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

Kaluzeviciute, Greta

doi:10.1186/s41155-021-00175-y

Greta Kaluzeviciute Correspondence: gkaluz@essex.ac.uk

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

http://orcid.org/0000-0003-1197-177X

Correspondence: gkaluz@essex.ac.uk

Author's contributions

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

Competing interests

The authors declare that they have no competing interests.

Figures (4)
Tables (14)

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Fig. 1
Typical knowledge generation process in evidence-based practice (EBP)

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Fig. 2
Internal validity

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Fig. 3
Typical knowledge generation process in practice-based evidence (PBE)

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Fig. 4
External validity

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Fig. 3
Typical knowledge generation process in practice-based evidence (PBE)

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Fig. 4
External validity

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Table 1
Key concept: systematic case study

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Table 2
How can Case Study Evaluation-tool (CaSE) be used in psychotherapy research and practice?

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Table 3
Key concept: evidence-based practice (EBP)

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Table 4
Key concept: practice-based evidence (PBE)

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Table 5
Key concept: research appraisal tool

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Table 6
CASP (Critical Appraisal Skills Programme-tool)

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Table 7
JBI (Joanna Briggs Institute-tool)

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Table 8
ETQS (Evaluation Tool for Qualitative Studies)

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Table 9
Comparing the relevance of JBI (Joanna Briggs Institute), CASP (Critical Appraisal Skills Program) and ETQS (Evaluation Tool for Qualitative Studies) for appraising components specific to systematic case studies

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Table 10
Recommended reviewer responses to JBI (Joanna Briggs Institute), CASP (Critical Appraisal Skills Program) and ETQS (Evaluation Tool for Qualitative Studies)

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Table 11
Case Study Evaluation-tool (CaSE) checklist for essential components in systematic case studies. Recommended responses: Yes, No, unclear or not applicable

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Table 12
Key concept: purpose-based systematic case studies

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Table 13
Case Study Evaluation-tool (CaSE) purpose-based evaluative framework for systematic case studies. Recommended responses: open-ended questionnaire

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Table 14
Using Case Study Evaluation-tool (CaSE): Lunn et al. (2016)Lunn, S., Daniel, S. I. F., & Poulsen, S. (2016). Psychoanalytic psychotherapy with a client with bulimia nervosa. Psychotherapy, 53(2), 206–215. https://doi.org/10.1037/pst0000052.
https://doi.org/10.1037/pst0000052... 's case ‘Psychoanalytic psychotherapy with a client with bulimia nervosa’

Systematic case study components		JBI Evaluation Criteria	CASP Evaluation Criteria	ETQS Evaluation Criteria
Methodological components
	Case context and method	Congruity between the research methodology and the research question or objectives	Methodological screening questions: Is a qualitative methodology appropriate? Was the research design appropriate to address the aims of the research?	No assessment criteria for the suitability of the case study method
	Research participants (description of patients, therapists, researchers)	Cultural and theoretical context of the researcher; researcher's impact on the research (and vice versa); adequate patient representation	No assessment criteria for the description of researchers and data analysts	How do the authors locate the study within the existing knowledge base? What role does the researcher adopt within the setting? Are the researcher's own position, assumptions, and possible biases outlined?
	Research procedure (data collection and analysis methods)	Congruity between the research methodology and the analysis of data and interpretation of results	Was the recruitment strategy appropriate to the aims of the research? Were the data collected in a way that addressed the research issue? Was the data analysis sufficiently rigorous?	What theoretical framework guides or informs the study? What data collection methods are used to obtain and record data? How were data analysed?
Clinical components
	Case introduction	Clear description of patient demographics and current clinical condition	No assessment criteria for case description	What are the key characteristics of the sample (events, persons, times and settings)?
	Assessment of the client's problems, goals, strengths, and history (includes many data sources and methods, such as diagnostic tools and questionnaires)	Participants and their voices are clearly represented No assessment criteria for patient's clinical assessment or the use of other methods and data sources No assessment criteria for the formulation and planning of the treatment	No assessment criteria for patient's clinical assessment or the use of other methods and data sources	Within what geographical and care setting is the study carried out? Is sufficient detail given about the setting? No assessment criteria for patient's clinical assessment or the use of other methods and data sources
	Course of therapy and treatment plan	Clear description of patient's history, including a timeline of relevant events	No assessment criteria for course of treatment or progress	Over what time period is the study conducted? No assessment criteria for therapeutic progress
Theoretical components
	Clinical decision-making (includes assessment of clinical outcomes and theoretical findings)	Research conclusions flow from the analysis and interpretation of the data	Is there a clear statement of findings? (e.g. triangulation, respondent validation, more than one analyst)	Is there sufficient breadth (e.g. contrast of two or more perspective) and depth (e.g. insight into a single perspective)? What are the implications for policy and practice?
	Research limitations	No assessment criteria for research limitations	No assessment criteria for research limitations	Is there evidence of reflexivity? Is adequate evidence provided to support the analysis (validity and reliability)?
	Transferability of findings	No assessment criteria for transferability of findings	How valuable is the research? Consider the findings in relation to current practice or policy, or relevant research-based literature and how findings can be transferred to other populations or other ways in which the research may be used	To what setting and population are the study findings generalizable?

JBI evaluation responses	CASP evaluation responses	ETQS evaluation responses
Checklist:	Checklist:	Open-ended questionnaire:
Yes	Yes	Comprehensive and detailed responses in relation to the study
No	No
Unclear	Can't tell
Not applicable	Additional space for comments available

Methodology
	1. The rationale behind choosing the case study method
	2. Description of research design and aims
	3. Description of research participants, including:
		3a. Patients/clients
		3b. Therapists, clinical supervisors
		3c. Researchers/data analysts (research team)
	4. Description of research procedures, including:
		4a. Evaluation of existing literature and research
		4b. Data collection methods
		4c. Data analysis methods
		4d. Data triangulation procedures
		4e. Research appraisal tools and instruments
	5. Description of researchers’ reflexivity (awareness of the relationship between the researcher and research study), including:
		5a. Research assumptions pertaining to objectives
		5b. Research biases pertaining to data analysis
		5c. Differentiation between assumptions and views made by different researchers/therapists
	6. Description of research limitations, including:
		6a. Congruity between research data and research aims and objectives
		6b. Research appraisal and validity
	7. Relevant ethical information, including:
		7a. Patient's informed consent
		7b. Anonymisation of specific clinical material
Clinical components
	8. Description of patient's history, including:
		8a. Demographics
		8b. Cultural context
		8c. Socio-economic context
		8d. Interpersonal history (family and other relationships)
	9. Description of patient's clinical condition, including:
		9a. Current and past diagnosis (with reference to DSM, ICD and other diagnostic manuals)
		9b. Current and past symptoms and experiences
		9c. Previously received treatment
		9d. The use of medication
	10. Description of patient's problems through:
		10a. Diagnostic tools (therapist's assessment)
		10b. Self-report questionnaires (patient's self-assessment)
	11. Description of course of therapy and treatment, including:
		11a. Therapeutic modality
		11b. Therapeutic setting (number of sessions, frequency, private/public practice)
		11c. Therapeutic relationship
		11d. Timeline of relevant treatment events/sessions
		11e. Follow-up information
		11f. Treatment outcomes
		11g. Complicating factors
	12. Description of clinical decision-making and reflexivity (awareness of the relationship between the therapist and the treatment process), including:
		12a. Clinical assumptions pertaining to diagnosis
		12b. Clinical biases pertaining to therapeutic techniques and interpretations (especially in relation to therapist's therapeutic modality)
	13. Description of therapist where relevant, including:
		13a. Professional experience
		13b. Demographics
		13c. Cultural context
		13d. Socio-economic context
Theory
	14. Clear description of theoretical references and key concepts
	15. Description of how clinical decision-making relates to the chosen theoretical framework
	16. Clear statement of theoretical findings
	17. Clear description of evidence for and limitations of the chosen theoretical framework, including:
		17a. Validity (does the case study attend its research objectives and aims sufficiently? Do researchers use relevant theoretical concepts, clinical techniques and research methods?)
		17b. Reliability (does the case study provide sufficient, detailed and reflexive information on how it arrived at its findings?)
	18. Description of transferability of findings (relevance to other cases), including:
		18a. Transferability to psychotherapy research
		18b. Transferability to psychotherapy practice
		18c. Relevance to policy in private and/or public healthcare
		18d. Relevance to specific clinical population and setting

1 Representative cases (purpose: typicality)
	The studied phenomenon
		What is the studied phenomenon or ‘conceptual type’ (e.g, clinical condition, therapeutic technique, patient's symptoms)? There is generally one specific phenomenon. Is the studied phenomenon sufficiently distinguished from other kinds of (potentially similar) phenomena?
	Patient data
		Are patient characteristics relevant to the wider clinical population? (e.g. is there a good match between symptoms and experiences?) What is the rationale for choosing this patient? Does the patient present any unique or deviant characteristics? (e.g. symptoms that are not representative of the studied clinical condition)
	The clinical discourse
		Is there a detailed clinical narrative in the form of therapist reflections and observations? Does the case move from the particularity of the patient to a more general(theoretically abstract) claim about the studied phenomenon?
	Research
		Is there a sufficient review of literature on the studied phenomenon? Does the case refer to other cases and/or studies that replicate their findings?
	Case purpose
		Does the case demonstrate the typical characteristics of the studied phenomenon? Does the case provide findings relevant for the broader clinical population? Can the case contribute to psychotherapy theory?
2 Descriptive cases (purpose: particularity)
	The studied phenomenon
		What phenomena are studied in the case (e.g. clinical condition, therapeutic technique, patient's symptoms)? There can be multiple phenomena. Does the case present events and processes common to clinical practice? (e.g. therapeutic relationship difficulties)
	Patient data
		Are patient characteristics described in detail, with particular attention to uniqueness, subjectivity and meaning of “lived experiences”? Does the case narrative convey interpersonally sharable statements, ruminations, metaphors? Is the patient clearly positioned within their cultural and psycho-social context?
	The clinical discourse
		Does the case convey the process behind therapist's practical decisions in the consulting room? Does the case provide ‘know-how’ knowledge on how practitioners can deal with clinically salient issues and situations? Does the therapist provide a reflexive account on how their views and theoretical assumptions might impact the therapeutic relationship and clinical decision-making?
	Research
		Does the case include patient's self-assessment? (e.g. through self-report measures and dialogic exchange) Does the case include excerpts of dialogue between therapist and patient?
	Case purpose
		Does the case provide a relational understanding (with which readers can empathise) of the studied phenomenon? Does the case narrative sufficiently portray ‘real analytic practice’ rather than ‘ideal models’? (e.g. by demonstrating disparity between clinical theory/research and practice) Can the case contribute to psychotherapy training and practice?
3 Unique cases (purpose: deviation)
	The studied phenomenon
		What phenomena are studied in the case (e.g. clinical condition, therapeutic technique, patient's symptoms)? There can be multiple phenomena. Does the case explain how the studied phenomena are different or unique from the established theory/research? (e.g. the patient's experience of transference is different from the experiences of transference across a broader clinical population)
	Patient data
		Are patient characteristics described in detail, with particular attention to uniqueness, subjectivity and meaning of “lived experiences”? What is the rationale for choosing this patient?
	The clinical discourse
		Does the case convey a detailed description of therapeutic interventions and their effectiveness? Does the therapist provide a reflexive account on how their views and theoretical assumptions might impact clinical decision-making, particularly in terms of their understanding of the uniqueness/deviation in the case? Does the case include sufficient considerations as to the cause of the deviation/uniqueness in patient's clinical condition or symptoms?
	Research
		Does the case convey more than one theoretical and/or research perspective? (e.g. clinical assessment by multiple practitioners or data analysis by multiple researchers) Are there considerations of alternative explanations to the observed deviation/uniqueness of the case? (e.g. by referring to other published case studies or research)
	Case purpose
		Does the case provide insight into a novel phenomenon? (e.g. by describing unique patient symptoms or experiences) Does the case provide novel theoretical knowledge in relation to unique/deviant phenomenon? (E.g., by developing a new therapeutic technique) Can the case contribute to psychotherapy theory, training and/or practice?
4 Critical cases (purpose: falsification/confirmation)
	The studied phenomenon
		What is the studied phenomenon in the case (e.g. clinical condition, therapeutic technique, patient's symptoms)? There is generally one specific phenomenon. Does the case seek to test an existing theory/research about the studied phenomenon? (e.g. testing the effectiveness of a well-established therapeutic intervention)
	Patient data
		Are patient characteristics described in detail? Is the patient clearly outlined within their cultural and psycho-social context? What is the rationale for choosing this patient?
	The clinical discourse
		Does the case link therapist narrative and observations with the theoretical/research considerations? Does the case convey a detailed description of therapeutic interventions and their effectiveness?
	Research
		Does the case convey more than one theoreticaland/or research perspective? (e.g. clinical assessment by multiple practitioners or data analysis by multiple researchers) Does the case show how the theory/research that is being tested accounts for the clinical observations in the case? Does the case provide a sufficient explanation on why their chosen theory/research is more appropriate than another? If the case falsifies an existing theory/research, are there sufficient sample considerations? (e.g. the case may be unique and therefore the original theory/research still stands)
	Case purpose
		Does the case examine an existing theory/research successfully? (e.g. by showing whether a theory is effective with a specific patient) If the case falsifies an existing theory/research, does it offer any novel suggestions or revisions to the falsified theory/research? If the case confirms an existing theory/research, does it rule out alternative explanations for the tested hypothesis? (e.g. to show that a therapeutic intervention is effective, the positive effects of other variables like medication may need to be ruled out)
5 Exploratory cases (purpose: hypothesis generation)
	The studied phenomenon
		What phenomena are studied in the case (e.g. clinical condition, therapeutic technique, patient's symptoms)? There can be multiple phenomena. Is the case discovery-led, in the sense that it explores data as it emerges?
		Does the case contain new hypotheses about the studied phenomena?
	Patient data
		Are patient characteristics described in detail? Is the patient clearly outlined within their cultural and psycho-social context?
	The clinical discourse
		Does the case link therapist narrative and observations with the theoretical/research considerations? Does the case narrative explore the ‘how’ and ‘what’ questions in relation to patient experiences and treatment processes? Does the case identify complex processes and mechanisms in the treatment and link them to theory?
	Research
		Is there a sufficient review of literature of the studied phenomenon? Does the case convey more than one theoretical and/or research perspective? (e.g. clinical assessment by multiple practitioners or data analysis by multiple researchers) Does the data converge? Are different/conflicting findings reported?
	Case purpose
		Does the case convey more than one set of outcomes? Does the case indicate future research trajectories? Can the case contribute to psychotherapy theory, training and/or practice?
6 Transferable cases (purpose: generalisability)
	The studied phenomenon
		What is studied phenomenon (e.g. clinical condition, therapeutic technique, patient's symptoms)? There is generally one specific phenomenon. Is the studied phenomenon explicitly defined and differentiated from other kinds of (potentially similar) phenomena?
	Patient data
		Are patient characteristics described in detail? Is the patient clearly outlined within their cultural and psycho-social context? Does the patient present characteristics typical of the studied phenomenon? Is there sufficient information (clinical, theoretical) to link the patient with the studied phenomenon?
	The clinical discourse
		Is there a detailed clinical narrative in the form of therapist reflections and observations? Does the case shed light on specific characteristics of the therapeutic process? (e.g. the development of therapeutic alliance) Is the case narrative theme-focused? (e.g. the case identifies specific treatment patterns across different sessions) Is there a clear description of the therapeutic process, usually involving a session-by-session description?
	Research
		Is there a sufficient review of literature on the studied phenomenon? Does the case involve a specific therapeutic, theoretical and research framework, and is the framework made explicit by the researchers? Is there a clear description of the research process? (e.g. step-by-step description of data analysis procedures)
	Case purpose
		Does the case provide information about common or specific psychotherapy processes? Can the case be compared to and aggregated with other psychotherapy case studies on the basis of its studied phenomenon and formulation?

Type of case	The studied phenomenon	Patient data	The clinical discourse	Research	Case purpose
Critical	The studied phenomenon is identified as the treatment of bulimia nervosa. The case tests the need of adapting therapeutic approaches to individual patients on the basis of their specific therapeutic needs and goals rather than providing manualised therapy across the entire clinical population.	A patient was selected from an RCT trial where cognitive behavioural therapy (CBT) was found, on average, more effective than psychoanalytic psychotherapy (PP). However, this patient's symptoms and context indicated that she may benefit from techniques and principles common to PP, which is why she was chosen for this case study. The case involves a lengthy patient description, including previous diagnosis of anorexia nervosa, binge and purge episodes, early object relations, and childhood-rooted trauma. The case provides substantial information on patient's psychological context and demographics but does not contain cultural information (this may have been deemed not relevant).	The case contains a detailed description of therapeutic interventions, such as therapeutic containment, reflection, and acknowledgement of unconscious, split-off, or disavowed aspects of patient's experiences. Therapist observations and clinical decision-making are informed by the theoretical PP principles, particularly in terms of affirming and interpreting patient's experiences. The effectiveness of therapeutic interventions is described as highly positive: patient has stopped binging and purging and was able to develop a closer relationship with her family.	Several theoretical and research perspectives are explored in order to tailor the most suitable approach for the patient, including attachment styles, mentalization and integrative approaches. One of the authors acted as a therapist, while the two other authors were involved in data analysis; this improved the data triangulation process. Several hypothetical assumptions were made about therapeutic setting and relationship and their suitability for this patient; they are shown to be highly effective and helpful later in the case (e.g. non-directive PP therapy was experienced as more helpful by the patient than directive CBT therapy).	The case demonstrates that insight-oriented, nondirective PP can yield significant successes for patients with bulimia nervosa who also display low reflective functioning and insecure attachments. This case is an important critical follow-up to larger RCT study, which by and large favoured CBT to PP for patients with eating disorders.

[1] Correspondence: gkaluz@essex.ac.uk

Brasil

Brasil

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

Abstract