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Counseling Today

A Publication of the American Counseling Association

Counseling today , knowledge share, case conceptualization: key to highly effective counseling.

By Jon Sperry and Len Sperry December 7, 2020

counselling case study

After processing this session in supervision, the intern was no longer surprised that Jane had not kept a follow-up appointment. The initial session had occurred near the end of the intern’s second week, and she had been eager to practice cognitive disputation, which she believed was appropriate in this case. In answer to the supervisor’s question of why she had concluded this, the intern responded that “it felt right.”

The supervisor was not surprised by this response because the intern had not developed a case conceptualization. With one, the intern could have anticipated the importance of immediately establishing an effective and collaborative therapeutic alliance and gently processing Jane’s emotional distress sufficiently before dealing with her guilt-producing thought.

This failure to develop an adequate and appropriate case conceptualization is not just a shortcoming of trainees, however. It is also common enough among experienced counselors.

What is case conceptualization?

Basically, a case conceptualization is a process and cognitive map for understanding and explaining a client’s presenting issues and for guiding the counseling process. Case conceptualizations provide counselors with a coherent plan for focusing treatment interventions, including the therapeutic alliance, to increase the likelihood of achieving treatment goals.

We will use the definition from our integrated case conceptualization model to operationalize the term for the purposes of explaining how to utilize this process. Case conceptualization is a method and clinical strategy for obtaining and organizing information about a client, understanding and explaining the client’s situation and maladaptive patterns, guiding and focusing treatment, anticipating challenges and roadblocks, and preparing for successful termination.

We believe that case conceptualization is the most important counseling competency besides developing a strong therapeutic alliance. If our belief is correct, why is this competency taught so infrequently in graduate training programs, and why do counselors-in-training struggle to develop this skill? We think that case conceptualization can be taught in graduate training programs and that counselors in the field can develop this competency through ongoing training and deliberate practice.

This article will articulate one method for practicing case conceptualization.

The eight P’s

We use and teach the eight P’s format of case conceptualization because it is brief, quick to learn and easy to use. Students and counselors in the community who have taken our workshops say that the step-by-step format helps guide them in forming a mental picture — a cognitive map — of the client. They say that it also aids them in making decisions about treatment and writing an initial evaluation report.

The format is based on eight elements for articulating and explaining the nature and origins of the client’s presentation and subsequent treatment. These elements are described in terms of eight P’s: presentation, predisposition (including culture), precipitants, protective factors and strengths, pattern, perpetuants, (treatment) plan, and prognosis.

Presentation

Presentation refers to a description of the nature and severity of the client’s clinical presentation. Typically, this includes symptoms, personal concerns and interpersonal conflicts.

Four of the P’s — predisposition, precipitants, pattern and perpetuants — provide a clinically useful explanation for the client’s presenting concern.

Predisposition

Predisposition refers to all factors that render an individual vulnerable to a clinical condition. Predisposing factors usually involve biological, psychological, social and cultural factors.

This statement is influenced by the counselor’s theoretical orientation. The theoretical model espouses a system for understanding the cause of suffering, the development of personality traits, and a process for how change and healing can occur in counseling. We will use a biopsychosocial model in this article because it is the most common model used by mental health providers. The model incorporates a holistic understanding of the client.

Biological: Biological factors include genetic, familial, temperament and medical factors, such as family history of a mental or substance disorder, or a cardiovascular condition such as hypertension.

Psychological: Psychological factors might include dysfunctional beliefs involving inadequacy, perfectionism or overdependence, which further predispose the individual to a medical condition such as coronary artery disease. Psychological factors might also involve limited or exaggerated social skills such as a lack of friendship skills, unassertiveness or overaggressiveness.

Social: Social factors could include early childhood losses, inconsistent parenting style, an overly enmeshed or disengaged family environment, and family values such as competitiveness or criticalness. Financial stressors can further exacerbate a client’s clinical presentations. The “social” element in the biopsychosocial model includes cultural factors. We separate these factors out, however.

Cultural: Of the many cultural factors, three are particularly important in developing effective case conceptualizations: level of acculturation, acculturative stress and acculturation-specific stress. Acculturation is the process of adapting to a culture different from one’s initial culture. Adapting to another culture tends to be stressful, and this is called acculturative stress. Such adaptation is reflected in levels of acculturation that range from low to high.

Generally, clients with a lower level of acculturation experience more distress than those with a higher level of acculturation. Disparity in acculturation levels within a family is noted in conflicts over expectations for language usage, career plans, and adherence to the family’s food choices and rituals. Acculturative stress differs from acculturation-specific stresses such as discrimination, second-language competence and microaggressions.

Precipitants

Precipitants refer to physical, psychological and social stressors that may be causative or coincide with the onset of symptoms or relational conflict. These may include physical stressors such as trauma, pain, medication side effects or withdrawal from an addictive substance. Common psychological stressors involve losses, rejections or disappointments that undermine a sense of personal competence. Social stressors may involve losses or rejections that undermine an individual’s social support and status. Included are the illness, death or hospitalization of a significant other, job demotion, the loss of Social Security disability payments and so on.

Protective factors and strengths

Protective factors are factors that decrease the likelihood of developing a clinical condition. Examples include coping skills, a positive support system, a secure attachment style and the experience of leaving an abusive relationship. It is useful to think of protective factors as being the mirror opposite of risk factors (i.e., factors that increase the likelihood of developing a clinical condition). Some examples of risk factors are early trauma, self-defeating beliefs, abusive relationships, self-harm and suicidal ideation.

Related to protective factors are strengths. These are psychological processes that consistently enable individuals to think and act in ways that benefit themselves and others. Examples of strengths include mindfulness, self-control, resilience and self-confidence. Because professional counseling emphasizes strengths and protective factors, counselors should feel supported in identifying and incorporating these elements in their case conceptualizations.

Pattern (maladaptive)

Pattern refers to the predictable and consistent style or manner in which an individual thinks, feels, acts, copes, and defends the self both in stressful and nonstressful circumstances. It reflects the individual’s baseline functioning. Pattern has physical (e.g., a sedentary and coronary-prone lifestyle), psychological (e.g., dependent personality style or disorder) and social features (e.g., collusion in a relative’s marital problems). Pattern also includes the individual’s functional strengths, which counterbalance dysfunction.

Perpetuants

Perpetuants refer to processes through which an individual’s pattern is reinforced and confirmed by both the individual and the individual’s environment. These processes may be physical, such as impaired immunity or habituation to an addictive substance; psychological, such as losing hope or fearing the consequences of getting well; or social, such as colluding family members or agencies that foster constrained dysfunctional behavior rather than recovery and growth. Sometimes precipitating factors continue and become perpetuants.

Plan (treatment)

Plan refers to a planned treatment intervention, including treatment goals, strategy and methods. It includes clinical decision-making considerations and ethical considerations.

Prognosis refers to the individual’s expected response to treatment. This forecast is based on the mix of risk factors and protective factors, client strengths and readiness for change, and the counselor’s experience and expertise in effecting therapeutic change.  

Case example

To illustrate this process, we will provide a case vignette to help you practice and then apply the case to our eight P’s format. Ready? Let’s give it a shot.

Joyce is a 35-year-old Ph.D. student at an online university. She is white, identifies as heterosexual and reports that she has never been in a love relationship. She is self-referred and is seeking counseling to reduce her chronic anxiety and social anxiety. She recently started a new job at a bookstore — a stressor that brought her to counseling. She reports feeling very anxious when speaking in her online classes and in social settings. She is worried that she will not be able to manage her anxiety at her new job because she will be in a managerial role.

Joyce reports that she has been highly anxious since childhood. She denies past psychological or psychiatric treatment of any kind but reports that she has recently read several self-help books on anxiety. She also manages her stress by spending time with her close friend from class, spending time with her two dogs, drawing and painting. She appears to be highly motivated for counseling and states that her goals for therapy are “to manage and reduce my anxiety, increase my confidence and eventually get in a romantic relationship.”

Joyce describes her childhood as lonely and herself as “an introvert seeking to be an extrovert.” She states that her parents were successful lawyers who valued success, achievement and public recognition. They were highly critical of Joyce when she would struggle with academics or act shy in social situations. As an only child, she often played alone and would spend her free time reading or drawing by herself.

When asked how she views herself and others, Joyce says, “I often don’t feel like I’m good enough and don’t belong. I usually expect people to be self-centered, critical and judgmental.”

Case conceptualization outline

We suggest developing a case conceptualization with an outline of key phrases for each of the eight P’s. Here is what these phrases might look like for Joyce’s case. These phrases are then woven together into sentences that make up a case conceptualization statement that can be imported into your initial evaluation report.

Presentation: Generalized anxiety symptoms and social anxiety

Precipitant: New job and concerns about managing her anxiety

Pattern (maladaptive): Avoids cl oseness to avoid perceived harm

Predisposition:

  • Biological: Paternal history of anxiety
  • Psychological: Views herself as inadequate and others as critical; deficits in assertiveness skills, self-soothing skills and relational skills
  • Social: Few friends, a history of social anxiety, and parents who were highly successful and critical
  • Cultural: No acculturative stress or cultural stressors but from upper-middle-class socioeconomic status, so from privileged background — access to services and resources

Perpetuants: Small support system; believes that she is not competent at work

Protective factors/strengths: Compassionate, creative coping, determined, hardworking, has access to various resources, motivated for counseling

Plan (treatment): Supportive and strengths-based counseling, thought testing, self-monitoring, mindfulness practice, downward arrow technique, coping and relationship skills training, referral for group counseling

Prognosis: Good, given her motivation for treatment and the extent to which her strengths and protective factors are integrated into treatment

Case conceptualization statement

Joyce presents with generalized anxiety symptoms and social anxiety (presentation) . A recent triggering event includes her new job at a local bookstore — she is concerned that she will make errors and will have high levels of anxiety (precipitant) . She presents with an avoidant personality — or attachment — style and typically avoids close relationships. She has one close friend and has never been in a love relationship. She typically moves away from others to avoid being criticized, judged or rejected (pattern) . Some perpetuating factors include her small support system and her belief that she is not competent at work (perpetuants) .

Some of her protective factors and strengths include that she is compassionate, uses art and music to cope with stress, is determined and hardworking, and is collaborative in the therapeutic relationship. Protective factors include that she has a close friend from school, has access to university services such as counseling services and student clubs and organizations, is motivated to engage in counseling, and has health insurance (strengths & protective factors) .

The following biopsychosocial factors attempt to explain Joyce’s anxiety symptoms and avoidant personality style: a paternal history of anxiety (biological) ; she views herself as inadequate and others as critical and judgmental, and she struggles with deficits in assertiveness skills, self-soothing skills and relational skills (psychological) ; she has few friends, a history of social anxiety and parents who were highly successful and critical toward her (social) . Given Joyce’s upper-middle-class upbringing, she was born into a life of opportunity and privilege, so her entitlement of life going in a preferred and comfortable path may also explain her challenges with managing life stress (cultural) .

Besides facilitating a highly supportive, empathic and encouraging counseling relationship, treatment will include psychoeducation skills training to develop assertiveness skills, self-soothing skills and relational skills. These skills will be implemented through modeling, in-session rehearsal and role-play. Her challenges with relationship skills and interpersonal patterns will also be addressed with a referral to a therapy group at the university counseling center. Joyce’s negative self-talk, interpersonal avoidance and anxiety symptoms will be addressed with Socratic questioning, thought testing, self-monitoring, mindfulness practice and the downward arrow technique (plan-treatment) .

The outcome of therapy with Joyce is judged to be good, given her motivation for treatment, if her strengths and protective factors are integrated into the treatment process (prognosis) .

Notice how the treatment plan is targeted at the presenting symptoms and pattern dynamics of Joyce’s case. Each of the eight P’s was identified in the case conceptualization, and you can see the flow of each element and its interconnections to the other elements.

counselling case study

Tips for writing effective case conceptualizations

1) Seek consultation or supervision with a peer or supervisor for feedback on your case conceptualizations. Often, another perspective will help you understand the various elements (eight P’s) that you are trying to conceptualize.

2) Be flexible with your hypotheses and therapeutic guesses when piecing together case conceptualizations. Sometimes your hunches will be accurate, and sometimes you will be way off the mark.

3) Consider asking the client how they would explain their presenting problem. We begin with a question such as, “How might you explain the (symptoms, conflict, etc.) you are experiencing?” The client’s perspective may reveal important predisposing factors and cultural influences as well as their expectations for treatment.

4) Be OK with being imperfect or being completely wrong. This process takes practice, feedback and supervision.

5) After each initial intake or assessment, jot down the presenting dynamics and make some guesses of the cause or etiology of them.

6) Have a solid understanding of at least one theoretical model. Read some of the seminal textbooks or watch counseling theory videos to help you gain a comprehensive assessment of a specific theory. Knowing the foundational ideas of at least one theory will help with your conceptual map of piecing together the information that you’ve gathered about a client.

We realize that putting together case conceptualizations can be a challenge, particularly in the beginning. We hope you will find that this approach works for you. Best wishes!

For more information and ways of learning and using this approach to case conceptualization, check out the recently published second edition of our book, Case Conceptualization: Mastering This Competency With Ease and Confidence .

Also, Len and Jon Sperry published a new book in November 2021, titled The 15 Minute Case Conceptualization: Mastering the Pattern-Focused Approach .

Jon Sperry is an associate professor of clinical mental health counseling at Lynn University in Florida. He teaches, writes about and researches case conceptualization and conducts workshops on it worldwide. Contact him at [email protected] or visit his website at drjonsperry.com .

Len Sperry is a professor of counselor education at Florida Atlantic University and a fellow of the American Counseling Association. He has long advocated for counselors learning and using case conceptualization, and his research team has completed eight studies on it. Contact him at [email protected] .

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

23 Comments

Great article with clarication and step by step process to follow.

I will be checking out videos on counseling theory. Any recommendations?

Really appreciated this article! I come from a social work background so haven’t heard of the 8 P’s before but it helps to have that as a foundation for assessing clients. Thank you!

This is such an excellent article for professionals at every stage. It is greatly appreciated as this gives a new perspective on case conceptualization. The 8 P’s definitely help in clearly assessing all aspects of the client. I will keep this article as a reference.

Nice article! Give P’s a chance.

I really appreciate the article. This article has given me a much needed clear understanding of case conceptualization, thank you very much!

I love this article so much. It makes me more clearer about principlee and every steps of case conceptyualization. This is my first time to hear 8P’s which it includes 4P’s as I was familiar with before. It help me understand the whole process clearly. Thank you for your generosity and kindly share this knowledge. Would you mind alowing me to use this knowledge as a reference in the training of psychotherapists and counselors in my country.

Sincerely appreciate you, Jintana Singkhornard M.Sc. (Clinical Psychology) Senior Clinical Psychologist Thailand

Jintana, thank you for your kind words. Feel free to share this information in your training.

This article gave me a clear idea of what is a Case conceptualisation – 8ps – Excellent !!!

Counselling student

I’m a beginning counseling student (1st semester) and have to write a case conceptualization using a specific counseling theory. I went through and marked my own answers first, then reviewed your responses for the case conceptualization P’s in your example. This has helped me a ton in understanding how to do a proper case conceptualization with a clear example.

Great information and easy to understand! Thank you!!

Very informative, very helpful. great concept. Thank you

Love this concept and how conceptualization helps plan a treatment plan for clients. especially being a New Intern very helpful indeed and easy to understand.

A very good guideline for conducting counseling. Well done

This was a well written article. I really appreciate you sharing this as I find it valuable. My clinical background as an MSW did not include mastering this process , and since I graduated a few years ago and now an LMSW, still feeling like I need a lot of help. This article created a clear, process in achieving an effective case conceptualization. Thank you!

excellent work !!!helped me a lot!!! thanking you once again

Hello, thank you for the detailed informative article, I wonder is it enough to learn from the book and will I be able to apply the concepts on my own? do you have a course on case conceptualization? I think it will be more interactive, or any more interactive form of training would be more helpful for such a topic.

Thank you for sharing this information. I am an LMSW, working with people (18 +) who are diagnosed with schizophrenia plus other disorders. This article will help me with a more definitive plan of action. My position is to assess their mental stability and guide those who have goals or want to improve their lives.

Hello.Thanks for this eye-opener on case conceptualization. It has been very helpful

Insightful good and appropriate in policy guidance

Thank you for sharing this amazing case. Very easy to follow and understable. I am a student counsellor busy doing my internship and this case steps really helped me alot. I am sure I will be able to apply case conceptualization during my work

Wonderful job explaining case conceptualization! I can tell you are educators by heart! And that means a lot to the eager to learn student. I am very appreciate of your article, knowledge, and the manner which it was well presented. Have a wonderful day! Warm Wishes, MFT student at Capella University

Hello this is an excellent article! I explained things very clearly and concisely. Very practical!

I would have enjoyed reading how to correct the original situation of the mother whose son had brain cancer. Where did the therapist go wrong and what would have been a better route to take with her?

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Child and Adolescent Counseling Case Studies

Developmental, relational, multicultural, and systemic perspectives.

Brenda Jones, PhD, LPC

Thelma Duffey, PhD

Shane Haberstroh, PhD

This state-of-the-art collection of 28 real-life cases on counseling children and adolescents emphasizes the developmental, relational, and cultural contexts of working with this population, and incorporates innovative techniques across a wide range of approaches. Intended as a companion to child and adolescent counseling texts, it offers counselors-in-training examples of hands-on, concrete, and workable applications that provide opportunities for skill and theory development. These case studies are distinguished by their emphasis on the critical impact of such systemic contexts as family, peers, and school, along with developmental and cultural contexts. The inclusion of creative and expressive interventions--often the most effective strategies in working with this population--makes this an outstanding educational resource.

The case studies--representing an esteemed variety of contributing authors--address such ubiquitous themes as abuse, anxiety, giftedness, disability, body image, substance abuse, social media, grief, bullying, changing families, military families, incarcerated family members, race and ethnicity, and sexual identity and orientation. Each case follows a consistent format, comprising a description of the young person's presenting issues, a conceptualization of these issues, a description of the counseling process, an outline of desired outcomes, and a detailed discussion that includes systemic contexts, developmental and relational considerations, multicultural perspectives, and options for use of creative interventions.

KEY FEATURES:

  • Delivers a wide variety of cases covering contemporary issues prevalent among children and adolescents
  • Emphasizes developmental, systemic, and contextual impacts including family, school, peer, and cultural influences
  • Includes such treatment approaches as brief, solution-focused, CBT, reality/choice, narrative, and relational/cultural
  • Includes options for creative interventions with each case and time-efficient methods when applicable

Contributors

Foreword by Ann Vernon, Phd, LPC

Acknowledgments

PART I: Case Studies Relating to Children

1: Somewhere Over the Rainbow

Maria Haiyasoso

2: Good Guys and Bad Guys

Stephanie Eberts

3: A Gift for Jeffrey

Taryne M. Mingo

4: Jimmy in the Middle

Claudia Morales

5: Michael and the Camouflage Crutches

Jenn Pereira

6: Creating Space for Dominic’s Peace

Ariel Mitchell

7: Conquering the Worry Bully

Huma Bashir

8: Paula’s Picturesque Persona

Katherine Bacon and Natasha Young

9: Finding Shay

Melissa Luke

10: Whitney and Rook: Finding Connection in Play Therapy

Suzanne M. Dugger and Jennifer Austin Main

11: Zarack and the Land of Dreams

JoLynne Reynolds

PART II: Case Studies Relating to Adolescents

12: Renewed Through Charted Memories

Alexandria K. Kerwin and Eric Suddeath

13: Hope Deferred

Caroline M. Brackette

14: To Booth or Not to Booth

Brenda L. Jones

15: Brice and the Brightly Colored Socks

Kristopher M. Goodrich

16: The Mystery of HIStory

Angie D. Wilson and Glenda S. Johnson

17: Natalie’s New Vision

Ernest Cox, Jr.

18: The Winding Road Through Addiction and Family Loss

Shane Haberstroh and Thelma Duffey

19: Imprisoned Identities

Thomas Anthony Chávez

20: Growing a Gentle Giant

Thelma Duffey, Shane Haberstroh, and Stacy Waterman

21: Growing Up Lily

Donna A. Tonrey

22: Labels Limit and Relationships Heal

Tammy L. Wilborn

23: Bucking the System

Lisa L. Beijan

24: Killian’s Killer Love Affair

Norèal F. Armstrong

25: Uncovering Mike

Tamarine Foreman

26: The Gifted Girl

Michelle Robinson

27: Gingerbread Sentiments

M. Michelle Thornbury Kelley

28: Brittany—The Social Media Queen

Mona Robinson

CACREP Signature Assignments

An assignment written specifically for the case study, Imprisoned Identities

Assignment 1 written specifically for a child and adolescent counseling class

Assignment 2 written specifically for a child and adolescent counseling class

An assignment written specifically for group work for gifted children and used in child and adolescent counseling classes

An assignment written specifically for co-creating therapeutic stories with clients

Brenda Jones, PhD, LPC, NCC, CSC is a Clinical Assistant Professor at the University of Texas at San Antonio.

Thelma Duffey, PhD, LPC, LMFT, is professor and chair in the Department of Counseling at the University of Texas at San Antonio.

Shane Haberstroh, EdD, LPC, is currently an associate professor and Doctoral Program Director in the Department of Counseling at the University of Texas at San Antonio.

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Case Study Research: In Counselling and Psychotherapy

  • By: John McLeod
  • Publisher: SAGE Publications Ltd
  • Publication year: 2010
  • Online pub date: December 20, 2013
  • Discipline: Counseling and Psychotherapy
  • Methods: Case study research , Narrative research , Single cases
  • DOI: https:// doi. org/10.4135/9781446287897
  • Keywords: clients , counseling research , knowledge , outcomes , persons , psychotherapy , publications Show all Show less
  • Print ISBN: 9781849208055
  • Online ISBN: 9781446287897
  • Buy the book icon link

Subject index

Case-based knowledge forms an essential element of the evidence base for counselling and psychotherapy practice. This book provides the reader with a unique introduction to the conceptual and practical tools required to conduct high quality case study research that is grounded in their own therapy practice or training. Drawing on real-life cases at the heart of counselling and psychotherapy practice, John McLeod makes complex debates and concepts engaging and accessible for the trainees and practitioners at all levels, and from all theoretical orientations. Key topics covered in the book include: the role of case studies in the development of theory, practice and policy in counselling and psychotherapy; strategies for responding to moral and ethical issues in therapy case study research; practical tools for collecting case data; ‘how-to-do-it’ guides for carrying out different types of case study; team-based case study research for practitioners and students; questions, issues and challenges that may have been raised for readers through their study.

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

All trainees in counselling, psychotherapy and clinical psychology are required to complete case reports, and this is the only textbook to cover the topic in real depth. The book will also be valuable to people who intend to use existing case studies to inform their practice, and it will help experienced practitioners to generate publishable case reports.

Front Matter

  • Praise for the Book
  • Acknowledgements
  • Chapter 1 | The Role of Case Studies in the Development of Theory and Practice in Counselling and Psychotherapy
  • Chapter 2 | The Development of Systematic Methods and Principles for Collecting and Analysing Case Material
  • Chapter 3 | Justifying Case-Based Research: The Role of Systematic Case Studies in Building an Evidence Base for Therapy Policy and Practice
  • Chapter 4 | Moral and Ethical Issues in Therapy Case Study Research
  • Chapter 5 | Collecting and Analysing Case Material: A Practitioner and Student Toolkit
  • Chapter 6 | Documenting Everyday Therapeutic Practice: Pragmatic Case Studies
  • Chapter 7 | Evaluating the Effectiveness of Therapy: N=1 Time-Series Case Studies
  • Chapter 8 | Using Multiple Judges in Evaluating the Effectiveness of Therapy: The Hermeneutic Single Case Efficacy Design (HSCED)
  • Chapter 9 | Theory-Building Case Studies
  • Chapter 10 | Exploring the Meaning of the Therapy Experience: Narrative Case Research
  • Chapter 11 | Team-Based Case Study Research for Practitioners and Students

Back Matter

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  • Psicol Reflex Crit
  • v.34; 2021 Dec

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

Greta kaluzeviciute.

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

Associated Data

Not applicable.

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

Introduction

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

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

Unlike the classic clinical case study, systematic cases usually involve a team of researchers, who gather data from multiple different sources (e.g., questionnaires, observations by the therapist, interviews, statistical findings, clinical assessment, etc.), and involve a rigorous data triangulation process to assess whether the data from different sources converge (McLeod, 2010 ). Since systematic case studies are methodologically pluralistic, they have a greater interest in situating patients within the study of a broader population than clinical case studies (Iwakabe & Gazzola, 2009 ). Systematic case studies are considered to be an accessible method for developing research evidence-base in psychotherapy (Widdowson, 2011 ), especially since they correct some of the methodological limitations (e.g. lack of ‘third party’ perspectives and bias in data analysis) inherent to classic clinical case studies (Iwakabe & Gazzola, 2009 ). They have been used for the purposes of clinical training (Tuckett, 2008 ), outcome assessment (Hilliard, 1993 ), development of clinical techniques (Almond, 2004 ) and meta-analysis of qualitative findings (Timulak, 2009 ). All these developments signal a revived interest in the case study method, but also point to the obvious lack of a research assessment tool suitable for case studies in psychotherapy (Table ​ (Table1 1 ).

Key concept: systematic case study

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

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

Given the significance of methodological pluralism and diverse research aims in systematic case studies, CaSE will not seek to prescribe explicit case study writing guidelines, which has already been done by numerous authors (McLeod, 2010 ; Meganck, Inslegers, Krivzov, & Notaerts, 2017 ; Willemsen et al., 2017 ). Instead, CaSE will enable the retrospective assessment of systematic case study findings and their relevance (or lack thereof) to broader psychotherapy research and practice. However, there is no reason to assume that CaSE cannot be used prospectively (i.e. producing systematic case studies in accordance to CaSE evaluative framework, as per point 3 in Table ​ Table2 2 ).

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

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

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

The common approach: evidence-based practice.

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

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

The EBP paradigm prioritises the quantitative approach to causality, most notably through its focus on high generalisability and the ability to deal with bias through randomisation process. These conditions are associated with randomised controlled trials (RCTs) but are limited (or, as some argue, impossible) in qualitative research methods such as the case study (Margison et al., 2000 ) (Table ​ (Table3 3 ).

Key concept: evidence-based practice (EBP)

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

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

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

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Internal validity

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

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

The alternative approach: practice-based evidence

In an attempt to dissolve or lessen the research–practice divide, an alternative paradigm of practice-based evidence (PBE) has been suggested (Barkham & Mellor-Clark, 2003 ; Fox, 2003 ; Green & Latchford, 2012 ; Iwakabe & Gazzola, 2009 ; Laska, Motulsky, Wertz, Morrow, & Ponterotto, 2014 ; Margison et al., 2000 ). PBE represents a shift in how we think about evidence and knowledge generation in psychotherapy. PBE treats research as a local and contingent process (at least initially), which means it focuses on variations (e.g. in patient symptoms) and complexities (e.g. of clinical setting) in the studied phenomena (Fox, 2003 ). Moreover, research and theory-building are seen as complementary rather than detached activities from clinical practice. That is to say, PBE seeks to examine how and which treatments can be improved in everyday clinical practice by flagging up clinically salient issues and developing clinical techniques (Barkham & Mellor-Clark, 2003 ). For this reason, PBE is concerned with the effectiveness of research findings: it evaluates how well interventions work in real-world settings (Rosqvist et al., 2011 ). Therefore, although it is not unlikely for RCTs to be used in order to generate practice-informed evidence (Horn & Gassaway, 2007 ), qualitative methods like the systematic case study are seen as ideal for demonstrating the effectiveness of therapeutic interventions with individual patients (van Hennik, 2020 ) (Table ​ (Table4 4 ).

Key concept: practice-based evidence (PBE)

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

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

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

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

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External validity

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

A third way approach to validity and evidence

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

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

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

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

What is a research tool.

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

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

Because of these different approaches, there is some ambiguity in terminology, particularly between research appraisal instruments and research appraisal tools . These terms are often used interchangeably in appraisal literature (Williams et al., 2019 ). In this paper, research appraisal tool is defined as a method-specific (i.e. it identifies a specific research method or component) form of appraisal that draws from both checklist and framework approaches. Furthermore, a research appraisal tool seeks to inform decision making in EBP or PBE paradigms and provides explicit definitions of the tool’s evaluative framework (thus minimising—but by no means eliminating—the reviewers’ interpretation of the tool). This definition will be applied to CaSE (Table ​ (Table5 5 ).

Key concept: research appraisal tool

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

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

Comparing different qualitative tools

Hannes et al. ( 2010 ) identified CASP (Critical Appraisal Skills Programme-tool), JBI (Joanna Briggs Institute-tool) and ETQS (Evaluation Tool for Qualitative Studies) as the most frequently used critical appraisal tools by qualitative researchers. All three instruments are available online and are free of charge, which means that any researcher or reviewer can readily utilise CASP, JBI or ETQS evaluative frameworks to their research. Furthermore, all three instruments were developed within the context of organisational, institutional or consortium support (Tables ​ (Tables6, 6 , ​ ,7 7 and ​ and8 8 ).

CASP (Critical Appraisal Skills Programme-tool)

JBI (Joanna Briggs Institute-tool)

ETQS (Evaluation Tool for Qualitative Studies)

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

Based on Hannes et al. ( 2010 ) comparative study of qualitative appraisal tools as well as the different evaluation criteria explicated in CASP, JBI and ETQS evaluative frameworks, I assessed how well each of the three tools is attuned to the methodological , clinical and theoretical aspects of systematic case studies in psychotherapy. The latter components were based on case study guidelines featured in the journal of Pragmatic Case Studies in Psychotherapy as well as components commonly used by published systematic case studies across a variety of other psychotherapy journals (e.g. Psychotherapy Research , Research In Psychotherapy : Psychopathology Process And Outcome , etc.) (see Table ​ Table9 9 for detailed descriptions of each component).

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

The evaluation criteria for each tool in Table ​ Table9 9 follows Joanna Briggs Institute (JBI) ( 2017a , 2017b ); Critical Appraisal Skills Programme (CASP) ( 2018 ); and ETQS Questionnaire (first published in 2004 but revised continuously since). Table ​ Table10 10 demonstrates how each tool should be used (i.e. recommended reviewer responses to checklists and questionnaires).

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

Using CASP, JBI and ETQS for systematic case study appraisal

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

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

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

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

Finally, there is something to be said about the recommended reviewer responses (Table ​ (Table10). 10 ). Systematic case studies can vary significantly in their formulation and purpose. The methodological, theoretical and clinical components outlined in Table ​ Table9 9 follow guidelines made by case study journals; however, these are recommendations, not ‘set in stone’ case templates. For this reason, the straightforward checklist approaches adopted by JBI and CASP may be difficult to use for case study researchers and those reviewing case study research. The ETQS open-ended questionnaire approach suggested by Long and Godfrey ( 2004 ) enables a comprehensive, detailed and purpose-oriented assessment, suitable for the evaluation of systematic case studies. That said, there remains a challenge of ensuring that there is less space for the interpretation of evaluative criteria (Williams et al., 2019 ). The combination of checklist and framework approaches would, therefore, provide a more stable appraisal process across different reviewers.

Developing purpose-oriented evaluation criteria for systematic case studies

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

CaSE checklist for essential components in systematic case studies

In order to conceptualise purpose-oriented appraisal questions, we must first look at what unites and differentiates systematic case studies in psychotherapy. The commonly used theoretical, clinical and methodological systematic case study components were identified earlier in Table ​ Table9. 9 . These components will be seen as essential and common to most systematic case studies in CaSE evaluative criteria. If these essential components are missing in a systematic case study, then it may be implied there is a lack of information, which in turn diminishes the evidential quality of the case. As such, the checklist serves as a tool for checking whether a case study is, indeed, systematic (as opposed to experimental or clinical; see Iwakabe & Gazzola, 2009 for further differentiation between methodologically distinct case study types) and should be used before CaSE Purpose - based Evaluative Framework for Systematic Case Studie s (which is designed for the appraisal of different purposes common to systematic case studies).

As noted earlier in the paper, checklist approaches to appraisal are useful when evaluating the presence or absence of specific information in a research study. This approach can be used to appraise essential components in systematic case studies, as shown below. From a pragmatic point view (Levitt et al., 2017 ; Truijens et al., 2019 ), CaSE Checklist for Essential Components in Systematic Case Studies can be seen as a way to ensure the internal validity of systematic case study: the reviewer is assessing whether sufficient information is provided about the case design, procedure, approaches to inquiry, etc., and whether they are relevant to the researcher’s objectives and conclusions (Table ​ (Table11 11 ).

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

CaSE purpose-based evaluative framework for systematic case studies

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

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

Two other types of systematic case study research include: critical (testing and/or confirming existing theories) cases, which are described as an excellent method for falsifying existing theoretical concepts and testing whether therapeutic interventions work in practice with concrete patients (Kaluzeviciute, 2021 ), and unique (going beyond the ‘typical’ cases and demonstrating deviations) cases (Merriam, 1998 ). These two systematic case study types are often seen as less valuable for psychotherapy research given that unique/falsificatory findings are difficult to generalise. But it is clear that practitioners and researchers in our field seek out context-specific data, as well as detailed information on the effectiveness of therapeutic techniques in single cases (Stiles, 2007 ) (Table ​ (Table12 12 ).

Key concept: purpose–based systematic case studies

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

With this plurality in mind, it is evident that CaSE has a challenging task of appraising research components that are distinct across six different types of purpose-based systematic case studies. The purpose-specific evaluative criteria in Table ​ Table13 13 was developed in close consultation with epistemological literature associated with each type of case study, including: Yin’s ( 1984 , 1993 ) work on establishing the typicality of representative cases; Duncan and Sparks’ ( 2020 ) and Iwakabe and Gazzola’s ( 2009 ) case selection criteria for meta-synthesis and meta-analysis; Stake’s ( 1995 , 2010 ) research on particularising case narratives; Merriam’s ( 1998 ) guidelines on distinctive attributes of unique case studies; Kennedy’s ( 1979 ) epistemological rules for generalising from case studies; Mahrer’s ( 1988 ) discovery oriented case study approach; and Edelson’s ( 1986 ) guidelines for rigorous hypothesis generation in case studies.

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

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

For the analysis of more complex research components (e.g. the degree of therapist reflexivity), the purpose-based evaluation will utilise a framework approach, in line with comprehensive and open-ended reviewer responses in ETQS (Evaluation Tool for Qualitative Studies) (Long & Godfrey, 2004 ) (Table ​ (Table13). 13 ). That is to say, the evaluation here is not so much about the presence or absence of information (as in the checklist approach) but the degree to which the information helps the case with its unique purpose, whether it is generalisability or typicality. Therefore, although the purpose-oriented evaluation criteria below encompasses comprehensive questions at a considerable level of generality (in the sense that not all components may be required or relevant for each case study), it nevertheless seeks to engage with each type of purpose-based systematic case study on an individual basis (attending to research or clinical components that are unique to each of type of case study).

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

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

To illustrate the use of CaSE Purpose - based Evaluative Framework for Systematic Case Studies , a case study by Lunn, Daniel, and Poulsen ( 2016 ) titled ‘ Psychoanalytic Psychotherapy With a Client With Bulimia Nervosa ’ was selected from the Single Case Archive (SCA) and analysed in Table ​ Table14. 14 . Based on the core questions associated with the six purpose-based systematic case study types in Table ​ Table13(1 13 (1 to 6), the purpose of Lunn et al.’s ( 2016 ) case was identified as critical (testing an existing theoretical suggestion).

Using Case Study Evaluation-tool (CaSE): Lunn et al. ( 2016 )’s case ‘ Psychoanalytic psychotherapy with a client with bulimia nervosa ’

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

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

Finally, it is also possible to use CaSE to gather specific type of systematic case studies for one’s research, practice, training, etc. For example, a CaSE reviewer might want to identify as many descriptive case studies focusing on negative therapeutic relationships as possible for their clinical supervision. The reviewer will therefore only need to refer to CaSE questions in Table ​ Table13(2) 13 (2) on descriptive cases. If the reviewed cases do not align with the questions in Table ​ Table13(2), 13 (2), then they are not suitable for the CaSE reviewer who is looking for “know-how” knowledge and detailed clinical narratives.

Concluding comments

This paper introduces a novel Case Study Evaluation-tool (CaSE) for systematic case studies in psychotherapy. Unlike most appraisal tools in EBP, CaSE is positioned within purpose-oriented evaluation criteria, in line with the PBE paradigm. CaSE enables reviewers to assess what each systematic case is good for (rather than determining an absolute measure of ‘good’ and ‘bad’ systematic case studies). In order to explicate a purpose-based evaluative framework, six different systematic case study purposes in psychotherapy have been identified: representative cases (purpose: typicality), descriptive cases (purpose: particularity), unique cases (purpose: deviation), critical cases (purpose: falsification/confirmation), exploratory cases (purpose: hypothesis generation) and transferable cases (purpose: generalisability). Each case was linked with an existing epistemological network, such as Iwakabe and Gazzola’s ( 2009 ) work on case selection criteria for meta-synthesis. The framework approach includes core questions specific to each purpose-based case study (Table 13 (1–6)). The aim is to assess the external validity and effectiveness of each case study against its set out research objectives and aims. Reviewers are required to perform a comprehensive and open-ended data analysis, as shown in the example in Table ​ Table14 14 .

Along with CaSE Purpose - based Evaluative Framework (Table ​ (Table13), 13 ), the paper also developed CaSE Checklist for Essential Components in Systematic Case Studies (Table ​ (Table12). 12 ). The checklist approach is meant to aid reviewers in assessing the presence or absence of essential case study components, such as the rationale behind choosing the case study method and description of patient’s history. If essential components are missing in a systematic case study, then it may be implied that there is a lack of information, which in turn diminishes the evidential quality of the case. Following broader definitions of validity set out by Levitt et al. ( 2017 ) and Truijens et al. ( 2019 ), it could be argued that the checklist approach allows for the assessment of (non-quantitative) internal validity in systematic case studies: does the researcher provide sufficient information about the case study design, rationale, research objectives, epistemological/philosophical paradigms, assessment procedures, data analysis, etc., to account for their research conclusions?

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

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

Finally, further research needs to be developed on how (and, indeed, whether) systematic case studies should be reviewed with specific ‘grades’ or ‘assessments’ that go beyond the qualitative examination in Table ​ Table14. 14 . This would be particularly significant for the processes of qualitative meta-synthesis and meta-analysis. These research developments will further enhance CaSE tool, and, in turn, enable psychotherapy researchers to appraise their findings within clear, purpose-based evaluative criteria appropriate for systematic case studies.

Acknowledgments

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

Author’s contributions

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

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

Availability of data and materials

Declarations.

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Defining the Counseling Process and Its Stages

Counseling process

The process begins with exploring the challenges a client faces before assisting them in resolving developmental and situational difficulties (Sajjad, 2017).

The counselor supports clients with physical, emotional, and mental health issues, helping them resolve crises, reduce feelings of distress, and improve their sense of wellbeing (American Psychological Association, 2008).

When successful, treatment can change how a client thinks, feels, and behaves regarding an upsetting experience or situation (Krishnan, n.d.).

This article explores what counseling is and is not, and the stages and steps involved in a successful outcome.

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This Article Contains

Defining the counseling process, the stages of the counseling process, 7 steps in the counseling process, real-life examples of the counseling phases, 12 valuable skills for each phase, a look at the process in group counseling, a take-home message, frequently asked questions.

All of us will, occasionally, take on the role of counselor. We informally offer family, friends, and colleagues advice regarding their relationships, finances, career, and education.

On the other hand, “a professional counselor is a highly trained individual who is able to use a different range of counseling approaches with their clients” (Krishnan, n.d., p. 5).

Counseling as a profession involves (Krishnan, n.d.):

  • Dedicated time set aside to explore difficulties, stressful situations, or emotional upset faced by a client
  • Helping that client see their situation and feelings from a different viewpoint, potentially to facilitate change
  • Building a relationship based on trust and confidentiality

The counseling process should not include:

  • Providing advice
  • Being judgmental
  • Pushing the counselor’s values
  • Encouraging the client to behave as the counselor would in their own life
  • Emotional attachment between the counselor and client

According to the American Psychological Association (2008), counseling psychologists “help people with physical, emotional and mental health issues improve their sense of wellbeing, alleviate feelings of distress and resolve crises.”

Counseling works with clients from childhood through to old age, focusing on “developmental (lifespan), environmental and cultural perspectives,” including (American Psychological Association, 2008):

  • Issues and concerns in education and career
  • Decisions regarding school, work, and retirement transitions
  • Marital and family relationship difficulties
  • Managing stressful life events
  • Coping with ill health and physical disability
  • Mental disorders
  • Ongoing difficulties with getting along with people in general

While we often see counseling and psychotherapy as interchangeable, there are subtle distinctions. Counseling is typically short term, dealing with present issues and involving a helping approach that “highlights the emotional and intellectual experience of a client,” including how they feel and think about a problem or concern (Krishnan, n.d., p. 6).

Psychotherapy is often a longer term intensive treatment, helping the client overcome profound difficulties resulting from their psychological history and requiring them to return to earlier experiences (Krishnan, n.d.; Australia Counselling, n.d.).

The counseling process has been described as both an art and a science, helping to bring about changes in thought, emotion, and behavior in the client (Sajjad, 2017).

Counseling Stages

Counselors and clients must both be aware that the counseling process requires patience. There is rarely a quick fix, and things may need to get worse before they get better. In addition, the counseling process is collaborative. The counselor does not fix the client; the work requires interaction and commitment from both parties (Krishnan, n.d.).

The counseling process is a planned and structured dialogue between client and counselor. The counselor is a trained and qualified professional who helps the client identify the source of their concerns or difficulties; then, together, they find counseling approaches to help deal with the problems faced (Krishnan, n.d.).

Hackney and Cormier (2005) propose a five-stage model for defining the counseling process through which both counselor and client move (Krishnan, n.d.).

Stage one: (Initial disclosure) Relationship building

The counseling process begins with relationship building . This stage focuses on the counselor engaging with the client to explore the issues that directly affect them.

The vital first interview can set the scene for what is to come, with the client reading the counselor’s verbal and nonverbal signals to draw inferences about the counselor and the process. The counselor focuses on using good listening skills and building a positive relationship.

When successful, it ensures a strong foundation for future dialogue and the continuing counseling process.

Stage two: (In-depth exploration) Problem assessment

While the counselor and client continue to build a beneficial, collaborative relationship, another process is underway: problem assessment .

The counselor carefully listens and draws out information regarding the client’s situation (life, work, home, education, etc.) and the reason they have engaged in counseling.

Information crucial to subsequent stages of counseling includes identifying triggers, timing, environmental factors, stress levels, and other contributing factors.

Stage three: (Commitment to action) Goal setting

Effective counseling relies on setting appropriate and realistic goals, building on the previous stages. The goals must be identified and developed collaboratively, with the client committing to a set of steps leading to a particular outcome.

Stage four: Counseling intervention

This stage varies depending on the counselor and the theories they are familiar with, as well as the situation the client faces.

For example, a behavioral approach may suggest engaging in activities designed to help the client alter their behavior. In comparison, a person-centered approach  seeks to engage the client’s self-actualizing tendency.

Stage five: Evaluation, termination, or referral

Termination may not seem like a stage, but the art of ending the counseling is critical.

Drawing counseling to a close must be planned well in advance to ensure a positive conclusion is reached while avoiding anger, sadness, or anxiety (Fragkiadaki & Strauss, 2012).

Part of the process is to reach an early agreement on how the therapy will end and what success looks like. This may lead to a referral if required.

While there are clear stages to the typical counseling process, other than termination, each may be ongoing. For example, while setting goals, new information or understanding may surface that requires additional assessment of the problem.

Many crucial steps go together to form the five stages of the counseling process. How well they are performed can affect the success of each stage and overall outcome of counseling (Krishnan, n.d.).

Key steps for the client

The client must take the following four steps for counseling to be successful (Krishnan, n.d.):

  • Willingness Being willing to seek and attend counseling is a crucial step for any individual. It involves the recognition that they need to make changes and require help to do so. Taking the next action often involves overcoming the anxiety of moving out of the comfort zone and engaging in new thinking patterns and behaviors.
  • Motivation Being willing to make changes and engage in them involves maintaining and sustaining motivation. Without it, the counseling process will falter when the real work begins.
  • Commitment The client may be willing and motivated, but change will not happen without continued patience and commitment. Commitment may be a series of repeating decisions to persist and move forward.
  • Faith Counseling is unlikely to succeed unless the client has faith in themselves, the counselor, and the process. Taking the step to begin and continue with counseling requires the belief that it can be successful.

Key steps for the counselor

Each step in the counseling process is vital to forming and maintaining an effective counselor–client relationship. Together they support what Carl Rogers (1957) describes as the core conditions for successful therapy:

  • Unconditional positive regard Through acceptance and nonjudgmental behavior, the therapist makes space for the needs of the client and treats them with dignity. For more on developing this, we have these Unconditional Positive Regard worksheets , which may prove helpful.
  • Empathy The counselor shows genuine understanding, even if they disagree with the client.
  • Congruence The words, feelings, and actions of the counselor embody consistency.

Counselors often help clients make important and emotional decisions in their lives. To form empathy, they must intimately take part in the client’s inner realm or inscape .

Several well-performed steps can help the counselor engage with the client and ensure they listen openly, without judgment or expectation. The counselor must work on the following measures to build and maintain the relationship with the client (Krishnan, n.d.):

  • Introduce themselves clearly and with warmth.
  • Invite the client to take a seat.
  • Address the client by the name they are most comfortable with.
  • Engage in relaxed social conversation to reduce anxiety.
  • Pay attention to nonverbal communication to identify the client’s emotional state.
  • Invite the client using open questions to explain their reason for coming to counseling.
  • Allow the client time to answer fully, without pressure.
  • Show that they are interested in the client as a person.

Each of the above steps is important. Taken together, they can facilitate the formation of a valuable counseling relationship.

Ultimately, counseling is collaborative and requires a series of ongoing steps – some taken by the client, others by the counselor, and several jointly. For a successful outcome, appropriate resources, time, and focus must be given to each one, and every win must be recognized and used to support the next.

counselling case study

While there are guiding theories and principles, the counselor must make the counseling process specific to the individual.

The following two real-life examples provide a brief insight into the counseling process and richness of the scenarios counselors face.

Lost direction

‘Jenny’ arrived in counseling with little income, no sense of direction, and lacking a sense of control over her life (Fielding, 2014).

The counselor began by forming a picture of her situation and what had led her to that point.

Sessions then moved on to explore Jenny’s beliefs about herself: where they came from, how they affected her, and their appropriateness for current and future circumstances.

A series of brainstorming sessions were used to understand Jenny’s needs, family relationships, and past, and identify her irrational beliefs. Once Jenny uncovered her core beliefs, the counselor worked with her to replace them with more rational ones.

Jenny ended counseling overjoyed with her new preferred beliefs, along with a renewed sense of confidence and control over her life.

Saving a marriage

It is not just individuals who need help, but relationships too. When ‘John’ and ‘Sue-Anne’ attended counseling early on in their marriage, it was because, having lost their group of friends, they found themselves on their own with only each other’s company (Starak, 2010).

Early on in counseling, it became clear that they both needed time to ponder some serious questions, including:

Who am I? What values do I bring to this relationship?

The exercises helped John and Sue-Anne better understand their values, strengths, and what motivated their daily actions. By focusing on what each of them wanted their relationship to look like, they could clarify how much time they wanted to spend together and their roles within the marriage.

The counseling process enabled them to form a shared picture of how their marriage and life would look from now on.

Good communication is vital to all stages of counseling. Skills should ideally include (Krishnan, n.d.; Lesley University, n.d.; American Psychological Association, 2008):

  • Active listening techniques
  • Clarification
  • Effective questioning

Beyond that, to build rapport with the client, counselors must also:

  • Be able to experience and show empathy (rather than sympathy)
  • See things from the client’s perspective
  • Have a genuine interest in others’ wellbeing
  • Use self-reflection to observe themselves and empathize with others
  • Show accessibility and authenticity during counseling sessions
  • Be flexible in their views and thinking regarding differing values and multicultural issues
  • Be able to maintain a sense of humor
  • Be resilient and able to bounce back from difficult situations

A mental health practitioner delivering positive outcomes in increasingly diverse populations benefits from developing theory, knowledge, and skills.

Group Counseling

Partly due to its high degree of success, low cost, and wide availability, group therapy can be a good option for many clients.

It is essential to remember that group therapy is not the same as individual therapy performed within a group setting; it has specific and dedicated techniques and an additional skillset. Unfortunately, however, training has not always kept up with the specialist needs of group therapy (Novotney, 2019).

There are other, unique considerations and processes involved when offering and running group therapy, including being able to (Novotney, 2019):

  • Get the right fit Not all clients are suitable for group therapy. They may be better placed in a one-to-one setting. High-quality screening is required to ensure the fit of the individual to the group and vice versa.

The Group Readiness Questionnaire has been designed to identify risk factors and the potential for dropout.

  • Explain expectations upfront Individuals’ expectations of group therapy must be realistic. Change takes time, whether in a group or an individual setting. Also, the counselor must educate clients that group therapy is not about shouting and heated exchanges. Sessions can be fun and rewarding.
  • Build cohesion quickly The issues being addressed can set the tone of the group and the speed at which it bonds. Grief groups, for example, often form cohesion quickly, while others can take more work and require splitting into smaller groups or pairs.
  • Seek feedback Early and regular feedback can help assess how individuals and the group are functioning and whether dropout is likely.
  • Identify and address ruptures Group work can lead to disagreements. Concerns and ruptures should be worked through early on, either bringing up issues directly with the members involved or more generally as a group.

Counseling helps clients by bringing much-needed change to their lives (Sajjad, 2017).

While personal and theoretical approaches may vary, a professional counselor will typically begin by building a relationship with the client before understanding their situation and their reason for seeking help. They can then explore how to move forward and assist the client in changing their thinking, emotional responses, and behavior.

Whether performed individually or as a group, empathy and a collaborative approach are crucial to therapeutic success. The stronger the relationship and the more committed and motivated the client, the more likely a robust and appropriate outcome is reached.

When successful, counseling offers the client the opportunity to change by establishing specific goals, improving their coping skills, promoting decision making, and improving relationships across life domains (Sajjad, 2017).

Time spent gaining knowledge, training, and practicing is vital to gaining the required skills for this challenging yet rewarding profession. In return, mental health professionals have the potential to help people in a wide variety of situations live more productive and satisfying lives.

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free .

The 10 principles of counseling are:

  • Respect for client autonomy
  • Empathy and understanding
  • Non-judgmental attitude
  • Confidentiality
  • Cultural sensitivity and competence
  • Trust and rapport
  • Collaborative approach
  • Professional boundaries
  • Self-awareness and self-reflection
  • Ethical and legal standards

The 5 C’s of counseling refer to the essential qualities that a counselor should possess:

  • Competence: possessing the necessary knowledge and skills to effectively help clients
  • Compassion: showing empathy and caring for clients
  • Confidence: having confidence in oneself and one’s abilities as a counselor
  • Connection: building a strong therapeutic relationship with clients
  • Character: demonstrating ethical and professional behavior

The golden rule in counseling is to treat others how you would like to be treated. This means being respectful, empathetic, and non-judgmental with clients, and creating a safe and supportive environment for them to explore their issues and concerns. It also means adhering to ethical and professional standards and always acting in the best interest of the client.

  • American Psychological Association. (2008). Counseling psychology. Retrieved June 17, 2021, from https://www.apa.org/ed/graduate/specialize/counseling
  • Australia Counselling. (n.d.). What’s the difference between counselling and psychotherapy?  Retrieved June 17, 2021, from https://www.australiacounselling.com.au/whats-difference-between-counselling-and-psychotherapy/
  • Fielding, L. (2014, November 25). A case of lost direction.  Australian Institute of Professional Counsellors.  Retrieved June 17, 2021, from https://www.aipc.net.au/articles/a-case-of-lost-direction/
  • Fragkiadaki, E., & Strauss, S. M. (2012). Termination of psychotherapy: The journey of 10 psychoanalytic and psychodynamic therapists. Psychology and Psychotherapy: Theory, Research and Practice , 85 (3), 335–350.
  • Hackney, H., & Cormier, L. S. (2005). The professional counselor: A process guide to helping . Pearson.
  • Krishnan, S. (n.d.). The counselling process . Retrieved June 15, 2021, from http://www.dspmuranchi.ac.in/pdf/Blog/stages%20of%20counselling.pdf
  • Lesley University. (n.d.). 6 critical skills every counselor should cultivate. Retrieved June 17, 2021, from https://lesley.edu/article/6-critical-skills-every-counselor-should-cultivate
  • Novotney, A. (2019). Keys to great group therapy. Monitor on Psychology. Retrieved June 17, 2021, from https://www.apa.org/monitor/2019/04/group-therapy
  • Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology , 21 , 95–103.
  • Sajjad, K. S. M. (2017). Essentials of counseling . Abosar Prokashana Sangstha.
  • Starak, Z. (2010, October 6). How to save your marriage by creating a relationship. Australian Institute of Professional Counsellors. Retrieved June 17, 2021, from https://www.aipc.net.au/articles/how-to-save-your-marriage-by-creating-a-relationship/

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Sr. Benedicta Mante

I wish to thank you very much for this useful article, which throws more light on both the concept and process of counselling. I am a Guidance – Counsellor in a secondary school where students have a lot of behavioural issues. I believe this article has thrown more light that will help me figure out how best to journey with them.

Kanak

I loved this article. So precise and to the point and so easy to understand. I am an undergraduate psychology student and needed to study this topic for my exam. From the examination point of view this is perfect.

Dr Radhakrishnan Sreedharakurup

The theme of Counseling explained in practical and easily understandable language.Respect to the client and unconstitutional positive regard, confidentiality and maintaining professional etiquette must be of prime concern. I am highly benefited.

EN Imani Kosasih

I love the simplicity, directness and comprehensiveness of this well written article on Counselling. It contains all that’s needed to impart the knowledge and skills of this important and useful process that counselling is.

Folake Abimbola

Well written article and simplest in all forms of understanding. Very useful in imparting knowledge to others

Mariam Musa

The articles here are very informative and relevant to my work. I am a counseling psychologist from Kenya. I would love to learn more.

David Nuhu Adze

This peice is carefully researched and clearly presented in a simple and clear term. I hope this is collectively applied in all areas to solve psychological problems.

David Kastom Omwony

Refugee needs counseling to reduce mental tension. I wish I could have such a book. Domestic conflict and violence are rampant in the community.Thanks.(Koboko Uganda)

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All in the Family Counselling

Couple Cases

Below you’ll find case studies of real clients that have attended couple’s counselling at All in the Family Counselling with our professional trained marriage expat counsellor. These cases do not represent all cases seen at our centre but rather are intended to give you insight into what makes for successful outcomes and the time and effort the clients choose to put in to make their relationship change. Each couple’s relationship is unique and has its own history which our therapist will attend to. But we hope you will find it helpful to see what successful clients choose to do and their outcomes.

counselling case study

Case Study 1

Profile : Professional couple married for 6 years but known each other for 10 years. The couple is in their early 30s.

Reason for Counselling : Couple came into counselling because of husband’s excessive use of pornography, a reduced sexual life and overall lower intimacy in the relationship. Wife was prepared to file for divorce if things didn’t improve rapidly. Wife had loss of trust due to pornography use.

Number of Sessions:   Couple had a total of 4 sessions with husband attending to 2 individual sessions. At the client’s initial session everyone agreed to the problem and what a positive marriage would look like for them.  They were taught basic relationship skills and given homework to practice. At their 2 nd  session, which was 10 days later, we reviewed their homework and both individuals had great revelations about themselves, each other and the relationship. They were taught additional relationship skills and given more homework to practice for 14 days.  The 3 rd  session we reviewed homework and refined skills and integrated new relationship concepts into the relationship including negotiating win-win for the relationship and managing perceptions in communication. Final session was 30 days later in which we reviewed their homework, revised some of their skills and gave them a framework to help identify and remedy problems if they were heading back into old relationship habits.

Success Factors:   This is an unusual case for a couple in crises to come to counselling and so dramatically turn their relationship around. The reason the couple experienced such dramatic success was that they had come into counselling early once the issue of intimacy and pornography were discovered. This couple was also highly motived to make counselling work and they energetically completed their homework in between sessions. The couple also had a lot of positive regard for each other and good personal insight into themselves and each other. The husband also attended a couple of individual sessions to work on stress management.

Case Study 2

Profile : Couple married for over 10 years in their mid 30s. Both have a college education and are professionally employed. Couple has no children.

Reason for Counselling : Counselling was initiated by the wife who had found out only 4 days prior to contacting our agency that her husband had an affair and both of them wanted to repair and improve the relationship.

Number of Sessions:   Couple had a total of 6 sessions over 3 months.  The first session was getting agreement that both couples wanted to repair and improve the relationship. Both parties agreed to not introduce punishment into the relationship as a result of the affair. The couples were given some new basic relationship skills and given homework to complete in between session including not discussing the affair.  Session 2 was 10 days later and the focus was on building a unified goal for the relationship. Four goals for the relationship were mutually identified and agreed to. Couples were given more relationship skills and homework to practice. The next 3 sessions were spread out over 2 months and focused on relationship skills that targeted communications, perceptions and internal control all with the couple doing homework in between sessions. The final session the clients evaluated how they did meeting their goals and they felt they got about 70–85% of each of their goals which was satisfactory for them. They felt confident with their new relationship skills. Trust had been restored, forgiveness was given and communication dramatically improved and the couple was established in their new and improved relationship behaviours.

Success Factors:   Couple came in quickly after finding out about the relationship. Both individuals in the relationship agreed to not introduce punishment into the relationship. This couple was focused on the present and building the future relationship.  The incident and issues of the past were only used as guidelines to help us know what worked and did not work. The couple was highly motivated to repair and improve their relationship and would complete their homework and came prepared to fully engage during the counselling sessions.

Case Study 3

Profile : Professional couple married for 7 years. The couple is in their late 30s. Had a history of infertility and infertility treatments that resulted in 2 children in last 3 years prior to treatment.

Reason for Counselling : Couple came into counselling because of dramatically reduced intimacy, increased fighting, difficulty communicating and negative perceptions of each other’s behaviours.

Number of Sessions:   Couple had a total of 12 sessions with each client engaging in 2 individual sessions within 5 months. The first session focused on stabilizing the relationship and providing them with basic relationship skills. The homework started to focus the couple on building positive regard towards each other.  Then next 2 sessions were focused on developing a new relationship base from which to make all decisions-shifting it away from the children as the base and back to the couple.  The next 4 sessions included reviewing the homework the clients were completing in between sessions, the lessons and observations they were learning as well as modifying and enhancing basic communication skills that included perception taking, learning to negotiate a win–win for the relationship and continuing to build positive regard.  The individual sessions were focused on personal issues that were affecting the relationship.  Individual sessions addressed some of the loss and trauma related to infertility treatments and stress and anxiety management.

Complicating & Success Factors:   This couple had a more complex prolonged history of infertility, stress and trauma that went on for a couple of years prior to entering counselling resulting in a more negative view of each other that reduced trust and positive regard for each other. This increased the number of sessions for the couple and individuals session were recommended.

However, the couple still had enough positive regard for each other and was committed to the counselling process because they really valued what they had earlier in their relationship. While the couple experienced some setbacks initially and was slower to implement their new relationship skills than the previous couples, they managed to keep coming to counselling and do most of the work.  As they start the client was successful because they gave counselling enough time to work and practice their new skills and continue to get feedback and guidance while working both on their relationship issues and individual issues. This couple needed more sessions because there were complicating factors and the issues had been developing for a longer period before coming for help.

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Counselling Case Study: Using REBT

Thomas is a 33 year old married man, who has recently become a father. He explains that he feels his self-esteem has been gradually deteriorating ever since he was married. He says that he can’t find reasons to enjoy life with his wife due to feelings of inadequacy as a husband.

In his new role as a father, Thomas had hoped to find the happiness that he was looking for; however this has not been the case. He mentions that his relationship with his wife’s family is strained and thinks that this is the root of his problem. In this scenario, the Professional Counsellor will be using a Rational Emotive Behavioural approach with Thomas.

For ease of writing the Professional Counsellor is abbreviated to “C”.

Background Information

Thomas was married 4 years ago to Helen. They met after leaving school and have been in a continuous relationship since that time. Thomas describes his relationship with Helen as a strong friendship, but also explains that they have experienced recurring problems in their relationship.

Thomas feels that the main problem is the interference of Helen’s family in their partnership. Helen has had a close relationship with her mother and father and had been living with them up until 5 years ago. Neither Helen’s mother or father approved of her relationship with Thomas, since their first meeting. Thomas is at a loss to explain their disapproval of him, and it appears that he has tried in many ways, to gain their respect.

Initially Helen was hesitant to continue a relationship with Thomas, due to her parent’s strong reaction to him. At times they even carried on their relationship in secret to avoid her parent’s reaction. It became more apparent to them that they would eventually have to overlook Helen’s parents’ opinions of their relationship and follow their own wishes.

Finally, Helen and Thomas moved into their own apartment and became engaged to be married. Since becoming married and having their first child, Thomas has continued to extend himself to great personal lengths to maintain any of his parents-in-law’s support. It is his belief that if he extends himself enough, that they will come to love him as much as they love their daughter.

He finds this position very demanding. Of particular difficulty is that Helen’s parents expect to be visited on a weekly basis, by their daughter and new grandchild. These weekly meetings are very draining for Thomas as his parents-in-law are still openly critical of him. At best, he says, they ignore him. In these situations, he finds that Helen is quite passive, though she tells him that she wishes her parents were less critical. Helen has said to him that it is usually best to just let them have their way, and this appears to reflect her pattern of coping with the situation.

Session Content

“C” firstly aims to assist Thomas to understand his feelings and beliefs about the current difficulties. They discuss Thomas’s beliefs and feelings about his relationship with his wife and parents-in-law. It appears that for a long time Thomas has held the belief that if he just tries hard enough, Helen’s parents will stop their criticism and come to respect him. He also thinks that without their approval, he will never completely gain the full respect of his wife.

“C” used humour to begin to challenge Thomas about his views. The use of humour in REBT is a strategy to reduce the importance and value that clients place on certain irrational beliefs. This strategy does need to be balanced with sensitivity and timing, to ensure clients do not become offended by the counsellor’s use of humour. Humour is most effective when the client is also able to enter into the joke and it shouldn’t be used to belittle the client or their feelings.

“Thomas it seems to me that you have been seeking the approval of these people, since the first day that you met them. In that time you have been ignored, belittled, backstabbed and denied respect. Even after your public declaration of love to their daughter, their behaviour towards you has not changed. Under these trying circumstances, I must congratulate you on your undying loyalty to your wife and her family!”

Thomas reacted well to the humour and responded with a joke about his wedding vows, “On my wedding day, I never realised that I also had to love, honour and cherish my wife’s mother and father!”

“I am absolutely certain that you never would have vowed that on your wedding day. After all, a marriage is the unity of only two people”, replied “C”. “This leads me to wonder about your reasons for continuing to appease Helen’s parents, in what appears to be beyond the call of duty and in the face of such adversity.”

Thomas responded to “C’s” confrontation. “I’ve always felt this need for their approval. To me, it is all wrapped up in my role as a husband. It is my duty to be a good son-in-law and I’ve just hoped that they’ll come to accept me in time.”

“C” asked Thomas about how he would prefer to be treated by his parents-in-law. Thomas replied that he wanted a friendship with his new family and to be respected by them. He wanted them to be less pushy and more cooperative with himself and Helen.

“C” spent some time then explaining the nature of irrational beliefs with Thomas. “Due to certain learning experiences in our lives, we come to accept certain beliefs about ourselves and others. These beliefs may be inappropriate for us if they don’t allow us to realise happiness or acceptance of the disappointments in life. Our beliefs are reinforced by particular thoughts that we should behave in certain ways.

If our thoughts and behaviours are more concerned with the welfare of others, rather than ourselves, this can lead to lowered self-esteem and further self-condemnation. The task that all of us face at sometime, is to realise that some of our thoughts and behaviours are not healthy and to replace these with more self-appreciating thoughts and behaviours.”

From this discussion, Thomas came to understand that he had control over his own beliefs and therefore, control over his behaviour and a chance to improve his self-esteem. The first step, “C” explained, was to identify the irrational beliefs that were controlling his life. The irrational beliefs that “C” and Thomas identified are listed below:

  • “I must have the respect of my parents-in-law”.
  • “It is my duty as a good son-in-law and husband to meet the approval of my wife’s parents”.
  • “My wife will never completely respect me if her parents do not respect me”.
  • “If I keep trying, they’ll eventually accept me”.
  • “My need for happiness is secondary to the needs of my in-laws”.

“C” said, “Thomas, you said before that you want Helen’s parents to be less pushy and more respectful of you. I would challenge you that these are preferences that you have, which you have little personal control over. You cannot expect to change another’s behaviour. Instead I would like you to think about your own behaviours and how you might have more control of them, by changing your irrational beliefs. We can do this through a process of debate, where we weigh up the pros and cons of your beliefs”

“C” began the debate by challenging Thomas about his beliefs through a series of questions. “Why do you need your parent’s-in-law approval to be a good son in law? What constitutes good parents-in-laws? If you had a son-in-law, how would you treat him? At what point do parents need to reduce their control of their children? Do you expect to be meeting your parents-in-laws demands for the rest of your married life? Where did you learn that you have a duty to obey Helen’s parent’s wishes?”

Through open debate and discussion of these questions, Thomas was able to view his irrational beliefs from different angles. He was able to see how his belief impacted on his own well being, and that his future happiness was dependent on his ability to change his belief and subsequent behaviours.

The next step involved identifying and constructing new, more appropriate beliefs with Thomas. “C” encouraged Thomas to rethink alternatives to the irrational thoughts that he identified earlier. Instead of the belief, “I must have the respect of my in-laws,” Thomas was encouraged to rephrase this as a preference. “I would like to have the respect of my in-laws.” To this belief he also added some other preferences such as “I would like to be able to respect my in-laws in return.” Other modified beliefs for Thomas included:

  • “It is not my duty as a son-in-law to accept personal criticism or being ignored”.
  • “It is my duty to be respectful of my wife’s family, though not to the point of sacrificing my happiness”.
  • “My wife respects me as her husband and partner”.
  • “My wife’s love is not determined by the influence of her parents”.
  • “My wife and I have the right to determine how we will be involved in the life of our families”.
  • “My priorities for happiness begin with myself, my wife and my son”.
  • “I accept that my in-laws may never accept me for who I am”.

“C” and Thomas also listed behaviours that could increase his personal happiness and reflect his new beliefs about himself:

  • Personally invite his parents-in-law around for visits, instead of visiting them.
  • Address any demands from parents as requests and notify them that the matter will be discussed by Helen and himself in private. With Helen, redefine boundaries between couple issues and family issues. For example, discuss the amount of time that should be spent with various family members.
  • Expect parents to be more respectful of him and do not tolerate criticism. Determine the consequences if this behaviour is not forthcoming, ie: politely leaving, hanging up the phone or ending conversations if no respect is shown to him. Encourage ways in which Helen could also expect more respect from her parents.
  • Discuss his personal changes with Helen and talk about the implication of these for both of them.

In summary of the session, “C” expressed enthusiasm at Thomas’s willingness to explore his irrational thoughts and self-condemning behaviours. “C” recommended a further discussion of Thomas’s self-statements and establishment of a program of behaviour change, structured on his new beliefs.

For homework, Thomas was required to identify other problems and self-defeating beliefs that were affecting his life. For each of these, he needed to challenge their rationality and record these thoughts in a personal log book. The log book would act as an inventory of all of Thomas’s irrational thoughts and beliefs. He could refer to this book as a reminder to himself of the beliefs that he was challenging.

“C” also suggested that he could begin to identify more appropriate thoughts to supplement his irrational thoughts and record these in his log book. “C” highlighted to Thomas that disputing irrational beliefs was something that required practice and to not expect this to happen automatically.

Thomas also suggested inviting Helen to take part in counselling with him, so that she would be more aware of his new beliefs and for them to discuss mutual strategies for managing their family problems.

At the end of the session, “C” reminded Thomas of the presence of irrational and self-defeating beliefs that he holds and how these impact on his opportunity for personal happiness and self-confidence. The challenge for Thomas was to continue to become more aware of the presence of self-defeating beliefs in his life and to energetically replace these with more personally satisfying thoughts.

End of Session

Some points to consider with Rational Emotive Behaviour Therapy are as follows:

People have the capacity for rational and irrational thoughts and beliefs . Irrational beliefs can also be described as absolutistic cognition’s. Absolutistic cognitions by nature demand that certain situations or behaviours should, or must occur in order to meet certain standards that the client believes to be necessary.

REBT proposes that humans are fallible and imperfect and endeavours to help clients realise and accept their fallibility and construct more satisfying thoughts and beliefs . We often seek counselling due to the consequences that we are experiencing because of our irrational thoughts and beliefs.

The focus of REBT is to help the client to understand the connection between their irrational beliefs and their present problem . The counsellor aims to expose the irrational and self-destructive beliefs and to challenge their value to the client. For example, if a client thinks that they need the approval of everyone around them, then the REBT therapist will identify this belief and dispute the client’s reasons for holding this belief.

Once exposed, the therapist and client can then work towards identifying more appropriate and rational beliefs . From these beliefs it is hoped that new feelings and thoughts will arise for the client. This process is known as the ABC theory of personality where:

(a) The activating event or stimulus, paired with the (b) belief about the activating event, causes a (c) consequence (the emotional and behavioural response) (d) is the disputing intervention that is introduced to change the (b) belief. After which a new (e) effect (more appropriate belief) becomes associated with the original (a) activating event. Lastly new (f) feelings arise which are associated with the new beliefs about ourselves.

The methods involved in REBT include:

  • Disputing irrational beliefs in a systematic and logical way.
  • Changing one’s language from shoulds, oughts and musts to preferences.
  • Using humour to reduce the exaggerated effects of irrational thoughts and beliefs.
  • Doing cognitive homework to identify absolutistic beliefs behind their problem. This can include assignments to observe their self-fulfilling prophesies, reading self-help books and listening to tapes of earlier counselling sessions to critique their original self-defeating beliefs.
  • Using modelling and role play in the session to encourage the client’s use of more rational thoughts and beliefs.

Author: Jane Barry

  • September 7, 2009
  • Case Study , Families , Parenting , REBT , Self-Esteem
  • Case Studies , Relationship & Families

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Comments: 14

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It’s. Very informatic and can follow easily.

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It was interesting and informative. Liked the way hi irrational belief was debated.

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Great found it helpful. Thank you.

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This is awesomely helpful. It is insightful and very applicable.

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Very helpful.thank You

The article helped me a lot. Thank you

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I found it helpful and very relevant to what I needed. Thank you for your help.

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Very imp. explanation of case study.

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Issue Cover

Article Contents

Introduction, research design and method, opening of the encounter: developing a reciprocal relationship, active listening: power sharing, vision of the future: emphasizing the positive, conclusions.

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Empowering counseling—a case study: nurse–patient encounter in a hospital

  • Article contents
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Tarja Kettunen, Marita Poskiparta, Leena Liimatainen, Empowering counseling—a case study: nurse–patient encounter in a hospital , Health Education Research , Volume 16, Issue 2, April 2001, Pages 227–238, https://doi.org/10.1093/her/16.2.227

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This study illustrates practices that a nurse uses in order to empower patients. The emphasis is on speech formulae that encourage patients to discuss their concerns and to solicit information about impending surgery. The study is a part of a larger research project and a single case was selected for presentation in this article because it differed from the rest of the data by manifesting empowering practice. A videotaped nurse–patient health counseling session was conducted in a hospital and transcribed verbatim. The investigator interviewed the nurse and the patient after the conversation, and these interviews were transcribed as well. The encounter that is presented here as a case study is a concrete example of a counseling session during which the patient is free to discuss with the nurse. The empowering practices that the nurse employed were as follows: encouraging the patient to speak out, tactfully sounding out the patient's concerns and knowledge of impending surgery, listening to feedback, and building a positive vision of the future for the patient. We suggest that nurses should pay attention to verbal expression and forms of language. This enables them to gain self-awareness and discover new tools to work with.

In recent literature, empowerment has become an important concept of health education ( Feste and Anderson, 1995 ; van Ryn and Heaney, 1997 ), health promotion ( Labonte, 1994 ; Tones, 1994 , 1995 ; Williams, 1995 ; McWilliam et al. , 1997 ) and health counseling ( Poskiparta et al. , 2000 ). The process of empowerment has been related more to community and organizational levels than to micro levels of practice ( van Ryn and Heaney, 1997 ) where it is constantly crucial ( Tones, 1994 ). In addition, operationalization of the concept of empowerment has been relatively vague. According to Tones ( Tones, 1994 ), empowerment is a major goal of health promotion. This article focuses on health counseling as a means of interpersonal health education practice and uses health promotion as an umbrella term.

Empowerment is as much a process as an outcome of developing the skills and perceptions of clients. It is not only something that happens but a process that is facilitated. In interpersonal health counseling, the primary goal is not to change clients' behavior and seek their compliance with the presented message but rather to raise critical awareness through learning and support, to give clients tools for making changes on their own. The aim is personal empowerment, control and choice, which means that patients become aware of changes in their knowledge and understanding, decision-making skills, enhanced self-esteem/sense of personal control, and development of various social, health and life skills ( Labonte, 1994 ; Tones 1994 ; Anderson et al. , 1995 ; Feste and Anderson, 1995 ; van Ryn and Heaney, 1997 ; Kar et al. , 1999 ).

The basic point of departure for empowerment is taking into consideration the interactive nature of the individual and the environment: people are not completely controlled by their environment nor can they fully control their physical, social or economic circumstances ( Tones, 1994 ). Empowering health counseling is based on recognizing clients' competence, resources, explanations of action styles of coping and support networks. Client initiative, clients' realizations and clients' expressions of their opinions and interpretations are the basis on which clients can approach health issues in collaboration with professionals. They are of crucial importance for their decisions on future action ( Anderson, 1996 ). All this supports the notion that empowering health counseling is significant.

Because learning about personal health is complex, the key issue of empowering health counseling is partnership and reciprocal conversation in a confidential relationship. This means that clients not only analyze their situation but also have an opportunity to plan what to do next, and how to go on and to construct their own solutions to health issues. In this type of hospital health counseling, either patients raise the issues (i.e. determine the topics) or the nurses do so in a sensitive and non-threatening manner ( Poskiparta et al. , 2000 ). Nurses recognize and respect patients' experiences, knowledge and skills, and make their own professional knowledge and expertise available to them ( Williams, 1995 ; McWilliam, et al. , 1997 ), which are important aspects of nurse–patient relationships that are also reported by patients ( Häggman-Laitila and Åstedt-Kurki, 1994 ; Lindsey and Hartrick, 1996 ; Wiles 1997 ). The emphasis is placed on patient-driven [see ( Lindsey and Hartrick, 1996 )] health counseling, where patients' life situations are respected, patient-initiated actions are supported, and shared knowledge and deep understanding are nurtured.

The nurse's institutional task is not only to facilitate patient participation but also to promote patients' awareness of their routines and preconceptions as they are revealed to both interlocutors. This should lead to the aim of interaction, which is to activate self-reflection and re-evaluation and reorganization of patients' activities. The assumption is that new knowledge is gained in this process as a result of empirical realization and deliberation ( Feste and Anderson, 1995 ), which means that both patients and nurses have linked new knowledge to existing knowledge. Thus, patients learn to interpret and outline even familiar health problems in new ways that conform to their worldview [ cf . ( Mattus, 1994 )]. As for nurses, empowerment calls for not only sensitivity but also an ability to accurately perceive patients' messages.

From this point on, the focus is on the content of the interactive process. Tones ( Tones, 1994 ) discusses empowerment theoretically, Labonte ( Labonte, 1994 ) expresses ideas for practice in general, while Feste and Anderson ( Feste and Anderson, 1995 ) provide three empowerment tools for facilitating patients' empowering process: using questions, behavioral language and storytelling. According to them, questions maintain the process of pursuing wisdom, i.e. exploring the meaning of health problems in the context of everyday life. This kind of questioning involves broad questions that relate to one's personal philosophy and lifelong dreams. In addition, it includes practical, day-to-day issues of successfully integrating into one's personal, family, social and professional life. Behavioral language means using words such as `list', `describe', `identify', `decide', etc., in order to encourage patients to act and make choices instead of being satisfied with receiving information. Stories help to facilitate the process of self-discovery because diseases affect all areas of life and each individual's health status is unique.

Van Ryn and Heaney ( Van Ryn and Heaney, 1997 ) pay attention to interpersonal relations by suggesting concrete strategies and examples for empowering practice. In their article, they demonstrate two principles of interaction: (1) provide clients with unconditional positive regard and acceptance, and (2) facilitate client participation. Both principles include several practical strategies (Table I ).

However, the authors pay less attention to empirical findings ( Northouse, 1997 ). The present article describes some linguistic realizations of empowering practice. This article describes a nurse's empowering speech formulae during her efforts to give a patient information about an impending surgical operation and to strengthen her feelings of security by providing her with an opportunity to discuss her concerns. This study adopts a holistic approach to interaction and does not focus on isolated sentences or dialogue structure. The relationship of language and context in comprehension, as well as non-verbal communication, are also discussed.

This article describes a single case derived from qualitative data collected from a total of 38 counseling sessions in a Finnish hospital. Nurse–patient encounters were videotaped and transcribed verbatim. Interviews with the nurses and the patients after the sessions were transcribed as well. All participants volunteered to take part in the research, signed a research license and granted permission for the transcribed data to be used in publications. Nineteen nurses participated in this study. Each nurse conducted two videotaped counseling sessions with different patients. There was only one male nurse while the patient group consisted of 24 female and 14 male patients. The research material took shape as nurses volunteered in the hospital and it was found to be adequate for qualitative analysis. The length of the nurses' careers varied from 1 to 25 years. The ages of the nurses were between 24 and 50 years (mean age 36.9 years) while the patients' ages ranged from 18 to 70 years (mean age 47.9 years). The researcher did not attend the counseling sessions, which lasted from 5 to 45 min. The participating patients were experiencing diverse health problems. Various surgical problems, e.g. knee surgery, hernia operation, breast surgery, hip operation, back operation, post status of brain bleeding and post care of bypass surgery, were among the most representative. In addition to the health problems that had led to hospitalization, many patients also suffered from chronic diseases, such as hypertension, asthma, rheumatic illnesses or diabetes. Many patients also found themselves in an insecure situation when a chronic disease had suddenly been manifested or they were undergoing examinations. There were also some mothers in the group who had delivered recently and had no health problems.

The health counseling sessions were genuine counseling situations that were related to the patients' treatment. A single video camera was used, which meant that the observation of non-verbal communication was limited to examining the session as a whole, including only eye contact, smiles, laughter, tone of voice, gestures and, to some extent, facial expressions. Consequently, the emphasis of this study was examining verbal communication. Separate interviews with the nurses and the patients where both parties were encouraged to express their evaluations of the health counseling were used for partial support of the interpretations, e.g. when describing the patients' opinions about health counseling. We also checked if there were any nurses or patients who were nervous about the videotaping.

This article concentrates on videotaped data. When we examined all of the data we found many encounters that involved some empowering features from time to time, but there were none that were consistently empowering. In this article, we present a single case from the data. This particular encounter was selected because it differed from the rest of the data ( Stake, 1994 ) by manifesting empowering practice most widely. In order to study the interactive nature of communication, the coding and analysis of the videotaped data was based on principles of Conversation Analysis ( Drew and Heritage, 1998 ). The videotapes were transcribed word by word, including stammering, etc. At the same time, additional data were added to the transcriptions, such as pauses during and between turns, onset and termination of overlapping talk, intonation information, and some non-verbal communication. The following transcription symbols were used to indicate this information:

ha+ hands support speech

vo+ rising voice

vo– falling voice

[ ] at the beginning and end of overlapping speech, words enclosed

(( )) transcriber's comments, e.g. smile, laughter, body movements

(.) small but detectable pause

underlining emphasis

… omission of text

=no interval between the end of prior and start of next speech unit

°speech° speech in low volume, words enclosed

`speech'pitch change, words enclosed

The analysis was carried out on a turn-by-turn basis. The principle behind this analysis was to examine how turns were taken with regard to other participants' speech and what sequential implications each turn had for the next. After reading the transcript and watching the recording several times, we discovered a number of empowering expressions in the nurse's speech and concluded that this case was the one which best manifested empowering action in the data.

The particular case describes at the individual level information about the patient's situation, the nurse's interview after the encounter, an in-depth description of the nurse–patient conversation and the observational data derived from it. Pearson ( Pearson, 1991 ) and Patton ( Patton, 1990 ) indicate that a case study can be used, for example, for examining how different concepts emerge or change in particular contexts. However, an even more important question is what can be learned from a single case. Stake ( Stake, 1994 ) suggests that one should select a case that seems to offer an opportunity to learn and contributes to our understanding of specific phenomena. Here, a detailed single case analysis illustrates how empowerment may be practiced during health counseling and demonstrates how new working tools for empowerment can be developed on the basis of a single encounter ( Laitakari, 1998 ). The present study describes the speech of a nurse when she helped a patient to deal with anxiety and to receive information about surgery in an empowering way.

The nurse anesthetist has come to see a patient who is scheduled to have surgery the next day. The encounter involves, besides interviewing, producing a lot of information about the operation, counseling on the preparations for the surgery and advising how to manage after the surgery. The encounter takes place at a table, with the nurse and the patient facing each other. Both are women; the nurse is 50 and the patient 41 years old. The patient had had problems with her back for 10 years and was suddenly admitted to the hospital because of these problems. The patient has recently been examined and a decision has been made to operate on her the next morning. The interviewing session lasted 14 min.

At the beginning of a conversation the participants evaluate each others aims and concerns, and the communication situation as a whole, and this evaluation directs the entire discussion because the participants base their actions on it (Goffman, 1982). In a hospital, it is typical that nurses initiate a discussion ( Leino-Kilpi, 1991 ) and that is what happened in this case ( Extract 1 ). Professional dominance common in medical encounters ( Fairclough, 1992 ) is not so obvious in this conversation. After greeting the patient, the nurse refers to the goal of the discussion and individualizes it by using familiar `you' (line 1) instead of the formal, plural form of `you'. This form of address can be viewed as an act of communicating an appropriate degree of informality. It implies intimacy and mutual respect when a relationship is established ( van Ryn and Heaney, 1997 ).

1 N: Hello, Rose (.) you are going to have surgery 
 2 tomorrow…but now I would like to ask you 
 3 you well about the operation tomorrow if 
 4 there is (.) something that would influence 
 5 the preparations for your operation (.) and 
 6 then you ((ha+)) can bring things up ask well 
 7 er if something is unclear to you ((nod+)) If 
 8 you want to know anything about what's 
 9 going to happen to you tomorrow ((vo–))

((at first the nurse looks at papers on the table, while she speaks she turns her eyes to the patient and nods))

This opening was not typical of the other interviews in the data set, because in the data these encounters were usually initiated with the nurses' brief statements about the impending operation. They explained that they interviewed patients in advance in order to get information and that they could provide information to the patients as well. Nurses usually used formal, plural forms of address when speaking. When referring to the preoperative encounter, they used the plural, institutionalized form `we' [see ( Drew and Heritage, 1998 )], instead of first person singular `I', and plural `you', instead of the singular, when addressing the patient. Other nurses did not individualize their speech. On the contrary, they maintained a distance from the patients. In this particular case, a familiar mode of address reduces social distance, which is very important in health education practice [ cf . ( van Ryn and Heaney, 1997 )]. We explain our interpretations in more detail below.

The nurse uses the verb `ask' (line 2), but her remark further on (line 6–9) `then you can bring up ask well er if you were unclear about something if you want to know something about what's going to happen to you tomorrow' introduces a context for the discussion. Even though the nurse goes on to ask a question about previous operations, the interview becomes an interactive dialogue, with the patient actively participating. On her own initiative the patient discloses symptoms that she has experienced during the last few months, what happened when she needed to come to the hospital and the doctor's decision to perform surgery.

Thus, the nurse introduces the context of the discussion with her opening words [ cf . ( Peräkylä, 1995 )]. She expresses her acceptance by offering collaboration [ cf . ( van Ryn and Heaney, 1997 )] when asking questions. The verb form `would like to' (line 2) gives the discussion an air of voluntariness. The conditional form softens the notion of the necessity of the questions, and the verbal mode implies respect for the patient. At the beginning of the session (lines 1–9), the nurse combines two topics into a single long sentence, which also encourages (lines 6–9) the patient to clarify matters that are unclear to her. The nurse's words leave room for the patient's own thoughts and invites her to look for a personally meaningful way to connect the nurse's questions about the preparations (line 5) for the operation to her lack of information (lines 7–9). Encouraging statements can stimulate the patient to think in a way that is personally meaningful to her and to participate in the conversation ( van Ryn and Heaney, 1997 ; Tomm, 1988). Here, encouragement takes a form that is different from what Feste and Anderson ( Feste and Anderson, 1995 ) suggested; it is given in a more sophisticated manner. The opening words ( Extract 1 ) correspond with the goal that the nurse states later during the interview: `that the patient would receive the information she needs, what she wants to know and that she would feel safe to come, that at least those worst fears would be like forgotten. That she would feel safe'.

An encounter can threaten a patient's need for autonomy and freedom because it gives the nurse the legitimate power to request information about the patient's private life ( van Ryn and Heaney, 1997 ). Here, the nurse is mitigating her power by avoiding threatening terms and using tentative formulations (`would like to, well er, you you'), the emphasis being on the patient's needs. The opening of the interview by the nurse plays an important role in the development of the atmosphere. The act has been planned in advance but is not thoroughly thought out. In addition to conveying information, the main consideration in setting the goal for the discussion is to help the patient deal with her concerns. These are issues that have also been stressed in earlier studies ( Häggman-Laitila and Åstedt-Kurki, 1994 ; Breemhaar et al. , 1996 ; Leinonen et al. , 1996 ; Lindsey and Hartrick, 1996 ; Otte, 1996 ).

Tactful exploration: activation of reflection

Later during the interview, the patient mentions having thought about the impending surgery, which the nurse interprets as an indication of fear for the operation ( Extract 2 ). She indirectly gives the patient an opportunity to deal with her fears. The patient's words (lines 1, 3, 5 and 7) are related to the previous topic and her status during the operation and conclude the discussion. The nurse changes the subject (line 9) by praising the doctor's skill. The nurse and the patient look at each other.

1 P:mmm[think about during the day]= 
 2 N:[of] course ((nod+)) 
 3 P:=what's going to happen and (.) 
 4 N:right ((nod+)) 
 5 P:°like[that]° (.) 
 6 N:[mmm] 
 7 P:°it's[okay]° ((nod+, vo–)) 
 8 N: [that's] right (.) ((glance at papers: doctor's 
 9 name)) is is an excellent surgeon so in that 
 10 respect you can definitely (.) ((vo–)) feel 
 11 safe ((nod+)) that 
 12 P:yes of course I am 
 13 N:mmm 
 14 P: and and absolutely 110% (.) I trust that (.) 
 15 the thing is that (.) this is small case for 
 16 him but this is a horribly big thing for me…

The nurse's comment about the operating surgeon contains an allusion to fear of surgery. Instead of soothing the patient by telling her not to be afraid or asking if the patient is scared, the nurse indirectly comments on the doctor's professional skill (line 9) and emphasizes the expertise as a guarantee of success (line 10 and 11). Thus, the nurse allows the patient to save face when she leaves her to interpret her words. Her indirectness implies politeness and gives the patient options: if she does not want to deal with her fear, she may choose not to take the hint [see ( Brown and Levinson, 1987 )]. Here, politeness can also be linked to and interpreted through empowering practice, where the nurse holds the patient in high regard [ cf . ( van Ryn and Heaney, 1997 )].

The extract might have been interpreted as an example of the nurse cutting the patient off if one had not seen the videotape. Our interpretation is supported by a number of factors. First of all, the entire conversation until this extract has been tranquil and calm, the nurse has spoken and asked questions at a gentle pace, with pauses, and she has explored the patient's experiences. In this extract, the situation is similar, and she looks at the patient and nods. She speaks quite slowly, and her voice is low, friendly, and convincing ( van Ryn and Heaney, 1997 ). We can also see that the patient completes her speech by pausing (lines 3 and 5) and lowering her voice (lines 5 and 7). Therefore, after the nurse's words (lines 8–11), the patient presents her fear for discussion (lines 15 and 16) and also returns to the matter later during the interview. The extract shows how the issue has been constructed together by the nurse and the patient. The nurse raises the theme in a sensitive and non-threatening manner, and the patient continues the same topic. It also shows that the relationship is confidential enough for the patient to disclose her concerns and become aware of her own understanding, and thus contributes to empowerment. Salmon ( Salmon, 1993 ) has stressed that the main goal in the discussions between nurses and patients before surgery is not to reduce the patients' fears but to help them to deal with them.

Indirectness is a polite feature of discourse. There is `strategic indefiniteness' in indirectness that offers patients an opportunity to continue a discussion according to their own wishes ( Brown and Levinson, 1987 ). In general, nurses' empowering acts are mostly manifested in the form of questions ( Poskiparta et al. , 2000 ). In some cases, an indirect comment by a nurse, instead of a question, may encourage patients to talk about topics that they fear. Here it generates reflection in the patient. After disclosing her concerns, the patient analyzes the situation and recounts the conversation that she had with the doctor who explained the reason for her back surgery ( Extract 3 ).

Extract 3 .

1 P:this morning ((doctor's name)) said that 
 2 N:`this morning' ((surprised)) 
 3 P:this morning 
 4 N:that's recent for sure 
 4 P:yes 
 5 N:well it happened so 
 6 P: so it happened suddenly because yesterday 
 7 it became evident that (.) there was in the 
 8 X-ray ((doctor's name)) said that there was 
 9 a cause when I asked if there was anything 
 10 that caused the pain or if I was just imagining 
 11 it (.) so he said that yes there was a 
 12 genuine cause…

The amount of information given always depends on the situation and the nurse needs to continually evaluate the patient's needs: what it is that the patient knows, wants to know and how much she does want to know. This is also important because there are several persons that the patient sees before surgery ( Breemhaar et al. , 1996 ). Furthermore, nurses and doctors may deal with the same issues in their counseling. In Finland, the doctors, the surgeon and the consultant anaesthetist inform patients about the medical facts, risks, and benefits of operations. The patient also has an interview with a nurse on the surgical ward and, in addition to these encounters, there will occasionally be an encounter with a nurse anesthetist.

The nurse's empowering approach is manifested in how she raises issues or questions from time to time as if with hesitation. A pause precedes questions [`I don't have any (.) questions to ask you any more but do you—you have anything to ask from me like such things about tomorrow that worry you') ((looks at the patient))]. She asks the questions more quietly than normal and looks at the patient. According to Beck and Ragan's ( Beck and Ragan, 1992 ) study, nurses' softening words and their hesitant and tentative manner of speaking indicate discretion and tact and are aimed at not embarrassing patients. In our data, slow and hesitant speech also encourages the patients to comment more than nurses' more usual and brief question does: `Do you have any questions?'.

The nurse's tentative manner of asking questions makes it easier for the patient to start dealing with her concerns. She repeatedly pauses briefly and, in addition to the closed questions in the medical history questionnaire, she asks open-ended questions that explore the patient's experiences: `What kind of memories do you have of previous operations?' `Is there anything else you remember (.) is there something?'. Open-ended questions encourage the patient to speak and participate, e.g. in the naming and solving of a problem [ cf . ( Feste and Anderson, 1995 ; van Ryn and Heaney, 1997 )]. In this particular case, indirectness and hesitation are polite speech formulae that help the patient to save face ( Fairclough, 1992 ). They can also serve as empowering strategies that provide unconditional positive regard and acceptance for patients.

Despite these quite extensive empowering acts, the nurse subsequently evaluated her information skills only. She indicated how difficult it was for her to decide what kind of information to give to the patient:

I wondered if I should have maintained a more professional role, I mean more facts, if the patient got all that she wanted. Because this is not really medical science, you know, that's up to the doctor. It has to happen on the patient's terms, what she wants to know. I tried to check the patient's needs several times.

The content of the session satisfied the patient as well:

I got enough information about the operation, things that occupied my mind, so I didn't, she even told me before I asked. There's nothing to find out any more. As I said to her, I'm terribly afraid but I'll go ahead with confidence.

The nurse's way of posing questions builds up interaction. With her questions she steers the discussion thematically. This is how she controls the conversation. On the other hand, it is the patient who determines the content of the discussion. Her answers are reflective and bring up new issues. When the patient speaks, the nurse supports her with various feedback (e.g. Extracts 2 and 3) `mmm, right, of course, yes, exactly' and sometimes by paraphrasing. She nods a lot, bends toward the patient and looks at her. The feedback also occasionally includes completing the patient's sentences. According to van Ryn and Heaney ( van Ryn and Heaney, 1997 ), such non-verbal cues signal acceptance and, according to Caris-Verhallen et al. ( Caris-Verhallen et al. , 1999 ), they are patient-centered. With her feedback the nurse shows that she is there to listen to the patient, that she does not want to interrupt. Her feedback encourages the patient to speak in a similar way as in the doctor–patient conversation of an alternative medical interview described by Fairclough ( Fairclough, 1992 ). The patient interprets the feedback as encouragement, goes on to discuss the matter, and indicates her intention to continue by using the expressions `What I have been wondering…', `I did that when…' and `on the other hand, it's…'. This is how the nurse supports the patient's right to speak, which is not necessarily typical of a medical conversation ( Fairclough, 1992 ). The nurse's multi-facetted listening feedback is empowering, and this can be seen here and there in the data [see also ( Poskiparta et al. , 2000 )]. In this encounter, the feedback is exceptional because it disregards the participant's status. Generally, this type of feedback is directed to the dominant person ( Hakulinen, 1989 ). In a medically oriented environment, the hospital staff are viewed as superior to patients in knowledge ( van Ryn and Heaney, 1997 ; Tones, 1994 ). In this particular case, the nurse's listening feedback manifests power sharing.

When the patient discusses the reason for her admission to the hospital, the nurse builds up a positive, healthier vision of the future through other patients' experiences ( Extract 4 ). She makes her professional knowledge and expertise available to the patient ( Williams, 1995 ; McWilliam et al. , 1997 ). This lends a touch of reality and possibly builds on the patient's strengths ( van Ryn and Heaney, 1997 ) in this situation. The nurse attempts to dispel the patient's concerns about the risks of the operation. Her tone is convincing, and her non-verbal messages also inspire confidence: she looks at the patient, reinforces her message by nodding her head and gestures with her hands. Encouraged by the nurse, the patient can have a vision of her postoperative future.

Extract 4 .

1 N:these these ((ha+)) back operations are 
 2 like such that patients in them are usually 
 3 really grateful ((nod+)) after the operation 
 4 because if the operation like succeeds and 
 5 something is found (.) then the pain will be 
 6left in the operating room (.) ((ha+)) and 
 7 in that in that this is like like different from 
 8 other operations (.) and then because the 
 9 woundpainisinthebacksomehowit's 
 10 different than in here if the wound was here 
 11 inthestomach(ha+))andit'snotthatthat 
 12bad when it is if[you]= 
 13 P:[yeah] 
 14 N:=afterthosestomachoperationsyouoften 
 15 often hear that these patients who have had 
 16their back operated are such fortunate 
 17((nod+)) cases in the sense [that]= 
 18 P:[yeah] ((nod+)) 
 19 N:= because the pain will be left in the 
 20 operating room and and that's it then 
 21 ((nod+/ha+))

The nurse encourages the patient to examine her life at some hypothetical future point of time when the operation will have succeeded. Hypothetical questions encourage patients to discuss issues that they fear [ cf . ( Peräkylä, 1995 ; Tomm, 1987 )], while a hypothetical positive situation encourages patients indirectly. In this case, discussing the past would not calm the patient but rather lead her thoughts to the incident that caused her hospitalization. The vision of the future that the nurse provides to the patient with may help relieve her. A positive example is an empowering message and displays the nurse's understanding of the patient's anxiety. This vision can tap new resources in the patient for facing the future that is suddenly uncertain [ cf . ( van Ryn and Heaney, 1997 )]. Some manifestations of this can be seen in the patient's words: `…I'm very happy that if it's going to be over (.) yes I'm ready though I feel nervous' or `…I'm going ahead with confidence…'. A skilful use of future focus by the nurse helps the patient to find new solutions to her problems [ cf . ( Tomm, 1987 )]. As Atwood ( Atwood, 1995 ) suggests, confining the clients' thoughts to their problems is not sufficient in therapy work (focus on the past). In addition, we need to assist clients to expand their outlook by re-visioning their lives (future focus).

The encounter that is presented here as a case study demonstrates empowering nursing practice in hospital. It is a concrete example of a discussion during which the official and formal nature that characterizes the role of an institutional nurse is not emphasized. It actually emphasizes partnership and reciprocal conversation [ cf . ( van Ryn and Heaney, 1997 ; Poskiparta et al. , 2000 )], with the nurse's social interaction skills at the heart of the encounter [ cf . ( Wiles, 1997 )]. The patient is free to discuss her thoughts, concerns, experiences and even fears with the nurse, and the nurse adopts an empowerment strategy in order to facilitate the patient's participation. This encounter included the following empowering practices: (1) opening the session in an encouraging and constructive manner, which improves the atmosphere, (2) tactful exploration when examining the patient's need for information and concerns for surgery, (3) active, power sharing listening, and (4) building up a positive vision of the future.

The descriptions of empowerment strategies reported by van Ryn and Heaney ( van Ryn and Heaney, 1997 ) support our findings. However, we agree with Northouse's ( Northouse, 1997 ) criticism that the reported strategies are not completely separated. In our study, empowerment was manifested through intimacy and mutual respect. The nurse's encouragement of the patient's participation and her attempt to share power signaled acceptance, and perhaps gave the patient new insights for controlling her feelings about the impending surgery. Furthermore, the perceptions of active listening feedback and questioning are consistent with our previous studies ( Poskiparta et al. , 1998 , 2000 ; Kettunen et al. , 2000 ), where we found them to be a means of activating patients' self-evaluation and self-determination. In this study, we did not find evidence for empowering stories or questions that relate to patients' personal philosophy, as mentioned by Feste and Anderson ( Feste and Anderson, 1995 ). In addition, the nurse's encouragement was more sophisticated than what Feste and Anderson suggest with their empowering tools.

Our research data consisted of only one videotaped session per patient. Thus we have no evidence about how patients' decision-making skills develop or their self-esteem improves. During the interviews we did not ask the patients' opinion on the effects of counseling and that is why the patients evaluated conversations at a quite general level. In this particular case, the patient said that an encounter was ` illuminating ' for her. She mentioned that she received enough information and again spoke about her fears but used the same words as the nurse did when she emphasized a positive vision of future (see Extract 4 , lines 5, 6, 19 and 20): `if it's a fact that the pain will be left in the operating room, if it really is possible…that there's going to be an operation and they'll do it tomorrow, then that's how it's going to be'. This could, perhaps, signify some kind of relief or new resources to face an uncertain future. During the interview it also became evident that the patient's fears had not been diminished, but she talked about them and stressed a strong reliance on the professionals and on the operation as a whole: `I believe what I'm told'. This is in line with the perspective of Salmon ( Salmon, 1993 ), who emphasized that patients' anxiety about surgery should not be seen as a problem but rather as a normal phenomenon, a sign of patients' emotional balance, of an ability to feel fear. Thus, the nurse's task is not to diminish the patient's fears but to facilitate the patient's disclosure and offer help for dealing with fear.

With caution, we can speculate on the factors behind this kind of empowering practice, which became evident during the subsequent interviews. There was no evidence that nurses' or patients' age, education or work experience influenced the format of the counseling. What makes this case different from traditional rigid counseling sessions is that the nurse had a goal that she had planned in advance and pursued flexibly. This indicates that she had reflected on the significance of this situation from the patient's perspective. In most cases, nurses approached counseling without any goal or the hospital provided a detailed agenda based on professional knowledge of diseases, their care and prevention. Then, different kinds of institutionalized health counseling packages seemed to restrict nurses' communication, and health counseling often followed the standard institutional order of phases mentioned by Drew and Heritage ( Drew and Heritage 1998 ).

This study highlights empowering opportunities that arise in actual situations and that nurses can consciously use in their work. The results of this study can be applied to other health counseling practices and we would argue that every nurse should consider how (s)he initiates discussion. The analysis of the encounter shows that a tentative discussion style gives the patient a chance to deal with her concerns and to absorb the information that she needs. Thus, the patient has an opportunity to participate more actively in the discussion from the beginning than she could in the case of filling out a questionnaire in a strict predetermined order.

Clearly there are limitations to the generalizability of these findings. For example, both interlocutors were women, and this could in part explain the nature of the conversation since the highest levels of empathic and positive behavior occur between females [see ( Coates, 1986 ; Roter and Hall, 1993 ), p. 63]. There is also some concern whether the nurse may have been subject to a performance bias because she was aware of being videotaped and possibly behaved differently. However, we think that this was limited because only two nurses discussed this type of bias in the interviews afterwards and other nurses did not even notice the camera or did so only briefly at the beginning of counseling [see also ( Caris-Verhallen et al. , 1998 )]. Techniques to enhance the credibility of the findings included data and methodological triangulation of research data ( Patton, 1990 ; Stake, 1994 ; Begley, 1996 ), and acquiring data that included both verbal and non-verbal communication from the videotaped health counseling sessions and the subsequent interviews. In addition, team analysis sessions (investigator triangulation) ensured the accuracy of data interpretation (Polit and Hunger 1995). Different expertise helped us to get more complete picture from this case and empowerment philosophy when we discussed interpretations together.

However, in the last analysis, the effect of an empowering encounter could be checked after the operation by checking the patient's perspective, e.g. her satisfaction, recovery rate, etc. Evidence from nursing and medical staff might also be offered as additional evidence. Further research from larger numbers of patients is needed and more evidence from different settings will be required for a more extensive description of empowering practice. We will continue our research, and, for example, present qualitative analysis of interaction by describing how power features and patients' taciturnity are manifested in nurse–patient counseling. In addition, we will investigate how student nurses make progress in empowering counseling.

We suggest that nurses should pay attention to verbal expression and forms of language, in addition to non-verbal messages, because then they can empower patients by opening new and important perspectives for them. Nurses' every question, remark or piece of advice leads to individualized understanding and interpretation by the patient. It is important to remember that each communication situation is a unique, dynamic and transforming process. Nurses should observe what figures of speech they use and thus gain self-awareness and discover new tools to work with. We suggest a training program where the development of health care professionals' empowering skills can occur in practical, dynamic communication situations, be videotaped and transcribed for later theoretical, conscious and instructive evaluation. Analyzing the transcripts of video or tape-recorded counseling sessions opens up the possibility of an exact evaluation of empowering skills.

In health counseling, it is important that patients are able to maintain and strengthen a positive image of themselves as communicators. Positive experiences build up patients' self-esteem and increase their confidence in their ability to influence their care. The mere opportunity to discuss one's opinions and interpretations or different health concerns with a nurse may have the effect of unlocking patients' mental resources. This article demonstrates particularly how unconditional acceptance and facilitation of participation can be used in interpersonal counseling [see ( van Ryn and Heaney, 1997 )]. The empowering practices that are presented in this article should not be regarded as rigid and formalistic, rather they should be adapted to one's personal style.

Empowering principles of interpersonal practice ( van Ryn and Heaney, 1997 )

This study was supported by the Ministry of Health and Social Affairs of Finland and by the Finnish Cultural Foundation. We are sincerely grateful to all that participated in this study.

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  • Published: 22 February 2024

Determinants of low birth weight among newborns delivered at Mettu Karl comprehensive specialized hospital, southwest Ethiopia: a case–control study

  • Samuel Ejeta Chibsa 1 ,
  • Mustafa Adem Hussen 1 ,
  • Kenbon Bayisa 1 &
  • Bilisumamulifna Tefera Kefeni 2  

Scientific Reports volume  14 , Article number:  4399 ( 2024 ) Cite this article

Metrics details

  • Health care
  • Medical research

Low birth weight is a newborn delivered with birth weight of less than 2500 g regardless of gestational age is called. It is a significant issue affecting over 30 million infants worldwide. Thus, the study determine factors associated with low birth weight among newborns delivered at Mettu Karl Comprehensive Specialized Hospital, Southwest Ethiopia. A facility-based case–control study was conducted with 336 newborns (112 cases and 224 controls) from September 12 to December 23, 2022. The study population was newborns with birth weights of 2500 g to 4000 g as controls and newborns with birth weights < 2500 g were cases. Simple random sampling techniques were used to recruit study participants with a ratio of 1 to 3 cases to controls, respectively. Data was collected by interviews and a checklist. Data were entered and analysed using SPSS version 23. Binary and multivariate logistic regression analyses were computed to identify factors associated with low birth weight, a p -value less than 0.05 was used to declare the strength of statistical significance. A total of 327 newborns were contacted, yielding a 97% response rate. MUAC < 23 cm (AOR = 2.72, 95% CI 1.24 to 6.19), inadequate diet diversification (AOR = 4.19, 95% CI 2.04 to 8.60), lack of iron and folic acid supplementation (AOR = 2.94, 95% CI 1.25 to 6.88), history of hypertension (AOR = 2.55, 95% CI 1.09 to 6.00), and lack of nutritional counselling (AOR = 4.63, 95% CI 2.22 to 9.64) were determinants of low birth weight. Low birth weight is linked to residence, maternal MUAC, hypertension history, and ANC visit. Lifestyle modifications, early detection, management, and nutrition information can reduce risk.

Introduction

Low birth weight (LBW) is a baby delivered with a birth weight of less than 2500 g (5.5 pounds), regardless of gestational age 1 . A large group of infants are born preterm, intrauterine growth-restricted, or both preterm and intrauterine growth-restricted 1 , 2 . Birth weight is a predictor of perinatal and infant survival, morbidity and mortality, and later risk for developmental disabilities in their lives 3 , 4

Globally, more than 30 million newborns are delivered annually; of this, almost one-quarter of them have low birth weight 1 . The majority of births occur in south-central Asia, with one-third of them weighing less than 2500 g 4 , 5 . Low birth weight: in Sub-Saharan Africa, 15 percent of them grow up as stunted children, developing different complicated infections that require later hospital admission 3 , 6 .

Low birth weight is primarily determined by maternal health condition and nutrition status in developing countries, unlike in developed countries, where usually cigarette smoking during pregnancy is the primary cause of low birth weight 7 . Additionally, genetic, socio-demographic, maternal medical illness, intrauterine fetal complications, and environmental factors are predictors of low birth weight across the world 6 , 8 . In Ethiopia, low birth weights ranged from (10.4 to 17.3%) and this makes Ethiopia grouped under five countries that are accountable for half of global neonatal deaths among Sub-Saharan Africa 9 , 10 , 11 .

The World Health Organisation is set to reduce the burden of low birth weight by as little as 30% by 2025 through nutritional policies on getting affordable, accessible, and appropriate health care for preventing and treating low birth weight 1 . Based on WHO reccomendation, the Ethiopian government declares different strategies to reduce low birth weight and neonatal death 12 . The burden of low birth weight still remained high in Ethiopia 9 , 10 , 11 . The available studies were mainly focuses on the prevalence of low birth weight. therefore, these studies account some of the factors linked with LBW such asnutritional-related factors and nutritional assessment in the the study area. Thus, the study was conducted to determine factors associated with low birth weight among newborns delivered at Mettu Karl Comprehensive Specialised Hospital,South West Ethiopia.

Methods and materials

Study design, setting, and period.

A facility-based, unmatched case–control study was conducted at Mettu Karl Comprehensive Specialised Hospital from September 12 to December 23, 2022. The hospital is located in Mettu town about 600 km from Addis Ababa, the capital city of Ethiopia. The hospital provides service for in patients and out patients, maternal and child health as well as ART services for patients in the ilu abba bor zone, south-western Ethiopia and Gambella regional states, with a catchment population of more than 2.4 million in 2007 G.C.

Sourse and study population

The cases were a single alive newborns whose birth weight < 2500 g and had not gross congeital anomalies at Mettu Karl Comprehensive Specialised Hospital (MKCSH) between September 12, 2022 and Decemember 23, 2022. Whereas the controlswere a single alive ewborns weight ≥ 2500 g, but ≤ 4000 g of who were delivered in the same health facilities within 24 h of the delivery of cases and had not gross congeital anomalies.

Sample size determination

The sample size was determined by using double population proportion formula. By the following assumptions a cases to controls ratio of 1:2. Power = 80%, Zβ = 0.84 for 0.05 significance level, Zα = 1.96 OR = Minimal detectable odds ratio is 2, P1 = proportion of exposure among the cases = 40.9% P2 = the proportion exposed in the control = 24.8% 13

Sampling procedures

After additional consideration of the non-response rate of 5%, the total sample size was 336 (112 cases and 224 controls). A simple random sampling techiques were used to select cases. Whereas controls were selected consequatively at the same and same day of delivey with the ratio of 1 to 2 case to controls within 24 h after delivery. Data was collected each time a low birth weight baby had been delivered until the required sample size was attained.

Operational defiitions

Minimum dietary diversity for women (mdd-w).

The amounts of woman consumes from 10 dietary diversity food groups.

Adequate dietary diversity for women

If women consumed at least five different food groups during the previous day or night, from ten food groups.

Inadequate dietary diversity for women

If women consumed less than five different food groups during the previous day or night, from ten food groups.

Antenatal care (ANC) visits

Which was dichotomized as Yes if a woman has at least one Antenatal care visits and No if a woman has no any Antenatal care visits during the last pregnancy.

Study variables

Sociodemographic factors.

Maternal age, educational status, family income, place of residence, occupation, and family size.

Obstetric factors

ANC visit, Gravidity, Parity, Gestational age, Pregnancy-induced Hypertension, Labor complication, and vaginal bleeding.

Maternal nutritional associated factors

Maternal dietary diversity (MDD-women), Maternal Anthropometric measurements, nutritional counseling during pregnancy, IFA, and Micronutrient supplementations.

Maternal medical/lifestyle factors

History of chronic diseases like Hypertension, Diabetes Mellitus, Anemia, TB, Malaria, History of Smoking, Chewing chat, and severe physical work during pregnancy.

Data collection tools and management procedures

The data were collected through interviews, structured questionnaires, and medical record reviews. The newborn's weight was measured using a balanced Seca scale (German) to the nearest 0.01 g within 1 h of birth. To assure the quality of data two days of training was given to data collectors and supervisors. Trainings started before actual data collection regarding how to approach the study subjects, how to use questionnaires, the data collection procedures, the context of specific questions, and the anthropometric measurement procedures. Minimum Dietary Diversity for Women (MDD-W) was measured by the ten questions developed by FAO and FANTA as a proxy indicator to reflect the micronutrient adequacy of women’s diets. The MDD-W indicator is dichotomous, it returns the value Yes or No. The woman achieves minimum dietary diversity, i.e. Yes, if she consumed at least five different food groups during the previous day or night, and No otherwise (1) Grains, white roots and tubers, and plantains, (2) Pulses (beans, peas and lentils), (3) Nuts and seeds, (4) Milk and milk products, (5) Meat, poultry and fish. (6) Eggs, (7) Dark green leafy vegetables, (8) Other vitamin A-rich fruits and vegetables, (9) Other vegetables, (10) Other fruits 14 . Mid-upper arm circumference (MUAC) was also measured using a non-stretchable MUAC tape according to procedures. The questionaries’ was adapted by reviewing different related literature reviews 15 , 16 , 17 , 18 , 19 , 20 .

Data processing and analysis

Data were checked for completeness, accuracy, and then cleaned, coded, and were entered to Epi data version 7.0 then exported to SPSS version 23.0 for statistical analysis. Descriptive statistics such as frequency,and percentages were used to describe the study subjects. Binary and multivariate logistic regression analayis was computed to identify factors associated with LBW and a p-value less than 0.05 were used to declare the strength of statistical significances.

Ethical consideration

This research was performed in accordance with the Helsinki Declaration of Principles. A letter of ethical clearance was obtained from the ethics committee of the College of Health Science at Mattu University, with a reference letter of DPH/157/2022.

Consent to participate

All the study participants were informed about the purpose of the study and their right to refuse participation or terminate their involvement during the study. Written informed consent was obtained from each study participant.. Information was provided to each study participant before signing the informed consent form on the purpose of the study, data handling, and confidentiality of the information.

Socio-demographic characteristics of study participants

A total of 327 were contacted (109 cases and 218 controls) agreed to take part in the study, yielding a 97% response rate. Male constituted in the majority 54% and 59.2% of cases and controls respectively in the study. From the study participants, 35 (32.1%) of the case and 11 (5%) of the control of mothers age were under 20 years (Table 1 ).

Obstetrics, medical, and nutritional related factors of study participants

In this study, majority of study partcipants 73.3% case and 88.9% control have ANC visits, whereas, 26.7% of cases and 11.1% of controls has no ANC visits. Among study participants 49.5% of cases have no IFA supplementation, whereas 87.6% of controls have IFA supplementation. However only 50.5% of cases have IFA supplementation and 12.4% of control has no IFA supplementation (Table 2 ).

Logestics regression analysis

A significant association were identified between low birth weight were living the rural area, lack of nutritional counseling History of Hypertension, Having ANC visits, Inadequate minimum MDD-women ( Table 3 ).

This study reveals that rural women have a higher odds of having a low birth weight than urban mothers. This agreed with individuals reside influences their behaviours, income, and, most significantly, their health and nutrition 15 . The findings are comparable with studies undertaken in Bale, Oromia, Ethiopia, Malaysia, and Yemen, which found that rural pregnant women are more likely to have low birth weights than urban pregnant women 13 , 16 , 17 . However, a study conducted in the Jimma Zone found that women living in urban areas had a higher risk of having low-birth-weight babies 18 . This disparity could be attributed to differences in study design, health awareness, geographical location, and demographic features of study participants.

Odds of pregnancy-induced hypertension more risk of developing low birth weight than women who do not have a history of pregnancy-induced hypertension. In fact, high blood pressure may reduce blood flow to the placenta, and as a result, the fetus may not get enough of the nutrients and oxygen needed to grow 15 . Our findings, consistent with studies conducted in north Shewa, Addis Ababa, and Malaysia, showed that pregnant mothers who have a history of pregnancy-induced hypertension were at higher risk of developing low birth weight than pregnant women who have no history of hypertension 9 , 18 , 21 respectively. The possible consistency of the finding could be that hypertension in pregnancy causes narrowing placental blood vessels, will be complicated by utero placental insufficiency, and increases the risk of low birth weight outcomes 9 . However, a study conducted in China showed that hypertensive mothers did not show an increased risk for lowbirth weight 16 . This discrepancy may be due to differences in the study setting, methods, and sociodemographics of the subjects. Additionally, women who were not counselled about nutritional intake during pregnancy had higher odds of having a low birth weight than pregnant women who had been counselled about nutritional intake. Our finding are consistent with a study conducted in North Shewa, Dessie town, Dire Dawa, and Hawassa Ethiopia 10 , 11 , 21 , 22 respectively. The possible consistency of nutritional counselling may improve their intake habits, and having information about eating a healthy diet can reduce the chance of fetal growth restriction and high blood pressure, reducing the risk of low birth weight in pregnant women 15 .

Iron and folic acid supplementation showed significant assocaiation in this study. Pregnant women who do not receive iron and folic acid supplements have a higher odds of developing low birth weight than their counterparts. Our finding agreed with a study in Nekemte town and north Shewa, Ethiopia 21 , 23 . This is supported by evidence that IFA supplementation protects against low birth weight as a multiple micronutrient supplement 19 . Additionally, having IFA supplementation during pregnancy decreases the odds of developing a low birth weight compared to the uterine parts of pregnant women 9 , 20 , 24 . The possible outcomes could be additional intakes of supplementation, reducing morbidities and risks of congenital malformation.

This study discovered that mothers whose MUAC is less than 23 cm have a higher risk of developing a low birth weight than mothers whose MUAC is greater than or equal to 23 cm. This is supported by a study conducted in the Sidama Zone in south Ethiopia, Yemen, and India 3 , 17 , 25 respectively. This consistency was supported by the available evidence. Low birth weight is a result of undernutrition and the health status of the mother during her pregnancy; MUAC less than normal affects birth weight outcomes 15 .

Inadequate minimum women's dietary diversification increases the risk of being exposed to low birth weight compared to those who had adequate minimum women's dietary diversification during pregnancy. Our findings aligned with a study conducted in Ghana, systematic review reports where women's dietary diversity scores and dietary patterns were found to be protective against low birth weight 26 , 27 . This consistency could be due to similarities in background characteristics, study design, and study population.

Lastly, women who have antenatal care are 89 percent more protected from low birth than mothers who had non-ANC visits during their recent pregnancy. This is also consistent with studies in Sidama, Bale, Gondar Shewa, Ethiopia, and Italy 3 , 13 , 28 , 29 respectively. This could be due to the fact that the World Health Organisation strongly recommends during pregnancy the utilisation of antenatal care used for early identification of risky pregnancy and screening for pregnancy complications, as well as early treatments that improve the birth outcomes of pregnancy.

Strength and limitation of the study

The data was collected with consistent inclusion and exclusion criteria from cases and controls by case control study design to minimise selection bias. Self-reporting methods may lead to recall bias and subjective diagnosis, which may affect the generaliability of findings but not the quality of the study.

Conclusions

Low birth weight was significantly associated with residence, maternal MUAC, non-compliance with IFA supplementation, hypertension history, nutiritonal counselling, minimum MDD-women, and ANC visit of the mother. Life style Modification, early detection, and management of maternal hypertension, as well as strengthening nutrition information and counselling during pregnancy, will help minimise the risk of low birth weight.

Data availability

Data we used in this manuscript were available on behalf of corresponding authors based on reseanble requests.

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Acknowledgements

First of all we would like to thank data collectors and supervisors, and study participants for their cooperation through data collection time. Likewise, we thank our families and friends who gave support and inspiration without them nothing is accomplished.

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Midwifery Department, College of Health Science, Mattu University, Mettu, Ethiopia

Samuel Ejeta Chibsa, Mustafa Adem Hussen & Kenbon Bayisa

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S.E., M.A., B.T. inception designed the proposal, data analysis, interpretation, manuscript draft, revised the manuscript, and wrote the paper. K.B. participates in data collection, entry, and wrote reports. S.E. and B.T. participated in the analysis. All Authors read and approved the final paper.

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Correspondence to Samuel Ejeta Chibsa .

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Ejeta Chibsa, S., Adem Hussen, M., Bayisa, K. et al. Determinants of low birth weight among newborns delivered at Mettu Karl comprehensive specialized hospital, southwest Ethiopia: a case–control study. Sci Rep 14 , 4399 (2024). https://doi.org/10.1038/s41598-024-54248-w

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Additional information about International Student Program reforms

Ottawa, February 5, 2024— Further information is being provided to clarify the announcement of an intake cap on new international study permit applications and other changes . International students make important contributions to Canada’s campuses, communities and economy; however, we have seen unsustainable growth in the International Student Program in recent years. These recently announced reforms will support sustainable population growth in Canada and improve system integrity, while helping to ensure that international students have a positive experience in Canada.

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ScienceDaily

Case study: Drug-resistant bacteria responds to phage-antibiotic combo therapy

It was a last-ditch effort. For years doctors had tried to keep a patient's recurrent drug-resistant bacterial blood infection at bay, but it kept coming back and antibiotics were no longer working.

The family agreed to try an experimental treatment that uses viruses to kill bacteria. The patient's Enterococcus faecium bacterial strain, which had become zombie-like and was almost impossible to treat with currently available antibiotics, was tested against wastewater collected from across the country to find a virus -- called a bacteriophage -- that scientists theorized would specifically target the drug-resistant bacteria.

It worked so well the patient was able to leave the hospital for a much-anticipated vacation with her family. The case study by University of Pittsburgh School of Medicine scientists is published today in the American Society for Microbiology journal mBio .

"I was pleasantly surprised, but others on our team were, frankly, shocked at how quickly it worked," said senior author Daria Van Tyne, Ph.D., assistant professor of infectious diseases at Pitt. "Of course, this is what we wanted, what we hoped for. But the patient's response was so much better than we expected."

The case study, which required emergency investigational new drug approval from the U.S. Food and Drug Administration (FDA), is one of only a handful that have used bacteriophage therapy to treat E. faecium infection. The researchers expect the results from this study will inform future use of the therapy.

Bacteriophages -- known informally as 'phages' -- are viruses that target and infect bacteria, killing the bacteria as they replicate. Different phages target different bacteria and can be so selective that they only target a specific strain of a bacterium and won't infect other bacteria or injure human cells. Phages are abundant and can be found everywhere from water and soil to the human body. Wastewater from sewage treatment plants is a common source researchers use to isolate new phages.

Doctors are increasingly interested in phage therapy when all else fails to fight a deadly bacterial infection. But as the therapy is not currently standardized or approved by the FDA, it is not widely available. Several clinical trials -- including at Pitt -- are underway to confirm its safety and test its efficacy.

The patient in the case study was a 57-year-old woman who had a complex medical history and an autoimmune condition that required immunosuppression to treat. Along the course of her medical journey, drug-resistant E. faecium colonized her gut and spread to her blood, causing recurrent bloodstream infections that required multiple and prolonged hospitalizations between 2013 and 2020. Finally, in late 2020, after a month-long hospitalization, doctors determined that antibiotics were no longer working and suggested phage therapy.

Scientists at the University of Colorado discovered the phage that targeted her bacterial strain and sent it to Pittsburgh where it was grown and prepared in Van Tyne's lab and then given to the patient alongside antibiotics.

"Phages attack bacteria in a different way than antibiotics," said lead author Madison Stellfox, M.D., Ph.D., postdoctoral infectious diseases fellow at Pitt. "We believe that the phage therapy worked in tandem with the antibiotics to help the patient fight the infection."

Within 24 hours of receiving phage therapy, the patient's blood infection had resolved and she could go home, where she continued the phage and antibiotic combination. She developed a few short-lived breakthrough infections, which indicated the bacteria was getting around the therapy, so the researchers found an additional phage that targeted her bacteria.

With the addition of the new phage, the patient was blood infection-free for four months and able to travel out of state for a for a family beach vacation.

However, just over six months after starting phage therapy, the blood infection returned, and the phage-antibiotic combination was thought to be no longer effective. The patient died in 2022.

In order to learn why the infections recurred despite the combination being previously effective, laboratory testing revealed that the patient's immune system had likely activated in a way that blocked the phages from attacking the bacteria. Van Tyne and Stellfox suspect that either the addition of the second phage or the increased dose of the phage combination -- or both -- had prompted the immune response.

"What we learned from this patient and her allowing us to follow and document her medical journey will help future patients," said Van Tyne. "Phage therapy could be a powerful tool against the ever-growing threat of antibiotic resistance and the data from her case will help shape clinical trials that could one day make it widely available to patients in need."

Additional authors on this release are Carolyn Fernandes, M.D., Ryan K. Shields, Pharm.D., M.S., Ghady Haidar, M.D., Kailey Hughes Kramer, Ph.D., and Emily Dembinski, all of Pitt, and Mihnea R. Mangalea, Ph.D., Garima Arya, Ph.D., Gregory S. Canfield, M.D., Ph.D., and Breck A. Duerkop, Ph.D., all of the University of Colorado at the time of the work.

This research was supported by the National Institutes of Health (T32AI138954, R01AI165519, R21AI151363, R01AI141479, T32AR007534 and K23AI154546).

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  • Madison E. Stellfox, Carolyn Fernandes, Ryan K. Shields, Ghady Haidar, Kailey Hughes Kramer, Emily Dembinski, Mihnea R. Mangalea, Garima Arya, Gregory S. Canfield, Breck A. Duerkop, Daria Van Tyne. Bacteriophage and antibiotic combination therapy for recurrent Enterococcus faecium bacteremia . mBio , 2024; DOI: 10.1128/mbio.03396-23

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