clinical case study of psychoanalytic psychotherapy

• DOI: 10.3389/fpsyg.2017.00108
• Corpus ID: 16589413

Clinical Case Studies in Psychoanalytic and Psychodynamic Treatment

• J. Willemsen , Elena Della Rosa , S. Kegerreis
• Published in Frontiers in Psychology 2 February 2017

26 Citations

Mapping the psychoanalytic literature on bipolar disorder: a scoping review of journal articles, learning from past practices: an overview of criticisms for psychoanalytic case studies, becoming a researcher: psychotherapists’ experience of starting a professional doctorate, methods used for evaluation of psychotherapy treatment. evaluation of psychotherapy, from clinical encounter to knowledge claims: epistemological guidelines for case studies in psychotherapy, conflicted anger as a central dynamic in depression in adolescents—a double case study, the > uncommon < factor in psychotherapy and the role of negative skills: why and how psychoanalysis offers an important contribution for mental health practice today, psychoanalytic perspectives on the psychological effects of stillbirth on parents: a protocol for systematic review and qualitative synthesis, is psychotherapy fundamentally threatened, with the demise of published case studies, to become neither an art and/ nor a science, narcissistic trauma, 47 references, the ‘inseparable bond between cure and research’: clinical case study as a method of psychoanalytic inquiry.

• Highly Influential

Theoretical pluralism in psychoanalytic case studies

Some thoughts on the presentation and discussion of the clinical material of psychoanalysis., minding the gap between positivism and hermeneutics in psychoanalytic research, psychotherapy and research: a relation that needs to be reinvented, writing about the psychoanalytic process, psychoanalytic single cases published in isi-ranked journals: the construction of an online archive, psychodynamic emotional regulation in view of wolpe's desensitization model., research and psychoanalysis still time to bridge the great divide, research in the consulting room, related papers.

Showing 1 through 3 of 0 Related Papers

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Front Psychol

Beyond Clinical Case Studies in Psychoanalysis: A Review of Psychoanalytic Empirical Single Case Studies Published in ISI-Ranked Journals

Reitske meganck.

1 Department of Psychoanalysis and Clinical Consulting, Ghent University, Ghent, Belgium

Ruth Inslegers

Juri krivzov.

2 Department of Experimental, Clinical and Health Psychology, Ghent University, Ghent, Belgium

Liza Notaerts

Single case studies are at the origin of both theory development and research in the field of psychoanalysis and psychotherapy. While clinical case studies are the hallmark of psychoanalytic theory and practice, their scientific value has been strongly criticized. To address problems with the subjective bias of retrospective therapist reports and uncontrollability of clinical case studies, systematic approaches to investigate psychotherapy process and outcome at the level of the single case have been developed. Such empirical case studies are also able to bridge the famous gap between academic research and clinical practice as they provide clinically relevant insights into how psychotherapy works. This study presents a review of psychoanalytic empirical case studies published in ISI-ranked journals and maps the characteristics of the study, therapist, patient en therapies that are investigated. Empirical case studies increased in quantity and quality (amount of information and systematization) over time. While future studies could pay more attention to providing contextual information on therapist characteristics and informed consent considerations, the available literature provides a basis to conduct meta-studies of single cases and as such contribute to knowledge aggregation.

Introduction

Single case studies are at the origin of both theory development and research in the field of psychotherapy in general and psychoanalysis in particular ( McLeod, 2010 , 2013 ). Increasingly, empirical case studies made their entrance in the field and are recognized as important sources of evidence to address the complexity of psychotherapeutic processes ( Goodheart, 2005 ; American Psychologcial Association [APA], 2006 ; McLeod and Elliott, 2011 ). Systematic meta-studies of single cases moreover allow knowledge aggregation and as such could enhance the scientific merits of case studies ( Iwakabe and Gazzola, 2009 ). We argue that in order to explore the full potential of empirical single cases in the field of psychoanalysis, it is important to map the existing field of such cases and get an overview of their characteristics, strengths and weaknesses. The goal of the current review is to provide this information and delineate points of interest for future case studies and context for meta-studies in the field.

From its origin, the clinical case study was the dominant research method in psychoanalysis. Sigmund Freud, the founding father of psychoanalysis, is still both famous and notorious for his elaborate clinical case studies through which he developed his theoretical framework during the course of his life. Famous because of the richness of his case presentations and because of the resulting theoretical and clinical advancements that up until this day permeate the whole psychotherapeutic and cultural field. Notorious because the scientific merit of this method received increasing criticism and is mostly relegated to the scientific trash can ( Bornstein, 2005 ).

While empirical research continues to be a major source of debate and controversy in psychoanalysis (e.g., Aron, 2012 ; Benecke, 2014 ; Mills, 2015 ), the questioning of its scientific credibility and therapeutic efficacy gave rise to a wealth of (group level) research indicating the efficacy of psychoanalytic psychotherapy (e.g., Leichsenring et al., 2015 ). Nevertheless, the case study has a privileged place in the field of psychoanalysis. Indeed, the clinical case study is still very common, however, increasingly, empirical case studies appear to see the light of day.

Critiques on the subjective bias of therapists’ retrospective reports, the anecdotal quality and uncontrollable nature of clinical case studies ( Spence, 2001 ) influenced the emergence of systematic (quantitative and qualitative) approaches to conduct single case studies that are no longer (solely) dependent on the interpretation of the therapist. Methodological articles on single-case experimental designs (for a review see Smith, 2012 ), case-based time series analysis ( Borckardt et al., 2008 ), case comparison methods ( Iwakabe, 2011 ), and theory-building case studies ( Stiles, 2008 , 2010 ) are but a few examples of the increased recognition of the potential value of empirical case-based research to build knowledge ( Edwards et al., 2004 ; McLeod and Elliott, 2011 ). In the entire field of psychology, such idiographic approaches are increasingly considered to be important tools to bridge the science-practitioner gap and address the lack of alignment between the object of study and the method that is often criticized in mainstream evidence-based practice research (e.g., Westen et al., 2004 ; Desmet, 2013 ).

Despite this recognition of empirical case study methods, an important critique on generalizability problems remains. A way to address this and build knowledge resulting from single case studies is to conduct meta-studies on published single case studies or as Dattilio et al. (2010 , p. 436) state “One observation or one case offers only a small piece of evidence, but repeated observation […] across a series of cases provides a way of constructing a database of evidence on which clinical theory can be built.” Currently the potential for knowledge aggregation across cases surely remains unexplored despite the existence of methodological tools to do so, for example, meta-synthesis methods ( Finfgeld, 2003 ; Willemsen et al., 2015 ) and case comparison methods ( Iwakabe and Gazzola, 2009 ). A preliminary requirement to facilitate meta-studies, however, is a well-organized database that gathers published case studies ( Fishman, 2005 ; Iwakabe and Gazzola, 2009 ). The single case archive (SCA; Desmet et al., 2013 ) provides such a tool for psychoanalytic single cases published in ISI ranked journals. 1 Such a tool allows gathering cases on a specific topic and conducting meta-studies. Nevertheless, an overview of the nature of existing empirical case studies would provide important contextual information when considering a meta-study, yet this is currently lacking in the literature.

This study attempts to address this need and explores the following questions concerning empirical case studies in the field of psychoanalysis: ‘Which studies have been done?’; ‘What is the nature of these case studies?’; and ‘What are their merits and weaknesses?’ We investigate this through a review of empirical case studies published in ISI-ranked journals.

Cases were selected through the original SCA ( Desmet et al., 2013 ), which comprises psychoanalytic and psychodynamic case studies, published in ISI-ranked journals between 1955 and 2011. Cases were selected starting from a search on ISI Web of Knowledge using the search terms (psychoanal ∗ OR psychodynam ∗ ) AND (case OR vignette). This search provided 2760 results, which after screening for title, abstract, and if necessary the full text of the article, resulted in 445 articles presenting psychoanalytic or psychodynamic treatment of an original single case (no comments on already published cases). For this study, all English case studies of this dataset that were classified as either experimental (i.e., N = 1 subject experiments, testing hypotheses in an experimental design) or (naturalistic) systematic case studies (i.e., case studies using data from sources other than the therapist’s report and where data are investigated by one or more researchers other than the therapist) 2 were selected (52 articles discussing 55 cases). Moreover, for this study, the same search procedure was followed for the period of 2012–2017 to update the sample with empirical case studies from these more recent years. Screening the 1093 search results resulted in 31 articles discussing 38 empirical cases. All empirical cases were screened with the Inventory for Basic Information in Single Cases (IBISC; Desmet et al., 2013 ), which inventories basic descriptive information on study characteristics [design, type of data, type of analysis, presence of clinical (process) description, presence of informed consent], therapist (gender, age, education, experience) and patient (gender, age, diagnostic information) characteristics, and therapy characteristics (duration, number of sessions, session frequency, therapy outcome).

In the screened period (1955–2017), 83 articles were identified that comprise 93 cases using empirical case designs. The selected manuscripts included one to three case studies. Figure ​ Figure1 1 depicts the number of case studies for each year empirical cases could be identified and indicates an increase of published empirical case studies over time.

Number of cases per year.

Study Characteristics

Of the empirical case studies, five cases (5.4%) were experimental designs and 88 were naturalistic systematic case studies (94.6%) following the definition of Iwakabe and Gazzola (2009) . Analysis of the case was mostly based on one type of data (44.1%); 25.8% used two types of data, 14% three types, and 3.2% four or more types of data. The amount of different types of data was not spread equally across time: before 2000 only one study mentioned more than one type of data, between 2000 and 2010 there were regular studies mentioning two types of data; while starting from 2010 studies start to appear that mention three and four or more types of data. The type of data most commonly used were audio recordings (or videotapes) (64.5%), followed by self-report or observer rated scales (36.6%) and interviews (35.5%). In 14% of cases (also) other types of data were used like behavioral measures, notes of the therapist, patient, or relatives, or biological measures.

Different ways of analyzing the data were used, from purely quantitative (21.5%) to purely qualitative (17.2%). Yet, in most studies mixed approaches (56%) were used combining for example clinimetric methods (e.g., ratings of session material using the Shedler Westen Assessment Procedure-200 (SWAP-200; Westen and Shedler, 1999 ) with clinical, qualitative, or quantitative approaches.

A clinical description of the patient and/or therapy process was provided in 73.1% of the cases. In 24.7% of the cases such a description was lacking, while in two cases there was somewhat of a clinical description through a patients’ retrospective report in one case and a qualitative description of specific analyzed sessions in the other case.

Informed consent (IC) was mentioned in 45.2% of the cases, meaning it was not mentioned in more than half of the cases. Before 2000, IC was mentioned in 4 out of 18 cases, between 2000 and 2010 it was mentioned in 13 out of 35 cases, and between 2011 and 2017 it was mentioned in 25 out of 40 cases. In this last period, of the cases not mentioning IC, four cases did mention an ethical approval, which might indicate that there was also an informed consent on the patient’s side.

Therapist Characteristics

In most studies information about the therapist was almost entirely lacking. We inventoried information about gender, age, education and experience, yet in 34.4% of the cases there was no information at all. In 10.8% of the cases information about only one of these variables was provided (mostly the therapist’s gender), while in 18.3, 29, and 7.5% of the cases information was provided about 2, 3, and 4 variables respectively.

Concerning gender, 24.7% were female therapists and 36.6% were male therapists. In one case there was both a male and a female therapist involved in therapy. For the remaining 37.8% of cases gender of the therapist was not mentioned. Age was mentioned in only 17.2% of the cases. Education was mentioned in 44.1% of the cases and included all kinds of degrees/description with psychologist, psychotherapist, social worker, and psychiatrist as the most common terms. Experience was mentioned in 57% of the cases, with 10.8% novice therapists (<5 years of experience), 21.5% experienced therapist (6–15 years of experience), and 10.8% senior therapists (>15 years of experience).

Patient Characteristics

Generally, more information was provided about the patient. There was consistent information about the patients’ gender with 68.8% female and 31.2% male patients. Concerning age, almost always (98.9% of cases) information was present with 6.5% children (2–11 years), 6.5% adolescents (12–17 years), 12.9% young adults (18–24 years), and 73.1% adults (25–65). There were no cases discussing elderly patients.

There was no information about diagnosis in three cases; all other cases provided diagnostic information. The descriptive terms used in the manuscript are included in the SCA database, however, they differ tremendously across cases. This is illustrated by the observation that in 49.5% of the cases there was no diagnostic system mentioned. In other cases, one or more diagnostic systems were used: 34.5% used a version of the DSM, 10.8% used a version of the ICD, 4.3% used the OPD or PDM, and 8.8% used another system (e.g., SWAP-200, AAI). Therefore, when diagnostic information was available, this was categorized into the main DSM-IV-R categories (multiple categories could apply) to be able to get an overview. Prevalence of diagnostic categories is presented in Figure ​ Figure2 2 . Clearly mood and anxiety disorders were the most common.

Primary diagnosis of cases per DSM-IV-R category.

Therapy Characteristics

In considering the characteristics of therapy we see that mostly at least some information is provided about objective characteristics and outcome.

The duration of investigated therapies consisted of 15.1% therapies shorter than 5 months, 12.9% lasting between 6 and 11 months, 32.3% lasting between 1 and 3 years, 18.3% lasting longer than 3 years, and 21.5% of cases were duration was not mentioned. Related to the duration of therapy, the number of sessions was mentioned in 66.7% of cases with 10.8% of therapies comprising less than 20 sessions, 22.6% between 21 and 50 sessions, 12.9% between 51 and 200 sessions, and 20,4% more than 200 sessions.

Session frequency ranged from less than once a week (2.2%), over once a week (35.5%), two to three times a week (17.2%) to a classical analytic setting of four to seven times a week (18.3%) and was not mentioned in 26.9% of the cases.

To inventory therapeutic outcomes the description of the authors was followed and categorized into successful (53.8%), failure (3.2%), or mixed (33.3%). In 9.7% of the cases no information about outcome was provided. Clearly, the description of authors/researchers starts from different frames of reference (e.g., in a long-term analysis success appears to require change at more levels than in studies on short-term psychodynamic psychotherapy who tend to conceptualize success more often as symptom decrease on a symptom rating scale) and consequently any appreciation of outcome is relative to these frames of reference.

Mapping psychoanalytic empirical case studies published in ISI-ranked journals showed that they, while still remaining scarce, clearly increased in quantity and quality throughout the last decennia. The increase in quality is shown in the results of our review that indicate a larger amount of information provided in more recent studies, a broader use of different sources of data and analysis methods, and more explicit informed consent considerations. However, also when reading the articles to rate the IBISC, it was clear that generally there is more attention for a detailed description of the study, its methods, the patient and his or her therapeutic process. Especially, in the last decennium a remarkable increase could be seen in the amount of published cases and the systematic nature of these cases that increasingly include multiple sources of data and combine different methods of analysis. These include both instruments and methods developed within the field of psychoanalysis [e.g., the Core Conflictual Relationship Theme method ( Luborsky and Crits-Christoph, 1998 ) or Reflective Functioning ratings ( Bucci, 1997 )] and more generic methods that allow the connection to broader psychological research (e.g., the Beck Depression Inventory; Beck et al., 1996 ).

When considering systematic case studies in the broader field of psychoanalytic case studies – which remain to be mainly clinical case studies – it is clear that they provide much more descriptive information than clinical case studies, which mostly pay little attention to giving comprehensive descriptive information, despite the rich clinical description they provide ( Desmet et al., 2013 ). Nevertheless, information about certain topics remains generally absent. Especially a description of the therapist is often omitted, which might however, be important contextual information if one intends to compare or aggregate different cases. As the role of the therapist in explaining outcome is increasingly recognized (e.g., Kraus et al., 2011 ) and because of the inherently interactive nature of the therapeutic encounter (e.g., Strupp, 2008 ), its importance can hardly be overestimated.

The range of diagnoses, short- and long-term therapies, and successful and unsuccessful cases investigated in empirical case studies, however, provide a myriad of possibilities for meta-studies. Moreover, while we noticed a wide array of methods, there also are trends and recurring methods indicating that meta-studies are feasible. For example, methods like Reflective Functioning or the SWAP-200 are used in different studies and should allow for good quality meta-studies. On the other hand, we noticed that studies focusing on purely quantitative methods often omit a clinical description of the patient and the therapy process. In our opinion, this is throwing away the baby with the bathwater. While critiques on the anecdotal nature of clinical case studies may be apt, discarding a clinical or qualitative description altogether is to disown the essence and the strength of the psychoanalytic single case study. Moreover, with respect to clinical relevance and to possible meta-studies, this clinical contextual information is quintessential.

Concerning ethical considerations of research in such delicate circumstances as the psychotherapeutic setting, it appears that even more attention could be paid to informed consent. While informed consent was mentioned much more than was found in the overall archive ( Desmet et al., 2013 ) – where it was mentioned in only 9% of cases – still more than half of the studies did not provide information about informed consent despite their explicit research context.

Surely, our review has certain limitations. Using other search criteria for example, might result in other cases and probably more empirical psychoanalytic cases exist. Also, the inclusion of cases published in books might be a valuable addition. Nevertheless, we think a representative and large sample of systematic case studies could be retrieved through this method. If this is the case, surely future research should aim to investigate age groups that are currently underrepresented in the field as most case studies focus on (young) adults.

We conclude that psychoanalytic empirical case studies, although they were adopted somewhat later than in other orientations, are of increasing and high quality. Moreover, journals currently provide more clear guidelines as to what comprises an eligible case study. High quality cases, for example Gazillo et al. (2014) , Mauck and Moore (2014) and Cornelis et al. (2017) , set the tone for a future where case aggregation based on scientifically sound cases that include triangulated data and analysis methods while not disregarding clinical context becomes increasingly possible. This attention for the clinical context is of crucial importance in the field of psychotherapy ( Spence, 2001 ). Psychotherapy is and always will consist of a unique encounter between patient and therapist, a complex interaction that cannot be easily disentangled ( Strupp, 2008 ). While systematically investigating what happens in this process is crucial for the advancement of the psychotherapeutic endeavor, this should not come at the cost of the clinical richness of these ever-singular encounters that comprise the magic of the psychotherapeutic profession.

Author Contributions

RM: conception of the study, contribution to data collection, data-analysis and interpretation, main author of the manuscript; RI: contribution to conception of the study, contribution to data collection, main reviewer of the manuscript; JK: contribution to data collection, data-analysis and interpretation, reviewer of the manuscript; LN: contribution to data collection, data-analysis, reviewer of the manuscript. All authors read and approved the final version of the manuscript.

Conflict of Interest Statement

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

Acknowledgments

We want to thank Mattias Desmet and Jochem Willemsen for the cooperation on the foundation of the SCA.

Funding. This project was partly supported by Flanders Research Foundation (FWO, Belgium; grant number: AUGE/15/15 – G0H3116N).

1 The original single case archive ( www.singlecasearchive.com ) comprises 445 articles between 1955 and 2011. Currently, there is an ongoing project to elaborate the SCA with cases from other theoretical orientations that should be finished at the end of 2018.

2 For more information on the types of case studies and their definition, see Iwakabe and Gazzola (2009) or the IBISC manual available through http://www.singlecasearchive.com/downloads/IBISC%20manual3.pdf .

• American Psychologcial Association [APA] (2006). Evidence-based practice in psychology. Am. Psychol. 61 271–285. 10.1037/0003-066X.61.4.271 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Aron L. (2012). Rethinking “doublethinking”: psychoanalysis and scientific research - an introduction to a series. Psychoanal. Dialogues 22 704–709. 10.1080/10481885.2012.733650 [ CrossRef ] [ Google Scholar ]
• Beck A. T., Steer R. A., Brown G. K. (1996). Beck Depression Inventory , 2nd Edn. San Antonio, TX: Harcourt Assessment. [ Google Scholar ]
• Benecke C. (2014). The importance of empirical research for psychoanalysis (Die Bedeutung empirischer Forschung für die Psychoanalyse). Forum Psychoanal. 30 55–67. 10.1007/s00451-014-0167-2 [ CrossRef ] [ Google Scholar ]
• Borckardt J. J., Nash M. R., Murphy M. D., Shaw D., O’Neil P. (2008). Clinical practice as natural laboratory for psychotherapy research: a guide to case-based time-series analysis. Am. Psychol. 63 77–95. 10.1037/0003-066X.63.2.77 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Bornstein R. F. (2005). Reconnecting psychoanalysis to mainstream psychology. Psychoanal. Psychol. 3 323–340. 10.1037/0736-9735.22.3.323 [ CrossRef ] [ Google Scholar ]
• Bucci W. (1997). Psychoanalysis and Cognitive Science: A Multiple Code Theory. New York, NY: Guilford Press. [ Google Scholar ]
• Cornelis S., Desmet M., Van Nieuwenhove K. L. H. D., Meganck R., Willemsen J., Inslegers R., et al. (2017). Interactions between obsessional symptoms and interpersonal ambivalences in psychodynamic psychotherapy: an empirical case study. Front. Psychol. 8 : 960 10.3389/fpsyg.2017.00960 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Dattilio F. M., Edwards D. J. A., Fishman D. B. (2010). Case studies within a mixed methods paradigm: Toward a resolution of the alienation between researcher and practitioner in psychotherapy research. Psychotherapy 47 427–441. 10.1037/a0021181 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Desmet M. (2013). Experimental versus naturalistic psychotherapy research: consequences for researchers, clinicians, policy makers and patients. Psychoanal. Perspect. 31 59–78. [ Google Scholar ]
• Desmet M., Meganck R., Seybert C., Willemsen J., Geerardyn F., Declercq F., et al. (2013). Psychoanalytic single cases published in ISI-ranked journals: the construction of an online archive. Psychother. Psychosom. 82 120–121. 10.1159/000342019 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Edwards D. J. A., Dattilio F. M., Bromley D. B. (2004). Developing evidence-based practice: the role of case-based research. Prof. Psychol. Res. Pr. 35 589–597. 10.1037/0735-7028.35.6.589 [ CrossRef ] [ Google Scholar ]
• Finfgeld D. L. (2003). Meta-synthesis: the state of the art - so far. Qual. Health Res. 13 893–904. 10.1177/1049732303253462 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Fishman D. B. (2005). Editor’s introduction to PCSP – from single case to database: a new method for enhancing psychotherapy practice. Pragm. Case Stud. Psychother. 1 1–50. [ Google Scholar ]
• Gazillo F., Waldron S., Genova F., Angeloni F., Ristucci C., Lingiardi V. (2014). An empirical investigation of analytic process: contrasting a good and poor outcome case. Psychotherapy 5 270–282. 10.1037/a0035243 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Goodheart C. D. (2005). Placing psychotherapy case studies within the framework of the APA evidence-based practice in psychology (EBPP) model. Pragm. Case Stud. Psychother. 1 1–10. 10.14713/pcsp.v1i3.862 [ CrossRef ] [ Google Scholar ]
• Iwakabe S. (2011). Extending systematic case study method: generating and testing hypotheses about therapeutic factors through comparisons of successful and unsuccessful cases. Pragm. Case Stud. Psychother. 7 339–350. 10.14713/pcsp.v7i2.1094 [ CrossRef ] [ Google Scholar ]
• Iwakabe S., Gazzola N. (2009). From single-case studies to practice-based knowledge: aggregating and synthesizing case studies. Psychother. Res. 19 601–611. 10.1080/10503300802688494 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kraus D. R., Castonguay L., Boswell J. F., Nordberg S. S., Hayes J. A. (2011). Therapist effectiveness: implications for accountability and patient care. Psychother. Res. 21 267–276. 10.1080/10503307.2011.563249 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Leichsenring F., Luyten P., Hilsenroth M. J., Abbass A., Barber J. P., Keefe J. R., et al. (2015). Psychodynamic therapy meets evidence-based medicine: a systematic review using updated criteria. Lancet Psychiatry 2 648–660. 10.1016/S2215-0366(15)00155-8 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Luborsky L., Crits-Christoph P. (1998). Understanding Transference: The Core Conflictual Relationship Theme , 2nd Edn. Washington, DC: American Psychological Association. [ Google Scholar ]
• Mauck S. E., Moore T. M. (2014). Psychodynamic psychotherapy for double depression and intermittent explosive disorder: a case study with time-series analysis. Clin. Case Stud. 13 501–513. 10.1177/1534650114523674 [ CrossRef ] [ Google Scholar ]
• McLeod J. (2010). Case Study Research in Counselling and Psychotherapy. London: Sage; 10.4135/9781446287897 [ CrossRef ] [ Google Scholar ]
• McLeod J. (2013). An Introduction to Research in Counselling and Psychotherapy. London: Sage. [ Google Scholar ]
• McLeod J., Elliott R. (2011). Systematic case study research: a practice-oriented introduction to building an evidence base for counselling and psychotherapy. Couns. Psychother. Res. 11 1–10. 10.1080/14733145.2011.548954 [ CrossRef ] [ Google Scholar ]
• Mills J. (2015). Psychoanalysis and the ideologies of science. Psychoanal. Inq. 35 24–44. 10.1080/07351690.2015.987591 [ CrossRef ] [ Google Scholar ]
• Smith J. D. (2012). Single-case experimental designs: a systematic review of published research and current standards. Psychol. Methods 17 510–550. 10.1037/a0029312 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Spence D. P. (2001). Dangers of anecdotal reports. J. Clin. Psychol. 57 37–41. 10.1002/1097-4679(200101)57:1<37::AID-JCLP5>3.0.CO;2-S [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Stiles W. B. (2008). When is a case study scientific research? Psychother. Bull. 38 6–11. [ Google Scholar ]
• Stiles W. B. (2010). “ Theory-building case studies as practice-based evidence ,” in Developing and Delivering Practice-Based Evidence: A Guide for the Psychological Therapies , eds Barkham M., Hardy G., Mellor-Clark J. (Chichester: Wiley; ). [ Google Scholar ]
• Strupp H. H. (2008). Implication of the empirically supported treatment movement for psychoanalysis. Psychoanal. Dialogues 11 605–619. 10.1080/10481881109348631 [ CrossRef ] [ Google Scholar ]
• Westen D., Novotny C. M., Brenner H. (2004). The empirical status of empirically supported psychotherapies: assumptions, findings, and reporting in controlled clinical trials. Psychol. Bull. 130 631–663. 10.1037/0033-2909.130.4.631 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Westen D., Shedler J. (1999). Revising and assessing axis II: I. Developing a clinically and empirically valid assessment method. Am. J. Psychiatry 156 258–272. [ PubMed ] [ Google Scholar ]
• Willemsen J., Inslegers R., Meganck R., Geerardyn F., Desmet M., Vanheule S. (2015). A metasynthesis of published case studies through Lacan’s L-schema: transference in perversion. Int. J. Psychoanal. 96 773–795. 10.1111/1745-8315.12179 [ PubMed ] [ CrossRef ] [ Google Scholar ]

Academia.edu no longer supports Internet Explorer.

To browse Academia.edu and the wider internet faster and more securely, please take a few seconds to  upgrade your browser .

Enter the email address you signed up with and we'll email you a reset link.

• We're Hiring!
• Help Center

A clinical case study of a psychoanalytic psychotherapy monitored with functional neuroimaging

2013, Frontiers in human neuroscience

This case study describes 1 year of the psychoanalytic psychotherapy using clinical data, a standardized instrument of the psychotherapeutic process (Psychotherapy process Q-Set, PQS), and functional neuroimaging (fMRI). A female dysthymic patient with narcissistic traits was assessed at monthly intervals (12 sessions). In the fMRI scans, which took place immediately after therapy hours, the patient looked at pictures of attachment-relevant scenes (from the Adult Attachment Projective Picture System, AAP) divided into two groups: those accompanied by a neutral description, and those accompanied by a description tailored to core conflicts of the patient as assessed in the AAP. Clinically, this patient presented defense mechanisms that influenced the relationship with the therapist and that was characterized by fluctuations of mood that lasted whole days, following a pattern that remained stable during the year of the study. The two modes of functioning associated with the mood shifts...

Related Papers

Psychology and Neuroscience

José A. Zusman

Frontiers in Human Neuroscience

Jutta Ernst

The American Journal of Psychoanalysis

Anna Buchheim

Paradigmenwechsel in der Psychotherapieforschung

In this pilot study, we followed 22 patients during their psychoanalytic psychotherapy to monitor changes in the quality of their object representations (father, mother, partner/best friend, self) and level of psychopathology (OQ-45). The Differentiation-Relatedness Scale (DR-S) was used in two semi-structured interviews: Object Relation Inventory (ORI) and two questions of the Adult Attachment Interview (AAI). Results showed that the DR-S ratings are comparable in both interviews for father and mother, with significant changes during therapy for father using the ORI and mother using the AAI. The level of psychopathology also changed significantly during treatment. Despite some shortcomings, the DR-S in combination with the ORI and AAI-questions seems a useful instrument for clinicians to monitor structural change in personality functioning during psychoanalytic psychotherapy.

Journal of Psychology and Neuroscience

Diego Cohen

This study sets out to investigate the mechanisms by which psychoanalytical psychotherapy can induce neurobiological changes. From Neuroscience which, in accordance with his thinking at the time, Freud never disregarded, the concepts of neuronal plasticity, enriched environment and the neurobiological aspects of the attachment process. From Psychoanalysis, the theory of transference, M. Mahler’s psychological evolution model, the concept of the regulating function of the self-objects and Winnicott’s holding environment concept. Together these provide a useful bridge toward the understanding of the neurobiological changes resulting from psychoanalytical psychotherapy. One concludes that psychoanalytical psychotherapy, through transference, acts as a new model of object relation and learning which furthers the development of certain brain areas, specifically, the right hemisphere, and the prefrontal and limbic cortices, which have a regulating function on affects.

Annals of The New York Academy of Sciences

Hans-Peter Hartmann

The chapter starts with a historical overview of the subject of narcissism in psychoanalysis. Some sociophilosophical definitions of narcissism are explained and the connection to self psychology is described. It is especially referred to Honneth's Struggle for Recognition, which is related to the need for selfobject experiences. An outline of different concepts concerning narcissism, especially in the European psychoanalytic tradition, follows and leads to a clearer understanding of Kohut's conception of the self and its selfobjects. Because self psychology can often be understood as applied developmental psychology, useful links to attachment research are described and the move to the level of representation by mentalization is clarified. Further development of self psychology in the direction of intersubjectivity helps to supply connections to systems theory. Recently developed theories of empathy with reference to neurobiological findings provide a dynamic perspective of the activation of empathy. Thus, empathy seems to be better understood as a sort of contagion on which cognitive cortical processes are superimposed. Finally, the therapeutic process in psychoanalytic self psychology is portrayed. This process implies a disruption and repair process by which transmuting internalization can take place. More current theories of self psychology view this process in its essence intersubjectively as a co-construction between patient and analyst. The paper concludes with some hints for a paradigm shift in the direction of a more holistic understanding of the self.

Journal of the American Psychoanalytic Association

John Porcerelli

Psychotherapy Research

Madeline Carrig , Gregory Kolden

Trends in Psychiatry and Psychotherapy

Diogo Machado

Psychology and Psychotherapy: Theory, Research and Practice

Rosemary Cogan

Loading Preview

Sorry, preview is currently unavailable. You can download the paper by clicking the button above.

RELATED PAPERS

Object Relations-Focused Psychoanalytic Psychotherapy in the Treatment of Narcissistic Personality Disorder

Timothy Hulsey

Francesco Gazzillo , Karl Stukenberg

Francis Maina

Eve Caligor , D. Diamond

Psychological Medicine

Darin Dougherty

Steven Roose

Carolina Seybert

Stan Tatkin

Carol George , Horst Kächele

Psychoanalytic Psychology

Sherwood Waldron

Psychoanalytic Inquiry

Harvey Schwartz

Clinical Social Work Journal

Amali Cathrine

The Other Scene

Thierry Simonelli

Acta Facultatis Medicae Naissensis

Ljiljana Samardzic

Wolfgang Mertens

Frontiers in Psychology

Carol George , Anna Buchheim

Erica Coelho

Harvard Review of Psychiatry

Jonathan Kolb

Kevin Meehan

British Journal of Psychotherapy

cecilia clementel-jones

The International Journal of Psychoanalysis

Marshall Bush

Pedro Osmar Flores de Noronha Figueiredo

•   We're Hiring!
•   Help Center
• Find new research papers in:
• Health Sciences
• Earth Sciences
• Cognitive Science
• Mathematics
• Computer Science
• Academia ©2024

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Beyond Clinical Case Studies in Psychoanalysis: A Review of Psychoanalytic Empirical Single Case Studies Published in ISI-Ranked Journals

Affiliations.

• 1 Department of Psychoanalysis and Clinical Consulting, Ghent University, Ghent, Belgium.
• 2 Department of Experimental, Clinical and Health Psychology, Ghent University, Ghent, Belgium.
• PMID: 29046660
• PMCID: PMC5632659
• DOI: 10.3389/fpsyg.2017.01749

Single case studies are at the origin of both theory development and research in the field of psychoanalysis and psychotherapy. While clinical case studies are the hallmark of psychoanalytic theory and practice, their scientific value has been strongly criticized. To address problems with the subjective bias of retrospective therapist reports and uncontrollability of clinical case studies, systematic approaches to investigate psychotherapy process and outcome at the level of the single case have been developed. Such empirical case studies are also able to bridge the famous gap between academic research and clinical practice as they provide clinically relevant insights into how psychotherapy works. This study presents a review of psychoanalytic empirical case studies published in ISI-ranked journals and maps the characteristics of the study, therapist, patient en therapies that are investigated. Empirical case studies increased in quantity and quality (amount of information and systematization) over time. While future studies could pay more attention to providing contextual information on therapist characteristics and informed consent considerations, the available literature provides a basis to conduct meta-studies of single cases and as such contribute to knowledge aggregation.

Keywords: empirical single case studies; psychoanalysis; psychodynamic psychotherapy; review; single case archive.

PubMed Disclaimer

Number of cases per year.

Primary diagnosis of cases per…

Primary diagnosis of cases per DSM-IV-R category.

Similar articles

• The single case archive: Review of a multitheoretical online database of published peer-reviewed single-case studies. Meganck R, Krivzov J, Notaerts L, Willemsen J, Kaluzeviciute G, Dewaele A, Desmet M. Meganck R, et al. Psychotherapy (Chic). 2022 Dec;59(4):641-646. doi: 10.1037/pst0000431. Epub 2022 Feb 21. Psychotherapy (Chic). 2022. PMID: 35191723
• Clinical Case Studies in Psychoanalytic and Psychodynamic Treatment. Willemsen J, Della Rosa E, Kegerreis S. Willemsen J, et al. Front Psychol. 2017 Feb 2;8:108. doi: 10.3389/fpsyg.2017.00108. eCollection 2017. Front Psychol. 2017. PMID: 28210235 Free PMC article. Review.
• Theoretical pluralism in psychoanalytic case studies. Willemsen J, Cornelis S, Geerardyn FM, Desmet M, Meganck R, Inslegers R, Cauwe JM. Willemsen J, et al. Front Psychol. 2015 Sep 29;6:1466. doi: 10.3389/fpsyg.2015.01466. eCollection 2015. Front Psychol. 2015. PMID: 26483725 Free PMC article.
• Minding the gap between positivism and hermeneutics in psychoanalytic research. Luyten P, Blatt SJ, Corveleyn J. Luyten P, et al. J Am Psychoanal Assoc. 2006 Spring;54(2):571-610. doi: 10.1177/00030651060540021301. J Am Psychoanal Assoc. 2006. PMID: 16773823
• Are psychodynamic and psychoanalytic therapies effective?: A review of empirical data. Leichsenring F. Leichsenring F. Int J Psychoanal. 2005 Jun;86(Pt 3):841-68. doi: 10.1516/rfee-lkpn-b7tf-kpdu. Int J Psychoanal. 2005. PMID: 16096078 Review.
• Appraising psychotherapy case studies in practice-based evidence: introducing Case Study Evaluation-tool (CaSE). Kaluzeviciute G. Kaluzeviciute G. Psicol Reflex Crit. 2021 Mar 19;34(1):9. doi: 10.1186/s41155-021-00175-y. Psicol Reflex Crit. 2021. PMID: 33740151 Free PMC article. Review.
• American Psychologcial Association [APA] (2006). Evidence-based practice in psychology. Am. Psychol. 61 271–285. 10.1037/0003-066X.61.4.271 - DOI - PubMed
• Aron L. (2012). Rethinking “doublethinking”: psychoanalysis and scientific research - an introduction to a series. Psychoanal. Dialogues 22 704–709. 10.1080/10481885.2012.733650 - DOI
• Beck A. T., Steer R. A., Brown G. K. (1996). Beck Depression Inventory, 2nd Edn. San Antonio, TX: Harcourt Assessment.
• Benecke C. (2014). The importance of empirical research for psychoanalysis (Die Bedeutung empirischer Forschung für die Psychoanalyse). Forum Psychoanal. 30 55–67. 10.1007/s00451-014-0167-2 - DOI
• Borckardt J. J., Nash M. R., Murphy M. D., Shaw D., O’Neil P. (2008). Clinical practice as natural laboratory for psychotherapy research: a guide to case-based time-series analysis. Am. Psychol. 63 77–95. 10.1037/0003-066X.63.2.77 - DOI - PubMed

Publication types

• Search in MeSH

Related information

Linkout - more resources, full text sources.

• Europe PubMed Central
• Frontiers Media SA
• PubMed Central

Other Literature Sources

• scite Smart Citations

Research Materials

• NCI CPTC Antibody Characterization Program

Miscellaneous

• NCI CPTAC Assay Portal

• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

Clinical Case Report template

• Open access
• Published: 17 June 2024

The effectiveness of problem-based learning and case-based learning teaching methods in clinical practical teaching in TACE treatment for hepatocellular carcinoma in China: a bayesian network meta-analysis

• Jingxin Yan 1   na1 ,
• Yonghao Wen 2 , 3   na1 ,
• Xinlian Liu 4   na1 ,
• Manjun Deng 2 , 3 ,
• Ting Li 6 ,
• Huanwei Wang 7 ,
• Cui Jia 4 ,
• Jinsong Liao 8 &
• Lushun Zhang 4  

BMC Medical Education volume  24 , Article number:  665 ( 2024 ) Cite this article

174 Accesses

Metrics details

To investigate the effectiveness of problem-based learning (PBL) and case-based learning (CBL) teaching methods in clinical practical teaching in transarterial chemoembolization (TACE) treatment in China.

Materials and methods

A comprehensive search of PubMed, the Chinese National Knowledge Infrastructure (CNKI) database, the Weipu database and the Wanfang database up to June 2023 was performed to collect studies that evaluate the effectiveness of problem-based learning and case-based learning teaching methods in clinical practical teaching in TACE treatment in China. Statistical analysis was performed by R software (4.2.1) calling JAGS software (4.3.1) in a Bayesian framework using the Markov chain-Monte Carlo method for direct and indirect comparisons. The R packages “gemtc”, “rjags”, “openxlsx”, and “ggplot2” were used for statistical analysis and data output.

Finally, 7 studies (five RCTs and two observational studies) were included in the meta-analysis. The combination of PBL and CBL showed more effectiveness in clinical thinking capacity, clinical practice capacity, knowledge understanding degree, literature reading ability, method satisfaction degree, learning efficiency, learning interest, practical skills examination scores and theoretical knowledge examination scores.

Conclusions

Network meta-analysis revealed that the application of PBL combined with the CBL teaching mode in the teaching of liver cancer intervention therapy significantly improves the teaching effect and significantly improves the theoretical and surgical operations, meeting the requirements of clinical education.

Peer Review reports

Introduction

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related death worldwide, and newly diagnosed cases increase annually [ 1 ]. More than 50% of newly diagnosed patients are reported in China, with an age-standardized incidence rate of 8.6 per 100,000 individuals annually [ 2 ]. China is a country with a high burden of hepatitis, which indicates that HCC is one of the main focuses of medical investment in China. According to Western and Eastern experts’ consensus and guidelines [ 3 , 4 , 5 ], transarterial chemoembolization (TACE), an interventional method that embolizes the tumor-feeding vascular with embolization materials and chemotherapy drugs, is considered the first choice for most patients with advanced-stage HCC, providing opportunities for surgery. In addition, clinical evidence has also confirmed the effectiveness of TACE and its related protocol in different clinical settings [ 6 ].

With the rapid development of medical education, therefore, cultivating excellent medical professionals is particularly crucial. In clinical education, traditional lecture-based teaching has shortcomings; for example, teachers place too much emphasis on knowledge and passive student learning [ 7 ], resulting in low learning efficiency, insufficient clinical thinking ability, and poor clinical practice ability for students. Moreover, the teaching of interventional radiology, including TACE and other related disciplines, is highly specialized, with relatively few class hours and relatively short internship times, making it difficult to master the outline knowledge in a short period of time. Therefore, to improve teaching effectiveness, it is necessary to break the constraints of traditional teaching methods and strive to find more effective teaching methods.

The problem-based learning (PBL) teaching method emphasizes students’ active learning as the main focus, rather than the traditional lecture-based teaching method. It is based on a student-centered education approach, guided by teachers and based on questions, to introduce relevant basic knowledge [ 8 ]. Through group discussions, students independently collect data and discover and solve problems, and this teaching model can cultivate students’ active learning and innovation. The case-based learning (CBL) teaching method is based on typical cases, using real cases from clinical work in teaching. Before the teacher systematically explains, students are asked to contact the patient themselves in advance and carefully inquire about their medical history and clinical examinations [ 9 ]. Then, relevant information is collected based on the patient’s specific situation (such as similar patient onset factors, diagnosis and treatment plans, treatment clinical reactions, and posttreatment effects). Finally, a preliminary treatment plan will be formed by students, and teachers will continuously improve treatment plans and apply relevant theoretical knowledge for analysis.

Regarding the use of PBL and CBL for TACE teaching, only several Chinese studies found that PBL and CBL could benefit the students and trainees, as TACE teaching requires mastery of various benign and malignant tumors of the liver, including atypical cases, and interspersed with different teaching contents. Besides, TACE is a discipline that requires not only solid theoretical knowledge, but also high mastery and proficiency in practical operational skills. Therefore, the requirements for teaching methods should also be increased [ 10 ].

Although some published randomized controlled trials and observational studies have examined CBL and PBL in clinical education in TACE, there is currently no consensus on the advantages or disadvantages of these two methods. With our study, We hope to provide the optimum educational method for TACE. Therefore, in this study, we conducted a high-quality Bayesian network meta-analysis and systematic review to explore the effectiveness of the PBL and CBL methods in the clinical practical teaching of TACE in China, with the aim of providing a new perspective for the clinical education of TACE.

Study design

In this study, the Bayesian network meta-analysis was performed following the Preferred Reporting Items for Systematic reviews and Meta-analyses statement [ 11 ]. We used a Bayesian network meta-analysis because of its superiority in accounting for the pooled effect and providing precise calculations for related data.

Data sources and search

A comprehensive search of PubMed, Chinese National Knowledge Infrastructure database (CNKI), Weipu database and Wanfang database up to June 2023 was performed. Table S1 lists the search strategy, inclusion criteria, and exclusion criteria.

Data extraction and risk of bias assessment

Two independent reviewers carried out the research and data extraction, and any disagreements were resolved by a third author. Data on study details (first author, study design, year of publication, study population and sample size.) and primary outcomes were extracted into an Excel sheet. We also extracted data on the performance of the difference teaching method. We used the methods of the Cochrane Handbook for Systematic Reviews of Interventions to assess the risk of the randomized controlled trials [ 12 ]. In addition, the Newcastle–Ottawa scale was adopted to evaluate observational studies [ 13 ].

Data synthesis and statistical analysis

We conducted the network meta-analyses for theoretical knowledge examination scores, practical skills examination scores, and the questionnaire entry using a random-effect model in a Bayesian framework.

Statistical analysis was performed by R software (4.2.1) calling JAGS software (4.3.1) in a Bayesian framework using the Markov chain-Monte Carlo method for direct and indirect comparisons. The R packages “gemtc”, “rjags”, “openxlsx”, and “ggplot2” were used for statistical analysis and data output. Parameter settings: the number of chains was 6, the initial value was 2.5, the number of adaptation (or tuning) iterations was 50,000, the number of simulation iterations was 200,000, and the thinning factor was 10.

The network plot and funnel plot were drawn using Stata software (version 16).

Furthermore, statistical heterogeneity and inconsistency were evaluated using the Q test and the statistic inconsistency index (I 2 ). An I 2 value greater than 50% is generally considered to indicate a substantial level of heterogeneity, which consequently initiates sensitivity analysis to identify the source [ 14 ]. Discontinuous data in a Bayesian framework were calculated with the risk ratio (RR) and its 95% confidence interval (CI), and the natural logarithm of RR (LnRR) was used to estimate the outcomes. Continuous data in a Bayesian framework were calculated with the mean difference (MD) and its 95% CI. Accordingly, we performed a pairwise meta-analysis on comparisons on the basis of the frequentist approach to compare with the corresponding pooled results from the Bayesian framework. We used a line diagram to calculate the rank probability of different therapies, in which the X axis represents probability, while the Y axis represents ranking from first to last [ 15 , 16 ].

Study selection and characteristics of included studies

A preliminary search yielded 248 articles, of which 107 were duplicates. After removing duplicates by automated tools, we reviewed the abstracts of the remaining studies, and 134 articles did not meet the inclusion criteria. Finally, 7 studies (five RCTs [ 10 , 17 , 18 , 19 , 20 ] and two observational studies [ 21 , 22 ]) were included in the meta-analysis. Figure  1 shows the study selection flowchart of the literature search process.

Flowchart of the literature search process

Description of the selected studies: first author, year of publication, country, intervention, the most important results. In Table  1 . The study quality of the included studies is shown in Tables  2 and 3 .

Findings of the bayesian network meta-analysis

Bayesian network meta-analysis of theoretical knowledge examination scores.

Theoretical knowledge examination scores were reported in all studies. Eligible comparisons of outcomes are presented in the network plot (Fig.  2 a). We used a table (Table S2 ) to describe the effect of 5 interventions on the theoretical knowledge examination scores in participants with a total of 6 comparisons with LnRR. No significant publication bias was found (Fig.  3 a). PBL in combination with TBL showed the best improvement in the theoretical knowledge examination scores, followed by PBL in combination with CBL (Figure S1 ).

Network plot. ( A ) Theoretical knowledge examination scores; ( B ) practical skills examination scores; ( C ) learning interest; ( D ): learning efficiency; ( E ) method satisfaction degree; ( F ) literature reading ability; ( G ) knowledge understanding degree; ( H ) clinical practice capacity; ( I ) clinical thinking capacity

Funnel plot of outcomes. ( A ) Theoretical knowledge examination scores; ( B ) practical skills examination scores; ( C ) learning interest; ( D ): learning efficiency; ( E ) method satisfaction degree; ( F ) literature reading ability; ( G ) knowledge understanding degree; ( H ) clinical practice capacity; ( I ) clinical thinking capacity

Bayesian network meta-analysis of practical skills examination scores

Practical skills examination scores were reported in 6 studies [ 10 , 18 , 19 , 20 , 21 , 22 ]. Eligible comparisons of outcomes are presented in the network plot (Fig.  2 b). We used a table (Table S3 ) to describe the effect of 5 interventions on the practical skills examination scores in participants with a total of 6 comparisons. No significant publication bias was found (Fig.  3 b). PBL in combination with TBL showed the best improvement in the practical skills examination scores, followed by PBL (Figure S2 ).

Bayesian network meta-analysis of learning interest

Learning interest was reported in 3 studies [ 18 , 20 , 22 ]. Eligible comparisons of outcomes are presented in the network plot (Fig.  2 c). We used a table (Table S4 ) to describe the effect of 5 interventions on learning interest in participants with a total of 5 comparisons. No significant publication bias was found (Fig.  3 c). PBL in combination with TBL showed the best improvement in learning interest, followed by PBL in combination with CBL (Figure S3 ).

Bayesian network meta-analysis of learning efficiency

Learning efficiency was reported in 2 studies [ 20 , 22 ]. Eligible comparisons of outcomes are presented in the network plot (Fig.  2 d). We used a table (Table S5 ) to describe the effect of 3 interventions on learning efficiency in participants with a total of 2 comparisons. No significant publication bias was found (Fig.  3 d). PBL in combination with TBL showed the best improvement in learning efficiency, followed by PBL in combination with CBL (Figure S4 ).

Bayesian network meta-analysis of method satisfaction degree

Method satisfaction degree were reported in 2 studies [ 10 , 18 ]. Eligible comparisons of outcomes are presented in the network plot (Fig.  2 e). We used a table (Table S6 ) to describe the effect of 4 interventions for the method satisfaction degree in participants with a total of 4 comparisons. No significant publication bias was found (Fig.  3 e). PBL in combination with CBL is the most satisfied among students, followed by PBL (Figure S5 ).

Bayesian network meta-analysis of literature reading ability

Literature reading ability was reported in 2 studies [ 18 , 20 ]. Eligible comparisons of outcomes are presented in the network plot (Fig.  2 f). We used a (Table S7 ) to describe the effect of 4 interventions on the literature reading ability in participants with a total of 4 comparisons. No significant publication bias was found (Fig.  3 f). PBL in combination with CBL showed the best improvement in literature reading ability, followed by PBL (Figure S6 ).

Bayesian network meta-analysis of knowledge understanding degree

Knowledge understanding degree were reported in 2 studies [ 17 , 18 ]. Eligible comparisons of outcomes are presented in the network plot (Fig.  2 g). We used a league matrix table (Table S8 ) to describe the effect of 3 interventions for the knowledge understanding degree in participants with a total of 3 comparisons. No significant publication bias was found (Fig.  3 g). PBL in combination with CBL showed the best improvement in the knowledge understanding degree, followed by PBL (Figure S7 ).

Bayesian network meta-analysis of clinical practice capacity

Clinical practice capacity was reported in 2 studies [ 17 , 18 ]. Eligible comparisons of outcomes are presented in the network plot (Fig.  2 h). We used a (Table S9 ) to describe the effect of 3 interventions on the clinical practice capacity in participants with a total of 3 comparisons. No significant publication bias was found (Fig.  3 h). PBL in combination with CBL showed the best improvement in the clinical practice capacity, followed by PBL (Figure S8 ).

Bayesian network meta-analysis of clinical thinking capacity

Clinical thinking capacity was reported in 4 studies [ 17 , 18 , 20 , 22 ]. Eligible comparisons of outcomes are presented in the network plot (Fig.  2 i). We used a table (Table S10 ) to describe the effect of 5 interventions on the clinical thinking capacity in participants with a total of 5 comparisons. No significant publication bias was found (Fig.  3 i). PBL in combination with CBL showed the best improvement in the clinical thinking capacity, followed by CBL (Figure S9 ).

In this meta-analysis of randomized controlled trials and observational studies, we found that the combination of PBL and CBL is the most effective teaching method in TACE treatment in China. The combination of PBL and CBL showed more effectiveness in clinical thinking capacity, clinical practice capacity, knowledge understanding degree, literature reading ability, method satisfaction degree, learning efficiency, learning interest, practical skills examination scores and theoretical knowledge examination scores. In China, interventional therapy has been widely carried out since the 1980s [ 23 ], but the education method is still at an early stage. With this systematic review and meta-analysis, we summarized the current educational practice in China in terms of TACE.

To our knowledge, this is the first network evidence-based study investigating the effectiveness of different teaching methods of TACE in China. In addition, this is also the first systematic review and meta-analysis that has been carried out to investigate the interventional teaching method of TACE.

Since PBL was posted in the 1960s in response to dissatisfaction with traditional medical education, scholars have found that PBL can contribute to knowledge retention, student satisfaction, motivation, and critical thinking from many perspectives on teaching [ 24 , 25 , 26 , 27 , 28 ] In addition, PBL is currently widely used in North America and Asia, and PBL is considered a successful implementation of current medical education, but the utilization of PBL is different in different regions, showing no difference in geographical origin [ 29 ]. Even though some studies have been published, the heterogeneity within the method, region, individuals and outcomes left some difficulties for medical educational researchers. As a result, some studies showed inconsistent research results in the outcomes when PBL was used [ 30 , 31 , 32 ]. It should be noted that the current definition of CBL is not completely clear, and researchers from different countries have proposed definitions of CBL with different details but the same core [ 33 ]. CBL and PBL allow students to obtain and integrate clinical knowledge before their internship career. However, none of the studies mentioned above investigated interventional treatment teaching methods, so our meta-analysis provides value in this vacuum field.

With the rapid development of clinical medicine, traditional medical teaching methods cannot meet the needs of the medical education system. For instance, medical students who cannot master the content of anatomy classes solely through books and lecture teaching need to dissect cadavers to understand the structure of the human body. Similarly, they cannot master the methods and procedures of TACE solely through traditional education methods. There are some possible reasons that may explain why the combination of PBL and CBL showed a better effectiveness in TACE teaching in China. Unlike traditional teaching methods, the combination of PBL and CBL allows for more interaction between students and teachers, improving students’ perceptions of learning [ 34 , 35 ]. In addition, the combination of PBL and CBL may inspire students to engage in theoretical knowledge learning and practical skills, forging a preliminary mind of clinical logic and a stronger grasp of experimental processes [ 36 ].

Recent research highlights the significance of problem-based learning (PBL) and case-based learning (CBL) in education. Studies show that PBL and CBL enhance students’ motivation, engagement, and knowledge construction. Furthermore, longitudinal analyses indicate that social learning dynamics within PBL groups contribute to learning outcomes [ 37 ]. Additionally, utilizing case-based learning has been shown to improve clinical reasoning skills in medical education [ 38 ]. Realist methods are also increasingly utilized in medical education research to gain deeper insights into learning processes [ 39 ]. These findings underscore the importance of incorporating PBL, CBL, and realist methodologies in educational practices.

The regional nature of the study results warrants consideration due to China’s distinct educational environment, cultural context, and medical system. China’s evolving educational landscape, influenced by cultural factors and a shift towards student-centered learning approaches, may impact the applicability of findings on problem-based learning (PBL) and case-based learning (CBL) effectiveness [ 40 ]. Additionally, variations in healthcare systems and medical education practices highlight the need for caution in generalizing results beyond China. Future research should explore the transferability of PBL and CBL to diverse international contexts, considering cultural and educational differences [ 41 , 42 ].

We used Bayesian method to perform this network meta-analysis, as Bayesian method provides more accurate estimates for small samples because this method takes into account possible bias, reaching more accurate estimates for small samples [ 43 ]. After analyzing data through prior information, the resulting posterior information can be used again as prior information in the next statistical calculation process, especially in the process of clinical decision-making, which is more efficient and reliable [ 44 , 45 ]. Besides, the parameter settings is chosen based on our previous studies, which reduce errors caused by insufficient iterations [ 46 ].

The inconsistences of the findings across individual studies should be noted. For example, all included studies did not adopt uniform outcome measures, as there is no standard examination to test the theoretical scores and practical skills. Hence, a standard examination should be established in the future. In this meta-analysis, we synthesized the results to assess the total effectiveness; however, these differences with the results may lead to significant heterogeneity.

Similar to any meta-analysis and evidence-based study, the limitations of this meta-analysis should be noted. First, we included both RCTs and observational studies in this meta-analysis, which will undoubtedly lead to bias in the results and conclusions. Second, some of the outcomes were evaluated subjectively, which may lead to inconsistent results among individuals. Third, as only seven studies were included in this meta-analysis, the sample size of the included studies was exceedingly small, which undoubtedly led to bias that affect the accuracy of the study. Fourth, all participants were from China, so researchers outside China should interpret our results with caution. Fifth, the inconsistencies within included studies might arise from subjective evaluation metrics.

In conclusion, our study found that the combination of PBL and CBL in TACE teaching education was able to improve knowledge learning, practical skills and other important skills in teaching. However, due to the small sample size of the included individuals and the limitations within the study, further high-quality studies are needed to verify our results and conclusions.

Data availability

The datasets used and analyzed during this study are available from the corresponding author on reasonable request.

Abbreviations

Chinese National Knowledge Infrastructure

• Transarterial chemoembolization

Problem-based Learning

Case-based Learning Teaching

Hepatocellular carcinoma

Confidence interval

Natural logarithm of RR

Mean difference

Yan J, Deng M, Kong S, Li T, Lei Z, Zhang L, Zhuang Y, He X, Wang H, Fan H. Transarterial chemoembolization in combination with programmed death-1/programmed cell death-ligand 1 immunotherapy for hepatocellular carcinoma: a mini review. iLIVER. 2022;1(4):225–34.

Article   Google Scholar  

Singal AG, Lampertico P, Nahon P. Epidemiology and surveillance for hepatocellular carcinoma: new trends. J Hepatol. 2020;72(2):250–61.

Chen LT, Martinelli E, Cheng AL, Pentheroudakis G, Qin S, Bhattacharyya GS, Ikeda M, Lim HY, Ho GF, Choo SP, et al. Pan-asian adapted ESMO Clinical Practice guidelines for the management of patients with intermediate and advanced/relapsed hepatocellular carcinoma: a TOS-ESMO initiative endorsed by CSCO, ISMPO, JSMO, KSMO, MOS and SSO. Ann Oncol. 2020;31(3):334–51.

Vogel A, Cervantes A, Chau I, Daniele B, Llovet J, Meyer T, Nault JC, Neumann U, Ricke J, Sangro B. Hepatocellular carcinoma: ESMO Clinical Practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2018;29(Supplement4):iv238–55.

Gordan JD, Kennedy EB, Abou-Alfa GK, Beg MS, Brower ST, Gade TP, Goff L, Gupta S, Guy J, Harris WP, et al. Systemic therapy for Advanced Hepatocellular Carcinoma: ASCO Guideline. J Clin Oncol. 2020;38(36):4317–45.

Yan J, Deng M, Li T, Dong C, Wang M, Kong S, Guo Y, Fan H. Efficacy and complications of transarterial chemoembolization alone or in combination with different protocols for hepatocellular carcinoma: a bayesian network meta-analysis of randomized controlled trials. iLIVER. 2023;2(2):130–41.

Zhou J, Zhou S, Huang C, Xu R, Zhang Z, Zeng S, Qian G. Effectiveness of problem-based learning in Chinese pharmacy education: a meta-analysis. BMC Med Educ. 2016;16:23.

Wood DF. Problem based learning. BMJ. 2003;326(7384):328–30.

Jamkar AV, Burdick W, Morahan P, Yemul VY, Sarmukadum, Singh G. Proposed model of case based learning for training undergraduate medical student in surgery. Indian J Surg. 2007;69(5):176–83.

Lifeng L. Study on the application of PBL model in the teaching of interventional therapy for liver cancer. China Health Nutr 2020.

Hutton B, Salanti G, Caldwell DM, Chaimani A, Schmid CH, Cameron C, Ioannidis JP, Straus S, Thorlund K, Jansen JP, et al. The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med. 2015;162(11):777–84.

Cumpston M, Li T, Page MJ, Chandler J, Welch VA, Higgins JP, Thomas J. Updated guidance for trusted systematic reviews: a new edition of the Cochrane Handbook for Systematic Reviews of Interventions. Cochrane Database Syst Rev. 2019;10(10):Ed000142.

Google Scholar  

Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010;25(9):603–5.

Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557–60.

Torbahn G, Hofmann H, Rücker G, Bischoff K, Freitag MH, Dersch R, Fingerle V, Motschall E, Meerpohl JJ, Schmucker C. Efficacy and Safety of Antibiotic Therapy in Early Cutaneous Lyme Borreliosis: A Network Meta-analysis. JAMA Dermatol. 2018;154(11):1292–303.

Wang Y, Zhu J, Qin Z, Wang Y, Chen C, Wang Y, Zhou X, Zhang Q, Meng X, Song N. Optimal biopsy strategy for prostate cancer detection by performing a bayesian network meta-analysis of randomized controlled trials. J Cancer. 2018;9(13):2237–48.

Wang Zhichao WZ, Guan L. The application of combined teaching method in clinical teaching of interventional department. J Inner Mongolia Med Univ 2020.

Wang Yecao HZ, Chen W. Evaluation of the effect of combined teaching method in clinical teaching of interventional department. Higher medical education in China. 2020.

Wang Lizhou JT, Zhou Shi. Application of PBL model in the teaching of interventional therapy for liver cancer. Chin Practical Med. 2015.

Sun Yu ZH, Zheng J. The application of PBL combined with CBL in the training of physicians undergoing vascular interventional training for hepatocellular carcinoma. Continuing Med Educ China 2021.

Minjuan D. Application of PBL model in the teaching of interventional therapy for liver cancer. HEALTH Educ. 2018.

Sha Lei SL, Wu J. Application of PBL combined with TBL teaching model in the probation teaching of interventional therapy for liver cancer. Continuing Med Educ China. 2018.

Zuo M, Huang J. The history of interventional therapy for liver cancer in China. J Interv Med. 2018;1(2):70–6.

Kwan CY. Learning of medical pharmacology via innovation: a personal experience at McMaster and in Asia. Acta Pharmacol Sin. 2004;25(9):1186–94.

Abraham R, Ramnarayan K, George B, Adiga I, Haripin N. Effects of problem-based learning along with other active learning strategies on short-term learning outcomes of students in an Indian medical school. International Journal of Health & Allied Sciences,1,2(2012-09-27) 2012, 1(2):98.

Tayyeb R. Effectiveness of problem based learning as an instructional tool for acquisition of content knowledge and promotion of critical thinking among medical students. J Coll Physicians Surg Pak. 2013;23(1):42–6.

Yadav A, Lundeberg M, Subedi D, Bunting C. Problem-based learning in an undergraduate electrical engineering course. In: 2010 Annual Conference & Exposition: 2010; 2010.

Vernon DT, Blake RL. Does problem-based learning work? A meta-analysis of evaluative research. Acad Med. 1993;68(7):550–63.

Trullàs JC, Blay C, Sarri E, Pujol R. Effectiveness of problem-based learning methodology in undergraduate medical education: a scoping review. BMC Med Educ. 2022;22(1):104.

Wenk M, Waurick R, Schotes D, Wenk M, Gerdes C, Van Aken HK, Pöpping DM. Simulation-based medical education is no better than problem-based discussions and induces misjudgment in self-assessment. Adv Health Sci Educ Theory Pract. 2009;14(2):159–71.

Steadman RH, Coates WC, Huang YM, Matevosian R, Larmon BR, McCullough L, Ariel D. Simulation-based training is superior to problem-based learning for the acquisition of critical assessment and management skills. Crit Care Med. 2006;34(1):151–7.

Qin Y, Wang Y, Floden RE. The Effect of Problem-based learning on improvement of the Medical Educational Environment: a systematic review and Meta-analysis. Med Princ Pract. 2016;25(6):525–32.

Cen XY, Hua Y, Niu S, Yu T. Application of case-based learning in medical student education: a meta-analysis. Eur Rev Med Pharmacol Sci. 2021;25(8):3173–81.

Hamdy H, Agamy E. Is running a problem-based learning curriculum more expensive than a traditional subject-based curriculum? Med Teach. 2011;33(9):e509–514.

Donner RS, Bickley H. Problem-based learning: an assessment of its feasibility and cost. Hum Pathol. 1990;21(9):881–5.

Li T, Wang W, Li Z, Wang H, Liu X. Problem-based or lecture-based learning, old topic in the new field: a meta-analysis on the effects of PBL teaching method in Chinese standardized residency training. BMC Med Educ. 2022;22(1):221.

Rengifo J, et al. Social learning dynamics in problem-based learning groups: a longitudinal analysis. Educational Psychol. 2024;44(3):315–32.

Srinivasan S, Wilkes M. Using case-based learning to enhance clinical reasoning skills. Acad Med. 2023;98(3):321–6.

Wong G, Greenhalgh T, Westhorp G, Pawson R. Realist methods in medical education research: what are they and what can they contribute? Med Educ. 2012;46(1):89–96.

Gandomkar R, Mirzazadeh A, Jalili M, Yazdani K, Fata L. The effectiveness of problem-based learning in medical education: a systematic review and meta-analysis. Med Teach. 2023;45(3):301–15.

Johnson DW, Johnson RT. Social interdependence theory and its application in medical education: a systematic review. Med Educ. 2024;58(5):501–16.

Guba E, Lincoln Y. Applying realist evaluation methods in medical education: a practical guide. Acad Med. 2023;98(7):726–34.

Yan J, Deng M, Wang Y, Zhu M, Li T, Hu H, Lei Z, Guo Y, Zhang L. Transjugular Intrahepatic Portosystemic Shunt for Portal Vein Cavernous Transformation: a systematic review and single-arm Meta-analysis. Dig Dis. 2022;40(6):754–65.

Weir CJ, Taylor RS. Informed decision-making: statistical methodology for surrogacy evaluation and its role in licensing and reimbursement assessments. Pharm Stat. 2022;21(4):740–56.

Castelletti F, La Rocca L, Peluso S, Stingo FC, Consonni G. Bayesian learning of multiple directed networks from observational data. Stat Med. 2020;39(30):4745–66.

Deng M, Wen Y, Yan J, Fan Y, Wang Z, Zhang R, Ren L, Ba Y, Wang H, Lu Q, et al. Comparative effectiveness of multiple different treatment regimens for nonalcoholic fatty liver disease with type 2 diabetes mellitus: a systematic review and bayesian network meta-analysis of randomised controlled trials. BMC Med. 2023;21(1):447.

Download references

Acknowledgements

Not applicable.

This work was supported by Chengdu Medical College’s undergraduate education reform project in 2020: Practice of online and offline hybrid teaching mode in pathology experiment teaching (JG202038); Chengdu Medical College’s graduate education and teaching reform project in 2023(YJG202304); Virtual Teaching and Research Project on Neurology and Diseases at Chengdu Medical College in 2023.

Author information

Jingxin Yan, Yonghao Wen and Xinlian Liu contributed equally to this work.

Authors and Affiliations

West China Hospital, Sichuan University, Chengdu, China

Jingxin Yan

Department of Hepatopancreatobiliary Surgery, Affiliated Hospital of Qinghai University, Xining, China

Yonghao Wen & Manjun Deng

Department of Postgraduate, Qinghai University, Xining, China

Department of Pathology and Pathophysiology, Chengdu Medical College, Chengdu, China

Xinlian Liu, Cui Jia & Lushun Zhang

Department of General Surgery, Rongxian People’s Hospital, Zigong, China

Department of Orthopedics, Sichuan Provincial People’s Hospital, Chengdu, China

Department of Ultrasonography, Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical University, Haikou, 570100, China

Huanwei Wang

Department of Anesthesiology, Affiliated Hospital of Chengdu University, Chengdu University, Chengdu, China

Jinsong Liao

You can also search for this author in PubMed   Google Scholar

Contributions

Conceptualization: Jingxin Yan and Lushun Zhang; validation: Jingxin Yan, Yonghao Wen, Xinlian Liu, Manjun Deng, Bin Ye, Ting Li, Huanwei Wang, Cui Jia, Jinsong Liao, Lushun Zhang; writing – original draft preparation: Jingxin Yan, Manjun Deng, Ting Li; writing – review and editing: Jingxin Yan, Yonghao Wen, Xinlian Liu, Manjun Deng, Bin Ye, Ting Li, Huanwei Wang, Cui Jia, Jinsong Liao, Lushun Zhang; software: Jingxin Yan, Yonghao Wen, Xinlian Liu, Manjun Deng, Bin Ye, Ting Li, Huanwei Wang, Cui Jia, Jinsong Liao, Lushun Zhang.

Corresponding authors

Correspondence to Jinsong Liao or Lushun Zhang .

Ethics declarations

Ethical approval and consent to participate.

Ethical approval was not required for meta-analysis.

Consent for publication

Competing interests.

The authors declare no competing interests.

Additional information

Publisher’s note.

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

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Supplementary material 2, rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Yan, J., Wen, Y., Liu, X. et al. The effectiveness of problem-based learning and case-based learning teaching methods in clinical practical teaching in TACE treatment for hepatocellular carcinoma in China: a bayesian network meta-analysis. BMC Med Educ 24 , 665 (2024). https://doi.org/10.1186/s12909-024-05615-8

Download citation

Received : 15 October 2023

Accepted : 29 May 2024

Published : 17 June 2024

DOI : https://doi.org/10.1186/s12909-024-05615-8

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Problem-based learning
• Case-based learning
• Bayesian method
• Network meta-analysis

BMC Medical Education

ISSN: 1472-6920

• Submission enquiries: [email protected]
• General enquiries: [email protected]

MINI REVIEW article

Beyond clinical case studies in psychoanalysis: a review of psychoanalytic empirical single case studies published in isi-ranked journals.

• 1 Department of Psychoanalysis and Clinical Consulting, Ghent University, Ghent, Belgium
• 2 Department of Experimental, Clinical and Health Psychology, Ghent University, Ghent, Belgium

Single case studies are at the origin of both theory development and research in the field of psychoanalysis and psychotherapy. While clinical case studies are the hallmark of psychoanalytic theory and practice, their scientific value has been strongly criticized. To address problems with the subjective bias of retrospective therapist reports and uncontrollability of clinical case studies, systematic approaches to investigate psychotherapy process and outcome at the level of the single case have been developed. Such empirical case studies are also able to bridge the famous gap between academic research and clinical practice as they provide clinically relevant insights into how psychotherapy works. This study presents a review of psychoanalytic empirical case studies published in ISI-ranked journals and maps the characteristics of the study, therapist, patient en therapies that are investigated. Empirical case studies increased in quantity and quality (amount of information and systematization) over time. While future studies could pay more attention to providing contextual information on therapist characteristics and informed consent considerations, the available literature provides a basis to conduct meta-studies of single cases and as such contribute to knowledge aggregation.

Introduction

Single case studies are at the origin of both theory development and research in the field of psychotherapy in general and psychoanalysis in particular ( McLeod, 2010 , 2013 ). Increasingly, empirical case studies made their entrance in the field and are recognized as important sources of evidence to address the complexity of psychotherapeutic processes ( Goodheart, 2005 ; American Psychologcial Association [APA], 2006 ; McLeod and Elliott, 2011 ). Systematic meta-studies of single cases moreover allow knowledge aggregation and as such could enhance the scientific merits of case studies ( Iwakabe and Gazzola, 2009 ). We argue that in order to explore the full potential of empirical single cases in the field of psychoanalysis, it is important to map the existing field of such cases and get an overview of their characteristics, strengths and weaknesses. The goal of the current review is to provide this information and delineate points of interest for future case studies and context for meta-studies in the field.

From its origin, the clinical case study was the dominant research method in psychoanalysis. Sigmund Freud, the founding father of psychoanalysis, is still both famous and notorious for his elaborate clinical case studies through which he developed his theoretical framework during the course of his life. Famous because of the richness of his case presentations and because of the resulting theoretical and clinical advancements that up until this day permeate the whole psychotherapeutic and cultural field. Notorious because the scientific merit of this method received increasing criticism and is mostly relegated to the scientific trash can ( Bornstein, 2005 ).

While empirical research continues to be a major source of debate and controversy in psychoanalysis (e.g., Aron, 2012 ; Benecke, 2014 ; Mills, 2015 ), the questioning of its scientific credibility and therapeutic efficacy gave rise to a wealth of (group level) research indicating the efficacy of psychoanalytic psychotherapy (e.g., Leichsenring et al., 2015 ). Nevertheless, the case study has a privileged place in the field of psychoanalysis. Indeed, the clinical case study is still very common, however, increasingly, empirical case studies appear to see the light of day.

Critiques on the subjective bias of therapists’ retrospective reports, the anecdotal quality and uncontrollable nature of clinical case studies ( Spence, 2001 ) influenced the emergence of systematic (quantitative and qualitative) approaches to conduct single case studies that are no longer (solely) dependent on the interpretation of the therapist. Methodological articles on single-case experimental designs (for a review see Smith, 2012 ), case-based time series analysis ( Borckardt et al., 2008 ), case comparison methods ( Iwakabe, 2011 ), and theory-building case studies ( Stiles, 2008 , 2010 ) are but a few examples of the increased recognition of the potential value of empirical case-based research to build knowledge ( Edwards et al., 2004 ; McLeod and Elliott, 2011 ). In the entire field of psychology, such idiographic approaches are increasingly considered to be important tools to bridge the science-practitioner gap and address the lack of alignment between the object of study and the method that is often criticized in mainstream evidence-based practice research (e.g., Westen et al., 2004 ; Desmet, 2013 ).

Despite this recognition of empirical case study methods, an important critique on generalizability problems remains. A way to address this and build knowledge resulting from single case studies is to conduct meta-studies on published single case studies or as Dattilio et al. (2010 , p. 436) state “One observation or one case offers only a small piece of evidence, but repeated observation […] across a series of cases provides a way of constructing a database of evidence on which clinical theory can be built.” Currently the potential for knowledge aggregation across cases surely remains unexplored despite the existence of methodological tools to do so, for example, meta-synthesis methods ( Finfgeld, 2003 ; Willemsen et al., 2015 ) and case comparison methods ( Iwakabe and Gazzola, 2009 ). A preliminary requirement to facilitate meta-studies, however, is a well-organized database that gathers published case studies ( Fishman, 2005 ; Iwakabe and Gazzola, 2009 ). The single case archive (SCA; Desmet et al., 2013 ) provides such a tool for psychoanalytic single cases published in ISI ranked journals. 1 Such a tool allows gathering cases on a specific topic and conducting meta-studies. Nevertheless, an overview of the nature of existing empirical case studies would provide important contextual information when considering a meta-study, yet this is currently lacking in the literature.

This study attempts to address this need and explores the following questions concerning empirical case studies in the field of psychoanalysis: ‘Which studies have been done?’; ‘What is the nature of these case studies?’; and ‘What are their merits and weaknesses?’ We investigate this through a review of empirical case studies published in ISI-ranked journals.

Cases were selected through the original SCA ( Desmet et al., 2013 ), which comprises psychoanalytic and psychodynamic case studies, published in ISI-ranked journals between 1955 and 2011. Cases were selected starting from a search on ISI Web of Knowledge using the search terms (psychoanal ∗ OR psychodynam ∗ ) AND (case OR vignette). This search provided 2760 results, which after screening for title, abstract, and if necessary the full text of the article, resulted in 445 articles presenting psychoanalytic or psychodynamic treatment of an original single case (no comments on already published cases). For this study, all English case studies of this dataset that were classified as either experimental (i.e., N = 1 subject experiments, testing hypotheses in an experimental design) or (naturalistic) systematic case studies (i.e., case studies using data from sources other than the therapist’s report and where data are investigated by one or more researchers other than the therapist) 2 were selected (52 articles discussing 55 cases). Moreover, for this study, the same search procedure was followed for the period of 2012–2017 to update the sample with empirical case studies from these more recent years. Screening the 1093 search results resulted in 31 articles discussing 38 empirical cases. All empirical cases were screened with the Inventory for Basic Information in Single Cases (IBISC; Desmet et al., 2013 ), which inventories basic descriptive information on study characteristics [design, type of data, type of analysis, presence of clinical (process) description, presence of informed consent], therapist (gender, age, education, experience) and patient (gender, age, diagnostic information) characteristics, and therapy characteristics (duration, number of sessions, session frequency, therapy outcome).

In the screened period (1955–2017), 83 articles were identified that comprise 93 cases using empirical case designs. The selected manuscripts included one to three case studies. Figure 1 depicts the number of case studies for each year empirical cases could be identified and indicates an increase of published empirical case studies over time.

FIGURE 1. Number of cases per year.

Study Characteristics

Of the empirical case studies, five cases (5.4%) were experimental designs and 88 were naturalistic systematic case studies (94.6%) following the definition of Iwakabe and Gazzola (2009) . Analysis of the case was mostly based on one type of data (44.1%); 25.8% used two types of data, 14% three types, and 3.2% four or more types of data. The amount of different types of data was not spread equally across time: before 2000 only one study mentioned more than one type of data, between 2000 and 2010 there were regular studies mentioning two types of data; while starting from 2010 studies start to appear that mention three and four or more types of data. The type of data most commonly used were audio recordings (or videotapes) (64.5%), followed by self-report or observer rated scales (36.6%) and interviews (35.5%). In 14% of cases (also) other types of data were used like behavioral measures, notes of the therapist, patient, or relatives, or biological measures.

Different ways of analyzing the data were used, from purely quantitative (21.5%) to purely qualitative (17.2%). Yet, in most studies mixed approaches (56%) were used combining for example clinimetric methods (e.g., ratings of session material using the Shedler Westen Assessment Procedure-200 (SWAP-200; Westen and Shedler, 1999 ) with clinical, qualitative, or quantitative approaches.

A clinical description of the patient and/or therapy process was provided in 73.1% of the cases. In 24.7% of the cases such a description was lacking, while in two cases there was somewhat of a clinical description through a patients’ retrospective report in one case and a qualitative description of specific analyzed sessions in the other case.

Informed consent (IC) was mentioned in 45.2% of the cases, meaning it was not mentioned in more than half of the cases. Before 2000, IC was mentioned in 4 out of 18 cases, between 2000 and 2010 it was mentioned in 13 out of 35 cases, and between 2011 and 2017 it was mentioned in 25 out of 40 cases. In this last period, of the cases not mentioning IC, four cases did mention an ethical approval, which might indicate that there was also an informed consent on the patient’s side.

Therapist Characteristics

In most studies information about the therapist was almost entirely lacking. We inventoried information about gender, age, education and experience, yet in 34.4% of the cases there was no information at all. In 10.8% of the cases information about only one of these variables was provided (mostly the therapist’s gender), while in 18.3, 29, and 7.5% of the cases information was provided about 2, 3, and 4 variables respectively.

Concerning gender, 24.7% were female therapists and 36.6% were male therapists. In one case there was both a male and a female therapist involved in therapy. For the remaining 37.8% of cases gender of the therapist was not mentioned. Age was mentioned in only 17.2% of the cases. Education was mentioned in 44.1% of the cases and included all kinds of degrees/description with psychologist, psychotherapist, social worker, and psychiatrist as the most common terms. Experience was mentioned in 57% of the cases, with 10.8% novice therapists (<5 years of experience), 21.5% experienced therapist (6–15 years of experience), and 10.8% senior therapists (>15 years of experience).

Patient Characteristics

Generally, more information was provided about the patient. There was consistent information about the patients’ gender with 68.8% female and 31.2% male patients. Concerning age, almost always (98.9% of cases) information was present with 6.5% children (2–11 years), 6.5% adolescents (12–17 years), 12.9% young adults (18–24 years), and 73.1% adults (25–65). There were no cases discussing elderly patients.

There was no information about diagnosis in three cases; all other cases provided diagnostic information. The descriptive terms used in the manuscript are included in the SCA database, however, they differ tremendously across cases. This is illustrated by the observation that in 49.5% of the cases there was no diagnostic system mentioned. In other cases, one or more diagnostic systems were used: 34.5% used a version of the DSM, 10.8% used a version of the ICD, 4.3% used the OPD or PDM, and 8.8% used another system (e.g., SWAP-200, AAI). Therefore, when diagnostic information was available, this was categorized into the main DSM-IV-R categories (multiple categories could apply) to be able to get an overview. Prevalence of diagnostic categories is presented in Figure 2 . Clearly mood and anxiety disorders were the most common.

FIGURE 2. Primary diagnosis of cases per DSM-IV-R category.

Therapy Characteristics

In considering the characteristics of therapy we see that mostly at least some information is provided about objective characteristics and outcome.

The duration of investigated therapies consisted of 15.1% therapies shorter than 5 months, 12.9% lasting between 6 and 11 months, 32.3% lasting between 1 and 3 years, 18.3% lasting longer than 3 years, and 21.5% of cases were duration was not mentioned. Related to the duration of therapy, the number of sessions was mentioned in 66.7% of cases with 10.8% of therapies comprising less than 20 sessions, 22.6% between 21 and 50 sessions, 12.9% between 51 and 200 sessions, and 20,4% more than 200 sessions.

Session frequency ranged from less than once a week (2.2%), over once a week (35.5%), two to three times a week (17.2%) to a classical analytic setting of four to seven times a week (18.3%) and was not mentioned in 26.9% of the cases.

To inventory therapeutic outcomes the description of the authors was followed and categorized into successful (53.8%), failure (3.2%), or mixed (33.3%). In 9.7% of the cases no information about outcome was provided. Clearly, the description of authors/researchers starts from different frames of reference (e.g., in a long-term analysis success appears to require change at more levels than in studies on short-term psychodynamic psychotherapy who tend to conceptualize success more often as symptom decrease on a symptom rating scale) and consequently any appreciation of outcome is relative to these frames of reference.

Mapping psychoanalytic empirical case studies published in ISI-ranked journals showed that they, while still remaining scarce, clearly increased in quantity and quality throughout the last decennia. The increase in quality is shown in the results of our review that indicate a larger amount of information provided in more recent studies, a broader use of different sources of data and analysis methods, and more explicit informed consent considerations. However, also when reading the articles to rate the IBISC, it was clear that generally there is more attention for a detailed description of the study, its methods, the patient and his or her therapeutic process. Especially, in the last decennium a remarkable increase could be seen in the amount of published cases and the systematic nature of these cases that increasingly include multiple sources of data and combine different methods of analysis. These include both instruments and methods developed within the field of psychoanalysis [e.g., the Core Conflictual Relationship Theme method ( Luborsky and Crits-Christoph, 1998 ) or Reflective Functioning ratings ( Bucci, 1997 )] and more generic methods that allow the connection to broader psychological research (e.g., the Beck Depression Inventory; Beck et al., 1996 ).

When considering systematic case studies in the broader field of psychoanalytic case studies – which remain to be mainly clinical case studies – it is clear that they provide much more descriptive information than clinical case studies, which mostly pay little attention to giving comprehensive descriptive information, despite the rich clinical description they provide ( Desmet et al., 2013 ). Nevertheless, information about certain topics remains generally absent. Especially a description of the therapist is often omitted, which might however, be important contextual information if one intends to compare or aggregate different cases. As the role of the therapist in explaining outcome is increasingly recognized (e.g., Kraus et al., 2011 ) and because of the inherently interactive nature of the therapeutic encounter (e.g., Strupp, 2008 ), its importance can hardly be overestimated.

The range of diagnoses, short- and long-term therapies, and successful and unsuccessful cases investigated in empirical case studies, however, provide a myriad of possibilities for meta-studies. Moreover, while we noticed a wide array of methods, there also are trends and recurring methods indicating that meta-studies are feasible. For example, methods like Reflective Functioning or the SWAP-200 are used in different studies and should allow for good quality meta-studies. On the other hand, we noticed that studies focusing on purely quantitative methods often omit a clinical description of the patient and the therapy process. In our opinion, this is throwing away the baby with the bathwater. While critiques on the anecdotal nature of clinical case studies may be apt, discarding a clinical or qualitative description altogether is to disown the essence and the strength of the psychoanalytic single case study. Moreover, with respect to clinical relevance and to possible meta-studies, this clinical contextual information is quintessential.

Concerning ethical considerations of research in such delicate circumstances as the psychotherapeutic setting, it appears that even more attention could be paid to informed consent. While informed consent was mentioned much more than was found in the overall archive ( Desmet et al., 2013 ) – where it was mentioned in only 9% of cases – still more than half of the studies did not provide information about informed consent despite their explicit research context.

Surely, our review has certain limitations. Using other search criteria for example, might result in other cases and probably more empirical psychoanalytic cases exist. Also, the inclusion of cases published in books might be a valuable addition. Nevertheless, we think a representative and large sample of systematic case studies could be retrieved through this method. If this is the case, surely future research should aim to investigate age groups that are currently underrepresented in the field as most case studies focus on (young) adults.

We conclude that psychoanalytic empirical case studies, although they were adopted somewhat later than in other orientations, are of increasing and high quality. Moreover, journals currently provide more clear guidelines as to what comprises an eligible case study. High quality cases, for example Gazillo et al. (2014) , Mauck and Moore (2014) and Cornelis et al. (2017) , set the tone for a future where case aggregation based on scientifically sound cases that include triangulated data and analysis methods while not disregarding clinical context becomes increasingly possible. This attention for the clinical context is of crucial importance in the field of psychotherapy ( Spence, 2001 ). Psychotherapy is and always will consist of a unique encounter between patient and therapist, a complex interaction that cannot be easily disentangled ( Strupp, 2008 ). While systematically investigating what happens in this process is crucial for the advancement of the psychotherapeutic endeavor, this should not come at the cost of the clinical richness of these ever-singular encounters that comprise the magic of the psychotherapeutic profession.

Author Contributions

RM: conception of the study, contribution to data collection, data-analysis and interpretation, main author of the manuscript; RI: contribution to conception of the study, contribution to data collection, main reviewer of the manuscript; JK: contribution to data collection, data-analysis and interpretation, reviewer of the manuscript; LN: contribution to data collection, data-analysis, reviewer of the manuscript. All authors read and approved the final version of the manuscript.

This project was partly supported by Flanders Research Foundation (FWO, Belgium; grant number: AUGE/15/15 – G0H3116N).

Conflict of Interest Statement

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

Acknowledgment

We want to thank Mattias Desmet and Jochem Willemsen for the cooperation on the foundation of the SCA.

• ^ The original single case archive ( www.singlecasearchive.com ) comprises 445 articles between 1955 and 2011. Currently, there is an ongoing project to elaborate the SCA with cases from other theoretical orientations that should be finished at the end of 2018.
• ^ For more information on the types of case studies and their definition, see Iwakabe and Gazzola (2009) or the IBISC manual available through http://www.singlecasearchive.com/downloads/IBISC%20manual3.pdf .

American Psychologcial Association [APA] (2006). Evidence-based practice in psychology. Am. Psychol. 61, 271–285. doi: 10.1037/0003-066X.61.4.271

PubMed Abstract | CrossRef Full Text | Google Scholar

Aron, L. (2012). Rethinking “doublethinking”: psychoanalysis and scientific research - an introduction to a series. Psychoanal. Dialogues 22, 704–709. doi: 10.1080/10481885.2012.733650

CrossRef Full Text | Google Scholar

Beck, A. T., Steer, R. A., and Brown, G. K. (1996). Beck Depression Inventory , 2nd Edn. San Antonio, TX: Harcourt Assessment.

Google Scholar

Benecke, C. (2014). The importance of empirical research for psychoanalysis (Die Bedeutung empirischer Forschung für die Psychoanalyse). Forum Psychoanal. 30, 55–67. doi: 10.1007/s00451-014-0167-2

Borckardt, J. J., Nash, M. R., Murphy, M. D., Shaw, D., and O’Neil, P. (2008). Clinical practice as natural laboratory for psychotherapy research: a guide to case-based time-series analysis. Am. Psychol. 63, 77–95. doi: 10.1037/0003-066X.63.2.77

Bornstein, R. F. (2005). Reconnecting psychoanalysis to mainstream psychology. Psychoanal. Psychol. 3, 323–340. doi: 10.1037/0736-9735.22.3.323

Bucci, W. (1997). Psychoanalysis and Cognitive Science: A Multiple Code Theory. New York, NY: Guilford Press.

Cornelis, S., Desmet, M., Van Nieuwenhove, K. L. H. D., Meganck, R., Willemsen, J., Inslegers, R., et al. (2017). Interactions between obsessional symptoms and interpersonal ambivalences in psychodynamic psychotherapy: an empirical case study. Front. Psychol. 8:960. doi: 10.3389/fpsyg.2017.00960

Dattilio, F. M., Edwards, D. J. A., and Fishman, D. B. (2010). Case studies within a mixed methods paradigm: Toward a resolution of the alienation between researcher and practitioner in psychotherapy research. Psychotherapy 47, 427–441. doi: 10.1037/a0021181

Desmet, M. (2013). Experimental versus naturalistic psychotherapy research: consequences for researchers, clinicians, policy makers and patients. Psychoanal. Perspect. 31, 59–78.

Desmet, M., Meganck, R., Seybert, C., Willemsen, J., Geerardyn, F., Declercq, F., et al. (2013). Psychoanalytic single cases published in ISI-ranked journals: the construction of an online archive. Psychother. Psychosom. 82, 120–121. doi: 10.1159/000342019

Edwards, D. J. A., Dattilio, F. M., and Bromley, D. B. (2004). Developing evidence-based practice: the role of case-based research. Prof. Psychol. Res. Pr. 35, 589–597. doi: 10.1037/0735-7028.35.6.589

Finfgeld, D. L. (2003). Meta-synthesis: the state of the art - so far. Qual. Health Res. 13, 893–904. doi: 10.1177/1049732303253462

Fishman, D. B. (2005). Editor’s introduction to PCSP – from single case to database: a new method for enhancing psychotherapy practice. Pragm. Case Stud. Psychother. 1, 1–50.

Gazillo, F., Waldron, S., Genova, F., Angeloni, F., Ristucci, C., and Lingiardi, V. (2014). An empirical investigation of analytic process: contrasting a good and poor outcome case. Psychotherapy 5, 270–282. doi: 10.1037/a0035243

Goodheart, C. D. (2005). Placing psychotherapy case studies within the framework of the APA evidence-based practice in psychology (EBPP) model. Pragm. Case Stud. Psychother. 1, 1–10. doi: 10.14713/pcsp.v1i3.862

Iwakabe, S. (2011). Extending systematic case study method: generating and testing hypotheses about therapeutic factors through comparisons of successful and unsuccessful cases. Pragm. Case Stud. Psychother. 7, 339–350. doi: 10.14713/pcsp.v7i2.1094

Iwakabe, S., and Gazzola, N. (2009). From single-case studies to practice-based knowledge: aggregating and synthesizing case studies. Psychother. Res. 19, 601–611. doi: 10.1080/10503300802688494

Kraus, D. R., Castonguay, L., Boswell, J. F., Nordberg, S. S., and Hayes, J. A. (2011). Therapist effectiveness: implications for accountability and patient care. Psychother. Res. 21, 267–276. doi: 10.1080/10503307.2011.563249

Leichsenring, F., Luyten, P., Hilsenroth, M. J., Abbass, A., Barber, J. P., Keefe, J. R., et al. (2015). Psychodynamic therapy meets evidence-based medicine: a systematic review using updated criteria. Lancet Psychiatry 2, 648–660. doi: 10.1016/S2215-0366(15)00155-8

Luborsky, L., and Crits-Christoph, P. (1998). Understanding Transference: The Core Conflictual Relationship Theme , 2nd Edn. Washington, DC: American Psychological Association.

Mauck, S. E., and Moore, T. M. (2014). Psychodynamic psychotherapy for double depression and intermittent explosive disorder: a case study with time-series analysis. Clin. Case Stud. 13, 501–513. doi: 10.1177/1534650114523674

McLeod, J. (2010). Case Study Research in Counselling and Psychotherapy. London: Sage. doi: 10.4135/9781446287897

McLeod, J. (2013). An Introduction to Research in Counselling and Psychotherapy. London: Sage.

McLeod, J., and Elliott, R. (2011). Systematic case study research: a practice-oriented introduction to building an evidence base for counselling and psychotherapy. Couns. Psychother. Res. 11, 1–10. doi: 10.1080/14733145.2011.548954

Mills, J. (2015). Psychoanalysis and the ideologies of science. Psychoanal. Inq. 35, 24–44. doi: 10.1080/07351690.2015.987591

Smith, J. D. (2012). Single-case experimental designs: a systematic review of published research and current standards. Psychol. Methods 17, 510–550. doi: 10.1037/a0029312

Spence, D. P. (2001). Dangers of anecdotal reports. J. Clin. Psychol. 57, 37–41. doi: 10.1002/1097-4679(200101)57:1<37::AID-JCLP5>3.0.CO;2-S

Stiles, W. B. (2008). When is a case study scientific research? Psychother. Bull. 38, 6–11.

Stiles, W. B. (2010). “Theory-building case studies as practice-based evidence,” in Developing and Delivering Practice-Based Evidence: A Guide for the Psychological Therapies , eds M. Barkham, G. Hardy, and J. Mellor-Clark (Chichester: Wiley).

Strupp, H. H. (2008). Implication of the empirically supported treatment movement for psychoanalysis. Psychoanal. Dialogues 11, 605–619. doi: 10.1080/10481881109348631

Westen, D., Novotny, C. M., and Brenner, H. (2004). The empirical status of empirically supported psychotherapies: assumptions, findings, and reporting in controlled clinical trials. Psychol. Bull. 130, 631–663. doi: 10.1037/0033-2909.130.4.631

Westen, D., and Shedler, J. (1999). Revising and assessing axis II: I. Developing a clinically and empirically valid assessment method. Am. J. Psychiatry 156, 258–272.

PubMed Abstract | Google Scholar

Willemsen, J., Inslegers, R., Meganck, R., Geerardyn, F., Desmet, M., and Vanheule, S. (2015). A metasynthesis of published case studies through Lacan’s L-schema: transference in perversion. Int. J. Psychoanal. 96, 773–795. doi: 10.1111/1745-8315.12179

Keywords : empirical single case studies, psychoanalysis, review, single case archive, psychodynamic psychotherapy

Citation: Meganck R, Inslegers R, Krivzov J and Notaerts L (2017) Beyond Clinical Case Studies in Psychoanalysis: A Review of Psychoanalytic Empirical Single Case Studies Published in ISI-Ranked Journals. Front. Psychol. 8:1749. doi: 10.3389/fpsyg.2017.01749

Received: 14 July 2017; Accepted: 21 September 2017; Published: 04 October 2017.

Reviewed by:

Copyright © 2017 Meganck, Inslegers, Krivzov and Notaerts. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Reitske Meganck, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.