group therapy case study examples

Evidence-Based Case Study Guidelines: Group Dynamics

Group Dynamics issues an open call for authors to submit an Evidence-Based Case Study for possible publication. Developing such a series of Evidence-Based Case Studies will be useful in advancing the evidence for group psychology and group psychotherapy. Group practice for this call is defined broadly to include therapy groups, teams, organizations and other group contexts. The goal of these Evidenced-Based Case Studies is to integrate verbatim case material from the group with standardized, empirical measures of process and outcome evaluated at different times during the life of the group, team or organization. Authors should describe vignettes highlighting key interventions, processes and mechanisms regarding their specific approach in the context of empirical scales.

Such an investigation will provide much needed information to bridge the gap between research and practice. Evidence-based case studies will also provide an important model of how to integrate basic research into applied work in therapy, team, and organizational contexts. This will open an avenue for publication to those in full time private practice, those who work primarily as consultants or organizations and teams that integrate research measures into their applied work. Finally, this approach to studying group phenomena may provide a list of systematic case studies from various forms of treatment and interventions that meet the American Psychological Association's criteria for Evidence-Based Practice (APA, 2006) as well as the Clinical Utility dimension in the Criteria for Evaluating Treatment Guidelines (APA, 2002).

Authors who are interested in preparing an Evidence-Based Case Study must follow these guidelines:

• The report must include the assessment (from the individual group member or independent rater perspective at the group level, but not only the therapist/leader) of at least two standardized empirical outcome measures related to team, organization or group objective. Optimally, such a report would include several outcome measures assessing a wide array of functioning such as: global functioning, team or organizational objectives, target symptoms, subjective well-being, interpersonal functioning, social/occupational functioning and measures of personality.
• The report must also include at least one empirical process measure (e.g., therapeutic alliance, session depth, emotional experiencing, team functioning, organizational cohesion) evaluated on at least three separate occasions.
• At minimum, specific outcome data should be presented using standardized mean difference (i.e. effect size) and clinical significance methodology (i.e. unchanged, reliable change, movement into functional distribution, clinically significant change and deterioration [see Jacobson et al. 1999]). Group Dynamics encourages submission of both successful and unsuccessful cases. In addition, it might be instructive to compare and contrast the technical interventions that occurred during a positive change case with that of an unchanged or deteriorated case from the same approach. The Evidence-Based Case Study section is not necessarily for advanced statistical time series analyses of process or outcome data, although such articles would be welcomed. Simple analyses of standardized outcome measures by way of clinical significance and effect size methods are sufficient.
• Verbatim vignettes with several group participant and therapist/leader turns highlighting key interventions, processes, and mechanisms of change must be provided. Discussion of any therapeutic or group-level interventions should not be presented only from a global or abstract perspective.
• Manuscripts must be within the journal word limit, as indicated on the journal website .
• Appropriate informed consent must be obtained from participants, and the study must be approved by an internal review board. The author must indicate that vignettes were sufficiently de-identified to protect confidentiality and privacy.

The following provide examples of what an Evidence-Based Case Study article might look like:

• Granasen, M. & Andersson, D. (2016). Measuring team effectiveness in cyber-defense exercises: A cross-disciplinary case study, Cognition, Technology & Work, 18 , 121–143. This study reported on simulated exercises to assess team functioning and effectiveness in repelling cyberattacks. Team performance (outcome), team cognition (processes within teams) were assessed and reported. The authors provided recommendations to enhance team performance. However, missing from this case study were vignettes to illustrate the concepts.
• Maxwell, K., Callahan, J. L., Holtz, P., Janis, B. M., Gerber, M. M., & Connor, D. R. (2016). Comparative study of group treatments for posttraumatic stress disorder. Psychotherapy, 53 , 433-445. The authors assessed a new potential group treatment for PTSD compared to cognitive processing therapy (CPT) as a pre-cursor to a randomized controlled trial. Two groups from each treatment type were compared. The authors measured outcomes but did not provide process measures. Several clinical vignettes illustrate the treatments.
• Tasca, G. A., Foot, M., Leite, C., Maxwell, H., Balfour, L., & Bissada, H. (2011). Interpersonal processes in psychodynamic-interpersonal and cognitive behavioral group therapy: A systematic case study of two groups. Psychotherapy, 48 , 260-273. Outcomes were measured outcomes pre- and post-treatment (effect sizes and reliable change indices) comparing two group therapists who were highly adherent to their specific treatment approach. The authors measured interpersonal processes at three time points from observer ratings of video recordings. Outcomes were measured using standardized scales. Clinical vignettes illustrated the differing interpersonal styles between the two group therapists.

Authors who have conducted an effectiveness or efficacy trial on a particular type of intervention in which they collected standardized process and outcome measures in addition to the use of audio/videotape of sessions should consider submitting an Evidence-Based Case Study. Likewise, a clinician in private practice, or a team or organizational consultant who would like to add these elements at the start of a new or existing group or team should also consider submitting an Evidence-Based Case Study.

Group Dynamics will begin accepting submissions for Evidence-Based Case Studies starting January 2019. Anyone who may have an interest in submitting an Evidence-Based Case Study is encouraged to contact the editor .

American Psychological Association, (2002). Criteria for evaluating treatment guidelines. American Psychologist, 57 , 1052–1059.

American Psychological Association, (2006). Evidence-based practice in psychology. American Psychologist, 61 , 271–285.

Jacobson, N., Roberts, L., Berns, S., & McGlinchey, J. (1999). Methods for defining and determining the clinical significance of treatment effects: Description, application, and alternatives. Journal of Consulting and Clinical Psychology, 67 , 300–307.

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The Case for Group Therapy

There’s no one-size-fits-all approach to delivering mental health care..

Posted May 27, 2021 | Reviewed by Davia Sills

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• Between the rising demand and higher costs of therapy, different care modalities—such as group therapy—can be considered as treatment options.
• Group therapy is flexible and can be used to supplement one-on-one therapy depending on the individual patient's needs.
• The supportive community and opportunity to practice new skills learned in therapy are benefits of the group therapy experience.

The mental health needs of individuals shift over time, as do our preferences for how we want to receive care, and as such, there’s a need for a diverse set of care modalities that can be deployed as effective treatment options. These various modalities—from individualized therapy to self-guided care to group therapy—give people the flexibility to find the type of care that will best suit their mental health needs. But more than that, alternative care modalities are also necessary for expanding access to care and alleviating the burden that’s placed on the shoulders of individual therapists.

As a result of significant increases in demand for mental health care, it’s becoming harder for individuals to find an available and affordable therapist. And for therapists, it’s difficult to manage this demand without feeling the effects of burnout . By introducing alternative care modalities and broadening the accepted standard of care beyond one-on-one therapy, we can begin to even the scales of the current mental health care supply-demand crisis and ensure that everyone receives the right type of care at the right time.

One care modality with significant therapeutic promise is group therapy. If done correctly, a group therapy approach can be a highly effective and cost-saving alternative or supplement to one-on-one therapy for individuals who need mental health support.

The flexible format benefits many different individuals.

Group therapy is sometimes met with reluctance from individuals who feel anxious about sharing vulnerabilities in a group setting. But on the flip side, it is this aspect of community that can make group therapy incredibly effective. For example, for people with social anxiety , who may be among the most reluctant to engage in group-based care, the group model can be a form of exposure therapy, where a person is exposed to their source of anxiety in a safe and supportive environment. For example, one review paper analyzing the responses of individuals with a panic disorder found that 78 percent of patients no longer reported panic symptoms after group psychotherapy . In group therapy, generally, an individual is not just receiving care from the group leader , but change can also be facilitated by participating in the session and interacting with the other members.

The community aspect of group therapy also functions as a tool for destigmatization. Mental health challenges can be isolating experiences, but through a group discussion, individuals may come to realize that they are not alone in their experience and can receive support and validation in real-time from people with shared experiences.

The format of the group and the experiences of the individuals within the group are important to fostering a positive environment for attendees. Groups can take a variety of forms: They can be an open group, a series of drop-in sessions where individuals come and go as they please, or a closed group where the same individuals meet at a regular cadence. These format variations allow individuals to explore what works best for them; for example, there may be fewer barriers—whether in terms of time, comfort, or willingness—to sign up for a drop-in group session than signing up for a recurring group or 1:1 therapy.

This flexibility extends to the content of the group as well. Some groups may be focused on delivering evidence-based treatment through a combination of psychoeducation and practicing tools and techniques (e.g., a group following a protocol for depression treatment or a DBT skills group), while others may take more of a supportive or process-based approach.

A peer support group is more processed-oriented and is often built around shared experiences, such as grieving the loss of a loved one, navigating the world as a cancer survivor, or coping with addiction and substance abuse . These shared experiences can be based around specific topics as well, like groups for building mental resilience , quieting negative thoughts, or coping with isolation; these can also function effectively as single-session workshops. These groups give participants the room to process their emotions while fostering resilience and hope through shared human connections. The group format allows for flexibility and creates an iterative approach to therapy; the group can change depending on the evolving needs of its participants.

Whether open or closed, support groups or psychoeducational, the group therapy model offers increased choices for therapy, giving individuals agency to find the care option that will work best for them.

Group therapy can supplement or complement other care modalities

You can also think of group therapy as one stop on an individual’s longer care journey; for some people, the group model may be enough support, but for others, group therapy can be paired with other care modalities to be an even more effective tool.

A common treatment plan for individuals with borderline personality disorder (BPD), for example, often includes both one-on-one therapy and a skills-based group. In the group, people learn tactical approaches to managing and coping with BPD, including interpersonal or emotion regulation skills that complement the work they are doing with their 1:1 therapist. This model—of learning skills in a group setting and then practicing these skills in an individual therapy session—can also work in the opposite order. You could first work on skills with a therapist or coach and then maintain (and even share) that progress in a group setting.

At its core, group therapy is highly attuned to the needs of the individual and can be integrated into care plans depending on the person’s preference. For example, some people may be excited to start their mental health support journey with blended care (i.e., working with a coach and within a group), while others may start with one modality and then engage in different modalities as their needs or circumstances change. The group therapy model can extend to group coaching sessions as well—where a group of individuals meets with a coach on an ongoing or stand-alone basis—offering yet another modality of support for individuals who may not have a clinical need. All of these modalities, coupled with the rise in digital care, allow individuals to tap into a wider breadth of care options than ever before.

If we are to address the mental health crisis in this country, we have to expand our options for mental health support beyond one-on-one therapy. As inherently social beings, community is integral to our health and happiness . Group therapy is one such option that can not only provide excellent care but also build this community among individuals, ensuring greater support and care.

Myra Altman, Ph.D. , is a scholar with the Stanford Clinical Excellence Research Center. She is also an executive of clinical care at Modern Health.

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Group therapy.

Akshay Malhotra ; Jeff Baker .

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Last Update: December 13, 2022 .

• Continuing Education Activity

Group therapy is the treatment of multiple patients at once by one or more healthcare providers. It can be used to treat a variety of conditions including but not limited to emotional trauma, anxiety, depression, post-traumatic stress disorder (PTSD), and attention deficit hyperactivity disorder (ADHD). This activity outlines the principles of group therapy and explains the role of the interprofessional team in evaluating, treating, and improving care for patients who undergo group therapy.

• Describe the elements of group therapy that can increase the chance of patients benefiting from the treatment process.
• Review the presence and management of issues of patient confidentiality during group therapy sessions.
• Summarize the management of internal issues that disrupt group therapy sessions.
• Explain the importance of interprofessional collaborative efforts when providing treatment in a group setting.
• Introduction

As the need for behavioral intervention and long-term psychiatric care is steadily rising, alternative methods of treatment must be employed by physicians and healthcare teams to meet this increasing demand. Group therapy provides a solution to this problem by allowing for the treatment of multiple individuals simultaneously. Doing so allows healthcare providers to reduce wait times and increase accessibility. This approach is especially necessary for rural and low-income areas where clinics are often understaffed and have a high volume of patients. Furthermore, group therapy can be used to treat a multitude of conditions including, but not limited to, emotional trauma, anxiety, depression, post-traumatic stress disorder (PTSD), and attention deficit hyperactivity disorder (ADHD). [1] [2] [3] [4]

Yalom Therapeutic Factors

It is vital to patient success that providers understand the mechanisms that exist in group therapy. These factors are:

• Universality: Patients realize that others exist who share similar thoughts, feelings, and issues.
• Altruism: Patients can improve their self-concept by assisting other patients.
• Instillation of hope: Patients benefit from witnessing the success of other group members and can envision themselves following a similar path.
• Imparting information: Patients gain knowledge and information from both the group members and the provider.
• Corrective recapitulation of primary family experience: Patients can benefit from the opportunity to properly recreate family dynamics in a controlled environment.
• Development of socialization techniques: Patients learn effective and proper ways to interact with others.
• Imitate behavior:  Patients gain new insight and understanding through the observation of other group members.
• Cohesiveness: Patients experience feelings of support, trust, and belonging to one another.
• Existential factors: Patients realize that they are responsible for their life decisions.
• Catharsis: Patients share personal experiences from both the past and present.
• Interpersonal learning: Patients gain an understanding of their interpersonal impact via feedback from other members as well as create an environment for one another to learn.
• Self-understanding: Patients understand the covert factors influencing their behavior and emotions.
• The process goals of group therapy are to facilitate patients' growth in comfort and function within the group.
• The outcome goals of group therapy are applied to the patient's life outside of the group and include behavior corrections, development of interpersonal and relationship skills, education, the installation of preventative measures and coping skills, and an eventual return to normal functioning within society. [5]

Selection of Patients

When deciding which patients will benefit the most from group therapy, providers utilize the therapeutic alliance. The more the provider and patient agree on the goals and tasks of therapy as well as the stronger the relationship they share, the more likely the patient will have success in group therapy. [6]

An additional selection method providers can use to gauge group therapy viability is the NEO-Five-Factor Inventory. This measure of personality suggests that those who score high on extraversion (openness) and conscientiousness (hard-working) dimensions are more suited for group therapy, while those who score high levels of neuroticism (emotionally reactive) are less suitable for group therapy. [7]

Group therapy will be useful for the treatment of patients who exhibit interpersonal difficulties and pathology; patients who lack self-awareness; patients who are action-oriented; patients who suffer from isolation and require the stimulation group interaction provides, and those who will benefit from interacting with peers who can both challenge and support them. [8]

Special attention must be paid to ensure patients unfit for group therapy do not get selected as their inclusion can have deleterious effects on both the patient and the group. Specific exclusion criteria are limited to patients who are unable to participate in the major activities of the group due to logistical, cognitive, or interpersonal factors. Additionally, patients in acute distress or actively suicidal should not be considered for group therapy and instead need independent management. Outside of these factors, the exclusion criteria for patients should be more relative than absolute. As a result, a patient unfit for one group due to conflicting personality traits may fit in a group that has similar traits to the patient.

Different Stages of Treatment

It is necessary to include patients at different stages of treatment to help facilitate individual recovery. By comparing themselves to other patients further along in the recovery process, patients can start to imagine themselves in a similar position. Additionally, seeing patients worse off than them but still contributing to the group can provide motivation, keeping patients committed to the treatment process. [9]

Identical or Similar Conditions

Group therapy sessions should include members suffering from similar conditions. Doing so allows patients to realize that their symptoms are not exclusive to them, and others share similar feelings. This feeling of universality can create a sense of community within the group and facilitate the treatment process by fostering feelings of acceptance and belonging. 

Structuring groups with members diagnosed with similar conditions also allow group members to learn from and instruct one another. Interpersonal learning allows members to gain new perspectives on their conditions and learn successful ways to cope. Additionally, members who typically experience social fear as a result of their symptoms become more comfortable with exposure to social situations. [2] [9] [10] [11] [12]

In addition to adhering to the principles of group therapy, providers should use different styles of group therapy based on the diagnosis and needs of the patients.

Psychoeducational Groups

Psychoeducational groups are useful for educating patients about their diagnosis as well as their inclinations and consequences associated with these inclinations. These groups also serve to encourage patients to stay committed to their treatment plans. Additionally, psychoeducational groups teach patients to avoid maladaptive behaviors while also instilling positive behavior change. 

When organizing a psychoeducational group, the provider should follow a highly structured plan and develop a curriculum. Sessions should last anywhere from 15 to 90 minutes, and chairs should be organized in a horseshoe or circle configuration where the provider is the focus.

During psychoeducational group sessions, the provider will act as an educator. Teaching should be performed actively as passive note-taking is inefficient and allows patients to escape the focus of the group. To ensure patient engagement, providers must foster a culture of interaction by creating an environment where patients feel comfortable speaking. Additionally, when leading a session, the provider should incorporate different learning styles, such as visual learning, auditory presentations, and hands-on activities, to accommodate the wide variety of methods in which patients learn. [13]

Skills Development Groups

Skills development groups are useful for patients whose diagnosis has prevented the adequate skill development necessary to function in everyday life. This style of group therapy also focuses on coping methods, emotional control, and socialization techniques. By focusing on specific skills that patients lack, providers can help prepare patients for the treatment process and give them the tools to recover.

Providers running skills development groups should base the content of the group on the needs of that group's patients. As a result, the actual material discussed will vary significantly from group to group. Skills development sessions should range from 45 to 90 minutes in length and be organized in either a horseshoe or circle configuration. These groups should be limited to 8 to 10 patients as it is highly interactive and provides ample time for each patient to practice the skills taught. The provider themselves must have mastery of the skills they plan to teach so they can effectively teach them to the group. [14]

Cognitive-Behavioral Groups

Cognitive-Behavioral groups are useful for changing patients’ learned behaviors by altering their beliefs and perceptions. These groups can also change patients’ perceptions of themselves, turning negative thoughts of being different and unlovable into more positive thoughts. This change in thought process can be extremely freeing to patients as they learn to live with their issues rather than being ruled by them. 

The content discussed in these groups will also vary greatly. The provider should focus on beliefs, coping skills, thought processes, or behavior based on the needs of the patients. The orientation of the room for this particular style of the group should be a circle as the horseshoe orientation can interfere with the cohesiveness of this group. Sessions should last anywhere from 60 to 90 minutes. 

Similar to psychoeducational groups, the provider of cognitive-behavioral groups should take an active role during the session; however, discretion must be used to ensure the provider does not over-participate negating the members' ability to interact. It is vital to the patients’ success that the provider acts as a guide and let the group work through most issues themselves. 

Since the discussions in these sessions are focused on thought and behavior modification, patients may feel uncomfortable and try to resist these changes. Providers must be prepared for this resistance and gently guide the members through their issues with just the right amount of empathy and firmness. [15]

Support Groups

Support groups can be used to help patients who have already begun receiving treatment to maintain their new behaviors and reinforce their new belief systems and thought processes. These groups also focus on the management of symptoms of day-to-day life. During sessions, patients usually discuss recent problems and how they dealt with them. 

Support group sessions should last anywhere from 45 to 90 minutes. Sessions should also be conducted in a circular configuration. 

Unlike psychoeducational and cognitive-behavioral groups, the provider of support groups is less directive and should act only as a facilitator. As such, the provider should assist patients in developing connections with one another and emphasizing similarities between patients. The provider’s main contribution to the group should be limited to positive reinforcement and to bring to attention appropriate interactions patients exhibit. [16]

Group Development

Providers should be aware of the different stages of group development as a transition through each stage indicates group growth and change. Transitioning through all five stages is necessary for patients to benefit from group therapy.

• Forming stage: During the forming stage, patients will exhibit feelings of anxiety, distrust, and uncertainty concerning the group. There will be a high level of dependence on the provider, and actual group interaction will be low during this stage. Providers should use this opportunity to educate the group and establish cohesiveness by discussing goals and expectations. 
• Storming stage: In this stage, patients will now be comfortable sharing intimate details with one another. Additionally, the formation of subgroups may occur as patients establish a hierarchy. Internal conflict will predominantly occur in this stage of group development. The provider should aim to resolve disruptive conflict and encourage patients to develop strong and personal relationships with one another. The reinforcement of goals and the purpose of the group can help bring patients together. 
• Norming stage: After conflict resolution has occurred, the group will enter the norming stage. While in the norming stage, patients' commitment to the group and its goals will strengthen, and group cohesiveness will increase. Patients will take on much of the leadership work initially performed by the provider. As such, the provider should take a less active role in the discussion and instead facilitate discussion and provide insights. The return of conflict is a sign of regression to a previous developmental stage, and the provider should intervene to bring the group back to this stage.
• Performing stage: Upon entering the performing stage, the group has greatly matured relative to the earlier stages. Provider intervention is low, as the group functions almost entirely on its own.  Patients are aware of each other's strengths and weaknesses and can help each other develop and grow. 
• Adjourning stage: The final stage of group development is the adjourning stage, which signifies that group therapy is coming to an end. Patients may experience feelings of sadness and anxiety as they will no longer be attending sessions. During this stage, the provider should assist patients in voicing their feelings and facilitate discussion of closing topics. Additionally, the provider should help patients plan for life outside of group therapy and assist patients in saying goodbye. Improper management of a farewell process can negatively impact patients and hurt the progress they have made. [17]

Length of Treatment

The duration of group therapy treatment is highly individualized and subject to a high degree of variation. Patients should receive therapy until they achieve relief from their symptoms and can begin to develop a normal life with strong relationships and a sense of belonging; this can take anywhere from weeks to months or even years to occur. To facilitate patient improvement, providers should structure the ending of therapy processes. By establishing a set end date during treatment, the provider can prepare the patient for an eventual departure with the patient working towards the achievement of his or her goals until that date.

• Issues of Concern

Patient Confidentiality

Similar to individual treatment, the provider or group leader in group therapy sessions are bound to the laws of confidentiality concerning patients' medical history, diagnoses, and other personal information. The other group members, however, are not bound to these same laws and face no legal consequences for sharing information from sessions. As a result, individual patient confidentiality can be difficult to maintain, especially in larger groups where leaders have less control over what information gets shared within the group.

The ability to share personal information can play a positive role in the treatment process. Some patients may feel uneasy sharing certain details for fear of who may repeat them, which can cause harm to patients' mental wellbeing as they struggle to contribute while maintaining their confidentiality. To reduce this tension, providers should adopt a set of confidentiality/sharing guidelines that the group agrees to and discuss with members the limitations of confidentiality before the first session. [18]

• Clinical Significance

Effectiveness

Research has shown that group therapy is an effective method to treat a myriad of psychiatric and behavioral disorders. Patients often report a reduction in symptoms after receiving group therapy treatment. Additionally, group therapy is found to affect patients positively through Yalom Therapeutic Factors. These factors do reduce symptoms of diagnoses while also providing patients with beneficial skills to learn, develop, and live with their symptoms. As long as patients are subject to proper screening before group therapy sessions, they will receive benefits. [1] [10] [19]

Concurrent Treatment

Although group therapy is an effective method of treatment in itself, providers may also choose to incorporate other treatment methods to treat patients further. 

• Conjoint therapy: When performed conjointly, the provider treating the patient in the group differs from the provider treating the patient individually. Doing so provides patients with different therapeutic settings, allowing them to learn as an individual and apply those teachings in a group setting.
• Combined therapy, on the other hand, occurs when the provider treating in the group setting also treats the patient individually. This method of concurrent treatment allows providers to thoroughly assess patients and provide individual coaching, which is applicable in the group setting. When placing a patient into a group, special care should be used to ensure the patient gets put into a group homogenous for symptoms and diagnosis. [20]

Cost-efficiency  

Group therapy provides a cost-efficient method of treatment, as fewer trained professionals are required to provide treatment to a larger number of patients. A reduction in cost can increase the accessibility of therapy, as costs are often covered by insurance plans. [1]

Flexibility

Treatment in a group setting allows providers to be more flexible with their sessions. Doing so can increase attendance to therapy sessions since providers can schedule sessions during after work and after school hours. Additionally, the inclusion of multiple sessions throughout the day allows providers to treat a larger volume of patients throughout the day, further reducing wait times in high-volume areas. [1]

Training Opportunities

The group format can be used as an avenue to train medical students, residents, and other healthcare professionals by allowing them to serve as co-therapists. The provider can oversee the less experienced professionals as they work with patients, effectively creating on-the-job coaching; this can be especially useful in low resource areas where access to trained professionals is limited. [1]

• Other Issues

Conflict is a natural and expected aspect of group therapy sessions. Many conflicts may not be obvious to the group members, and it is the responsibility of the provider to bring these covert conflicts to the members’ attention. The provider is not required to solve the conflict; however, he or she must make an informed decision on how to deal with the conflict based on the interest of the group. It may be worthwhile to address the conflict, as there is an opportunity for the group to learn. 

Members’ responses to conflict can be complex and unpredictable. When conflict arises, providers should use the last five to ten minutes of the session to speak with patients individually and allow them to voice their concerns.

Patients Who Ramble

Occasionally, a patient may continue to talk for an unnecessary length of time. It is essential to address this patient and see what he or she hopes to gain when doing so. If the patient is unsure as to why they are dominating the conversation, the provider should use this opportunity to teach the patient how to express his or her thoughts and feelings better.

Lack of Engagement

It is the provider’s responsibility to ensure members are alert and attentive during group sessions. When members seem disengaged, the provider should interject and see why members are losing interest. The inclusion of interactive activities can help members to be more engaged in the group discussion. [11]

Patients’ Limits

Providers are encouraged to push their patients to engage with the sessions; however, it is crucial to be aware of a patient’s individual limits. If the provider’s initial request for the patient to continue engaging meets with resistance, then the provider should respect this wish. Providers should remain patient, understanding, and empathetic with their patients and continually encourage without forcing patients to act against their will. [9]

• Enhancing Healthcare Team Outcomes

Pharmacotherapy and Group Therapy

Occasionally, patients receiving group therapy will also benefit from the inclusion of pharmacotherapy. In situations where the provider prescribing the medication differs from the provider providing treatment, proper communication between the two parties is vital to patient success. A thorough report of the patient and his or her reaction and benefits from the medication must be shared with the provider treating with group therapy. Mutual respect for one another and the well-being of the patient are required to prevent adverse reactions and ensure the patient receives the highest quality of medical care. Additionally, putting less of a value on either of the two treatment processes can negatively impact patients, so the therapist should always follow proper inclusion and management of both treatment processes. [21]

When pharmacotherapy is part of the patient's therapy, it is prudent to have a qualified pharmacist examine the patient's medication record, checking for proper dosing, potential drug interactions, and inform the other members of the healthcare team of any red flags.

Social workers can play an important auxiliary role to providers during group therapy sessions. The social worker's presence as a layperson voicing their thoughts and feelings can help facilitate group interaction and reduce members’ resistance to contributing. Also, social workers can assist patients in attempting to reintegrate into their “normal” lives by answering patient’s questions concerning work, relationships, and other lifestyle changes. [22]

An interprofessional team approach can benefit participants in group therapy, where information is shared among various disciplines leading to improved patient outcomes, so long as appropriate privacy considerations are maintained at all times. [Level 5]

• Nursing, Allied Health, and Interprofessional Team Interventions

Nurses trained in psychiatric and behavioral sciences can take on the role of group therapy leader and host group therapy sessions. Their responsibilities reflect those of other healthcare providers, and supervision is not required when a properly trained nurse is leading group therapy. [23]

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Disclosure: Akshay Malhotra declares no relevant financial relationships with ineligible companies.

Disclosure: Jeff Baker declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

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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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The following resources can be found in the Positive Psychology Toolkit© , and their full versions can be accessed by a subscription.

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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Evidence-Based Practice in Group Psychotherapy

Welcome to the AGPA Practice Resource for Evidence-Based Practice in Group Psychotherapy!

    The term “evidence-based practice” is widely used across health disciplines, but what does it mean for practitioners and consumers of group therapy services?

  The purpose of this section is to:

    •    Explain how the material in this section of the website is organized     and how it can be useful to you as a practitioner or consumer of group     therapy services

    •    Define “evidence-based practice” in the context of providing and     accessing group therapy services

    •    Provide a brief summary of the evidence regarding the efficacy and     effectiveness of problem or disorder-focused therapy groups

    •    Provide a brief summary and definition of multicultural competence in     group practice

    •    Provide group practitioners and consumers with general references for     further learning

How is this section organized?

The material presented in this section is organized by problem or disorder-specific groups and the evidence to support the helpfulness of these group treatments when compared to another (or no) treatment.  Of course, group therapy practice does not always occur through matching a particular disorder or diagnosis with a particular group that has been organized specifically to treat members with that problem.  Despite this, research most often has examined questions about particular diagnoses or problems and whether a group intervention helps those facing that problem.  Because most clinical practice is conducted with clients who have different diagnoses in the same group, i.e., groups that are heterogeneous rather than homogenous with regard to diagnosis, sometimes makes it more difficult to directly apply findings based upon the most rigorous research.  However, most of the research included here has accounted for many of the real-world complexities (such as group members who have more than one diagnosis) that occur in groups.     

Practitioners and Consumers: How do I know if my group is evidence-based?

There are several different perspectives on what “evidence-based practice” means in the context of providing or accessing group therapy services.  One approach has to do with matching the treatment to the specific problem, and thus using treatments that have been tested in randomized clinical trials (the so-called “gold standard” of research) and shown to be efficacious in treating that problem.  Another perspective defines “evidence-based practice” as using the best available research, combined with clinical judgment and client preferences .  This is the perspective taken by the AGPA Science to Service Task Force as articulated in the Clinical Practice Guidelines (2008).  Becoming familiar with the research presented in this section of the AGPA website is one important part of the process of engaging in evidence-based practice.

What are some barriers to understanding “the evidence base”?

There are many ways to determine whether a small group treatment is helpful for participants.  An important way is through systematic, rigorous research design and testing.  However, what makes group therapy a rich, exciting, and rewarding experience also makes it complicated to study.  A group therapy experience involves many dynamic, interacting variables and relationships, over time, and at multiple levels.  Variables include the pre-group characteristics of each group member (i.e., personality, attachment style, cultural background, level of functioning, motivation, etc.); characteristics of the group therapist or therapists; characteristics of the particular treatment; the fit between the type of group and the goals of the group member; the type and quality of the relationship between group co-facilitators; the relationship between a facilitator and each group member; the relationship of each group member to the other members, and to the group-as-a-whole; and the characteristics (the content and the process) of a particular session (Miles & Paquin, 2013). 

How do I know if I can trust the group research found here on AGPA’s website?

A multi-level conceptualization of individual and group level processes, as well as sophisticated tools for gathering and understanding group data, are required in order to account for the inherent complexity that characterizes group therapy in clinical practice.  For example, quantitative data from small groups are inherently interdependent, and thus they violate many assumptions of most traditional statistical tests.  Why does this matter? If this interdependence is not accounted for in the research design and analysis of group therapy data, faulty conclusions can be made about the helpfulness of the treatment.  In a study by Baldwin, Murray, & Shaddish (2005) the researchers found that among the 33 studies of empirically supported group treatments, none accounted for non-independence of the data.  The researchers re-analyzed the data from these studies and found that a much smaller proportion of the studies that were reported as significant actually were significant. Group research since then, including most of the group research presented in this section, addresses these issues, therefore making conclusions about the effectiveness of group therapy more reliable.

Another challenge to understanding the usefulness of research findings (and one that is inherent to all kinds of treatment research) involves being able to determine whether changes observed in clients are due to the treatment or to other variables.  Specifically, in studies that are designed to test how well a particular kind of group treatment works when compared with no treatment or another kind of treatment, confounding variables (variables that are difficult or impossible to prevent or control) exist and can include just about anything that a group member does outside of the group session.  For instance, a group member who accesses other types of treatment in addition to participating in group therapy can make it difficult or impossible to determine the extent to which any improvements are due to the treatment of interest and not some other variable. 

“Efficacy vs. Effectiveness” – what is the difference?

The more controlled a study is in the research laboratory, the more confidently we can conclude that significant results are due to the treatment.  This type of study is likely to be testing the “efficacy” of a treatment.  However, how a treatment is implemented in a controlled, laboratory setting may look very different from how that treatment is implemented out in the field or “real world” setting, and may produce different results.  Studies designed to test how a treatment works in the field can be considered to be “effectiveness” studies.  Because both effectiveness and efficacy studies are essential to understanding “what works” in group intervention, both types of studies are included in this section of AGPA’s website.

What is “practice-based evidence?”

Another way of determining whether a therapy group is helpful to its participants involves tracking client and group-as-a-whole progress. Practice-based evidence refers to a process of information gathering about how the group and its particular members are faring, and can be done in several ways. The CORE-R Battery Revised (Burlingame et al., 2006) is one comprehensive resource designed to assist practitioners in tracking client progress, including selection, process, and outcome measures.

What are some things I can do to be an evidence-based group practitioner?

Evidence-based practice refers to basing one’s clinical practice on a combination of factors. Here are the resources an evidence-based group practitioner accesses when developing and delivering evidence-based group therapy services:

    •    Empirically supported treatments

    •    Best available empirical research

    •    Client preferences, values, and/or expectations regarding treatment

    •    Gathering practice-based evidence that your group processes are helping its members

    •    Clinical practice guidelines and other sources for working with diverse populations

    Furthermore, an evidence-based group practitioner pays attention to the ingredients of change that appear to be present in successful therapy groups across problems, populations, treatment approaches, and settings (Burlingame, et al., 2013). These include:

    •    One’s formal theory of change

    •    Knowledge of group dynamics and basic social processes

    •    Imposed structure (e.g., member selection, pre-group preparation, etc.)

    •    Emergent structure (e.g., group development, group norms, etc.)

    •    Emergent processes (e.g., therapeutic factors, the group’s climate or cohesion,      leader interventions, etc.)

    •    Individual characteristics of the group member and the group practitioner

    •    Knowledge, skills, and awareness related to working with culturally diverse clients in groups.

What is the evidence-base for multicultural competence in group practice?

One of the difficulties in establishing an evidence-base for group treatments for diverse populations is that historically, most treatment research has been conducted with samples of White, western (and in the case of disorder-specific research) men.  More recently, researchers have begun examining specific treatment questions regarding the efficacy or effectiveness of a particular group treatment approach with traditionally underserved populations, in particular settings, with a group practitioner who engages in a particular set of behaviors or demonstrates a specific set of competencies (Miles & Paquin, 2014).

At present, it is not uncommon for group practitioners to encounter a lack of research about group treatments when working with a historically underrepresented population.  This underscores the need for continued research to better understand how to develop, implement, and/or modify existing treatments to be maximally beneficial to historically underserved groups.  Meanwhile, to compensate for this lack of empirical knowledge about how a particular treatment approach works with an understudied population, Chen and colleagues (2008) encourage group practitioners to become “local clinical scientists” and to gather practice-based evidence (see above) about how their clients are responding to the group intervention.  Additionally, every group can be considered “multicultural” and therefore effective group practice requires multicultural competence (Chen, et al., 2008).

How do I become a multiculturally competent group therapist?

Multicultural competence has been noted to have three components: Awareness, knowledge, and skills (Sue, Arredondo, & McDavis, 1992):

    •    Awareness of beliefs and attitudes (e.g., awareness of one’s own cultural identities, values, and     biases)

    •    Knowledge (e.g., culture-specific knowledge about various cultural groups including sociopolitical     and historical knowledge)

    •    Skills (e.g., ability to respond verbally and nonverbally in manners appropriate to the culture of     one’s clients)

 Becoming a multiculturally competent group therapist is an ongoing process. This process can include the following markers or tasks:

    •    Developing a framework for understanding oneself and others as “cultured beings”

    •    Being able to evaluate the cultural appropriateness of a group intervention

    •    Developing knowledge and awareness of how power, privilege, and oppression operate in the lives     of group members as well as in the group

Lastly, Chen and colleagues (2008) point out that the diversity that exists in group therapy will be unique to the particular group, as each therapy group is wholly unique. Furthermore, diversity in a group setting is a dynamic, relational process determined by the particular identities of therapist(s), members of the group, and the temporal context (time and place) in which the group is taking place (Chen, et al., 2008).  Clinical practice guidelines in your discipline for working with diverse populations can provide further guidance on developing multicultural competence (e.g., APA, 2003).

We encourage citation of this page. 

Full authorship reference is as follows:   Barlow, S., Burlingame, G.M., Greene, L.R., Joyce, A., Kaklauskas, F., Kinley, J., Klein, R.H., Kobos, J.C., Leszcz, M., MacNair-Semands, R., Paquin, J.D., Tasca, G.A., Whittingham, M., & Feirman, D. (2015).  Evidence-based practice in group psychotherapy   [American Group Psychotherapy Association Science to Service Task Force web document]. Retrieved from  http://www.agpa.org/home/practice-resources/evidence-based-practice-in-group-psychotherapy

Shortened version for citation is as follows:   Barlow, S., Burlingame, G.M., Greene, LR,., Joyce, A., Kaklauskas, F., Kinley, J., ... & Feirman, D. (2015). Evidence-based practice in group psychotherapy   [American Group Psychotherapy Association Science to Service Task Force web document]. Retrieved from  http://www.agpa.org/home/practice-resources/evidence-based-practice-in-group-psychotherapy .

American Psychological Association (2003). Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists. The American psychologist, 58(5), 377. DOI: 10.1037/0003-066X.58.5.377

APA Presidential Task Force on Evidence-Based Practice (2006). Evidence-based practice in psychology. The American psychologist, 61(4), 271. DOI: 10.1037/0003-066X.61.4.271

Baldwin, S. A., Murray, D. M., & Shadish, W. R. (2005). Empirically supported treatments or type I errors? Problems with the analysis of data from group-administered treatments. Journal of consulting and clinical psychology, 73(5), 924. http://dx.doi.org/10.1037/0022-006X.73.5.924

Bernard, H., Burlingame, G., Flores, P., Greene, L, Joyce, A., Kobos, J., Leszcz, M., MacNair-Semands, R., Piper, W., McEneaney, A., & Feirman, D. (2008). Clinical practice guidelines for group psychotherapy. International Journal of Group Psychotherapy, 455-542. doi: 10.1521/ijgp.2008.58.4.455

Burlingame, G.M., Strauss, B; Joyce, A; MacNair-Semands, R; MacKenzie, KR; Ogrodniczuk, J; Taylor, S. (2006). CORE Battery-Revised: An assessment tool kit for promoting optimal group selection, process, and outcome.  American Group Psychotherapy Association, New York, NY.

Burlingame, G., Strauss, B. & Joyce, A (2013). Change mechanisms and effectiveness of small group treatments, In M. J. Lambert (Ed.), Bergin & Garfield’s Handbook of psychotherapy and behavior change, 6th Ed. (pp. 640-689). New York: Wiley & Sons.

Chen, E. C., Kakkad, D., & Balzano, J. (2008). Multicultural competence and evidence‐based practice in group therapy. Journal of Clinical Psychology, 64(11), 1261-1278. DOI: 10.1002/jclp.20533

DeLucia-Waack, J. L., Donigian, J., & Hernandez, T. (2004). The practice of  multicultural group work: Visions and perspectives from the field. Belmont, CA: Thomson/Brooks/Cole.

Miles, J.R. & Paquin, J.D. (2014). “Teaching at the intersection of evidence-based practice and multicultural competence in group training." Symposium presented at the American Psychological Association national meeting, Washington, DC.

Miles, J. R. & Paquin, J. D. (2013). Best practices in group counseling and psychotherapy research, In J. DeLucia-Waack, C. Kalodner, & M. Riva (Eds.) Handbook of group counseling and psychotherapy (2nd Ed) (pp. 178-192). New York: Sage Publications. DOI:http://dx.doi.org/10.4135/9781452229683.n10.

Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Counseling & Development, 70(4), 477-486. DOI: 10.1002/j.1556-6676.

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Writing a Counselling Case Study

As a counselling student, you may feel daunted when faced with writing your first counselling case study. Most training courses that qualify you as a counsellor or psychotherapist require you to complete case studies.

Before You Start Writing a Case Study

However good your case study, you won’t pass if you don’t meet the criteria set by your awarding body. So before you start writing, always check this, making sure that you have understood what is required.

For example, the ABC Level 4 Diploma in Therapeutic Counselling requires you to write two case studies as part of your external portfolio, to meet the following criteria:

• 4.2 Analyse the application of your own theoretical approach to your work with one client over a minimum of six sessions.
• 4.3 Evaluate the application of your own theoretical approach to your work with this client over a minimum of six sessions.
• 5.1 Analyse the learning gained from a minimum of two supervision sessions in relation to your work with one client.
• 5.2 Evaluate how this learning informed your work with this client over a minimum of two counselling sessions.

If you don’t meet these criteria exactly – for example, if you didn’t choose a client who you’d seen for enough sessions, if you described only one (rather than two) supervision sessions, or if you used the same client for both case studies – then you would get referred.

Check whether any more information is available on what your awarding body is looking for – e.g. ABC publishes regular ‘counselling exam summaries’ on its website; these provide valuable information on where recent students have gone wrong.

Selecting the Client

When you reflect on all the clients you have seen during training, you will no doubt realise that some clients are better suited to specific case studies than others. For example, you might have a client to whom you could easily apply your theoretical approach, and another where you gained real breakthroughs following your learning in supervision. These are good ones to choose.

Opening the Case Study

It’s usual to start your case study with a ‘pen portrait’ of the client – e.g. giving their age, gender and presenting issue. You might also like to describe how they seemed (in terms of both what they said and their body language) as they first entered the counselling room and during contracting.

If your agency uses assessment tools (e.g. CORE-10, WEMWBS, GAD-7, PHQ-9 etc.), you could say what your client scored at the start of therapy.

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Writing a Case Study: 5 Tips

Describing the Client’s Counselling Journey

This is the part of the case study that varies greatly depending on what is required by the awarding body. Two common types of case study look at application of theory, and application of learning from supervision. Other possible types might examine ethics or self-awareness.

Theory-Based Case Studies

If you were doing the ABC Diploma mentioned above, then 4.1 would require you to break down the key concepts of the theoretical approach and examine each part in detail as it relates to practice. For example, in the case of congruence, you would need to explain why and how you used it with the client, and the result of this.

Meanwhile, 4.2 – the second part of this theory-based case study – would require you to assess the value and effectiveness of all the key concepts as you applied them to the same client, substantiating this with specific reasons. For example, you would continue with how effective and important congruence was in terms of the theoretical approach in practice, supporting this with reasoning.

In both, it would be important to structure the case study chronologically – that is, showing the flow of the counselling through at least six sessions rather than using the key concepts as headings.

Supervision-Based Case Studies

When writing supervision-based case studies (as required by ABC in their criteria 5.1 and 5.2, for example), it can be useful to use David Kolb’s learning cycle, which breaks down learning into four elements: concrete experience, reflective observation, abstract conceptualisation and active experimentation.

Rory Lees-Oakes has written a detailed guide on writing supervision case studies – entitled How to Analyse Supervision Case Studies. This is available to members of the Counselling Study Resource (CSR).

Closing Your Case Study

In conclusion, you could explain how the course of sessions ended, giving the client’s closing score (if applicable). You could also reflect on your own learning, and how you might approach things differently in future.

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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."

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Predictive value of perioperative NT-proBNP levels for acute kidney injury in patients with compromised renal function undergoing cardiac surgery: a case control study

• Yiting Ma 1   na1 ,
• Jili Zheng 1   na1 ,
• Wanting Zhou 1 ,
• Zhe Luo 2 &
• Wuhua Jiang 3  

BMC Anesthesiology volume  24 , Article number:  298 ( 2024 ) Cite this article

Metrics details

Acute kidney injury (AKI) significantly increases morbidity and mortality following cardiac surgery, especially in patients with pre-existing renal impairments. N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a marker of cardiac stress and dysfunction, conditions often exacerbated during cardiac surgery and prevalent in chronic kidney disease (CKD) patients. Elevated NT-proBNP levels can indicate underlying cardiac strain, hemodynamic instability and volume overload. This study evaluated the association between perioperative changes in NT-proBNP levels and the incidence of AKI in this particular patient group.

This retrospective study involved patients with impaired renal function (eGFR 15–60 ml/min/1.73 m²) who underwent cardiac surgery from July to December 2022. It analyzed the association between the ratio of preoperative and ICU admittance post-surgery NT-proBNP levels and the development of AKI and AKI stage 2–3, based on KDIGO criteria, using multivariate logistic regression models. Restricted cubic spline analysis assessed non-linear associations between NT-proBNP and endpoints. Subgroup analysis was performed to assess the heterogeneity of the association between NT-proBNP and endpoints in subgroups.

Among the 199 participants, 116 developed postoperative AKI and 16 required renal replacement therapy. Patients with AKI showed significantly higher postoperative NT-proBNP levels compared to those without AKI. Decreased baseline eGFR and increased post/preoperative NT-proBNP ratios were associated with higher AKI risk. Specifically, the highest quantile post/preoperative NT-proBNP ratio indicated an approximately seven-fold increase in AKI risk and a ninefold increase in AKI stage 2–3 risk compared to the lowest quantile. The area under the receiver operating characteristic curve for predicting AKI and AKI stage 2–3 using NT-proBNP were 0.63 and 0.71, respectively, demonstrating moderate accuracy. Subgroup analysis demonstrated that the positive association between endpoints and logarithmic transformed post/preoperative NT-proBNP levels was consistently robust in subgroup analyses stratified by age, sex, surgery, CPB application, hypertension, diabetes status and fluid balance.

Perioperative NT-proBNP level changes are predictive of postoperative AKI in patients with pre-existing renal deficiencies undergoing cardiac surgery, aiding in risk assessment and patient management.

Peer Review reports

Introduction

Acute kidney injury (AKI) following cardiac surgery represents a significant complication that escalates morbidity and mortality among patients [ 1 , 2 ]. Despite advancements in surgical techniques and patient care, the incidence of AKI remains high, particularly among individuals with pre-existing renal impairment [ 3 ]. The capability to precisely predict postoperative AKI and its severity could guide preventive strategies and patient management, potentially improving outcomes [ 4 , 5 ].

Recent research has underscored the significance of biomarkers in the early prediction of AKI. Among these, N-terminal pro-B-type natriuretic peptide (NT-proBNP) has emerged as a promising indicator.

NT-proBNP is a fragment of the prohormone BNP (B-type natriuretic peptide), which is released by the heart in response to cardiac stress and dysfunction. Both NT-proBNP and BNP are used clinically to diagnose and manage heart failure, as they reflect similar pathophysiological processes. However, NT-proBNP has a longer half-life and is more stable in the bloodstream, making it a more reliable marker for assessing cardiac function [ 6 ]. Traditionally associated with cardiac function, NT-proBNP’s elevation has been correlated with renal outcomes as well. Elevated preoperative NT-proBNP levels have been linked with an increased risk of developing postoperative AKI. This correlation between NT-proBNP concentrations and the risk of any-stage AKI, as well as severe AKI following cardiac procedures, supports its utility as a predictive marker [ 7 , 8 ].

In another study, Patel et al. demonstrated that higher preoperative brain natriuretic peptide (BNP) levels significantly predict the risk of AKI after cardiac surgery. The study suggested that incorporating BNP levels into preoperative evaluations could improve risk stratification and outcomes for patients undergoing cardiac surgery [ 9 ]. Fiorentino et al. demonstrated that while NT-proBNP alone may not significantly predict AKI recovery, its combination with other biomarkers like plasma neutrophil gelatinase-associated lipocalin (NGAL) improves predictive accuracy [ 10 ].

While existing research predominantly focuses on the relationship between preoperative levels of BNP and postoperative AKI, the dynamics of postoperative BNP elevations remain critically underexplored. In addition, patients with impaired kidney function tend to have elevated preoperative BNP [ 11 ]. Therefore, in this specific population, it is difficult to draw effective conclusions only by measuring BNP before surgery. An increase in BNP levels following cardiac surgery may reflect augmented cardiac volume stress [ 12 ], which could indirectly impact renal function and promote the onset of AKI. Furthermore, monitoring perioperative BNP elevation could offer a novel approach for early identification of patients at elevated risk, enabling timely interventions aimed at mitigating the incidence and severity of AKI. In view of the stability of the prediction effect of NT-proBNP on cardiac function, investigating the association between perioperative elevations in NT-proBNP and the development of AKI holds significant promise for enhancing patient management and outcomes following cardiac procedures.

This study seek to bridge this knowledge gap by evaluating the association between postoperative increases in NT-proBNP and the emergence of AKI in a specific patient cohort - those with impaired preoperative renal function, for developing AKI and more severe stages of the condition following cardiac surgery.

Patients and inclusion/exclusion criteria

This research focused on adult individuals who had reduced preoperative kidney function (eGFR between 15 and 60 ml/min/1.73 m²) and who underwent valve, coronary artery bypass, or combined procedures at our facility from July to December 2022. Excluded were those previously on renal replacement therapy (RRT) or with a transplant, those meeting the KDIGO criteria [ 13 ] for preoperative acute kidney injury, those with incomplete health records, those who died within 48 h post-ICU, and those undergoing urgent surgery. The study received approval from the Ethics Committee of Shanghai Zhongshan Hospital (Approval Number B2021–873R), and all participants provided written consent.

This retrospective analysis involved gathering clinical information from electronic health records, covering (1) demographic information: age, gender, body mass index (BMI), and comorbidities such as hypertension and diabetes mellitus. (2) laboratory results: including preoperative and postoperative levels of NT-proBNP, (3) surgical details: type of surgery (valve, CABG, or combined), duration of cardiopulmonary bypass (CPB), and other intraoperative variables. (4) postoperative outcomes: central venous pressure (CVP) upon admission of intensive care unit (ICU), fluid balance, incidence and severity of AKI based on KDIGO criteria, RRT, length of hospital stay, and in-hospital mortality.

Rationale of perioperative care

We used an electronic ICU medical record system that dynamically monitored and followed up on renal function and urine output. This system included automated tracking and alerts for changes in key indicators such as serum creatinine levels and urine output.

Following surgery, SCr was tracked daily in the ICU, with kidney function assessments performed for the first three days after leaving the ICU and then every other day until hospital discharge.

At our institution, NT-proBNP measurement is routinely performed for all hospitalized patients, regardless of their department. This standard practice ensures that comprehensive cardiac monitoring is maintained across all patient populations. Consequently, the perioperative NT-proBNP measurements used in this study were part of the routine clinical care, reinforcing the retrospective nature of the study. The rationale for the blood tests is that blood samples were collected upon ICU admittance and every 24 h postoperatively until the patients were discharged from the ICU. The consistent monitoring typically continued for 3 to 7 days, depending on the patient’s clinical condition and recovery progress.

Definitions

The primary outcome of the study was the incidence of post-surgery AKI, defined by the KDIGO guidelines [ 13 ], which include both serum creatinine and urine output measurements. Participants were divided into two groups according to whether they developed AKI after their operation.

The primary exposure of interest in this study was the perioperative change in NT-proBNP levels, defined as the ratio of the last NT-proBNP level before surgery (usually the morning of the surgery day) to the NT-proBNP level upon admission to the ICU after surgery. This ratio was calculated for each patient and used to assess the association between perioperative NT-proBNP changes and the incidence of postoperative AKI. The NT-proBNP ratio was logarithmically transformed for statistical analysis to normalize its distribution.

The estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula [ 14 ] based on the last serum creatinine (SCr) level measured before surgery.

Fluid Balance (FB) was based on detailed records of fluid intake and output were collected for the first 48 h postoperatively or until the diagnosis of AKI, whichever came first. This included intraoperative fluid administration, postoperative fluid management, and daily fluid balance.

In the subgroup analysis, we categorized patients into volume overload (≥ 5%) and non-overload (< 5%) groups based on fluid balance (FB). This classification was derived from previous study [ 15 ].

Statistical analysis

Data analysis utilized R software, version 4.3.0. Data following a normal distribution were presented as mean ± standard deviation, while those not normally distributed were shown as medians with interquartile ranges. Categorical data were expressed as frequencies and percentages. The Kolmogorov-Smirnov test checked for normality and homogeneity of variances. Continuous data differences were assessed using the Student’s t-test or nonparametric equivalents, and categorical data differences were analyzed using Fisher’s exact or chi-square tests. For data not normally distributed, logarithmic (lg) transformed was applied before analysis. To explore the nonlinear association between perioperative change of NT-proBNP and postoperative AKI using restricted cubic splines (RCS) in the context of a clinical study, while adjusting for age, gender, CPB time, surgical type, pre-existing hypertension/diabetes mellitus, preoperative hemoglobin and albumin. Univariate logistic regression identified potential risk factors for postoperative AKI, calculating odds ratios and 95% confidence intervals. Multivariate analysis, employing stepwise forward selection, was applied to variables with P-values less than 0.05, considered predictive of postoperative AKI. To ensure the reliability of our regression analysis, we assessed multicollinearity among the explanatory variables. We calculated the variance inflation factors (VIFs) for each variable included in the model. A VIF value greater than 10 was considered indicative of significant multicollinearity and the variable was excluded from the regression [ 16 ]. Additionally, we performed trend analysis to evaluate the trending association between NT-proBNP quartiles and the endpoints. The optimal cutoff values for biomarkers in predicting the primary outcome were determined by maximizing the Youden index. Subgroup analyses were conducted to explore the associations between NT-proBNP classified with the optimal cut-off and outcomes among individuals of different sexes, ages, surgery, diabetes status, and hypertension status. Interaction tests determine the consistency of these associations across the various subgroups. A P-value of less than 0.05 was set as the threshold for statistical significance.

Basic characteristics

A total of 199 eligible patients were enrolled to this study (Fig.  1 ) and 116 patients (58.3%) developed AKI after cardiac surgery. RRT was performed in 16 patients. The AKI group had higher postoperative NT-proBNP levels (2973.00 vs. 1110.00 pg/mL, P  < 0.001), lower albumin levels (38.84 ± 3.33 vs. 40.92 ± 4.03 g/L, P  < 0.001), higher serum creatinine levels (142.54 ± 44.04 vs. 126.54 ± 37.46 µmol/L, P  = 0.006), and lower eGFR (45.39 ± 10.85vs. 50.04 ± 10.13 ml/min/1.73 m², P  = 0.003). Additionally, postoperative cTnT and CK-MB levels were higher in the AKI group (0.73 vs. 0.31 µg/L, P  < 0.001 and 29.50 vs. 20.00 U/L, P  = 0.001, respectively), and the length of hospital stay was longer (16.50 vs. 15.00 days, P  = 0.017) (Table  1 ).

Flowchart of the patients enrollment

Nonlinear association analysis

The RCS curve analysis was applied to identify potential nonlinear association between logarithmic transformed NT-proBNP and AKI (Fig.  2 A)/AKI stages 2–3 (Fig.  2 B). However, the statistical test for nonlinearity did not reach significance ( P for nonlinear = 0.272 and 0.121), indicating that the relationship between LgNT-proBNP and AKI/AKI stages 2–3 can be adequately described by logistic models in this study.

Potential nonlinear relationship between logarithmic transformed NT-proBNP and AKI

Association between perioperative NT-proBNP change and AKI

Because NT-proBNP in our study was not normally distributed, we performed logarithmic transformations of NT-proBNP and classified them according to their logarithmic quartiles: Q1[-0.701,0.0176), Q2[0.0176,0.282), Q3[0.282,0.629) and Q4[0.629,2.14]. In the logistic regression analysis for risk factors of AKI (Table  2 ), significant predictors in the multivariate analysis included baseline albumin (OR: 0.84, p  = 0.018) and logarithmic transformed Post/Preoperative NT-proBNP levels in the highest quantile (OR: 6.68, p  = 0.017). Trend analysis indicated that the risk of AKI increased with higher NT-proBNP levels (P for trend = 0.007). Gender, age, fluid balance, and other comorbidities like hypertension and diabetes mellitus were not statistically significant risk factors. Notably, elevated levels of logarithmic transformed Post/Preoperative cTnT and CK-MB were associated with an increased risk of AKI in univariate analysis but did not retain significance in the multivariate model. Figure  3  A showed that logarithmic transformed Post/Preoperative NT-proBNP levels significantly excelled with an AUROC of 0.63 (95%CI 0.552–0.708) for prediction of all stages AKI, indicating moderate predictive accuracy. The optimal cut-off point was determined to be 0.31, with a sensitivity of 57.8% and a specificity of 67.5%.

Receiver Operating Characteristic curves for the prediction of all stage AKI and AKI Stage 2–3 based on perioperative NT-proBNP ratio

For AKI stages 2–3, baseline albumin levels (OR:0.83, p  < 0.001), the third (OR:7.70, p  = 0.003) and highest quantiles of logarithmic transformed post/preoperative NT-proBNP (OR:9.38, p  = 0.001) were significant risk factors in the multivariate analysis (Table  3 ). Trend analysis indicated that the risk of AKI increased with higher NT-proBNP levels ( P for trend < 0.001). Other factors like age, gender, hypertension, diabetes mellitus, and CPB duration did not show significant associations. This highlighted the importance of monitoring preoperative albumin and perioperative NT-proBNP levels in predicting severe AKI post-operation. Figure 3B demonstrated the predictive accuracy for AKI stage 2–3, with logarithmic transformed Post/Preoperative NT-proBNP achieving an AUROC of 0.714 (95%CI 0.63–0.798), showcasing good predictive ability. Logarithmic transformed Post/Preoperative NT-proBNP = 0.365 was the best cut-off point, with a sensitivity of 75%, a specificity of 65.2%.

Subgroup analysis

Subgroup analysis was performed to elucidate the heterogeneity of the association between NT-proBNP and endpoints in subgroups. No significant differences were observed between endpoints and logarithmic transformed Post/Preoperative NT-proBNP levels classified with optimal cut-off points (P for interaction > 0.05, Tables  4 and 5 ). Specifically, the results demonstrated that the positive association between endpoints and logarithmic transformed Post/Preoperative NT-proBNP levels was consistently robust in subgroup analyses stratified by age, sex, surgery, CPB application, hypertension, diabetes status and fluid balance.

Advancements in cardiac surgical techniques have enabled an increasing number of patients with pre-existing renal insufficiency to undergo cardiac operations. However, this patient cohort is at heightened risk for developing AKI postoperatively [ 17 ], underscoring the imperative for early prediction of AKI risk among these high-risk individuals. In this study, we identified that changes in NT-proBNP levels during the perioperative period can predict the occurrence of AKI and severe AKI. Moreover, we found the optimal cut-off point for prediction of AKI and AKI stage 2–3, and subgroup analysis showed consistency of the association among subgroups. To the best of our knowledge, this is the first study addressing the predictive value of the perioperative change of NT-proBNP for cardiac surgery associated AKI .

While prior investigations in general populations have established a correlation between preoperative BNP levels and the incidence of postoperative AKI [ 7 , 8 , 9 ], the predictive value of preoperative BNP is compromised in patients with pre-existing renal insufficiency due to inherently elevated BNP levels [ 18 ]. Consequently, relying solely on preoperative BNP levels to predict postoperative AKI risk in this specific patient subset presents considerable challenges. The results of the present study underlined the significant role of elevated perioperative NT-proBNP levels in predicting AKI post-cardiac surgery, specifically in patients with compromised preoperative renal function.

In our study, NT-proBNP was not normally distributed; therefore, we performed a base-10 logarithmic transformation and grouped it according to its quartiles. Multivariate regression analysis showed that the highest quartile group, Q4 [0.629, 2.14], was associated with AKI, meaning that when postoperative NT-proBNP increased to 4.26 times the preoperative level, the risk of AKI was 5.68 times higher compared to patients in Q1, whose postoperative NT-proBNP increased to less than 1.04 times the preoperative level or decreased. Simultaneously, Q3 and Q4 were associated with AKI stages 2–3, meaning that when postoperative NT-proBNP increased to 1.91–4.26 times the preoperative level, the risk of AKI stages 2–3 was 6.7 times higher compared to patients in Q1, and when postoperative NT-proBNP increased to 4.26 times the preoperative level, the risk of AKI stages 2–3 was 8.38 times higher compared to patients in Q1.

Our findings showed that the sensitivity and specificity of NT-proBNP for predicting AKI (AUROC 0.63) and AKI stage 2–3 (AUROC 0.714) are moderate. Despite this, NT-proBNP remains valuable in clinical practice for several reasons: Firstly, even with moderate accuracy, NT-proBNP provides significant predictive information, especially in high-risk populations such as those with preoperative renal impairment.

Secondly, our subgroup analysis showed consistent associations between NT-proBNP levels and AKI risk across different patient groups, supporting its reliability as a predictive biomarker. In addition, NT-proBNP should be used alongside other biomarkers and clinical indicators to enhance overall predictive accuracy and provide a comprehensive assessment of AKI risk.

The utility of NT-proBNP measured at ICU admission is supported by its ability to reflect the immediate postoperative state of cardiac stress. For patients who developed AKI shortly after surgery, elevated NT-proBNP levels at ICU admission likely indicate early signs of cardiac stress and dysfunction. For those who developed AKI a few days later, NT-proBNP levels at admission may still serve as a indicative reference and provide valuable predictive information, indicating an ongoing risk due to increased cardiac stress and reduced renal clearance capacity [ 18 ].

While NT-proBNP is traditionally considered a marker of cardiac stress, it is important to note that elevated NT-proBNP levels can also result from impaired renal clearance due to AKI or CKD [ 18 ]. This suggested that NT-proBNP may serve more as an indicator of existing renal dysfunction rather than a direct cause of AKI or solely a marker of increased cardiac stress.

While NT-proBNP is typically associated with volume status, our study found no significant differences in fluid balance and CVP between the AKI and non-AKI groups. This suggested that the predictive value of NT-proBNP for AKI in our cohort may not be solely related to alteration in volume status.

Additionally, subgroup analyses showed that the association between NT-proBNP levels and AKI remained consistent across various subgroups, including those classified by fluid balance. This indicates that BNP’s predictive value for AKI is robust and not significantly influenced by volume status as measured by fluid balance or CVP.

However, while the predictive value of NT-proBNP is clear, our findings also echo the complexity of AKI as a multifactorial condition, particularly within the setting of cardiac surgery. This complexity mandates a multifactorial approach to risk assessment, highlighting the limitations of relying solely on NT-proBNP or any single biomarker for predicting postoperative renal outcomes. This perspective was bolstered by recent discussions in the literature which advocated for the use of multi-biomarker strategies for improving the accuracy and reliability of AKI predictions [ 19 ].

Nevertheless, while our study offers significant insights, it is not without limitations. The retrospective design limits our ability to infer causality between elevated NT-proBNP levels and the incidence of AKI. Prospective studies are needed to confirm our findings and establish a temporal relationship between NT-proBNP levels and AKI development. Additionally, our study population, derived from a single center, may limit the generalizability of our findings. The demographic and clinical characteristics specific to our institution may not be representative of other settings, highlighting the need for multicenter studies to validate our results across different populations and healthcare settings.

Additionally, the timing of NT-proBNP measurements in our retrospective study were based on routine clinical practice rather than a predefined protocol. In our hospital, the first postoperative NT-proBNP was measured at the admission to the ICU. This may mainly reflect the intraoperative cardiac function or fluid overload.

Moreover, our study did not account for all possible confounders that could influence NT-proBNP levels, such as intraoperative hemodynamic changes. The impact of these factors on NT-proBNP levels warrants further investigation to elucidate the multifaceted dynamics at play.

Other biomarkers such as serum and urine neutrophil gelatinase-associated lipocalin (NGAL), urinary kidney injury molecule-1 (KIM-1), and interleukin-18 (IL-18) are known to have predictive value for AKI [ 20 ]. Unfortunately, these biomarkers were not included in our routine diagnostic panel due to national health insurance policies. As these biomarkers are classified as out-of-pocket expenses, not all patients were willing or able to bear these additional costs, limiting their use in our study. As a result, we were unable to compare the predictive value of NT-proBNP with these other biomarkers.

Conclusions

This study highlighted the predictive value of perioperative changes in NT-proBNP levels for AKI and severe AKI in cardiac surgery patients with preoperative renal impairment. NT-proBNP levels, routinely available and indicative of both cardiac stress and renal function, can aid in early identification of high-risk patients.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Abbreviations

Acute Kidney Injury

Brain Natriuretic Peptide

Chronic Kidney Disease

Cardiopulmonary Bypass

Cardiac Troponin T

Estimated Glomerular Filtration Rate

Intensive Care Unit

Kidney Disease: Improving Global Outcomes

N-terminal pro-B-type Natriuretic Peptide

Restricted Cubic Spline

Serum Creatinine

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Acknowledgements

We are grateful for the contribution of the study personnel from the department of nephrology, cardiac surgery and critical care for persistent contribution to the maintenance of the cardiac surgery database.

This work was supported by National Nature Science Foundation of China, No. 82102289; Shanghai Federation of Nephrology Project supported by Shanghai ShenKang Hospital Development Center, No. SHDC2202230; Shanghai “science and technology innovation plan " Yangtze River Delta scientific and technological Innovation Community project, No. 21002411500.

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Yiting Ma and Jili Zheng contributed equally to this work.

Authors and Affiliations

Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China

Yiting Ma, Jili Zheng & Wanting Zhou

Department of Cardiac Surgery Intensive Care Unit, Zhongshan Hospital, Fudan University, Shanghai, China

Department of Nephrology, Zhongshan Hospital, Fudan University, No 180 Fenglin Rd, Shanghai, China

Wuhua Jiang

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Contributions

JZ, ZL and WJ designed and directed the study, YM and WZ participated in data collection and maintenance, YM, WZ and JZ analyzed the data, YM, WZ and WJ interpreted the results and writing. WJ and ZL participated in reviewing the manuscript, the maintenance of dataset and facilitating the acquisition of data. All authors read and approved the final manuscript.

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Correspondence to Wuhua Jiang .

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This study was approved by the ethical board from Zhongshan Hospital, Fudan University (Approval Number B2021–873R). All participants provided written consent. The study was conducted in accordance with the Helsinki Declaration (WMA Declaration of Helsinki, 2013).

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Ma, Y., Zheng, J., Zhou, W. et al. Predictive value of perioperative NT-proBNP levels for acute kidney injury in patients with compromised renal function undergoing cardiac surgery: a case control study. BMC Anesthesiol 24 , 298 (2024). https://doi.org/10.1186/s12871-024-02672-w

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Received : 17 May 2024

Accepted : 02 August 2024

Published : 28 August 2024

DOI : https://doi.org/10.1186/s12871-024-02672-w

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