cbt case study examples

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).

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.

17 Science-Based Ways To Apply Positive CBT

These 17 Positive CBT & Cognitive Therapy Exercises [PDF] include our top-rated, ready-made templates for helping others develop more helpful thoughts and behaviors in response to challenges, while broadening the scope of traditional CBT.

Created by Experts. 100% Science-based.

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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20 Cognitive Behavioral Therapy (CBT) Techniques with Examples

Muhammad Sohail

Table of contents.

Cognitive Behavioral Therapy (CBT) stands as a powerful, evidence-based therapeutic approach for various mental health challenges. At its core lies a repertoire of techniques designed to reframe thoughts, alter behaviors, and alleviate emotional distress. This article explores 20 most commonly used cbt techniques. These therapy techniques are scientifcally valid, diverse in their application and effectiveness, serve as pivotal tools in helping individuals navigate and conquer their mental health obstacles.

Cognitive Restructuring or Reframing:

This is the most talked about of all cbt techniques. CBT employs cognitive restructuring to challenge and alter negative thought patterns. By examining beliefs and questioning their validity, individuals learn to perceive situations from different angles, fostering more adaptive thinking patterns.

John, feeling worthless after a rejected job application, questions his belief that he’s incompetent. He reflects on past achievements and reframes the situation, realizing the rejection doesn’t define his abilities.

Guided Discovery:

In guided discovery, therapists engage individuals in an exploration of their viewpoints. Through strategic questioning, individuals are prompted to examine evidence supporting their beliefs and consider alternate perspectives, fostering a more nuanced understanding and empowering them to choose healthier cognitive pathways.

During therapy, Sarah explores her fear of failure. Her therapist asks, “What evidence supports your belief that you’ll fail? Can we consider alternate outcomes?” Guided by these questions, Sarah acknowledges her exaggerated fears and explores more balanced perspectives.

Journaling and Thought Records:

Writing exercises like journaling and thought records aid in identifying and challenging negative thoughts. Tracking thoughts between sessions and noting positive alternatives enables individuals to monitor progress and recognize cognitive shifts.

James maintains a thought journal. Between sessions, he records negative thoughts about social situations. He then challenges these thoughts, jotting down positive alternatives and notices a shift in his mindset.

Activity Scheduling and Behavior Activation:

By scheduling avoided activities and implementing learned strategies, individuals establish healthier habits and confront avoidance tendencies, fostering behavioral change.

Emily, struggling with social anxiety, schedules coffee outings with friends. By implementing gradual exposure, she confronts her fear and eventually feels more comfortable in social settings.

Relaxation and Stress Reduction Techniques:

CBT incorporates relaxation techniques like deep breathing, muscle relaxation, and imagery to mitigate stress. These methods equip individuals with practical skills to manage phobias, social anxieties, and stressors effectively.

David practices deep breathing exercises when faced with work stress. By incorporating this technique into his routine, he manages work-related anxiety more effectively.

Successive Approximation:

Breaking overwhelming tasks into manageable steps cultivates confidence through incremental progress, enabling individuals to tackle challenges more effectively.

Maria, overwhelmed by academic tasks, breaks down her study sessions into smaller, manageable sections. As she masters each segment, her confidence grows, making the workload seem more manageable.

Interoceptive Exposure:

This technique targets panic and anxiety by exposing individuals to feared bodily sensations, allowing for a recalibration of beliefs around these sensations and reducing avoidance behaviors.

Tom, experiencing panic attacks, deliberately induces shortness of breath in a controlled setting. As he tolerates this discomfort without avoidance, he realizes that the sensation, though distressing, is not harmful.

Play the Script Until the End:

Encouraging individuals to envision worst-case scenarios helps alleviate fear by demonstrating the manageability of potential outcomes, reducing anxiety.

Facing fear of public speaking, Rachel imagines herself stumbling during a presentation. By playing out this scenario mentally, she realizes that even if it happens, it wouldn’t be catastrophic.

Shaping (Successive Approximation):

Shaping involves mastering simpler tasks akin to the challenging ones, aiding individuals in overcoming difficulties through gradual skill development.

Chris, struggling with public speaking, begins by speaking to small groups before gradually addressing larger audiences. Each step builds his confidence for the next challenge.

Contingency Management:

This method utilizes reinforcement and punishment to promote desirable behaviors, leveraging the consequences of actions to shape behavior positively.

To encourage healthier eating habits, Sarah rewards herself with a favorite activity after a week of sticking to a balanced diet.

Acting Out (Role-Playing):

Role-playing scenarios allow individuals to practice new behaviors in a safe environment, facilitating skill development and desensitization to challenging situations.

Alex, preparing for a job interview, engages in role-playing with a friend. They simulate the interview scenario, allowing Alex to practice responses and manage anxiety.

Sleep Hygiene Training:

Addressing the link between depression and sleep problems, this technique provides strategies for improving sleep quality, a critical aspect of mental well-being.

Lisa, struggling with sleep, follows sleep hygiene recommendations. She creates a calming bedtime routine and eliminates screen time before sleep, noticing improvements in her sleep quality.

Mastery and Pleasure Technique:

Encouraging engagement in enjoyable or accomplishment-driven activities serves as a mood enhancer and distraction from depressive thoughts.

After feeling low, Mark engages in gardening (a mastery activity) and then spends time painting (a pleasure activity). He finds joy in these activities, which uplifts his mood.

Behavioral Experiments:

This technique involves creating real-life experiments to test the validity of certain beliefs or assumptions. By actively exploring alternative thoughts or behaviors, individuals gather concrete evidence to challenge and modify their existing perspectives.

Laura believes people judge her negatively. She experiments by initiating conversations at social gatherings and observes that most interactions are positive, challenging her belief.

Externalizing:

Externalizing helps individuals separate themselves from their problems by giving those issues an identity or persona. This technique encourages individuals to view their problems as separate entities, facilitating a more objective approach to problem-solving.

Adam, dealing with anger issues, visualizes his anger as a separate entity named “Fury.” This helps him view his emotions objectively and manage them more effectively.

Acceptance and Commitment Therapy (ACT):

ACT combines mindfulness strategies with commitment and behavior-change techniques. It focuses on accepting difficult thoughts and emotions while committing to actions aligned with personal values, promoting psychological flexibility.

Sarah practices mindfulness exercises to accept her anxiety while committing to attend social events aligned with her values of connection and growth.

Imagery-Based Exposure:

This technique involves mentally visualizing feared or distressing situations, allowing individuals to confront and manage their anxieties in a controlled, imaginative setting.

Jack, afraid of flying, visualizes being on a plane, progressively picturing the experience in detail until he feels more comfortable with the idea of flying.

Mindfulness-Based Stress Reduction (MBSR):

MBSR incorporates mindfulness meditation and awareness techniques to help individuals manage stress, improve focus, and enhance overall well-being by staying present in the moment.

Rachel practices mindfulness meditation daily. By focusing on the present moment, she reduces work-related stress and enhances her overall well-being.

Systematic Desensitization:

Similar to exposure therapy, systematic desensitization involves pairing relaxation techniques with gradual exposure to anxiety-inducing stimuli. This process helps individuals associate relaxation with the feared stimuli, reducing anxiety responses over time.

Michael, with a fear of heights, gradually exposes himself to elevators first, then low floors in tall buildings, gradually working up to higher levels, reducing his fear response.

Narrative Therapy:

Narrative therapy focuses on separating individuals from their problems by helping them reconstruct and retell their life stories in a more empowering and positive light, emphasizing strengths and resilience.

Emily reevaluates her life story by focusing on instances where she overcame challenges, emphasizing her resilience and strength rather than her setbacks.

Each of these CBT techniques plays a unique role in helping individuals transform their thoughts, behaviors, and emotions. While some focus on cognitive restructuring, others emphasize behavioral modification or stress reduction. Together, they form a comprehensive toolkit empowering individuals to navigate their mental health challenges and foster positive change in their lives.

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In this article, I use a fictitious case study to help to describe and demonstrate how CBT Therapy can be used to reduce depression and anxiety.

CBT Therapy – A Simple Case Study

Carol is a fictional character used to explain the ways in which I may work. She presented with anxiety and feelings of depression, and hopelessness. I helped her challenge her thinking and fear.

My Response

I can hear your emotional distress and the presentation seems impossible for you at the moment. Let’s see if we can break things down and work on a little at a time, to hopefully make things feel more positive and manageable for you.

Using the ABC model of CBT.

This is based on the premise that an Activating event (A)

• In your case, it is your presentation at work.

Leads to emotional and behavioural Consequences (C)

• Which you could avoid the presentation/ phone in sick, and others will not see how well you know your stuff. This is discounting the positive.

The consequences are seen as arising from your individual belief (B)

• You described self-doubt. It makes you feel nervous and afraid, you think you might feel humiliated in front of others, and they might think you are an idiot.

From past experience, you have shared some unpleasant physical symptoms: your heart racing, feeling tongue-tied, sweating.

• These inferences could be seen as jumping to conclusions, every situation is different, and you are also describing emotional reasoning. If you do your presentation, symptoms will happen because it did last time.

You have evaluated that you cannot do it, others will judge you, and others can do better. You are magnifying the negatives, discounting the positives.

Fact – You have explained that you know your subject thoroughly and the management seem to have faith in you as they have asked you to do this. Let’s focus on this and aim to achieve your presentation.

To make this more manageable, we break things down into small tasks. We work on these smaller tasks in our sessions and as homework.

• Practice your presentation in front of others, trust the feedback, work on this and practice as necessary.
• While you concentrate on your knowledge, projection, confidence, delivery, body language and professionalism, record as necessary and we can discuss.
• Tap into the emotions and physical sensations you are feeling; we could look at grading them compared to the last time you spoke publicly and each time you practiced.
• We can practice relaxation strategies and positive thinking to help with physical symptoms and nervousness. You can continue to practice alone when in times of need.
• We will look at your common cognitive errors, look for evidence of them and disregard those that do not fit.
• We can check into your self-esteem and confidence levels and record results as we go along. Assessing progress and exploring and working on sticking points.
• I would like you to list all of the facts why you can complete your presentation, and we will explore the results.

I will support you through this Carol. I have faith in this process and in you, and evidence says you can do it. We can make a plan for the sessions/homework for the time we have before your presentation.

CBT Techniques and behavioural techniques used:  The ABC Model

• Identifying faulty thoughts and feelings
• Identifying faulty thinking and looking at how it affects feelings and behaviour
• Challenging facts and focusing on positive
• Setting homework and goal and revisiting to look at progress
• Relaxation techniques
• Looking for evidence and Correcting distorted thinking
• Focusing on the client’s thoughts and feelings and underlying and irrational beliefs
• Looking at self-defeating beliefs and unrealistic beliefs
• Distinguishing between inferences and evaluations
• Teaching the client understanding and CBT method of change
• Triadic structure of CBT
• To help the client overcome blocks to change and independence
• To encourage positive thinking and change
• Looking at Schemata- underlying beliefs
• Applying distancing and decentring
• Using graded task performance
• Explaining and setting tasks/homework if the client agrees, and checking understanding.
• Explain and Test client commitment to tasks.
• Demonstrating how Carol might benefit from the sessions
• Reality testing
• Work on changing unhelpful work patterns
• Highlighting gaps between fears, experience and reality
• Review blocks and failure
• Empowering client to successfully take control
• Encouraging self-monitoring

So to summarise, for CBT therapy we work in manageable chunks. We identify the negatives and work on the fears you feel, finding strategies for you to cope and be calmer. We focus on you feeling confident and well equipped to deliver your presentation as we know you can.

About the Author:

I have many years of experience counselling individuals, young people and couples, supporting them through their struggles. I hope this article is of some help to you.

Please do get in touch through my “ Contact Me ” page to discuss your interest in CBT Therapy , or if you prefer, you are welcome to give me a call for a free introductory consultation.

Yours sincerely

BACP Accredited Counsellor Manchester

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Cognitive-Behavioral Therapy for a 9-Year-Old Girl With Disruptive Mood Dysregulation Disorder

Megan e. tudor.

1 Yale School of Medicine, New Haven, CT, USA

Karim Ibrahim

Emilie bertschinger, justyna piasecka, denis g. sukhodolsky.

Disruptive mood dysregulation disorder (DMDD) is a relatively new diagnosis in the field of childhood onset disorders. Characterized by both behavior and mood disruption, DMDD is a purportedly unique clinical presentation with few relevant treatment studies to date. The current case study presents the application of cognitive-behavioral therapy (CBT) for anger and aggression in a 9-year-old girl with DMDD, co-occurring attention deficit hyperactivity disorder (ADHD), and a history of unspecified anxiety disorder. At the time of intake evaluation, she demonstrated three to four temper outbursts and two to three episodes of aggressive behavior per week, in addition to prolonged displays of non-episodic irritability lasting hours or days at a time. A total of 12 CBT sessions were conducted over 12 weeks and 5 follow-up booster sessions were completed over a subsequent 3-month period. Irritability-related material was specially designed to target the DMDD clinical presentation. Post-treatment and 3-month follow-up assessments, including independent evaluation, demonstrated significant decreases in the target symptoms of anger, aggression, and irritability. Although the complexities of diagnosing and treating DMDD warrant extensive research inquiry, the current case study suggests CBT for anger and aggression as a viable treatment for affected youth.

1 Theoretical and Research Basis for Treatment

Anger, aggression, and irritability in youth are associated with various clinical diagnoses, including attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and depression ( G. A. Carlson, Danzig, Dougherty, Bufferd, & Klein, 2016 ; Stringaris, 2011 ; Sukhodolsky, Smith, McCauley, Ibrahim, & Piasecka, 2016 ). A more recent diagnostic category now exists that also captures these symptoms: disruptive mood dysregulation disorder (DMDD; American Psychiatric Association [APA], 2013 ). DMDD is a childhood onset disorder characterized by at least three severe temper outbursts per week with distress that is disproportionate to emotional triggers. Furthermore, mood between these outbursts is disrupted, with children presenting as irritable or angry at least 50% of their waking hours. To meet criteria for the diagnosis, irritability symptoms should be present for at least 12 months without symptom-free intervals longer than 3 months. DMDD has significant overlap with symptoms of both disruptive behavior and mood disorders ( Dougherty et al., 2014 ; Mayes, Waxmonsky, Calhoun, & Bixler, 2016 ), leading to contention as to whether or not DMDD is truly a distinct diagnostic category ( Noller, 2016 ; Runions et al., 2016 ; Wakefield, 2013 ). Nevertheless, the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5 ; APA, 2013 ) includes DMDD as such ( APA, 2013 ; Roy, Lopes, & Klein, 2014 ), thus warranting further research on related assessment and treatment.

Children and adolescents with DMDD may benefit from behavioral interventions for anger and aggression. A large evidence base exists for cognitive-behavioral therapy (CBT) as a treatment for anger and aggression ( Sukhodolsky, Kassinove, & Gorman, 2004 ). Because anger outbursts, angry mood, and aggression are the core symptoms of DMDD, CBT may also be useful for children who meet diagnostic criteria for this newly characterized disorder.

Treatment studies related to DMDD are rare, despite converging evidence that DMDD may be common among clinic-referred youth ( Freeman, Youngstrom, Youngstrom, & Findling, 2016 ) and stable throughout childhood development ( Mayes et al., 2015 ). Two studies have demonstrated some effectiveness of treating concurrent ADHD and disruptive mood symptoms in children ( Baweja et al., 2016 ; Blader et al., 2016 ). One randomized controlled trial (RCT) to date has examined psychotherapeutic treatment effectiveness, specifically for youth with psychostimulant-medicated ADHD and an earlier diagnostic iteration of DMDD, known as severe mood dysregulation (SMD; Waxmonsky et al., 2015 ). The treatment program, ADHD plus Impairments in Mood (AIM), drew from extant CBT, behavioral parent training (BPT), and problem-solving models to target children’s awareness of and responses to mood dysregulation. Irritability symptoms were measured by the three items (temper loss, angry or sad mood, and hyperarousal) on two clinical parent interviews that focus on disruptive behaviors in children: the Washington University of St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS; Geller et al., 2001 ) and the Disruptive Behavior Disorders Structured Parent Interview (DBD-I; Hartung, McCarthy, Milich, & Martin, 2005 ). Disruptive behaviors were shown to significantly decrease in the experimental treatment versus an active control, whereas effects on the measured mood symptoms were not significant. Temper outbursts decreased during the course of treatment but were reported to substantially increase during treatment follow-up phase. Overall, the study indicates that behavioral interventions built from CBT and parent management training (PMT) principles may be helpful in youth with DMDD, though time-limited booster sessions may be warranted to maintain treatment benefits.

Many questions regarding the treatment of DMDD in children remain, especially in an individual therapy format. The present case study allows for an initial exploration of specially tailored CBT for anger and aggression ( Sukhodolsky & Scahill, 2012 ) as a viable treatment for a child with DMDD.

2 Case Introduction

“Bella” was a 9-year-old Hispanic girl whose mother enrolled her in our RCT for youth with anger and aggression ( Sukhodolsky, Vander Wyk et al., 2016 ). This ongoing RCT subscribes to a Research Domain Criteria (RDoC) approach by identifying dimensions of behavior and related neural markers that are not confined to specific diagnostic categories ( Cuthbert, 2014 ). Thus, Bella’s presentation of multiple diagnoses (explained below) complemented a trans-diagnostic approach to treating a broader spectrum of irritable behavior. Following assessment protocol, Bella was randomly assigned to CBT treatment (as opposed to supportive psychotherapy).

3 Presenting Complaints

Bella’s mother sought treatment due to increasing disruptive behaviors over the past year, including non-compliance at home and at school, physical aggression toward peers, and frequent behavioral meltdowns which resembled the temper tantrums of a much younger child. Tantrums included screaming, yelling, slamming doors, and crying. Triggers could include being asked to take her daily medication or feeling that someone was standing too close to her. Bella and her mother both noted that it was difficult for Bella to “move on” when something angered her. She also noted that Bella had an underlying irritable mood, manifesting as Bella appearing “cranky” the majority of the time and the family feeling they needed to “walk on eggshells” to avoid upset. Bella was at risk for suspension from her sports teams due to recurrent unprovoked aggression toward her teammates. At school, at least one phone call home per week was being placed due to Bella’s refusal to comply or sometimes to even speak to her teacher for days at a time. Bella and her mother noted that Bella was generally well liked by peers and teachers, given that she was hardworking and funny, yet her current disruptive behaviors were causing significant interference in making new friends and meeting academic goals.

Bella lived with her mother, stepfather, and three older siblings. She visited with her father who lived nearby approximately once per month. Bella’s mother denied any pre- or perinatal complications and stated that Bella met developmental milestones on time. Behavioral difficulties reportedly began around age 3, where Bella’s mother noted that she was extremely active and markedly stubborn. These concerns were exacerbated in the school setting and, by age 6, Bella participated in a pediatric evaluation that yielded a diagnosis of ADHD-Combined presentation due to ongoing difficulties with inattention and hyperactivity that were impeding her academic performance. Bella’s history was further complicated by persistent difficulties with math and related anxiety about math performance. These combinations of symptoms led to the provision of a school 504 plan that afforded Bella intensive math support, extra time on tests, and classroom breaks, as needed. At the time of intake, Bella was attending fourth grade in mainstream classes and described herself as doing well in school, save for assignments in math assignments which remained her least favored subject.

Bella had not participated in any form of psychological treatment prior to participating in our treatment study. Bella was prescribed Stratera (18 mg/day) at age 7 by her pediatrician, which was maintained at the time of our intake interview and throughout treatment. In our study, we include participants with either no medication or stable medication regimens, though medication management is not provided. Stratera is a brand name version of atomoxetine, a selective norepinephrine reuptake inhibitor. Although psychostimulant medication is generally recommended as the first-line treatment for ADHD in children ( Blader et al., 2016 ), there are sometimes reasons for prescribing alternative medications such as atomoxetine ( Pliszka, 2007 ). According to Bella’s mother, at age 7, Bella presented with mild anxiety, particularly related to school performance. Comorbid anxiety has been observed in 25% to 35% of children diagnosed with ADHD, and atomoxetine is accepted as effective with this dual diagnosis ( Hammerness, McCarthy, Mancuso, Gendron, & Geller, 2009 ). Overall, this relatively low dose of medication had reportedly proven useful in addressing both anxiety and ADHD symptoms for Bella and, according to our team’s psychiatry consultants, was appropriate for progressing with therapy without psychiatric re-evaluation.

Our study does not provide medication management or consultation regarding medication that children are receiving in the community. Children are eligible to participate if medication has been stable without plans for change for the 4-month study period. We generally only recommend psychiatric evaluation or re-evaluation for ADHD symptoms if these symptoms are clearly an underlying factor in the participant’s anger and aggression, or if symptoms grossly affect the participant’s ability to understand the material or engage in treatment. Neither of these descriptions applied to Bella, who met criteria for ADHD diagnosis based on clinical interview and was in the borderline clinical range on parent report measures ( T = 68 on the Attention Deficit/Hyperactivity subscale of the Child Behavior Checklist [CBCL]; Achenbach & Rescorla, 2001 ), but whose symptoms appeared relatively non-impairing at the time of intake.

5 Assessment

As part of the study, Bella and her mother were administered comprehensive assessments of irritability and associated psychopathology, including clinical interviews and parent report measures. With Bella’s assessment, we maintained adherence to the study protocol, which only required participation of one parent. However, we would have been happy to obtain information from Bella’s father or engage him in the study process if it had been requested by the family. In addition, Bella and her mother stated that behavior presentation was largely similar across the two households.

Diagnostic Interview

DSM-5 diagnoses were assigned based on the structured interview conducted by an experienced clinical psychologist (last author). The Kiddie Schedule for Affective Disorder and Schizophrenia for School-Age Children, Present and Lifetime (K-SADS-PL; Kaufman et al., 1997 ) is a diagnostic interview that assesses psychopathology in children based on child and parent report. Interview questions are presented to both children and parents separately, followed by integration of both informants’ report. DMDD symptoms were evaluated by the K-SADS addendum ( Leibenluft, 2011 ). DMDD symptoms are coded as “Not present,” “Sub-threshold,” or “Threshold” for DSM-5 diagnostic criteria. At the time of the interview, Bella’s prior diagnosis of ADHD-Combined presentation was confirmed due to impairing symptoms of inattention, distractibility, and hyperactivity, though these symptoms were reportedly significantly decreased and minimally impairing since medication prescription at age 7. Her preexisting community diagnosis of unspecified anxiety disorder was not confirmed with K-SADS; both Bella and her mother reported occasional bouts of worry about school performance but not to the frequency or intensity that warrants clinical diagnosis.

Per the K-SADS, Bella and her mother shared that Bella typically presented with out-of-control 30-min temper outbursts approximately 3 to 5 times per week. Outbursts consistently appeared out of proportion to the situation at hand and reportedly resembled that of a much younger child, around 3 to 4 years old. Outbursts consisted of screaming, crying, insulting others, and general non-compliance occurring at home and, less often, in the community (e.g., in the grocery store, at the sidelines of a soccer match). In between outbursts, Bella’s mood was described as generally “cranky” and her mother described feeling that she was “walking on eggshells” around Bella. Bella’s mother shared that this irritability occurred approximately 75% of the time, with Bella appearing neutral or cheerful the remaining 25% of each day. Bella’s persistently angry and irritable presentation was not only endorsed by her mother but also her elder siblings, teacher, and soccer coach. Opposition and defiance were noted since age 3; however, the outbursts and irritability described here had manifested for approximately 2 years preceding assessment (since age 7). The longest symptom-free period was as a few days, and such bouts were reportedly rare. Overall, symptoms were described as causing impairment for Bella in her family relationships, friendships, and school performance. The obtained symptom profile, in addition to the absence of past or current mania, warranted a diagnosis of DMDD. Of note, Bella also met criteria for ODD; however, a diagnosis of DMDD contraindicates ODD diagnosis ( APA, 2013 ).

Of note, we do not collect teacher ratings as part of study assessment procedure, although sometimes families bring copies of past assessments that include teacher ratings. However, in clinical settings, it is advisable to collect teacher ratings of ADHD as well as symptoms of other behavioral and mood disorders. For example, clinicians could seek out teacher report versions of the parent report measures described below, to then be integrated into the clinical assessment. Further information gathering can include discussion of core DMDD symptoms with teachers or other school professionals in order to better understand presentation of these symptoms across multiple settings.

Parent Report Measures

Bella’s mother filled out a battery of parent report measures. Scores on the measures of anger/irritability and aggression are presented in Table 1 . The 18-item CBCL–Aggressive Behavior subscale ( Achenbach & Rescorla, 2001 ) was completed as a “gold standard” measure of aggressive behavior and yielded a clinically elevated score for Bella. The Affective Reactivity Index (ARI; Stringaris et al., 2012 ) consists of seven items, six of which are averaged as an index of irritability. Youth with SMD were reported to have an average score of 7 on this measure. As such, Bella’s score of 10 reflected clinical elevation. The Disruptive Behavior Rating Scale (DBRS; Barkley, 1997 ) is an eight-item measure keyed to the DSM symptoms of ODD. A mean DBRS score of 12 and above indicates clinically significant symptoms, and Bella’s score of 13 was above this clinical threshold. Parent ratings of depression and anxiety conducted per the Child Depression Inventory ( Kovacs, 2011 ) and the Multidimensional Anxiety Scale for Children ( March, 2012 ) indicated that Bella was experiencing normative levels of internalizing symptoms. Together, these parent ratings indicated that Bella’s particular presentation of DMDD was characterized by externalizing behaviors and irritability, rather than depressive mood.

Pre-Treatment, Post-Treatment, and Follow-Up Assessments.

Note . MOAS = Modified Overt Aggression Scale; CGI-I = Clinical Global Impression–Improvement score (as compared with baseline functioning); CBCL = Child Behavior Checklist ( t scores); ARI = Affective Reactivity Index; DBRS = Disruptive Behavior Rating Scale.

Aggressive behavior was measured using the Modified Overt Aggression Scale (MOAS; Silver & Yudofsky, 1991 ; Yudofsky, Silver, Jackson, Endicott, & Williams, 1986 ) tailored to the assessment of aggression in clinical trials ( Blader, Schooler, Jensen, Pliszka, & Kafantaris, 2009 ). The MOAS was administered as an interview with the parent and child (separately) by an independent evaluator (licensed clinical social worker) who was not involved in treatment and was unaware of the treatment that Bella was receiving. The MOAS is used as a primary outcome measure in the relevant clinical trial ( Sukhodolsky, Vander Wyk et al., 2016 ) and consists of 16 items related to the aggressive behavior over the past week. Items are weighted based on potential harm and create four aggression subscales, including Verbal Aggression, Aggression Against Objects, Self-Directed Aggression, and Aggression Against Others. Bella evidenced significant levels of aggressive behaviors in all subscales excepting for self-directed aggression, resulting in an overall score of 32. For example, Bella was reported as presenting with three aggressive incidents (e.g., punching) toward non-relative peers in the week preceding evaluation.

Target Symptoms

In addition to the MOAS, the independent evaluator also elicited the two most pressing concerns in the area of anger and aggression and described these concerns, which are referred to as “target symptoms.” Target symptoms are coded in terms of frequency, duration, severity, and impact on adaptive functioning across all contexts ( McGuire et al., 2014 ). Bella’s target symptoms were (a) anger outbursts and meltdowns, characterized by verbal aggression and subsequent “shutting down,” with refusal to comply or communicate, and (b) physical aggression, such as hitting, punching, and shoving which most commonly occurred toward sports teammates, classmates, and her older brother.

Intellectual Functioning

Per study protocol, Bella completed the Wechsler Abbreviated Scale of Intelligence (WASI), indicating a verbal IQ of 93, a performance IQ of 99, and a full-scale IQ of 96. Overall, this intellectual functioning screener suggested that Bella’s intelligence was uniform across abilities and fell in the Average range of functioning. These results indicated that Bella would be a good candidate for the CBT content and activities ( Lickel, MacLean, Blakeley-Smith, & Hepburn, 2012 ).

6 Case Conceptualization

Bella, like many youth with ADHD, exhibited disruptive behavior concurrent with inattention and hyperactivity symptoms ( C. L. Carlson, Tamm, & Gaub, 1997 ). Although pharmacological treatment significantly decreased Bella’s school difficulties by age 7, anger and aggression persisted. Evidence suggests that children like Bella may possess an inherent predisposition for irritability, including impaired functioning in the amygdala and frontal lobe ( Vidal-Ribas, Brotman, Valdivieso, Leibenluft, & Stringaris, 2016 ). Her early onset of irritable behavior and aggression may have resulted in teachers and family members responding in an inadvertently reinforcing manner, for example, separating Bella from other children versus problem solving. Thus, Bella’s clinical profile reflected both a predisposition to disruptive behavior and an interaction with her environment that resulted in interference with developmental maturation of emotion regulation or social skills that were expected for her age. In addition to disruptive behaviors, Bella has also experienced some academic difficulties, particularly in the area of math. Academic performance became a source of anxiety which further compounded non-compliance with homework and behavioral problems at school. As such, Bella had learned from a young age to primarily communicate her negative emotions through avoidance, physical aggression, and tantrums, which were reinforced by Bella’s attainment of desired goals (e.g., a child going away or obeying her demands, family offering her several hours of personal space). Alone, these behaviors would have warranted a diagnosis of ODD. For Bella, however, her prolonged instances of angry and irritable mood in between temper outbursts indicated a diagnosis of DMDD. It is also important to note that early onset of ADHD and co-occurring symptoms of anxiety are also consistent with the diagnosis of DMDD ( Dougherty et al., 2014 ; Mulraney et al., 2015 ; Uran & Kılıç, 2015 ).

Although Bella demonstrated many strengths, such as athletic ability and sense of humor, many of her social experiences became overshadowed by negative interactions, which were interfering with her enjoyment of home and school life. As such, our treatment goal was to replace Bella’s maladaptive anger outbursts and aggressive behaviors with age-appropriate skills of managing frustration and communicating with others. Simultaneously, Bella’s mother was taught parenting tools for supporting Bella’s progress in learning of new emotion regulation and problem-solving skills.

7 Course of Treatment and Assessment of Progress

Bella and her mother were seen by a post-doctoral clinical psychologist (first author) for 12 weekly 60-min CBT sessions. Then, she participated in five booster sessions over the subsequent 3 months. Our program typically offers three booster sessions; however, additional booster sessions were requested by the family to maintain treatment gains. We agreed to provide extra boosters because in a recently published study of behavioral intervention for children with SMD, immediate irritability-related treatment gains were not maintained at 6-week follow-up ( Waxmonsky et al., 2015 ). Manualized CBT for anger and aggression in youth was administered using a structured treatment manual ( Sukhodolsky & Scahill, 2012 ). The treatment is organized into three modules: emotion regulation, social problem solving, and social skills.

After each session, children received a therapeutic homework, which is referred to as “anger management practice” with the child to avoid using the word homework . As part of this practice, children are asked to fill out an anger management log, different for each session, which asks for specific examples of using each skill discussed in the last session in the context of an angry or aggressive outburst, whether anger management strategies were implemented successfully or unsuccessfully. Completion of anger logs is rewarded at the next session with enthusiastic praise from the therapist and small prizes when developmentally appropriate. Parenting skills are also integrated into treatment and coached during additional parenting sessions.

The manual includes built-in flexibility features that allow the child and the therapist to select therapeutic techniques and activities that match the child’s developmental level and target symptoms. Additional material was integrated that focused on DMDD-specific symptoms (described further below). Progress was assessed through the battery of interview and parent report measures described previously, which were conducted before and after treatment, and following a 3-month “booster” phase. Treatment progress was also discussed at weekly check-ins with Bella’s mother about the form, frequency, duration, and intensity of Bella’s target symptoms (i.e., temper outbursts, physical aggression).

Emotion Regulation and Anger Management

Sessions 1 to 3 involved an introduction to therapy, psychoeducation, identification of anger triggers, and the development of strategies to prevent anger episodes, such as scripting verbal reminders and relaxation training. Bella responded well to this phase of treatment and was particularly impressed that there were alternative approaches to handling angry behaviors. She stated that she was unaware that anger could be changed. Bella’s anger triggers typically included the perception that peers or family members had wronged her and the desire to “teach them” it was not okay through yelling or aggression. For example, immediately preceding the first session, Bella had punched a basketball teammate for “putting her hands on” her. Bella’s mother confirmed that the girl had simply brushed against Bella while walking by her. Bella took to silently singing a popular song lyric, “Stop! Wait a minute!” in her mind when recognizing an anger cue or early signs of anger escalation (e.g., a 1 or a 2 on her 5-point anger thermometer), and then engaging in deep breathing or reciting verbal reminders to guide her behaviors, such as, “You are going to get in trouble” or “Maybe this isn’t something to get worked up over.” Each week, Bella earned small prizes (e.g., shopkins) for completing anger management practice logs that described her handling of an anger-provoking episode.

Social Problem Solving

Sessions 4 to 6 covered social problem-solving skills including problem identification, generating different solutions, and evaluating the possible consequences to reduce conflict. Identifying the differences between responses that are passive, assertive , or aggressive was especially useful in enhancing Bella’s ability to generating solutions to conflicts. The therapist helped Bella and her mother to collaborate on developing behavioral contracts to prevent specific conflicts at home. For instance, Bella initially presented with a 5- to 10-min anger outbursts approximately 5 times per week when asked to take her medication. This occurred despite the fact that Bella’s mother did not alter the request and, ultimately, Bella took her medication successfully each time. In treatment, Bella agreed to calmly and immediately take her medication each night and her mother agreed to take her to get doughnuts every Saturday based on that behavior. Subsequently, Bella’s tantrums regarding medication decreased to 0 within 2 weeks and maintained for the several subsequent months of treatment.

Bella also excelled at decreasing her hostile attribution bias by reframing her previously negative perceptions of others’ intentions. She recognized that many past incidents where she believed that people were attempting to bother or assault her were misunderstood. Bella showed pride in her new ways of handling these situations, making statements like, “People want to be my friend more now. They used to think I was cool but kind of crazy. Now they just think I am cool.”

Social Skills

Sessions 7 to 9 addressed social skills for preventing and resolving conflicts or anger-provoking situations with siblings, peers, teachers, and family. Potential solutions to conflicts were role-played in session, for example, acting out how to calmly handle disagreements with friends about what to play or how to politely ask her brother to stop teasing her. For example, when playing with others, Bella practiced asking for the opinions of her friends, like, “Would you all like to play it this way?” rather than insisting that they play her way at the beginning of a play session (e.g., “I’m in charge, I don’t care if you don’t like it”). These skills were practiced in session with her therapist playing the part of other children who may disagree, which was effective in escalating anger and allowing for practice of positive interactions. Monitoring of voice tone and facial expression was exercised through the use of video recording, thereby helping Bella monitor and modify her outward expression of anger. Bella agreed that these skills contributed to more positive play time and more fun with her friends, which she noted as a more important goal than getting her way.

Importantly, Bella practiced simply stating, “I need help” or “I need a break” when feeling upset, rather than using harsh words or physical aggression. Her teacher and family reinforced this effective communication by calmly and briefly discussing the situation at hand, problem solving, and allowing Bella some alone time, as needed. These communication skills were integral in decreasing aggression, as Bella felt that she had a new tool for resolving social problems that did not put her at risk for getting in trouble (unlike punching others).

Parent Training

Parents are an integral component in CBT for anger and aggression ( Sukhodolsky & Scahill, 2012 ). Three separate 60-min sessions were conducted with Bella’s mother to address family conflict and provide strategies for encouraging positive behaviors such as giving praise, attention, and privileges. This duration of sessions was sufficient with Bella’s treatment, although more flexibility may be required in other cases. The treatment manual suggests conducting parent sessions in conjunction with the first, middle, and final CBT sessions, though flexible administration is often required due to family scheduling needs and to ensure that parent training coincides effectively with CBT sessions. Treatment progress and skills covered in each CBT session were also reviewed with the parent at each visit so that parents could track and reward application of new anger management skills at home. These parenting skills were especially important to Bella’s progress, given that she was growing up in a household with multiple siblings and expected behaviors often went unnoticed, whereas misbehavior resulted in one-on-one attention. In parenting sessions, the converse response was practiced with Bella’s mother, wherein “shut down mode” or yelling received no attention, whereas Bella’s problem solving and use of other coping strategies received praise and encouragement.

School Consultation

To maximize treatment gains in the school setting, Bella’s therapist had intermittent phone conversations with Bella’s fourth-grade schoolteacher. Target behaviors (e.g., decreasing aggression, increasing compliance) and related strategies (e.g., Bella’s recognition of anger cues, practicing effective communication in place of aggression) were relayed to Bella’s teacher, who was eager to encourage Bella’s progress in the school setting through prompting and praise. Bella’s teacher provided invaluable insight into behavioral progress, including report that Bella’s decrease in irritable behaviors made her more amenable to math tutoring. Subsequently, Bella arrived to several sessions sharing about success with math during the previous week.

Adapting Treatment for DMDD

Although much of the extant CBT treatment manual was appropriate for addressing Bella’s target behaviors of aggression and tantrums, some specialized material was integrated into Bella’s care to target the prolonged periods of irritability she demonstrated at home, school, and, sometimes, in the therapy session. These adaptations included (a) extending psychoeducation, (b) emphasizing on behavioral activation, (c) building an emotion regulation template for reducing duration of irritable mood periods, and (d) including extra booster sessions during the 3-month booster period (five instead of the usual three sessions). Psychoeducation included characteristics of prolonged irritable episodes, such as specific triggers, the common feeling of being “stuck” in that mood, and creating a creative metaphor for the irritable mood. Bella described her prolonged irritable episodes as “shut down mode” wherein her brain withdrew and could only react “in a snappy way” toward others. This allowed Bella to quickly identify irritability and remind herself that it was possible to coach her brain to “reverse shut down mode” where she could enjoy herself and interactions with others.

Behavioral activation was used to reduce prolonged periods of negative mood (e.g., Pass, Whitney, & Reynolds, 2016 ). Specifically, Bella maintained a list of enjoyable activities she could do in any setting to help herself keep active and busy, which, in turn, reduced the intensity of her “shut down mode” and increased her chances of being happy. For example, she would read, watch television, or ask family members to play with her during these instances. Prior to treatment, when in “shut down mode,” she was most likely to retreat to her room and dwell on the situation that triggered her anger.

Last, although decreasing irritability was an important goal, it was also recognized that some occasional irritable mood is typical, especially after a child is particularly disappointed or frustrated. As such, Bella and her mother collaborated with the therapist to identify a goal for the form and duration of irritable behavior. Specifically, Bella decided that 20 min of alone time, which she would request of her family calmly, would be sufficient to take part in a fun activity and help her “move on,” to which her mother agreed. These skills were especially relevant during the booster sessions of therapy, likely because tantrums and aggression had significantly decreased and “shut down mode” became a more pressing behavioral concern.

Post-Treatment Assessments

All outcome data are presented in Table 1 . Bella’s improvement was assessed following 12 sessions of CBT (and also at follow-up, presented in the “Follow-Up” section below). All post-treatment measures indicated a significant decrease in anger/irritability and aggression and fell within the normative range of functioning.

MOAS score reduced from 32 to 2, demonstrating that Bella had exhibited zero instances of verbal or physical aggression in the past week, and only one instance involving property damage: slamming a door when asked to clean her room before watching a movie. At that time, her mother noted that “shutting down” occurred once during the past week and was disruptive to family activities. As such, this behavior was targeted in later booster sessions.

The independent evaluator assigned a Clinical Global Impression-Improvement (CGI-I) score as a primary categorical outcome measure in the present research study ( Arnold et al., 2003 ). This score indicates the level of behavioral change from baseline rated on a 7-point scale (1 = very much improved ; 7 = very much worse ). Bella’s target symptoms of decreasing meltdowns and decreasing physical aggression were rated as 1 “ very much improved .”

8 Complicating Factors

Bella’s irritability served as a mildly complicating factor in two treatment sessions (Session 5 and a booster session). Specifically, irritability and opposition presented to a degree that limited Bella’s engagement in session material. In both occurrences, Bella was angered by something that occurred prior to session and initially refused to speak to her therapist. Although these instances were challenging in terms of completing planned session material, they were recognized as inherent to Bella’s target symptoms and, ultimately, helpful in exercising in-vivo practice of emotion regulation skills. Fortunately, Bella and her therapist were always able to end these sessions on a positive and meaningful note by offering validation and clear contingencies that both modeled and rewarded behavior activation (e.g., “I’m sorry to see you are having a rough day, Bella. When you are ready to talk, let me know. I want to ask you one question about the past week and then I have a very funny video to show you!”). These potentially complicating factors are especially important for the consideration of students and professionals, and are addressed further in “Recommendations to Clinicians and Students” section.

9 Access and Barriers to Care

It is important to note that the current treatment was conducted as part of a research study and, thus, may not reflect the typical clinic environment. As part of the study, the family received free clinical services, monetary compensation for their time, and flexible scheduling options. These characteristics of the study likely lessened the burden of participation for the family, who did not report any significant difficulties with completing all study visits. A family of a child referred to an outpatient clinic for a similar treatment would be responsible for the treatment cost, without compensation for time dedicated to assessment and treatment, which could limit some families’ ability to access and complete treatment.

10 Follow-Up

Bella participated in five booster sessions over the course of 3 months, immediately following the completion of the standard 12 CBT sessions offered as part of our research study. These sessions were designed to review and reinforce the content of the therapy program and to identify ongoing areas of need. These sessions are administered once per month on average, although in Bella’s case, we added two additional sessions to address DMDD symptoms. In Bella’s case, these boosters were useful for check-ins regarding irritability and behavioral activation skills, which were relevant to the remaining behavioral goals at that time. Our study typically offers three booster sessions for families but, given past evidence that suggests the utility of follow-up sessions for youth with DMDD ( Waxmonsky et al., 2015 ), two additional sessions appeared appropriate. Bella and her mother noted that these sessions were helpful at maintaining progress and continuing to target irritability goals. This report was supported by the follow-up data that were consistent with data collected post treatment (see Table 1 ). During the week preceding follow-up assessment, she was reported to have slammed a door three times when frustrated by homework assignments related to math. No instances of “shut down” were reported.

Following study completion, the family was encouraged to seek out consultation from the team should any concerns arise regarding Bella’s behavior management. No such requests have been made (4 months post study at the time of manuscript preparation).

11 Treatment Implications of the Case

The current case demonstrates the feasibility of CBT for anger and aggression in children with DMDD. No existing studies have examined individually administered CBT for anger and aggression in youth with DMDD, though the need thereof is increasingly important as this new diagnosis gains clinical attention ( Leibenluft, 2011 ; Roy et al., 2014 ). Our current case study shows how a child with DMDD can be effectively treated with a structured CBT for anger and aggression treatment ( Sukhodolsky & Scahill, 2012 ) enhanced with psychoeducation and behavioral activation strategies ( Hopko, Lejuez, Ruggiero, & Eifert, 2003 ). The enhancements to the CBT program may have been especially important to Bella’s excellent response to treatment. The five booster sessions allowed for a more gradual transition out of therapy and focused on decreasing non-episodic irritability, which may have been key to her long-term progress. These results are in contrast to previous findings that treatment gains were not maintained 3 months after group therapy for SMD ( Waxmonsky et al., 2015 ).

Notably, Bella was a participant in our ongoing randomized controlled study that tests the utility of CBT for irritability in children across diagnostic categories. This study is based on the RDoC initiative ( National Institutes of Mental Health, 2016 ) that aims to explore the core dimensions of psychopathology based on neurobiology and behavior, as opposed to the traditional categorical approach to diagnosis. Ultimately, RDoC attempts to integrate findings in genetics, neurology, molecular biology, cognitive science, and other disciplines to better inform our diagnostic classification system. The Negative Valence System, one of the five RDoC domains, encapsulates anger and aggression—the variables targeted in Bella’s treatment. Applying a treatment for a core symptom area (anger and aggression) rather than a specific diagnosis may have been ideal in treating Bella. Given DMDD’s high co-morbidity with other DSM diagnoses, including ADHD, and its significant overlap with ODD and depression, treatment of a specific categorical diagnosis would be challenging and likely misguided. In addition, almost all childhood psychiatric diagnoses are associated with increased risk of aggression ( Jensen et al., 2007 ). If a treatment such as CBT for anger and aggression can be implemented successfully across diagnostic categories, it may decrease the need for diagnostic precision in an imperfect system such as the DSM-5 . The current case study indicates that this singular treatment may be applied and/or modified to effectively treat a core symptom area in children that meets criteria for various DSM-5 disorders. It will be especially useful to identify other treatment packages that may be applied trans-diagnostically, especially for commonly co-occurring disorders in youth.

A benefit of the current treatment may be the ease of implementation across professionals. Bella’s provider possessed a PhD in clinical psychology, whereas other clinicians in our current study are psychology graduate students and child and adolescent psychiatry fellows. This flexibility in implementation may be particularly relevant for treatment of children with DMDD who may present with psychiatry referrals. Potential psychopharmacologic treatments for DMDD that have been suggested might include antidepressants, mood stabilizers, stimulants, and antipsychotics ( Tourian et al., 2015 ); however, medication alone may not be ideal. Medications, of course, are not without side effects, many of them significant and/or requiring regular monitoring over the course of treatment, including with blood work. In addition, given that there are two distinct symptoms clusters being treated in DMDD—irritable or depressed mood and angry outbursts—it is reasonable to conclude that in many cases, more than one medication might be required to treat symptoms. Our CBT program with some modification appears to be effective in treating DMDD over a short period of time with minimal modifications and, as such, may be ideal for first-line treatment for youth DMDD, particularly those who present with irritable mood in between outbursts.

Bella’s presentation did not reflect the symptom profile of some other youth DMDD. Namely, while she experienced significant and impairing irritability, she did not experience depressive symptoms such as withdrawal, anhedonia, or suicidal ideation. Therefore, the treatment implications of the current case are cautioned in terms of application to youth experiencing depressive mood between anger outbursts, wherein additional or different modifications would likely be warranted for treatment results and, above all, patient safety. It is of interest to note that behavioral but not mood symptom changes were an outcome of group therapy for SMD ( Waxmonsky et al., 2015 ), which further speaks to the complex nature of treating the co-occurring symptoms captured by DMDD. Furthermore, the same must be stated in reference to anxiety symptoms, which commonly co-occur with DMDD but were not endorsed for Bella. Youth with DMDD and significant anxiety may benefit from additional anxiety-focused behavioral interventions (i.e., exposure and response prevention).

Another caution toward the current results is the fact that Bella was receiving medication for ADHD and mild anxiety. The medication was stable during the study, and it is unknown what effect the treatment would have had in a child with the same diagnostic profile without medication. Lastly, the fact that the current case study focuses on a female is not to be overlooked. Like all disruptive behavioral disorders, early evidence suggests that females may be less likely to be given a diagnosis of DMDD ( Dougherty et al., 2014 ; Tufan et al., 2016 ). We are glad to provide evidence of treatment utility with a female patient, given that they may be less likely to be featured in this area of child psychology, though further study of treatment implications as they differ (or do not differ) across the sexes is warranted.

12 Recommendations to Clinicians and Students

Although we have previously stated that CBT for anger and aggression can be delivered by a range of clinicians, it is important that clinicians feel familiar and competent with delivering the complete manual prior to starting treatment. The modules reflect a variety of themes and strategies that may be useful to children; however, a high degree of flexibility is recommended ( Kendall & Beidas, 2007 ). For example, it can be useful to improvise and incorporate material from later sessions if that material is pertinent to a child’s presenting complaint on a given day. Furthermore, some children may dislike particular strategies (e.g., deep breathing), and it is significantly more important to maintain a strong therapeutic alliance by collaborating on goals and strategies than it is to achieve 100% fidelity for every session. In fact, as part of our current research study, an 80% fidelity rating is encouraged.

In addition, children with DMDD can be difficult to engage with due to both their baseline anger and irritability, as well as recurrent temper outbursts or meltdowns. It is likely that the clinician will experience at least one disruptive behavior episode (or many more) during session. These incidents are par for the course and, perhaps in a counterintuitive manner, are extremely beneficial to the child’s progress in treatment. Specifically, therapists are able to demonstrate appropriate behavioral contingencies and extinction schedules that will be useful for parents to observe. Bella, for example, once came to session angry at her sister and refused to speak to her therapist. The therapist use the opportunity to remind Bella of the skills she could apply to “turn it around” and checked in with Bella’s mother until Bella was observed putting effort into that goal (i.e., taking deep breaths, attempting to join the conversation), at which time she was praised and given a choice of a fun activity. Thus, Bella’s mother was able to observe selective attention, which can be a particularly difficult parenting skill for parents of children with disruptive behavior, and Bella was able to practice skills with the direct support of her clinician. We encourage clinicians and students not to dread disruptive behavior in session, but rather to welcome it as a unique and effective learning opportunity. However, clinicians must, of course, have a sound understanding of behavioral intervention to successfully respond to such incidents.

As with any type of behavioral modification, progress can be quite gradual. It may take several sessions before the child “buys in” to the treatment. It can be helpful to frame the treatment in terms of tangible benefits for the child; there is often a noticeable switch where the child recognizes that decreasing anger and aggression leads to specific and appreciable outcomes. For example, most children will recognize that hitting a peer will make that peer less likely to play with them in the future, even if they feel that the peer “deserves it,” or that insulting a teacher will lead to them getting detention even if they feel it is “unfair.” It is important to remember that these children often have a long history of feeling that they are “bad,” and an integral component of treatment is to counter this belief. A strong rapport can be built in the first session, simply by validating the child’s point of view and listening to recent difficulties without criticism. It is often helpful to alert the children that nothing shared in session will get them into trouble and, in fact, that the goal of therapy is to help them get in trouble less and enjoy their day-to-day life more. Ultimately, it is ideal for the child to recognize how their behavioral change will benefit them in their day-to-day life, which usually leads to them feeling proud about their efforts and accomplishments.

The parent check-ins at the end of each session are crucial to the success of the therapy. As outlined in the manual, be sure to stress to the parents during the first session how important it is to consistently praise positive behavior and to “catch the child being good.” At each parent check-in, the parent should provide a concrete example to the clinician of the child engaging in a positive behavior or attempting to apply skills and tools learned during the previous CBT session. Due to the “review” nature of these check-ins, a notable risk is present that the parent and/or child will attempt to use the time to simply list complaints about the past week, which is counterproductive to long-term progress. As such, clinicians should troubleshoot specific concerns and integrate them into session material (e.g., problem solving) but should also assertively request “highlights” of the past week. In addition, it can be helpful to supplement the three parent sessions and parent check-ins with concepts and tools from Parent Management Training, including structured behavior plans for the home. The clinician should also remind parents that the goal of treatment is not 100% remission. Occasional outbursts are a normal part of development and are not always pathological. It is best to frame the child’s success in terms of a decrease in the frequency and intensity of the target symptoms that were defined at the beginning of the treatment.

It is also important to point out to clinicians and students that the study of treatment for DMDD is new. Here, we present the results of an extant treatment that was adapted for a child with DMDD. It would be remiss for us to imply that this may be the only viable treatment for youth with DMDD, though it is difficult to expound upon treatment alternatives. Nevertheless, as mentioned previously, DMDD overlaps with other diagnostic categories that have long-standing evidence for the utility of cognitive (e.g., Boxer & Butkus, 2005 ), behavioral (e.g., Folino, Ducharme, & Conn, 2008 ; Rote & Dunstan, 2011 ), and combined (e.g., Pass et al., 2016 ) approaches to treatment. We are not currently aware of an evidence-based psychotherapeutic approach that would be definitively distinct from the CBT treatment presented here.

Last, as shown in the current case, these youth are likely to present with a complex history and multiple diagnoses, including ADHD and internalizing disorders. Thus, it is important for clinicians and students working with these youth to be well versed in a variety of clinical presentations, as well as related behavioral and pharmacological treatments. Furthermore, in the age of RDoC, clinical training will likely benefit from integrating behavioral treatments for core symptoms—such as anger and aggression. Such a training priority may help to serve a larger population of youth, including those with more complex clinical presentations such as DMDD.

Acknowledgments

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is supported by National Institute of Mental Health (Grant/Award Number “R01 MH101514” to Drs. Denis Sukhodolsky and Kevin Pelphrey).

Biographies

Megan E. Tudor , PhD, is a postdoctoral associate at the Yale Child Study Center where she conducts clinical research, including diagnostic assessment and therapy for research participants. Her research interests relate to imporoving clinical services for youth with a variety of neurodevelopmental and behavioral disorders, as well as their family members.

Karim Ibrahim , MS, is a former trainee of the Yale Child Study Center where his focus was on behavioral interventions for autism and disruptive behavior disorders. He is a doctoral candidate in clinical psychology at the University of Hartford.

Emilie Bertschinger , BA, is a post-graduate associate at the Yale Child Study Center. She completed her bachelor’s in psychology at Boston University in 2015. She coordinates the clinical research study described in the current case study.

Justyna Pasecka , MD, is a fellow in the Solnit Integrated Training Program in Adult and Child Psychiatry at the Yale Child Study Center. She will complete her training in 2017 and will continue providing clinical services with children and adolescents.

Denis G. Sukhodolsky , PhD, is an associate professor and director of the Evidence-Based Practice Unit at the Yale Child Study Center. His lab conducts research on the efficacy and mechanisms of behavioral treatmetns for children with neurodevelopmental disorders such as autism spectrum disorder, Tourette syndrome, OCD, anxiety, and disruptive behavior disorder.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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A Counselling Case Study Using CBT

Jocelyn works as a Human Resources Manager for a large international organisation. She is becoming more and more stressed at work as the company is constantly changing and evolving. It is a requirement of her job that she keeps up with this change by implementing new strategies as well as ensuring focus is kept on her main role of headhunting new employees.

She finds that she is working twelve-hour days, six days a week and doesn’t have time for her friends and family. She has started yelling at staff members when they ask her questions and when making small mistakes in their work. Concerned about her stress levels, Jocelyn decided to attend a counselling session.

Below is an extract from Jocelyn’s first session with her counsellor:

Transcript from counselling session

Counsellor: So Jocelyn, let’s spend a few minutes talking about the connection between your thoughts and your emotions. Can you think of some times this week when you were frustrated with work? Jocelyn : Yes, definitely. It was on Friday and I had just implemented a new policy for staff members. I had imagined that I would get a lot of phone calls about it because I always do but I ended up snapping at people over the phone. Counsellor : And how were you feeling at that time? Jocelyn : I felt quite stressed and also annoyed at other staff members because they didn’t understand the policy. Counsellor : And what was going through your mind? Jocelyn : I guess I was thinking that no-one appreciates what I do. Counsellor : Okay. You just identified what we call an automatic thought. Everyone has them. They are thoughts that immediately pop to mind without any effort on your part. Most of the time the thought occurs so quickly you don’t notice it but it has an impact on your emotions. It’s usually the emotion that you notice, rather than the thought. Often these automatic thoughts are distorted in some way but we usually don’t stop to question the validity of the thought. But today, that’s what we are going to do?

The counsellor proceeds to work through the cognitive behaviour process with Jocelyn as follow:

Step 1 – Identify the automatic thought

Together, the counsellor and Jocelyn identified Jocelyn’s automatic thought as: “No-one appreciates what I do”.

Step 2 – Question the validity of the automatic thought

To question the validity of Jocelyn’s automatic thought, the counsellor engages in the following dialogue:

Counsellor : Tell me Jocelyn, what is the effect of believing that ‘no-one appreciates you?’ Jocelyn : Well, it infuriates me! I feel so undervalued and it puts me in such a foul mood. Counsellor : Okay, now I’d just like you to think for a moment what could be the effect if you changed that way of thinking Jocelyn: You mean, if I didn’t think that ‘no-one appreciates me’? Counsellor : Yes. Jocelyn : I guess I’d be a lot happier in my job. Ha, ha, I’d probably be nicer to be around. I’d be less snappy, more patient.

Step 3 – Challenge core beliefs

To challenge Jocelyn’s core belief, the counsellor engages in the following dialogue:

Counsellor : Jocelyn, I’d like you to read through this list of common false beliefs and tell me if you relate to any of them (hands Jocelyn the list of common false beliefs). Jocelyn : (Reads list)Ah, yes,I can see how I relate to number four, ‘that it’s necessary to be competent and successful in all those things which are attempted’.That’s so true for me. Counsellor : The reason these are called “false beliefs” is because they are extreme ways of perceiving the world. They are black or white and ignore the shades of grey in between.

Applications of CBT

Cognitive approaches have been applied as means of treatment across a variety of presenting concerns and psychological conditions. Cognitive approaches emphasise the role of thought in the development and maintenance of unhelpful or distressing patterns of emotion or behaviour.

Beck originally applied his cognitive approach to the treatment of depression. Cognitive therapy has also been successfully used to treat such conditions as anxiety disorders, obsessive disorders, substance abuse, post-traumatic stress, eating disorders, dissociative identity disorder, chronic pain and many other clinical conditions. In addition, it has been widely utilised to assist clients in enhancing their coping skills and moderating extremes in unhelpful thinking.

• March 18, 2010
• Case Study , CBT , Counselling , Workplace
• Case Studies , Counselling Therapies , Workplace Issues

Comments: 11

I recently had a call (lifeline) from a young person with similar issues as Jocelyn so it was interresting to me to see that I was on the right track helping my client to change her thinking.

I am employed as a counselling psychologist in the dept. of professional studies for graduate students, it’s the way i had been challenging irrational beliefs students hold about themselves, & CBT helps a lot in improving their academic achievement, & helps my counselling to gain ground successfully.

it was a good case study helped a lot I as a student studying about case study on CBT patients !! thanks a lot

Thank you very much. it helped me as I am a student of basic counselling course.

I think the way the process is explained is very helpful.

It’s a very good article.Therapist explicitly challenged the automatic thought and could elicit it very well. CBT is more realistic and genuine. Great case study. Expect more such case details. Thanks.

I concur many students don’t fail exams because they don’t work hard but lack of confidence and negative self talk like I can never pass cbt is powerful in replacing the negative self talk

This type of case study is useful to know about the basic job awareness and what kind of stress the employee has. Mainly useful to know about the lot of information about counseling knowledge.

I am preparing for my internship in counseling and looking for case studies. I found this case study helpful and useful in how to utilize the CBT techniques when working with my potential clients. Thanks

what psychological theory would best help understand the client’s problems and how therapy from that theoretical standpoint will help them?

Cognitive Theory Behaviorism – Operant Conditioning Behaviorism – Classic Conditioning Psychoanalytic Theory Object Relations/Attachment Theory Existential Theory Humanistic Theory

As a psychology student this case study helped me alot in understanding the core values of CBT as well as how important of a role it is in counseling. Thank you!

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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.

Free Handout Download

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

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

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

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

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

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

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

At a Glance

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

What Are the Benefits and Limitations of Case Studies?

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

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

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

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

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

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

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

Case Study Examples

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

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

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

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

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

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

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

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

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

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

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

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

Section 1: A Case History

This section will have the following structure and content:

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

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

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

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

Section 2: Treatment Plan

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

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

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

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

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

Need More Tips?

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

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

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

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

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

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

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

• Open access
• Published: 14 May 2024

Developing a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study

• Jocelyn Schroeder 1 ,
• Barbara Pesut 1 , 2 ,
• Lise Olsen 2 ,
• Nelly D. Oelke 2 &
• Helen Sharp 2  

BMC Nursing volume  23 , Article number:  326 ( 2024 ) Cite this article

31 Accesses

Metrics details

Medical Assistance in Dying (MAiD) was legalized in Canada in 2016. Canada’s legislation is the first to permit Nurse Practitioners (NP) to serve as independent MAiD assessors and providers. Registered Nurses’ (RN) also have important roles in MAiD that include MAiD care coordination; client and family teaching and support, MAiD procedural quality; healthcare provider and public education; and bereavement care for family. Nurses have a right under the law to conscientious objection to participating in MAiD. Therefore, it is essential to prepare nurses in their entry-level education for the practice implications and moral complexities inherent in this practice. Knowing what nursing students think about MAiD is a critical first step. Therefore, the purpose of this study was to develop a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context.

The design was a mixed-method, modified e-Delphi method that entailed item generation from the literature, item refinement through a 2 round survey of an expert faculty panel, and item validation through a cognitive focus group interview with nursing students. The settings were a University located in an urban area and a College located in a rural area in Western Canada.

During phase 1, a 56-item survey was developed from existing literature that included demographic items and items designed to measure experience with death and dying (including MAiD), education and preparation, attitudes and beliefs, influences on those beliefs, and anticipated future involvement. During phase 2, an expert faculty panel reviewed, modified, and prioritized the items yielding 51 items. During phase 3, a sample of nursing students further evaluated and modified the language in the survey to aid readability and comprehension. The final survey consists of 45 items including 4 case studies.

Systematic evaluation of knowledge-to-date coupled with stakeholder perspectives supports robust survey design. This study yielded a survey to assess nursing students’ attitudes toward MAiD in a Canadian context.

The survey is appropriate for use in education and research to measure knowledge and attitudes about MAiD among nurse trainees and can be a helpful step in preparing nursing students for entry-level practice.

Peer Review reports

Medical Assistance in Dying (MAiD) is permitted under an amendment to Canada’s Criminal Code which was passed in 2016 [ 1 ]. MAiD is defined in the legislation as both self-administered and clinician-administered medication for the purpose of causing death. In the 2016 Bill C-14 legislation one of the eligibility criteria was that an applicant for MAiD must have a reasonably foreseeable natural death although this term was not defined. It was left to the clinical judgement of MAiD assessors and providers to determine the time frame that constitutes reasonably foreseeable [ 2 ]. However, in 2021 under Bill C-7, the eligibility criteria for MAiD were changed to allow individuals with irreversible medical conditions, declining health, and suffering, but whose natural death was not reasonably foreseeable, to receive MAiD [ 3 ]. This population of MAiD applicants are referred to as Track 2 MAiD (those whose natural death is foreseeable are referred to as Track 1). Track 2 applicants are subject to additional safeguards under the 2021 C-7 legislation.

Three additional proposed changes to the legislation have been extensively studied by Canadian Expert Panels (Council of Canadian Academics [CCA]) [ 4 , 5 , 6 ] First, under the legislation that defines Track 2, individuals with mental disease as their sole underlying medical condition may apply for MAiD, but implementation of this practice is embargoed until March 2027 [ 4 ]. Second, there is consideration of allowing MAiD to be implemented through advanced consent. This would make it possible for persons living with dementia to receive MAID after they have lost the capacity to consent to the procedure [ 5 ]. Third, there is consideration of extending MAiD to mature minors. A mature minor is defined as “a person under the age of majority…and who has the capacity to understand and appreciate the nature and consequences of a decision” ([ 6 ] p. 5). In summary, since the legalization of MAiD in 2016 the eligibility criteria and safeguards have evolved significantly with consequent implications for nurses and nursing care. Further, the number of Canadians who access MAiD shows steady increases since 2016 [ 7 ] and it is expected that these increases will continue in the foreseeable future.

Nurses have been integral to MAiD care in the Canadian context. While other countries such as Belgium and the Netherlands also permit euthanasia, Canada is the first country to allow Nurse Practitioners (Registered Nurses with additional preparation typically achieved at the graduate level) to act independently as assessors and providers of MAiD [ 1 ]. Although the role of Registered Nurses (RNs) in MAiD is not defined in federal legislation, it has been addressed at the provincial/territorial-level with variability in scope of practice by region [ 8 , 9 ]. For example, there are differences with respect to the obligation of the nurse to provide information to patients about MAiD, and to the degree that nurses are expected to ensure that patient eligibility criteria and safeguards are met prior to their participation [ 10 ]. Studies conducted in the Canadian context indicate that RNs perform essential roles in MAiD care coordination; client and family teaching and support; MAiD procedural quality; healthcare provider and public education; and bereavement care for family [ 9 , 11 ]. Nurse practitioners and RNs are integral to a robust MAiD care system in Canada and hence need to be well-prepared for their role [ 12 ].

Previous studies have found that end of life care, and MAiD specifically, raise complex moral and ethical issues for nurses [ 13 , 14 , 15 , 16 ]. The knowledge, attitudes, and beliefs of nurses are important across practice settings because nurses have consistent, ongoing, and direct contact with patients who experience chronic or life-limiting health conditions. Canadian studies exploring nurses’ moral and ethical decision-making in relation to MAiD reveal that although some nurses are clear in their support for, or opposition to, MAiD, others are unclear on what they believe to be good and right [ 14 ]. Empirical findings suggest that nurses go through a period of moral sense-making that is often informed by their family, peers, and initial experiences with MAID [ 17 , 18 ]. Canadian legislation and policy specifies that nurses are not required to participate in MAiD and may recuse themselves as conscientious objectors with appropriate steps to ensure ongoing and safe care of patients [ 1 , 19 ]. However, with so many nurses having to reflect on and make sense of their moral position, it is essential that they are given adequate time and preparation to make an informed and thoughtful decision before they participate in a MAID death [ 20 , 21 ].

It is well established that nursing students receive inconsistent exposure to end of life care issues [ 22 ] and little or no training related to MAiD [ 23 ]. Without such education and reflection time in pre-entry nursing preparation, nurses are at significant risk for moral harm. An important first step in providing this preparation is to be able to assess the knowledge, values, and beliefs of nursing students regarding MAID and end of life care. As demand for MAiD increases along with the complexities of MAiD, it is critical to understand the knowledge, attitudes, and likelihood of engagement with MAiD among nursing students as a baseline upon which to build curriculum and as a means to track these variables over time.

Aim, design, and setting

The aim of this study was to develop a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context. We sought to explore both their willingness to be involved in the registered nursing role and in the nurse practitioner role should they chose to prepare themselves to that level of education. The design was a mixed-method, modified e-Delphi method that entailed item generation, item refinement through an expert faculty panel [ 24 , 25 , 26 ], and initial item validation through a cognitive focus group interview with nursing students [ 27 ]. The settings were a University located in an urban area and a College located in a rural area in Western Canada.

Participants

A panel of 10 faculty from the two nursing education programs were recruited for Phase 2 of the e-Delphi. To be included, faculty were required to have a minimum of three years of experience in nurse education, be employed as nursing faculty, and self-identify as having experience with MAiD. A convenience sample of 5 fourth-year nursing students were recruited to participate in Phase 3. Students had to be in good standing in the nursing program and be willing to share their experiences of the survey in an online group interview format.

The modified e-Delphi was conducted in 3 phases: Phase 1 entailed item generation through literature and existing survey review. Phase 2 entailed item refinement through a faculty expert panel review with focus on content validity, prioritization, and revision of item wording [ 25 ]. Phase 3 entailed an assessment of face validity through focus group-based cognitive interview with nursing students.

Phase I. Item generation through literature review

The goal of phase 1 was to develop a bank of survey items that would represent the variables of interest and which could be provided to expert faculty in Phase 2. Initial survey items were generated through a literature review of similar surveys designed to assess knowledge and attitudes toward MAiD/euthanasia in healthcare providers; Canadian empirical studies on nurses’ roles and/or experiences with MAiD; and legislative and expert panel documents that outlined proposed changes to the legislative eligibility criteria and safeguards. The literature review was conducted in three online databases: CINAHL, PsycINFO, and Medline. Key words for the search included nurses , nursing students , medical students , NPs, MAiD , euthanasia , assisted death , and end-of-life care . Only articles written in English were reviewed. The legalization and legislation of MAiD is new in many countries; therefore, studies that were greater than twenty years old were excluded, no further exclusion criteria set for country.

Items from surveys designed to measure similar variables in other health care providers and geographic contexts were placed in a table and similar items were collated and revised into a single item. Then key variables were identified from the empirical literature on nurses and MAiD in Canada and checked against the items derived from the surveys to ensure that each of the key variables were represented. For example, conscientious objection has figured prominently in the Canadian literature, but there were few items that assessed knowledge of conscientious objection in other surveys and so items were added [ 15 , 21 , 28 , 29 ]. Finally, four case studies were added to the survey to address the anticipated changes to the Canadian legislation. The case studies were based upon the inclusion of mature minors, advanced consent, and mental disorder as the sole underlying medical condition. The intention was to assess nurses’ beliefs and comfort with these potential legislative changes.

Phase 2. Item refinement through expert panel review

The goal of phase 2 was to refine and prioritize the proposed survey items identified in phase 1 using a modified e-Delphi approach to achieve consensus among an expert panel [ 26 ]. Items from phase 1 were presented to an expert faculty panel using a Qualtrics (Provo, UT) online survey. Panel members were asked to review each item to determine if it should be: included, excluded or adapted for the survey. When adapted was selected faculty experts were asked to provide rationale and suggestions for adaptation through the use of an open text box. Items that reached a level of 75% consensus for either inclusion or adaptation were retained [ 25 , 26 ]. New items were categorized and added, and a revised survey was presented to the panel of experts in round 2. Panel members were again asked to review items, including new items, to determine if it should be: included, excluded, or adapted for the survey. Round 2 of the modified e-Delphi approach also included an item prioritization activity, where participants were then asked to rate the importance of each item, based on a 5-point Likert scale (low to high importance), which De Vaus [ 30 ] states is helpful for increasing the reliability of responses. Items that reached a 75% consensus on inclusion were then considered in relation to the importance it was given by the expert panel. Quantitative data were managed using SPSS (IBM Corp).

Phase 3. Face validity through cognitive interviews with nursing students

The goal of phase 3 was to obtain initial face validity of the proposed survey using a sample of nursing student informants. More specifically, student participants were asked to discuss how items were interpreted, to identify confusing wording or other problematic construction of items, and to provide feedback about the survey as a whole including readability and organization [ 31 , 32 , 33 ]. The focus group was held online and audio recorded. A semi-structured interview guide was developed for this study that focused on clarity, meaning, order and wording of questions; emotions evoked by the questions; and overall survey cohesion and length was used to obtain data (see Supplementary Material 2  for the interview guide). A prompt to “think aloud” was used to limit interviewer-imposed bias and encourage participants to describe their thoughts and response to a given item as they reviewed survey items [ 27 ]. Where needed, verbal probes such as “could you expand on that” were used to encourage participants to expand on their responses [ 27 ]. Student participants’ feedback was collated verbatim and presented to the research team where potential survey modifications were negotiated and finalized among team members. Conventional content analysis [ 34 ] of focus group data was conducted to identify key themes that emerged through discussion with students. Themes were derived from the data by grouping common responses and then using those common responses to modify survey items.

Ten nursing faculty participated in the expert panel. Eight of the 10 faculty self-identified as female. No faculty panel members reported conscientious objector status and ninety percent reported general agreement with MAiD with one respondent who indicated their view as “unsure.” Six of the 10 faculty experts had 16 years of experience or more working as a nurse educator.

Five nursing students participated in the cognitive interview focus group. The duration of the focus group was 2.5 h. All participants identified that they were born in Canada, self-identified as female (one preferred not to say) and reported having received some instruction about MAiD as part of their nursing curriculum. See Tables  1 and 2 for the demographic descriptors of the study sample. Study results will be reported in accordance with the study phases. See Fig.  1 for an overview of the results from each phase.

Fig. 1  Overview of survey development findings

Phase 1: survey item generation

Review of the literature identified that no existing survey was available for use with nursing students in the Canadian context. However, an analysis of themes across qualitative and quantitative studies of physicians, medical students, nurses, and nursing students provided sufficient data to develop a preliminary set of items suitable for adaptation to a population of nursing students.

Four major themes and factors that influence knowledge, attitudes, and beliefs about MAiD were evident from the literature: (i) endogenous or individual factors such as age, gender, personally held values, religion, religiosity, and/or spirituality [ 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 ], (ii) experience with death and dying in personal and/or professional life [ 35 , 40 , 41 , 43 , 44 , 45 ], (iii) training including curricular instruction about clinical role, scope of practice, or the law [ 23 , 36 , 39 ], and (iv) exogenous or social factors such as the influence of key leaders, colleagues, friends and/or family, professional and licensure organizations, support within professional settings, and/or engagement in MAiD in an interdisciplinary team context [ 9 , 35 , 46 ].

Studies of nursing students also suggest overlap across these categories. For example, value for patient autonomy [ 23 ] and the moral complexity of decision-making [ 37 ] are important factors that contribute to attitudes about MAiD and may stem from a blend of personally held values coupled with curricular content, professional training and norms, and clinical exposure. For example, students report that participation in end of life care allows for personal growth, shifts in perception, and opportunities to build therapeutic relationships with their clients [ 44 , 47 , 48 ].

Preliminary items generated from the literature resulted in 56 questions from 11 published sources (See Table  3 ). These items were constructed across four main categories: (i) socio-demographic questions; (ii) end of life care questions; (iii) knowledge about MAiD; or (iv) comfort and willingness to participate in MAiD. Knowledge questions were refined to reflect current MAiD legislation, policies, and regulatory frameworks. Falconer [ 39 ] and Freeman [ 45 ] studies were foundational sources for item selection. Additionally, four case studies were written to reflect the most recent anticipated changes to MAiD legislation and all used the same open-ended core questions to address respondents’ perspectives about the patient’s right to make the decision, comfort in assisting a physician or NP to administer MAiD in that scenario, and hypothesized comfort about serving as a primary provider if qualified as an NP in future. Response options for the survey were also constructed during this stage and included: open text, categorical, yes/no , and Likert scales.

Phase 2: faculty expert panel review

Of the 56 items presented to the faculty panel, 54 questions reached 75% consensus. However, based upon the qualitative responses 9 items were removed largely because they were felt to be repetitive. Items that generated the most controversy were related to measuring religion and spirituality in the Canadian context, defining end of life care when there is no agreed upon time frames (e.g., last days, months, or years), and predicting willingness to be involved in a future events – thus predicting their future selves. Phase 2, round 1 resulted in an initial set of 47 items which were then presented back to the faculty panel in round 2.

Of the 47 initial questions presented to the panel in round 2, 45 reached a level of consensus of 75% or greater, and 34 of these questions reached a level of 100% consensus [ 27 ] of which all participants chose to include without any adaptations) For each question, level of importance was determined based on a 5-point Likert scale (1 = very unimportant, 2 = somewhat unimportant, 3 = neutral, 4 = somewhat important, and 5 = very important). Figure  2 provides an overview of the level of importance assigned to each item.

Ranking level of importance for survey items

After round 2, a careful analysis of participant comments and level of importance was completed by the research team. While the main method of survey item development came from participants’ response to the first round of Delphi consensus ratings, level of importance was used to assist in the decision of whether to keep or modify questions that created controversy, or that rated lower in the include/exclude/adapt portion of the Delphi. Survey items that rated low in level of importance included questions about future roles, sex and gender, and religion/spirituality. After deliberation by the research committee, these questions were retained in the survey based upon the importance of these variables in the scientific literature.

Of the 47 questions remaining from Phase 2, round 2, four were revised. In addition, the two questions that did not meet the 75% cut off level for consensus were reviewed by the research team. The first question reviewed was What is your comfort level with providing a MAiD death in the future if you were a qualified NP ? Based on a review of participant comments, it was decided to retain this question for the cognitive interviews with students in the final phase of testing. The second question asked about impacts on respondents’ views of MAiD and was changed from one item with 4 subcategories into 4 separate items, resulting in a final total of 51 items for phase 3. The revised survey was then brought forward to the cognitive interviews with student participants in Phase 3. (see Supplementary Material 1 for a complete description of item modification during round 2).

Phase 3. Outcomes of cognitive interview focus group

Of the 51 items reviewed by student participants, 29 were identified as clear with little or no discussion. Participant comments for the remaining 22 questions were noted and verified against the audio recording. Following content analysis of the comments, four key themes emerged through the student discussion: unclear or ambiguous wording; difficult to answer questions; need for additional response options; and emotional response evoked by questions. An example of unclear or ambiguous wording was a request for clarity in the use of the word “sufficient” in the context of assessing an item that read “My nursing education has provided sufficient content about the nursing role in MAiD.” “Sufficient” was viewed as subjective and “laden with…complexity that distracted me from the question.” The group recommended rewording the item to read “My nursing education has provided enough content for me to care for a patient considering or requesting MAiD.”

An example of having difficulty answering questions related to limited knowledge related to terms used in the legislation such as such as safeguards , mature minor , eligibility criteria , and conscientious objection. Students were unclear about what these words meant relative to the legislation and indicated that this lack of clarity would hamper appropriate responses to the survey. To ensure that respondents are able to answer relevant questions, student participants recommended that the final survey include explanation of key terms such as mature minor and conscientious objection and an overview of current legislation.

Response options were also a point of discussion. Participants noted a lack of distinction between response options of unsure and unable to say . Additionally, scaling of attitudes was noted as important since perspectives about MAiD are dynamic and not dichotomous “agree or disagree” responses. Although the faculty expert panel recommended the integration of the demographic variables of religious and/or spiritual remain as a single item, the student group stated a preference to have religion and spirituality appear as separate items. The student focus group also took issue with separate items for the variables of sex and gender, specifically that non-binary respondents might feel othered or “outed” particularly when asked to identify their sex. These variables had been created based upon best practices in health research but students did not feel they were appropriate in this context [ 49 ]. Finally, students agreed with the faculty expert panel in terms of the complexity of projecting their future involvement as a Nurse Practitioner. One participant stated: “I certainly had to like, whoa, whoa, whoa. Now let me finish this degree first, please.” Another stated, “I'm still imagining myself, my future career as an RN.”

Finally, student participants acknowledged the array of emotions that some of the items produced for them. For example, one student described positive feelings when interacting with the survey. “Brought me a little bit of feeling of joy. Like it reminded me that this is the last piece of independence that people grab on to.” Another participant, described the freedom that the idea of an advance request gave her. “The advance request gives the most comfort for me, just with early onset Alzheimer’s and knowing what it can do.” But other participants described less positive feelings. For example, the mature minor case study yielded a comment: “This whole scenario just made my heart hurt with the idea of a child requesting that.”

Based on the data gathered from the cognitive interview focus group of nursing students, revisions were made to 11 closed-ended questions (see Table  4 ) and 3 items were excluded. In the four case studies, the open-ended question related to a respondents’ hypothesized actions in a future role as NP were removed. The final survey consists of 45 items including 4 case studies (see Supplementary Material 3 ).

The aim of this study was to develop and validate a survey that can be used to track the growth of knowledge about MAiD among nursing students over time, inform training programs about curricular needs, and evaluate attitudes and willingness to participate in MAiD at time-points during training or across nursing programs over time.

The faculty expert panel and student participants in the cognitive interview focus group identified a need to establish core knowledge of the terminology and legislative rules related to MAiD. For example, within the cognitive interview group of student participants, several acknowledged lack of clear understanding of specific terms such as “conscientious objector” and “safeguards.” Participants acknowledged discomfort with the uncertainty of not knowing and their inclination to look up these terms to assist with answering the questions. This survey can be administered to nursing or pre-nursing students at any phase of their training within a program or across training programs. However, in doing so it is important to acknowledge that their baseline knowledge of MAiD will vary. A response option of “not sure” is important and provides a means for respondents to convey uncertainty. If this survey is used to inform curricular needs, respondents should be given explicit instructions not to conduct online searches to inform their responses, but rather to provide an honest appraisal of their current knowledge and these instructions are included in the survey (see Supplementary Material 3 ).

Some provincial regulatory bodies have established core competencies for entry-level nurses that include MAiD. For example, the BC College of Nurses and Midwives (BCCNM) requires “knowledge about ethical, legal, and regulatory implications of medical assistance in dying (MAiD) when providing nursing care.” (10 p. 6) However, across Canada curricular content and coverage related to end of life care and MAiD is variable [ 23 ]. Given the dynamic nature of the legislation that includes portions of the law that are embargoed until 2024, it is important to ensure that respondents are guided by current and accurate information. As the law changes, nursing curricula, and public attitudes continue to evolve, inclusion of core knowledge and content is essential and relevant for investigators to be able to interpret the portions of the survey focused on attitudes and beliefs about MAiD. Content knowledge portions of the survey may need to be modified over time as legislation and training change and to meet the specific purposes of the investigator.

Given the sensitive nature of the topic, it is strongly recommended that surveys be conducted anonymously and that students be provided with an opportunity to discuss their responses to the survey. A majority of feedback from both the expert panel of faculty and from student participants related to the wording and inclusion of demographic variables, in particular religion, religiosity, gender identity, and sex assigned at birth. These and other demographic variables have the potential to be highly identifying in small samples. In any instance in which the survey could be expected to yield demographic group sizes less than 5, users should eliminate the demographic variables from the survey. For example, the profession of nursing is highly dominated by females with over 90% of nurses who identify as female [ 50 ]. Thus, a survey within a single class of students or even across classes in a single institution is likely to yield a small number of male respondents and/or respondents who report a difference between sex assigned at birth and gender identity. When variables that serve to identify respondents are included, respondents are less likely to complete or submit the survey, to obscure their responses so as not to be identifiable, or to be influenced by social desirability bias in their responses rather than to convey their attitudes accurately [ 51 ]. Further, small samples do not allow for conclusive analyses or interpretation of apparent group differences. Although these variables are often included in surveys, such demographics should be included only when anonymity can be sustained. In small and/or known samples, highly identifying variables should be omitted.

There are several limitations associated with the development of this survey. The expert panel was comprised of faculty who teach nursing students and are knowledgeable about MAiD and curricular content, however none identified as a conscientious objector to MAiD. Ideally, our expert panel would have included one or more conscientious objectors to MAiD to provide a broader perspective. Review by practitioners who participate in MAiD, those who are neutral or undecided, and practitioners who are conscientious objectors would ensure broad applicability of the survey. This study included one student cognitive interview focus group with 5 self-selected participants. All student participants had held discussions about end of life care with at least one patient, 4 of 5 participants had worked with a patient who requested MAiD, and one had been present for a MAiD death. It is not clear that these participants are representative of nursing students demographically or by experience with end of life care. It is possible that the students who elected to participate hold perspectives and reflections on patient care and MAiD that differ from students with little or no exposure to end of life care and/or MAiD. However, previous studies find that most nursing students have been involved with end of life care including meaningful discussions about patients’ preferences and care needs during their education [ 40 , 44 , 47 , 48 , 52 ]. Data collection with additional student focus groups with students early in their training and drawn from other training contexts would contribute to further validation of survey items.

Future studies should incorporate pilot testing with small sample of nursing students followed by a larger cross-program sample to allow evaluation of the psychometric properties of specific items and further refinement of the survey tool. Consistent with literature about the importance of leadership in the context of MAiD [ 12 , 53 , 54 ], a study of faculty knowledge, beliefs, and attitudes toward MAiD would provide context for understanding student perspectives within and across programs. Additional research is also needed to understand the timing and content coverage of MAiD across Canadian nurse training programs’ curricula.

The implementation of MAiD is complex and requires understanding of the perspectives of multiple stakeholders. Within the field of nursing this includes clinical providers, educators, and students who will deliver clinical care. A survey to assess nursing students’ attitudes toward and willingness to participate in MAiD in the Canadian context is timely, due to the legislation enacted in 2016 and subsequent modifications to the law in 2021 with portions of the law to be enacted in 2027. Further development of this survey could be undertaken to allow for use in settings with practicing nurses or to allow longitudinal follow up with students as they enter practice. As the Canadian landscape changes, ongoing assessment of the perspectives and needs of health professionals and students in the health professions is needed to inform policy makers, leaders in practice, curricular needs, and to monitor changes in attitudes and practice patterns over time.

Availability of data and materials

The datasets used and/or analysed during the current study are not publicly available due to small sample sizes, but are available from the corresponding author on reasonable request.

Abbreviations

British Columbia College of Nurses and Midwives

Medical assistance in dying

Nurse practitioner

Registered nurse

University of British Columbia Okanagan

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We would like to acknowledge the faculty and students who generously contributed their time to this work.

JS received a student traineeship through the Principal Research Chairs program at the University of British Columbia Okanagan.

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JS made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and drafting and substantively revising the work. JS has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. BP made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and drafting and substantively revising the work. BP has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. LO made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and substantively revising the work. LO has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. NDO made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and substantively revising the work. NDO has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. HS made substantial contributions to drafting and substantively revising the work. HS has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

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Schroeder, J., Pesut, B., Olsen, L. et al. Developing a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study. BMC Nurs 23 , 326 (2024). https://doi.org/10.1186/s12912-024-01984-z

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