Guidelines on the writing and use of case histories

1. Introduction

Case studies can be invaluable, providing that informed consent is obtained when required and effective steps are taken to preserve client confidentiality/privacy, as set out in these guidelines.  (It is, of course, also effective to illustrate an aspect of therapy and its underlying principles and application without direct reference to an actual therapeutic episode. This approach avoids the issue of privacy and consent.)

In general, case studies are used to illustrate successful – or unsuccessful – treatments and outcomes for the benefit of colleagues. They are valuable teaching tools.

These guidelines are mainly concerned with narrative case studies (or case histories) where the content is presented as events in an unfolding plot featuring participants (client, therapist, significant others), situation, treatment and outcomes, and are designed for publication or broadcast, including on websites such as YouTube, or in any other format.

A distinction is to be made between narrative case studies, as described above, and brief case illustrations/examples used in the context of verbal interaction during training, supervision and indeed therapy (e.g. ‘My friend John’ stories). The latter should be sufficiently condensed and generalised that they neither reveal confidential material nor require permission from anyone involved. Longer and more detailed case studies, however, need to be carefully anonymised. In accordance with guidance produced by the Information Commissioners Office, case studies that are completely anonymised do not require the consent of the client (See GDPR section below).

In practice, case studies should include:

• A description of the client’s presenting problem and the initial context/circumstances of their case essential to foster the reader’s understanding; incidental details should be omitted;
• A description of the ‘trigger’ incident, for example a traumatic event, if applicable;
• The client’s symptoms and the resulting consequences/sequelae – for example, detrimental effect on the client’s relationships or ability to live their lives to the full;
• The treatment provided and the outcome.

2. The Ethical Dimension

a) Informed Consent to Case Study

• If, at the end of therapy with a particular client, a therapist decides that it will be useful to produce an anonymised description of the therapeutic episode as a case study for publication or broadcast, it is up to the therapist to decide whether they want to seek the client’s written permission, taking care to explain that their identity will be protected;
• A case study consent form is available on the professional members’ area of this website and should be used for the purpose of obtaining the written permission of clients.  Completed consent forms should be retained with client records;
• In cases where permission has been sought, it should be made clear to clients that they can, if they wish, see a copy of the proposed case study before it is submitted for publication.  Where a client requests sight of a completed case study prior to giving permission, the therapist must provide them with a copy together with a copy of the case study consent form.

b) The Protection of Client Identity

It is of paramount importance that the identity of clients who are the subject of case study reports is protected. The following guidelines and examples are to be observed in the writing and publishing of case studies.

• To minimise the risk of identification, clients’ names and the names of other participants in the case must be changed;
• Incidental information, such as the occupations of clients, their relatives or other key characters must be changed or, if they do not lend meaning to the narrative, omitted;
• Reference to locations or organisations that might assist identification must be changed or, where not essential to the narrative, omitted. Examples here could be towns, other countries which clients might have come from or visited, organisations used by the client, etc.;
• Where it is considered appropriate for the further protection of identity, the gender of clients and other participants in the case can be changed;
• The content of several similar cases can be combined to form a single case study, provided that the above guidelines are followed.
• According to telephone advice provided by the Information Commissioners Office (January 2025), it is acceptable to keep details of the condition and treatment as is, if absolutely necessary for case history purposes, as long as all identifying personal details are changed – for instance, in a case study about someone who receives treatment for a balloon phobia, where the treatment involved highly creative guided imagery around balloons, the intervention details can be retained. The HGI recommends, however, that if the principles of the guided imagery can be illustrated just as well by using another phobia and different creative imagery that would have achieved the same purpose, then this should be the preferred option.

It is good practice for therapists to consult their supervisor as to whether their proposed case study conforms to these guidelines. If in doubt, the supervisor and/or the therapist must consult with the Registration and Professional Standards Committee (RPSC).

c) The Responsibility of HG Editors and Publishers

Those responsible for producing/editing material for HG publications (inc. HGI membership bulletins, newsletters, books, website content, etc) must satisfy themselves as far as possible through communication with authors of the material that informed consent has been properly obtained where necessary and that the possibility of a client being identified has been eliminated through adherence to the above guidelines.

d) Clean Intentions

The HGI suggests that therapists carefully examine their motives and intentions before producing case studies for publication. For example they should ask themselves the following question as it relates to their own needs:

• ‘Am I seeking to gain attention, raise my status or gain “payment” in any other way through the process, or am I on balance, seeking to extend human knowledge?’

Also apply the ‘Can you look them in the face?’ test:

• ‘Would I be able to show the case study to my client in the knowledge that the account is fair and accurate and that their identity is adequately protected?’

e) GDPR advice in relation to publication of case histories

“In the Information Commissioner’s Office (ICO)’s view, it follows therefore that provided there is no likelihood of anonymisation causing unwarranted damage or distress – as will be the case if it is done effectively – then there will be no need to obtain consent as a means of legitimising the processing.” (https://ico.org.uk/media/1061/anonymisation-code.pdf)

The ICO recommends, however, that, when creating a case study for publication, it is good practice to complete a DPIA (Data Protection Impact Assessment) to cover yourself. DPIAs are usually created for ‘high risk processing’, ie creating data that could potentially cause serious harm to specific individuals.

As stated, “The GDPR does not require a DPIA to be carried out for every processing operation which may result in risks for the rights and freedoms of natural persons. The carrying out of a DPIA is only mandatory where processing is “likely to result in a high risk to the rights and freedoms of natural persons”. … In cases where it is not clear whether a DPIA is required, the WP29 recommends that a DPIA is carried out nonetheless as a DPIA is a useful tool to help controllers comply with data protection law.”  (ICO, Article 29, Data Protection Working Party, 17/EN WP 248 rev.01)

The DPIA should state what has been done (eg creation and publication of an anonymised case history); why (eg for educative/illustrative purposes); what the risks are (eg clients may recognise themselves); how you have mitigated risk (eg fully anonymised the cases); and whether your actions will be viewed as appropriate (eg cite supervisor approval). This document should be kept with your records.

Complaints  >