Pragmatic Case Studies in Psychotherapy

Regulation Focused Psychotherapy for Children (RFP-C) with Externalizing Behaviors: Comparing the Successful Case of "Jack," and the Unsuccessful Case of "Oliver"

Carly Brooks — 2025-01-26

Regulation Focused Psychotherapy for Children (RFP-C) is a manualized, time-limited, psychodynamic approach for children who experience challenges with emotion regulation and demonstrate externalizing behavior problems (Hoffman et al., 2016). In research settings, it takes place over ten weeks and includes 16 sessions with the child and four with the child’s parents. This protocol can be extended or modified in regular clinical practice.

The current study utilized a dual case study method to analyze pretreatment and post-treatment measures and compare psychotherapy outcomes and process in RFP-C between a successful and an unsuccessful case. Data examined included (a) quantitative outcome measures; (b) case conceptualizations and clinical vignettes drawn from review of session videos; (c) post-treatment interviews with parent, child, and therapist; and (d) psychotherapy process codings of child and parent sessions. These data were employed to (a) identify differential psychotherapy processes; (b) assess parental defense mechanisms; (c) assess parental attachment classifications; and (d) evaluate therapist countertransference ratings.

Results indicated that many variables contributed to successful versus unsuccessful treatment outcomes, including but not limited to (a) the child’s spontaneity; (b) the child’s active participation and emotional expression throughout treatment; (c) themes of child play; (d) the therapist’s countertransference; (e) the child and parental defense mechanisms; and (f) the parental attachment styles. Taken together, findings from this study contribute to the literature on therapeutic outcomes for children and families and highlight some of the essential characteristics of successful psychotherapy process. Limitations of the study and directions for future research are also discussed.

Insights from a Dual Case Study of Regulation Focused Psychotherapy for Children (RFP-C) with Externalizing Behaviors: The Cases of "Jack" and "Oliver"

Antonella Cirasola — 2025-01-26

This dual case study involving "Jack" and "Oliver" provides critical insights into the efficacy and therapeutic processes of Regulation Focused Psychotherapy for Children (RFP-C), a manualized psychodynamic approach designed to address emotion regulation difficulties in school-age children. The study demonstrates both the strengths and limitations inherent in case study research within child therapy. Strengths include the extensive use of diverse measures and a thorough examination of the complexities involved in child therapy. Nevertheless, limitations arise from challenges in generalizing findings and the intricacies of the methodology. This commentary addresses these aspects, highlighting how case studies can enrich and complement randomized controlled trial results by offering a nuanced understanding of psychotherapy processes and outcomes. Such insights are essential for enhancing clinical practice. Future research should improve methodological rigor and investigate key psychotherapy variables, especially the dynamics of building and maintaining therapeutic alliances with children and parents. Additionally, rigorous qualitative analysis of interviews with children, parents, and therapists could offer valuable insights into the complexities of therapeutic interventions.

Comparing Parent Child Interaction Therapy (PCIT) to Regulation Focused Psychotherapy for Children (RFP-C) with Externalizing Behavior Problems: The Cases of "Jack" and "Oliver"

Patrick Kigin — 2025-01-26

This commentary examines the case studies by Brooks et al. (2025) of “Jack” and “Oliver,” two children with externalizing behavior problems. Both cases were drawn from a successful randomized control trial (RCT) using the model of Regulation Focused Psychotherapy for Children (RFP-C), with Jack being a successful case, and Oliver, an unsuccessful case. We first commend Brooks et al. in a number of ways for the contributions their RCT and the cases of Jack and Oliver make to the psychotherapy research literature. At the same time, we raise methodological questions about the selection of Jack and Oliver and the fact that Jack’s pre-test questionnaires were completed by Jack’s mother, while the post-test measures were completed by Jack's father, introducing the unassessed variable of inter-rater reliability.

We next compare the psychodynamic, RFP-C theoretical approach with the behavioral theoretical approach we employ–Parent Child Interaction Therapy (PCIT). This comparison includes (a) our suggestion of behavioral alternatives to Brooks et al.’s psychodynamic interpretations of Jack’s and Oliver’s therapeutic interactions; and (b) an alternative case formulation and treatment plan for Jack and Oliver if they were to be seen in PCIT therapy. Regarding the case formulations and the treatment plans, utilization of standard PCIT is illustrated with the case of Oliver. Because Jack presents with many symptoms of anxiety, an adaptation of PCIT (“CALM”) for young children with anxiety is also presented.

We suggest that PCIT is able to produce large magnitude improvements that last over time in part due to the use of parents as change agents who employ treatment techniques in their everyday interactions with their children. In addition, PCIT relies on weekly direct coaching as the most potent method for teaching parents therapy skills. This is contrasted with RFP-C’s reliance on two hours per week of therapist child interactions and four total hours of parent education. We conclude with suggestions for incorporating a key feature of PCIT into RFP- C, which may enhance its potency and efficacy.

Reflections on Methods, Therapeutic Alliance, and Possibilities for Psychotherapy Integration in the RFP-C Cases of "Jack" and "Oliver"

Tracy Prout — 2025-01-26

The commentaries by Cirasola (2025) and Kigin and Hembree-Kigin (2025) on the comparison case study of a successful and unsuccessful treatment of Regulation-Focused Psychotherapy for Children (RFP-C; Brooks et al., 2025) explore ways to extend the depth and breadth of child psychotherapy research; highlight the importance of therapeutic alliance research; and offer alternative perspectives on the treatment of externalizing behaviors. Cirasola (2025) notes concepts regarding the importance of case selection in comparative case studies, the crucial role of interviewers when obtaining interview data, and offers suggestions about ways to enhance analysis of qualitative data. Kigin and Hembree-Kigin (2025) approach the case studies from a behavioral perspective, using Parent Child Interaction Therapy (PCIT) as a framework for reconceptualizing the clinical material and emphasizing the importance of parents as agents of change in child psychotherapy outcomes. In our response we aim to, in essence, converse with these colleagues who have generously taken the time to read the original comparative case study and have shared their expertise with us.