good Practice and Permeability in Qualitative ResearchTypes of ValidityTruth and Theory in Qualitative ResearchAlternative Discourse FormsConcluding CommentsAcknowledgmentsReferences