sample case study in clinical psychology

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Descriptive Research and Case Studies

Learning objectives.

• Explain the importance and uses of descriptive research, especially case studies, in studying abnormal behavior

Types of Research Methods

There are many research methods available to psychologists in their efforts to understand, describe, and explain behavior and the cognitive and biological processes that underlie it. Some methods rely on observational techniques. Other approaches involve interactions between the researcher and the individuals who are being studied—ranging from a series of simple questions; to extensive, in-depth interviews; to well-controlled experiments.

The three main categories of psychological research are descriptive, correlational, and experimental research. Research studies that do not test specific relationships between variables are called descriptive, or qualitative, studies . These studies are used to describe general or specific behaviors and attributes that are observed and measured. In the early stages of research, it might be difficult to form a hypothesis, especially when there is not any existing literature in the area. In these situations designing an experiment would be premature, as the question of interest is not yet clearly defined as a hypothesis. Often a researcher will begin with a non-experimental approach, such as a descriptive study, to gather more information about the topic before designing an experiment or correlational study to address a specific hypothesis. Descriptive research is distinct from correlational research , in which psychologists formally test whether a relationship exists between two or more variables. Experimental research goes a step further beyond descriptive and correlational research and randomly assigns people to different conditions, using hypothesis testing to make inferences about how these conditions affect behavior. It aims to determine if one variable directly impacts and causes another. Correlational and experimental research both typically use hypothesis testing, whereas descriptive research does not.

Each of these research methods has unique strengths and weaknesses, and each method may only be appropriate for certain types of research questions. For example, studies that rely primarily on observation produce incredible amounts of information, but the ability to apply this information to the larger population is somewhat limited because of small sample sizes. Survey research, on the other hand, allows researchers to easily collect data from relatively large samples. While surveys allow results to be generalized to the larger population more easily, the information that can be collected on any given survey is somewhat limited and subject to problems associated with any type of self-reported data. Some researchers conduct archival research by using existing records. While existing records can be a fairly inexpensive way to collect data that can provide insight into a number of research questions, researchers using this approach have no control on how or what kind of data was collected.

Correlational research can find a relationship between two variables, but the only way a researcher can claim that the relationship between the variables is cause and effect is to perform an experiment. In experimental research, which will be discussed later, there is a tremendous amount of control over variables of interest. While performing an experiment is a powerful approach, experiments are often conducted in very artificial settings, which calls into question the validity of experimental findings with regard to how they would apply in real-world settings. In addition, many of the questions that psychologists would like to answer cannot be pursued through experimental research because of ethical concerns.

The three main types of descriptive studies are case studies, naturalistic observation, and surveys.

Clinical or Case Studies

Psychologists can use a detailed description of one person or a small group based on careful observation.  Case studies  are intensive studies of individuals and have commonly been seen as a fruitful way to come up with hypotheses and generate theories. Case studies add descriptive richness. Case studies are also useful for formulating concepts, which are an important aspect of theory construction. Through fine-grained knowledge and description, case studies can fully specify the causal mechanisms in a way that may be harder in a large study.

Sigmund Freud   developed  many theories from case studies (Anna O., Little Hans, Wolf Man, Dora, etc.). F or example, he conducted a case study of a man, nicknamed “Rat Man,”  in which he claimed that this patient had been cured by psychoanalysis.  T he nickname derives from the fact that among the patient’s many compulsions, he had an obsession with nightmarish fantasies about rats. 

Today, more commonly, case studies reflect an up-close, in-depth, and detailed examination of an individual’s course of treatment. Case studies typically include a complete history of the subject’s background and response to treatment. From the particular client’s experience in therapy, the therapist’s goal is to provide information that may help other therapists who treat similar clients.

Case studies are generally a single-case design, but can also be a multiple-case design, where replication instead of sampling is the criterion for inclusion. Like other research methodologies within psychology, the case study must produce valid and reliable results in order to be useful for the development of future research. Distinct advantages and disadvantages are associated with the case study in psychology.

A commonly described limit of case studies is that they do not lend themselves to generalizability . The other issue is that the case study is subject to the bias of the researcher in terms of how the case is written, and that cases are chosen because they are consistent with the researcher’s preconceived notions, resulting in biased research. Another common problem in case study research is that of reconciling conflicting interpretations of the same case history.

Despite these limitations, there are advantages to using case studies. One major advantage of the case study in psychology is the potential for the development of novel hypotheses of the  cause of abnormal behavior   for later testing. Second, the case study can provide detailed descriptions of specific and rare cases and help us study unusual conditions that occur too infrequently to study with large sample sizes. The major disadvantage is that case studies cannot be used to determine causation, as is the case in experimental research, where the factors or variables hypothesized to play a causal role are manipulated or controlled by the researcher. 

Link to Learning: Famous Case Studies

Some well-known case studies that related to abnormal psychology include the following:

• Harlow— Phineas Gage
• Breuer & Freud (1895)— Anna O.
• Cleckley’s case studies: on psychopathy ( The Mask of Sanity ) (1941) and multiple personality disorder ( The Three Faces of Eve ) (1957)
• Freud and  Little Hans
• Freud and the  Rat Man
• John Money and the  John/Joan case
• Genie (feral child)
• Piaget’s studies
• Rosenthal’s book on the  murder of Kitty Genovese
• Washoe (sign language)
• Patient H.M.

Naturalistic Observation

If you want to understand how behavior occurs, one of the best ways to gain information is to simply observe the behavior in its natural context. However, people might change their behavior in unexpected ways if they know they are being observed. How do researchers obtain accurate information when people tend to hide their natural behavior? As an example, imagine that your professor asks everyone in your class to raise their hand if they always wash their hands after using the restroom. Chances are that almost everyone in the classroom will raise their hand, but do you think hand washing after every trip to the restroom is really that universal?

This is very similar to the phenomenon mentioned earlier in this module: many individuals do not feel comfortable answering a question honestly. But if we are committed to finding out the facts about handwashing, we have other options available to us.

Suppose we send a researcher to a school playground to observe how aggressive or socially anxious children interact with peers. Will our observer blend into the playground environment by wearing a white lab coat, sitting with a clipboard, and staring at the swings? We want our researcher to be inconspicuous and unobtrusively positioned—perhaps pretending to be a school monitor while secretly recording the relevant information. This type of observational study is called naturalistic observation : observing behavior in its natural setting. To better understand peer exclusion, Suzanne Fanger collaborated with colleagues at the University of Texas to observe the behavior of preschool children on a playground. How did the observers remain inconspicuous over the duration of the study? They equipped a few of the children with wireless microphones (which the children quickly forgot about) and observed while taking notes from a distance. Also, the children in that particular preschool (a “laboratory preschool”) were accustomed to having observers on the playground (Fanger, Frankel, & Hazen, 2012).

It is critical that the observer be as unobtrusive and as inconspicuous as possible: when people know they are being watched, they are less likely to behave naturally. For example, psychologists have spent weeks observing the behavior of homeless people on the streets, in train stations, and bus terminals. They try to ensure that their naturalistic observations are unobtrusive, so as to minimize interference with the behavior they observe. Nevertheless, the presence of the observer may distort the behavior that is observed, and this must be taken into consideration (Figure 1).

The greatest benefit of naturalistic observation is the validity, or accuracy, of information collected unobtrusively in a natural setting. Having individuals behave as they normally would in a given situation means that we have a higher degree of ecological validity, or realism, than we might achieve with other research approaches. Therefore, our ability to generalize the findings of the research to real-world situations is enhanced. If done correctly, we need not worry about people modifying their behavior simply because they are being observed. Sometimes, people may assume that reality programs give us a glimpse into authentic human behavior. However, the principle of inconspicuous observation is violated as reality stars are followed by camera crews and are interviewed on camera for personal confessionals. Given that environment, we must doubt how natural and realistic their behaviors are.

The major downside of naturalistic observation is that they are often difficult to set up and control. Although something as simple as observation may seem like it would be a part of all research methods, participant observation is a distinct methodology that involves the researcher embedding themselves into a group in order to study its dynamics. For example, Festinger, Riecken, and Shacter (1956) were very interested in the psychology of a particular cult. However, this cult was very secretive and wouldn’t grant interviews to outside members. So, in order to study these people, Festinger and his colleagues pretended to be cult members, allowing them access to the behavior and psychology of the cult. Despite this example, it should be noted that the people being observed in a participant observation study usually know that the researcher is there to study them. [1]

Another potential problem in observational research is observer bias . Generally, people who act as observers are closely involved in the research project and may unconsciously skew their observations to fit their research goals or expectations. To protect against this type of bias, researchers should have clear criteria established for the types of behaviors recorded and how those behaviors should be classified. In addition, researchers often compare observations of the same event by multiple observers, in order to test inter-rater reliability : a measure of reliability that assesses the consistency of observations by different observers.

Often, psychologists develop surveys as a means of gathering data. Surveys are lists of questions to be answered by research participants, and can be delivered as paper-and-pencil questionnaires, administered electronically, or conducted verbally (Figure 3). Generally, the survey itself can be completed in a short time, and the ease of administering a survey makes it easy to collect data from a large number of people.

Surveys allow researchers to gather data from larger samples than may be afforded by other research methods . A sample is a subset of individuals selected from a population , which is the overall group of individuals that the researchers are interested in. Researchers study the sample and seek to generalize their findings to the population.

There is both strength and weakness in surveys when compared to case studies. By using surveys, we can collect information from a larger sample of people. A larger sample is better able to reflect the actual diversity of the population, thus allowing better generalizability. Therefore, if our sample is sufficiently large and diverse, we can assume that the data we collect from the survey can be generalized to the larger population with more certainty than the information collected through a case study. However, given the greater number of people involved, we are not able to collect the same depth of information on each person that would be collected in a case study.

Another potential weakness of surveys is something we touched on earlier in this module: people do not always give accurate responses. They may lie, misremember, or answer questions in a way that they think makes them look good. For example, people may report drinking less alcohol than is actually the case.

Any number of research questions can be answered through the use of surveys. One real-world example is the research conducted by Jenkins, Ruppel, Kizer, Yehl, and Griffin (2012) about the backlash against the U.S. Arab-American community following the terrorist attacks of September 11, 2001. Jenkins and colleagues wanted to determine to what extent these negative attitudes toward Arab-Americans still existed nearly a decade after the attacks occurred. In one study, 140 research participants filled out a survey with 10 questions, including questions asking directly about the participant’s overt prejudicial attitudes toward people of various ethnicities. The survey also asked indirect questions about how likely the participant would be to interact with a person of a given ethnicity in a variety of settings (such as, “How likely do you think it is that you would introduce yourself to a person of Arab-American descent?”). The results of the research suggested that participants were unwilling to report prejudicial attitudes toward any ethnic group. However, there were significant differences between their pattern of responses to questions about social interaction with Arab-Americans compared to other ethnic groups: they indicated less willingness for social interaction with Arab-Americans compared to the other ethnic groups. This suggested that the participants harbored subtle forms of prejudice against Arab-Americans, despite their assertions that this was not the case (Jenkins et al., 2012).

Think it Over

Research has shown that parental depressive symptoms are linked to a number of negative child outcomes. A classmate of yours is interested in  the associations between parental depressive symptoms and actual child behaviors in everyday life [2] because this associations remains largely unknown. After reading this section, what do you think is the best way to better understand such associations? Which method might result in the most valid data?

clinical or case study:  observational research study focusing on one or a few people

correlational research:  tests whether a relationship exists between two or more variables

descriptive research:  research studies that do not test specific relationships between variables; they are used to describe general or specific behaviors and attributes that are observed and measured

experimental research:  tests a hypothesis to determine cause-and-effect relationships

generalizability:  inferring that the results for a sample apply to the larger population

inter-rater reliability:  measure of agreement among observers on how they record and classify a particular event

naturalistic observation:  observation of behavior in its natural setting

observer bias:  when observations may be skewed to align with observer expectations

population:  overall group of individuals that the researchers are interested in

sample:  subset of individuals selected from the larger population

survey:  list of questions to be answered by research participants—given as paper-and-pencil questionnaires, administered electronically, or conducted verbally—allowing researchers to collect data from a large number of people

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• Descriptive Research.  Provided by : Boundless.  Located at :  https://www.boundless.com/psychology/textbooks/boundless-psychology-textbook/researching-psychology-2/types-of-research-studies-27/descriptive-research-124-12659/ .  License :  CC BY-SA: Attribution-ShareAlike
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• Research Designs.  Authored by : Christie Napa Scollon.  Provided by : Singapore Management University.  Located at :  https://nobaproject.com/modules/research-designs#reference-6 .  Project : The Noba Project.  License :  CC BY-NC-SA: Attribution-NonCommercial-ShareAlike
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• Scollon, C. N. (2020). Research designs. In R. Biswas-Diener & E. Diener (Eds), Noba textbook series: Psychology. Champaign, IL: DEF publishers. Retrieved from http://noba.to/acxb2thy ↵
• Slatcher, R. B., & Trentacosta, C. J. (2011). A naturalistic observation study of the links between parental depressive symptoms and preschoolers' behaviors in everyday life. Journal of family psychology : JFP : journal of the Division of Family Psychology of the American Psychological Association (Division 43), 25(3), 444–448. https://doi.org/10.1037/a0023728 ↵

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Case Study Research Method in Psychology

Saul McLeod, PhD

Editor-in-Chief for Simply Psychology

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

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

Learn about our Editorial Process

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

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

On This Page:

Case studies are in-depth investigations of a person, group, event, or community. Typically, data is gathered from various sources using several methods (e.g., observations & interviews).

The case study research method originated in clinical medicine (the case history, i.e., the patient’s personal history). In psychology, case studies are often confined to the study of a particular individual.

The information is mainly biographical and relates to events in the individual’s past (i.e., retrospective), as well as to significant events that are currently occurring in his or her everyday life.

The case study is not a research method, but researchers select methods of data collection and analysis that will generate material suitable for case studies.

Freud (1909a, 1909b) conducted very detailed investigations into the private lives of his patients in an attempt to both understand and help them overcome their illnesses.

This makes it clear that the case study is a method that should only be used by a psychologist, therapist, or psychiatrist, i.e., someone with a professional qualification.

There is an ethical issue of competence. Only someone qualified to diagnose and treat a person can conduct a formal case study relating to atypical (i.e., abnormal) behavior or atypical development.

 Famous Case Studies

• Anna O – One of the most famous case studies, documenting psychoanalyst Josef Breuer’s treatment of “Anna O” (real name Bertha Pappenheim) for hysteria in the late 1800s using early psychoanalytic theory.
• Little Hans – A child psychoanalysis case study published by Sigmund Freud in 1909 analyzing his five-year-old patient Herbert Graf’s house phobia as related to the Oedipus complex.
• Bruce/Brenda – Gender identity case of the boy (Bruce) whose botched circumcision led psychologist John Money to advise gender reassignment and raise him as a girl (Brenda) in the 1960s.
• Genie Wiley – Linguistics/psychological development case of the victim of extreme isolation abuse who was studied in 1970s California for effects of early language deprivation on acquiring speech later in life.
• Phineas Gage – One of the most famous neuropsychology case studies analyzes personality changes in railroad worker Phineas Gage after an 1848 brain injury involving a tamping iron piercing his skull.

Clinical Case Studies

• Studying the effectiveness of psychotherapy approaches with an individual patient
• Assessing and treating mental illnesses like depression, anxiety disorders, PTSD
• Neuropsychological cases investigating brain injuries or disorders

Child Psychology Case Studies

• Studying psychological development from birth through adolescence
• Cases of learning disabilities, autism spectrum disorders, ADHD
• Effects of trauma, abuse, deprivation on development

Types of Case Studies

• Explanatory case studies : Used to explore causation in order to find underlying principles. Helpful for doing qualitative analysis to explain presumed causal links.
• Exploratory case studies : Used to explore situations where an intervention being evaluated has no clear set of outcomes. It helps define questions and hypotheses for future research.
• Descriptive case studies : Describe an intervention or phenomenon and the real-life context in which it occurred. It is helpful for illustrating certain topics within an evaluation.
• Multiple-case studies : Used to explore differences between cases and replicate findings across cases. Helpful for comparing and contrasting specific cases.
• Intrinsic : Used to gain a better understanding of a particular case. Helpful for capturing the complexity of a single case.
• Collective : Used to explore a general phenomenon using multiple case studies. Helpful for jointly studying a group of cases in order to inquire into the phenomenon.

Where Do You Find Data for a Case Study?

There are several places to find data for a case study. The key is to gather data from multiple sources to get a complete picture of the case and corroborate facts or findings through triangulation of evidence. Most of this information is likely qualitative (i.e., verbal description rather than measurement), but the psychologist might also collect numerical data.

1. Primary sources

• Interviews – Interviewing key people related to the case to get their perspectives and insights. The interview is an extremely effective procedure for obtaining information about an individual, and it may be used to collect comments from the person’s friends, parents, employer, workmates, and others who have a good knowledge of the person, as well as to obtain facts from the person him or herself.
• Observations – Observing behaviors, interactions, processes, etc., related to the case as they unfold in real-time.
• Documents & Records – Reviewing private documents, diaries, public records, correspondence, meeting minutes, etc., relevant to the case.

2. Secondary sources

• News/Media – News coverage of events related to the case study.
• Academic articles – Journal articles, dissertations etc. that discuss the case.
• Government reports – Official data and records related to the case context.
• Books/films – Books, documentaries or films discussing the case.

3. Archival records

Searching historical archives, museum collections and databases to find relevant documents, visual/audio records related to the case history and context.

Public archives like newspapers, organizational records, photographic collections could all include potentially relevant pieces of information to shed light on attitudes, cultural perspectives, common practices and historical contexts related to psychology.

4. Organizational records

Organizational records offer the advantage of often having large datasets collected over time that can reveal or confirm psychological insights.

Of course, privacy and ethical concerns regarding confidential data must be navigated carefully.

However, with proper protocols, organizational records can provide invaluable context and empirical depth to qualitative case studies exploring the intersection of psychology and organizations.

• Organizational/industrial psychology research : Organizational records like employee surveys, turnover/retention data, policies, incident reports etc. may provide insight into topics like job satisfaction, workplace culture and dynamics, leadership issues, employee behaviors etc.
• Clinical psychology : Therapists/hospitals may grant access to anonymized medical records to study aspects like assessments, diagnoses, treatment plans etc. This could shed light on clinical practices.
• School psychology : Studies could utilize anonymized student records like test scores, grades, disciplinary issues, and counseling referrals to study child development, learning barriers, effectiveness of support programs, and more.

How do I Write a Case Study in Psychology?

Follow specified case study guidelines provided by a journal or your psychology tutor. General components of clinical case studies include: background, symptoms, assessments, diagnosis, treatment, and outcomes. Interpreting the information means the researcher decides what to include or leave out. A good case study should always clarify which information is the factual description and which is an inference or the researcher’s opinion.

1. Introduction

• Provide background on the case context and why it is of interest, presenting background information like demographics, relevant history, and presenting problem.
• Compare briefly to similar published cases if applicable. Clearly state the focus/importance of the case.

2. Case Presentation

• Describe the presenting problem in detail, including symptoms, duration,and impact on daily life.
• Include client demographics like age and gender, information about social relationships, and mental health history.
• Describe all physical, emotional, and/or sensory symptoms reported by the client.
• Use patient quotes to describe the initial complaint verbatim. Follow with full-sentence summaries of relevant history details gathered, including key components that led to a working diagnosis.
• Summarize clinical exam results, namely orthopedic/neurological tests, imaging, lab tests, etc. Note actual results rather than subjective conclusions. Provide images if clearly reproducible/anonymized.
• Clearly state the working diagnosis or clinical impression before transitioning to management.

3. Management and Outcome

• Indicate the total duration of care and number of treatments given over what timeframe. Use specific names/descriptions for any therapies/interventions applied.
• Present the results of the intervention,including any quantitative or qualitative data collected.
• For outcomes, utilize visual analog scales for pain, medication usage logs, etc., if possible. Include patient self-reports of improvement/worsening of symptoms. Note the reason for discharge/end of care.

4. Discussion

• Analyze the case, exploring contributing factors, limitations of the study, and connections to existing research.
• Analyze the effectiveness of the intervention,considering factors like participant adherence, limitations of the study, and potential alternative explanations for the results.
• Identify any questions raised in the case analysis and relate insights to established theories and current research if applicable. Avoid definitive claims about physiological explanations.
• Offer clinical implications, and suggest future research directions.

5. Additional Items

• Thank specific assistants for writing support only. No patient acknowledgments.
• References should directly support any key claims or quotes included.
• Use tables/figures/images only if substantially informative. Include permissions and legends/explanatory notes.
• Provides detailed (rich qualitative) information.
• Provides insight for further research.
• Permitting investigation of otherwise impractical (or unethical) situations.

Case studies allow a researcher to investigate a topic in far more detail than might be possible if they were trying to deal with a large number of research participants (nomothetic approach) with the aim of ‘averaging’.

Because of their in-depth, multi-sided approach, case studies often shed light on aspects of human thinking and behavior that would be unethical or impractical to study in other ways.

Research that only looks into the measurable aspects of human behavior is not likely to give us insights into the subjective dimension of experience, which is important to psychoanalytic and humanistic psychologists.

Case studies are often used in exploratory research. They can help us generate new ideas (that might be tested by other methods). They are an important way of illustrating theories and can help show how different aspects of a person’s life are related to each other.

The method is, therefore, important for psychologists who adopt a holistic point of view (i.e., humanistic psychologists ).

Limitations

• Lacking scientific rigor and providing little basis for generalization of results to the wider population.
• Researchers’ own subjective feelings may influence the case study (researcher bias).
• Difficult to replicate.
• Time-consuming and expensive.
• The volume of data, together with the time restrictions in place, impacted the depth of analysis that was possible within the available resources.

Because a case study deals with only one person/event/group, we can never be sure if the case study investigated is representative of the wider body of “similar” instances. This means the conclusions drawn from a particular case may not be transferable to other settings.

Because case studies are based on the analysis of qualitative (i.e., descriptive) data , a lot depends on the psychologist’s interpretation of the information she has acquired.

This means that there is a lot of scope for Anna O , and it could be that the subjective opinions of the psychologist intrude in the assessment of what the data means.

For example, Freud has been criticized for producing case studies in which the information was sometimes distorted to fit particular behavioral theories (e.g., Little Hans ).

This is also true of Money’s interpretation of the Bruce/Brenda case study (Diamond, 1997) when he ignored evidence that went against his theory.

Breuer, J., & Freud, S. (1895).  Studies on hysteria . Standard Edition 2: London.

Curtiss, S. (1981). Genie: The case of a modern wild child .

Diamond, M., & Sigmundson, K. (1997). Sex Reassignment at Birth: Long-term Review and Clinical Implications. Archives of Pediatrics & Adolescent Medicine , 151(3), 298-304

Freud, S. (1909a). Analysis of a phobia of a five year old boy. In The Pelican Freud Library (1977), Vol 8, Case Histories 1, pages 169-306

Freud, S. (1909b). Bemerkungen über einen Fall von Zwangsneurose (Der “Rattenmann”). Jb. psychoanal. psychopathol. Forsch ., I, p. 357-421; GW, VII, p. 379-463; Notes upon a case of obsessional neurosis, SE , 10: 151-318.

Harlow J. M. (1848). Passage of an iron rod through the head.  Boston Medical and Surgical Journal, 39 , 389–393.

Harlow, J. M. (1868).  Recovery from the Passage of an Iron Bar through the Head .  Publications of the Massachusetts Medical Society. 2  (3), 327-347.

Money, J., & Ehrhardt, A. A. (1972).  Man & Woman, Boy & Girl : The Differentiation and Dimorphism of Gender Identity from Conception to Maturity. Baltimore, Maryland: Johns Hopkins University Press.

Money, J., & Tucker, P. (1975). Sexual signatures: On being a man or a woman.

Further Information

• Case Study Approach
• Case Study Method
• Enhancing the Quality of Case Studies in Health Services Research
• “We do things together” A case study of “couplehood” in dementia
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What Is a Case Study?

Weighing the pros and cons of this method of research

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

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

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

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

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

At a Glance

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

What Are the Benefits and Limitations of Case Studies?

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

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

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

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

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

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

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

Case Study Examples

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

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

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

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

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

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

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

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

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

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

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

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

Section 1: A Case History

This section will have the following structure and content:

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

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

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

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

Section 2: Treatment Plan

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

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

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

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

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

Need More Tips?

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

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

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

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

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

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

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

How to Write a Case Conceptualization: 10 Examples (+ PDF)

Such understanding can be developed by reading relevant records, meeting with clients face to face, and using assessments such as a mental status examination.

As you proceed, you are forming a guiding concept of who this client is, how they became who they are, and where their personal journey might be heading.

Such a guiding concept, which will shape any needed interventions, is called a case conceptualization, and we will examine various examples in this article.

Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with detailed insight into positive Cognitive-Behavioral Therapy (CBT) and give you the tools to apply it in your therapy or coaching.

This Article Contains:

What is a case conceptualization or formulation, 4 things to include in your case formulation, a helpful example & model, 3 samples of case formulations, 6 templates and worksheets for counselors, relevant resources from positivepsychology.com, a take-home message.

In psychology and related fields, a case conceptualization summarizes the key facts and findings from an evaluation to provide guidance for recommendations.

This is typically the evaluation of an individual, although you can extend the concept of case conceptualization to summarizing findings about a group or organization.

Based on the case conceptualization, recommendations can be made to improve a client’s self-care , mental status, job performance, etc (Sperry & Sperry, 2020).

• Summary of the client’s identifying information, referral questions, and timeline of important events or factors in their life . A timeline can be especially helpful in understanding how the client’s strengths and limitations have evolved.
• Statement of the client’s core strengths . Identifying core strengths in the client’s life should help guide any recommendations, including how strengths might be used to offset limitations.
• Statement concerning a client’s limitations or weaknesses . This will also help guide any recommendations. If a weakness is worth mentioning in a case conceptualization, it is worth writing a recommendation about it.

Note: As with mental status examinations , observations in this context concerning weaknesses are not value judgments, about whether the client is a good person, etc. The observations are clinical judgments meant to guide recommendations.

• A summary of how the strengths, limitations, and other key information about a client inform diagnosis and prognosis .

You should briefly clarify how you arrived at a given diagnosis. For example, why do you believe a personality disorder is primary, rather than a major depressive disorder?

Many clinicians provide diagnoses in formal psychiatric terms, per the International Classification of Diseases (ICD-10) or Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Some clinicians will state a diagnosis in less formal terms that do not coincide exactly with ICD-10 or DSM-5 codes. What is arguably more important is that a diagnostic impression, formal or not, gives a clear sense of who the person is and the support they need to reach their goals.

Prognosis is a forecast about whether the client’s condition can be expected to improve, worsen, or remain stable. Prognosis can be difficult, as it often depends on unforeseeable factors. However, this should not keep you from offering a conservative opinion on a client’s expected course, provided treatment recommendations are followed.

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Based on the pointers for writing a case conceptualization above, an example for summarizing an adolescent case (in this instance, a counseling case for relieving depression and improving social skills) might read as follows.

Background and referral information

This is a 15-year-old Haitian–American youth, referred by his mother for concerns about self-isolation, depression, and poor social skills. He reportedly moved with his mother to the United States three years ago.

He reportedly misses his life and friends in Haiti. The mother states he has had difficulty adjusting socially in the United States, especially with peers. He has become increasingly self-isolating, appears sad and irritable, and has started to refuse to go to school.

His mother is very supportive and aware of his emotional–behavioral needs. The youth has been enrolled in a social skills group at school and has attended three sessions, with some reported benefit. He is agreeable to start individual counseling. He reportedly does well in school academically when he applies himself.

Limitations

Behavioral form completed by his mother shows elevated depression scale (T score = 80). There is a milder elevation on the inattention scale (T score = 60), which suggests depression is more acute than inattention and might drive it.

He is also elevated on a scale measuring social skills and involvement (T score = 65). Here too, it is reasonable to assume that depression is driving social isolation and difficulty relating to peers, especially since while living in Haiti, he was reportedly quite social with peers.

Diagnostic impressions, treatment guidance, prognosis

This youth’s history, presentation on interview, and results of emotional–behavioral forms suggest some difficulty with depression, likely contributing to social isolation. As he has no prior reported history of depression, this is most likely a reaction to missing his former home and difficulty adjusting to his new school and peers.

Treatments should include individual counseling with an evidence-based approach such as Cognitive-Behavioral Therapy (CBT). His counselor should consider emotional processing and social skills building as well.

Prognosis is favorable, with anticipated benefit apparent within 12 sessions of CBT.

How to write a case conceptualization: An outline

The following outline is necessarily general. It can be modified as needed, with points excluded or added, depending on the case.

• Client’s gender, age, level of education, vocational status, marital status
• Referred by whom, why, and for what type of service (e.g., testing, counseling, coaching)
• In the spirit of strengths-based assessment, consider listing the client’s strengths first, before any limitations.
• Consider the full range of positive factors supporting the client.
• Physical health
• Family support
• Financial resources
• Capacity to work
• Resilience or other positive personality traits
• Emotional stability
• Cognitive strengths, per history and testing
• The client’s limitations or relative weaknesses should be described in a way that highlights those most needing attention or treatment.
• Medical conditions affecting daily functioning
• Lack of family or other social support
• Limited financial resources
• Inability to find or hold suitable employment
• Substance abuse or dependence
• Proneness to interpersonal conflict
• Emotional–behavioral problems, including anxious or depressive symptoms
• Cognitive deficits, per history and testing
• Diagnoses that are warranted can be given in either DSM-5 or ICD-10 terms.
• There can be more than one diagnosis given. If that’s the case, consider describing these in terms of primary diagnosis, secondary diagnosis, etc.
• The primary diagnosis should best encompass the client’s key symptoms or traits, best explain their behavior, or most need treatment.
• Take care to avoid over-assigning multiple and potentially overlapping diagnoses.

When writing a case conceptualization, always keep in mind the timeline of significant events or factors in the examinee’s life.

• Decide which events or factors are significant enough to include in a case conceptualization.
• When these points are placed in a timeline, they help you understand how the person has evolved to become who they are now.
• A good timeline can also help you understand which factors in a person’s life might be causative for others. For example, if a person has suffered a frontal head injury in the past year, this might help explain their changeable moods, presence of depressive disorder, etc.

Sample #1: Conceptualization for CBT case

This is a 35-year-old Caucasian man referred by his physician for treatment of generalized anxiety.

Strengths/supports in his case include willingness to engage in treatment, high average intelligence per recent cognitive testing, supportive family, and regular physical exercise (running).

Limiting factors include relatively low stress coping skills, frequent migraines (likely stress related), and relative social isolation (partly due to some anxiety about social skills).

The client’s presentation on interview and review of medical/psychiatric records show a history of chronic worry, including frequent worries about his wife’s health and his finances. He meets criteria for DSM-5 generalized anxiety disorder. He has also described occasional panic-type episodes, which do not currently meet full criteria for panic disorder but could develop into such without preventive therapy.

Treatments should include CBT for generalized anxiety, including keeping a worry journal; regular assessment of anxiety levels with Penn State Worry Questionnaire and/or Beck Anxiety Inventory; cognitive restructuring around negative beliefs that reinforce anxiety; and practice of relaxation techniques, such as progressive muscle relaxation and diaphragmatic breathing .

Prognosis is good, given the evidence for efficacy of CBT for anxiety disorders generally (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012).

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Sample #2: Conceptualization for DBT case

This 51-year-old Haitian–American woman is self-referred for depressive symptoms, including reported moods of “rage,” “sadness,” and “emptiness.” She says that many of her difficulties involve family, friends, and coworkers who regularly “disrespect” her and “plot against her behind her back.”

Her current psychiatrist has diagnosed her with personality disorder with borderline features, but she doubts the accuracy of this diagnosis.

Strengths/supports include a willingness to engage in treatment, highly developed and marketable computer programming skills, and engagement in leisure activities such as playing backgammon with friends.

Limiting factors include low stress coping skills, mild difficulties with attention and recent memory (likely due in part to depressive affect), and a tendency to self-medicate with alcohol when feeling depressed.

The client’s presentation on interview, review of medical/psychiatric records, and results of MMPI-2 personality inventory corroborate her psychiatrist’s diagnosis of borderline personality disorder.

The diagnosis is supported by a longstanding history of unstable identity, volatile personal relationships with fear of being abandoned, feelings of emptiness, reactive depressive disorder with suicidal gestures, and lack of insight into interpersonal difficulties that have resulted in her often stressed and depressive state.

Treatments should emphasize a DBT group that her psychiatrist has encouraged her to attend but to which she has not yet gone. There should also be regular individual counseling emphasizing DBT skills including mindfulness or present moment focus, building interpersonal skills, emotional regulation, and distress tolerance. There should be a counseling element for limiting alcohol use. Cognitive exercises are also recommended.

Of note, DBT is the only evidence-based treatment for borderline personality disorder (May, Richardi, & Barth, 2016). Prognosis is guardedly optimistic, provided she engages in both group and individual DBT treatments on a weekly basis, and these treatments continue without interruption for at least three months, with refresher sessions as needed.

Sample #3: Conceptualization in a family therapy case

This 45-year-old African-American woman was initially referred for individual therapy for “rapid mood swings” and a tendency to become embroiled in family conflicts. Several sessions of family therapy also appear indicated, and her psychiatrist concurs.

The client’s husband (50 years old) and son (25 years old, living with parents) were interviewed separately and together. When interviewed separately, her husband and son each indicated the client’s alcohol intake was “out of control,” and that she was consuming about six alcoholic beverages throughout the day, sometimes more.

Her husband and son each said the client was often too tired for household duties by the evening and often had rapid shifts in mood from happy to angry to “crying in her room.”

On individual interview, the client stated that her husband and son were each drinking about as much as she, that neither ever offered to help her with household duties, and that her son appeared unable to keep a job, which left him home most of the day, making demands on her for meals, etc.

On interview with the three family members, each acknowledged that the instances above were occurring at home, although father and son tended to blame most of the problems, including son’s difficulty maintaining employment, on the client and her drinking.

Strengths/supports in the family include a willingness of each member to engage in family sessions, awareness of supportive resources such as assistance for son’s job search, and a willingness by all to examine and reduce alcohol use by all family members as needed.

Limiting factors in this case include apparent tendency of all household members to drink to some excess, lack of insight by one or more family members as to how alcohol consumption is contributing to communication and other problems in the household, and a tendency by husband and son to make this client the family scapegoat.

The family dynamic can be conceptualized in this case through a DBT lens.

From this perspective, problems develop within the family when the environment is experienced by one or more members as invalidating and unsupportive. DBT skills with a nonjudgmental focus, active listening to others, reflecting each other’s feelings, and tolerance of distress in the moment should help to develop an environment that supports all family members and facilitates effective communication.

It appears that all family members in this case would benefit from engaging in the above DBT skills, to support and communicate with one another.

Prognosis is guardedly optimistic if family will engage in therapy with DBT elements for at least six sessions (with refresher sessions as needed).

Introduction to case conceptualization – Thomas Field

The following worksheets can be used for case conceptualization and planning.

• Case Conceptualization Worksheet: Individual Counseling helps counselors develop a case conceptualization for individual clients.
• Case Conceptualization Worksheet: Couples Counseling helps counselors develop a case conceptualization for couples.
• Case Conceptualization Worksheet: Family Counseling helps counselors develop a case conceptualization for families.
• Case Conceptualization and Action Plan: Individual Counseling helps clients facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
• Case Conceptualization and Action Plan: Couples Counseling helps couples facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
• Case Conceptualization and Action Plan: Family Counseling helps families facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.

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Analyzing Strengths Use in Different Life Domains can help clients understand their notable strengths and which strengths can be used to more advantage in new contexts.

Family Strength Spotting is another relevant resource. Each family member fills out a worksheet detailing notable strengths of other family members. In reviewing all worksheets, each family member can gain a greater appreciation for other members’ strengths, note common or unique strengths, and determine how best to use these combined strengths to achieve family goals.

Four Front Assessment is another resource designed to help counselors conceptualize a case based on a client’s personal and environmental strengths and weaknesses. The idea behind this tool is that environmental factors in the broad sense, such as a supportive/unsupportive family, are too often overlooked in conceptualizing a case.

If you’re looking for more science-based ways to help others through CBT, check out this collection of 17 validated positive CBT tools for practitioners. Use them to help others overcome unhelpful thoughts and feelings and develop more positive behaviors.

In helping professions, success in working with clients depends first and foremost on how well you understand them.

This understanding is crystallized in a case conceptualization.

Case conceptualization helps answer key questions. Who is this client? How did they become who they are? What supports do they need to reach their goals?

The conceptualization itself depends on gathering all pertinent data on a given case, through record review, interview, behavioral observation, questionnaires completed by the client, etc.

Once the data is assembled, the counselor, coach, or other involved professional can focus on enumerating the client’s strengths, weaknesses, and limitations.

It is also often helpful to put the client’s strengths and limitations in a timeline so you can see how they have evolved and which factors might have contributed to the emergence of others.

Based on this in-depth understanding of the client, you can then tailor specific recommendations for enhancing their strengths, overcoming their weaknesses, and reaching their particular goals.

We hope you have enjoyed this discussion of how to conceptualize cases in the helping professions and that you will find some tools for doing so useful.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

• Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research , 36 (5), 427–440.
• May, J. M., Richardi, T. M., & Barth, K. S. (2016). Dialectical behavior therapy as treatment for borderline personality disorder. The Mental Health Clinician , 6 (2), 62–67.
• Sperry, L., & Sperry, J. (2020).  Case conceptualization: Mastering this competency with ease and confidence . Routledge.

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5 Fascinating Clinical Psychology Case Studies

If you pursue work as a clinical psychologist, you’ll be able to make a major difference in people’s lives. In most cases, these psychologists are the first practitioners to recognize and diagnose mental health disorders. Many clinical psychologists also practice “talk therapy,” where they talk through issues with patients and help them develop better coping mechanisms. But what’s it really like to work in clinical psychology? Take a look at each case study psychology below to get an idea.

A Day in the Life of a Clinical Psychologist

As you might be able to tell from the name, a clinical psychologist applies psychology knowledge in a clinical setting. Using their knowledge of different mental disorders and how they present, clinical psychologists help patients identify and then treat mental health disorders. They also can help patients work through psychological issues even if no disorder is present.

However, it’s important to note that clinical psychologists do not prescribe medication. Often, once a clinical psychologist makes a diagnosis that requires medication, they will refer a patient to a psychiatrist. The psychiatrist handles the medication, but a clinical psychologist will often help a patient manage some of their symptoms through some form of talk therapy. In the case of some complex disorders, a psychologist may be able to coordinate with the patient’s psychiatrist in order to ensure the best care possible.

Some people believe that talk therapy is just a patient talking while the psychologist listens. However, this couldn’t be further from the truth. Clinical psychologists are tasked with assessing each patient and developing an individualized treatment plan. Often, that plan includes delving into the patient’s issues and helping them understand their roots. From there, the psychologist can help the patient develop healthier coping mechanisms for dealing with those issues.

Usually, clinical psychologists primarily work with patients on an individual basis. They do this either as part of a group practice or in private practice. Sometimes, they may teach classes, although this usually isn’t the bulk of their workload. Clinical psychologists often will conduct and publish research that sometimes involves case studies of patients.

Becoming a Clinical Psychologist

To become a clinical psychologist, you will need to pursue a doctoral degree. Most clinical psychologists have either a Ph.D. or a PsyD, though the Ph.D. is more common in the field and will usually afford you more career opportunities. PsyD programs tend to accept more applicants than Ph.D. programs. A PsyD degree places more focus on applying concepts of psychology to the clinical setting. A Ph.D. program certainly applies concepts of psychology as well, but it has much more of a focus on research than PsyD programs do.

Regardless of which program you choose, becoming a clinical psychologist involves a considerable time commitment. The first step is obtaining a four-year bachelor’s degree. From there, some candidates pursue a master’s degree, while others go straight into a Ph.D. training program.

Most PsyD programs take four to five years to complete, while most Ph.D. programs take between five and seven years. In the case of a Ph.D., graduates will need to complete a residency program much like medical doctors. Residency programs usually last about one to three years. During that time, new psychologists are overseen by an experienced psychologist. Upon completion of the residency, a clinical psychologist must also take and pass a licensure exam in order to practice in their state. Most states will also allow you to obtain different certifications in specialized areas.

As you can see, the decision to become a clinical psychologist isn’t one to make on a whim. Usually, though, you’ll be able to get a sense of the field from the undergraduate courses you take early on.

What’s a Case Study?

In a moment, we’ll take you through five interesting case studies from real clinical psychologists. But what exactly is a case study?

Simply put, a case study is a very detailed account of an individual patient’s case. (The case studies below are abbreviated versions of case studies.) Psychologists usually keep notes on all patients, but a case study is much more formal. Each study is an in-depth exploration of a patient’s disorder, and it usually contains information on the patient’s personal history as well as how their disorder presents. Most case studies also have information on treatments that have worked (and those that have not worked) for a given patient.

So why is a single case study valuable, especially when most studies survey larger groups of patients? For one, case studies are extremely valuable in the case of rare conditions. With very rare mental health disorders, it can be near-impossible to find larger studies. With case studies, it’s still possible to get an accurate picture of the disorder and what it looks like in different patients.

Case studies can also help future clinical psychologists to sharpen their diagnostic skills. In a broader study, you might learn about some of the common symptoms of a diagnose. But individual patients have their own quirks, and the same disorder can look different from patient to patient. Reading case studies can be a great way to see how different mental health issues can look in different people.

Lastly, case studies can be useful in supporting or refuting existing research. In some cases, they may point to issues that need to be researched further.

To really start to get a sense of what it’s like to be a clinical psychologist, check out these five interesting case studies reported by actual clinicians:

Wishing for Death

Even if you seem to have a promising future, it’s still possible to deal with severe depression. This is what happened to Jessica, a woman who had successfully completed medical school and obtained a residency at a large hospital. In Jessica’s case, her mental state declined seemingly overnight; she awoke one day feeling especially sad. But instead of lifting, that sadness continued and even worsened.

As is the case with many people with depression, Jessica lost interest in things she had previously enjoyed. She stopped having sex with her husband and even found interacting with her children to be a chore. She even found that her job was in jeopardy, as she stopped caring about work and began missing shifts.

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Often, people suffering from severe depression will consider suicide. Some will go as far as making and going through with suicide plans. Jessica wasn’t considering or fantasizing about suicide. But she did begin to wish she was dead, and these thoughts slowly became all-consuming. Despite feeling drained from her low mood, Jessica still had trouble sleeping at night. This is when her thoughts of death were at their worst.

Jessica continued to insist that nothing was wrong. But her coworkers at the hospital saw that something was off. Jessica wasn’t being lazy or slacking for no reason; it was clear her mental health was suffering. Her colleagues were able to convince Jessica to see a mental health professional. She was diagnosed with major depressive disorder, a mental health disorder that causes severe and persistent sadness and loss of interest.

College Struggles

Many mental health issues present themselves when people are college-aged, and this is what happened to Gerry, a 21-year-old college student who got good grades. Gerry got along well with his friends and roommates until he started having trouble sleeping. At night, his thoughts began to race and felt as though they were spinning out of control.

But that wasn’t all. Gerry was usually a kind and mild-mannered person, but he began calling his friends at all hours of the night, becoming angry if they didn’t give him the attention he wanted. Within a few days, Gerry started to believe his roommates were spying on him. He told them as much. Instead of writing it off as simply a quirk, his friends became very concerned. They talked to Gerry and explained the strange changes they’d been seeing in his behavior. Ultimately, they were able to convince Gerry to seek mental health help.

After talking with a clinician, Gerry was ultimately diagnosed with bipolar disorder. It can be an intimidating diagnosis to receive, but Gerry was referred to a psychiatrist who could work with him to find the right medication. The combination of medication and cognitive-behavioral therapy helped him to return back to his normal self.

A Case of Obsession

Plenty of people are fastidious about certain things, but one salesman took it a little too far. The salesman was having trouble leaving his house on time to get to work because he had an overwhelming and obsessive need to follow a set of rituals. Many of them were about securing the home. It started with double-checking and triple-checking that doors were locked.

The salesman also became incredibly worried about the electrical wiring in the home. He began to obsess over whether it would cause an electrical fire. If he didn’t complete the various rituals he felt compelled to do, the man believed he would experience bad luck.

Once he saw a psychologist, the man was diagnosed with obsessive-compulsive disorder. Since this disorder involves holding onto irrational beliefs, cognitive-behavioral therapy is essential. The man’s psychologist worked with him through therapy and helped him to manage and then overcome his obsessive thoughts. Ultimately, the salesman was able to get back to a much more normal life.

Unexpected Panic

Panic disorders and anxiety disorders can seem to poison your life. That’s what it felt like for one forest ranger. Up until his mid-30s, he didn’t suffer from more than normal anxiety. But one day, while standing in line at the grocery store, he suddenly felt an overwhelming wave of panic. His heart rate went up and he started sweating. The panic attack was so bad that the forest ranger thought he would pass out, so he abandoned his shopping cart and returned to the car.

Naturally, the forest ranger didn’t want the same thing to happen again. Because that first panic attack had occurred in a grocery store, he began avoiding supermarkets. But that didn’t help for long. He began to experience intense anxiety in many areas of his life. His symptoms were so severe that his family life began to suffer, so he sought help.

The forest ranger saw a psychologist and was diagnosed with an anxiety disorder. Though some people with anxiety disorders benefit from medication, the forest ranger was able to work through and manage his symptoms through cognitive behavioral therapy.

Bizarre Behaviors

Most severe mental disorders don’t start in childhood. When they do appear, these disorders often involve someone who previously seemed outwardly normal suddenly exhibiting strange behaviors. This is what happened to a 21-year-old business student. He suddenly began becoming agitated for no ostensible reason. During his bouts of agitation, other people heard him whispering angrily to himself.

The young man’s friends and family were very concerned, but they were unable to reach him by phone. He explained that aliens had placed a chip in his brain and that it would explode if he answered his phone.

Sometimes, symptoms like those the young man had can be caused or made worse by abusing alcohol or drugs. However, the young man didn’t abuse either. A family history of mental illness can sometimes be a risk factor, and the man did say he had an aunt who had been treated at psychiatric hospitals several times.

Thanks in part to the concern of his friends and family, the young man talked to a psychologist and gave a detailed account of his symptoms. He was diagnosed with paranoid schizophrenia. This is a difficult diagnosis to receive. But as the young man found, schizophrenia is possible to manage with good care. The young man’s psychologist was able to continue therapy, and he was also referred to a psychiatrist for help with medication. Often, for those diagnosed with paranoid schizophrenia, a combination of therapy and the right medications can effectively manage symptoms.

Each case study psychology above is just a short introduction to the types of cases you may encounter working as a clinical psychologist. And when working in the field, you’ll be asked to write your own case studies, too. While in school, you’ll learn the correct way to write case studies and how sharing case studies with other psychologists can help the field grow as a whole. Hopefully, these case studies have also shed some light on one of the best parts of working as a clinical psychologist — you can help people confront and work through mental health challenges and work toward healthier, happier lives.

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Psychology Case Study Examples: A Deep Dive into Real-life Scenarios

Peeling back the layers of the human mind is no easy task, but psychology case studies can help us do just that. Through these detailed analyses, we’re able to gain a deeper understanding of human behavior, emotions, and cognitive processes. I’ve always found it fascinating how a single person’s experience can shed light on broader psychological principles.

Over the years, psychologists have conducted numerous case studies—each with their own unique insights and implications. These investigations range from Phineas Gage’s accidental lobotomy to Genie Wiley’s tragic tale of isolation. Such examples not only enlighten us about specific disorders or occurrences but also continue to shape our overall understanding of psychology .

As we delve into some noteworthy examples , I assure you’ll appreciate how varied and intricate the field of psychology truly is. Whether you’re a budding psychologist or simply an eager learner, brace yourself for an intriguing exploration into the intricacies of the human psyche.

Understanding Psychology Case Studies

Diving headfirst into the world of psychology, it’s easy to come upon a valuable tool used by psychologists and researchers alike – case studies. I’m here to shed some light on these fascinating tools.

Psychology case studies, for those unfamiliar with them, are in-depth investigations carried out to gain a profound understanding of the subject – whether it’s an individual, group or phenomenon. They’re powerful because they provide detailed insights that other research methods might miss.

Let me share a few examples to clarify this concept further:

• One notable example is Freud’s study on Little Hans. This case study explored a 5-year-old boy’s fear of horses and related it back to Freud’s theories about psychosexual stages.
• Another classic example is Genie Wiley (a pseudonym), a feral child who was subjected to severe social isolation during her early years. Her heartbreaking story provided invaluable insights into language acquisition and critical periods in development.

You see, what sets psychology case studies apart is their focus on the ‘why’ and ‘how’. While surveys or experiments might tell us ‘what’, they often don’t dig deep enough into the inner workings behind human behavior.

It’s important though not to take these psychology case studies at face value. As enlightening as they can be, we must remember that they usually focus on one specific instance or individual. Thus, generalizing findings from single-case studies should be done cautiously.

To illustrate my point using numbers: let’s say we have 1 million people suffering from condition X worldwide; if only 20 unique cases have been studied so far (which would be quite typical for rare conditions), then our understanding is based on just 0.002% of the total cases! That’s why multiple sources and types of research are vital when trying to understand complex psychological phenomena fully.

In the grand scheme of things, psychology case studies are just one piece of the puzzle – albeit an essential one. They provide rich, detailed data that can form the foundation for further research and understanding. As we delve deeper into this fascinating field, it’s crucial to appreciate all the tools at our disposal – from surveys and experiments to these insightful case studies.

Importance of Case Studies in Psychology

I’ve always been fascinated by the human mind, and if you’re here, I bet you are too. Let’s dive right into why case studies play such a pivotal role in psychology.

One of the key reasons they matter so much is because they provide detailed insights into specific psychological phenomena. Unlike other research methods that might use large samples but only offer surface-level findings, case studies allow us to study complex behaviors, disorders, and even treatments at an intimate level. They often serve as a catalyst for new theories or help refine existing ones.

To illustrate this point, let’s look at one of psychology’s most famous case studies – Phineas Gage. He was a railroad construction foreman who survived a severe brain injury when an iron rod shot through his skull during an explosion in 1848. The dramatic personality changes he experienced after his accident led to significant advancements in our understanding of the brain’s role in personality and behavior.

Moreover, it’s worth noting that some rare conditions can only be studied through individual cases due to their uncommon nature. For instance, consider Genie Wiley – a girl discovered at age 13 having spent most of her life locked away from society by her parents. Her tragic story gave psychologists valuable insights into language acquisition and critical periods for learning.

Finally yet importantly, case studies also have practical applications for clinicians and therapists. Studying real-life examples can inform treatment plans and provide guidance on how theoretical concepts might apply to actual client situations.

• Detailed insights: Case studies offer comprehensive views on specific psychological phenomena.
• Catalyst for new theories: Real-life scenarios help shape our understanding of psychology .
• Study rare conditions: Unique cases can offer invaluable lessons about uncommon disorders.
• Practical applications: Clinicians benefit from studying real-world examples.

In short (but without wrapping up), it’s clear that case studies hold immense value within psychology – they illuminate what textbooks often can’t, offering a more nuanced understanding of human behavior.

Different Types of Psychology Case Studies

Diving headfirst into the world of psychology, I can’t help but be fascinated by the myriad types of case studies that revolve around this subject. Let’s take a closer look at some of them.

Firstly, we’ve got what’s known as ‘Explanatory Case Studies’. These are often used when a researcher wants to clarify complex phenomena or concepts. For example, a psychologist might use an explanatory case study to explore the reasons behind aggressive behavior in children.

Second on our list are ‘Exploratory Case Studies’, typically utilized when new and unexplored areas of research come up. They’re like pioneers; they pave the way for future studies. In psychological terms, exploratory case studies could be conducted to investigate emerging mental health conditions or under-researched therapeutic approaches.

Next up are ‘Descriptive Case Studies’. As the name suggests, these focus on depicting comprehensive and detailed profiles about a particular individual, group, or event within its natural context. A well-known example would be Sigmund Freud’s analysis of “Anna O”, which provided unique insights into hysteria.

Then there are ‘Intrinsic Case Studies’, which delve deep into one specific case because it is intrinsically interesting or unique in some way. It’s sorta like shining a spotlight onto an exceptional phenomenon. An instance would be studying savants—individuals with extraordinary abilities despite significant mental disabilities.

Lastly, we have ‘Instrumental Case Studies’. These aren’t focused on understanding a particular case per se but use it as an instrument to understand something else altogether—a bit like using one puzzle piece to make sense of the whole picture!

So there you have it! From explanatory to instrumental, each type serves its own unique purpose and adds another intriguing layer to our understanding of human behavior and cognition.

Exploring Real-Life Psychology Case Study Examples

Let’s roll up our sleeves and delve into some real-life psychology case study examples. By digging deep, we can glean valuable insights from these studies that have significantly contributed to our understanding of human behavior and mental processes.

First off, let me share the fascinating case of Phineas Gage. This gentleman was a 19th-century railroad construction foreman who survived an accident where a large iron rod was accidentally driven through his skull, damaging his frontal lobes. Astonishingly, he could walk and talk immediately after the accident but underwent dramatic personality changes, becoming impulsive and irresponsible. This case is often referenced in discussions about brain injury and personality change.

Next on my list is Genie Wiley’s heart-wrenching story. She was a victim of severe abuse and neglect resulting in her being socially isolated until she was 13 years old. Due to this horrific experience, Genie couldn’t acquire language skills typically as other children would do during their developmental stages. Her tragic story offers invaluable insight into the critical periods for language development in children.

Then there’s ‘Little Hans’, a classic Freudian case that delves into child psychology. At just five years old, Little Hans developed an irrational fear of horses -or so it seemed- which Sigmund Freud interpreted as symbolic anxiety stemming from suppressed sexual desires towards his mother—quite an interpretation! The study gave us Freud’s Oedipus Complex theory.

Lastly, I’d like to mention Patient H.M., an individual who became amnesiac following surgery to control seizures by removing parts of his hippocampus bilaterally. His inability to form new memories post-operation shed light on how different areas of our brains contribute to memory formation.

Each one of these real-life psychology case studies gives us a unique window into understanding complex human behaviors better – whether it’s dissecting the role our brain plays in shaping personality or unraveling the mysteries of fear, language acquisition, and memory.

How to Analyze a Psychology Case Study

Diving headfirst into a psychology case study, I understand it can seem like an intimidating task. But don’t worry, I’m here to guide you through the process.

First off, it’s essential to go through the case study thoroughly. Read it multiple times if needed. Each reading will likely reveal new information or perspectives you may have missed initially. Look out for any patterns or inconsistencies in the subject’s behavior and make note of them.

Next on your agenda should be understanding the theoretical frameworks that might be applicable in this scenario. Is there a cognitive-behavioral approach at play? Or does psychoanalysis provide better insights? Comparing these theories with observed behavior and symptoms can help shed light on underlying psychological issues.

Now, let’s talk data interpretation. If your case study includes raw data like surveys or diagnostic tests results, you’ll need to analyze them carefully. Here are some steps that could help:

• Identify what each piece of data represents
• Look for correlations between different pieces of data
• Compute statistics (mean, median, mode) if necessary
• Use graphs or charts for visual representation

Keep in mind; interpreting raw data requires both statistical knowledge and intuition about human behavior.

Finally, drafting conclusions is key in analyzing a psychology case study. Based on your observations, evaluations of theoretical approaches and interpretations of any given data – what do you conclude about the subject’s mental health status? Remember not to jump to conclusions hastily but instead base them solidly on evidence from your analysis.

In all this journey of analysis remember one thing: every person is unique and so are their experiences! So while theories and previous studies guide us, they never define an individual completely.

Applying Lessons from Psychology Case Studies

Let’s dive into how we can apply the lessons learned from psychology case studies. If you’ve ever studied psychology, you’ll know that case studies offer rich insights. They shed light on human behavior, mental health issues, and therapeutic techniques. But it’s not just about understanding theory. It’s also about implementing these valuable lessons in real-world situations.

One of the most famous psychological case studies is Phineas Gage’s story. This 19th-century railroad worker survived a severe brain injury which dramatically altered his personality. From this study, we gained crucial insight into how different brain areas are responsible for various aspects of our personality and behavior.

• Lesson: Recognizing that damage to specific brain areas can result in personality changes, enabling us to better understand certain mental conditions.

Sigmund Freud’s work with a patient known as ‘Anna O.’ is another landmark psychology case study. Anna displayed what was then called hysteria – symptoms included hallucinations and disturbances in speech and physical coordination – which Freud linked back to repressed memories of traumatic events.

• Lesson: The importance of exploring an individual’s history for understanding their current psychological problems – a principle at the heart of psychoanalysis.

Then there’s Genie Wiley’s case – a girl who suffered extreme neglect resulting in impaired social and linguistic development. Researchers used her tragic circumstances as an opportunity to explore theories around language acquisition and socialization.

• Lesson: Reinforcing the critical role early childhood experiences play in shaping cognitive development.

Lastly, let’s consider the Stanford Prison Experiment led by Philip Zimbardo examining how people conform to societal roles even when they lead to immoral actions.

• Lesson: Highlighting that situational forces can drastically impact human behavior beyond personal characteristics or morality.

These examples demonstrate that psychology case studies aren’t just academic exercises isolated from daily life. Instead, they provide profound lessons that help us make sense of complex human behaviors, mental health issues, and therapeutic strategies. By understanding these studies, we’re better equipped to apply their lessons in our own lives – whether it’s navigating personal relationships, working with diverse teams at work or even self-improvement.

Challenges and Critiques of Psychological Case Studies

Delving into the world of psychological case studies, it’s not all rosy. Sure, they offer an in-depth understanding of individual behavior and mental processes. Yet, they’re not without their share of challenges and criticisms.

One common critique is the lack of generalizability. Each case study is unique to its subject. We can’t always apply what we learn from one person to everyone else. I’ve come across instances where results varied dramatically between similar subjects, highlighting the inherent unpredictability in human behavior.

Another challenge lies within ethical boundaries. Often, sensitive information surfaces during these studies that could potentially harm the subject if disclosed improperly. To put it plainly, maintaining confidentiality while delivering a comprehensive account isn’t always easy.

Distortion due to subjective interpretations also poses substantial difficulties for psychologists conducting case studies. The researcher’s own bias may color their observations and conclusions – leading to skewed outcomes or misleading findings.

Moreover, there’s an ongoing debate about the scientific validity of case studies because they rely heavily on qualitative data rather than quantitative analysis. Some argue this makes them less reliable or objective when compared with other research methods such as experiments or surveys.

To summarize:

• Lack of generalizability
• Ethical dilemmas concerning privacy
• Potential distortion through subjective interpretation
• Questions about scientific validity

While these critiques present significant challenges, they do not diminish the value that psychological case studies bring to our understanding of human behavior and mental health struggles.

Conclusion: The Impact of Case Studies in Understanding Human Behavior

Case studies play a pivotal role in shedding light on human behavior. Throughout this article, I’ve discussed numerous examples that illustrate just how powerful these studies can be. Yet it’s the impact they have on our understanding of human psychology where their true value lies.

Take for instance the iconic study of Phineas Gage. It was through his tragic accident and subsequent personality change that we began to grasp the profound influence our frontal lobes have on our behavior. Without such a case study, we might still be in the dark about this crucial aspect of our neurology.

Let’s also consider Genie, the feral child who showed us the critical importance of social interaction during early development. Her heartbreaking story underscores just how vital appropriate nurturing is for healthy mental and emotional growth.

Here are some key takeaways from these case studies:

• Our brain structure significantly influences our behavior.
• Social interaction during formative years is vital for normal psychological development.
• Studying individual cases can reveal universal truths about human nature.

What stands out though, is not merely what these case studies teach us individually but collectively. They remind us that each person constitutes a unique combination of various factors—biological, psychological, and environmental—that shape their behavior.

One cannot overstate the significance of case studies in psychology—they are more than mere stories or isolated incidents; they’re windows into the complexities and nuances of human nature itself.

In wrapping up, I’d say that while statistics give us patterns and trends to understand groups, it’s these detailed narratives offered by case studies that help us comprehend individuals’ unique experiences within those groups—making them an invaluable part of psychological research.

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Psychology and Psychotherapy Case Examples

Our clinical psychologists and psychotherapists here at evidence-based therapy centre work with people to improve their emotional, psychological, and physical health..

The following are examples of how attending therapy helped to facilitate meaningful changes in people’s lives.  

Julie’s experience of depression

Read how Julie’s low mood and lack of motivation meant that she risked losing her job and friends and how a focused course of treatment helped turn things around.

Joe’s experience of pain

Read how Joe’s panic attacks led him to avoid things that might trigger another one and how therapy helped him reduce his anxiety and get his life back on track.

Gerry’s experience of bipolar disorder

Read how Gerry learned to recognise and manage signs and symptoms of relapse in bipolar disorder.

Anna and Brian’s experience of relationship difficulties

Read how Couples Therapy helped Brian and Anna to build a happier future together.

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Clinical Case Studies in Psychoanalytic and Psychodynamic Treatment

This manuscript provides a review of the clinical case study within the field of psychoanalytic and psychodynamic treatment. The method has been contested for methodological reasons and because it would contribute to theoretical pluralism in the field. We summarize how the case study method is being applied in different schools of psychoanalysis, and we clarify the unique strengths of this method and areas for improvement. Finally, based on the literature and on our own experience with case study research, we come to formulate nine guidelines for future case study authors: (1) basic information to include, (2) clarification of the motivation to select a particular patient, (3) information about informed consent and disguise, (4) patient background and context of referral or self-referral, (5) patient's narrative, therapist's observations and interpretations, (6) interpretative heuristics, (7) reflexivity and counter-transference, (8) leaving room for interpretation, and (9) answering the research question, and comparison with other cases.

Introduction

Psychoanalysis has always been, according to its inventor, both a research endeavor and a therapeutic endeavor. Furthermore it is clear from Freud's autobiography that he prioritized the research aspect; he did not become a doctor because he wished to cure people in ill health (Freud, 2001 [1925] ). His invention of the psychoanalytic approach to therapy, involving the patient lying down and associating freely, served a research purpose as much as a therapeutic purpose. Through free association, he would be able to gain unique insight in the human mind. Next, he had to find a format to report on his findings, and this would be the case study. The case study method already existed in medicine (Forrester, 2016 ), but Freud adjusted it considerably. Case studies in medical settings were more like case files, in which the patient was described or reduced to a number of medical categories: the patient became a case of some particular ailment (Forrester, 2016 ). In Freud's hands, the case study developed into Kranken Geschichten in which the current pathology of the patient is related to the whole of his life, sometimes even over generations.

Although Freud's case studies have demonstrably provided data for generations of research by analysts (Midgley, 2006a ) and various scholars (Pletsch, 1982 ; Sealey, 2011 ; Damousi et al., 2015 ), the method of the case study has become very controversial. According to Midgley ( 2006b ), objections against the case study method can be grouped into three arguments. First there is the data problem: case studies provide no objective clinical data (Widlöcher, 1994 ), they only report on what went right and disregard any confusion or mistakes (Spence, 2001 ). Second, there is the data analysis problem: the way in which the observations of the case study are analyzed lack validity; case studies confirm what we already know (Spence, 2001 ). Some go even so far to say that they are purely subjective: Michels calls case studies the “crystallization of the analyst's countertransference” (Michels, 2000 , p. 373). Thirdly, there is the generalizability problem: it is not possible to gain generalizable insight from case studies. Reading, writing and presenting case studies has been described as being a group ritual to affirm analysts in their professional identity, rather than a research method (Widlöcher, 1994 ).

These criticisms stand in contrast to the respect gained by the case study method in the last two decades. Since the 1990s there has been an increasing number of psychoanalytic and psychodynamic clinical case study and empirical case studies being published in scientific journals (Desmet et al., 2013 ; Cornelis et al., in press ). It has also been signaled that the case study method is being revived more broadly in the social sciences. In the most recent, fifth edition of his seminal book on case study research, Yinn ( 2014 ) includes a figure showing the steady increase of the frequency with which the term “case study research” appears in published books in the period from 1980 to 2008.

KEY CONCEPT 1

Clinical case study.

A clinical case study is a narrative report by the therapist of what happened during a therapy together with the therapist's interpretations of what happened. It is possible that certain (semi)-structured assessment instruments, such as a questionnaire or a diagnostic interview are included in clinical case studies, yet it is still the therapist that uses these, interprets and discusses them.

KEY CONCEPT 2

Empirical case studies.

In an empirical case study data are gathered from different sources (e.g., self-report, observation,…) and there is a research team involved in the analyses of the data. This study can take place either in a naturalistic setting (systematic case study) or in a controlled experimental environment (single-case experiment).

In addition to the controversy about the case study method, psychoanalysis has developed into a fragmented discipline. The different psychoanalytic schools share Freud's idea of the unconscious mind, but they focus on different aspects in his theoretical work. Some of the schools still operate under the wings of the International Psychoanalytic Association, while others have established their own global association. Each school is linked to one or several key psychoanalysts who have developed their own version of psychoanalysis. Each psychoanalytic school has a different set of theories but there are also differences in the training of new psychoanalysts and in the therapeutic techniques that are applied by its proponents.

Based on this heterogeneity of perspectives in psychoanalysis, a research group around the Single Case Archive investigated the current status of case study research in psychoanalysis (Willemsen et al., 2015a ). They were particularly interested to know more about the output and methodology of case studies within the different psychoanalytic schools.

KEY CONCEPT 3

Single case archive.

The Single Case Archive is an online archive of published clinical and empirical case studies in the field of psychotherapy ( http://www.singlecasearchive.com ). The objective of this archive is to facilitate the study of case studies for research, clinical, and teaching purposes. The online search engine allows the identification of sets of cases in function of specific clinical or research questions.

Our survey among case study authors about their psychoanalytic school

In order to investigate and compare case studies from different psychoanalytic schools, we first had to find a way of identifying to which school the case studies belonged. This is very difficult to judge straightforwardly on the basis of the published case study: the fact that someone cites Winnicott or makes transference interpretations doesn't place him or her firmly within a particular psychoanalytic school. The best approach was to ask the authors themselves. Therefore, we contacted all case study authors included in the Single Case Archive (since the time of our original study in 2013, the archive has expanded). We sent emails and letters in different languages to 445 authors and received 200 replies (45% response rate). We asked them the following question: “ At the time you were working on this specific case, to which psychoanalytic school(s) did you feel most attached? ” Each author was given 10 options: (1) Self Psychology (1.a Theory of Heinz Kohut, 1.b Post-Kohutian Theories, 1.c Intersubjective psychoanalysis), (2) Relational psychoanalysis, (3) Interpersonal psychoanalysis, (4) Object relational psychoanalysis (4.a Theory of Melanie Klein, 4.b Theory of Donald W. Winnicott, 4.c Theory of Wilfred R. Bion, 4.d Theory of Otto F. Kernberg), (5) Ego psychology (or) “Classic psychoanalysis” (5.a Theories of Sigmund Freud, 5.b Ego psychology, 5.c Post-Ego psychology), (6) Lacanian psychoanalysis, (7) Jungian psychoanalysis, (8) National Psychological Association for Psychoanalysis (NPAP) related theory, (9) Modern psychoanalysis related to the Boston or New York Graduate School of Psychoanalysis (BGSP/NYGSP), (10) Other. Respondents could indicate one or more options.

Analysis of the responses indicated that the two oldest schools in psychoanalysis, Object-relations psychoanalysis and Ego psychology, dominate the field in relation to case studies that are published in scientific journals. More than three quarters of all case study authors (77%) reported these schools of thought to be the ones with which they considered themselves most affiliated. Three more recent schools were also well-represented among case studies: Self Psychology, Relational Psychoanalysis, and Interpersonal Psychoanalysis. Lacanian Psychoanalysis, Jungian Psychoanalysis, NPAP related Theory and Modern Psychoanalysis related to the BGSP/NYGSP were only rarely mentioned by case study authors as their school of thought. This does not mean that clinicians or researchers within these latter schools do not write any case studies. It only means that they publish few case studies in the scientific journals included in ISI-ranked journals indexed in Web of Science. But they might have their own journals in which they publish clinical material.

Our survey demonstrated that the majority of case study authors (59%) feel attached to more than one psychoanalytic school. This was in fact one of the surprising findings in our study. It seems that theoretical pluralism is more rule than exception among case study authors. There were some differences between the psychoanalytic schools though in terms of pluralism. Case study authors who feel attached to Self Psychology and Interpersonal Psychoanalysis are the most pluralistic: 92 and 86%, respectively also affiliate with one or more other psychoanalytic schools. Case study authors who feel attached to Object Relations Psychoanalysis are the “purest” group: only 69% of them affiliate with one or more other psychoanalytic schools.

KEY CONCEPT 4

Theoretical pluralism.

A situation in which several, potentially contradicting, theories coexist. It is sometimes interpreted as a sign of the immaturity of a science, under the assumption that a mature science should arrive at one single coherent truth. Others see theoretical pluralism as unavoidable for any applied discipline, as each theory can highlight only part of reality.

Psychoanalytic pluralism and the case study method

We were not really surprised to find that Object Relations psychoanalysis and Ego psychology were the most dominant schools in the field of psychoanalytic case studies, as they are very present in European, Latin-American and North-American psychoanalytic institutes. We were more surprised to find such a high degree of pluralism among these case study authors, given the fact that disputes between analysts from different schools can be quite ardent (Green, 2005 ; Summers, 2008 ). Others have compared the situation of psychoanalytic schools with the Tower of Babel (Steiner, 1994 ).

It has been argued that the case study method contributes to the degree of theoretical pluralism within psychoanalysis. The reason for this is situated in the reasoning style at the basis of case study research (Chiesa, 2010 ; Fonagy, 2015 ). The author of a psychoanalytic case study makes a number of observations about the patient within the context of the treatment, and then moves to a conclusion about the patient's psychodynamics in general. The conclusion he or she arrives at inductively gains its “truth value” from the number and quality of observations it is based on. This style of reasoning in case study research is very similar to how clinicians reason in general. Clinicians look for patterns within patients and across patients. If they make similar observations in different patients, or if other psychoanalysts make similar observations in their patients, the weight of the conclusion becomes greater and greater. The problem with this reasoning style is that one can never arrive at definite conclusions: even if a conclusion is based on a large number of observations, it is always possible that the next observation disconfirms the conclusion. Therefore, it could be said, it is impossible to attain “true” knowledge.

The above argument is basically similar to objections against any kind of qualitative research. To this, we argue with Rustin ( 2003 ) that there is not one science and no hierarchy of research methods. Each method comes with strengths and weaknesses, and what one gains in terms of control and certainty in a conventional experimental setup is lost in terms of external validity and clinical applicability. Numerous researchers have pleaded for the case study approach as one method among a whole range of research methods in the field of psychoanalysis (Rustin, 2003 ; Luyten et al., 2006 ; Midgley, 2006b ; Colombo and Michels, 2007 ; Vanheule, 2009 ; Hinshelwood, 2013 ). Leuzinger-Bohleber makes a distinction between clinical research and extra-clinical research (Leuzinger-Bohleber, 2015 ). Clinical research is the idiographic type of research conducted by a psychoanalyst who is working with a patient. Unconscious phantasies and conflicts are symbolized and put into words at different levels of abstraction. This understanding then molds the perception of the analyst in subsequent clinical situations; even though the basic psychoanalytic attitude of “not knowing” is maintained. The clinical case study is clinical research par excellence . Extra-clinical research consists in the application of different methodologies developed in the natural and human sciences, to the study of the unconscious mind. Leuzinger-Bohleber refers to empirical psychotherapy research, experimental research, literature, cultural studies, etc. We believe that the clinical case study method should step up and claim its place in psychoanalytic research, although we agree that the method should be developed further. This paper and a number of others such as Midgley ( 2006b ) should facilitate this methodological improvement. The clinical research method is very well-suited to address any research question related to the description of phenomena and sequences in psychotherapy (e.g., manifestation and evolution of symptoms and therapeutic relationship over time). It is not suitable for questions related to causality and outcome.

We also want to point out that there is a new evolution in the field of psychotherapy case study research, which consists in the development of methodologies for meta-studies of clinical case studies (Iwakabe and Gazzola, 2009 ). The evolution builds on the broader tendency in the field of qualitative research to work toward integration or synthesis of qualitative findings (Finfgeld, 2003 ; Zimmer, 2006 ). The first studies which use this methodology have been published recently: Widdowson ( 2016 ) developed a treatment manual for depression, Rabinovich ( 2016 ) studied the integration of behavioral and psychoanalytic treatment interventions, and Willemsen et al. ( 2015b ) investigated patterns of transference in perversion. The rich variety of research aims demonstrates the potential of these meta-studies of case studies.

KEY CONCEPT 5

Meta-studies of clinical case studies.

A meta-study of clinical case studies is a research approach in which findings from cases are aggregated and more general patterns in psychotherapeutic processes are described. Several methodologies for meta-studies have been described, including cross-case analysis of raw data, meta-analysis, meta-synthesis, case comparisons, and review studies in general.

Lack of basic information in psychoanalytic case studies

The second research question of our study (Willemsen et al., 2015a ) concerned the methodological, patient, therapist, and treatment characteristics of published psychoanalytic case studies. All studies included in the Single Case Archive are screened by means of a coding sheet for basic information, the Inventory of Basic Information in Single Cases (IBISC). The IBISC was designed to assess the presence of basic information on patient (e.g., age, gender, reasons to consult), therapist (e.g., age, gender, level of experience), treatment (e.g., duration, frequency, outcome), and the methodology (e.g., therapy notes or audio recoding of sessions). The IBISC coding revealed that a lot of basic information is simply missing in psychoanalytic case studies (Desmet et al., 2013 ). Patient information is fairly well-reported, but information about therapist, treatment and methodology are often totally absent. Training and years of experience are not mentioned in 84 and 94% of the cases, respectively. The setting of the treatment is not mentioned in 61% of the case studies. In 80% of the cases, it was not mentioned whether the writing of the case studies was on the basis of therapy notes, or audiotapes. In 91% of the cases, it was not mentioned whether informed consent was obtained.

Using variables on which we had more comprehensive information, we compared basic information of case studies from different psychoanalytic schools. This gave us a more detailed insight in the type of case studies that have been generated within each psychoanalytic school, and into the difference between these schools in terms of the kind of case study they generate. We found only minimal differences. Case studies in Relational Psychoanalysis stand out because they involve older patients and longer treatments. Case studies in Interpersonal Psychoanalysis tend to involve young, female patients and male therapists. Case study authors from both these schools tend to report on intensive psychoanalysis in terms of session frequency. But for the rest, it seems that the publication of case studies throughout the different psychoanalytic schools has intensified quite recently.

Guidelines for writing clinical case studies

One of the main problems in using psychoanalytic case studies for research purposes is the enormous variability in quality of reporting and inconsistency in the provision of basic information about the case. This prevents the reader from contextualizing the case study and it obstructs the comparison of one case study with another. There have been attempts to provide guidelines for the writing of case studies, especially in the context of analytic training within the American Psychoanalytic Association (Klumpner and Frank, 1991 ; Bernstein, 2008 ). However, these guidelines were never enforced for case study authors by the editors from the main psychoanalytic journals. Therefore, the impact of these guidelines on the field of case study research has remained limited.

Here at the end of our focused review, we would like to provide guidelines for future case study authors. Our guidelines are based on the literature and on our experience with reading, writing, and doing research with clinical case studies. We will include fragments of existing case studies to clarify our guidelines. These guidelines do not provide a structure or framework for the case study; they set out basic principles about what should be included in a case study.

Basic information

First of all, we think that a clinical case study needs to contain basic information about the patient, the therapist, the treatment, and the research method. In relation to the patient , it is relevant to report on gender, age (or an age range in which to situate the patient), and ethnicity or cultural background. The reader needs to know these characteristics in order to orientate themselves as to who the patient is and what brings them to therapy. In relation to the therapist , it is important to provide information about professional training, level of professional experience, and theoretical orientation. Tuckett ( 2008 ) emphasizes the importance for clinicians to be explicit about the theory they are using and about their way of practicing. It is not sufficient to state membership of a particular group or school, because most groups have a wide range of different ways of practicing. In relation to the treatment itself, it is important to be explicit about the kind of setting, the duration of treatment, the frequency of sessions, and details about separate sequences in the treatment (diagnostic phase, follow-up etc.). These are essential features to share, especially at a time when public sector mental health treatment is being subjected to tight time restrictions and particular ways of practising are favored over others. For example short-term psychotherapies are being implemented in public services for social and economic reasons. While case studies carried out in the public sector can give us information on those short-term therapies, private practice can offer details about the patient's progress on a long-term basis. Moreover, it is important to report whether the treatment is completed. To our astonishment, there are a considerable number of published case studies on therapies that were not finished (Desmet et al., 2013 ). As Freud ( 2001 [1909] , p. 132) already advised, it is best to wait till completion of the treatment before one starts to work on a case study. Finally, in relation to the research method , it is crucial to mention which type of data were collected (therapy notes taken after each session, audio-recordings, questionnaires, etc.), whether informed consent was given, and in what way the treatment was supervised. Clinicians who would like to have help with checking whether they included all necessary basic information case use the Inventory for Basic Information in Single Cases (IBISC), which is freely available on http://www.singlecasearchive.com/resources .

Motivation to select a particular patient

First of all, it is crucial to know what the motivation for writing about a particular case comes from. Some of the following questions should be kept in mind and made explicit from the beginning of the case presentation. Why is it interesting to look at this case? What is it about this case or the psychotherapist's work that can contribute to the already existing knowledge or technique?

“This treatment resulted in the amelioration of his [obsessive-compulsive] symptoms, which remained stable eight years after treatment ended. Because the standard of care in such cases has become largely behavioral and pharmacological, I will discuss some questions about our current understanding of obsessive-compulsive phenomena that are raised by this case, and some of the factors that likely contributed to the success of psychoanalytic treatment for this child (McGehee, 2005 , p. 213–214).”

This quotation refers to a case that has been selected on the basis of its successful outcome. The author is then interested to find out what made this case successful.

Informed consent and disguise

As regulations on privacy and ethics are becoming tighter, psychotherapists find themselves with a real problem in deciding what is publishable and what is not. Winship ( 2007 ) points out that there is a potential negative effect of research overregulation as clinicians may be discouraged from reporting ordinary and everyday findings from their clinical practice. But he also offers very good guidelines for approaching the issue of informed consent. A good practice is asking for consent either at the start of the treatment or after completion of the treatment: preferably not during treatment. It is inadvisable to complete the case study before the treatment has ended. It is also advisable that the process of negotiating consent with the patient is reported in the case study.

“To be sure that Belle's anonymity was preserved, I contacted her while writing this book and told her it would not be published without her complete approval. To do this, I asked if she would review every word of every draft. She has (Stoller, 1986 , p. 217).”

In relation to disguise, one has to strike a balance between thin and thick disguise. Gabbard ( 2000 ) suggests different useful approaches to disguising the identity of the patient.

Patient background and context of referral or self-referral

It is important to include relevant facts about the patient's childhood, family history, siblings, any trauma or losses and relationship history (social and romantic) and the current context of the patient's life (family, working, financial). The context of referral is also key to understanding how and why the patient has come to therapy. Was the patient encouraged to come or had wanted to come? Has there been a recent crisis which prompted the intervention or an on-going problem which the patient had wanted to address for some time?

“Michael was one of the youngest children in his family of origin. He had older brothers and sisters who had been received into care before his birth. His parents separated before he was born. There had been some history of violence between them and Michael was received into care on a place of safety order when he was an infant because his mother had been unable to show consistent care toward him (Lykins Trevatt, 1999 , p. 267).”

Patient's narrative, therapist's observations, and interpretations

A case study should contain detailed accounts of key moments or central topics, such as a literal transcription of an interaction between patient and therapist, the narration of a dream, a detailed account of associations, etc. This will increase the fidelity of the case studied, especially when both patient's and therapist's speech are reported as carefully as possible.

“Martha spoke in a high-pitched voice which sounded even more tense than usual. She explained that her best friend's mum had shouted at her for being so withdrawn; this made her angry and left her feeling that she wanted to leave their home for good. I told Martha that she often tried to undo her bad feelings by acting quickly on her instincts, as she did not feel able to hold her feelings in her mind and bring them to her therapy to think about with me. Martha nodded but it was not clear whether she could really think about what I just said to her. She then said that she was being held in the hospital until a new foster placement could be found. “In the meantime,” she said in a pleased tone, “I have to be under constant supervision” (Della Rosa, 2015 , p. 168).”

In this example, observations of nonverbal behavior and tonality are also included, which helps to render a lively picture of the interaction.

Interpretative heuristics

In which frame of reference is the writer operating? It is important to know what theories are guiding the therapist's thinking and what strategies he employs in order to deal with the clinical situation he is encountering. Tuckett ( 1993 ) writes about the importance of knowing what “explanatory model” is used by the therapist in order to make sense of the patient and to relate his own thinking to a wider public for the purpose of research. This idea is also supported by Colombo and Michels ( 2007 ) who believe that making theoretical orientations as explicit as possible would make the case studies intelligible and more easily employed by the research community. This can be done by the therapists explaining why they have interpreted a particular situation in the way they have. For example, Kegerreis in her paper on time and lateness (2013) stresses throughout how she is working within the object-relations framework and looking out for the patient's use of projective mechanisms.

“She was 10 minutes late. Smiling rather smugly to herself she told me that the wood supplied for her new floor had been wrongly cut. The suppliers were supposed to come and collect it and hadn't done so, so she had told them she was going to sell it to a friend, and they are now all anxious and in a hurry to get it. I said she now feels as if she has become more powerful, able to get a response. She agrees, grinning more, telling me she does have friends who would want it, that it was not just a ploy. She said she had found it easier to get up today but was still late. I wondered if she had a sense of what the lateness was about. She said it was trying to fit too much in. She had been held up by discussing the disposal of rubble with her neighbors. I said I thought there was a link here with the story about the wood. In that she had turned the situation around. She had something that just didn't work, had a need for something, but it was turned around into something that was the suppliers' problem. They were made to feel the urgency and the need. Maybe when she is late here she is turning it around, so it is me who is to be uncertain and waiting, not her waiting for her time to come. We maybe learn here something of her early object relationships, in which being in need is felt to be unbearable, might lead to an awful awareness of lack and therefore has to be exported into someone else. One could go further and surmise that in her early experience she felt teased and exploited by the person who has the power to withhold what you need (Kegerreis, 2013 , p. 458).”

There can be no doubt reading this extract about the theoretical framework which is being used by the therapist.

Reflexivity and counter-transference

A good case study contains a high degree of reflexivity, whereby the therapist is able to show his feelings and reactions to the patient's communication in the session and an ability to think about it later with hindsight, by himself or in supervision. This reflexivity needs to show the pattern of the therapist's thinking and how this is related to his school of thought and to his counter-transferential experiences. How has the counter-transference been dealt with in a professional context? One can also consider whether the treatment has been influenced by supervision or discussion with colleagues.

“Recently for a period of a few days I found I was doing bad work. I made mistakes in respect of each one of my patients. The difficulty was in myself and it was partly personal but chiefly associated with a climax that I had reached in my relation to one particular psychotic (research) patient. The difficulty cleared up when I had what is sometimes called a ‘healing’ dream. […] Whatever other interpretations might be made in respect of this dream the result of my having dreamed it and remembered it was that I was able to take up this analysis again and even to heal the harm done to it by my irritability which had its origin in a reactive anxiety of a quality that was appropriate to my contact with a patient with no body (Winnicott, 1949 , p. 70).”

Leaving room for interpretation

A case study is the therapist's perspective on what happened. A case study becomes richer if the author can acknowledge aspects of the story that remain unclear to him. This means that not every bit of reported clinical material should be interpreted and fitted within the framework of the research. There should be some loose ends. Britton and Steiner ( 1994 ) refer to the use of interpretations where there is no room for doubt as “soul murder.” A level of uncertainty and confusion make a case study scientifically fruitful (Colombo and Michels, 2007 ). The writer can include with hindsight what he thinks he has not considered during the treatment and what he thinks could have changed the course for the treatment if he had been aware or included other aspects. This can be seen as an encouragement to continue to be curious and maintain an open research mind.

Answering the research question, and comparison with other cases

As in any research report, the author has to answer the research question and relate the findings to the existing literature. Of particular interest is the comparison with other similar cases. Through comparing, aggregating, and contrasting case studies, one can discover to what degree and under what conditions, the findings are valid. In other words, the comparison of cases is the start of a process of generalization of knowledge.

“Although based on a single case study, the results of my research appear to concur with the few case studies already in the field. In reviewing the literature on adolescent bereavement, it was the case studies that had particular resonance with my own work, and offered some of the most illuminating accounts of adolescent bereavement. Of special significance was Laufer's ( 1966 ) case study that described the narcissistic identifications of ‘Michael’, a patient whose mother had died in adolescence. Both Laufer's research and my own were conducted using the clinical setting as a basis and so are reflective of day-to-day psychotherapy practice (Keenan, 2014 , p. 33).”

As Yinn ( 2014 ) has argued for the social sciences, the case study method is the method of choice when one wants to study a phenomenon in context, especially when the boundaries between the phenomenon and the context are fussy. We are convinced that the same is true for case study methodology in the fields of psychoanalysis and psychotherapy. The current focused review has positioned the research method within these fields, and has given a number of guidelines for future case study researchers. The authors are fully aware that giving guidelines is a very tricky business, because while it can channel and stimulate research efforts it can as well-limit creativity and originality in research. Moreover, guidelines for good research change over time and have to be negotiated over and over again in the literature. A similar dilemma is often pondered when it comes to qualitative research (Tracy, 2010 ). However, our first impetus for providing these guidelines is pedagogical. The three authors of this piece are experienced psychotherapists who also work in academia. A lot of our students are interested in doing case study research with their own patients, but they struggle with the methodology. Our second impetus is to improve the scientific credibility of the case study method. Our guidelines for what to include in the written account of a case study, should contribute to the improvement of the quality of the case study literature. The next step in the field of case study research is to increase the accessibility of case studies for researchers, students and practitioners, and to develop methods for comparing or synthesizing case studies. As we have described above, efforts in that direction are being undertaken within the context of the Single Case Archive.

Author contributions

JW has written paragraphs 1–4; ER and JW have written paragraph 5 together; SK has contributed to paragraph 5 and revised the whole manuscript.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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“You’re Ugly and Bad!“: a path analysis of the interplay between self-criticism, alexithymia, and specific symptoms

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• Published: 17 September 2024

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• Carolina Papa 1 ,
• Francesca D’Olimpio 2 ,
• Vittoria Zaccari 2 , 3 , 4 ,
• Micaela Di Consiglio 1 , 2 ,
• Francesco Mancini 3 , 4 &
• Alessandro Couyoumdjian   ORCID: orcid.org/0000-0003-4973-4091 1  

Self-criticism is a transdiagnostic factor of significant clinical relevance. Research has studied its detrimental role on mental health without discriminating how this differs based on individual psychological functioning. Furthermore, little research has considered the lack of emotional awareness as an essential competence that contributes to dysfunctional self-critical processes and, consequently, to psychopathological outcomes. The objective of the study was to investigate how different forms of self-criticism are associated with specific symptoms, considering social anxiety, obsessive-compulsive, and eating disorder symptoms. Furthermore, we wanted to explore the role of alexithymia in this relationship. The sample comprised 564 subjects (M = 35.12, SD = 12.8), 389 females and 175 males. Participants completed online questionnaires to investigate levels of self-criticism, alexithymia, and specific symptoms. Hierarchical regression and path analyses showed that aspects of self-criticism have different importance in psychopathological features. Furthermore, the subscales of alexithymia differently mediate the relationship between self-criticism and symptomatological features, depending on the type of feature considered (social anxiety, eating or obsessive-compulsive). In light of the results, since self-criticism is a contributing factor to the onset and maintenance of many mental disorders, it becomes important to distinguish its specific characteristics and how they are linked to the disorders. A better understanding of these processes would help to prepare more targeted interventions.

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Introduction

Self-criticism and symptomatology.

The transdiagnostic approach to psychopathology aims to identify all those psychological processes that cut across different symptom profiles and contribute to the etiology and maintenance of different disorders (Andersen et al., 2016 ). One of the transdiagnostic processes with more significant clinical implications is self-criticism, a mode of thinking aimed at self-evaluation and self-analysis rooted in human experience that becomes dysfunctional when it takes the form of a pervasive hostile internal dialogue aimed at self-accusation and self-persecution (Gilbert et al., 2004 ). In this meaning, self-criticism reflects a global devaluation of self, driven by an irrational belief whereby the individuals define themselves as entirely negative in their totality as human beings, regardless of situation and context (Ellis, 1962 ). Self-criticism has shown an increasing intersection with various psychopathologies. Self-criticism predicts depression, eating, and anxiety symptomatology severity over time, and it is also associated with several other forms of psychopathology and symptoms, such as bipolar disorder, suicidal behaviors, and self-injurious behaviors (Werner et al., 2019 ). Self-criticism is also significantly associated with worse therapeutic outcomes (Loew et al., 2020 ), playing a considerable role in the therapeutic process. The relevance of self-criticism in various disorders is explained by the fact that negative self-evaluation intensifies emotional reactivity in the face of setbacks and failures, increasing symptomatology. Several theories have been proposed to explain self-criticism and its role in psychological vulnerability. Among the best-known is the model of Blatt and colleagues (Blatt, 2008 ). It distinguishes between two fundamental dimensions of personality development: self-definition , which refers to the development of a person’s identity focused on differentiation from others (i.e., introjective personality), and interpersonal relatedness , which implies the individual’s ability to develop deep relationships (i.e., anaclitic personality). According to Blatt ( 2008 ), self-criticism is a sub-dimension of self-definition and implies a strong emphasis on control, autonomy, and achieving personal goals and high standards. Research has shown that the self-critical personality is associated with shame, guilt, self-directed and hetero-directed anger, then expressed towards others, concern about the inability to function, and loneliness, but with not such a clear differentiation between symptom patterns in the two dimensions (Marfoli et al., 2021 ). Dunkley et al. ( 2003 ) introduce the concept of self-criticism in relation to the idea of perfectionism ( self-critical perfectionism ), which incorporates Blatt’s ( 1974 ) construct but focuses on how responses to stressful events impact distress. According to the author, in self-critical perfectionism, there is constant and severe self-examination accompanied by concern about one’s inability to handle stressful situations, which leads the individual to disengage using avoidance coping that increases self-denigration and leads to chronic dysphoria (Dunkley & Blankstein, 2000 ). Shahar ( 2015 ) proposes a model called the “Axis of Criticism Model” that originates from psychoanalytic and psychodynamic theory: the author defines self-criticism as a tendency to set unrealistically high standards for oneself that, when not met, lead to the adoption of a self-punishing attitude. The model postulates that self-criticism arises from the criticism expressed by the parent and the child’s subsequent failure to develop adequate self-knowledge. According to Shahar ( 2015 ), distorted self-knowledge would impede the expression of one’s authenticity, leading, along with criticism expressed by others, to the development of greater self-criticism (Lassri & Shahar, 2012 ). Also, from a developmental perspective, Thompson and Zuroff ( 2004 ) identified and operationalized two levels of self-criticism. The first level refers to comparative self-criticism (CSC), which focuses on the unfavorable comparison of self with others seen as superior or critical. The second level is internalized self-criticism (ISC), defined as a poor view of oneself about internal and personal standards that tend to be high. Several studies have found an association between these two forms of self-criticism and depression, suggesting that the tendency to self-criticism might develop through two different pathways: an interpersonal one, according to which perceived parental criticism generates a cognitive vulnerability to criticism made by others, and an internalized one, according to which children might directly learn to relate to themselves in the same way their parents related to them (Manfredi et al., 2016 ). The effect of self-criticism in the onset and maintenance of psychopathology has led research to study the phenomenon from a clinical perspective. Such models failed to capture the phenomenology of self-criticism, which appears to present itself heterogeneously in patients, suggesting that it could manifest itself in different subtypes and functions (Castilho et al., 2015 ). In this regard, Gilbert et al. ( 2004 ) hypothesized the existence of different forms of self-criticism: the inadequate-self , which concerns a sense of inadequacy and inferiority due to the idea of having failed and focuses on the idea of having to correct or improve certain aspects of oneself, and the hated-self , characterized by feelings of disgust and contempt towards oneself, focuses on the desire to attack and punish oneself (Castilho et al., 2015 ). Finally, they identify an alternative form of self-report - the reassured-self - reflecting a compassionate attitude towards oneself, allowing acceptance and understanding of failure as part of human frailty (Gilbert et al., 2004 ). Self-criticism becomes pathogenic when it is linked to powerful negative emotions of anger and disgust directed at oneself and the inability to activate self-relaxation systems in the face of failure or setbacks (Gilbert et al., 2004 ). Several studies have confirmed the distinction between these forms of self-criticism, concluding that the hated-self is the most harmful form as it is more persistent than the inadequate-self , shows stronger correlations with depressive symptoms, and is more resistant to psychotherapeutic treatment (Werner et al., 2019 ). Both the forms of the inadequate-self and the hated-self are associated with eating disorder symptoms (Palmeira et al., 2017 ), while in social anxiety, inadequate-self appears to predominate (Shahar et al., 2015 ). The multiplicity of existing theoretical models highlights how self-criticism can constitute a heterogeneous and multidimensional phenomenon with specific characteristics that can be analyzed from various points of view and according to different perspectives. In fact, these theories should not be conceived as opposing each other, but rather attempt to grasp different features of the phenomenon. Despite the clinical relevance of self-criticism and its relation to various symptom patterns, there is currently a lack of a comprehensive examination that takes into account its different aspects as they are articulated in the various psychopathological profiles (e.g., anxiety disorders, obsessive-compulsive disorder, eating disorders). Making this distinction would increase knowledge about the variables associated with the most harmful forms of self-criticism and its specific characteristics based on the patient’s symptoms, with important implications for clinical practice.

Self-criticism and alexithymia

Failures or setbacks may generate intense anger towards oneself for letting oneself down or making oneself vulnerable to others, and self-criticizing or directing hostility towards oneself rather than outwardly may be considered safer (Castilho et al., 2015 ). Indeed, the individual’s patterns of interpreting life situations can generate dysfunctional responses and promote self-critical states, such as unforgiving standards and punitiveness (Kannan & Levitt, 2013 ). Some authors hypothesize that a highly self-critical thinking style may prevent individuals from allowing themselves the time necessary to reflect on their emotions (Gilbert et al., 2011 ), helping them to modulate these emotions quickly. Indeed, self-criticism has been studied as a cognitive regulation strategy that individuals can use to prevent or reduce their emotional distress in emotionally activating situations (Kamholz et al., 2006 ). Several studies have found an association between alexithymia and self-criticism (Speranza et al., 2005 ; Akariya et al., 2022 ), suggesting that individuals who have a poor ability to explore emotions lack compassion and kindness towards themselves (Gilbert et al., 2011 ). Indeed, individuals with better emotional awareness use complex and specific strategies to regulate their emotions, leading to a lower likelihood of developing depressive self-criticism than those who use simple and general strategies (Pascual-Leone et al., 2016 ). One of the best-known interventions for reducing self-criticism is the two-chair dialogue (Young et al., 2003 ), which allows the patient, through a simulated dialogue between the patient’s critical and criticized parts, to stay with the complicated feelings and process them instead of avoiding them. Consistent with the idea that self-criticism is a mechanism used to regulate unpleasant emotions, it is possible to hypothesize that chairwork reduces self-criticism by enhancing emotional awareness, cognitive restructuring and needs satisfaction related to such emotions. These assumptions concerning cognitive and emotional processes of change in self-critical individuals lead to considering the lack of emotional awareness as an essential element that predisposes the individual to engage in maladaptive regulation strategies. Alexithymia is a multidimensional construct that refers to a set of cognitive and affective characteristics concerning the difficulty in how individuals experience and express their emotions (Sifneos, 1973 ). Alexithymia includes difficulty identifying and distinguishing emotions from bodily sensations, communicating emotions to others, and an outwardly oriented cognitive style (Bagby et al., 1994 ). The causal relationship between self-criticism and alexithymia remains uncertain. Several authors conceptualize self-criticism as a process that hinders emotional awareness because it leads the individual to avoid adverse emotional states or, on the contrary, to focus more on them in a counterproductive way, which makes it difficult to identify them (Lumley, 2000 ). Others, on the other hand, postulate that people with higher levels of alexithymia, such as difficulty discerning between emotions and physical states, experience feelings of inadequacy that are reinforced by self-directed criticism (Speranza et al., 2005 ), conceptualizing the difficulty in identifying emotions as a predictor of the self-critical trait. Indeed, by preventing individuals from understanding what they feel and why they feel it, alexithymia leads to uncertainty that can lead to low self-efficacy and consequent inadequacy. Alexithymia is also a transdiagnostic factor that co-occurs in various clinical conditions such as somatic symptom disorders (De Gucht & Heiser, 2003 ), anxiety disorders (Berardis et al., 2008 ), and eating disorders (Westwood et al., 2017 ). Given the relevance of emotional awareness as an essential competence that favors implementing adaptive emotional regulation strategies, it would be necessary to investigate how the difficulty in getting in touch with one’s inner emotional world is linked to implementing maladaptive self-critical processes.

The current study

Although self-criticism is a construct that cuts across different clinical phenotypes (Werner et al., 2019 ), the different conceptualizations result in a significant gap in terms of clarity in its definition. In light of its heterogeneity and multidimensionality, self-criticism could include certain peculiarities that are differentially declined depending on the psychological functioning of individuals. For example, considering the typical functioning profiles of certain mental disorders, it is possible to hypothesize that there will be differences between the criticisms made by an individual who presents with eating disorder symptoms and by one who presents with social anxiety. In the first case, we know there is a link between high standards and perfectionism (Flett & Hewitt, 2002 ); in the second a fear related to the possible negative judgment of the other and an overestimation of social standards (Hofmann & Scepkowski, 2006 ): therefore, self-criticism concerning eating disorder symptoms may be related to an ideal objective the individual has failed to achieve. In contrast, anxiety within social relationships is related to a standard that the individual perceives in the other with whom they are confronted and compared to which they perceive themselves as inadequate or inferior. Moreover, in obsessive-compulsive symptomatology we can imagine that self-criticism has moral characteristics in relation to the fear of guilt arising from the idea of having caused harm for which the individual feels responsible (Mancini et al., 2021 ). A recent meta-review highlighted several studies that emphasize the need to better understand the mechanisms of self-criticism and psychopathology by considering individual differences, but despite this, no studies have drawn conclusions on this (Zaccari et al., 2024 ). Indeed, research to date has only considered the role of self-criticism in promoting or maintaining specific psychopathological outcomes without discriminating between these. The present study aims to analyze the relationship between different forms of self-criticism and specific symptomatologies to make an initial differentiation between the different ways people criticize themselves. This would also make it possible to test the validity of currently existing theories in discriminating aspects of self-criticism that measure different constructs through the questionnaires derived from them. Therefore, consistent with the hypothesis that psychopathological phenomena and mechanisms occur as a spectrum of symptoms that can emerge in different patterns from the core pathology (Simonsen, 2010 ), this research intends to investigate the link between self-criticism and different symptom patterns within the general population, considering these characteristics as factors along a psychopathological continuum. Based on our hypothesis, we expect to take the first step towards a classification of the different forms of self-criticism according to the subject’s psychological functioning: in particular, we expect to be able to distinguish how self-criticism is expressed differently according to specific symptom profiles, taking into consideration eating, obsessive-compulsive and social anxiety symptoms. We consider these profiles of psychological functioning as representative of certain peculiar characteristics that differ in terms of beliefs about oneself and others and in terms of the goals relevant to the individual. Consequently, this allows us to explore the different declinations of self-criticism regarding content and function. In individuals who present higher scores in social anxiety, we expect the subject to compare their own characteristics with those of others rather than with an ideal self and, consequently, to find comparative self-criticism , i.e. characterized by a feeling of inferiority with respect to the other who is considered better (Thompson & Zuroff, 2004 ). In addition, we should expect a greater presence of the inadequate-self than the hated-self , consistent with Clark and Wells’ ( 1995 ) cognitive model of SAD, which states that in social anxiety, there are excessively high standards for social performance and persistent negative self-beliefs about one’s own inadequacy regarding social evaluation. Similarly, we expect to find more internalized self-criticism in eating symptomatology, in which we know there is a tendency towards clinical perfectionism and high self-imposed standards (Flett & Hewitt, 2002 ), and feelings of hated-self , consistent with a more destructive relationship with the self and also associated with body image shame and weight-related self-worth (Palmeira et al., 2017 ). In obsessive-compulsive symptomatology, which is characterized by a propensity to fear guilt arising from irresponsibility (Mancini et al., 2021 ), we expect the individual to adopt a punitive attitude towards themselves due to the idea of not having met a high moral standard, for which we hypothesize high feelings of hated-self and self-punishment. This hypothesis also aligns with research investigating the relationship between self-criticism and hoarding, finding that a sense of responsibility potentiates the severity of obsessive symptoms (Chou et al., 2018 ). From their findings, the authors inferred that individuals with greater self-criticism and shame may feel a greater sense of responsibility and a greater fear of harm. In doing so, in the light of the relationship between self-criticism and alexithymia (Speranza et al., 2005 ; Akariya et al., 2022 ), we want to test the contribution of alexithymia in determining the specific self-critical modalities, considering the forms of alexithymia most associated with the symptoms assessed. Several studies indicate an association between obsessive-compulsive functioning and externally-oriented thinking, which would result in poor insight and symbolic capacity (Berardis et al., 2008 ), suggesting that this cognitive style characterized by the constriction of imaginative activity could be a relevant aspect in obsessive-compulsive disorder that the individual uses to cope with emotional stress. We hypothesize that externally-oriented thinking may be a contributing factor in the development of obsessive symptoms that the individual uses to avoid getting in touch with negative self-hating beliefs that lead them to self-attack. Similarly, the relationship between eating symptomatology and difficulty identifying emotions is well-established in the literature (Westwood et al., 2017 ), including difficulty recognizing emotions from faces (Zonnevijlle-Bendek et al., 2002 ). This finding also applies to individuals with sub-clinical eating disorder symptoms (Ridout et al., 2010 ) and provides evidence in support of the fact that difficulty in emotional introspection underlies dysfunctional eating and body-related behaviors. The difficulty in identifying internal and external emotional states could be related to using concrete and rigid criteria to define what ‘is good’ and to the reinforcement of eating disorder symptoms. So, we hypothesize that the inability to recognize emotions contributes substantially to defining a self-critical mode oriented by high personal standards. Lastly, several clinical studies have found positive correlations between alexithymia and social anxiety (Panayiotou et al., 2020 ), but it is the difficulty in identifying and communicating feelings that is predictive of anxiety and avoidance (Dalbudak et al., 2013 ). We, therefore, wondered whether the difficulty in recognizing and verbalizing one’s emotions with others does not act as a factor that maintains and reinforces beliefs of inadequacy about oneself and the resulting negative self-evaluation, hypothesizing a contribution of alexithymia in fostering social anxiety. Investigating the role of alexithymia makes it possible to assess the construct of self-criticism in its function of regulating unpleasant emotions.

A non-probabilistic convenience sampling method was used for this study. The study consisted of 564 participants from the general population, 175 males and 389 females (M = 35.12, SD = 12.8). 4.1% of the sample had a middle school diploma, 39% a high school diploma, 18.3% a bachelor’s degree, 24.1% a master’s degree, and 14.5% a postgraduate degree. The participants fulfilled the following inclusion criteria: age 18 or older, good knowledge of the Italian language, education level of secondary school or higher, and easy access to the Internet. All subjects who met these criteria were then included, including those with a diagnosis of a psychological disorder, sub-clinical conditions, or no psychological problems at all. Only individuals with suicidal ideation or diagnosed with clinically severe disorders (e.g., schizophrenic spectrum disorders and other psychotic disorders, bipolar and related disorders, dissociative disorders) were excluded from the sample. The presence or absence of a diagnosis was based on what the participant declared in the demographic form.

The participants, recruited from the general population, completed a survey lasting about 20 min. Recruitment took place by word of mouth and sharing information on the main social networks (e.g., Facebook, Instagram). Recruitment took place through the sharing of the study by the research managers, who were assisted by collaborators and provided with sampling guidelines to balance the age groups, gender, and socio-economic status of the subjects to be recruited. Some participants voluntarily accessed the research via the access link shared on social networks, while others received the link via WhatsApp or text message. Informed consent was obtained via electronic means prior to survey completion. Furthermore, in compliance with Legislative Decree No. 196 of 30 June 2003, the “Personal Data Protection Code” (which adapts Italian data protection legislation to the new provisions of the GDPR) guaranteed the participants’ anonymity. Prior to survey completion, participants completed a demographic form requesting information regarding their gender, age, nationality, city of residence, educational qualification, occupation, marital status, presence of psychological, psychiatric, or organic diagnosis, standardized questionnaires aimed at investigating levels of self-criticism, alexithymia, and the presence of specific symptomatology.

Two instruments were used to assess the different forms of self-criticism. The Forms of Self-Criticizing/Attacking and Self-Reassuring Scale (Gilbert et al., 2004 ; Italian adaptation by Petrocchi & Couyoumdjian, 2016 ) is a 22-item instrument that consists of three subscales: self-reassurance ( reassured-self ; FSCRS-RS) which assesses the ability to be self-assured and regard oneself with kindness and compassion, and two types of self-criticism inadequate-self (FSCRS-IS), which assesses feelings of inadequacy and a sense of irritation and frustration with oneself, and hated-self (FSCRS-HS), which assesses a more extreme form of self-criticism characterized by feelings of self-repugnance and a desire to hurt oneself in response to failures and setbacks. Sample items for inadequate-self include “ there is a part of me that feels I am not good enough ” or “ I can’t accept failures and setbacks without feeling inadequate ”, while hated-self’s subscale includes items such as “ I do not like being me ” or “ I have a sense of disgust with myself ”. In the study, we only included the subscales evaluating the inadequate-self and the hated-self . These scales indeed measure the presence of a negative critical self and have the strongest associations with psychopathological factors. Cronbach’s alpha ranges from 0.86 to 0.90 for the three subscales (Gilbert et al., 2004 ). Adequate levels of internal consistency (α between 0.76 and 0.91) and construct validity were found for all subscales in the Italian version (Petrocchi & Couyoumdjian, 2016 ). In our sample, Cronbach’s alpha value was 0.76 for the hated-self subscale and 0.89 for the inadequate-self subscale.

Furthermore, the Levels of Self-Criticism Scale (Thompson & Zuroff, 2004 ; Italian adaptation by Manfredi et al., 2016 ) was used: it is a questionnaire consisting of 22 items that measures two different forms of negative self-evaluation, comparative self-criticism ( Comparative Self-Criticism -CSC) and internalized self-criticism ( Internalized Self-Criticism -ISC). The CSC refers to a negative view of oneself compared to others, focusing on the unfavorable comparison between oneself and others, seen as superior, hostile, or critical (a sample item is “ I often worry that other people will find out what I’m really like and be upset with me ”). The other level of self-criticism, ISC, on the other hand, is characterized by a negative view of self in comparison to internalized personal standards (a sample item is “I’m very frustrated with myself when I don’t meet the standards I have for myself ”). These internal standards are high and result in chronic failure to meet them. At this level, the focus is on viewing oneself as inadequate. In the original validation study, Cronbach’s alpha was 0.88 for ISC and 0.84 for CSC (Thompson & Zuroff, 2004 ). The Italian version of the Level of Self-Criticism Scale showed good reliability (Manfredi et al., 2016 ), and in our sample, Cronbach’s alpha for ISC was 0.87 and 0.73 for CSC.

The presence of eating disorder symptoms was assessed using the Eating Attitudes Test (Garner et al., 1982 ; Italian validation by Dotti & Lazzari, 1998 ). EAT-26 is a questionnaire designed to capture the psychological traits and symptoms characteristic of eating disorders. The individuals are asked to indicate how often they engage in certain behaviors, e.g. “ Avoid foods with sugar in them ”, or experience certain feelings, e.g. “ Feel extremely guilty after eating ”, about food. The test consists of 3 subscales: dieting, bulimia and food preoccupation, and oral control. Cronbach’s alpha in the Italian validation study was 0.86 for the total score, while in our sample it was 0.83.

The Obsessive-Compulsive Inventory-Revised (Foa et al., 1998 ; Italian validation by Sica et al., 2009 ) was used to quantify the main dimensions that characterize obsessive-compulsive disorder. It consists of 18 items belonging to seven subscales: Washing, Checking, Doubting, Ordering, Obsessing, Hoarding, and Mental Neutralizing. Sample items include “ I need things to be arranged in a particular way ”, “I collect things I don’t need ”, and “ I check things more often than necessary ”. In the Italian validation, Cronbach’s alpha for the OCI-R was 0.85; in our study, it was 0.88 for the total score.

Fear or anxiety of one or more social situations in which the individual is subject to possible judgment was assessed using the Social Interaction Anxiety Scale (Mattick & Clarke, 1998 ; Italian validation by Sica et al., 2007 ), which measures discomfort in meeting and talking with other people, be they friends, members of the opposite sex, or strangers. Primary concerns include fear of being unable to express oneself, appearing dull or stupid, not knowing what to say or how to respond, and being ignored. It consists of 20 items that investigate the fear of interacting in social situations and measure the emotional aspects of anxiety. On a 5-point Likert scale, the subject rates how well he or she feels in line with each proposed item (e.g. “ I find it difficult to disagree with another’s point of view ”, “ I feel I’ll say something embarrassing when talking ”). Cronbach’s alpha in the Italian validation study was 0.86 for the total score, while in our sample, it was 0.91.

The multidimensional construct of alexithymia was assessed through the use of TAS-20 (Toronto Alexithymia Scale-20; Bagby et al., 1994 ; Italian validation by Bressi et al., 1996 ). It consists of a self-report questionnaire composed of 20 items and three subscales: difficulty identifying feelings, difficulty communicating feelings, and externally oriented thinking. The difficulty in identifying feelings is investigated through items such as “ When I am upset I don’t know if I am sad , frightened , or angry ”and “ I don’t know what’s going on inside me ”. Difficulty in communicating feelings is investigated by items such as “ It is difficult for me to find the right words for my feelings ” and “ People tell me to describe my feelings more ”. Finally, externally-oriented thinking includes items such as “ I prefer talking to people about their daily activities rather than their feelings ” and “ I prefer to just let things happen rather than to understand why they turned out that way ”. TAS-20 also provides a total score indicating the absence or presence of alexithymia. The three subscales of the TAS-20 had a Cronbach’s alpha value of .77 for difficulty in identifying feelings, .67 for difficulty in describing feelings, and .52 for externally oriented thinking. In the current study, however, the alpha value was .84 for the first factor, .78 for the second factor, and .62 for the third factor. For our study, we used the individual subscales of the FSCRS, LOSCS, and TAS-20 questionnaires, as they were the main variables of interest for which we formulated specific hypotheses. On the contrary, we used the total scores of the SIAS, OCI-R, and EAT-26 questionnaires as we aimed to investigate the mechanisms of self-criticism and alexithymia in their relationship with these variables considering the psychological profile and not the specific symptomatological phenomenology of each disorder considered. The coefficient α, ω, skewness, and kurtosis values for the variables used in the study are shown in Table  1 .

Statistical analysis

Statistical analyses were conducted using the Jamovi software version 2.3.28. All data were initially screened for missing data and outliers. The relationship among the variables was tested using Pearson’s correlation analysis ( p  < .05). Three hierarchical linear regression models were estimated to analyze the relationship between the specific forms of self-criticism and the symptomatologies considered, with social anxiety, obsessive-compulsive, and eating disorder symptoms as dependent variables and the different forms of self-criticism as independent variables, respectively. The following were included as independent variables: in the first block, the dimensions of hated-self and inadequate-self (Gilbert et al., 2004 ); in the second block, the dimensions of internalized and comparative self-criticism (Thompson & Zuroff, 2004 ). We did not include the form of the reassured-self because our goal was to discriminate between the negative forms of self-criticism that can take on pathological characteristics and constitute mental health risk factors. The order of the predictors was assessed based on the finding that the dimensions of the Gilbert scale are most strongly associated with symptomatology, with hated-self in particular (Werner et al., 2019 ) and that internalized self-beliefs are especially important in explaining the development of symptomatology (Aafjes-van Doorn et al., 2020 ). In contrast, the object with which the self confronts themself (e.g. “ I am usually uncomfortable in social situations where I don’t know what to expect” ) is less explanatory of its psychological functioning and presupposes a mental action that we hypothesize to be subsequent a negative belief about the self (e.g. “ there is a part of me that thinks I’m not good enough”). Secondly, to determine how alexithymia was involved in determining the specific self-critical modalities, the dimensions of alexithymia most associated in the literature with the symptoms considered (DIF and DDF for social anxiety and eating symptoms, EOT for obsessive-compulsive symptomatology) were included in the third block of the linear regression model. Finally, a path analysis (PATHj module, Jamovi project) was performed to assess the effects of significant predictors of self-criticism and alexithymia on each outcome (Figs.  1 , 2 and 3 ). To assess the model fit we used the following indices: the Chi-square (χ 2 ), the root mean square error of approximation (RMSEA) with 95% confidence intervals, the comparative fit index (CFI), the Tucker-Lewis index (TLI), and the standardized root mean square residual (SRMR) index. The model fit is acceptable when it results in a non-significant χ 2 value, a RMSEA value < 0.08, CFI and TLI values > 0.95, and a SRMR value < 0.05. Furthermore, the results were composed of indirect and direct effects. Indirect effects were the relationships between the independent and dependent variables operating through the intermediate variables; direct effects were the relationships between the independent (both exogenous and endogenous) and dependent variables. All effects were standardized coefficients estimated through maximum likelihood. Path analysis was performed using a sequential approach. The forms of self-criticism that contributed most to predicting symptomatology were considered independent (exogenous) variables, the remaining forms of self-criticism and alexithymia were considered intermediate variables, and symptomatology was considered the dependent variable.

Descriptive statistics are reported in Table  1 . All variables were approximately normally distributed, except for hated-self and eating disorders (skewness and kurtosis > 1). However, according to Hair et al. ( 2010 ) and Bryne ( 2010 ) we can consider values between − 2 and + 2 for skewness and − 7 and + 7 for kurtosis in an acceptable range for normal distribution. Bivariate correlations for the main constructs under investigation are reported in Table  2 . Correlation analyses showed that all dimensions of self-criticism (both from FSCRS and LOSC) were associated with each of the symptomatologies considered. The TAS dimensions (total and subscales) are positively correlated with social anxiety, obsessive-compulsive, eating disorder symptoms, and self-criticism in general. Otherwise, the externally-oriented thinking subscale is not related to eating disorder symptoms, internalized self-criticism (LOSC) and inadequate-self (FSCRS).

The hierarchical regression analyses (Table 3 ) revealed that self-criticism (FSCRS alone) explain 25% of the variance of social anxiety, and the introduction of internalized and comparative forms of self-criticism (LOSC) add further 11% of explained variance for social anxiety. Finally, in the third step, a further 3% is explained, with TAS dimensions. In the last model, three variables predict social anxiety, namely inadequate-self (FSCRS), comparative self-criticism (LOSC), and difficulty in communicating feelings (TAS). Interestly, comparative self-criticism seems to partially mediate the relation between both hated and inadequate-self and social anxiety (step 2) and difficulty in communicating feelings appears to be a full mediator between hated-self and social anxiety and partially mediate between comparative self-criticism and social anxiety. As for OCI, the FSCRS subscales explain the 15% of the total OCI scores variance at the first step, and only a further 1%, increases when adding LOSC subscales. At the end, externally-oriented thinking (TAS) contributed an additional 2% of the variance. In this case, at last there are two predictors of OCI scores, that are hated-self and externally-oriented thinking. In other words, looking at the single steps, we can observe that comparative self-criticism mediates between inadequate-self and OCI scores and EOT mediates the relation between comparative self-criticism and OCI scores. Furthermore, eating symptomatology scores are explained in the first block from both hated-self and inadequate-self, explaining 13% of the variance. When LOSC self-criticism scales were included (step 2), variance explained increased by 2%, with comparative self-criticism as significant predictors. In the third step TAS subscales resulted in a further 1% of explained variance. In this last step, hated-self, comparative self-criticism, and difficulty identifying emotions result in significant predictors.

Building upon the findings from regression analyses, we tested three models through path analysis on the pattern relation among self-criticism (both FSCRS and LOSC), alexithymia and psychopathological characteristics (social anxiety, eating, obsessive compulsive).

Figure  1 shows the first path analysis model relating to social anxiety symptomatology. The overall model showed a good fit: χ 2 (2) = 3.66, p  = .161, RMSEA = 0.038 (95% CI [0.00, 0.10]; SRMR = 0.01; CFI = 0.99; TLI = 0.98. Figure  1 presents the standardized path coefficients. The results of the path analysis showed that hated-self has an indirect positive relationship with social anxiety symptomatology through comparative self-criticism and difficulty communicating feelings with a mediation effect (β = 0.01, z = 3.22, p  = .001) but also an indirect effect through difficulty communicating feelings (β = 0.02, z = 2.30, p  < .001). Similarly, the inadequate-self also shows an indirect effect of sequential mediation with social anxiety symptomatology through comparative self-criticism and difficulty communicating feelings (β = 0.02, z = 3. 87, p  < .001) and an indirect effect through alexithymia (β = 0.15, z = 6.21, p  < .001), but there is also a direct relationship between this form of self-criticism and the considered symptomatology (β = 0.22, z = 5.47, p  < .001). The results of the second path analysis model, presented in Fig.  2 , relating to obsessive-compulsive symptomatology, showed an acceptable fit: χ 2 (1) = 3.65, p  = .056; RMSEA = 0.07 (95% CI [0.00, 0.15]; SMRM = 0.013; CFI = 0.993; TLI = 0.941. Hated-self showed a positive indirect effect on obsessive-compulsive symptomatology through comparative self-criticism and externally-oriented thinking (β = 0.009, z = 2.53, p  = .01) and a positive direct effect on symptomatology (β = 0.21, z = 3.99, p  < .001). The inadequate-self, however, was found to have a positive indirect relationship with obsessive symptomatology through comparative self-criticism and externally oriented thinking (β = 0.02, z = 2.37, p  = .018) and a positive direct relationship with the dependent variable (β = 0.21, z = 4.19, p  < .001). Path analysis on eating symptomatology is presented in Fig.  3 . The model shows a good fit: χ 2 (1) = 2.05, p  = .152; RMSEA = 0.04 (95% CI [0.00, 0.13], SMRM = 0.008; CFI = 0.998; TLI = 0.981. The path model showed that hated-self has a positive indirect effect on symptomatology both through comparative self-criticism (β = 0.04, z = 2.90, p  = .004, that through the latter and the difficulty in identifying emotions (β = 0.005, z = 2.10, p  = .03), as well as a direct effect on the dependent variable of the model (β = 0.19, z = 4.03, p < .001). The inadequate-self revealed three positive indirect effects on eating symptomatology but no direct effects. The first was with a sequential effect through comparative self-criticism and difficulty identifying feelings (β = 0.009, z = 2.25, p  = .02), the second only through comparative self-criticism (β = 0.07, z = 3.35, p  < .001), the third only through difficulty identifying feelings (β = 0.02, z = 2.16, p  = .03), but all paths were significant.

Path diagram for social anxiety. Note:  Standardized solution

Path diagram for obsessive-compulsive symptoms. Note:  Standardized solution

Path diagram for eating symptoms. Note:  Standardized solution

Discussion and conclusions

The study aimed to discriminate between different forms of self-criticism depending on the specific symptomatology, considering obsessive-compulsive, eating, and social anxiety symptoms. In this case, our hypothesis was confirmed since the results show that for each outcome, only specific predictors of self-criticism are significant. Furthermore, a further objective was to evaluate how the dimensions of alexithymia most associated with the symptoms contributed to discriminating the forms of self-criticism, hypothesizing that it would be possible to outline specific paths between these factors in determining the outcomes. This also makes it possible to assess whether self-criticism can be regarded as a strategy for regulating emotions about a poor ability to understand and be in touch with them. Correlation analyses confirm the significant association of symptomatology with self-criticism and a relative inability to generate feelings of warmth, acceptance, and self-consolation towards oneself. The association between alexithymia and different psychopathological functioning is also consistent with research data suggesting that alexithymia is associated with greater vulnerability to mental illness (Leweke et al., 2011 ). However, our data also support the multidimensionality of the construct of alexithymia, indicating differences in the association of externally-oriented thinking with some forms of self-criticism (i.e., internalized self-criticism and inadequate-self) and with some outcomes (i.e., eating symptomatology). This result may also be due to the fact that the EOT scale tends to have poor internal consistency (ω = 0.58), with some items having low factor loadings (Kooiman et al., 2002 ). This finding is, moreover, in line with a recent systematic review on alexithymia in eating disorders, which found that in several studies, there was no significant difference in the EOT scale between the control group and the clinical group (Westwood et al., 2017 ), while the lack of association between some internalized forms of self-criticism and externally-oriented thinking seems consistent with conceptualizations of the constructs where on the one hand there is attention to one’s internal view of self as lacking (Thompson & Zuroff, 2004 ), on the other hand, a lack of introspection (Kooiman et al., 2002 ). Our results indicate that there are direct and indirect effects of specific forms of self-criticism and alexithymia that help to explain specific symptomatic outcomes. The forms of self-criticism of the hated-self and the inadequate-self (Gilbert et al., 2004 ) appear to be significant in the first block of the multiple linear regression models for all examined symptoms, not initially allowing for the discrimination of specific forms of self-criticism by outcomes, probably also because the participants did not suffer from established psychological disorders. The first discrimination begins when internalized and comparative forms of self-criticism are included in the second block (Thompson & Zuroff, 2004 ), confirming that the various questionnaires assess different dimensions of the complex construct of self-criticism (Werner et al., 2019 ). Considering each symptomatology individually, it is observed that for social anxiety symptomatology, the associated forms of self-criticism are the inadequate-self , the hated-self (Gilbert et al., 2004 ), and comparative self-criticism (Thompson & Zuroff, 2004 ). However, when difficulty identifying and describing feelings are included in the model (Bagby et al., 1994 ), just inadequate-self and comparative self-criticism remain significant predictors. This result is in line with the initial hypotheses and consistent with the typical characteristics of individuals who experience anxiety in social situations. These individuals fear being criticized, ridiculed, and, consequently, excluded because of their inadequacy and incapacity (Gragnani et al., 2021 ). Individuals representing themselves as socially inept or strange may attempt to compensate for this belief about themselves through the imposition of very high standards to avoid failures that would lead them to be evaluated negatively by others (Frost et al., 2010 ). This is also consistent with the path analysis results, from which a direct effect of the inadequate-self emerges, indicative of feelings of shame, inferiority, and a sense of defect, on social anxiety. About alexithymia, it has been shown that alexithymic individuals experience feelings of inadequacy and distrust at the interpersonal level (Courty et al., 2015 ). In our research, it was found that the dimension relating to difficulty in verbalizing and describing feelings can predict the symptoms of social anxiety significantly. Furthermore, this represents a mediator between self-criticism and anxious symptoms. A study by Suslow et al. ( 2000 ) showed that the TAS-20 factor related to difficulties in describing feelings does not primarily measure a deficit in symbolization but shame anxiety, and shyness. Furthermore, this scale was associated with several measures of shame, consistent with these individuals’ reluctance to make contact with others for fear of being humiliated. This shows that underlying this factor is not a difficulty in emotional expression per se but rather a readiness to experience social shame (Suslow et al., 2000 ), an emotion that is very much present in social anxiety.It is possible, therefore, that starting from criticism directly addressed to the self regarding their sense of inferiority and inadequacy, the individual begins to compare themselves with another who is perceived as more adequate and that this increases the sense of shame and the consequent difficulty to communicate with others, fueling the symptoms of social anxiety. On the contrary, it is possible that the difficulty in expressing oneself acts as a confirmation of one’s inability and leads the person to increase self-criticism, predisposing one more to the development of anxiety symptoms. Indeed, even in post-event processing in social anxiety, one can see a bias in the processes of retrospective reenactment in which the individuals re-evaluate their social performance by feeling inferior to others. Thus, self-criticism in social anxiety seems to take on peculiar characteristics by regulating the unprocessed, scornful emotions arising from a sense of inadequacy and defectiveness about others.

Obsessive-compulsive symptomatology showed in the second block of the regression analysis a significant association with hated-self and comparative self-criticism. However, when externally-oriented thinking was included in the model, in line with our hypothesis, this symptomatology was significantly associated with hated-self, in contrast to other forms of self-criticism, except for the inadequate-self, which was marginally significant. Obsessive persons aim to prevent or neutralize guilt (Stewart & Shapiro, 2011 ), and the main feared threat consists of moral debasement of the self and the consequent deservedly contemptuous attitudes of others (Mancini et al., 2021 ). Self-hatred represents an enduring, dysfunctional, destructive self-evaluation characterized by attributions of undesirable qualities and failure to meet perceived standards and values (Turnell et al., 2019 ). It is plausible to think that this feeling is present in people who have fear of transgressing an introjected moral standard: in fact, deontological guilt sensitivity tends to reduce the perception of one’s moral worth (Mancini et al., 2021 ), leading the individual to feel ‘dirty’ or ‘disgusting.’ Catastrophic appraisal of the possibility of feeling morally unworthy combined with early experiences of unpredictable punishments based on severing the relationship with the parent (Mariaskin, 2009 ) may lead these individuals to feel they deserve the self-persecution typical of feelings of unworthiness. Concrete thinking, characterized by low imaginative activity and a notable absence of imagination, may be relevant in persons with obsessive-compulsive functioning and may be oriented towards avoiding intrusive and unwanted images that cause distress. In fact, the EOT subscale, which is most connected to this symptomatology according to the literature (Berardis et al., 2008 ) and also shows stability over time (Rufer et al., 2006 ), seems to evaluate a tendency towards cognitive avoidance. In support of this, utilitarian thinking is positively associated with emotional detachment (Lander et al., 2012 ), indicating that this cognitive strategy could function in avoiding experiencing certain types of unpleasant emotions. In the path analysis, both hated-self and the inadequate-self had direct effects on obsessive-compulsive symptoms. This finding is consistent with the idea that a belief in oneself as defective or morally disgusting, added to a personal expectation of performing inadequately in subjectively perceived important outcomes, can lead to increased control over one’s behavior (Mancini et al., 2004 ). From what emerges in the second step of the hierarchical regression and the significance of hated-self and externally-oriented thinking in predicting obsessive-compulsive symptomatology, it could be that the tendency to prefer situations or activities that do not contain emotionally charged content could be a coping used by these subjects to defend themselves against the threat of perceiving themselves as disgusting and unworthy. Interestingly, the inadequate-self , not the hated-self , positively predicts externally-oriented thinking. If the latter is conceived as a strategy for regulating unwanted emotional states, such negative feelings towards the self of the hated-self prevent individuals from enacting the cognitive-emotional avoidance that would help them function better, leading to the preferred strategy of self-attack. This finding could further prove to explain the persistence of the hated-self (Werner et al., 2019 ). An unexpected result concerns the association of comparative self-criticism and its mediating effect with this symptomatology. A possible explanation is the conceptualization of comparative self-criticism, defined as a sense of inferiority in relational terms (Thompson & Zuroff, 2004 ). Considering that this construct is also compared to socially prescribed perfectionism (Flett & Hewitt, 2002 ), it may represent a mechanism in obsessive symptomatology guided by the vision of others as people who impose severe and unreasonable demands on themselves. Therefore, in obsessive functioning, self-criticism seems to take the peculiar form of self-persecution that the individual enacts to regulate unpleasant emotions exacerbated by the attempt to avoid and detach from them.

Our hypotheses about eating disorder symptoms were only partially confirmed. This functioning is more associated with hated-self, inadequate-self, and comparative self-criticism but not with internalized self-criticism. In line with Gilbert’s (Gilbert et al., 2004 ) theoretical model, according to which the self-critical person is based on dominant-submissive relational models, control and mastery in eating disorders may result in a feeling of less obligation to take into account the expectations of others as if it were a declaration of autonomy. Indeed, hated-self may result from an over-investment in the goal of not being fat, which in the mind of the person suffering from an eating disorder coincides with vulgarity, contempt, and immorality (Basile et al., 2021 ). To be fat is to be unworthy, disgusting, and deserving of blame. The rigidity of thought typical of psychological functioning in eating disorders is based on a system of self-evaluation founded on incredibly wasteful control strategies (Dalle Grave, 2012 ) but functional for maintaining a sense of worth. The perceived contrast between the ideal self and the authentic self would suggest the presence of internalized self-criticism. In contrast, the results reveal that comparative self-criticism significantly predicts eating disorder symptoms. This result can be explained because, in recent years, especially in the Western countries where the study occurred, increased exposure to social media directly influences body image (Meier & Gray, 2014 ). Indeed, such use leads to an increase in unfavorable social comparison, in which individuals attribute high characteristics to others against which they do not measure up and experience dissatisfaction (Marks et al., 2020 ). The use of social media, in short, leads individuals to self-evaluate themselves through comparison with others and determines the appearance and maintenance of food-related behaviors. Therefore, social comparison is more the criterion by which the individual evaluates themselves in eating disorder symptoms than the comparison with an internalized ideal self. Interestingly, the results of the model change when the variables related to the difficulty in identifying and verbalizing emotions are included: in fact, hated-self loses predictive power, remaining only a marginally significant effect, and only the difficulty in identifying feelings seems to show a strong association with eating disorder symptoms. Although in the literature, both dimensions of alexithymia are known to be associated with eating disorder symptoms (Westwood et al., 2017 ), in our study, which included the investigation of self-criticism, only the first dimension showed a strong association with such psychological functioning. The family environment of people presenting with eating disorder symptoms is usually characterized by viewing emotions as unacceptable and as something that should not be experienced or expressed, leading to a decrease in coping skills and engagement in eating control or body-centered behaviors designed to manage emotions (Corstorphine, 2006 ). The path analysis shows the direct effects of negative self-beliefs related to hated-self and inadequate-self on the difficulty in identifying emotions. However, only hated-self directly affected eating disorder symptoms, confirming the hypothesis that overestimation of weight and body shape is associated with a critical relationship with oneself with the strategy of attacking or punishing oneself for one’s shortcomings. It is possible to explain the path that emerged as if, starting from such a defective and disgusting idea of ​themselves, the person compares themselves critically with others using an external criterion of an aesthetic type. This leads them never to acquire an internal criterion that allows them to recognize their emotional states or physical sensations (such as hunger or tiredness), fueling the symptoms of food control. On the contrary, the lack of emotional awareness could favor control strategies that are never considered up to the standards imposed, favoring self-criticism, as if the two processes influenced and reinforced each other, resulting in increased symptoms and worse mental health. In summary, in eating symptomatology, self-criticism takes on the characteristics of self-persecution and disadvantageous comparison with others in light of the difficulty in identifying one’s internal states.

The study’s results identified how different forms of self-criticism are associated with specific symptomatologies. In fact, according to the psychological characteristics present in social anxiety, obsessive-compulsive, and eating disorders, self-criticism seems to take on peculiar characteristics depending on the beliefs about oneself and the function it has to fulfill. Furthermore, the findings support the relationship between a lack of emotional awareness and dysfunctional emotional regulation strategies, leading one to consider self-criticism as a mode individuals use to manage unpleasant emotions. Such evidence raises an essential question regarding the approach to studying self-criticism and its relationship with psychopathology. The results also suggest that the forms of self-criticism identified by Gilbert et al. ( 2004 ) have the power to explain the attitude individuals have toward themselves as a factor that predisposes and maintains symptomatology in various types of functioning. Thompson & Zuroff’s ( 2004 ) theory, although it does not capture the relevant aspect concerning the individual function that self-criticism assumes, allows us to add a piece in its light of the disadvantageous comparison with others that seems to act as maintenance for various symptomatologies. In contrast, the internalized self-criticism did not show predictive power on any of the symptomatologies considered, raising a question about the scale’s ability to capture the construct it intends to measure. In conclusion, as self-criticism is a heterogeneous and multidimensional construct for which a clear and unambiguous definition is lacking (Zaccari et al., 2024 ), it is of paramount importance to be able to distinguish its specificity in light of its relation to different psychopathological conditions (Werner et al., 2019 ). Furthermore, in light of moving beyond a categorical approach to the study of mental health, it becomes increasingly important to conduct pathway analyses that consider the specific dimensions of cross-cutting constructs in psychopathology, such as alexithymia. It is increasingly important to take into consideration the different processes that intervene in predisposing to psychopathology and how these influence each other. This would allow us to broaden the magnifying glass on the pervasive dysfunctional processes that generate psychological suffering, allowing for more excellent knowledge of the relationships between the mechanisms underlying the development of symptoms. Such a result would have relevant clinical implications as it would allow the structuring of increasingly complete and advanced prevention and intervention protocols, counteracting the progression of clinical and sub-clinical conditions of mental suffering.

Limits and future directions

The main limitation of the research is that it is a cross-sectional study, which makes it impossible to make inferences on the directionality of the relationships in causal terms between the variables examined. The results obtained, while outlining a contribution of specific forms of self-criticism and alexithymia in favoring the symptomatology, do not allow us to clarify whether there is a causal direction between the two, or a reciprocal influence impacting the outcome. Indeed, the order of the predictors to be included in the Path Analysis models was selected on the basis of theoretical assumptions concerning the definition of the different forms of self-criticism and not strictly based on statistically relevant results. A further limitation is that the study was conducted on the general population. In addition, the presence of diagnoses that fell within the exclusion criteria was based on the mere declaration of the participants that they might be misrepresenting themselves or not be aware that they met the diagnostic criteria for a mental disorder. Therefore, it is not possible to conclude the actual association of specific forms of self-criticism and alexithymia with various mental disorders, but only with symptoms that reflect particular psychological functioning. Furthermore, other constructs that could explain the relationship between self-criticism, alexithymia, and the symptoms considered, for example, metacognitive skills, were not measured. In summary, our results should, therefore, be interpreted with caution. Future research should consider patients with different diagnoses to check whether the specificity of self-criticism can also be generalized to clinical samples. In addition, these should take a qualitative approach, assessing the specific content of self-criticism and other peculiar features, e.g., the characteristics of the critical voice or the function it assumes for the individual. Such an approach would also allow us to distinguish those cases in which self-criticism can have adaptive and motivational effects aimed at self-improvement from those that constitute a highly detrimental factor for mental health outcomes.

Data availability

The data supporting this study’s findings are available from the corresponding author, Alessandro Couyoumdjian, upon reasonable request. The data are not publicly available due to privacy or ethical restrictions.

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Open access funding provided by Università degli Studi di Roma La Sapienza within the CRUI-CARE Agreement. This study was funded by the Italian Ministry of University and Research (MIUR) within the PRIN 2022 project “SOCRATE- Self-criticism On Chair: Realizing an Application for Therapeutic Exercises (Principal Investigator: Prof. Francesca D’Olimpio, proj. #20222B4ZHF, CUP: B53D2301411 0006; CUP MASTER B53D2301411 0006).

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Carolina Papa, Micaela Di Consiglio & Alessandro Couyoumdjian

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Francesca D’Olimpio, Vittoria Zaccari & Micaela Di Consiglio

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Conceptualization: Carolina Papa, Alessandro Couyoumdjian, Micaela Di Consiglio, Francesco Mancini; Methodology: Carolina Papa, Alessandro Couyoumdjian; Literature searches: Vittoria Zaccari, Micaela Di Consiglio; Formal analysis and investigation: Francesca D’Olimpio, Carolina Papa; Writing - original draft preparation: Carolina Papa; Writing - review and editing: Carolina Papa, Francesca D’Olimpio, Alessandro Couyoumdjian; summary of previous research studies: Micaela Di Consiglio, Vittoria Zaccari; Supervision: Alessandro Couyoumdjian, Francesco Mancini.

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Papa, C., D’Olimpio, F., Zaccari, V. et al. “You’re Ugly and Bad!“: a path analysis of the interplay between self-criticism, alexithymia, and specific symptoms. Curr Psychol (2024). https://doi.org/10.1007/s12144-024-06653-7

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DOI : https://doi.org/10.1007/s12144-024-06653-7

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