psychological case study conclusion

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What Is a Case Study?

Weighing the pros and cons of this method of research

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

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

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

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

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

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

At a Glance

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

What Are the Benefits and Limitations of Case Studies?

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

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

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

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

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

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

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

Case Study Examples

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

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

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

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

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

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

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

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

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

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

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

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

Section 1: A Case History

This section will have the following structure and content:

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

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

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

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

Section 2: Treatment Plan

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

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

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

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

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

Need More Tips?

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

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

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

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

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

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

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

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How to write the conclusion of your case study

You worked on an amazing UX project. You documented every detail and deliverable and when the time came, you began to write a UX case study about it. In the case study, you highlighted how you worked through a Design Thinking process to get to the end result; so, can you stop there and now move on to the next thing? Well, no! There’s just one more bit left to finish up and make the perfect case study. So, get ready; we will now explore how you can write the perfect conclusion to wrap it all up and leave a lasting great impression.

Every start has an end – we’re not just repeating the famous quote here, because for case studies, a proper end is your last and final chance to leave a lasting great (at the very least, good) impression with whoever is reading your work (typically, recruiters!). Many junior UX designers often forget about the conclusion part of the case study, but this is a costly mistake to make. A well-written case study must end with an appropriate final section, in which you should summarize the key takeaways that you want others to remember about you and your work. Let’s see why.

Last impressions are just as important as first ones

We’ll go to some length here to convince you about the importance of last impressions, especially as we can understand the reason behind not wanting to pay very much attention to the end of your case study, after all the hard work you put into writing the process section. You are tired, and anyone who’s read your work should already have a good idea about your skills, anyway. Surely—you could be forgiven for thinking, at least—all that awesome material you put in the start and middle sections must have built up the momentum to take your work into orbit and make the recruiter’s last impression of you a lasting—and very good—one, and all you need to do now is take your leave. However, psychologist Saul McLeod (2008) explains how early work by experimental psychology pioneers Atkinson & Shriffin (1968) demonstrated that when humans are presented with information, they tend to remember the first and last elements and are more likely to forget the middle ones.

This is known as the “ serial position effect ” (more technically, the tendency to remember the first elements is known as the “ primacy effect ”, while the tendency to remember the last elements is known as the “ recency effect ”). Further work in human experiences discovered that the last few things we see or hear at the end of an experience can generate the most powerful memories that come back to us when we come across a situation or when we think about it. For example, let’s say you stayed in a hotel room that left a bit to be desired. Maybe the room was a little cramped, or the towels were not so soft. But if the receptionist, as you leave, shakes your hand warmly, smiles and thanks you sincerely for your custom, and goes out of his way to help you with your luggage, or to get you a taxi, you will remember that person’s kind demeanor more than you will remember the fact that the room facilities could be improved.

A good ending to your case study can help people forget some of the not-so-good points about your case study middle. For example, if you missed out a few crucial details but can demonstrate some truly interesting takeaways, they can always just ask you about these in an interview. Inversely, a bad ending leaves the recruiter with some doubt that will linger. Did this person learn nothing interesting from all this work? Did their work have no impact at all? Did they even write the case study themselves? A bad last impression can certainly undo much of the hard work you’ve put into writing the complicated middle part of your case study.

What to put in your case study conclusions

A case study ending is your opportunity to bring some closure to the story that you are writing. So, you can use it to mention the status of the project (e.g., is it ongoing or has it ended?) and then to demonstrate the impact that your work has had. By presenting some quantifiable results (e.g., data from end evaluations, analytics, key performance indicators ), you can demonstrate this impact. You can also discuss what you learned from this project, making you wiser than the next applicant – for example, something about a special category of users that the company might be interested in developing products for, or something that is cutting-edge and that advances the frontiers of science or practice.

As you can see, there are a few good ways in which you can end your case study. Next, we will outline four options that can be part of your ending: lessons learned, the impact of the project, reflections, and acknowledgements.

Lessons learned

A recruiter wants to see how you improve yourself by learning from the projects you work on. You can discuss interesting insights that you learned from user research or the evaluation of your designs – for example, surprising behaviors that you found out about the technology use in a group of users who are not typically considered to be big proponents of technology (e.g., older adults), or, perhaps, the reasons a particular design pattern didn’t work as well as expected under the context of your project.

Another thing you can discuss is your opinion on what the most difficult challenge of the project was, and comment on how you managed to overcome it. You can also discuss here things that you found out about yourself as a professional – for example, that you enjoyed taking on a UX role that you didn’t have previous experience with, or that you were able to overcome some personal limitations or build on your existing skills in a new way.

Impact of the project

Showing impact is always good. How did you measure the impact of your work? By using analytics, evaluation results, and even testimonials from your customers or users, or even your development or marketing team, you can demonstrate that your methodical approach to work brought about some positive change. Use before-after comparison data to demonstrate the extent of your impact. Verbatim positive quotes from your users or other project stakeholders are worth their weight (or rather, sentence length) in gold. Don’t go overboard, but mix and match the best evidence for the quality of your work to keep the end section brief and to the point.

Copyright holder: Andreas Komninos, Interaction Design Foundation. Copyright terms and license: CC BY-SA 3.0

User reviews from app stores are a great source of obtaining testimonials to include in your case studies. Overall app ratings and download volumes are also great bits of information to show impact.

An excerpt from a case study ending section. Here, text and accompanying charts are used to demonstrate the impact of the work done by the UX professional.

Reflections on your experiences

You can include some information that shows you have a clear understanding of how further work can build on the success of what you’ve already done. This demonstrates forward thinking and exploratory desire. Something else you can reflect on is your choices during the project. In every project, there might be things you could do differently or improve upon. But be aware that the natural question that follows such statements is this: “Well, so why haven’t you done it?”

Don’t shoot yourself in the foot by listing all the things you wish you could have done, but focus on what you’ve actually done and lay out future directions. For example, if you’ve done the user research in an ongoing project, don’t say, “ After all this user research, it would have been great to progress to a prototype, but it’s not yet done ”; instead, say, “ This user research is now enabling developers to quickly progress to the prototyping stage. ”

Acknowledgments

The end of the case study section is where you should put in your acknowledgments to any other members of your team, if this wasn’t a personal project. Your goal by doing so is to highlight your team spirit and humility in recognizing that great projects are most typically the result of collaboration . Be careful here, because it’s easy to make the waters muddy by not being explicit about what YOU did. So, for example, don’t write something like “ I couldn’t have done it without John X. and Jane Y. ”, but instead say this: “ My user research and prototype design fed into the development work carried out by John X. User testing was carried out by Jane Y., whose findings informed further re-design that I did on the prototypes. ”

What is a good length for a UX case study ending?

UX case studies must be kept short, and, when considering the length of your beginning, process and conclusion sections, it’s the beginning and the conclusion sections that should be the shortest of all. In some case studies, you can keep the ending to two or three short phrases. Other, longer case studies about more complex projects may require a slightly longer section.

Remember, though, that the end section is your chance for a last, short but impactful impression. If the hotel receptionist from our early example started to say goodbye and then went on and on to ask you about your experience, sharing with you the comments of other clients, or started talking to you about where you are going next, and why, and maybe if he had been there himself, started to tell you all about where to go and what to see, well… you get the point. Keep it short, sincere and focused. And certainly, don’t try to make the project sound more important than it was. Recruiters are not stupid – they’ve been there and done that, so they know.

Putting it all together

In the example below, we will show how you can address the points above using text. We are going to focus on the three main questions here, so you can see an example of this in action, for a longer case study.

An example ending section for a longer case study, addressing all aspects: Lessons, impact, reflection and acknowledgments.

Here is how we might structure the text for a shorter version of the same case study, focusing on the bare essentials:

An example ending section for a shorter case study, addressing the most critical aspects: Lessons, impact and reflection. Acknowledgments are being sacrificed for the sake of brevity here, but perhaps that’s OK – you might mention it in the middle part of the case study.

The Take Away

The end part of your case study needs as much care and attention as the rest of it does. You shouldn’t neglect it just because it’s the last thing in the case study. It’s not hard work if you know the basics, and here, we’ve given you the pointers you need to ensure that you don’t miss out anything important. The end part of the case study should leave your recruiters with a good (hopefully, very good) last impression of you and your work, so give it the thorough consideration it needs, to ensure it doesn’t undo all the hard work you’ve put into the case study.

References & Where to Learn More

Copyright holder: Andrew Hurley, Flickr. Copyright terms and license: CC BY-SA 2.0

Atkinson, R. C., & Shiffrin, R. M. (1968). Chapter: Human memory : A proposed system and its control processes. In Spence, K. W., & Spence, J. T. The psychology of learning and motivation (Volume 2). New York: Academic Press. pp. 89–195.

McLeod, S. (2008). Serial Position Effect

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How to Write a Psychology Case Study: Expert Tips

Have you ever heard of Phineas Gage, a man whose life story became a legendary case study in the annals of psychology? In the mid-19th century, Gage, a railroad construction foreman, survived a near-fatal accident when an iron rod pierced through his skull, severely damaging his brain. What makes this tale truly remarkable is that, despite his physical recovery, Gage's personality underwent a dramatic transformation. He went from being a mild-mannered and responsible individual to becoming impulsive and unpredictable. This remarkable case marked the dawn of psychology's fascination with understanding the intricate workings of the human mind. Case studies, like the one of Phineas Gage, have been a cornerstone of our understanding of human behavior ever since.

Short Description

In this article, we'll unravel the secrets of case study psychology as the powerful tool of this field. We will explore its essence and why these investigations are so crucial in understanding human behavior. Discover the various types of case studies, gain insights from real-world examples, and uncover the essential steps and expert tips on how to craft your very own compelling study. Get ready to embark on a comprehensive exploration of this invaluable research method.

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Our team of skilled psychologists and wordsmiths is here to craft a masterpiece from your ideas.

What Is a Case Study in Psychology

A case study psychology definition can be compared to a magnifying glass turned toward a single individual, group, or phenomenon. According to our paper writer , it's a focused investigation that delves deep into the unique complexities of a particular subject. Rather than sifting through mountains of data, a case study allows us to zoom in and scrutinize the details, uncovering the 'whys' and 'hows' that often remain hidden in broader research.

A psychology case study is not about generalizations or sweeping theories; it's about the intricacies of real-life situations. It's the detective work of the field, aiming to unveil the 'story behind the data' and offering profound insights into human behavior, emotions, and experiences. So, while psychology as a whole may study the forest, a case study takes you on a journey through the trees, revealing the unique patterns, quirks, and secrets that make each one distinct.

The Significance of Psychology Case Studies

Writing a psychology case study plays a pivotal role in the world of research and understanding the human mind. Here's why they are so crucial, according to our ' do my essay ' experts:

• In-Depth Exploration: Case studies provide an opportunity to explore complex human behaviors and experiences in great detail. By diving deep into a specific case, researchers can uncover nuances that might be overlooked in broader studies.
• Unique Perspectives: Every individual and situation is unique, and case studies allow us to capture this diversity. They offer a chance to highlight the idiosyncrasies that make people who they are and situations what they are.
• Theory Testing: Case studies are a way to test and refine psychological theories in real-world scenarios. They provide practical insights that can validate or challenge existing hypotheses.
• Practical Applications: The knowledge gained from case studies can be applied to various fields, from clinical psychology to education and business. It helps professionals make informed decisions and develop effective interventions.
• Holistic Understanding: Case studies often involve a comprehensive examination of an individual's life or a particular phenomenon. This holistic approach contributes to a more profound comprehension of human behavior and the factors that influence it.

Varieties of a Psychology Case Study

When considering how to write a psychology case study, you should remember that it is a diverse field, and so are the case studies conducted within it. Let's explore the different types from our ' write my research paper ' experts:

• Descriptive Case Studies: These focus on providing a detailed description of a particular case or phenomenon. They serve as a foundation for further research and can be valuable in generating hypotheses.
• Exploratory Case Studies: Exploratory studies aim to investigate novel or scarcely explored areas within psychology. They often pave the way for more in-depth research by generating new questions and ideas.
• Explanatory Case Studies: These delve into the 'why' and 'how' of a particular case, seeking to explain the underlying factors or mechanisms that drive a particular behavior or event.
• Instrumental Case Studies: In these cases, the individual or situation under examination is instrumental in testing or illustrating a particular theory or concept in psychology.
• Intrinsic Case Studies: Contrary to instrumental case studies, intrinsic ones explore a case for its own unique significance, aiming to understand the specific details and intricacies of that case without primarily serving as a tool to test broader theories.
• Collective Case Studies: These studies involve the examination of multiple cases to identify common patterns or differences. They are helpful when researchers seek to generalize findings across a group.
• Longitudinal Case Studies: Longitudinal studies track a case over an extended period, allowing researchers to observe changes and developments over time.
• Cross-Sectional Case Studies: In contrast, cross-sectional case studies involve the examination of a case at a single point in time, offering a snapshot of that particular moment.

The Advantages of Psychology Case Studies

Learning how to write a case study offers numerous benefits, making it a valuable research method in the field. Here are some of the advantages:

• Rich Insights: Case studies provide in-depth insights into individual behavior and experiences, allowing researchers to uncover unique patterns, motivations, and complexities.
• Holistic Understanding: By examining a case in its entirety, researchers can gain a comprehensive understanding of the factors that influence human behavior, including psychological, environmental, and contextual aspects.
• Theory Development: Case studies contribute to theory development by providing real-world examples that can validate or refine existing psychological theories.
• Personalized Approach: Researchers can tailor their methods to fit the specific case, making it a flexible approach that can adapt to the unique characteristics of the subject.
• Application in Practice: The knowledge gained from case studies can be applied in various practical settings, such as clinical psychology, education, and organizational management, to develop more effective interventions and solutions.
• Real-World Relevance: Psychology case studies often address real-life issues, making the findings relevant and applicable to everyday situations.
• Qualitative Data: They generate qualitative data, which can be rich in detail and context, offering a deeper understanding of the subject matter.
• Hypothesis Generation: Case studies can spark new research questions and hypotheses, guiding further investigations in psychology.
• Ethical Considerations: In some cases, case studies can be conducted in situations where experimental research may not be ethical, providing valuable insights that would otherwise be inaccessible.
• Educational Value: Case studies are commonly used as teaching tools, helping students apply theoretical knowledge to practical scenarios and encouraging critical thinking.

How to Write a Psychology Case Study

Crafting a psychology case study requires a meticulous approach that combines the art of storytelling with the precision of scientific analysis. In this section, we'll provide you with a step-by-step guide on how to create an engaging and informative psychology case study, from selecting the right subject to presenting your findings effectively.

Step 1: Gathering Information for Subject Profiling

To create a comprehensive psychology case study, the first crucial step is gathering all the necessary information to build a detailed profile of your subject. This profile forms the backbone of your study, offering a deeper understanding of the individual or situation you're examining.

According to our case study writing service , you should begin by collecting a range of data, including personal history, demographics, behavioral observations, and any relevant documentation. Interviews, surveys, and direct observations are common methods to gather this information. Ensure that the data you collect is relevant to the specific aspects of the subject's life or behavior that you intend to investigate.

By meticulously gathering and organizing this data, you'll lay the foundation for a robust case study that not only informs your readers but also provides the context needed to make meaningful observations and draw insightful conclusions.

Step 2: Selecting a Case Study Method

Once you have gathered all the essential information about your subject, the next step in crafting a psychology case study is to choose the most appropriate case study method. The method you select will determine how you approach the analysis and presentation of your findings. Here are some common case study methods to consider:

• Single-Subject Case Study: This method focuses on a single individual or a particular event, offering a detailed examination of that subject's experiences and behaviors.
• Comparative Case Study: In this approach, you analyze two or more cases to draw comparisons or contrasts, revealing patterns or differences among them.
• Longitudinal Case Study: A longitudinal study involves tracking a subject or group over an extended period, observing changes and developments over time.
• Cross-Sectional Case Study: This method involves analyzing subjects at a specific point in time, offering a snapshot of their current state.
• Exploratory Case Study: Exploratory studies are ideal for investigating new or underexplored areas within psychology.
• Explanatory Case Study: If your goal is to uncover the underlying factors and mechanisms behind a specific behavior or phenomenon, the explanatory case study is a suitable choice.

Step 3: Gathering Background Information on the Subject

In the process of learning how to write a psychology case study, it's essential to delve into the subject's background to build a complete and meaningful narrative. The background information serves as a crucial context for understanding the individual or situation under investigation.

To gather this information effectively:

• Personal History: Explore the subject's life history, including their upbringing, family background, education, and career path. These details provide insights into their development and experiences.
• Demographics: Collect demographic data, such as age, gender, and cultural background, as part of your data collection process. These factors can be influential in understanding behavior and experiences.
• Relevant Events: Identify any significant life events, experiences, or transitions that might have had an impact on the subject's psychology and behavior.
• Psychological Factors: Assess the subject's psychological profile, including personality traits, cognitive abilities, and emotional well-being, if applicable.
• Social and Environmental Factors: Consider the subject's social and environmental context, including relationships, living conditions, and cultural influences.

Step 4: Detailing the Subject's Challenges

While writing a psychology case study, it is crucial to provide a thorough description of the subject's symptoms or the challenges they are facing. This step allows you to dive deeper into the specific issues that are the focus of your study, providing clarity and context for your readers.

To effectively describe the subject's symptoms or challenges, consider the following from our psychology essay writing service :

• Symptomatology: Enumerate the symptoms, behaviors, or conditions that the subject is experiencing. This could include emotional states, cognitive patterns, or any psychological distress.
• Onset and Duration: Specify when the symptoms or challenges began and how long they have persisted. This timeline can offer insights into the progression of the issue.
• Impact: Discuss the impact of these symptoms on the subject's daily life, relationships, and overall well-being. Consider their functional impairment and how it relates to the observed issues.
• Relevant Diagnoses: If applicable, mention any psychological or psychiatric diagnoses that have been made in relation to the subject's symptoms. This information can shed light on the clinical context of the case.

Step 5: Analyzing Data and Establishing a Diagnosis

Once you have gathered all the necessary information and described the subject's symptoms or challenges, the next critical step is to analyze the data and, if applicable, establish a diagnosis.

To effectively analyze the data and potentially make a diagnosis:

• Data Synthesis: Organize and synthesize the collected data, bringing together all the relevant information in a coherent and structured manner.
• Pattern Recognition: Identify patterns, themes, and connections within the data. Look for recurring behaviors, triggers, or factors that might contribute to the observed symptoms or challenges.
• Comparison with Diagnostic Criteria: If the study involves diagnosing a psychological condition, compare the subject's symptoms and experiences with established diagnostic criteria, such as those found in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
• Professional Consultation: It is advisable to consult with qualified professionals, such as clinical psychologists or psychiatrists, to ensure that the diagnosis, if applicable, is accurate and well-informed.
• Thorough Assessment: Ensure a comprehensive evaluation of the data, considering all possible factors and nuances before reaching any conclusions.

Step 6: Choosing an Intervention Strategy

Choosing an appropriate intervention approach is a pivotal phase in case study psychology, especially if your subject's case involves therapeutic considerations. Here's how to navigate this step effectively:

• Review Findings: Revisit the data and analysis you've conducted to gain a comprehensive understanding of the subject's symptoms, challenges, and needs.
• Consultation: If you're not a qualified mental health professional, it's advisable to consult with experts in the field, such as clinical psychologists or psychiatrists. They can offer valuable insights and recommendations for treatment.
• Tailored Approach: Select a treatment approach that is tailored to the subject's specific needs and diagnosis, if applicable. This could involve psychotherapy, medication, lifestyle changes, or a combination of interventions.
• Goal Setting: Clearly define the goals and objectives of the chosen treatment approach. What do you hope to achieve, and how will progress be measured?
• Informed Consent: If the subject is involved in the decision-making process, ensure they provide informed consent and are fully aware of the chosen treatment's details, potential benefits, and risks.
• Implementation and Monitoring: Once the treatment plan is established, put it into action and closely monitor the subject's progress. Make necessary adjustments based on their responses and evolving needs.
• Ethical Considerations: Be mindful of ethical standards and maintain the subject's confidentiality and well-being throughout the treatment process.

Step 7: Explaining Treatment Objectives and Procedures

In the final phases of your psychology case study, it's essential to provide a clear and detailed description of the treatment goals and processes that have been implemented. This step ensures that your readers understand the therapeutic journey and its intended outcomes.

Here's how to effectively describe treatment goals and processes:

• Specific Goals: Outline the specific goals of the chosen treatment approach. What are you aiming to achieve in terms of the subject's well-being, symptom reduction, or overall improvement?
• Interventions: Describe the therapeutic interventions that have been employed, including psychotherapeutic techniques, medications, or other strategies. Explain how these interventions are intended to address the subject's challenges.
• Timelines: Specify the expected timeline for achieving treatment goals. This may include short-term and long-term objectives, as well as milestones for assessing progress.
• Monitoring and Evaluation: Discuss the methods used to monitor and evaluate the subject's response to treatment. How are you measuring progress or setbacks, and how frequently are assessments conducted?
• Adjustments: Explain how the treatment plan is adaptable as you would in a persuasive essay . If modifications to the goals or interventions are required, clarify the decision-making process for making such adjustments.
• Collaboration: If relevant, highlight any collaboration with other professionals involved in the subject's care, emphasizing a multidisciplinary approach for comprehensive treatment.
• Patient Involvement: If the subject is actively engaged in their treatment, detail their role, responsibilities, and any tools or resources provided to support their participation.

Step 8: Crafting the Discussion and Concluding Remarks

In the final phase of your psychology case study, the discussion section is where you interpret the findings, reflect on the significance of your study, and offer insights into the broader implications of the case. Here's how to effectively write this section:

• Interpretation: Begin by interpreting the data and analysis you've presented in your case study. What do the findings reveal about the subject's psychology, behavior, or experiences?
• Relevance to Research Questions: Discuss how your findings align with or deviate from the initial research questions or hypotheses you set out to investigate.
• Comparison with Literature: Compare your findings with existing literature and research in the field of psychology. Highlight any consistencies or disparities and explain their significance.
• Clinical Considerations: If your case study has clinical or practical relevance, address the implications for therapeutic approaches, interventions, or clinical practices.
• Generalizability: Evaluate the extent to which the insights from your case study can be generalized to a broader population or other similar cases.
• Strengths and Limitations: Be candid about the strengths and limitations of your case study. Acknowledge any constraints or biases and explain how they might have influenced the results.
• Future Research Directions: Suggest areas for future research or additional case studies that could build on your findings and deepen our understanding of the subject matter.
• Conclusion: Summarize the key takeaways from your case study and provide a concise conclusion that encapsulates the main findings and their significance.

5 Helpful Tips for Crafting a Psychology Case Study

Much like learning how to write a synthesis essay , writing a compelling case study involves careful planning and attention to detail. Here are some essential guidelines to help you in the process:

• Consider Cultural Sensitivity: Recognize the importance of cultural diversity and sensitivity in your case study. Take into account the cultural background of your subject and its potential impact on their behavior and experiences.
• Use Clear Citations: Properly cite all sources, including previous research, theories, and relevant literature. Accurate citations lend credibility to your case study and acknowledge the work of others.
• Engage in Peer Discussion: Engage in discussions with peers or colleagues in the field throughout the case study process. Collaborative brainstorming and sharing insights can lead to a more well-rounded study.
• Be Mindful of Ethics: Continuously monitor and reassess the ethical considerations of your case study, especially when it involves sensitive topics or individuals. Prioritize the well-being and rights of your participants.
• Practice Patience and Persistence: Case studies can be time-consuming and may encounter setbacks. Exercise patience and persistence to ensure the quality and comprehensiveness of your research.

Case Study Psychology Example

In this psychology case study example, we delve into a compelling story that serves as a window into the fascinating realm of psychological research, offering valuable insights and practical applications.

Final Outlook

As we conclude this comprehensive writing guide on how to write a psychology case study, remember that every case holds a unique story waiting to be unraveled. The art of crafting a compelling case study lies in your hands, offering a window into the intricate world of the human mind. We encourage you to embark on your own investigative journeys, armed with the knowledge and skills acquired here, to contribute to the ever-evolving landscape of psychology.

Ready to Unravel the Mysteries of the Human Mind?

Our team of psychologists and researchers is adept at transforming complex concepts into engaging stories, ensuring that when you request us to ' write my case study for me ,' your unique vision is effectively brought to life.

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Understanding Case Study Method in Research: A Comprehensive Guide

Table of Contents

Have you ever wondered how researchers uncover the nuanced layers of individual experiences or the intricate workings of a particular event? One of the keys to unlocking these mysteries lies in the qualitative research focusing on a single subject in its real-life context.">case study method , a research strategy that might seem straightforward at first glance but is rich with complexity and insightful potential. Let’s dive into the world of case studies and discover why they are such a valuable tool in the arsenal of research methods.

What is a Case Study Method?

At its core, the case study method is a form of qualitative research that involves an in-depth, detailed examination of a single subject, such as an individual, group, organization, event, or phenomenon. It’s a method favored when the boundaries between phenomenon and context are not clearly evident, and where multiple sources of data are used to illuminate the case from various perspectives. This method’s strength lies in its ability to provide a comprehensive understanding of the case in its real-life context.

Historical Context and Evolution of Case Studies

Case studies have been around for centuries, with their roots in medical and psychological research. Over time, their application has spread to disciplines like sociology, anthropology, business, and education. The evolution of this method has been marked by a growing appreciation for qualitative data and the rich, contextual insights it can provide, which quantitative methods may overlook.

Characteristics of Case Study Research

What sets the case study method apart are its distinct characteristics:

• Intensive Examination: It provides a deep understanding of the case in question, considering the complexity and uniqueness of each case.
• Contextual Analysis: The researcher studies the case within its real-life context, recognizing that the context can significantly influence the phenomenon.
• Multiple Data Sources: Case studies often utilize various data sources like interviews, observations, documents, and reports, which provide multiple perspectives on the subject.
• Participant’s Perspective: This method often focuses on the perspectives of the participants within the case, giving voice to those directly involved.

Types of Case Studies

There are different types of case studies, each suited for specific research objectives:

• Exploratory: These are conducted before large-scale research projects to help identify questions, select measurement constructs, and develop hypotheses.
• Descriptive: These involve a detailed, in-depth description of the case, without attempting to determine cause and effect.
• Explanatory: These are used to investigate cause-and-effect relationships and understand underlying principles of certain phenomena.
• Intrinsic: This type is focused on the case itself because the case presents an unusual or unique issue.
• Instrumental: Here, the case is secondary to understanding a broader issue or phenomenon.
• Collective: These involve studying a group of cases collectively or comparably to understand a phenomenon, population, or general condition.

The Process of Conducting a Case Study

Conducting a case study involves several well-defined steps:

• Defining Your Case: What or who will you study? Define the case and ensure it aligns with your research objectives.
• Selecting Participants: If studying people, careful selection is crucial to ensure they fit the case criteria and can provide the necessary insights.
• Data Collection: Gather information through various methods like interviews, observations, and reviewing documents.
• Data Analysis: Analyze the collected data to identify patterns, themes, and insights related to your research question.
• Reporting Findings: Present your findings in a way that communicates the complexity and richness of the case study, often through narrative.

Case Studies in Practice: Real-world Examples

Case studies are not just academic exercises; they have practical applications in every field. For instance, in business, they can explore consumer behavior or organizational strategies. In psychology, they can provide detailed insight into individual behaviors or conditions. Education often uses case studies to explore teaching methods or learning difficulties.

Advantages of Case Study Research

While the case study method has its critics, it offers several undeniable advantages:

• Rich, Detailed Data: It captures data too complex for quantitative methods.
• Contextual Insights: It provides a better understanding of the phenomena in its natural setting.
• Contribution to Theory: It can generate and refine theory, offering a foundation for further research.

Limitations and Criticism

However, it’s important to acknowledge the limitations and criticisms:

• Generalizability : Findings from case studies may not be widely generalizable due to the focus on a single case.
• Subjectivity: The researcher’s perspective may influence the study, which requires careful reflection and transparency.
• Time-Consuming: They require a significant amount of time to conduct and analyze properly.

Concluding Thoughts on the Case Study Method

The case study method is a powerful tool that allows researchers to delve into the intricacies of a subject in its real-world environment. While not without its challenges, when executed correctly, the insights garnered can be incredibly valuable, offering depth and context that other methods may miss. Robert K\. Yin ’s advocacy for this method underscores its potential to illuminate and explain contemporary phenomena, making it an indispensable part of the researcher’s toolkit.

Reflecting on the case study method, how do you think its application could change with the advancements in technology and data analytics? Could such a traditional method be enhanced or even replaced in the future?

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Research Methods in Psychology

1 Introduction to Psychological Research – Objectives and Goals, Problems, Hypothesis and Variables

• Nature of Psychological Research
• The Context of Discovery
• Context of Justification
• Characteristics of Psychological Research
• Goals and Objectives of Psychological Research

2 Introduction to Psychological Experiments and Tests

• Independent and Dependent Variables
• Extraneous Variables
• Experimental and Control Groups
• Introduction of Test
• Types of Psychological Test
• Uses of Psychological Tests

3 Steps in Research

• Research Process
• Identification of the Problem
• Review of Literature
• Formulating a Hypothesis
• Identifying Manipulating and Controlling Variables
• Formulating a Research Design
• Constructing Devices for Observation and Measurement
• Sample Selection and Data Collection
• Data Analysis and Interpretation
• Hypothesis Testing
• Drawing Conclusion

4 Types of Research and Methods of Research

• Historical Research
• Descriptive Research
• Correlational Research
• Qualitative Research
• Ex-Post Facto Research
• True Experimental Research
• Quasi-Experimental Research

5 Definition and Description Research Design, Quality of Research Design

• Research Design
• Purpose of Research Design
• Design Selection
• Criteria of Research Design
• Qualities of Research Design

6 Experimental Design (Control Group Design and Two Factor Design)

• Experimental Design
• Control Group Design
• Two Factor Design

7 Survey Design

• Survey Research Designs
• Steps in Survey Design
• Structuring and Designing the Questionnaire
• Interviewing Methodology
• Data Analysis
• Final Report

8 Single Subject Design

• Single Subject Design: Definition and Meaning
• Phases Within Single Subject Design
• Requirements of Single Subject Design
• Characteristics of Single Subject Design
• Types of Single Subject Design
• Advantages of Single Subject Design
• Disadvantages of Single Subject Design

9 Observation Method

• Definition and Meaning of Observation
• Characteristics of Observation
• Types of Observation
• Advantages and Disadvantages of Observation
• Guides for Observation Method

10 Interview and Interviewing

• Definition of Interview
• Types of Interview
• Aspects of Qualitative Research Interviews
• Interview Questions
• Convergent Interviewing as Action Research
• Research Team

11 Questionnaire Method

• Definition and Description of Questionnaires
• Types of Questionnaires
• Purpose of Questionnaire Studies
• Designing Research Questionnaires
• The Methods to Make a Questionnaire Efficient
• The Types of Questionnaire to be Included in the Questionnaire
• Advantages and Disadvantages of Questionnaire
• When to Use a Questionnaire?

12 Case Study

• Definition and Description of Case Study Method
• Historical Account of Case Study Method
• Designing Case Study
• Requirements for Case Studies
• Guideline to Follow in Case Study Method
• Other Important Measures in Case Study Method
• Case Reports

13 Report Writing

• Purpose of a Report
• Writing Style of the Report
• Report Writing – the Do’s and the Don’ts
• Format for Report in Psychology Area
• Major Sections in a Report

14 Review of Literature

• Purposes of Review of Literature
• Sources of Review of Literature
• Types of Literature
• Writing Process of the Review of Literature
• Preparation of Index Card for Reviewing and Abstracting

15 Methodology

• Definition and Purpose of Methodology
• Participants (Sample)
• Apparatus and Materials

16 Result, Analysis and Discussion of the Data

• Definition and Description of Results
• Statistical Presentation
• Tables and Figures

17 Summary and Conclusion

• Summary Definition and Description
• Guidelines for Writing a Summary
• Writing the Summary and Choosing Words
• A Process for Paraphrasing and Summarising
• Summary of a Report
• Writing Conclusions

18 References in Research Report

• Reference List (the Format)
• References (Process of Writing)
• Reference List and Print Sources
• Electronic Sources
• Book on CD Tape and Movie
• Reference Specifications
• General Guidelines to Write References

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A case study is a research method that extensively explores a particular subject, situation, or individual through in-depth analysis, often to gain insights into real-world phenomena or complex issues. It involves the comprehensive examination of multiple data sources, such as interviews, observations, documents, and artifacts, to provide a rich and holistic understanding of the subject under investigation.

Case studies are conducted to:

• Investigate a specific problem, event, or phenomenon
• Explore unique or atypical situations
• Examine the complexities and intricacies of a subject in its natural context
• Develop theories, propositions, or hypotheses for further research
• Gain practical insights for decision-making or problem-solving

A typical case study consists of the following components:

• Introduction: Provides a brief background and context for the study, including the purpose and research questions.
• Case Description: Describes the subject of the case study, including its relevant characteristics, settings, and participants.
• Data Collection: Details the methods used to gather data, such as interviews, observations, surveys, or document analysis.
• Data Analysis: Explains the techniques employed to analyze the collected data and derive meaningful insights.
• Findings: Presents the key discoveries and outcomes of the case study in a logical and organized manner.
• Discussion: Interprets the findings, relates them to existing theories or frameworks, discusses their implications, and addresses any limitations.
• Conclusion: Summarizes the main findings, highlights the significance of the research, and suggests potential avenues for future investigations.

Case studies offer several benefits, including:

• Providing a deep understanding of complex and context-dependent phenomena
• Generating detailed and rich qualitative data
• Allowing researchers to explore multiple perspectives and factors influencing the subject
• Offering practical insights for professionals and practitioners
• Allowing for the examination of rare or unique occurrences that cannot be replicated in experimental settings

What Is a Case Study in Psychology?

Categories Research Methods

A case study is a research method used in psychology to investigate a particular individual, group, or situation in depth . It involves a detailed analysis of the subject, gathering information from various sources such as interviews, observations, and documents.

In a case study, researchers aim to understand the complexities and nuances of the subject under investigation. They explore the individual’s thoughts, feelings, behaviors, and experiences to gain insights into specific psychological phenomena. 

This type of research can provide great detail regarding a particular case, allowing researchers to examine rare or unique situations that may not be easily replicated in a laboratory setting. They offer a holistic view of the subject, considering various factors influencing their behavior or mental processes. 

By examining individual cases, researchers can generate hypotheses, develop theories, and contribute to the existing body of knowledge in psychology. Case studies are often utilized in clinical psychology, where they can provide valuable insights into the diagnosis, treatment, and outcomes of specific psychological disorders. 

Case studies offer a comprehensive and in-depth understanding of complex psychological phenomena, providing researchers with valuable information to inform theory, practice, and future research.

Table of Contents

Examples of Case Studies in Psychology

Case studies in psychology provide real-life examples that illustrate psychological concepts and theories. They offer a detailed analysis of specific individuals, groups, or situations, allowing researchers to understand psychological phenomena better. Here are a few examples of case studies in psychology: 

Phineas Gage

This famous case study explores the effects of a traumatic brain injury on personality and behavior. A railroad construction worker, Phineas Gage survived a severe brain injury that dramatically changed his personality.

This case study helped researchers understand the role of the frontal lobe in personality and social behavior. 

Little Albert

Conducted by behaviorist John B. Watson, the Little Albert case study aimed to demonstrate classical conditioning. In this study, a young boy named Albert was conditioned to fear a white rat by pairing it with a loud noise.

This case study provided insights into the process of fear conditioning and the impact of early experiences on behavior. 

Genie’s case study focused on a girl who experienced extreme social isolation and deprivation during her childhood. This study shed light on the critical period for language development and the effects of severe neglect on cognitive and social functioning. 

These case studies highlight the value of in-depth analysis and provide researchers with valuable insights into various psychological phenomena. By examining specific cases, psychologists can uncover unique aspects of human behavior and contribute to the field’s knowledge and understanding.

Types of Case Studies in Psychology

Psychology case studies come in various forms, each serving a specific purpose in research and analysis. Understanding the different types of case studies can help researchers choose the most appropriate approach. 

Descriptive Case Studies

These studies aim to describe a particular individual, group, or situation. Researchers use descriptive case studies to explore and document specific characteristics, behaviors, or experiences.

For example, a descriptive case study may examine the life and experiences of a person with a rare psychological disorder. 

Exploratory Case Studies

Exploratory case studies are conducted when there is limited existing knowledge or understanding of a particular phenomenon. Researchers use these studies to gather preliminary information and generate hypotheses for further investigation.

Exploratory case studies often involve in-depth interviews, observations, and analysis of existing data. 

Explanatory Case Studies

These studies aim to explain the causal relationship between variables or events. Researchers use these studies to understand why certain outcomes occur and to identify the underlying mechanisms or processes.

Explanatory case studies often involve comparing multiple cases to identify common patterns or factors. 

Instrumental Case Studies

Instrumental case studies focus on using a particular case to gain insights into a broader issue or theory. Researchers select cases that are representative or critical in understanding the phenomenon of interest.

Instrumental case studies help researchers develop or refine theories and contribute to the general knowledge in the field. 

By utilizing different types of case studies, psychologists can explore various aspects of human behavior and gain a deeper understanding of psychological phenomena. Each type of case study offers unique advantages and contributes to the overall body of knowledge in psychology.

How to Collect Data for a Case Study

There are a variety of ways that researchers gather the data they need for a case study. Some sources include:

• Directly observing the subject
• Collecting information from archival records
• Conducting interviews
• Examining artifacts related to the subject
• Examining documents that provide information about the subject

The way that this information is collected depends on the nature of the study itself

Prospective Research

In a prospective study, researchers observe the individual or group in question. These observations typically occur over a period of time and may be used to track the progress or progression of a phenomenon or treatment.

Retrospective Research

A retrospective case study involves looking back on a phenomenon. Researchers typically look at the outcome and then gather data to help them understand how the individual or group reached that point.

Benefits of a Case Study

Case studies offer several benefits in the field of psychology. They provide researchers with a unique opportunity to delve deep into specific individuals, groups, or situations, allowing for a comprehensive understanding of complex phenomena.

Case studies offer valuable insights that can inform theory development and practical applications by examining real-life examples. 

Complex Data

One of the key benefits of case studies is their ability to provide complex and detailed data. Researchers can gather in-depth information through various methods such as interviews, observations, and analysis of existing records.

This depth of data allows for a thorough exploration of the factors influencing behavior and the underlying mechanisms at play. 

Unique Data

Additionally, case studies allow researchers to study rare or unique cases that may not be easily replicated in experimental settings. This enables the examination of phenomena that are difficult to study through other psychology research methods . 

By focusing on specific cases, researchers can uncover patterns, identify causal relationships, and generate hypotheses for further investigation.

General Knowledge

Case studies can also contribute to the general knowledge of psychology by providing real-world examples that can be used to support or challenge existing theories. They offer a bridge between theory and practice, allowing researchers to apply theoretical concepts to real-life situations and vice versa. 

Case studies offer a range of benefits in psychology, including providing rich and detailed data, studying unique cases, and contributing to theory development. These benefits make case studies valuable in understanding human behavior and psychological phenomena.

Limitations of a Case Study

While case studies offer numerous benefits in the field of psychology, they also have certain limitations that researchers need to consider. Understanding these limitations is crucial for interpreting the findings and generalizing the results. 

Lack of Generalizability

One limitation of case studies is the issue of generalizability. Since case studies focus on specific individuals, groups, and situations, applying the findings to a larger population can be challenging. The unique characteristics and circumstances of the case may not be representative of the broader population, making it difficult to draw universal conclusions. 

Researcher bias is another possible limitation. The researcher’s subjective interpretation and personal beliefs can influence the data collection, analysis, and interpretation process. This bias can affect the objectivity and reliability of the findings, raising questions about the study’s validity. 

Case studies are often time-consuming and resource-intensive. They require extensive data collection, analysis, and interpretation, which can be lengthy. This can limit the number of cases that can be studied and may result in a smaller sample size, reducing the study’s statistical power. 

Case studies are retrospective in nature, relying on past events and experiences. This reliance on memory and self-reporting can introduce recall bias and inaccuracies in the data. Participants may forget or misinterpret certain details, leading to incomplete or unreliable information.

Despite these limitations, case studies remain a valuable research tool in psychology. By acknowledging and addressing these limitations, researchers can enhance the validity and reliability of their findings, contributing to a more comprehensive understanding of human behavior and psychological phenomena. 

While case studies have limitations, they remain valuable when researchers acknowledge and address these concerns, leading to more reliable and valid findings in psychology.

Alpi, K. M., & Evans, J. J. (2019). Distinguishing case study as a research method from case reports as a publication type. Journal of the Medical Library Association , 107(1). https://doi.org/10.5195/jmla.2019.615

Crowe, S., Cresswell, K., Robertson, A., Huby, G., Avery, A., & Sheikh, A. (2011). The case study approach. BMC Medical Research Methodology , 11(1), 100. https://doi.org/10.1186/1471-2288-11-100

Paparini, S., Green, J., Papoutsi, C., Murdoch, J., Petticrew, M., Greenhalgh, T., Hanckel, B., & Shaw, S. (2020). Case study research for better evaluations of complex interventions: Rationale and challenges. BMC Medicine , 18(1), 301. https://doi.org/10.1186/s12916-020-01777-6

Willemsen, J. (2023). What is preventing psychotherapy case studies from having a greater impact on evidence-based practice, and how to address the challenges? Frontiers in Psychiatry , 13, 1101090. https://doi.org/10.3389/fpsyt.2022.1101090

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

How to Write a Good Case Study in Psychology (A Step-by-Step Guide)

• March 4, 2022
• Teaching Kids

A case study psychology is a type of research that uses real-life examples to help understand psychological concepts. This type of research can be used in a variety of settings, such as business, health care, education, and social services.

Case studies are typically composed of three parts: the problem or issue, the intervention or treatment, and the outcome. The problem or issue is what caused the person to seek help, and the intervention or treatment is what was done to try to solve it. The outcome is how things changed after the intervention or treatment was implemented.

Step by step instructions on how to write an effective case study in Psychology

1. Gain Knowledge About The Topic

To write a case study in psychology, you will need to do some research on the topic you are writing about. Make sure that you read journal articles, books, a case study example, and any other reliable sources in order to get a comprehensive understanding of the topic. You will also need to find a suitable example or examples of how psychological concepts have been applied in real-life situations. For example, a psychology student might interview a friend about how she balances her time between work and studies.

2. Research the Individual or Event

In this case, you can choose either a person or an event for your case study research. If you are writing about a specific event, look for past issues that relate to it and any ongoing ones that may have a connection to it.

You may choose to write about a specific problem or situation that affected the individual in some way, such as how it relates to their psychology. For example, you may want to study a man who has been in relationships with several women within the same time period and what effects this has on them.

If you are writing about a person, obtain biographical information and look for any psychological assessments that have been done on the individual.

3. Analyze The Information

Once you have gathered all the necessary information, it is time to go through it and identify important facts that will influence your paper.

This is where you use your skills of inductive and deductive reasoning, to analyze the information that you have gathered. You will usually look for patterns within this information and draw conclusions about how it has affected or contributed to their psychology.

Summarize each point in order to make note-taking easier later on when writing your case study.

4. Draft A Plan

Once you have gathered all the relevant information, it is time to start drafting a plan for your case study. This case study format should include an introduction, body, and conclusion.

The body of the case study should be divided into different sections that will discuss different aspects of the topic. Make sure that your argument is clear and concise, and that you use data to support your ideas, rather than simply stating them as facts or personal opinions.

5. Structure Your Work

As mentioned in the previous step, the body of the case study should be divided into different sections for effective writing. The introduction should include a short paragraph about what you plan to write in the study and what the case study method will be, while the conclusion should summarize your argument and leave the reader with a sense of closure. Each section in the body should have its own heading to help the reader follow your line of argument.

6. Write The Case Study

Now that you have a plan and structure for your case study, it is time to start writing!

Even if you are writing a case study on your own, break it down into small sections and make sure you include every aspect of the topic within each section. Think about how you will present your case study and what points are essential to make in the body.

Include details, quotes, infographics or numeric data that help support your arguments and overall conclusion. This is what makes a great case study: An overview of every aspect of the topic researched within it!

7. Write a Theoretical Introduction

In this section, you will introduce your topic and explain why it is significant in relation to the area of psychology that you are studying.

In the theoretical introduction, you will write about the basic principles of human psychology and growth, then explain how you think this situation relates to your study topic.

After explaining the theoretical part in detail, state why studying this particular aspect will help psychologists understand aspects of humanity within different areas such as sociology or anthropology.

8. Describe How The Individual or Event Was Studied

Researchers in psychology write case studies to gain an in-depth understanding of specific topics pertaining to their field. For this reason, you should explain how you came across your sources of information and why this was beneficial to your research.

In describing how the individual or event was studied, you may also include information about what you discovered through your research and why it is important.

9. Write a Conclusion

In this part of your essay, bring together all key points discussed in the course of writing the case study. You should summarize what you have written and state your own conclusions based on the research that you have conducted.

10. Edit And Proofread The Case Study

Once you have finished writing the case study, it is important to edit and proofread it carefully. This will help to correct any grammatical errors that may have slipped into the writing process, and will also ensure that you are producing an accurate document. You might find it helpful to seek advice from someone who has experience in this field before sending it off for submission.

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By following these steps, you can create a well-written case study that will provide readers with a clear understanding of the topic at hand. Remember to take your time while researching and writing, and to be as thorough as possible in order to produce a high-quality document. Good luck!

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• Perspective
• Published: 22 November 2022

Single case studies are a powerful tool for developing, testing and extending theories

• Lyndsey Nickels   ORCID: orcid.org/0000-0002-0311-3524 1 , 2 ,
• Simon Fischer-Baum   ORCID: orcid.org/0000-0002-6067-0538 3 &
• Wendy Best   ORCID: orcid.org/0000-0001-8375-5916 4  

Nature Reviews Psychology volume  1 ,  pages 733–747 ( 2022 ) Cite this article

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• Neurological disorders

Psychology embraces a diverse range of methodologies. However, most rely on averaging group data to draw conclusions. In this Perspective, we argue that single case methodology is a valuable tool for developing and extending psychological theories. We stress the importance of single case and case series research, drawing on classic and contemporary cases in which cognitive and perceptual deficits provide insights into typical cognitive processes in domains such as memory, delusions, reading and face perception. We unpack the key features of single case methodology, describe its strengths, its value in adjudicating between theories, and outline its benefits for a better understanding of deficits and hence more appropriate interventions. The unique insights that single case studies have provided illustrate the value of in-depth investigation within an individual. Single case methodology has an important place in the psychologist’s toolkit and it should be valued as a primary research tool.

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The authors thank all of those pioneers of and advocates for single case study research who have mentored, inspired and encouraged us over the years, and the many other colleagues with whom we have discussed these issues.

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Nickels, L., Fischer-Baum, S. & Best, W. Single case studies are a powerful tool for developing, testing and extending theories. Nat Rev Psychol 1 , 733–747 (2022). https://doi.org/10.1038/s44159-022-00127-y

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Pryjmachuk S, Elvey R, Kirk S, et al. Developing a model of mental health self-care support for children and young people through an integrated evaluation of available types of provision involving systematic review, meta-analysis and case study. Southampton (UK): NIHR Journals Library; 2014 Jun. (Health Services and Delivery Research, No. 2.18.)

Developing a model of mental health self-care support for children and young people through an integrated evaluation of available types of provision involving systematic review, meta-analysis and case study.

Chapter 6 discussion and conclusion.

In the previous three chapters, we presented our findings from the three interconnected stages of the study: the literature reviews, the mapping exercise and the case study. In this chapter, we synthesise the three sets of findings, using an approach similar to that which we used to integrate the effectiveness and perception reviews in Chapter 3 , additionally discussing our findings with reference to current research, policy and practice and with due regard to the aims of the study and our research objectives. Figure 13 outlines this process schematically.

Schematic diagram of the overall study synthesis.

The strengths and limitations of the study and the degree of patient and public involvement (PPI) are then considered. We conclude this chapter, and the report, by discussing the implications for policy and practice that have emerged from our study and by offering some recommendations for further research.

We begin the discussion by making some general observations about the evidence that we have obtained. An observation across of all of our data sources is that the interventions and services we examined are largely targeted at CYP with mood disorders or behaviour problems. This is relatively unsurprising given that emotional and behavioural problems are by far the most common problems in CYP’s mental health. 3 However, it is worth noting that there is relatively little about the more serious mental health problems like self-harm, psychosis and eating disorders, given that these are the problems which tend to worry education and health professionals the most. 40 , 197

Most of the literature we examined originated in the USA and Australia. Again, this is a relatively unsurprising finding given that the most of the manualised treatments seem to emanate from these two countries: The Incredible Years 183 parenting and Coping Cat 198 CBT programmes in the USA, and the Triple-P 164 parenting and FRIENDS 199 CBT programmes in Australia, for example. Moreover, the architects of these programmes and their associated research teams are highly active in conducting research and publishing about their respective interventions; indeed, the studies we examined in the systematic reviews were conducted by relatively few research teams. This, of course, does not explain why these approaches originated in the USA and Australia in the first place, but it is notable that they have different health-care systems to that of the UK and no ‘national’ health service. It does, however, raise some questions about their transferability to a UK context, a point made by some of our case study participants when they talked about some of the manualised programmes’ materials.

Most of the interventions and services considered in our study were designed to manage and treat symptoms rather than prevent them. This may reflect the medical dominance in CAMHS provision in most countries – one that tends to have an overemphasis on outcomes relating to symptoms and a focus on deficits rather than strengths. Consequently, the ethical, political and clinical advantages of preventative interventions (normalisation and de-stigmatisation, for instance) may be overshadowed in systems that are concerned with ‘illness’ rather than ‘health’. It may also be that those interested in preventative approaches are those who often sit outside of, or challenge, the traditional medico-scientific culture. A disadvantage of this, however, is that they might not necessarily embrace the ‘hard’ outcomes that are required to further promote an intervention or service as effective in a literature where medico-scientific approaches (such as rigorous RCTs) have the most authority. 200

The remainder of our discussion focuses on four overarching themes that provide a framework for the application of our findings to policy and practice, and in the context of the existing literature. These themes are: what works in supporting self-care in CYP’s mental health?; choice and flexibility; the interface between the NHS and other providers of self-care support; and how self-care support in CYP’s mental health might be conceptualised.

What works in supporting self-care in children and young people’s mental health?

One of the aims of our study was an evaluation of mental health self-care support for CYP. Clearly, in carrying out such an evaluation, we were interested in finding out ‘what works?’ in terms of self-care support, but in asking this question some significant tensions have emerged. These tensions arise because the answer to the question depends on two inter-related factors: how the question is interpreted (whether ‘works’ means effective, enjoyable or satisfying, for example) and who is being asked the question (the researcher, parent, clinician or child/young person).

From the meta-analysis, we found that self-care support interventions appear to be modestly effective in improving CYP’s mental health symptoms, a finding not dissimilar from other reviews and meta-analyses examining psychosocial interventions in CYP’s mental health. For example, meta-analyses on technology-based self-help in CYP, 25 parenting for early-onset conduct problems 201 and psychological and educational interventions for preventing depression in CYP 202 have all identified small to medium intervention effects on relevant mental health symptomatology.

However, two further questions arise here: one concerns the sustainability of these effects, and the other relates to our earlier point about whose perspective – researcher’s, parent’s, clinician’s, or child or young person’s – is the more important when the value of (small to medium) intervention effects on mental health symptomatology is being considered.

Sustainability

An evaluation of CAMHS innovation projects over a decade ago 203 identified a number of key elements in services that work, including having a capacity to keep in touch with CYP over the long term and offer additional, short-term intervention or support if needed. This message of sustainability in self-care support interventions has been repeated more recently in both adult mental health 12 and CYP’s mental health, 204 in mental health promotion in schools 200 as well as in a general review of the evidence on self-management. 205 From a service user perspective, it has also been neatly summarised by a SAG member who argued that the principle should be one of ‘give us the skills, remind us of the skills and help us when we get stuck’. Given that our effectiveness review focused on short- to medium-term follow-up (6- and 12-month time points), it can, to some extent, also be seen as a ‘sustainability’ review. Our findings thus suggest that few of the self-care support interventions examined were sustainable, as effectiveness was only moderate at 6-month follow-up and it subsequently declined at 12-month follow-up. Moreover, our effectiveness review found that interventions that were longer also tended to be more effective, an observation that further suggests that a longer-term commitment may be beneficial.

Different perspectives

One clear finding from our data is that, in evaluating mental health self-care support for CYP, a range of different perspectives surface. Not only is the perceived value of an intervention or service dependent on who is asked, but some biases in the overall literature imply that certain information about interventions and services is valued more than others. Regarding the former, our satisfaction data, for example, noted that adults (parents and teachers) often rated interventions better than CYP, a finding that has been observed elsewhere, 206 and in both our satisfaction and qualitative data, there was evidence that CYP did not agree among themselves about the value of a particular intervention or which specific components were the most valuable to them.

Regarding the latter, the dominance of trial studies compared with perceptions studies suggests that an effectiveness perspective is generally more valued. In addition, the observation that most outcome measures in the effectiveness studies were concerned with mental health symptomatology (see Chapter 2 , Table 4 ) also demonstrates a particular (i.e. clinical) perspective regarding the importance of particular outcomes. This contrasts with our previous NIHR study exploring children’s long-term physical health conditions, 15 where a much wider range of outcome measures were considered, including health service use, which was notably absent from all of the studies we included. Moreover, the effectiveness of an intervention or service can be measured across many domains, such as a child or young person’s ability to cope or move on from a difficult situation, and not just in improvements in symptoms, and there is evidence that CYP’s problems can be addressed more effectively if their strengths, self-efficacy and resilience are promoted. 204 This is a point that the recent CYP’s IAPT programme seems to have conceded, given that the programme considers a range of outcomes including strengths, general well-being, employment, and education uptake and attendance, as well as mental health symptoms. 31

Choice and flexibility

The most salient finding of our study is, perhaps, the contrast between the effectiveness data and the perceptions data. In comparing the effectiveness and perceptions data, two related tensions arise: the tension between flexibility and fidelity, and the tension between choice and constraint.

Flexibility versus fidelity

Flexibility appears to be a key element of self-care support. Inflexibility of services was a common criticism made about standard CAMHS services by CYP and parents in the case study sites, and flexibility was identified as a valued feature of self-care support in both our previous NIHR report 15 and the recent NIHR project on self-care support in adult mental health. 12 However, almost all of the interventions considered in our effectiveness review were manualised, a status that implies that there are ‘rules’ as to how an intervention should be delivered. This raises the issue of fidelity , a concept that it is somewhat at odds with flexibility. Compare, for example, the case study sites that used The Incredible Years, where fidelity to the manual appeared to be paramount (to the service lead, at least), to the perceived inflexibility of some of the manualised interventions that was evident in the perceptions review.

The issue of fidelity in manualised interventions is interesting as there is no consensus on its importance in achieving the best outcomes in psychosocial interventions. The evidence for fidelity in parenting interventions, in particular, is equivocal, with some arguing that it is a necessary component for effectiveness, 207 while others argue that there is scant evidence that manuals improve treatment effects. 208 A recent discussion paper from the British Psychological Society 209 attempted to reconcile these two positions in the context of the real-life service delivery of parenting programmes, arguing that fidelity is important but not at the expense of acceptability, and that fidelity should be redefined as those principles critical to effectiveness, rather than being seen as the duplication of an original in vitro model.

Choice versus constraint

In attempting to integrate the effectiveness and perceptions reviews at the end of Chapter 3 , we concluded that a key message might be one of service providers constrained by homogeneity, in terms of largely providing manualised, group-based, face-to-face (cognitive–)behavioural interventions. Homogeneity of intervention erroneously assumes homogeneity of recipient, an assumption that has been challenged in many aspects of CYP’s health-care delivery. For example, this has been pointed out in relation to human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) prevention programmes for CYP 210 and the mental health needs of homeless CYP, 211 and in a review of CYP’s general perspectives on health and health services. 212 Treating patient groups as homogenous purely on the basis of qualifying for a specific diagnosis has also been critised, 208 a fair point given that CYP diagnosed with a specific mental health condition such as anxiety will vary immensely in their needs, their experiences and the resources they have, as will their families. In terms of effectiveness, it might therefore be more appropriate to ask ‘what works for whom and in what circumstances?’ rather than merely asking ‘what works?’.

However, assuming that different things work for different people brings about the question of choice . Choice does not necessarily mean choice only in terms of specific interventions or services. It might also mean choice in terms of specific elements of the service: face to face or telephone, or group or individual. It might mean choice in terms of location: home or school. It might mean choice in the referral process including the opportunity for self-referral, a feature of two of our case study sites and a salient observation in the recent NIHR study on self-care support in adult mental health. 12 Finally, it might mean choice in terms of who makes that choice: the child or young person, a parent or, as is too often the case, the staff providing the service. In other words, choice should mean taking into account the CYP’s and their families’ individual needs. 203

In raising the issue of choice, it is not to say that effectiveness is unimportant, just that some generally effective interventions might not work for some CYP. Standard effectiveness tools such as meta-analysis are not able to assess the issues of accessibility and engagement very well, where choice might be a more significant issue and driver of outcomes. A pragmatic compromise, therefore, is that services should still consider effectiveness when providing interventions but that there should also be a reasonable choice in evidence-based approaches. To some extent, this has been recognised by the CYP’s IAPT programme, 31 in that initially only cognitive–behavioural and parent training (the dominant models in terms of effectiveness data) were available but the programme has recently been extended to include other interventions with evidence of effectiveness, such as systemic family therapy and interpersonal therapy. However, even if a range of evidence-based interventions are available, the issue of who makes the choice remains. Moreover, if it is to be CYP and their parents who make that choice, there is a need to ensure that sufficient information about interventions and services, including information about their effectiveness with different CYP, different problems and different circumstances, is available so that CYP and their parents can make informed choices.

A further issue in discussing choice, and a key element of the overall acceptability of a service or intervention, is an appreciation of the CYP’s or their parents’ readiness to self-care. 12 , 24 Although there was little explicit reference to readiness in our findings, there were definite hints from the case study data that readiness could be an issue in terms of accessing self-care support, and it was a noticeably absent concept in most of the interventions examined in our literature reviews. Our previous NIHR study 15 also picked up some hints about readiness in relation to decisions about whether to access services or not. A related concept to readiness is health activation , 213 a concept we will discuss further in the Conceptualising self-care support in CYP’s mental health section later in this chapter.

Choice and groups

While discussing choice, it is worth talking about one particular feature of our overall findings. Group interventions and services dominated all of our data sets, although the groups varied from relatively small groups to groups as large as whole primary or secondary school classes. It is not difficult to understand the popularity of groups, given the peer support and shared experience advantages of group approaches in health care identified in this study, our previous study 15 and elsewhere, 214 – 216 their relatively low costs compared with individual attention, and the evidence that social support networks are associated with better mental health outcomes, fewer problem behaviours and more health-promoting behaviours in CYP. 217

However, there was some evidence from our meta-analysis that individual interventions may be more effective than group interventions for CYP, though the difference in effect size between the two (a difference in SMD of –0.11 in favour of individual interventions at 6 months) may be insufficient to counter the additional benefits that groups provide and the additional costs involved.

Furthermore, there is evidence that there are some risks to CYP in group interventions. A recent review on the role and impact of social capital on the health and well-being of CYP 217 reported that, in certain circumstances, social support networks could increase participation in health-risk behaviours such as alcohol and tobacco misuse, an observation backed up by our case study reports concerning the risk of ‘contagion’ in eating disorders and self-harm groups.

Interface between the NHS and other providers of self-care support

The second aim of our study concerned the interface between the NHS and other providers of self-care support. Compared with our previous study, 15 the role of the NHS was less defined in self-care support in CYP’s mental health than it was in CYP’s physical health. In particular, the voluntary sector dominated the services identified in the service mapping. This could, of course, be down to the NHS not publicising any self-care support services it operates in its CAMHS provision; however, it is more likely to be an accurate reflection of current service configuration, given that commissioners of CYP’s mental health services are looking increasingly at alternative providers to NHS organisations to deliver NHS-commissioned and funded services, a situation we found previously in relation to CYP’s physical health. 15 Indeed, the voluntary sector currently has significant involvement – even to the point of subcontracting from the NHS – in two flagship CAMH service innovations in England: the CYP’s IAPT 31 and the Better Outcomes New Delivery (BOND) early intervention programmes. 218

The general policy consensus is that the interface between statutory services such as the NHS and the voluntary sector should be one of partnership . 9 In the recent NIHR study on self-care support in adult mental health, 12 projects not under the control of the NHS (i.e. voluntary sector projects) were seen as risky by the NHS, which implies a lack of either understanding or communication between one or both parties. This might be down, in part, to tensions between two sets of ‘experts’, each feeling their expertise to be more important than the other’s, and to some extent this parallels the tensions already seen between provider and recipient when we considered the ‘effectiveness’ and ‘acceptability’ of self-care support interventions.

It terms of service provision, it is worth looking at a couple of other salient findings from our study: the location in which the service is provided, and the underuse of technology.

Location of service

The evidence on where services should be located is somewhat equivocal. Our effectiveness review findings suggest that the setting (clinic, home, school, etc.) is a largely irrelevant factor in the effectiveness of an intervention and no argument in favour of any particular location emerged from the perceptions review. This suggests that other factors need to be taken into account when considering the location at which self-care support should be delivered. The case for hospital-based services is generally weak. A recent King’s Fund paper 219 argues that health service delivery in general needs fundamental change and that hospital-based care should be reserved for those who cannot be treated more appropriately elsewhere. Our case study data also suggested that inpatient hospital care was not particularly well liked by participants. In terms of mental health provision, current government policy 9 is that people with mental health problems – including CYP – should be treated in the least restrictive environment. For CYP, the least restrictive environment usually means school, home or some other community-based location such as a clinic or community centre. All of these locations have advantages and disadvantages. Clinics, community centres and schools often have town centre locations close to transport hubs, a factor seen as important in terms of access 214 though our case study data implied that physical access was not necessarily a critical factor for participants. Formal clinics, however, may, at best, reinforce the medicalisation of the CYP’s problems and, at worse, stigmatise the CYP. The family’s own home offers convenience and few access problems but not everyone is comfortable with professionals intervening at home. Perhaps the best candidate for location is schools: schools are part of the CYP’s normal experience, and the fact that most of the studies in the effectiveness review were school based demonstrates that schools are feasible places for delivering such interventions. Moreover, there is evidence that schools are substantially more cost-effective at delivering mental health interventions for CYP than routine CAMHS. 220 On the other hand, there was some evidence in our case study data that schools are not necessarily prepared for the task (as they came in for criticism, along with inpatient hospital care, from some of our participants), and there is some evidence, at least in terms of preventative approaches, 200 that schools may need to have the right ethos in place to be centres for mental health support.

Use of technology

Given the commonly held view that CYP are inherently comfortable and confident with new technologies – that they are ‘digitally native’ – there was surprisingly little use of computers and internet technology in the interventions and services we examined. None of the interventions examined in the effectiveness review used computer or internet technology, there were only three such interventions in the perceptions review and only five were identified from the service mapping. This might be because the peer support and shared experience elements of face-to-face, group self-care support are harder to replicate online (though not impossible, as the eating disorders online support case study site has demonstrated); or it might be because NHS services in particular are inherently conservative and have not yet caught up with the technology. 221 On the other hand, it might be that the assumptions about CYP being digitally native are incorrect 180 , 222 – that CYP have no greater a preference for computers and internet technology than adults or that, again, homogeneity is being assumed in CYP when in fact some may embrace technology more than others. This is a salient point because it brings about once more the issues of choice and readiness, in that some CYP may not be ready to use technological interventions and some – as we found in our perceptions review – may not particularly like them. Nevertheless, there is evidence from elsewhere that technology can help in engaging CYP in mental health services: for example, the use of text messaging to reduce ‘did not attend’ rates. 214 , 223

Conceptualising self-care support in children and young people’s mental health

It is clear from this study that self-care support services in CYP’s mental health do exist, and are being researched, but what is interesting is that very few of these services make explicit reference to ‘self-care’ in their names or service specifications though, occasionally, a related term such as ‘self-help’ or ‘self-management’ may be used. This is in direct contrast to CYP’s physical health where self-care is an established part of the vocabulary. A similar conclusion was drawn in the recent NIHR-funded study on self-care support in adult mental health. 12 One reason for this might be the increasing adoption of ‘recovery’ as a general philosophy of mental health service provision over the last decade or so. In addition, the move towards strengths, rather than deficits, models in CYP’s mental health has brought into focus a related concept: resilience . The key elements of recovery are hope; the establishment of a positive identity; a meaningful life; and taking responsibility for, and control over, one’s own life. 18 All of these elements could describe self-care; indeed, they are implicit, if not explicit, in our definition of self-care (see Chapter 1 ). Moreover, in embracing a philosophy of recovery, the role of mental health practitioners becomes more about doing things with service users than doing things to them, and so, in a recovery framework, mental health practitioners are essentially guides, facilitators and coaches. It is thus not difficult to see how ‘recovery’ might simply be a synonym for self-care in a mental health context, or how it might be encapsulated as part of ‘resilience’ if the self-care support agent helps the CYP identify, and build upon, their strengths; at the very least the concepts are closely related. 12 , 224

Another interesting dimension in conceptualising self-care support in CYP’s mental health is the observation from the literature review and mapping exercise that most of the interventions and services are targeted at CYP rather than at families. This assumes that CYP are the ‘problem’, and there is perhaps a need within recovery- or resilience-focused approaches to ensure that (a) the emphasis is on strengths rather than problems, and (b) any problems are considered within the context of the family and the CYP’s social networks.

Conceptualising mental health

When considering how self-care support might be conceptualised in CYP’s mental health, it is not surprising to find that conceptualisations of ‘mental health’ can also be somewhat vague. For example, when reporting the case study findings, we noted that conceptualisations of mental health seemed to be connected to the CYP’s age, with mental health being conceptualised in younger children as a lack of confidence or difficulties with emotion and behaviour, and in older children as diagnosed conditions or severe mental health problems. The reasons for this are far from simple; being ‘diagnosed’, for example, may be down to capacity and configuration of local services, the expectations of the child and/or parent, and social constructions of mental illness. There is, nevertheless, a balance to be struck in conceptualising a child or young person’s difficulties as mental health problems or not. A diagnosis is often a criterion that triggers access to a potentially helpful service or it can act as a filter for different interventions and services, as there is evidence in self-care support that different conditions benefit from different approaches. 205 Yet a diagnosis can also have negative connotations (leading to stigmatisation and exclusion, for example), as one of our case study sites made clear when it asked for the removal of any reference to ‘mental health’ from our recruitment materials, even though it was delivering an ostensible mental health service. Maybe choice needs to be considered here too in that CYP should be allowed a choice as to whether they accept a diagnostic label or prefer to focus on, for example, identifying specific needs, feelings and opportunities to develop strengths. This is also reflected in the current debates expressing concerns about the increasing ‘medicalisation’ of emotions and behaviours in CYP. 225 , 226

It is also worth asking whether CYP’s mental health problems and needs should be considered as long-term conditions because the focus for many families is, as it is for the families of CYP with long-term physical health needs, often more about quality of life and living (well) with a condition than it is about ‘curing’ the condition. Mental health self-care support interventions for CYP need to be considered in a context where the majority of adult mental health problems have their origins in developmental problems in childhood; 227 yet, as our study illustrates, what tends to be on offer are relatively short interventions with erratic follow-up periods (often merely for research purposes) for CYP who have problems and mental health needs that are likely to extend into adulthood. Clearly, there is a relationship here with our earlier discussions on sustaining self-care, and a conceptualisation of CYP’s mental health in a longer-term context may help address some of the shortcomings in the sustainability of specific interventions and services.

A conceptual model of mental health self-care support in children and young people

In modifying the typology of self-care support (see Chapter 4 , Table 19 ), we argued that self-care support in CYP’s mental health can be seen as a process . There needs to be the acquisition of knowledge and skills, which require input and motivation on the child or young person’s (or parent’s) part; opportunities to practise and consolidate these requisite skills, with support and facilitation from a self-care support agent; and some positive outcomes for the child or young person and his or her family. Moreover, as we earlier argued, there is some evidence that this process should be long term rather than short term. On the basis of our findings and the discussion herein, a conceptual model of mental health self-care support is proposed in Figure 14 .

A conceptual model of mental health self-care support in CYP.

We have discussed a significant number of the elements of this model already, including effectiveness, acceptability, readiness and outcomes. Choice and flexibility, though not explicit in the model, permeate the whole model in that various elements of it, such as the types of skills on offer and the means of acquiring them, the outcomes used and even the self-care support agent, can all be tailored according to the individual needs of the child or young person and his or her family. Two critical elements of the model – skills and the self-care support agent – warrant further discussion, however.

Regarding skills, it seems that skills and the activities that support their development are a central feature of effective self-care support programmes 12 , 15 , 200 , 203 , 205 and of recovery in CYP’s mental health in general. 214 , 217 However, as mentioned above, choice and flexibility need to be considered when identifying these skills and providing the support CYP and their families need in acquiring them. This raises the issue of the personalisation of health-care services and the associated issue of personal health budgets, 219 , 228 although it seems these two issues raise tensions similar to the ones we identified when discussing effectiveness and acceptability, in that the patient preferences inherent in personalisation have to be reconciled with a co-existing framework of ‘payment by results’ where effectiveness is the key concern. 229

Regarding the self-care support agent, the principal issues that need discussing are the attitudes and attributes of the professional or lay person taking on this role. This involves some discussion of both the attitudes of the agent and their interpersonal skills, as well as some comments about education and training.

Qualities of the self-care support agent

Our case study data suggested that the personal qualities of the staff providing the self-care support were important, with staff generally seen to have positive attitudes such as being non-judgemental, welcoming and an active listener. There were also some hints in the perceptions review that the quality of the relationship with the agent and the expertise of the agent may be as important as, if not more important than, the intervention itself. This is a common theme in the literature: participants in our previous NIHR study 15 remarked on the approachability of the self-care support agents and their abilities to listen and be non-judgemental; a recent Health Foundation review on self-management 205 found that the attitudes and skills of staff can have a significant effect on perceived levels of engagement and support; and in CYP’s mental health, the ‘therapeutic alliance’ has been identified as a significant but neglected factor in treatment. 230

Leadership in self-care support services may also be an important personal and organisational attribute, and we saw evidence of strong leadership in our case study sites. Effective and consistent leadership was identified as a key element of ‘what works’ in CAMHS provision, 203 and the recent NIHR study on self-care support in adult mental health 12 noted that charismatic leadership was a feature of many of the projects examined.

Another key personal and organisational attribute is child-centredness. As in our previous NIHR study, 15 being child-centred was a feature of most of the case study sites. The general literature indicates that effective patient-centred care requires two specific elements: the straightforward eliciting and discussion of the patient’s perspective and ‘activation’, i.e. a deeper understanding of the individual’s motivation and readiness to become involved in a service, change their behaviour or self-care. 231 This suggests that for the self-care support agent to be truly child-centred, they need to understand not only the CYP’s problems and needs but also recognise the extent to which they are ready. This raises the question of whether or not a readiness measure of some sort, whether standardised and formal like the Patient Activation Measure 213 or something more informal like simply asking the question ‘do you feel you are ready?’, should be routinely used in health-care practice.

From an organisational perspective, child-centredness requires – as we saw in the case study sites in this study and in our previous study 15 – a friendly, fun, welcoming atmosphere where the CYP’s views are listened to and respected. Above all, child-centredness requires a partnership between the provider and family, one that demands that CYP and their families be seen as part of the care team or, to use a phrase currently gathering momentum in adult mental heath care, as ‘coproducers’ of their care. 232

A consideration of the attributes and skills of the self-care support agent inevitably raises the issue of education and training. None of the attributes and skills required of the support agent necessitate mental health training, and it was interesting to note that our effectiveness data suggested that there is no specific advantage in the agent being mental health trained, although there is some evidence 82 in the literature to counter this, and it was notable that around three-quarters of those delivering interventions in the effectiveness studies were specifically trained for the role. What seems to be essential is the ability to understand the CYP’s perspective, and to focus on their needs and the needs of their families, rather than on the needs of the service or the people leading the service. This may require attitude changes among CAMHS staff and those managing services and, certainly, if an eclectic range of interventions is to be made available within CAMHS, then it will require opportunities for staff to retrain and develop new skills. 204 In terms of attitude, in England and Wales at least, our findings suggest that the voluntary sector seems to be ahead of the NHS and other statutory services. However, as our case study data indicate, there is also excellent service provision in the NHS. Thus, it may not matter which sector delivers the service, so long as the staff are child-centred, have opportunities for training and development and are supported by strong leaders. Moreover, there could be considerable benefits for CYP with mental health needs and their families if opportunities are made available for the NHS and the voluntary sector to learn from each other.

• Limitations and strengths of the study

All research studies have limitations and in this section the limitations of the various aspects of the study are considered in turn, together with some overall limitations. Some comments are also made throughout about the study’s strengths.

Systematic reviews

As there was a common data pool for the effectiveness and perceptions reviews, the principal issue was the same for both: having to manage an unexpectedly large pool of literature. Although this was clearly related to the issue of how self-care is conceptualised in mental health, the sheer size of the returns we got from our searches and the time available for the systematic reviews meant that we had to make some post hoc, pragmatic decisions, and these decisions, while rational, may have introduced bias into the process. For example, searching electronically in Reference Manager and the Access databases to screen out irrelevant papers on the basis of title or abstract meant that we may have overlooked some relevant papers that manual inspection may have picked up. In hindsight, our search strategy may have been too inclusive although, given that self-care is an unexplored area in CYP’s mental health, we are confident that it needed to be broad.

The reason for the date from which we searched – 1 January 1995 – may have been tenuous, though again the decisions made were rational: it was the date used in our previous self-care support study 15 and the year in which major organisational change came about in UK CAMHS provision; 38 however, this latter point has less relevance to the international literature.

The effectiveness review and meta-analysis were limited in several ways. Firstly, the post hoc decision to exclude those RCTs with only short-term (postintervention) effectiveness data meant that we had a manageable number of RCTs to describe and meta-analyse, but it also meant that we may have missed some important findings in these studies. Nevertheless, there was an advantage in selecting only those RCTs with longer-term effectiveness data in that sustainable interventions are of more interest to policy-makers and practitioners. A second limitation was the generally poor quality of the included trials. Although we did not include a full Cochrane risk of bias analysis in the effectiveness review, we nonetheless explored the most significant risk – concealment of allocation – finding only seven and nine ‘high-quality’ RCTs at 6- and 12-month follow-ups, respectively. A further limitation is that we did not include cost-effectiveness as a factor in exploring mental health self-care support interventions for CYP.

The perceptions review was limited by the sizeable number of poor-quality studies. For the qualitative aspect, it was also confounded by a relatively small number of studies: just 33 in total, of which only 13 made it through qualitative appraisal. Moreover, of these, only two met all seven of the quality criteria on the quality appraisal tool used. For the quantitative aspect, there were no studies that collected numerical satisfaction data independently of a trial, i.e. all of the satisfaction data were nested within a trial of some sort, controlled or uncontrolled. Furthermore, almost all of these data – including those obtained from high-quality RCTs – were obtained from unvalidated, local satisfaction measures or tentative ‘proxy’ measures, such as attendance at sessions. Standardised statistics such as means and standard deviations were rarely reported; it was unfeasible, therefore, to conduct a second meta-analysis using ‘satisfaction’ as an outcome. It was also difficult to make any sort of quality judgement on the quantitative satisfaction data; indeed, it would have been rational to exclude all of the quantitative satisfaction data, but this would have left us without a ‘majority’ perspective to counterbalance the individual perceptions obtained from the qualitative studies. Again, therefore, a post hoc pragmatic decision was made and only studies initially qualifying for the effectiveness review were included.

Nevertheless, the size of the review is also one of its strengths in that we were able to give a broad overview of recent effectiveness evidence and explore some factors that may or may not be associated with outcome.

Service mapping

The service mapping stage was designed to enable us to provide a descriptive overview of mental health self-care support services for CYP in England and Wales, and was dependent on detective work on our behalf and the information that was volunteered by the networks we had contacted. To a large extent, service mapping is the process of trying to identify the ‘population’ of a particular service, and this brings about an inherent problem: in trying to identify, with little prior information, all members of a population, concepts like ‘sample’ or ‘response rate’ are meaningless. We thus have no way of knowing whether the services that we identified are the total population of mental health self-care support services for CYP in England and Wales, or a sample. If they are a sample, we likewise are unclear whether the sample is large or small, or whether or not it is representative of the total population. We are thus unable to say with any degree of confidence that we have produced a comprehensive overview of self-care support services in England and Wales, and although this is not a fatal aspect of our study, it does nevertheless have some bearing on the case study element in that the service map provided the sampling frame for our case study sites.

We could have been more assertive with the service mapping element by, for example, conducting a postal, telephone or online survey across the major statutory and non-statutory providers. However, we do not know whether or not the considerable additional resources required for this (especially in relation to postal and telephone surveys) would have elicited any more information than that which we gleaned using the methods we employed. Indeed, our experiences of an online survey in our previous study 15 suggested that it would not, and this, together with the generally low response rate in postal surveys of health-care professionals, 233 explains our approach here. There is nonetheless an argument for carrying out a more comprehensive service mapping exercise, and we make this one of our recommendations for further research.

A further limitation here involved the difficulties we had in tracking down sufficient information about potentially eligible services, when we only had very limited information about a service, such as its name or details of a website or a contact number. Following up these leads required considerable effort on our behalf, and numerous e-mails and telephone calls went unanswered, for a variety of reasons that we can only speculate on (the service having closed without our knowledge or the service having only a single member of staff, for example).

In selecting the case studies, we were careful to ensure that all of the typology and other relevant dimensions were considered, so that we obtained views on a range of different services. We also tried to ensure that we sought views from all stakeholders – CYP, parents and staff – at each of the sites. Although our case study sites are representative of the self-care support sites we identified in the service mapping, it is unknown how transferable they are to mental health self-care support services for CYP in general, given that we do not know what the true population of such services is. That our case study findings have resonance with other findings on CYP’s mental health services in the literature does, however, suggest some degree of transferability.

Regarding the source of our data for the case studies – CYP, parents and staff – there could be an inherent bias in that we were able only to speak to CYP and parents who had remained with a service. It was not possible for logistical and ethical reasons to recruit CYP or parents who had ‘dropped out’ of the services. In addition, although we managed to obtain ‘virtual’ non-participation observation at our online case study site, we could perhaps have enhanced our data pool by observing sessions at some of the other case study sites. Apart from the fact that it was not part of our original plan to obtain data by such means, there were several other reasons for not carrying out more general non-participation observation, including the ethical complexities of observing, rather than asking for views about, treatment and the practicalities of arranging it.

We outlined in Chapter 5 that the interview format was dictated largely by pragmatism, and that we allowed the sites and individual participants to determine the format most convenient for them. Given the views in the Choice and flexibility theme discussed earlier in this chapter, this was a somewhat fortuitous decision, though it is not without limitations. In the joint CYP–parent interviews, for example, we do not know the extent to which the presence of a parent influenced what the child or young person had to say, nor whether we would have obtained different data had the parent and the child or young person been interviewed separately. On the other hand, the variety of interview formats employed could be seen as a strength of the study in that we still managed to obtain some strong views from CYP regardless of whether parents were present in the interview or not, and the choice and flexibility offered may well have helped recruitment.

That we only managed to interview one young person at site 6 might be seen as inadequate if taken in isolation. However, as part of a collective case study designed to elicit a broad appreciation of a particular issue (see Chapter 5 , Design ), we are confident that the limited site 6 data have some value.

Across all stages of the study

Our experiences in conducting this study demonstrate that self-care support in CYP’s mental health is a complex area; there are multiple conditions, a variety of theoretical perspectives (though one or two dominate), widely different content in the services and interventions, and a range of agents and different intervention levels (most notably preventative vs. management interventions). Obviously, self-care support was a common feature of all the services and interventions. However, it may be that the multiple dimensions involved resulted in a somewhat unwieldy study that could have been better co-ordinated had we concentrated on a few specific aspects (e.g. interventions for CYP with mood disorders only) or, given our earlier discussion, avoided confounding management-level and preventative interventions and services by only studying one or the other. Nevertheless, there has been an advantage in exploring so many dimensions in that we are aware of where there are shortfalls in the knowledge, for example in relation to CYP with psychosis or an eating disorder or those who self-harm, and in relation to the use of technology.

Patient and public involvement in the study

One of the study’s strengths was its PPI. We had a significant advantage in this study in that it was planned and conducted with the support and involvement – as co-investigator – of YoungMinds, a specialist mental health charity for CYP and their carers. This was the first time that YoungMinds had been involved in NIHR-commissioned research, and the experience has led to further collaborations, including YoungMinds’ involvement in another NIHR-commissioned research study in which the principal investigator of the present study (Pryjmachuk) is a co-investigator. 7

As with most research projects, there were unexpected issues that prevented us from involving YoungMinds to the extent that we had anticipated. We originally intended to have a separate SAG made up of CYP only. However, when consulting with YoungMinds and other members of the stakeholder group, the consensus was that the CYP known to YoungMinds would be assertive enough to attend a single stakeholder group, and there was thus no need for a separate group. We planned to invite members of YoungMinds’ Very Important Kids (VIKs) – a group of CYP aged 11–24 years who advise YoungMinds on policy and campaign objectives – to this stakeholder group, but we were, unfortunately, unable to recruit any of the VIKs. We did, however, manage to recruit a project worker for the VIKs to the stakeholder group, who spoke on their behalf.

We did manage to involve the VIKs and some other CYP in some aspects of the study; they helped us out with the recruitment documentation for the case study element, giving us feedback about the age appropriateness and readability of the participant information sheets and consent/assent forms. We did plan to put the final results of the study to the VIKs for their views and for their assistance in ensuring that CYP could understand what we had found, but unfortunately, the VIK project ended during this study when its 3-year Big Lottery funding came to an end. Nonetheless, the final results have been put to a SAG that included advocates for CYP and parents, as well as representatives of health, education and social care.

• Conclusions

The aims of this study were to identify and evaluate the types of mental health self-care support used by, and available to, CYP and their parents, and to establish how such support interfaces with statutory and non-statutory service provision. Through two inter-related systematic reviews, a mapping exercise and a case study, we are confident that we have achieved these aims. Moreover, in doing so, we have developed a model of self-care support that can help policy-makers and practitioners make decisions about the organisation and delivery of mental health self-care support for CYP and their families, and help researchers identify gaps in the knowledge base that might be resolved with future research in this area.

Contribution of the study

This study makes a contribution to the knowledge base by being the first to formally explore self-care support in the context of CYP’s mental health, an area that is generally under-researched. It is also unique in that it has considered the evidence from a variety of perspectives – including both effectiveness and stakeholder views evidence – and has attempted to integrate those perspectives into a meaningful synthesis.

Implications for health care

In term of implications for policy and practice, we note the following:

• that self-care support in CYP’s mental health requires a partnership between service providers, the CYP and those who provide care for them
• that CYP and their families want ongoing support from, and contact with, services
• that the means by which professionals can support CYP and their families to self-care are not generally considered in the education and training of those working in all four tiers of CAMHS provision
• that effective services need not necessarily be delivered by mental health-trained staff or by NHS organisations – it is the child-centred skills and attributes of the individuals and organisations that are important
• that choice and flexibility seem to be important aspects of self-care support in CYP’s mental health, but true choice from a range of interventions is rarely available to CYP (although the continual rollout of the CYP’s IAPT project may resolve this)
• that practitioners working in CYP’s mental health rarely consider a child or young person’s readiness to engage with a service or commence an intervention
• that it is important that outcomes other than those relating to mental health symptoms are considered.

Recommendations for research

We make the following recommendations for research into mental health self-care support for CYP, in order of priority:

• that, because of under-representation in our data, research be undertaken on the potential for self-care support in the more serious mental health problems of psychosis, eating disorders and self-harm
• that, because of the surprisingly little work on the use and role of technology in self-care support for CYP’s mental health and a lack of consensus on its potential value, research be undertaken exploring the advantages and disadvantages of using computer and internet technology in self-care support
• that, because there were differences in perceptions of, and satisfaction with, services and interventions, both among CYP and between CYP and adults, more work is conducted on unpicking these differences
• that, because it is a relatively unexplored, yet important concept in self-care support, the concept of readiness to self-care be explored further
• that, because it is a relatively unexplored area and there were some potentially valuable findings from our study, research on leadership in CAMHS be commissioned
• that further research be undertaken on how self-care is conceptualised in CYP’s mental health and, in particular, its links to concepts such as recovery and resilience
• that, because of the limited service mapping data provided, a more systematic and comprehensive mapping exercise of self-care support services in CYP’s mental health be carried out
• that work be undertaken on the cost-effectiveness of providing self-care support in CYP’s mental health
• that there is more testing of interventions and services in real-life environments compared with laboratory or clinical environments (i.e. research on efficacy rather than effectiveness).

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• Cite this Page Pryjmachuk S, Elvey R, Kirk S, et al. Developing a model of mental health self-care support for children and young people through an integrated evaluation of available types of provision involving systematic review, meta-analysis and case study. Southampton (UK): NIHR Journals Library; 2014 Jun. (Health Services and Delivery Research, No. 2.18.) Chapter 6, Discussion and conclusion.
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Psychology Case Study Examples

Experiments are often used to help researchers understand how the human mind works. There have been many famous examples in psychology over the years. Some have shown how phenomena like memory and personality work. Others have been disproven over time. Understanding the study design, data, content, and analytical approach of case studies is important to verifying the validity of each study.

In considering case studies, researchers continuously test and reevaluate the conclusions made by past psychologists to continue offering the most up-to-date and effective care to modern clients. Prospective case studies are continually being developed based on previous findings and multiple case studies done in one area can lend credence to the findings. Learning about the famous psychology case studies can help you understand how research continues to shape what psychologists know about the human experience and mind. 

Examples of the most famous case study in psychology

Hundreds of thousands of case studies have been done in psychology, and narrowing a list of the most ground-breaking studies can be challenging. However, the following seven case studies present findings that have defied expectations, achieved positive outcomes for humanity, and launched further research into existing knowledge gaps within the niche.

Phineas Gage

The case of Phineas Gage is perhaps the  most cited study  in psychology. This famous case study showed how different areas of the brain affect personality and cognitive ability. While working as a construction foreman on a railroad, Phineas Gage was involved in an accident in which a rod was pushed through his cheek and brain. He survived, but because of the accident, both his personality and his ability to learn new skills were affected.

Although the case is frequently cited and referenced in psychology, relatively little information about Gage's life before and after the accident is known. Researchers have discovered that the last two decades of his life were spent in his original job, which may have been unlikely to have been possible if the extent of his injuries were as severe as initially believed. Still, his case was a starting point for psychology research on how memory and personality work in the brain, and it is a seminal study for that reason.

Genie the "feral child"

Although an outdated term, "feral children" referred to children raised without human interaction, often due to abuse or neglect. One famous case study of a neglected child was done with a child known as Genie. She was raised in a single bedroom with little human interaction. She never gained the cognitive ability of an average adult, even though she was found at age 13. Later in life, she regressed and stopped speaking altogether. Her case has been studied extensively by psychologists who want to understand how enculturation affects cognitive development. It's one of many cognitive psychology examples that have had an impact on this field.

If you or a loved one is experiencing abuse, contact the Domestic Violence Hotline at 1-800-799-SAFE (7233). Support is available 24/7.

If you are experiencing trauma, support is available. Please see our Get Help Now page for more resources.

Henry Molaison

The case study  of Henry Molaison has helped psychologists understand memory. It is one of the most famous case studies in neuroscience. Henry Molaison was in a childhood accident that left him with debilitating seizures. Doctors could stop the seizures by removing slivers of his brain's hippocampus, though they did not fully understand what they were doing at the time. As a result, scientists learned how important the hippocampus is to forming long-term memories. After the surgery, Molaison could no longer form long-term memories, and his short-term memory was brief. The case study started further research into memory and the brain.

Jill Price had one of a few documented cases of hyperthymesia, a term for an overactive memory that allowed her to remember such mundane things as what she had for dinner on an average day in August 20th years previously. Her  case study  was used as a jumping-off point to research how memory works and why some people have exceptional memories. 

However, through more research, it was discovered that her overall memory was not exceptional. Rather, she only remembered details of her own life. She was diagnosed with obsessive-compulsive disorder (OCD), with memories being part of her obsession. This case study is still relevant because it has helped modern psychologists understand how mental illness affects memory.

In the John/Joan  case study , a reputable sexologist tested his theory that nurture, not nature, determined gender. The case study has been cited extensively and laid the groundwork for other research into gender identity. However, the case study was not legitimate. In this study, Dr. John Money performed surgery on an infant whose genitals were damaged during circumcision. 

The boy was raised as a girl; however, he never identified as female and eventually underwent gender-affirming surgery as an adult. Because Dr. Money didn't follow up with the patient appropriately and did not report adverse findings, the case study is still often cited as successful.

Anna O. was the pseudonym given to a German woman who was one of the first to undergo psychoanalysis. Her case inspired many of the theories of Freud and other prominent psychologists of the time. It was determined at the time that Anna's symptoms of depression were eliminated through talk therapy. More recently, it has been suggested that Anna O. had another illness, such as epilepsy, from which she may have recovered during the therapy. This  case study is still cited as a reason psychologists believe that psychotherapy, or talk therapy, can be helpful to many patients. 

Victor the "wild boy" of Aveyron

Another study done on a child that had grown up without parents was done with a boy named "Victor" who had been found wandering in the wilderness and was thought to have been living alone for years. The boy could not speak, use the bathroom, or connect with others. However, through the study of his condition, he was able to learn bathroom habits, how to dress, writing, and primary language. Psychologists today speculate that he may have been autistic. 

Ethical concerns for doing a case study

When case studies are flawed through not having enough information or having the wrong information, they can be harmful. Valuable research hours and other resources can be wasted while theories are used for inappropriate treatment. Case studies can therefore cause as much harm as benefit, and psychologists are often careful about how and when they are used.

Those who are not psychologists and are interacting with studies can also practice caution. Psychologists and doctors often disagree on how case studies should be applied. In addition, people without education in psychology may struggle to know whether a case study is built on a faulty premise or misinformation. It can also be possible to generalize case studies to situations they do not apply. If you think a case study might apply to your case or that of a loved one, consider asking a therapist for guidance. 

Case studies are descriptions of real people. The individuals in the studies are studied intensively and often written about in medical journals and textbooks. While some clients may be comfortable being studied for science, others may not have consented due to the inability or lack of consent laws at the time. In addition, some subjects may not have been treated with dignity and respect. 

When considering case study content and findings from psychology, it can be helpful to think of the cases as stories of real individuals. When you strip away the science and look at the case as a whole person in a unique situation, you may get more out of the study than if you look at it as research that proves a theory. 

Therapeutic implications of a case study

Case examples are sometimes used in therapy to determine the best course of treatment. If a typical case study from psychology aligns with your situation, your therapist may use the treatment methods outlined in the study. Psychiatrists and other mental health professionals also use case examples to understand mental illness and its treatment.

Researchers have reviewed the role of case studies in counseling and psychotherapy. In one study, the authors discussed how reading case studies benefits therapists, providing a conceptual guide for clinical work and an understanding of the theory behind the practice. They also stressed the importance of teaching psychotherapy trainees to do better case study research. They encouraged practitioners to publish more case studies documenting the methods they use in their practice.

How a case study is used in counseling

If you want to meet with a psychologist, counseling may benefit you. Therapists often use theories behind popular case studies and can discuss their implications with you. In addition, you may be able to participate in case studies in your area, as psychologists and psychiatrists often perform clinical trials to understand treatments on a deeper level.

Online therapy can also be beneficial if you cannot find a therapist in your area. Through a platform like BetterHelp, you can get matched with a provider meeting your needs and choose between phone, video, or live chat sessions. When experiencing symptoms of a mental health condition, it can sometimes be hard to leave home for therapy. You can use many online therapy platforms from the comfort and safe space of your own home. 

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Henry Gustav Molaison: The Curious Case of Patient H.M. 

Erin Heaning

Clinical Safety Strategist at Bristol Myers Squibb

Psychology Graduate, Princeton University

Erin Heaning, a holder of a BA (Hons) in Psychology from Princeton University, has experienced as a research assistant at the Princeton Baby Lab.

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Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

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

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

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

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

On This Page:

Henry Gustav Molaison, known as Patient H.M., is a landmark case study in psychology. After a surgery to alleviate severe epilepsy, which removed large portions of his hippocampus , he was left with anterograde amnesia , unable to form new explicit memories , thus offering crucial insights into the role of the hippocampus in memory formation.

• Henry Gustav Molaison (often referred to as H.M.) is a famous case of anterograde and retrograde amnesia in psychology.
• H. M. underwent brain surgery to remove his hippocampus and amygdala to control his seizures. As a result of his surgery, H.M.’s seizures decreased, but he could no longer form new memories or remember the prior 11 years of his life.
• He lost his ability to form many types of new memories (anterograde amnesia), such as new facts or faces, and the surgery also caused retrograde amnesia as he was able to recall childhood events but lost the ability to recall experiences a few years before his surgery.
• The case of H.M. and his life-long participation in studies gave researchers valuable insight into how memory functions and is organized in the brain. He is considered one of the most studied medical and psychological history cases.

Who is H.M.?

Henry Gustav Molaison, or “H.M” as he is commonly referred to by psychology and neuroscience textbooks, lost his memory on an operating table in 1953.

For years before his neurosurgery, H.M. suffered from epileptic seizures believed to be caused by a bicycle accident that occurred in his childhood. The seizures started out as minor at age ten, but they developed in severity when H.M. was a teenager.

Continuing to worsen in severity throughout his young adulthood, H.M. was eventually too disabled to work. Throughout this period, treatments continued to turn out unsuccessful, and epilepsy proved a major handicap and strain on H.M.’s quality of life.

And so, at age 27, H.M. agreed to undergo a radical surgery that would involve removing a part of his brain called the hippocampus — the region believed to be the source of his epileptic seizures (Squire, 2009).

For epilepsy patients, brain resection surgery refers to removing small portions of brain tissue responsible for causing seizures. Although resection is still a surgical procedure used today to treat epilepsy, the use of lasers and detailed brain scans help ensure valuable brain regions are not impacted.

In 1953, H.M.’s neurosurgeon did not have these tools, nor was he or the rest of the scientific or medical community fully aware of the true function of the hippocampus and its specific role in memory. In one regard, the surgery was successful, as H.M. did, in fact, experience fewer seizures.

However, family and doctors soon noticed he also suffered from severe amnesia, which persisted well past when he should have recovered. In addition to struggling to remember the years leading up to his surgery, H.M. also had gaps in his memory of the 11 years prior.

Furthermore, he lacked the ability to form new memories — causing him to perpetually live an existence of moment-to-moment forgetfulness for decades to come.

In one famous quote, he famously and somberly described his state as “like waking from a dream…. every day is alone in itself” (Squire et al., 2009).

H.M. soon became a major case study of interest for psychologists and neuroscientists who studied his memory deficits and cognitive abilities to better understand the hippocampus and its function.

When H.M. died on December 2, 2008, at the age of 82, he left behind a lifelong legacy of scientific contribution.

Surgical Procedure

Neurosurgeon William Beecher Scoville performed H.M.’s surgery in Hartford, Connecticut, in August 1953 when H.M. was 27 years old.

During the procedure, Scoville removed parts of H.M.’s temporal lobe which refers to the portion of the brain that sits behind both ears and is associated with auditory and memory processing.

More specifically, the surgery involved what was called a “partial medial temporal lobe resection” (Scoville & Milner, 1957). In this resection, Scoville removed 8 cm of brain tissue from the hippocampus — a seahorse-shaped structure located deep in the temporal lobe .

Bilateral resection of the anterior temporal lobe in patient HM.

Further research conducted after this removal showed Scoville also probably destroyed the brain structures known as the “uncus” (theorized to play a role in the sense of smell and forming new memories) and the “amygdala” (theorized to play a crucial role in controlling our emotional responses such as fear and sadness).

As previously mentioned, the removal surgery partially reduced H.M.’s seizures; however, he also lost the ability to form new memories.

At the time, Scoville’s experimental procedure had previously only been performed on patients with psychosis, so H.M. was the first epileptic patient and showed no sign of mental illness. In the original case study of H.M., which is discussed in further detail below, nine of Scoville’s patients from this experimental surgery were described.

However, because these patients had disorders such as schizophrenia, their symptoms were not removed after surgery.

In this regard, H.M. was the only patient with “clean” amnesia along with no other apparent mental problems.

H.M’s Amnesia

H.M.’s apparent amnesia after waking from surgery presented in multiple forms. For starters, H.M. suffered from retrograde amnesia for the 11-year period prior to his surgery.

Retrograde describes amnesia, where you can’t recall memories that were formed before the event that caused the amnesia. Important to note, current research theorizes that H.M.’s retrograde amnesia was not actually caused by the loss of his hippocampus, but rather from a combination of antiepileptic drugs and frequent seizures prior to his surgery (Shrader 2012).

In contrast, H.M.’s inability to form new memories after his operation, known as anterograde amnesia, was the result of the loss of the hippocampus.

This meant that H.M. could not learn new words, facts, or faces after his surgery, and he would even forget who he was talking to the moment he walked away.

However, H.M. could perform tasks, and he could even perform those tasks easier after practice. This important finding represented a major scientific discovery when it comes to memory and the hippocampus. The memory that H.M. was missing in his life included the recall of facts, life events, and other experiences.

This type of long-term memory is referred to as “explicit” or “ declarative ” memories and they require conscious thinking.

In contrast, H.M.’s ability to improve in tasks after practice (even if he didn’t recall that practice) showed his “implicit” or “ procedural ” memory remained intact (Scoville & Milner, 1957). This type of long-term memory is unconscious, and examples include riding a bike, brushing your teeth, or typing on a keyboard.

Most importantly, after removing his hippocampus, H.M. lost his explicit memory but not his implicit memory — establishing that implicit memory must be controlled by some other area of the brain and not the hippocampus.

After the severity of the side effects of H.M.’s operation became clear, H.M. was referred to neurosurgeon Dr. Wilder Penfield and neuropsychologist Dr. Brenda Milner of Montreal Neurological Institute (MNI) for further testing.

As discussed, H.M. was not the only patient who underwent this experimental surgery, but he was the only non-psychotic patient with such a degree of memory impairment. As a result, he became a major study and interest for Milner and the rest of the scientific community.

Since Penfield and Milner had already been conducting memory experiments on other patients at the time, they quickly realized H.M.’s “dense amnesia, intact intelligence, and precise neurosurgical lesions made him a perfect experimental subject” (Shrader 2012).

Milner continued to conduct cognitive testing on H.M. for the next fifty years, primarily at the Massachusetts Institute of Technology (MIT). Her longitudinal case study of H.M.’s amnesia quickly became a sensation and is still one of the most widely-cited psychology studies.

In publishing her work, she protected Henry’s identity by first referring to him as the patient H.M. (Shrader 2012).

In the famous “star tracing task,” Milner tested if H.M.’s procedural memory was affected by the removal of the hippocampus during surgery.

In this task, H.M. had to trace an outline of a star, but he could only trace the star based on the mirrored reflection. H.M. then repeated this task once a day over a period of multiple days.

Over the course of these multiple days, Milner observed that H.M. performed the test faster and with fewer errors after continued practice. Although each time he performed the task, he had no memory of having participated in the task before, his performance improved immensely (Shrader 2012).

As this task showed, H.M. had lost his declarative/explicit memory, but his unconscious procedural/implicit memory remained intact.

Given the damage to his hippocampus in surgery, researchers concluded from tasks such as these that the hippocampus must play a role in declarative but not procedural memory.

Therefore, procedural memory must be localized somewhere else in the brain and not in the hippocampus.

H.M’s Legacy

Milner’s and hundreds of other researchers’ work with H.M. established fundamental principles about how memory functions and is organized in the brain.

Without the contribution of H.M. in volunteering the study of his mind to science, our knowledge today regarding the separation of memory function in the brain would certainly not be as strong.

Until H.M.’s watershed surgery, it was not known that the hippocampus was essential for making memories and that if we lost this valuable part of our brain, we would be forced to live only in the moment-to-moment constraints of our short-term memory .

Once this was realized, the findings regarding H.M. were widely publicized so that this operation to remove the hippocampus would never be done again (Shrader 2012).

H.M.’s case study represents a historical time period for neuroscience in which most brain research and findings were the result of brain dissections, lesioning certain sections, and seeing how different experimental procedures impacted different patients.

Therefore, it is paramount we recognize the contribution of patients like H.M., who underwent these dangerous operations in the mid-twentieth century and then went on to allow researchers to study them for the rest of their lives.

Even after his death, H.M. donated his brain to science. Researchers then took his unique brain, froze it, and then in a 53-hour procedure, sliced it into 2,401 slices which were then individually photographed and digitized as a three-dimensional map.

Through this map, H.M.’s brain could be preserved for posterity (Wb et al., 2014). As neuroscience researcher Suzanne Corkin once said it best, “H.M. was a pleasant, engaging, docile man with a keen sense of humor, who knew he had a poor memory but accepted his fate.

There was a man behind the data. Henry often told me that he hoped that research into his condition would help others live better lives. He would have been proud to know how much his tragedy has benefitted science and medicine” (Corkin, 2014).

Corkin, S. (2014). Permanent present tense: The man with no memory and what he taught the world. Penguin Books.

Hardt, O., Einarsson, E. Ö., & Nader, K. (2010). A bridge over troubled water: Reconsolidation as a link between cognitive and neuroscientific memory research traditions. Annual Review of Psychology, 61, 141–167.

Scoville, W. B., & Milner, B. (1957). Loss of recent memory after bilateral hippocampal lesions . Journal of neurology, neurosurgery, and psychiatry, 20 (1), 11.

Shrader, J. (2012, January). HM, the man with no memory | Psychology Today. Retrieved from, https://www.psychologytoday.com/us/blog/trouble-in-mind/201201/hm-the-man-no-memory

Squire, L. R. (2009). The legacy of patient H. M. for neuroscience . Neuron, 61 , 6–9.

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Key Study: HM’s case study (Milner and Scoville, 1957)

Travis Dixon January 29, 2019 Biological Psychology , Cognitive Psychology , Key Studies

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HM’s case study is one of the most famous and important case studies in psychology, especially in cognitive psychology. It was the source of groundbreaking new knowledge on the role of the hippocampus in memory. 

Background Info

“Localization of function in the brain” means that different parts of the brain have different functions. Researchers have discovered this from over 100 years of research into the ways the brain works. One such study was Milner’s case study on Henry Molaison.

The memory problems that HM experienced after the removal of his hippocampus provided new knowledge on the role of the hippocampus in memory formation (image: wikicommons)

At the time of the first study by Milner, HM was 29 years old. He was a mechanic who had suffered from minor epileptic seizures from when he was ten years old and began suffering severe seizures as a teenager. These may have been a result of a bike accident when he was nine. His seizures were getting worse in severity, which resulted in HM being unable to work. Treatment for his epilepsy had been unsuccessful, so at the age of 27 HM (and his family) agreed to undergo a radical surgery that would remove a part of his brain called the hippocampus . Previous research suggested that this could help reduce his seizures, but the impact it had on his memory was unexpected. The Doctor performing the radical surgery believed it was justified because of the seriousness of his seizures and the failures of other methods to treat them.

Methods and Results

In one regard, the surgery was successful as it resulted in HM experiencing less seizures. However, immediately after the surgery, the hospital staff and HM’s family noticed that he was suffering from anterograde amnesia (an inability to form new memories after the time of damage to the brain):

Here are some examples of his memory loss described in the case study:

• He could remember something if he concentrated on it, but if he broke his concentration it was lost.
• After the surgery the family moved houses. They stayed on the same street, but a few blocks away. The family noticed that HM as incapable of remembering the new address, but could remember the old one perfectly well. He could also not find his way home alone.
• He could not find objects around the house, even if they never changed locations and he had used them recently. His mother had to always show him where the lawnmower was in the garage.
• He would do the same jigsaw puzzles or read the same magazines every day, without ever apparently getting bored and realising he had read them before. (HM loved to do crossword puzzles and thought they helped him to remember words).
• He once ate lunch in front of Milner but 30 minutes later was unable to say what he had eaten, or remember even eating any lunch at all.
• When interviewed almost two years after the surgery in 1955, HM gave the date as 1953 and said his age was 27. He talked constantly about events from his childhood and could not remember details of his surgery.

Later testing also showed that he had suffered some partial retrograde amnesia (an inability to recall memories from before the time of damage to the brain). For instance, he could not remember that one of his favourite uncles passed away three years prior to his surgery or any of his time spent in hospital for his surgery. He could, however, remember some unimportant events that occurred just before his admission to the hospital.

Brenda Milner studied HM for almost 50 years – but he never remembered her.

Results continued…

His memories from events prior to 1950 (three years before his surgery), however, were fine. There was also no observable difference to his personality or to his intelligence. In fact, he scored 112 points on his IQ after the surgery, compared with 104 previously. The IQ test suggested that his ability in arithmetic had apparently improved. It seemed that the only behaviour that was affected by the removal of the hippocampus was his memory. HM was described as a kind and gentle person and this did not change after his surgery.

The Star Tracing Task

In a follow up study, Milner designed a task that would test whether or not HMs procedural memory had been affected by the surgery. He was to trace an outline of a star, but he could only see the mirrored reflection. He did this once a day over a period of a few days and Milner observed that he became faster and faster. Each time he performed the task he had no memory of ever having done it before, but his performance kept improving. This is further evidence for localization of function – the hippocampus must play a role in declarative (explicit) memory but not procedural (implicit) memory.

Cognitive psychologists have categorized memories into different types. HM’s study suggests that the hippocampus is essential for explicit (conscious) and declarative memory, but not implicit (unconscious) procedural memory.

Was his memory 100% gone? Another follow-up study

Interestingly, HM showed signs of being able to remember famous people who had only become famous after his surgery, like Lee Harvey Oswald (who assassinated JFK in 1963). (Image: wikicommons)

Another fascinating follow-up study was conducted by two researchers who wanted to see if HM had learned anything about celebrities that became famous after his surgery. At first they tested his knowledge of celebrities from before his surgery, and he knew these just as well as controls. They then showed him two names at a time, one a famous name (e.g. Liza Minelli, Lee Harvey Oswald) and the other was a name randomly taken from the phonebook. He was asked to choose the famous name and he was correct on a significant number of trials (i.e. the statistics tests suggest he wasn’t just guessing). Even more incredible was that he remembered some details about these people when asked why they were famous. For example, he could remember that Lee Harvey Oswald assassinated the president. One explanation given for the memory of these facts is that there was an emotional component. E.g. He liked these people, or the assassination was so violent, that he could remember a few details. 

HM became a hugely important case study for neuro and cognitive Psychologists. He was interviewed and tested by over 100 psychologists during the 53 years after his operation. Directly after his surgery, he lived at home with his parents as he was unable to live independently. He moved to a nursing home in 1980 and stayed there until his death in 2008. HM donated his brain to science and it was sliced into 2,401 thin slices that will be scanned and published electronically.

Critical Thinking Considerations

• How does this case study demonstrate localization of function in the brain? (e.g.c reating new long-term memories; procedural memories; storing and retrieving long term memories; intelligence; personality) ( Application )
• What are the ethical considerations involved in this study? ( Analysis )
• What are the strengths and limitations of this case study? ( Evaluation )
• Why would ongoing studies of HM be important? (Think about memory, neuroplasticity and neurogenesis) ( Analysis/Synthesis/Evaluation )
• How can findings from this case study be used to support and/or challenge the Multi-store Model of Memory? ( Application / Synthesis/Evaluation )

Exam Tips This study can be used for the following topics: Localization – the role of the hippocampus in memory Techniques to study the brain – MRI has been used to find out the exact location and size of damage to HM’s brain Bio and cognitive approach research method s – case study Bio and cognitive approach ethical considerations – anonymity Emotion and cognition – the follow-up study on HM and memories of famous people could be used in an essay to support the idea that emotion affects memory Models of memory – the multi-store model : HM’s study provides evidence for the fact that our memories all aren’t formed and stored in one place but travel from store to store (because his transfer from STS to LTS was damaged – if it was all in one store this specific problem would not occur)

Milner, Brenda. Scoville, William Beecher. “Loss of Recent Memory after Bilateral Hippocampal Lesions”. The Journal of Neurology, Neurosurgery and Psychiatry. 1957; 20: 11 21. (Accessed from web.mit.edu )

The man who couldn’t remember”. nova science now. an interview with brenda corkin . 06.01.2009.       .

  Here’s a good video recreation documentary of HM’s case study…

Travis Dixon is an IB Psychology teacher, author, workshop leader, examiner and IA moderator.

15 Famous Experiments and Case Studies in Psychology

Psychology has seen thousands upon thousands of research studies over the years. Most of these studies have helped shape our current understanding of human thoughts, behavior, and feelings.

The psychology case studies in this list are considered classic examples of psychological case studies and experiments, which are still being taught in introductory psychology courses up to this day.

Some studies, however, were downright shocking and controversial that you’d probably wonder why such studies were conducted back in the day. Imagine participating in an experiment for a small reward or extra class credit, only to be left scarred for life. These kinds of studies, however, paved the way for a more ethical approach to studying psychology and implementation of research standards such as the use of debriefing in psychology research .

Case Study vs. Experiment

Before we dive into the list of the most famous studies in psychology, let us first review the difference between case studies and experiments.

• It is an in-depth study and analysis of an individual, group, community, or phenomenon. The results of a case study cannot be applied to the whole population, but they can provide insights for further studies.
• It often uses qualitative research methods such as observations, surveys, and interviews.
• It is often conducted in real-life settings rather than in controlled environments.
• An experiment is a type of study done on a sample or group of random participants, the results of which can be generalized to the whole population.
• It often uses quantitative research methods that rely on numbers and statistics.
• It is conducted in controlled environments, wherein some things or situations are manipulated.

See Also: Experimental vs Observational Studies

Famous Experiments in Psychology

1. the marshmallow experiment.

Psychologist Walter Mischel conducted the marshmallow experiment at Stanford University in the 1960s to early 1970s. It was a simple test that aimed to define the connection between delayed gratification and success in life.

The instructions were fairly straightforward: children ages 4-6 were presented a piece of marshmallow on a table and they were told that they would receive a second piece if they could wait for 15 minutes without eating the first marshmallow.

About one-third of the 600 participants succeeded in delaying gratification to receive the second marshmallow. Mischel and his team followed up on these participants in the 1990s, learning that those who had the willpower to wait for a larger reward experienced more success in life in terms of SAT scores and other metrics.

This case study also supported self-control theory , a theory in criminology that holds that people with greater self-control are less likely to end up in trouble with the law!

The classic marshmallow experiment, however, was debunked in a 2018 replication study done by Tyler Watts and colleagues.

This more recent experiment had a larger group of participants (900) and a better representation of the general population when it comes to race and ethnicity. In this study, the researchers found out that the ability to wait for a second marshmallow does not depend on willpower alone but more so on the economic background and social status of the participants.

2. The Bystander Effect

In 1694, Kitty Genovese was murdered in the neighborhood of Kew Gardens, New York. It was told that there were up to 38 witnesses and onlookers in the vicinity of the crime scene, but nobody did anything to stop the murder or call for help.

Such tragedy was the catalyst that inspired social psychologists Bibb Latane and John Darley to formulate the phenomenon called bystander effect or bystander apathy .

Subsequent investigations showed that this story was exaggerated and inaccurate, as there were actually only about a dozen witnesses, at least two of whom called the police. But the case of Kitty Genovese led to various studies that aim to shed light on the bystander phenomenon.

Latane and Darley tested bystander intervention in an experimental study . Participants were asked to answer a questionnaire inside a room, and they would either be alone or with two other participants (who were actually actors or confederates in the study). Smoke would then come out from under the door. The reaction time of participants was tested — how long would it take them to report the smoke to the authorities or the experimenters?

The results showed that participants who were alone in the room reported the smoke faster than participants who were with two passive others. The study suggests that the more onlookers are present in an emergency situation, the less likely someone would step up to help, a social phenomenon now popularly called the bystander effect.

3. Asch Conformity Study

Have you ever made a decision against your better judgment just to fit in with your friends or family? The Asch Conformity Studies will help you understand this kind of situation better.

In this experiment, a group of participants were shown three numbered lines of different lengths and asked to identify the longest of them all. However, only one true participant was present in every group and the rest were actors, most of whom told the wrong answer.

Results showed that the participants went for the wrong answer, even though they knew which line was the longest one in the first place. When the participants were asked why they identified the wrong one, they said that they didn’t want to be branded as strange or peculiar.

This study goes to show that there are situations in life when people prefer fitting in than being right. It also tells that there is power in numbers — a group’s decision can overwhelm a person and make them doubt their judgment.

4. The Bobo Doll Experiment

The Bobo Doll Experiment was conducted by Dr. Albert Bandura, the proponent of social learning theory .

Back in the 1960s, the Nature vs. Nurture debate was a popular topic among psychologists. Bandura contributed to this discussion by proposing that human behavior is mostly influenced by environmental rather than genetic factors.

In the Bobo Doll Experiment, children were divided into three groups: one group was shown a video in which an adult acted aggressively toward the Bobo Doll, the second group was shown a video in which an adult play with the Bobo Doll, and the third group served as the control group where no video was shown.

The children were then led to a room with different kinds of toys, including the Bobo Doll they’ve seen in the video. Results showed that children tend to imitate the adults in the video. Those who were presented the aggressive model acted aggressively toward the Bobo Doll while those who were presented the passive model showed less aggression.

While the Bobo Doll Experiment can no longer be replicated because of ethical concerns, it has laid out the foundations of social learning theory and helped us understand the degree of influence adult behavior has on children.

5. Blue Eye / Brown Eye Experiment

Following the assassination of Martin Luther King Jr. in 1968, third-grade teacher Jane Elliott conducted an experiment in her class. Although not a formal experiment in controlled settings, A Class Divided is a good example of a social experiment to help children understand the concept of racism and discrimination.

The class was divided into two groups: blue-eyed children and brown-eyed children. For one day, Elliott gave preferential treatment to her blue-eyed students, giving them more attention and pampering them with rewards. The next day, it was the brown-eyed students’ turn to receive extra favors and privileges.

As a result, whichever group of students was given preferential treatment performed exceptionally well in class, had higher quiz scores, and recited more frequently; students who were discriminated against felt humiliated, answered poorly in tests, and became uncertain with their answers in class.

This study is now widely taught in sociocultural psychology classes.

6. Stanford Prison Experiment

One of the most controversial and widely-cited studies in psychology is the Stanford Prison Experiment , conducted by Philip Zimbardo at the basement of the Stanford psychology building in 1971. The hypothesis was that abusive behavior in prisons is influenced by the personality traits of the prisoners and prison guards.

The participants in the experiment were college students who were randomly assigned as either a prisoner or a prison guard. The prison guards were then told to run the simulated prison for two weeks. However, the experiment had to be stopped in just 6 days.

The prison guards abused their authority and harassed the prisoners through verbal and physical means. The prisoners, on the other hand, showed submissive behavior. Zimbardo decided to stop the experiment because the prisoners were showing signs of emotional and physical breakdown.

Although the experiment wasn’t completed, the results strongly showed that people can easily get into a social role when others expect them to, especially when it’s highly stereotyped .

7. The Halo Effect

Have you ever wondered why toothpastes and other dental products are endorsed in advertisements by celebrities more often than dentists? The Halo Effect is one of the reasons!

The Halo Effect shows how one favorable attribute of a person can gain them positive perceptions in other attributes. In the case of product advertisements, attractive celebrities are also perceived as intelligent and knowledgeable of a certain subject matter even though they’re not technically experts.

The Halo Effect originated in a classic study done by Edward Thorndike in the early 1900s. He asked military commanding officers to rate their subordinates based on different qualities, such as physical appearance, leadership, dependability, and intelligence.

The results showed that high ratings of a particular quality influences the ratings of other qualities, producing a halo effect of overall high ratings. The opposite also applied, which means that a negative rating in one quality also correlated to negative ratings in other qualities.

Experiments on the Halo Effect came in various formats as well, supporting Thorndike’s original theory. This phenomenon suggests that our perception of other people’s overall personality is hugely influenced by a quality that we focus on.

8. Cognitive Dissonance

There are experiences in our lives when our beliefs and behaviors do not align with each other and we try to justify them in our minds. This is cognitive dissonance , which was studied in an experiment by Leon Festinger and James Carlsmith back in 1959.

In this experiment, participants had to go through a series of boring and repetitive tasks, such as spending an hour turning pegs in a wooden knob. After completing the tasks, they were then paid either $1 or $20 to tell the next participants that the tasks were extremely fun and enjoyable. Afterwards, participants were asked to rate the experiment. Those who were given $1 rated the experiment as more interesting and fun than those who received $20.

The results showed that those who received a smaller incentive to lie experienced cognitive dissonance — $1 wasn’t enough incentive for that one hour of painstakingly boring activity, so the participants had to justify that they had fun anyway.

Famous Case Studies in Psychology

9. little albert.

In 1920, behaviourist theorists John Watson and Rosalie Rayner experimented on a 9-month-old baby to test the effects of classical conditioning in instilling fear in humans.

This was such a controversial study that it gained popularity in psychology textbooks and syllabi because it is a classic example of unethical research studies done in the name of science.

In one of the experiments, Little Albert was presented with a harmless stimulus or object, a white rat, which he wasn’t scared of at first. But every time Little Albert would see the white rat, the researchers would play a scary sound of hammer and steel. After about 6 pairings, Little Albert learned to fear the rat even without the scary sound.

Little Albert developed signs of fear to different objects presented to him through classical conditioning . He even generalized his fear to other stimuli not present in the course of the experiment.

10. Phineas Gage

Phineas Gage is such a celebrity in Psych 101 classes, even though the way he rose to popularity began with a tragic accident. He was a resident of Central Vermont and worked in the construction of a new railway line in the mid-1800s. One day, an explosive went off prematurely, sending a tamping iron straight into his face and through his brain.

Gage survived the accident, fortunately, something that is considered a feat even up to this day. He managed to find a job as a stagecoach after the accident. However, his family and friends reported that his personality changed so much that “he was no longer Gage” (Harlow, 1868).

New evidence on the case of Phineas Gage has since come to light, thanks to modern scientific studies and medical tests. However, there are still plenty of mysteries revolving around his brain damage and subsequent recovery.

11. Anna O.

Anna O., a social worker and feminist of German Jewish descent, was one of the first patients to receive psychoanalytic treatment.

Her real name was Bertha Pappenheim and she inspired much of Sigmund Freud’s works and books on psychoanalytic theory, although they hadn’t met in person. Their connection was through Joseph Breuer, Freud’s mentor when he was still starting his clinical practice.

Anna O. suffered from paralysis, personality changes, hallucinations, and rambling speech, but her doctors could not find the cause. Joseph Breuer was then called to her house for intervention and he performed psychoanalysis, also called the “talking cure”, on her.

Breuer would tell Anna O. to say anything that came to her mind, such as her thoughts, feelings, and childhood experiences. It was noted that her symptoms subsided by talking things out.

However, Breuer later referred Anna O. to the Bellevue Sanatorium, where she recovered and set out to be a renowned writer and advocate of women and children.

12. Patient HM

H.M., or Henry Gustav Molaison, was a severe amnesiac who had been the subject of countless psychological and neurological studies.

Henry was 27 when he underwent brain surgery to cure the epilepsy that he had been experiencing since childhood. In an unfortunate turn of events, he lost his memory because of the surgery and his brain also became unable to store long-term memories.

He was then regarded as someone living solely in the present, forgetting an experience as soon as it happened and only remembering bits and pieces of his past. Over the years, his amnesia and the structure of his brain had helped neuropsychologists learn more about cognitive functions .

Suzanne Corkin, a researcher, writer, and good friend of H.M., recently published a book about his life. Entitled Permanent Present Tense , this book is both a memoir and a case study following the struggles and joys of Henry Gustav Molaison.

13. Chris Sizemore

Chris Sizemore gained celebrity status in the psychology community when she was diagnosed with multiple personality disorder, now known as dissociative identity disorder.

Sizemore has several alter egos, which included Eve Black, Eve White, and Jane. Various papers about her stated that these alter egos were formed as a coping mechanism against the traumatic experiences she underwent in her childhood.

Sizemore said that although she has succeeded in unifying her alter egos into one dominant personality, there were periods in the past experienced by only one of her alter egos. For example, her husband married her Eve White alter ego and not her.

Her story inspired her psychiatrists to write a book about her, entitled The Three Faces of Eve , which was then turned into a 1957 movie of the same title.

14. David Reimer

When David was just 8 months old, he lost his penis because of a botched circumcision operation.

Psychologist John Money then advised Reimer’s parents to raise him as a girl instead, naming him Brenda. His gender reassignment was supported by subsequent surgery and hormonal therapy.

Money described Reimer’s gender reassignment as a success, but problems started to arise as Reimer was growing up. His boyishness was not completely subdued by the hormonal therapy. When he was 14 years old, he learned about the secrets of his past and he underwent gender reassignment to become male again.

Reimer became an advocate for children undergoing the same difficult situation he had been. His life story ended when he was 38 as he took his own life.

15. Kim Peek

Kim Peek was the inspiration behind Rain Man , an Oscar-winning movie about an autistic savant character played by Dustin Hoffman.

The movie was released in 1988, a time when autism wasn’t widely known and acknowledged yet. So it was an eye-opener for many people who watched the film.

In reality, Kim Peek was a non-autistic savant. He was exceptionally intelligent despite the brain abnormalities he was born with. He was like a walking encyclopedia, knowledgeable about travel routes, US zip codes, historical facts, and classical music. He also read and memorized approximately 12,000 books in his lifetime.

This list of experiments and case studies in psychology is just the tip of the iceberg! There are still countless interesting psychology studies that you can explore if you want to learn more about human behavior and dynamics.

You can also conduct your own mini-experiment or participate in a study conducted in your school or neighborhood. Just remember that there are ethical standards to follow so as not to repeat the lasting physical and emotional harm done to Little Albert or the Stanford Prison Experiment participants.

Asch, S. E. (1956). Studies of independence and conformity: I. A minority of one against a unanimous majority. Psychological Monographs: General and Applied, 70 (9), 1–70. https://doi.org/10.1037/h0093718

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Elliott, J., Yale University., WGBH (Television station : Boston, Mass.), & PBS DVD (Firm). (2003). A class divided. New Haven, Conn.: Yale University Films.

Festinger, L., & Carlsmith, J. M. (1959). Cognitive consequences of forced compliance. The Journal of Abnormal and Social Psychology, 58 (2), 203–210. https://doi.org/10.1037/h0041593

Haney, C., Banks, W. C., & Zimbardo, P. G. (1973). A study of prisoners and guards in a simulated prison. Naval Research Review , 30 , 4-17.

Latane, B., & Darley, J. M. (1968). Group inhibition of bystander intervention in emergencies. Journal of Personality and Social Psychology, 10 (3), 215–221. https://doi.org/10.1037/h0026570

Mischel, W. (2014). The Marshmallow Test: Mastering self-control. Little, Brown and Co.

Thorndike, E. (1920) A Constant Error in Psychological Ratings. Journal of Applied Psychology , 4 , 25-29. http://dx.doi.org/10.1037/h0071663

Watson, J. B., & Rayner, R. (1920). Conditioned emotional reactions. Journal of experimental psychology , 3 (1), 1.

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• Case Report
• Open access
• Published: 10 May 2024

Extreme behavioural and psychological symptoms of dementia: a case study

• Megha Mulchandani   ORCID: orcid.org/0009-0002-9614-2259 1 , 2 &
• Agatha Conrad   ORCID: orcid.org/0000-0003-1833-6584 1 , 3  

BMC Psychiatry volume  24 , Article number:  353 ( 2024 ) Cite this article

Metrics details

The seven tiered behavioural and psychological symptoms of dementia (BPSD) model of service delivery has been used by inpatient units. The classification of each tier is broadly defined and not always agreed upon by clinicians. The case study uses novel approach by combining the BPSD classification criteria with clinical presentation to identify the clinical characteristics of the case and match these characteristics against the BPSD classification. This process was enhanced by using case specific measures such as the Neuropsychiatric Inventory (NPI) and Cohen Mansfield Agitation Inventory (CMAI) scales and key clinical data.

Case Presentation

A case study of 76 year old male diagnosed with mixed Alzheimer’s and Vascular dementia. The clinical presentation of the symptomatology was deemed to be extreme, thus fitting into the seventh tier (Extreme) of the BPSD model of service delivery. The case is considered to fit into the Extreme BPSD category given the high levels of aggression, which were consistently reflected in high scores on NPI and CMAI, as well as long length of inpatient stay (over 3 years). The average number of Pro re nata (PRN) psychotropics medications per month was 56 and seclusion episodes of 6 times per month, with each episode lasting on average 132 min shows severity of behaviours. His level of aggression had resulted in environmental damage and staff injuries.

We recommend patient clinical characteristics, relevant hospital data and specific measures should be used to develop consensus around defining and classifying cases into Extreme BPSD.

Peer Review reports

Dementia, is also known as a Major Neurocognitive disorder, and is defined by a significant decline in cognitive function which impairs capacity to perform everyday activities independently [ 1 ]. Dementia is typically diagnosed based on a combination of clinical history, brain imaging, screening blood tests and cognitive screening tests or more detailed neurocognitive testing.

In addition to the diagnostic symptomology, dementia is often accompanied by BPSD. This is a broad umbrella term that encompasses various neuropsychiatric symptoms which include agitation, aberrant motor behaviour, anxiety, elation, irritability, depression, apathy, disinhibition, delusions, hallucination, sleep or appetite changes [ 2 ]. The estimated rates of BPSD are variable but have found to be to up to 99% of the population with dementia [ 3 , 4 ].

As shown in Fig.  1 below, Brodaty, Draper & Low (2003) proposed a seven tiered BPSD model for service delivery based on severity of symptoms and prevalence of BPSD, with tier 1 defined as those with no dementia and those is tier 7 are defined as having Extreme BPSD from high levels of unprovoked violent behaviour towards other residents and staff [ 5 ].

Seven tier BPSD model for service delivery

Individuals within Tier 7 are usually of younger age (under 70), male with a robust physique. The type of dementia is often non-Alzheimer’s (e.g.: vascular dementia, alcohol related brain damage, frontotemporal dementia). Due to the significant and specialised care needed in these circumstances, such people require high security specialist care unit [ 5 ].

Since the original concept of seven tiered BPSD model for service delivery was introduced, little work has been done to define each of the tiers, including ‘Extreme BPSD’. Not surprisingly, the interpretation of ‘Extreme BPSD’ symptoms are subjective and based on clinical experience and exposure. There is a possibility that clinicians may misclassify people in lower tiers into Extreme BPSD based on clinical presentation [ 6 ].

Anecdotally, within our unit, staff found it difficult to classify patients into the correct tier based on clinical presentation alone. In addition to patient clinical characteristics on presentation, we decided to include specific measures to quantify the behaviour as well as hospital data to allow for more accurate definition and classification of extreme BPSD. The current case study describes a patient with diagnosed dementia who has been classified as Extreme BPSD based a combination of patient clinical characteristics, hospital data and specific measures.

Case presentation

Mr X is a 76-year-old Caucasian male, with a diagnosis of mixed Alzheimer’s and Vascular dementia, who was a patient of our acute mental health inpatient service for 3 years, with ongoing significant levels of both verbal and physical aggression.

His background was defined by a diagnosis of Post-Traumatic Stress Disorder (PTSD) (combat related and complex childhood trauma) and major depression. He was also a domestic violence perpetrator. There was developmental delay as a child and his family have described him premorbidly as someone who was quick to temper.

Mr X’s medical history included Meniere’s disease with cochlear implant, benign prostate hypertrophy, asbestosis, Type II Diabetes Mellitus, Hypertension. There was history of syphilis exposure with patient self-report of treatment; further test results were not consistent with latent or neurosyphilis. He had a history of multiple head injuries, with loss of consciousness but whether this resulted in any cognitive deficits could not be ascertained through history. There was no history of epileptic seizures.

He was an ex-smoker and had a history of alcohol use which was reported to be heavy for approximately 4 years, many decades ago. There was no past history of illicit substance use. There was no family history of dementia, and no personal forensic history. Mr X was of average intellectual functioning who completed tertiary education and worked in the armed forces but retired medically due to PTSD.

Concerns around Mr Xs’ cognition, short- and long-term memory impairment, began 6 years ago when he was still living with his wife. The first assessment was conducted about 5 years ago where he scored 23/30 on Roland Universal Dementia Assessment Scale cognitive screening test. Approximately a year later he scored 21/30 on Mini Mental State Examination and 67/100 on Modified Mini-Mental State. A plain CT brain showed mild prominence of ventricles and sulci and mild chronic small vessel ischaemia within the periventricular, deep and peripheral white matter. CT SPECT revealed mild to moderately reduced perfusion in the occipital, temporal, parietal and frontal cortices. All screening blood test results were essentially normal apart from mild anaemia and low Vitamin D (33 nmol/L, range 50–140). It was around this time, about 5 years ago that he was diagnosed with mild to moderate Alzheimer’s dementia.

During this period and before coming into our service for the current admission, Mr X was admitted twice to acute older people’s mental health unit, first time when he was first diagnosed with dementia, and subsequently expressing suicidal and homicidal ideation, complicated by cognitive decline with persecutory and grandiose delusions, He was treated with Haloperidol 5 mg daily, Memantine 15 mg, Quetiapine 400 mg total daily dose, his symptoms stabilised and then was discharged home. However, his mental health continued to deteriorate, and he was re-admitted to the acute older people’s mental health unit, and then discharged to an aged care facility.

During the first five months in the aged care facility, he continued to be verbally and physically aggressive towards staff, resulting in an involuntary admission to our acute older people’s mental health unit. On assessment, he was observed to be experiencing psychosis with delusional content relating to other ethnic community and alien invasion from which he needed to be cleansed. On mental state examination, he was described as a tall well-groomed and dressed gentleman who was calm and seen to be smiling and happily greeting people in the department. His speech was of normal tone, and volume but noted to have some word finding difficulty. His mood was “pretty good” and his affect was reactive. His thought form was described to be disorganised with limited coherent responses to questions. No perceptual disturbance was noted but he admitted to experiencing nightmares relating to his time in the armed forces. He was noted to be disorientated to time and place, but not to person, and he scored 1 out of 4 on clockface drawing. His insight was partial, and he had some recollection of the aggression at the aged care facility but was unable to comprehend the ramifications of his actions. As part of the assessment, blood tests and CT scan was done, which were normal and in keeping with previous results.

During the entirety of his admission Mr X continued to display aggression, complicated by PTSD. His care required a high nursing ratio and low stimulus environment. This environment is staffed by experienced nursing staff, under the care of the Psychogeriatrics team and supported by specialised allied health team. As part of the treatment, multiple medication changes were made including change from Memantine to Rivastigmine 9.5 mg/24 hour. Other medications such as Sodium Valproate and Carbamazepine trials to therapeutic range did little to change behaviour. Prazosin was cross titrated with reducing doses of Quetiapine, again with little change in presentation. Fluoxetine to 20 mg showed some reduction in dissociative episodes.

Pain, constipation, sleep and infections were managed with a combination of pharmacological and non-pharmacological interventions. Intense work was done to develop a behaviour support plan which detailed his behaviour at every stage of the behavioural agitation scale from calm to extreme aggression.

Despite the intense care environment, with specialised multidisciplinary care, Mr X continued to display significant levels aggression, both verbal and physical. Whilst some were due to medical reasons (delirium), most were due to either psychological or environmental factors. Even minor environmental alterations would lead to agitation or aggression, such a change in his nursing special (from morning to afternoon shift) or socially unacceptable behaviour by other patients sharing his space, and noise or malfunctioning cochlear equipment.

His presentation was further complicated by use of rapid tranquillisers which were used to contain physical aggression, but instead resulted in increased confusion, exacerbating agitation and aggression. Seclusion was used a means of de-escalation and avoidance of parental rapid tranquillisers, and ultimately Mr X care was transferred to Mental Health Intensive Care Unit (MHICU). Mr X has remained in MHICU for the over 2 years and during the entirety of this period Mr X’s care involved 1:1 nursing special during his waking hours.

As an expected part of his diagnosis, Mr X showed both cognitive and functional decline over the period of his three-year admission.

There were two project specific measures used to monitor impact of intervention on Mr X behaviour (1) Neuropsychiatric inventory assess to assess the frequency and severity of symptoms and level of disruptiveness [ 7 ]; (2) Cohen-Mansfield Agitation Inventory which measures the level of aggression/agitation [ 8 ].

Neurodegenerative disorders were assessed by nursing staff using the Neuropsychiatric inventory (Nursing home version), consisting of 10 neuropsychiatric symptoms/domains rated on a frequency and severity scales. The frequency of symptoms is rated on a Likert scale from 1 to 4, with 1 indicating “rarely – less than once a week” and 4 being “ very often – essentially continuously present”. The severity of symptoms is rated from 1 to 3, with 1 being” mild – changes in appetite or eating are present but do not lead to changes in weight loss and are not disturbing” 3 – being “severe - obvious changes in appetite or eating are present and cause changes in weight, leading to weight loss which may upset the resident” [ 7 ]. The total score is calculated by multiplying frequency by severity for each domain, then adding the 10 domains together to get a total score. The total score can range from 10 to 120. In addition, each symptom/domain is rated in terms of occupational disruptiveness which measures how much does this behaviour negatively impact the staff or carer or creates extra work for staff or carer, The symptoms/domains are rated on 0 to 5 Likert scale with 0 being “not at all” and 5 being “very severely or extremely disruptive" (very disruptive major source of distress for staff and other residents, requires time usually devoted to other residents). The scores for occupational disruptiveness range from 0 to 50 [ 7 ].

The Neuropsychiatric inventory was administered on two separate occasions to Mr X by nursing staff on the unit. On the first occasion Mr X scored 67 (44 on frequency and severity and 23 points for occupational disruptiveness) and two months later, Mr X score increased to 98 (62 for frequency and severity, with 36 points for occupational disruptiveness).

The measured Cohen-Mansfield Agitation Inventory (CMAI) is a carer (staff) questionnaire. The 29 behaviours seen in dementia are rated for frequency – the lack of focus on severity is corrected by the breadth of behaviours covered. The behaviours covered include verbal aggression, repetitiveness, screaming, hitting, grabbing and sexual advances. The Cohen Mansfield Agitation Inventory (CMAI) was administered on two separate occasions two months apart, Mr X scored 90 on the first occasion and 106 on second occasion. Mr X tended to display aggressive behaviour towards staff most of the time in a day and even several times in an hour.

Over the 3-year period Mr X received numerous pharmacological interventions to manage his behaviour with an average of 56 PRN psychotropic medications per month to manage agitation and aggression. Seclusion was used as the main non-pharmacological intervention to manage risk to others and minimise the use of psychotropic medications. Over the 3-year period, Mr X was secluded on average 6 times per month, with each episode lasting on average 132 min. Furthermore, there have been over 400 incidents logged for physical and/or verbal aggression.

Attempts were made to gain data on staff injury (including time lost to work) and environmental damage, however, records were not kept on a central database. Anecdotally, Mr X’s level of aggression had led to significant damage to his environment, such as breaking doors off hinges. He had also assaulted staff resulting in shoulder and wrist injuries leading to time off work.

Discussion and conclusions

There is no widely agreed objective measures to quantify the behaviour and accurately classify the severity of BPSD. The current classification of extreme BPSD is broad in describing the behaviours in terms of high levels of unprovoked violent behaviour towards other residents and staff [ 8 ]. It was often difficult for staff to precisely define what the high level of unprovoked violent behaviour is and therefore staff didn’t feel as confident in using this classification model of care. The two measures chosen for the project, helped to quantify the violent behaviour in terms the level of disruption (NPI) and aggression (CMAI) towards staff and other patients. The scores from NPI and CMAI measures together with a patient clinical characteristics, and hospital data allowed staff to more confidently and accurately classify the severity of BPSD. The crucial clinical characteristics that were considered as part of the classification of BPSD, included a history of PTSD, alcohol abuse and domestic violence, as well as complex medical history.

He was robust male of a younger age group with difficulties in verbal communication due to his dementia. The level of severity, frequency and intractability of BPSD was evidenced by the length of admission in an acute inpatient environment with a 1:1 nursing special. Attempts to manage BPSD through various combination of high doses of psychotropics led to limited improvement in agitation and aggression. This approach was combined with a detailed tailored behavioural support plan and was regularly updated to meet his changing clinical needs.

The clinical history and observational data together with project specific measures were supplemented by more routinely collected hospital data. The high levels of disruptive behaviour and aggression when measures were collected was mirrored by the hospital data particularly the lengthy admission (over 3 years), number of PRN medications (average 56 medications per month) administered,  and number of seclusion episodes (6 times per month). The combination of data allowed staff to confidently and accurately classify this case into the extreme BPSD.

However, we have only anecdotal evidence on injury to staff and damage to property which is a limitation in this case study. We were unable to quantify psychological impact of aggression on other patients and staff. We would recommend that incident data pertaining to injuries to staff, patients and environment is collected routinely to provide a more complete picture and a stronger definition and classification of extreme BPSD.

We described in detail clinically, further supported by clinical data of a gentleman whose behaviours qualify for Tier 7 of the Brodaty et al., (2003) triangle. We found that it was the combination of patient characteristic, hospital data and specific measures that help staff to more accurately classify the case. We recommend patient clinical characteristics, relevant hospital data and specific measures should be used to develop consensus around defining and classifying cases into Extreme BPSD.

Data availability

The data that support the findings of this study are available from Hunter New England Local Health District but restrictions apply to the availability of these data, which were used under license for the current study, and also are not publicly available. Data are however available from authors upon reasonable request and permission from Hunter New England Local Health District. For any enquiries regarding data availability please contact Dr Megha Mulchandami, [email protected].

Abbreviations

Behavioural and Psychological Symptoms of Dementia

Neuropsychiatric Inventory

Cohen Mansfield Agitation Inventory scale

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Acknowledgements

We would like to thank the patient and his family for being involved in this project. Also we want to thank all the staff who were involved in the patient care.

The project had no funding.

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Mulchandani, M., Conrad , A. Extreme behavioural and psychological symptoms of dementia: a case study. BMC Psychiatry 24 , 353 (2024). https://doi.org/10.1186/s12888-024-05785-1

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• Emma C. Woodford   ORCID: orcid.org/0000-0001-9596-8636 1 ,
• Karyn G. France   ORCID: orcid.org/0000-0002-6943-5390 1 ,
• Neville M. Blampied   ORCID: orcid.org/0000-0002-0158-4904 2 ,
• Ursula Hanning   ORCID: orcid.org/0009-0009-8906-8303 1 ,
• Catherine E. Swan 3 &
• Laurie K. McLay   ORCID: orcid.org/0000-0001-7002-3695 1 , 4  

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Sleep difficulties are highly prevalent among children with rare genetic neurodevelopmental conditions (RGNC) such as Angelman and Smith-Magenis syndromes. Behavioral interventions are commonly used in the treatment of sleep difficulties in children; however, research is limited in children with RGNC. This study evaluated the overall effectiveness and acceptability of function-based behavioral sleep interventions for children with RGNC.

Data was collated from a series of experimental single-case research studies with 26 children (18 months to 19 years of age) with a range of RGNC, who received a behavioral sleep intervention. Intervention strategies included circadian (e.g., sleep/wake rescheduling), antecedent (e.g., sleep hygiene), and/or consequence (e.g., positive reinforcement of sleep-conducive behavior and modified extinction) modifications implemented by parents. Clinicians provided support for parents mostly via telehealth methods. Overall outcomes were examined using modified Brinley plots and effect size estimates. The effect of age, gender, and a range of psychological variables on intervention response was also examined.

Improvements in sleep problem severity were observed for 24/26 participants, and gains were maintained at long-term follow-up for 13/16. Interestingly, 50% of the children achieved clinically significant change with less restrictive strategies (e.g., circadian, antecedent and positive reinforcement strategies), suggesting extinction procedures may be used as the last option in a sequence of interventions. Parents generally perceived interventions to be acceptable. There was minimal evidence of any differential response to intervention as a function of age, gender, or psychological variables.

Conclusions

Results suggest function-based behavioral interventions offer an effective and socially valid method for treating sleep disturbance in children with RGNC.

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Rare genetic neurodevelopmental conditions (RGNC) are group of heterogeneous syndromes characterized by differences in the number and/or structure of chromosomes, which affect < 1:2000 of the general population (European Commission, 2021 ; Rare Diseases International, 2023 ). Phenotypic presentations often include physiological, intellectual, and developmental differences, typically manifested before 22 years of age. Examples of RGNC include Angelman, Prader-Willi, Fragile X, and Smith-Magenis syndromes (McLay et al., 2019 ; Neo et al., 2021 ).

Along with the phenotypic characteristics described, sleep difficulties are prevalent in children (encompassing children and adolescents) with RGNC compared to neurotypical children, with substantial variability depending on the type of sleep difficulty and RGNC (Agar et al., 2021 ; Annaz et al., 2011 ; Kronk et al., 2010 ; Veatch et al., 2021 ). Sleep difficulties experienced may include circadian rhythm disturbances, prolonged sleep onset latency (SOL), night wakings (NWs), unwanted bed-sharing, excessive daytime sleepiness, and early morning waking (EMW). These can have significant adverse short- and long-term effects on learning, behavior, and cognitive development (Kronk et al., 2010 ), as well as parent and family quality of life and physical and mental health (Annaz et al., 2011 ; Chu & Richdale, 2009 ; Kronk et al., 2010 ; Shochat et al., 2014 ; Mörelius & Hemmingsson, 2014 ). Thus, sleep disturbance may further compound the immense challenges already faced by children with RGNC and their families.

Research on the etiology of sleep difficulties associated with RGNC is scarce and mostly focused on biomedical causes (e.g., irregular melatonin production and/or co-occurring medical conditions; Agar et al., 2020 ; Stores, 2016 ; Woodford et al., 2021 ). Consequently, interventions are predominantly pharmacological, most commonly melatonin (e.g., Bailey et al., 2012 ; Braam et al., 2008 ). While melatonin is often effective (Bailey et al., 2012 ; Braam et al., 2008 ), it is not universally funded, many parents have general concerns about chronic use of medication, and problems that are not always associated with melatonin dysregulation (e.g., unwanted bed-sharing, NW and bedtime resistance) often persist (Blampied, 2013 ; McLay et al., 2022 ).

In children with neurodevelopmental conditions (e.g., autism, RGNC), sleep difficulties are generally understood to be the result of a complex interaction between biopsychosocial and behavioral variables (Richdale & Schreck, 2009 ; Veatch et al., 2021 ). Specifically, the behavioral model of sleep disturbance posits that sleep onset occurs at the end of a behavior chain, motivated by sleep pressure, that starts with a bedtime routine and ends with the behavioral quietude necessary for sleep to occur (Blampied, 2013 ; Blampied & van Deurs, 2022 ). Antecedent variables (i.e., variables that precede and/or regulate a behavior) can affect this behavior chain by altering motivation and cues for sleep (Loring & Malow, 2022 ). Homeostatic sleep pressure arising from sleep deprivation, delayed bedtime, or excessive daytime activity can increase an individual’s motivation to sleep and, thus, the reinforcing value of sleep (Borbély et al., 2016 ; Laraway et al., 2003 ). Further, each step in the behavior chain leading up to sleep onset is under stimulus control whereby each sequential step provides the discriminative stimulus for the step that follows (Blampied, 2013 ; Blampied & van Deurs, 2022 ). When discriminative stimuli are absent (e.g., because of a variable bedtime routine) or insufficiently salient, the behavior chain is disrupted. Moreover, when discriminative stimuli are consistently experienced at sleep onset, these cues may become required for sleep onset. Thus, some discriminative stimuli (e.g., a regularly available soft toy) can support, while others (e.g., the absence of parental presence following NWs when otherwise present at initial sleep onset) can interfere with sleep onset both at the start of the night and following NWs (Blampied & van Deurs, 2022 ). Furthermore, reinforcement contingencies also play a critical role in sleep. Consequences that occur immediately following a behavior may increase or decrease the future likelihood of that behavior (Cooper et al., 2020 ). If sleep-conducive (e.g., lying quietly in bed) or sleep-interfering (e.g., calling out) behaviors are reinforced (e.g., by some parental response), this is likely to result in continuation of that behavior (Blampied & van Deurs, 2022 ; McLay & Lang, 2022 ).

To effectively treat sleep difficulties that are underpinned by behavioral factors, it is essential to identify and address the contributing antecedent and consequence variables (Blampied & van Deurs, 2022 ; Jin et al., 2013 ; McLay et al., 2022 ). Functional Behavioral Assessment (FBA) guides the identification of relevant antecedents, contingencies of reinforcement, and other contextual factors to inform the development of individualized interventions for a range of behavioral difficulties including sleep disturbance (Blampied, 2013 ; Jin et al., 2013 ). Interventions may be based on the topography (i.e., presentation) or diagnostic classification of the behavior alone, but such an approach has many conceptual limitations (e.g., the lack of individualization and understanding of mechanisms; Ingram et al., 2005 ). Consequently, FBA-informed interventions are strongly recommended for children with neurodevelopmental conditions such as autism, attention-deficit hyperactivity disorder (ADHD), and intellectual disability (Soorya et al., 2018 ), with increased evidence to support their use in the treatment of sleep disturbance for these populations (e.g., Curfs et al., 1999 ; Didden et al., 1998 ; Jin et al., 2013 ; McLay et al., 2020 ; Weiskop et al., 2005 ).

Given the evidence supporting function-based interventions for children with higher incidence neurodevelopmental conditions such as autism, and the similarities in the type and topography of presenting sleep difficulties, such interventions merit investigation of their effectiveness for sleep difficulties in children with RGNC. Existing research is limited to individual case studies or small N projects (Curfs et al., 1999 ; Didden et al., 1998 ; Woodford et al., 2022 ) and has rarely included adolescents, and interventions have typically been generic rather than being individualized for each case (Allen et al., 2013 ; Weiskop et al., 2005 ). The current study is a retrospective review of 26 participants with RGNC who received function-based behavioral sleep interventions evaluated with experimental, single-case research designs (e.g., Woodford et al., 2022 ; 2024a ). Overall outcomes, possible moderators of intervention response (demographic and child characteristics) and the social validity of the interventions were examined.

The University of Canterbury research team has been investigating the effectiveness of behavioral sleep interventions for children with RGNC since 2018. For each participant, we used FBA to inform the design of individualized, parent-implemented interventions.

Participants and Recruitment

Participants were recruited from throughout New Zealand via service providers for children with RGNC. Between 2018 and 2022, approximately 50 families were screened for the sleep program. Of those screened, 26 families provided consent/assent and met criteria for inclusion in this study. Inclusion criteria were the child (a) was between 18 months and 21 years of age; (b) had or were likely to have a diagnosis of a RGNC, as defined above; (c) had parent-reported sleep difficulties (e.g., prolonged SOL, NWs, unwanted bed-sharing), verified during assessment using sleep diaries and/or video recordings; and (d) had at least commenced the intervention phase of the program and had provided at least one week of intervention data. If the child had a co-occurring condition not currently managed or that might interfere with the implementation of intervention (e.g., epilepsy, tube feeding), approval was obtained from the child’s primary physician; otherwise, they were excluded for safety reasons. Other reasons for exclusion included unstable medication use or withdrawal between the assessment phase and commencement of intervention.

Of the 26 participants (16 males; 10 females), 13 were aged ≤ 6 years, 9 were between 6 and 12 years, and 4 were > 12 years ( M  = 7.0, SD  = 4.2). This included 13 participants from previously published studies (Woodford et al., 2022 ; 2024a ) and 13 participants who did not meet the specific study criteria of these previous studies ( N  = 6) and/or who withdrew during intervention ( N  = 9). Inclusion of all participants regardless of whether they adhered to or completed intervention was important for determining the overall, relatively unbiased clinical effectiveness of behavioral sleep intervention (Lachin, 2000 ). Participant details are summarized in Table  1 . In summary, children presented with a range of RGNC. Four cases did not have a confirmed RGNC: Two had a primary diagnosis of cerebral palsy, one had cerebral maldevelopment with cleft frontal lobe and ventriculomegaly and one had a diagnosis of autism and a suspected genetic condition. However, these four children were included due to similarities with those with RGNC (i.e., developmental delay, confirmed neurological alterations and/or were awaiting genetic testing results). All participants had at least one parent-reported co-occurring condition.

Study Design

This study is a retrospective analysis of case data collected within a series of single case experimental studies (e.g., Woodford et al., 2022 ; 2024a ), similar to that conducted by McLay et al. ( 2020 ). Case data was gathered in the context of non-concurrent, multiple-baseline across participants experimental designs wherein all participants were randomly allocated pre-determined baseline lengths (namely, 7, 14, or 21 days). Such random allocation ensured that extraneous factors that may have affected response to intervention (e.g., researcher biases) were controlled for, while the assigned lengths were minimally sufficient to permit stability to be observed (Barlow et al., 2009 ; Christ, 2007 ; Cooper, et al., 2020 ; Kratochwill et al., 2010 ). Given the lack of prior research into the treatment of sleep disturbance with this population, constraints of time and financial support, the disruptions caused by COVID-19, and that by definition RGNC are rare, this N (26) is considered sufficient for research to be informative (Lakens, 2022 ).

All therapeutic support was provided remotely via email, phone, and video conferencing for all participants, except for seven who had in-person meetings in the family home or the university clinic. Sleep interventions were implemented by parents, in the family home, with the support of the research team through digital means.

Each family progressed through the following phases (a) assessment including FBA; (b) baseline; (c) behavioral case formulation and intervention; and (d) maintenance, including short-term (STFU) and long-term (LTFU) follow-up.

As part of the assessment, parents completed a clinical interview (conducted by the first author [EW] or a licensed psychologist or intern psychologist within the research team), at least three nights of parent-reported sleep diaries and/or video recording, and questionnaires (described under “ Measures ” section). The interview provided information about demographic characteristics, presenting sleep difficulties, goals for sleep, child developmental history, and parents’ motivation to engage in a sleep intervention. The Sleep Assessment Treatment Tool (SATT; Hanley, 2005 ), used extensively in prior research including neurodivergent children (e.g., Jin et al., 2013 ; McLay et al., 2020 ; Woodford et al., 2022 ), was used to guide interviewing around sleep.

FBAs for each participant considered data from the SATT (Hanley, 2005 ), sleep diaries, and video (for cases where data patterns were unclear), which were coded according to Antecedent, Behavior, Consequence event recording procedures (ABC recording; Cooper et al., 2020 ). Patterns that suggested potential behavioral (i.e., operant) functions, including (a) sleep/wake schedules that interfered with motivation for sleep; (b) other sleep-interfering antecedent variables (e.g., sleep hygiene, inappropriate discriminative stimuli for sleep, other environmental factors); and (c) reinforcement contingencies maintaining the sleep difficulties, were then identified by the research team.

Baseline data were collected using sleep diaries and video for a randomly assigned baseline length of 7, 14, or 21 days. If visual analysis indicated baseline trends were unstable, or there were threats to internal validity (e.g., unforeseen circumstances such as illness), additional data were collected until baseline stability was achieved (Kazdin, 2011 ). During baseline, parents maintained typical routines throughout the night.

Behavioral Case Formulation and Intervention

Behavioral case formulation and intervention planning as outlined in Blampied ( 2013 ) was undertaken with parents within the framework of the guided participation model (Sanders & Burke, 2014 ). This was done to individualize intervention for each participant to suit the child’s FBA and accommodate factors such as the child’s developmental status, physical functioning, co-occurring conditions, and family preferences (e.g., the number of verbal prompts, steps taken in modified extinction, or rewards chosen differed depending on such factors). Intervention plans typically included three components: (1) circadian modifications (i.e., sleep/wake scheduling); (2) antecedent modifications; and/or (3) consequence-based modifications.

Circadian modifications were designed to increase motivation for sleep in consideration of the National Sleep Foundation Guidelines for age-appropriate sleep durations (Hirshowitz et al., 2015 ) and family routines and preferences. Procedures included restricting/eliminating daytime naps, faded bedtime (see Schreck, 2022 for a discussion of faded bedtime), and establishing consistent sleep/wake schedules.

Antecedent modifications included changes to the sleep environment to minimize precipitants of the sleep difficulties, for example, physical environmental (e.g., the addition of light switch coverings), discriminative stimuli (i.e., consistent sleep setting, visual supports, and use of discriminative stimuli for sleep/wake times), and sleep hygiene modifications (i.e., a consistent bedtime routine, sleep-conducive environment) (Loring & Malow, 2022 ). In addition, visual prompts (e.g., Gro-clocks™, Social Stories™; Gray, 2010 ) were used to facilitate sleep conducive behavior.

Consequence-based modifications included reinforcement of sleep-conducive behavior (i.e., by social and tangible rewards) and modification of contingencies of reinforcement maintaining sleep-interfering behavior (i.e., by extinction and modified extinction). Extinction procedures involved immediate withdrawal of reinforcement for sleep-incompatible behaviors (e.g., digital device use). Modified extinction procedures included faded parental presence and minimal check (see Carnett & McLay, 2022 for a discussion of extinction procedures).

All strategies were parent-implemented. Parent-clinician contact (mostly by digital means) was frequent (i.e., daily in the early stages of implementing strategies and at least once a week at other times), to obtain updated information and provide guidance. Parents were also able to contact the researchers for ad hoc advice as required. The principle of less restriction (Johnston & Sherman, 1993 ) was used to guide intervention planning in most cases, so that consequence modifications were the last option in the sequence of interventions given their complexity and difficulty (Woodford et al., 2022 , 2024a ). Parents were provided revised recommendations both verbally and in written format via email, with systematic formative evaluation of intervention progress. Intervention continued until the parent-clinician determined goals had been met, the family withdrew, or the research team determined that further support would not be beneficial. Intervention duration (including baseline) ranged from 21 to 250 nights ( M  = 112). See Table  2 for a summary of intervention procedures and the number of participants who received each intervention.

Maintenance and Follow-Up

On conclusion of intervention, parents moved to the maintenance phase where there was no more nightly sleep data recording or researcher-initiated contact, except for an interview with an independent interviewer to gather program feedback. Parents also completed post-intervention questionnaires before STFU. STFU and LTFU data (available for 17 and 16 families, respectively) were collected via seven nights of video and/or sleep diary recordings commencing at 4–6 and 10–14 weeks after the final day of intervention.

Primary sleep outcome measures included time-series parent-reported sleep diary data and Sleep Problem Severity (SPS) scoring of the diaries. Secondary sleep outcome measures included the Children’s Sleep Habits Questionnaire (Owens et al., 2000 ) global scores and video recording. The CSHQ was completed at pre-intervention (assessment phase) and post-intervention (maintenance phase, before STFU). Other measures included the Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2001 ), Strengths and Difficulties Questionnaire (SDQ; Goodman, 2001 ), and the Communication domain of the Vineland Adaptive Behavior Scale, Third Edition Parent/Caregiver comprehensive form (VABS-III; Sparrow et al., 2016 ). These were completed by parents’ pre-intervention to assess for potential moderators of intervention response.

Sleep Outcome Measures

Parent-reported sleep diaries.

Sleep diaries, in paper or digital format, were provided to parents via post or email and completed daily, across study phases (Horne & Biggs, 2013 ). Parents’ recorded information regarding their child’s (a) sleep setting; (b) frequency, duration (minutes), and timing of daytime naps and NW; (c) SOL (minutes); (d) frequency of curtain calls (CCs, i.e., bids for parent attention during sleep onset); (e) onset and offset times of bed-sharing with parent(s); (f) and morning wake time. Parents also described occurrences of sleep interfering behavior and their responses to these, as well as disruptions such as illness and family events.

Video Recording

Swann Advanced-Series DVR4-1200 night-time, infrared video cameras, D-Link HD Cloud cameras, or TP-Link Tapo C100 cameras and recording hardware were posted to parents to set up where the child slept (e.g., their bedroom). Video recordings were used to provide a direct measure of children’s sleep (i.e., from the child’s bedtime to morning waketime) where necessary (including providing data on nights in which sleep diaries were incomplete), as well as for interobserver agreement (IOA) calculations (described below). Videos were coded to align with sleep diary data (bedtime, sleep onset time, time and duration of NWs, etc.). Coding was completed by the lead author (EW), a research assistant or the primary clinician for at least 20% of nights across phases, for whom sufficient video was available. All who coded video footage were blinded to the sleep diaries.

Sleep Problem Severity

Sleep Problem Severity (SPS) composite scores were calculated using coded sleep diary data averaged across the final seven nights of each of baseline, intervention, and STFU and LTFU, as in previous studies conducted by the research team (e.g., McLay et al., 2020 ; Clarke et al., 2024 ; Woodford et al., 2022 ; 2024a ). Missing sleep diary information was supplemented with video data, as required. Each child received a single (average) severity score per phase (range 0–22). Scoring code criteria were established based on previously published research defining adequate sleep quality and quantity for preschool (2–4 years 11 months), childhood (5–12 years 11 months), and adolescent (13–18 years) age groups (e.g., Crowley et al., 2014 ; Hirshkowitz et al., 2015 ; Mindell & Moore, 2014 ; Ohayon et al., 2017 ). An average score of > 2 indicates the presence of clinically significant sleep disturbance, i.e., severe disturbance in one sleep domain or moderate disturbance in two sleep domains (e.g., SOL, NWs) per night. SPS scoring criteria are outlined in Online Resource 1.

Children’s Sleep Habits Questionnaire

The CSHQ (Owens et al., 2000 ) is a 45-item parent-report measure of the frequency of specific sleep behaviors over the past seven nights in children 4–10 years of age. The CSHQ yields eight subscale scores and a total sleep disturbance score (range 33–99), with a clinical cutoff > 41 based on a neurotypical sample. This measure has acceptable sensitivity (0.80), specificity (0.72), internal consistency ( α  = 0.68–0.78) and test–retest reliability ( r  = 0.62–0.79) based on a neurotypical sample (Owens et al., 2000 ). Consequently, it has been rated by the American Psychological Association’s Evidence-based Assessment Task Force as “well-established” (Lewandowski et al., 2011 ). Although not validated for use with children with RGNC, it is widely used in research and practice as a measure of sleep disturbance among children both with and without neurodevelopmental conditions. The CSHQ was completed by parents of all children including those outside of the recommended age range (10/26 participants). This is not uncommon among children with neurodevelopmental conditions (Goodlin-Jones et al., 2008 ; Moss et al., 2014 ) and there was no alternative parent-report measure allowing for comparison across ages (Owens et al., 2000 ).

Treatment Acceptability

The Treatment Acceptability Rating Form-Revised (TARF-R; Reimers et al., 1992 ) is a 20-item parent-report measure given to parents to complete in the maintenance phase to evaluate their perceptions of the effectiveness and acceptability of intervention. Responses are provided on a 7-point Likert scale; 17 items rate treatment acceptability, and three items assess problem severity and parents’ understanding of the intervention process. Higher scores indicate greater acceptability.

Other Measures

Communication domain of the vabs-iii.

The Communication domain of the VABS-III is a parent-report measure of children’s communication level used primarily to inform intervention planning. The Communication domain has three sub-domains, namely expressive, receptive, and written language. Item scores per sub-domain are summed and then converted to standardized age equivalence scores to determine the child’s communicative level relative to developmental norms (Pepperdine & McCrimmon, 2018 ; Sparrow et al., 2016 ). The VABS-III domains have good psychometric properties (e.g., internal consistency, α  = 0.94–0.99, and test–retest reliability, r  = 0.64–0.94; Pepperdine & McCrimmon, 2018 ) and have been frequently used to assess a range of adaptive behaviors in neurodivergent children (e.g., De Bildt et al., 2005 ).

Child Behavior Checklist

The CBCL (Achenbach & Rescorla, 2001 ) is a parent-report measure of internalizing and externalizing symptoms in children and adolescents between 1.5 and 18 years of age. Specific item ratings are summed to provide internalizing and externalizing problem scale scores and a total score, with higher scores indicating greater symptom severity. These are converted to t -scores to determine whether the child meets criteria for classifying symptom severity as “normal” (non-clinical; t- score < 65), “borderline” (at-risk: t -score 65–69), or “clinical” ( t -score > 70). The CBCL has good psychometric properties based on a neurotypical sample (e.g., internal consistency, α  = 0.63–0.90; Achenbach & Rescorla, 2001 ) and sample of pre-schoolers with RGNC (e.g., internal consistency, α  = 0.82–0.94; Neo et al., 2021 ). Although not validated for use with children with RGNC > 5 years of age, Glasson et al. ( 2020 ) found it was the most used measure of internalizing and externalizing symptoms in this population.

Strengths and Difficulties Questionnaire

The SDQ is a 25-item parent-report measure of behavioral strengths and difficulties in young people 4–17 years of age (Goodman, 2001 ). It has five subscales: emotional symptoms, conduct problems, hyperactivity-inattention, peer problems, and prosocial behavior. Subscale scores (excluding prosocial behavior) are summed to give a total difficulties score, with higher scores indicating greater difficulty, and score ranges for classifying symptom severity as “normal” (0–13), “borderline” (14–16), and “abnormal” (i.e., clinical, 17–40). The SDQ has adequate psychometric properties based on a neurodiverse sample (e.g., internal consistency [ α  = 0.71]; Emerson, 2005 ).

Summary of Measures

The measures described contributed to varying components of data analysis for the 26 participants. In summary, data from sleep diaries and the derived SPS scores were used as the primary outcome measures, while CSHQ global scores were used as a secondary outcome measure in this study; data from sleep diaries and video recordings were the primary measures used for individual time-series analyses such as in (Woodford et al., 2022 ; 2024a ) and interobserver agreement and treatment fidelity calculations; and data from the questionnaires assessing child psychological variables were used for analysis of potential moderators of intervention response in this study and for the analysis of collateral effects in a separate study (Woodford et al., 2024b ).

Data Analysis

For the purposes of tracking outcome data for each case, individual time-series data was analyzed visually accompanied by percentage below the median (Parker et al., 2011 ) calculations as an individual effect size measure (see Woodford et al., 2022 ; 2024a ). For this study, i.e., the purposes of the retrospective analysis of overall outcome, changes in participant SPS and CSHQ scores from pre-intervention to the end of intervention phases (i.e., the final week of intervention, STFU and LTFU for SPS; post-intervention for CSHQ) were examined via modified Brinley plots created using SigmaPlot 14 software (systatsoftware.com). These are a type of scatterplot that displays an individual’s response to intervention within the context of group data (Blampied, 2017 ). Data for each individual is represented as a coordinate pair, with baseline/pre-intervention data on the X axis and data from any subsequent time point on the Y axis. Individual data points that lie on or near the 45° diagonal line show minimal or no therapeutic benefit (Blampied, 2017 ), while points that fall below the diagonal line indicate a reduction in SPS and CSHQ scores (i.e., the direction of therapeutic change). A cross gives the coordinates of the X and Y means and the length of each arm reflects the standard deviation of the respective mean.

Cohen’s d (the standardized mean difference; d av  = within-subjects and d s  = between-subjects; Lakens, 2013 ) and the percent superiority effect size (PSES; the probability that a randomly selected participant has an improved score at time two relative to time one; McGraw & Wong, 1992 ) were both calculated using Lakens ( 2013 ) calculator. Negative d values indicate clinically desirable change (i.e., improvement on a measure). Interpretation of small ( d  ≤ 0.2), medium ( d  =  ~ 0.5), and large ( d  ≥ 0.8) effect sizes were based tentatively on Cohen ( 1988 ) criteria. Confidence intervals (95% CI) about d were used to classify d as reliably different from zero ( p  < 0.05) and were calculated using the exploratory software for confidence intervals (ESCI) package by Cumming ( 2012 ).

A separate analysis was conducted to evaluate the possible impact of age, gender, and psychological variables on intervention outcome measured by the primary dependent variable (SPS scores) following the procedure of McLay et al. ( 2020 ). Psychological variables included VABS expressive and receptive language age equivalence scores, CBCL internalizing and externalizing symptom t -scores, and the SDQ total score. Gender was compared as natural groups, while the sample was split at the median score of the variables of interest to create groups (above or below the median) whose SPS scores could then be compared. First, Cohens d s was calculated to compare the groups’ SPS scores at baseline to see if the variable was associated with different SPS levels pre-intervention. Second, Cohens d av was calculated for each group to separately examine the response of the groups to intervention. A d value of at least medium size (≈0.5) on the SPS scores would indicate that the variable of interest either might be influencing baseline levels of severity and or response to intervention.

Interobserver Agreement and Treatment Fidelity

IOA and treatment fidelity were calculated for at least 20% and 30% of nights, respectively, across study phases for all participants for whom sufficient data were available, to determine the reliability of the parent-reported sleep diary data and parent adherence to intervention strategies, respectively. These percentage aims (≥ 20% and 30%) align with that of other sleep treatment evaluation studies (e.g., Kuhn et al., 2020 ; McLay et al., 2020 ) as well as research quality evaluation guidelines (e.g., Reichow et al., 2008 ).

To calculate IOA (%), participant data for all dependent variables (e.g., SOL, frequency and duration of NWs) from sleep diaries and video footage were compared (where variables were detectable by parents) and the formula (agreement/[agreement + disagreement]) × 100 was used. To calculate treatment fidelity (%), information regarding the intervention components implemented by parents as noted in sleep diaries, video coding and case notes were compared to the intervention protocol and the formula (number of intervention components implemented/total recommended components) × 100 was used.

Results are presented in the following order. First, the outcomes of FBA across participants are described. Second, the intervention outcomes, i.e., changes in the sleep measures (SPS and CSHQ scores), are presented, comparing baseline/pre-intervention to post-intervention, STFU and LTFU. Third, possible moderating effects on intervention outcomes of (a) demographic variables and (b) selected psychological variables are presented. Fourth, a summary is provided regarding participant withdrawal. Fifth, data on IOA, treatment fidelity and acceptability are summarized.

FBA Outcomes

All participants had more than one type of parent-reported sleep difficulty (range = 2–6). Sleep difficulties included bedtime resistance, problematic sleep setting, prolonged SOL, CCs, frequent and prolonged NWs, EMW (i.e., time awake prior to goal waketime), unwanted bed-sharing, and/or parental involvement (i.e., the presence and/or support) during sleep onset and NWs. The most common sleep difficulties were prolonged SOL and NWs, present for 23/26 (88%) children. Interestingly, unwanted bed-sharing and parental involvement during sleep onset and NWs was also common, occurring for 14 (54%) and 6 (23%) participants, respectively. Difficulties related to bedtime resistance (6 participants; 23%), sleep setting (5 participants; 19%), CCs (6 participants; 23%) and EMW (9 participants; 35%) were less common.

There was a range of functions underpinning sleep difficulties. Insufficient sleep pressure related to inconsistent and/or developmentally inappropriate sleep/wake times was common (22 participants; 85%). Parent attention related to unwanted bed-sharing or parent involvement in the night was also common (20 participants; 77%). Other functions included escape from the bedroom (12 participants; 46%) and access to tangible items that competed with sleep, such as digital devices (12 participants; 46%), food/drink (8 participants; 31%), toys (7 participants; 27%), and earmuffs (1 participant; 4%). Automatic reinforcement of stereotypy (e.g., repeated vocalizations or physical movements) in the sleep context was identified for six participants (23%). Other factors that contributed to sleep difficulties included toileting issues (3 participants; 12%), caffeine consumption (1 participant; 4%), and co-occurring medical/physical issues (e.g., reflux, colds, allergies, headlice) that either were not known by the researcher pre-intervention or arose during intervention (11 participants; 42%).

Intervention Outcomes

Group pre- and post-intervention SPS and CSHQ data are summarized in Table  3 and displayed in Fig.  1 . Mean SPS and CSHQ scores at baseline were 7.81 (SD = 2.83) and 57.29 (SD = 8.86), respectively, both above the respective clinical cut-offs. For SPS, all but three participants showed a reduction in scores from pre- to post-intervention. Of these three, one boy showed a slight deterioration, while the other two participant scores remained stable. The post-intervention scores of 13 participants fell on or below the clinical cut-off. Although nine participants dropped out in intervention or maintenance phases and do not have follow-up data, this pattern of improvement was maintained. For the CSHQ ( N  = 21), all but two participants showed a reduction in scores with intervention; however, the mean score remained above the cut-off ( M  = 47, SD = 7.92). Post-intervention scores fell on or below the clinical cut-off for five participants. Cohen’s d av values were − 1.26 (95%CI =  − 1.83, − 0.67) and − 1.35 (95%CI =  − 1.88, − 0.81) for the pre- to post-intervention CSHQ and SPS, respectively, indicating a large effect. The effect was also large for SPS from pre-intervention to STFU ( d av  =  − 1.69; 95%CI =  − 2.80, − 1.00; PSES = 93%) and LTFU ( d av  =  − 1.69; 95%CI =  − 2.43, − 0.94; PSES = 96%). All the 95% confidence intervals did not include zero, with the upper limits (the smallest probable effect given the negative range) consistently being either in the large or moderate effect range (− 0.67 to − 1.0).

Modified Brinley plots showing individual participants’ change for Sleep Problem Severity (SPS) scores from pre- to post-intervention and short-term (STFU) and long-term follow-up (LTFU) ( a , c , and d ) and for the Children’s Sleep Habits Questionnaire (CSHQ) total scores from pre- to post-intervention ( b ). Note. Filled and unfilled data points represent boys and girls, respectively. The 45° diagonal line (i.e., where X  =  Y ) represents “no-change.” The dashed lines represent the measure’s clinical cut-off. The means and standard deviations are displayed as a cross, with the mean at the center and the cross arms =  ± 1 SD

Analysis of Potential Moderator Variables

Summary data for the potential moderators of age, gender, and selected psychological variables are shown in Table  4 . The outcomes of the analysis of the impact of these potential moderators on intervention outcome are shown in Table  5 . Older children had somewhat lower SPS scores than younger children, suggesting older children had fewer sleep difficulties. Those above the median on the SDQ also had reduced SPS scores, suggesting those with greater social, behavioral, and emotional difficulties had fewer sleep difficulties. The associated effect size was large for both age and SDQ, but none of the other effect sizes were statistically significantly different from zero. All groups showed a consistently large response to intervention (range − 0.96 to − 2.15) with older age, being female, and having higher receptive and expressive language and lower CBCL internalizing symptoms associated with substantially better response to intervention than the respective comparison groups.

Participant Withdrawal

Of the 26 participants, nine (35%) withdrew at varying stages part way through intervention. Withdrawals included participant-initiated discontinuation of intervention prior to meeting parent-clinician determined goals. Reasons for withdrawal reported by parents included family stressors ( N  = 4), lack of parental readiness ( N  = 4), and/or child medical concerns ( N  = 6). The lack of parental readiness (i.e., ambivalence about the proposed intervention, or low motivation) was associated with concerns about the suitability of consequence modifications, which were recommended for some families as a last option in the sequence of interventions.

Data suggests that families who withdrew (i.e., non-completers), compared with those who completed intervention (i.e., completers), had a child younger in age ( M  = 3.8 versus 8.8 years) with greater sleep difficulties as measured by the baseline CSHQ ( M  = 60.2 versus 55) and SPS ( M  = 8.4 versus 7.5). Interestingly, these participants also had generally fewer reported co-occurring conditions ( M  = 2.9 versus 3.9) and took fewer medications ( M  = 1.2 versus 2.3). There were negligible differences between completers and non-completers in communication level and daytime functioning as measured by the VABS-III and CBCL, respectively.

Interobserver Agreement

IOA was calculated for 72% of cases. The remaining 28% did not have video recordings due to an equipment malfunction, or video was their primary data source (i.e., difficulties were undetectable to parents) meaning IOA was unable to be calculated. IOA was calculated for 15–34% of nights across all phases per participant. IOA was between 72 and 98% ( M  = 89%) for observed children, across all study phases and behaviors, suggesting parent-reported diary data were generally reliable.

Treatment Fidelity

Treatment fidelity was calculated over 32–66% of nights across intervention and follow-up phases, for 23 participants who had sufficient data available. Mean treatment fidelity overall was 78% (range 29–100%). Treatment fidelity declined across study phases with a mean of 80% (range 29–100%), 66% (range 43–100%), and 61% (29–100%) across intervention, STFU and LTFU, respectively.

The TARF-R was completed by 19 mothers and 9 fathers for 20/26 participants. The maximum possible total score and subscale scores differ; therefore, the percentage of the possible maximum score was calculated. Mean total TARF-R scores were 100.03 and 102.67 for mothers and fathers, respectively. There were negligible differences between mothers and fathers across subscales. Overall, taking 75% as the lower threshold of a highly acceptable rating, both mothers and fathers rated almost all aspects of intervention (except for disruptiveness) as highly acceptable. TARF-R results are detailed in Table  6 .

This study aimed to evaluate the overall effectiveness of parent-implemented, function-based sleep interventions for 26 children with RGNC. The results of the FBA across children identified a variety of co-occurring sleep difficulties, most commonly prolonged SOL and NWs, maintained by a combination of antecedent and consequence variables. At baseline, 77% of children required parental intervention (i.e., parental presence or bed-sharing) to manage prolonged SOL and NWs, suggesting social attention was a common function. However, sleep difficulties were often multi-functional; that is, they were maintained by social attention, insufficient sleep pressure, escape (i.e., avoidance of bed), automatic (i.e., sensory reinforcement), and/or tangible (e.g., access to devices, toys, and/or food and drink) functions. As a result, the function-based parent-implemented interventions consisted of a range of circadian, antecedent, and consequence modifications.

Results showed that behavioral sleep interventions were somewhat effective for 24/26 children, as reflected in reduced SPS scores and were maintained at follow-up (up to 14 weeks post-intervention). Interestingly, for approximately half, simple modifications to the sleep/wake schedule, sleep environment, and/or reinforcement of target behavior(s) were sufficient to reduce sleep disturbance. For one child, a faded bedtime procedure (Schreck, 2022 ) alone was sufficient to reduce NW and EMW to a clinically meaningful level. This suggests homeostatic sleep pressure may be used to promote sleep onset and maintenance as well as recalibrate the circadian rhythm (Deboer, 2018 ; Laraway et al., 2003 ; Woodford et al., 2022 ) even when behaviors are maintained by other functions (e.g., social, tangible, escape). For the remaining 13 participants, parents implemented an extinction or modified extinction procedure. For ten, addressing socially maintained difficulties, this involved faded parental presence or minimal check, with high rates of success.

Although highly effective for reducing sleep difficulties, particularly those maintained by parent attention, the finding that 50% of children did not require implementation of extinction-based procedures suggests that, for many, such procedures might not be needed. The principle of less restriction advises that practitioners should commence intervention using minimally sufficient and less intrusive strategies (Johnston & Sherman, 1993 ). In the sleep context, less restrictive strategies might comprise circadian and antecedent modifications, preliminary to consequence modifications involving extinction (Blampied & van Deurs, 2022 ; Woodford et al., 2022 ; 2024a ). This study suggests staggering intervention components starting with those that are less restrictive (Johnston & Sherman, 1993 ) may facilitate change using less restrictive methods (Woodford et al., 2022 ; 2024a ). Such an approach is particularly important for children with RGNC and their families, due to the high demands associated with the range and severity of co-occurring conditions or symptoms. In such cases, the need to minimize stress is important for the wellbeing of both the child and parents, as well as the child’s safety (Stores, 2016 ).

Given the range of needs with which children with RGNC present, it is also important that parents feel comfortable implementing behavioral sleep interventions. Only a few studies have evaluated the social validity of such interventions for parents of children with RGNC (Allen et al., 2013 ; McLay et al., 2020 ; Woodford et al., 2022 ), and our finding that these interventions were viewed as reasonable and effective is promising. Given the impact of child sleep disturbance on parents (Mörelius & Hemmingsson, 2014 ) and the acceptability of intervention being a moderator of intervention response (Miller & Rollnick, 2014 ), further research should continue to explore this area.

The influence of age, gender and child psychological variables on the response to behavioral intervention was also considered. Previous research has noted that a range of variables may influence children’s sleep and responses to intervention including behavioral difficulties and low communicative abilities and intellectual functioning (McLay et al., 2020 ; Stores, 2016 ). Interestingly, the present study found children who were younger in age, female and had fewer emotional and behavioral difficulties had slightly greater SPS at baseline. However, there was minimal evidence of any differential response to intervention as a function of those variables. While those with lower internalizing difficulties and greater communicative abilities responded better to intervention, the difference was small, and most children responded positively. Although these results are preliminary, they suggest sleep difficulties may be amenable to change, regardless of the presence and severity of co-occurring factors (France et al., 2022 ).

Furthermore, although physician approval and/or appropriate management of co-occurring medical and/or physical conditions were part of the inclusion criteria for this study, symptoms associated with these conditions likely still played a role in the presenting difficulties for some cases. In addition, alterations to biological sleep processes (e.g., altered melatonin regulation; Woodford et al., 2021 ) may have also played a role. The presence of such factors may explain why some children’s sleep difficulties did not fully resolve and provides context to working with children with RGNC in a clinical setting, i.e., behavioral sleep interventions must be applied in consideration of these (Hamilton et al., 2023 ).

Limitations and Future Research

There are several study limitations which should be considered. First, although the sample size was larger than most current studies that include children with RGNC ( N  = 1–66; M  = 13.44; McLay et al., 2019 ), it is small relative to the population of children with RGNC, especially given the heterogeneity of that population. The small N reduces confidence in the reliability of the effect size estimates and in the generality of our findings to particular sub-samples of the RGNC population. However, given that RGNC are by definition rare, any evidence of therapeutic effects may be useful, and it should be noted that many of the effect sizes reported were clearly not zero (as shown by their 95%CI). Second, some participants ( N  = 9) withdrew during intervention and did not complete follow-up, and so results regarding treatment acceptability gathered post-intervention are limited. Interestingly, however, outcomes suggest positive changes are possible without fully completing intervention. Third, assessment of treatment acceptability was also relatively limited (TARF-R; Reimers et al., 1992 ). A more extensive investigation of parents’ expectations, experiences, resource-limitations, and stress would be desirable. Fourth, IOA could not be calculated for all participants due mostly to technical issues and thus the reliability of parent-report is not known for all participants. Given the measures were based primarily on parent-report, they are susceptible to bias (e.g., halo effect, social desirability bias). Fifth, most of the measures used have not yet been validated for use with children with RGNC. Consequently, there is potential for type one or two errors (Hamrick et al., 2020 ; Neo et al., 2021 ). However, these measures have been widely used in sleep research with neurodivergent children (e.g., Glasson et al., 2020 ; Goodlin-Jones et al., 2008 ; Moss et al., 2014 ). Therefore, they were used for consistency with extant research and because there was a lack of alternative measures. Sixth, although an analysis of potential moderators was completed one variable of interest at a time, information regarding parent variables and the cumulative impact of multiple child and parent variables as potential moderators is lacking. Future research should evaluate the complex interplay of a range of variables simultaneously. Finally, the effectiveness and acceptability of individual intervention components were not evaluated in this study. Future research should continue to implement behavioral strategies in a sequential fashion or evaluate individual strategies, to determine what is minimally sufficient for these children. This is particularly important, since multi-component interventions often require substantial clinical support, which is not always readily available in clinical settings.

In conclusion, this study shows that behavioral interventions are a feasible option for a wide variety of families and children affected by RGNC, the challenges posed by their co-occurring conditions notwithstanding. Although internalizing symptoms and communicative abilities might play a small role in determining intervention response, further research into factors that might moderate the response to intervention is needed. It emphasizes the importance of conducting a comprehensive functional assessment considering behavioral, environmental, developmental, and biological factors. Sound clinical judgment is then required to determine how a behavioral intervention is best implemented for each individual child. Within this, it is important to consider whether parents might or might not need to implement extinction procedures to resolve, or at the very least improve children’s sleep difficulties. Finally, and importantly, this study also provides preliminary evidence to suggest that telehealth individualized sleep support is feasible, having been delivered completely remotely for 22 participants during the peak of the COVID-19 pandemic.

Data Availability

The data that support the findings of this study are available on request from the corresponding author (EW).

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EW designed and executed the study, completed assessment and intervention with most participants (EW was enrolled in a licensure-track Child and Family Psychology training program at the time of the project), conducted the data analyses, and wrote the paper. LM provided clinical supervision and collaborated with the design and execution of the study and writing of the paper. KF provided clinical supervision and collaborated with the design of the study and editing of the final manuscript. NB collaborated with the design of the study, data analyses, and the editing of the final manuscript. UH collaborated with data collation and editing of references. CS collaborated with editing the manuscript. All authors approved the final version of the manuscript for submission.

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Informed consent was obtained from all parent participants, and assent was provided by most children (in cases with an adequate level of comprehension determined in collaboration with parents, interaction with the child, and in consideration of the Communication domain Vineland Adaptive Behavior Scales, Third Edition [VABS-III; Sparrow et al., 2016 ] results) for both participation in the study and publishing of results.

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Woodford, E.C., France, K.G., Blampied, N.M. et al. Behavioral Sleep Interventions for Children with Rare Genetic Neurodevelopmental Conditions: A Retrospective Analysis of Overall Outcomes for 26 Cases. Adv Neurodev Disord (2024). https://doi.org/10.1007/s41252-024-00403-3

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What to Know About Ketamine-Assisted Psychotherapy

A summary and a case report.

Posted April 25, 2024 | Reviewed by Gary Drevitch

• What Is Ketamine?
• Find a therapist to overcome depression
• Evidence suggests that ketamine-assisted psychotherapy (KAP) can extend the benefits of ketamine treatment.
• In limited research findings, KAP appears helpful for treating PTSD, depression, and pain conditions.
• For ketamine and other psychedelic treatments, a trance-like state seems necessary for optimal results.

Part 1 of this series provided an overview of essential information about ketamine for psychiatric use; this post will focus on ketamine-assisted psychotherapy .

Ketamine-assisted psychotherapy (KAP) can encompass many different things. Treatment settings can range from exotic, remote locations (as per a ketamine retreat) to the more mundane, like a ketamine clinic or psychiatrist’s office. Similarly, psychotherapy in this modality can be a single session with a therapist you’ve just met or it can involve a series of sessions with your regular therapist.

Given that research into KAP is at a very early stage, there are few review articles on its efficacy, and those that exist examine just a handful of studies, with most having small sample sizes, so the findings need to be taken with a grain of salt. However, in one such review by Drozdz and colleagues (2022), the authors reported that, in general, KAP can “prolong clinically significant reductions in pain, anxiety and depressive symptoms” and that “longer-term psychotherapy may be helpful in sustaining these gains.”

Dore and colleagues (2019) explored the efficacy of KAP within a psychoanalytic framework in the first such study of its kind. Data were collected from 235 patients, across several diagnostic categories, and ketamine treatments ranged from one to 25 sessions. The authors reported significant decreases in anxiety and depression (relative to baseline) with combined treatments of ketamine and psychoanalytic psychotherapy. They also reported that the number of KAP sessions was significantly positively correlated with improvements in depression and anxiety.

How KAP Might Improve Psychological Well-Being

There seems to be a consensus forming among researchers and practitioners that, for psychedelic-assisted psychotherapy (PAP) in general, and KAP specifically, a psychedelic/dissociative/trance state needs to be achieved during the session for maximum efficacy to be achieved (Dore et al., 2019; Drozdz et al., 2022; Joneborg et al., 2022). Dore and colleagues even went so far as to report that no study to date on KAP has demonstrated an antidepressant effect without some degree of perceived psychoactivity. In speculating why such a dissociative/trance state may be necessary, Dore and colleagues suggested that the trance state produced by psychedelic drugs “promotes communication, access to difficult states of mind with less fear of those encounters, and a relief from obsessive and depressive concerns.” My clinical work with numerous patients receiving different forms of PAP validates Dore and colleagues' assessment.

In a recently published case report ( Cottone, 2023 ) I presented specific details of a KAP session with a long-term, psychodynamic psychotherapy patient, "Elizabeth"; an abridged version of this report is presented below. My KAP session with Elizabeth demonstrates why Dore and colleagues’ assertion may be true, as it seems that ketamine temporarily lessened her defense mechanisms , allowing us to elucidate connections in her life, as well as possible causes of her symptoms (with related interventions to treat them), in a way that would not have been possible without the psychedelic experience. Apropos of this, I believe that analytic/psychodynamic psychotherapy is uniquely suited for KAP given the importance placed on deconstructing defense mechanisms in the approaches from the Freudian tradition.

Case Report

Elizabeth began psychodynamic psychotherapy with me in 2019, about 8 years after a tragic fall that left her with permanent spinal damage and chronic pain . Stemming from this incident, as well as earlier sexual assault when she was 15, Elizabeth exhibited clear symptoms of posttraumatic stress disorder ( PTSD ). In addition to these traumas , her most recent slow-motion trauma is the progression of primary lateral sclerosis (PLS), a variant of ALS.

Before her injury, Elizabeth had strong (if not blind) faith in the medical establishment; however, after complications from multiple surgeries worsened her condition, and post-surgical regimens became increasingly problematic, Elizabeth’s faith in all things medical began to erode. Despite this, it’s notable that from the beginning of treatment, Elizabeth was bent on idealizing me, epitomized by her insistence in calling me by my initials: JC. This was especially ironic because she abandoned her Christian faith earlier in life. This aspect of Elizabeth’s transference was my first experience with her tendency to conceive of important people in her life — including her wife, Stephanie, her closest friends, her parents, and me — as “superheroes.” (All names changed to preserve privacy.)

Dynamics between Elizabeth and her superheroes often led to one of two types of problems. First, in Elizabeth’s eyes, her superheroes could do no wrong, and this invalidated the experience of anyone in her life who had ever been hurt by one of them. Second, whenever there were conflicts in Elizabeth’s life involving two of her superheroes, the ambivalence, anxiety, and tension that resulted would place her in a double bind. It’s here that her unconscious seemed to devise a creative, though uncomfortable, way to rescue her, as she would soon experience an exacerbation of her significant medical and physical needs. Consequently, seeing such an escalation of Elizabeth's physical pain and symptoms would elicit great concern among everyone in her life, including the two superheroes in conflict, ultimately leading to them laying down their arms and rallying around her.

Elizabeth began receiving racemic ketamine treatments once per week, in the fall of 2022, and though she was making considerable progress, she believed more was possible. She then requested that we have a psychotherapy session at her psychiatrist's office during one of her ketamine treatments, and in January 2023, we did just that.

Over the course of this 90-minute session, Elizabeth took 200 mg of racemic ketamine via nasal spray (i.e., 20 sprays). While under the influence of ketamine, Elizabeth spoke about being able to “cut the cord” between her wife Stephanie’s emotional reactivity and her own, and she also noted a growing emotional distance between herself and her past traumas. She then described a “spiritual” experience, which was unusual given that she’d consistently denied any inclinations toward spirituality .

Later, Elizabeth acknowledged, for the first time, her tendency to make the important people in her life — including her wife Stephanie and her friend Diane — into superheroes in her mind. She discovered, over the course of our session, that her need to do this started after her sexual assault to help manage the terror she had as a teenager , and this tendency only increased after the additional medical traumas she endured.

Elizabeth noted that the feeling of calm she had while on ketamine gave her the emotional distance and courage she needed to see that idealizing people as superheroes helped her to maintain a fantasy that they could rescue her from her various hardships, which gave her the hope she needed to endure. She then noted finally understanding how her tendency to ignore the flaws of her superheroes led to increasing conflicts in her life, particularly between Stephanie and Diane.

At the end of the session, it became clear to Elizabeth that the impasse caused by two superheroes being in conflict with each other could only be resolved by an exacerbation of her symptoms, as this was the only thing powerful enough to get these individuals to drop their anger and rally around her. This insight was crucial because it helped her see that her physical deterioration had an indirect benefit. It's at this point that Elizabeth and I discussed the need for her to try harder to see the flaws of her superheroes, so as to validate those in her life who were hurt by them.

Immediately after our KAP, Elizabeth began applying this intervention, and in the months that followed the frequency of conflict between Elizabeth's superheroes significantly decreased, as did the number of times she reported an escalation of physical symptoms. Though Elizabeth has not achieved remission of her PLS symptoms, or those emanating from her spinal injuries, she’s consistently reported less physical pain, a greater range of motion, and sustained remission from her depressive symptoms. She’s also enjoyed a renaissance in her marriage with Stephanie and rapprochement with many other people in her life, including other mutual friends who had been in conflict with Stephanie.

This case demonstrates what’s possible when ketamine treatment is paired with long-term psychotherapy (especially from a psychodynamic perspective), as Elizabeth likely wouldn’t have acquired the insights and benefits that led to the decline in depression and physical pain she experienced with either treatment alone. Elizabeth had been undergoing ketamine treatment for months before our KAP session, and though the treatments did much to enhance her mood, she didn’t come close to achieving the insights she had when psychotherapy was added.

Similarly, in her psychotherapy sessions with me without ketamine, Elizabeth never felt safe enough to consider that the people in her life she idealized — including myself — were not literal superheroes, even if her psychological stability required that we serve in that role. However, during our KAP session, her defense mechanisms relaxed enough for her to briefly consider, for the first time, the consequences of her idealizing tendencies. The insights emanating from that session were so profound for her, they gave her the confidence she needed to make the changes in her relationships that we subsequently discussed.

To find a therapist, visit the Psychology Today Therapy Directory .

Cottone JG. Ketamine-Assisted Psychodynamic Psychotherapy. Psychodynamic Psychiatry. 2023 Dec;51(4):467–478. doi: 10.1521/pdps.2023.51.4.467

Drozdz, S. J., Goel, A., McGarr, M. W., Katz, J., Ritvo, P., Mattina, G. F., Bhat, V., Diep, C., & Ladha, K. S. (2022). Ketamine assisted psychotherapy: A systematic narrative review of the literature. Journal of Pain Research, 15, 1691–1706. https://doi.org/10.2147/JPR.S360733

Dore, J., Tunipseed, B., Dwyer, S., Turnipseed, A., Andries, J., Ascani, G., Monnette, C., Huidekoper, A., Strauss, N. & Wolfson, P. (2019). Ketamine assisted psychotherapy (KAP): Patient demographics, clinical data and outcomes in three large practices administering ketamine with psychotherapy. Journal of Psychoactive Drugs , 51(2), 189–198. https://doi.org/10.1080/02791072.2019.1587556

Joneborg, I., Lee, Y., Di Vincenzo, J. D., Ceban, F., Meshkat, S., Lui, L. M. W., Fancy, F., Rosenblat, J. D., & McIntyre, R. S. (2022). Active mechanisms of ketamine-assisted psychotherapy: A systematic review. Journal of Affective Disorders, 315, 105–112. https://doi.org/10.1016/j.jad.2022.07.030

John G. Cottone, Ph.D., is a psychologist in private practice, a clinical assistant professor of psychiatry at the Renaissance School of Medicine at Stony Brook University, and the author of Who Are You?

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The Assassination Plot Exposed Against Volodymyr Zelensky? A Case Study in Information Warfare

I n the convoluted realm of international politics, the line between truth and deception often blurs, especially in conflicts like the ongoing tension between Ukraine and Russia. A recent revelation concerning an alleged assassination plot targeting Ukrainian President Volodymyr Zelensky sheds light on the intricate dynamics of disinformation and propaganda in modern warfare.

The Foiled Plot: The Ukrainian Government’s Revelation

The Ukrainian Security Service (SBU) revealed a chilling plot to assassinate President Zelensky and other high-ranking officials, implicating two colonels within the State Security Administration as alleged Russian agents. The motive behind the plot, according to Ukrainian authorities, was to present a sinister “gift” to Russian President Vladimir Putin on the eve of his fifth term inauguration.

The alleged involvement of Russian agents in such a brazen scheme underscores the depth of animosity between Ukraine and Russia, which has simmered since the annexation of Crimea and the outbreak of conflict in eastern Ukraine.

Disinformation Strikes: Russia’s Response to the Alleged Plot Against Volodymyr Zelensky

Russian disinformation operatives swiftly went into action, leveraging platforms like Infobrics.org to distort the narrative. The disinformation campaign aimed to cast doubt on Ukraine’s alliances and deflect blame onto Western powers. Infobrics.org, known for spreading pro-Russian propaganda, published an article denying Russian involvement and implicating the West instead.

The article’s author, Lucas Leiroz, is associated with a neo-fascist organization inspired by Russian ideology, raising questions about the ideological motivations behind the disinformation efforts. Leiroz’s involvement underscores the ideological battlegrounds on which disinformation campaigns are waged.

Coordinated Dissemination: How Falsehoods About the Zelensky Plot Spread

The disinformation campaign didn’t stop at Infobrics.org. Lucas Leiroz’s article was disseminated across multiple platforms, including “The Intel Drop” and “SouthFront,” known for their ties to Russian disinformation efforts. This coordinated dissemination highlights the breadth and depth of Russia’s influence operations.

These platforms serve as conduits for spreading falsehoods and manipulating public opinion, amplifying the reach and impact of disinformation campaigns. By saturating multiple channels with misleading narratives, Russian operatives seek to create confusion and sow distrust among their adversaries.

Response from Russian State Media: Denial and Doubt

Russian state media outlets like RT and TASS echoed the narrative of Russian non-involvement while amplifying doubts about the credibility of Ukrainian authorities and President Zelensky. This coordinated effort aims to sow discord among Western allies and undermine the international community’s response to Russian aggression.

The strategy of denial and deflection employed by Russian state media is a classic tactic in information warfare, designed to obfuscate the truth and undermine the credibility of opposing narratives. By casting doubt on the veracity of Ukrainian claims, Russia seeks to create fissures within the international coalition aligned against it.

International Response to Zelensky: Condemnation and Vigilance

Despite Russian efforts to obfuscate the truth, the international community, led by the United States Department of State, has condemned Russia’s actions as evidence of Kremlin depravity. This firm stance underscores the importance of remaining vigilant and united against disinformation and aggression.

Efforts to combat disinformation must be multifaceted, involving diplomatic, technological, and informational countermeasures. By exposing and debunking false narratives , the international community can mitigate the impact of disinformation and uphold the integrity of democratic institutions.

Conclusion: Pursuing Truth Amidst Deception

The alleged assassination plot against President Zelensky serves as a stark reminder of the dangers posed by disinformation and propaganda. As geopolitical tensions rise and information becomes weaponized, it is imperative to remain steadfast in our pursuit of truth and justice, lest we succumb to the machinations of those who seek to manipulate and deceive.

By shining a light on the shadowy world of disinformation and propaganda, we can empower individuals and nations to resist manipulation and uphold the principles of transparency and accountability. Only by confronting falsehoods with facts and narratives with truth can we hope to navigate the treacherous waters of modern information warfare.

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Coping with the Stress of Retirement

• Ruth C. White

Every stage of the transition comes with its own challenges. Here’s how to handle each one.

Retirement can seem like a dream. Will we ever be able to stop working? Will we want to? Will we be able to afford it? For those of us who have built our lives around work, the transition to not working can be stressful. Whether your worry about retirement is grounded in financial questions, health concerns, or filling your time in meaningful ways, identifying your sources of stress can help you take proactive steps to prepare for this significant life transition from an emotional and psychological standpoint, helping you reduce and manage your stress and enjoy a more positive retirement. The sources of stress will differ for individuals depending on your personal context and where in the seven phases of retirement you are. Provides definitions and coping mechanisms for six of the seven phases to help you identify them and manage your response during them. Regardless of the specific circumstances of your retirement, preparing for it emotionally and psychologically will help ameliorate the stresses that it can bring so that you can focus on enjoying the life you planned for with a sense of purpose, accomplishment, and connection that lasts.

For many of us, retirement is a dream. At the start of our careers, we don’t often give it more thought than enrolling in a savings plan or filling out tax forms. When retirement age grows closer to becoming a reality, we joke about it, daydream about it, and perhaps worry about it. Will we be lucky enough to have the money, good health, and companionship of family and friends to enjoy our golden years?

• Ruth C. White is a mental health advocate and stress management expert who often shares her journey of recovery and resilience with bipolar disorder in her talks, workshops, and writings. White is a therapist who has authored four books on mental health, including Bipolar 101: A Practical Guide to Identifying Triggers, Managing Medications, Coping with Symptoms and More and The Stress Management Workbook: De-Stress in 10 Minutes or Less . She has written for Fast Company and Thrive Global , blogs for Psychology Today , and from 2020 to 2023 she appeared frequently as a mental health commentator and educator on KRON4 TV Bay Area. She is currently a project advisor in Equity, Diversity, and Inclusion in the Rotman School of Management at the University of Toronto, where she also teaches in the Factor-Inwentash Faculty of Social Work. ruthcwhite

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