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What Is a Case Study?

Weighing the pros and cons of this method of research

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

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

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

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

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

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

At a Glance

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

What Are the Benefits and Limitations of Case Studies?

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

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

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

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

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

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

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

Case Study Examples

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

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

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

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

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

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

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

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

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

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

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

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

Section 1: A Case History

This section will have the following structure and content:

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

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

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

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

Section 2: Treatment Plan

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

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

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

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

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

Need More Tips?

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

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

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

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

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

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

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

Psychology Case Study Examples: A Deep Dive into Real-life Scenarios

Peeling back the layers of the human mind is no easy task, but psychology case studies can help us do just that. Through these detailed analyses, we’re able to gain a deeper understanding of human behavior, emotions, and cognitive processes. I’ve always found it fascinating how a single person’s experience can shed light on broader psychological principles.

Over the years, psychologists have conducted numerous case studies—each with their own unique insights and implications. These investigations range from Phineas Gage’s accidental lobotomy to Genie Wiley’s tragic tale of isolation. Such examples not only enlighten us about specific disorders or occurrences but also continue to shape our overall understanding of psychology .

As we delve into some noteworthy examples , I assure you’ll appreciate how varied and intricate the field of psychology truly is. Whether you’re a budding psychologist or simply an eager learner, brace yourself for an intriguing exploration into the intricacies of the human psyche.

Understanding Psychology Case Studies

Diving headfirst into the world of psychology, it’s easy to come upon a valuable tool used by psychologists and researchers alike – case studies. I’m here to shed some light on these fascinating tools.

Psychology case studies, for those unfamiliar with them, are in-depth investigations carried out to gain a profound understanding of the subject – whether it’s an individual, group or phenomenon. They’re powerful because they provide detailed insights that other research methods might miss.

Let me share a few examples to clarify this concept further:

• One notable example is Freud’s study on Little Hans. This case study explored a 5-year-old boy’s fear of horses and related it back to Freud’s theories about psychosexual stages.
• Another classic example is Genie Wiley (a pseudonym), a feral child who was subjected to severe social isolation during her early years. Her heartbreaking story provided invaluable insights into language acquisition and critical periods in development.

You see, what sets psychology case studies apart is their focus on the ‘why’ and ‘how’. While surveys or experiments might tell us ‘what’, they often don’t dig deep enough into the inner workings behind human behavior.

It’s important though not to take these psychology case studies at face value. As enlightening as they can be, we must remember that they usually focus on one specific instance or individual. Thus, generalizing findings from single-case studies should be done cautiously.

To illustrate my point using numbers: let’s say we have 1 million people suffering from condition X worldwide; if only 20 unique cases have been studied so far (which would be quite typical for rare conditions), then our understanding is based on just 0.002% of the total cases! That’s why multiple sources and types of research are vital when trying to understand complex psychological phenomena fully.

In the grand scheme of things, psychology case studies are just one piece of the puzzle – albeit an essential one. They provide rich, detailed data that can form the foundation for further research and understanding. As we delve deeper into this fascinating field, it’s crucial to appreciate all the tools at our disposal – from surveys and experiments to these insightful case studies.

Importance of Case Studies in Psychology

I’ve always been fascinated by the human mind, and if you’re here, I bet you are too. Let’s dive right into why case studies play such a pivotal role in psychology.

One of the key reasons they matter so much is because they provide detailed insights into specific psychological phenomena. Unlike other research methods that might use large samples but only offer surface-level findings, case studies allow us to study complex behaviors, disorders, and even treatments at an intimate level. They often serve as a catalyst for new theories or help refine existing ones.

To illustrate this point, let’s look at one of psychology’s most famous case studies – Phineas Gage. He was a railroad construction foreman who survived a severe brain injury when an iron rod shot through his skull during an explosion in 1848. The dramatic personality changes he experienced after his accident led to significant advancements in our understanding of the brain’s role in personality and behavior.

Moreover, it’s worth noting that some rare conditions can only be studied through individual cases due to their uncommon nature. For instance, consider Genie Wiley – a girl discovered at age 13 having spent most of her life locked away from society by her parents. Her tragic story gave psychologists valuable insights into language acquisition and critical periods for learning.

Finally yet importantly, case studies also have practical applications for clinicians and therapists. Studying real-life examples can inform treatment plans and provide guidance on how theoretical concepts might apply to actual client situations.

• Detailed insights: Case studies offer comprehensive views on specific psychological phenomena.
• Catalyst for new theories: Real-life scenarios help shape our understanding of psychology .
• Study rare conditions: Unique cases can offer invaluable lessons about uncommon disorders.
• Practical applications: Clinicians benefit from studying real-world examples.

In short (but without wrapping up), it’s clear that case studies hold immense value within psychology – they illuminate what textbooks often can’t, offering a more nuanced understanding of human behavior.

Different Types of Psychology Case Studies

Diving headfirst into the world of psychology, I can’t help but be fascinated by the myriad types of case studies that revolve around this subject. Let’s take a closer look at some of them.

Firstly, we’ve got what’s known as ‘Explanatory Case Studies’. These are often used when a researcher wants to clarify complex phenomena or concepts. For example, a psychologist might use an explanatory case study to explore the reasons behind aggressive behavior in children.

Second on our list are ‘Exploratory Case Studies’, typically utilized when new and unexplored areas of research come up. They’re like pioneers; they pave the way for future studies. In psychological terms, exploratory case studies could be conducted to investigate emerging mental health conditions or under-researched therapeutic approaches.

Next up are ‘Descriptive Case Studies’. As the name suggests, these focus on depicting comprehensive and detailed profiles about a particular individual, group, or event within its natural context. A well-known example would be Sigmund Freud’s analysis of “Anna O”, which provided unique insights into hysteria.

Then there are ‘Intrinsic Case Studies’, which delve deep into one specific case because it is intrinsically interesting or unique in some way. It’s sorta like shining a spotlight onto an exceptional phenomenon. An instance would be studying savants—individuals with extraordinary abilities despite significant mental disabilities.

Lastly, we have ‘Instrumental Case Studies’. These aren’t focused on understanding a particular case per se but use it as an instrument to understand something else altogether—a bit like using one puzzle piece to make sense of the whole picture!

So there you have it! From explanatory to instrumental, each type serves its own unique purpose and adds another intriguing layer to our understanding of human behavior and cognition.

Exploring Real-Life Psychology Case Study Examples

Let’s roll up our sleeves and delve into some real-life psychology case study examples. By digging deep, we can glean valuable insights from these studies that have significantly contributed to our understanding of human behavior and mental processes.

First off, let me share the fascinating case of Phineas Gage. This gentleman was a 19th-century railroad construction foreman who survived an accident where a large iron rod was accidentally driven through his skull, damaging his frontal lobes. Astonishingly, he could walk and talk immediately after the accident but underwent dramatic personality changes, becoming impulsive and irresponsible. This case is often referenced in discussions about brain injury and personality change.

Next on my list is Genie Wiley’s heart-wrenching story. She was a victim of severe abuse and neglect resulting in her being socially isolated until she was 13 years old. Due to this horrific experience, Genie couldn’t acquire language skills typically as other children would do during their developmental stages. Her tragic story offers invaluable insight into the critical periods for language development in children.

Then there’s ‘Little Hans’, a classic Freudian case that delves into child psychology. At just five years old, Little Hans developed an irrational fear of horses -or so it seemed- which Sigmund Freud interpreted as symbolic anxiety stemming from suppressed sexual desires towards his mother—quite an interpretation! The study gave us Freud’s Oedipus Complex theory.

Lastly, I’d like to mention Patient H.M., an individual who became amnesiac following surgery to control seizures by removing parts of his hippocampus bilaterally. His inability to form new memories post-operation shed light on how different areas of our brains contribute to memory formation.

Each one of these real-life psychology case studies gives us a unique window into understanding complex human behaviors better – whether it’s dissecting the role our brain plays in shaping personality or unraveling the mysteries of fear, language acquisition, and memory.

How to Analyze a Psychology Case Study

Diving headfirst into a psychology case study, I understand it can seem like an intimidating task. But don’t worry, I’m here to guide you through the process.

First off, it’s essential to go through the case study thoroughly. Read it multiple times if needed. Each reading will likely reveal new information or perspectives you may have missed initially. Look out for any patterns or inconsistencies in the subject’s behavior and make note of them.

Next on your agenda should be understanding the theoretical frameworks that might be applicable in this scenario. Is there a cognitive-behavioral approach at play? Or does psychoanalysis provide better insights? Comparing these theories with observed behavior and symptoms can help shed light on underlying psychological issues.

Now, let’s talk data interpretation. If your case study includes raw data like surveys or diagnostic tests results, you’ll need to analyze them carefully. Here are some steps that could help:

• Identify what each piece of data represents
• Look for correlations between different pieces of data
• Compute statistics (mean, median, mode) if necessary
• Use graphs or charts for visual representation

Keep in mind; interpreting raw data requires both statistical knowledge and intuition about human behavior.

Finally, drafting conclusions is key in analyzing a psychology case study. Based on your observations, evaluations of theoretical approaches and interpretations of any given data – what do you conclude about the subject’s mental health status? Remember not to jump to conclusions hastily but instead base them solidly on evidence from your analysis.

In all this journey of analysis remember one thing: every person is unique and so are their experiences! So while theories and previous studies guide us, they never define an individual completely.

Applying Lessons from Psychology Case Studies

Let’s dive into how we can apply the lessons learned from psychology case studies. If you’ve ever studied psychology, you’ll know that case studies offer rich insights. They shed light on human behavior, mental health issues, and therapeutic techniques. But it’s not just about understanding theory. It’s also about implementing these valuable lessons in real-world situations.

One of the most famous psychological case studies is Phineas Gage’s story. This 19th-century railroad worker survived a severe brain injury which dramatically altered his personality. From this study, we gained crucial insight into how different brain areas are responsible for various aspects of our personality and behavior.

• Lesson: Recognizing that damage to specific brain areas can result in personality changes, enabling us to better understand certain mental conditions.

Sigmund Freud’s work with a patient known as ‘Anna O.’ is another landmark psychology case study. Anna displayed what was then called hysteria – symptoms included hallucinations and disturbances in speech and physical coordination – which Freud linked back to repressed memories of traumatic events.

• Lesson: The importance of exploring an individual’s history for understanding their current psychological problems – a principle at the heart of psychoanalysis.

Then there’s Genie Wiley’s case – a girl who suffered extreme neglect resulting in impaired social and linguistic development. Researchers used her tragic circumstances as an opportunity to explore theories around language acquisition and socialization.

• Lesson: Reinforcing the critical role early childhood experiences play in shaping cognitive development.

Lastly, let’s consider the Stanford Prison Experiment led by Philip Zimbardo examining how people conform to societal roles even when they lead to immoral actions.

• Lesson: Highlighting that situational forces can drastically impact human behavior beyond personal characteristics or morality.

These examples demonstrate that psychology case studies aren’t just academic exercises isolated from daily life. Instead, they provide profound lessons that help us make sense of complex human behaviors, mental health issues, and therapeutic strategies. By understanding these studies, we’re better equipped to apply their lessons in our own lives – whether it’s navigating personal relationships, working with diverse teams at work or even self-improvement.

Challenges and Critiques of Psychological Case Studies

Delving into the world of psychological case studies, it’s not all rosy. Sure, they offer an in-depth understanding of individual behavior and mental processes. Yet, they’re not without their share of challenges and criticisms.

One common critique is the lack of generalizability. Each case study is unique to its subject. We can’t always apply what we learn from one person to everyone else. I’ve come across instances where results varied dramatically between similar subjects, highlighting the inherent unpredictability in human behavior.

Another challenge lies within ethical boundaries. Often, sensitive information surfaces during these studies that could potentially harm the subject if disclosed improperly. To put it plainly, maintaining confidentiality while delivering a comprehensive account isn’t always easy.

Distortion due to subjective interpretations also poses substantial difficulties for psychologists conducting case studies. The researcher’s own bias may color their observations and conclusions – leading to skewed outcomes or misleading findings.

Moreover, there’s an ongoing debate about the scientific validity of case studies because they rely heavily on qualitative data rather than quantitative analysis. Some argue this makes them less reliable or objective when compared with other research methods such as experiments or surveys.

To summarize:

• Lack of generalizability
• Ethical dilemmas concerning privacy
• Potential distortion through subjective interpretation
• Questions about scientific validity

While these critiques present significant challenges, they do not diminish the value that psychological case studies bring to our understanding of human behavior and mental health struggles.

Conclusion: The Impact of Case Studies in Understanding Human Behavior

Case studies play a pivotal role in shedding light on human behavior. Throughout this article, I’ve discussed numerous examples that illustrate just how powerful these studies can be. Yet it’s the impact they have on our understanding of human psychology where their true value lies.

Take for instance the iconic study of Phineas Gage. It was through his tragic accident and subsequent personality change that we began to grasp the profound influence our frontal lobes have on our behavior. Without such a case study, we might still be in the dark about this crucial aspect of our neurology.

Let’s also consider Genie, the feral child who showed us the critical importance of social interaction during early development. Her heartbreaking story underscores just how vital appropriate nurturing is for healthy mental and emotional growth.

Here are some key takeaways from these case studies:

• Our brain structure significantly influences our behavior.
• Social interaction during formative years is vital for normal psychological development.
• Studying individual cases can reveal universal truths about human nature.

What stands out though, is not merely what these case studies teach us individually but collectively. They remind us that each person constitutes a unique combination of various factors—biological, psychological, and environmental—that shape their behavior.

One cannot overstate the significance of case studies in psychology—they are more than mere stories or isolated incidents; they’re windows into the complexities and nuances of human nature itself.

In wrapping up, I’d say that while statistics give us patterns and trends to understand groups, it’s these detailed narratives offered by case studies that help us comprehend individuals’ unique experiences within those groups—making them an invaluable part of psychological research.

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Case Study Research in Counselling and Psychotherapy

• John McLeod - University of Oslo, Norway
• Description

- the role of case studies in the development of theory, practice and policy in counselling and psychotherapy

- strategies for responding to moral and ethical issues in therapy case study research

- practical tools for collecting case data

- 'how-to-do-it' guides for carrying out different types of case study

- team-based case study research for practitioners and students

- questions, issues and challenges that may have been raised for readers through their study.

Concrete examples, points for reflection and discussion, and recommendations for further reading will enable readers to use the book as a basis for carrying out their own case investigation.

See what’s new to this edition by selecting the Features tab on this page. Should you need additional information or have questions regarding the HEOA information provided for this title, including what is new to this edition, please email [email protected] . Please include your name, contact information, and the name of the title for which you would like more information. For information on the HEOA, please go to http://ed.gov/policy/highered/leg/hea08/index.html .

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This text offers students the opportunity to grasp the importance of using case studies to inform research and is recommended for our students taking an Introduction to Evidence based practice in counselling module

An excellent textbook with clear guidelines to help students understand the importance of developing consistent methods for gathering evidence as they work with cases. The role of case studies for students as they learn about the different theories is essential for them to grasp a practical understanding of applications. This book covers the knowledge of writing case reports in a clear and comprehensive way.

John McLeod is and probably always will be the author we recommend when talking about evidence based practice. His other texts in Doing Counselling Research and Qualitative Research are seminal in this context. This text fills the gap around working with case studies in research, and is very relevant as this is an area that most counsellors will need to be familiar with. The book is well written and if possible makes the subject even more approachable and interesting. Our third year students are now recommended to read this title in relation to all of the third year professional level study modules, as it offers so the opportunity to become familiar with research methodologies and language.

An excellent book which helps people understand the ethics and processes involved in a case study approach. Some very useful examples contained within the book which makes the subject understandable. It has provided me with the motivation to consider applying this in my own practice.

Part of the beauty of this book is the accessibility of the author; as he brings the reader through an exciting, interesting, pragmatic and richly informed account of living qualitative research in action. The book considers; pragmatic, n=1, HSCED, theory-building adn one of my personal favourites - narrative approaches. This book is a required resource for anyone interested in qualitative research or therapy practice. A gem.

A thorough and rigorous review of the latest developments in case study research. Important reading for all counselling and psychotherapy research students, and practitioners who want to write up their clinical work.

This is a useful book, that makes a considered case for the the use of Case Studies for effective research as well as a developmental method for students.

Excellent book, which fills a gap in the current literature; especially useful in clinical psychology training where alternatives to n=1 empirical case studies are not widely accepted.

this has everything that you need for researching

This book has been useful in thinking about revalidation the Social Work degree and its themes will take a more central part in the revalidated degree from 2011-12 onwards.

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• v.34; 2021 Dec

Appraising psychotherapy case studies in practice-based evidence: introducing Case Study Evaluation-tool (CaSE)

Greta kaluzeviciute.

Department of Psychosocial and Psychoanalytic Studies, University of Essex, Wivenhoe Park, Colchester, CO4 3SQ UK

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Systematic case studies are often placed at the low end of evidence-based practice (EBP) due to lack of critical appraisal. This paper seeks to attend to this research gap by introducing a novel Case Study Evaluation-tool (CaSE). First, issues around knowledge generation and validity are assessed in both EBP and practice-based evidence (PBE) paradigms. Although systematic case studies are more aligned with PBE paradigm, the paper argues for a complimentary, third way approach between the two paradigms and their ‘exemplary’ methodologies: case studies and randomised controlled trials (RCTs). Second, the paper argues that all forms of research can produce ‘valid evidence’ but the validity itself needs to be assessed against each specific research method and purpose. Existing appraisal tools for qualitative research (JBI, CASP, ETQS) are shown to have limited relevance for the appraisal of systematic case studies through a comparative tool assessment. Third, the paper develops purpose-oriented evaluation criteria for systematic case studies through CaSE Checklist for Essential Components in Systematic Case Studies and CaSE Purpose-based Evaluative Framework for Systematic Case Studies. The checklist approach aids reviewers in assessing the presence or absence of essential case study components (internal validity). The framework approach aims to assess the effectiveness of each case against its set out research objectives and aims (external validity), based on different systematic case study purposes in psychotherapy. Finally, the paper demonstrates the application of the tool with a case example and notes further research trajectories for the development of CaSE tool.

Introduction

Due to growing demands of evidence-based practice, standardised research assessment and appraisal tools have become common in healthcare and clinical treatment (Hannes, Lockwood, & Pearson, 2010 ; Hartling, Chisholm, Thomson, & Dryden, 2012 ; Katrak, Bialocerkowski, Massy-Westropp, Kumar, & Grimmer, 2004 ). This allows researchers to critically appraise research findings on the basis of their validity, results, and usefulness (Hill & Spittlehouse, 2003 ). Despite the upsurge of critical appraisal in qualitative research (Williams, Boylan, & Nunan, 2019 ), there are no assessment or appraisal tools designed for psychotherapy case studies.

Although not without controversies (Michels, 2000 ), case studies remain central to the investigation of psychotherapy processes (Midgley, 2006 ; Willemsen, Della Rosa, & Kegerreis, 2017 ). This is particularly true of systematic case studies, the most common form of case study in contemporary psychotherapy research (Davison & Lazarus, 2007 ; McLeod & Elliott, 2011 ).

Unlike the classic clinical case study, systematic cases usually involve a team of researchers, who gather data from multiple different sources (e.g., questionnaires, observations by the therapist, interviews, statistical findings, clinical assessment, etc.), and involve a rigorous data triangulation process to assess whether the data from different sources converge (McLeod, 2010 ). Since systematic case studies are methodologically pluralistic, they have a greater interest in situating patients within the study of a broader population than clinical case studies (Iwakabe & Gazzola, 2009 ). Systematic case studies are considered to be an accessible method for developing research evidence-base in psychotherapy (Widdowson, 2011 ), especially since they correct some of the methodological limitations (e.g. lack of ‘third party’ perspectives and bias in data analysis) inherent to classic clinical case studies (Iwakabe & Gazzola, 2009 ). They have been used for the purposes of clinical training (Tuckett, 2008 ), outcome assessment (Hilliard, 1993 ), development of clinical techniques (Almond, 2004 ) and meta-analysis of qualitative findings (Timulak, 2009 ). All these developments signal a revived interest in the case study method, but also point to the obvious lack of a research assessment tool suitable for case studies in psychotherapy (Table ​ (Table1 1 ).

Key concept: systematic case study

To attend to this research gap, this paper first reviews issues around the conceptualisation of validity within the paradigms of evidence-based practice (EBP) and practice-based evidence (PBE). Although case studies are often positioned at the low end of EBP (Aveline, 2005 ), the paper suggests that systematic cases are a valuable form of evidence, capable of complimenting large-scale studies such as randomised controlled trials (RCTs). However, there remains a difficulty in assessing the quality and relevance of case study findings to broader psychotherapy research.

As a way forward, the paper introduces a novel Case Study Evaluation-tool (CaSE) in the form of CaSE Purpose - based Evaluative Framework for Systematic Case Studies and CaSE Checklist for Essential Components in Systematic Case Studies . The long-term development of CaSE would contribute to psychotherapy research and practice in three ways.

Given the significance of methodological pluralism and diverse research aims in systematic case studies, CaSE will not seek to prescribe explicit case study writing guidelines, which has already been done by numerous authors (McLeod, 2010 ; Meganck, Inslegers, Krivzov, & Notaerts, 2017 ; Willemsen et al., 2017 ). Instead, CaSE will enable the retrospective assessment of systematic case study findings and their relevance (or lack thereof) to broader psychotherapy research and practice. However, there is no reason to assume that CaSE cannot be used prospectively (i.e. producing systematic case studies in accordance to CaSE evaluative framework, as per point 3 in Table ​ Table2 2 ).

How can Case Study Evaluation-tool (CaSE) be used in psychotherapy research and practice?

The development of a research assessment or appraisal tool is a lengthy, ongoing process (Long & Godfrey, 2004 ). It is particularly challenging to develop a comprehensive purpose - oriented evaluative framework, suitable for the assessment of diverse methodologies, aims and outcomes. As such, this paper should be treated as an introduction to the broader development of CaSE tool. It will introduce the rationale behind CaSE and lay out its main approach to evidence and evaluation, with further development in mind. A case example from the Single Case Archive (SCA) ( https://singlecasearchive.com ) will be used to demonstrate the application of the tool ‘in action’. The paper notes further research trajectories and discusses some of the limitations around the use of the tool.

Separating the wheat from the chaff: what is and is not evidence in psychotherapy (and who gets to decide?)

The common approach: evidence-based practice.

In the last two decades, psychotherapy has become increasingly centred around the idea of an evidence-based practice (EBP). Initially introduced in medicine, EBP has been defined as ‘conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’ (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996 ). EBP revolves around efficacy research: it seeks to examine whether a specific intervention has a causal (in this case, measurable) effect on clinical populations (Barkham & Mellor-Clark, 2003 ). From a conceptual standpoint, Sackett and colleagues defined EBP as a paradigm that is inclusive of many methodologies, so long as they contribute towards clinical decision-making process and accumulation of best currently available evidence in any given set of circumstances (Gabbay & le May, 2011 ). Similarly, the American Psychological Association (APA, 2010 ) has recently issued calls for evidence-based systematic case studies in order to produce standardised measures for evaluating process and outcome data across different therapeutic modalities.

However, given EBP’s focus on establishing cause-and-effect relationships (Rosqvist, Thomas, & Truax, 2011 ), it is unsurprising that qualitative research is generally not considered to be ‘gold standard’ or ‘efficacious’ within this paradigm (Aveline, 2005 ; Cartwright & Hardie, 2012 ; Edwards, 2013 ; Edwards, Dattilio, & Bromley, 2004 ; Longhofer, Floersch, & Hartmann, 2017 ). Qualitative methods like systematic case studies maintain an appreciation for context, complexity and meaning making. Therefore, instead of measuring regularly occurring causal relations (as in quantitative studies), the focus is on studying complex social phenomena (e.g. relationships, events, experiences, feelings, etc.) (Erickson, 2012 ; Maxwell, 2004 ). Edwards ( 2013 ) points out that, although context-based research in systematic case studies is the bedrock of psychotherapy theory and practice, it has also become shrouded by an unfortunate ideological description: ‘anecdotal’ case studies (i.e. unscientific narratives lacking evidence, as opposed to ‘gold standard’ evidence, a term often used to describe the RCT method and the therapeutic modalities supported by it), leading to a further need for advocacy in and defence of the unique epistemic process involved in case study research (Fishman, Messer, Edwards, & Dattilio, 2017 ).

The EBP paradigm prioritises the quantitative approach to causality, most notably through its focus on high generalisability and the ability to deal with bias through randomisation process. These conditions are associated with randomised controlled trials (RCTs) but are limited (or, as some argue, impossible) in qualitative research methods such as the case study (Margison et al., 2000 ) (Table ​ (Table3 3 ).

Key concept: evidence-based practice (EBP)

‘Evidence’ from an EBP standpoint hovers over the epistemological assumption of procedural objectivity : knowledge can be generated in a standardised, non-erroneous way, thus producing objective (i.e. with minimised bias) data. This can be achieved by anyone, as long as they are able to perform the methodological procedure (e.g. RCT) appropriately, in a ‘clearly defined and accepted process that assists with knowledge production’ (Douglas, 2004 , p. 131). If there is a well-outlined quantitative form for knowledge production, the same outcome should be achieved regardless of who processes or interprets the information. For example, researchers using Cochrane Review assess the strength of evidence using meticulously controlled and scrupulous techniques; in turn, this minimises individual judgment and creates unanimity of outcomes across different groups of people (Gabbay & le May, 2011 ). The typical process of knowledge generation (through employing RCTs and procedural objectivity) in EBP is demonstrated in Fig. ​ Fig.1 1 .

Typical knowledge generation process in evidence–based practice (EBP)

In EBP, the concept of validity remains somewhat controversial, with many critics stating that it limits rather than strengthens knowledge generation (Berg, 2019 ; Berg & Slaattelid, 2017 ; Lilienfeld, Ritschel, Lynn, Cautin, & Latzman, 2013 ). This is because efficacy research relies on internal validity . At a general level, this concept refers to the congruence between the research study and the research findings (i.e. the research findings were not influenced by anything external to the study, such as confounding variables, methodological errors and bias); at a more specific level, internal validity determines the extent to which a study establishes a reliable causal relationship between an independent variable (e.g. treatment) and independent variable (outcome or effect) (Margison et al., 2000 ). This approach to validity is demonstrated in Fig. ​ Fig.2 2 .

Internal validity

Social scientists have argued that there is a trade-off between research rigour and generalisability: the more specific the sample and the more rigorously defined the intervention, the outcome is likely to be less applicable to everyday, routine practice. As such, there remains a tension between employing procedural objectivity which increases the rigour of research outcomes and applying such outcomes to routine psychotherapy practice where scientific standards of evidence are not uniform.

According to McLeod ( 2002 ), inability to address questions that are most relevant for practitioners contributed to a deepening research–practice divide in psychotherapy. Studies investigating how practitioners make clinical decisions and the kinds of evidence they refer to show that there is a strong preference for knowledge that is not generated procedurally, i.e. knowledge that encompasses concrete clinical situations, experiences and techniques. A study by Stewart and Chambless ( 2007 ) sought to assess how a larger population of clinicians (under APA, from varying clinical schools of thought and independent practices, sample size 591) make treatment decisions in private practice. The study found that large-scale statistical data was not the primary source of information sought by clinicians. The most important influences were identified as past clinical experiences and clinical expertise ( M = 5.62). Treatment materials based on clinical case observations and theory ( M = 4.72) were used almost as frequently as psychotherapy outcome research findings ( M = 4.80) (i.e. evidence-based research). These numbers are likely to fluctuate across different forms of psychotherapy; however, they are indicative of the need for research about routine clinical settings that does not isolate or generalise the effect of an intervention but examines the variations in psychotherapy processes.

The alternative approach: practice-based evidence

In an attempt to dissolve or lessen the research–practice divide, an alternative paradigm of practice-based evidence (PBE) has been suggested (Barkham & Mellor-Clark, 2003 ; Fox, 2003 ; Green & Latchford, 2012 ; Iwakabe & Gazzola, 2009 ; Laska, Motulsky, Wertz, Morrow, & Ponterotto, 2014 ; Margison et al., 2000 ). PBE represents a shift in how we think about evidence and knowledge generation in psychotherapy. PBE treats research as a local and contingent process (at least initially), which means it focuses on variations (e.g. in patient symptoms) and complexities (e.g. of clinical setting) in the studied phenomena (Fox, 2003 ). Moreover, research and theory-building are seen as complementary rather than detached activities from clinical practice. That is to say, PBE seeks to examine how and which treatments can be improved in everyday clinical practice by flagging up clinically salient issues and developing clinical techniques (Barkham & Mellor-Clark, 2003 ). For this reason, PBE is concerned with the effectiveness of research findings: it evaluates how well interventions work in real-world settings (Rosqvist et al., 2011 ). Therefore, although it is not unlikely for RCTs to be used in order to generate practice-informed evidence (Horn & Gassaway, 2007 ), qualitative methods like the systematic case study are seen as ideal for demonstrating the effectiveness of therapeutic interventions with individual patients (van Hennik, 2020 ) (Table ​ (Table4 4 ).

Key concept: practice-based evidence (PBE)

PBE’s epistemological approach to ‘evidence’ may be understood through the process of concordant objectivity (Douglas, 2004 ): ‘Instead of seeking to eliminate individual judgment, … [concordant objectivity] checks to see whether the individual judgments of people in fact do agree’ (p. 462). This does not mean that anyone can contribute to the evaluation process like in procedural objectivity, where the main criterion is following a set quantitative protocol or knowing how to operate a specific research design. Concordant objectivity requires that there is a set of competent observers who are closely familiar with the studied phenomenon (e.g. researchers and practitioners who are familiar with depression from a variety of therapeutic approaches).

Systematic case studies are a good example of PBE ‘in action’: they allow for the examination of detailed unfolding of events in psychotherapy practice, making it the most pragmatic and practice-oriented form of psychotherapy research (Fishman, 1999 , 2005 ). Furthermore, systematic case studies approach evidence and results through concordant objectivity (Douglas, 2004 ) by involving a team of researchers and rigorous data triangulation processes (McLeod, 2010 ). This means that, although systematic case studies remain focused on particular clinical situations and detailed subjective experiences (similar to classic clinical case studies; see Iwakabe & Gazzola, 2009 ), they still involve a series of validity checks and considerations on how findings from a single systematic case pertain to broader psychotherapy research (Fishman, 2005 ). The typical process of knowledge generation (through employing systematic case studies and concordant objectivity) in PBE is demonstrated in Fig. ​ Fig.3. 3 . The figure exemplifies a bidirectional approach to research and practice, which includes the development of research-supported psychological treatments (through systematic reviews of existing evidence) as well as the perspectives of clinical practitioners in the research process (through the study of local and contingent patient and/or treatment processes) (Teachman et al., 2012 ; Westen, Novotny, & Thompson-Brenner, 2004 ).

Typical knowledge generation process in practice-based evidence (PBE)

From a PBE standpoint, external validity is a desirable research condition: it measures extent to which the impact of interventions apply to real patients and therapists in everyday clinical settings. As such, external validity is not based on the strength of causal relationships between treatment interventions and outcomes (as in internal validity); instead, the use of specific therapeutic techniques and problem-solving decisions are considered to be important for generalising findings onto routine clinical practice (even if the findings are explicated from a single case study; see Aveline, 2005 ). This approach to validity is demonstrated in Fig. ​ Fig.4 4 .

External validity

Since effectiveness research is less focused on limiting the context of the studied phenomenon (indeed, explicating the context is often one of the research aims), there is more potential for confounding factors (e.g. bias and uncontrolled variables) which in turn can reduce the study’s internal validity (Barkham & Mellor-Clark, 2003 ). This is also an important challenge for research appraisal. Douglas ( 2004 ) argues that appraising research in terms of its effectiveness may produce significant disagreements or group illusions, since what might work for some practitioners may not work for others: ‘It cannot guarantee that values are not influencing or supplanting reasoning; the observers may have shared values that cause them to all disregard important aspects of an event’ (Douglas, 2004 , p. 462). Douglas further proposes that an interactive approach to objectivity may be employed as a more complex process in debating the evidential quality of a research study: it requires a discussion among observers and evaluators in the form of peer-review, scientific discourse, as well as research appraisal tools and instruments. While these processes of rigour are also applied in EBP, there appears to be much more space for debate, disagreement and interpretation in PBE’s approach to research evaluation, partly because the evaluation criteria themselves are subject of methodological debate and are often employed in different ways by researchers (Williams et al., 2019 ). This issue will be addressed more explicitly again in relation to CaSE development (‘Developing purpose-oriented evaluation criteria for systematic case studies’ section).

A third way approach to validity and evidence

The research–practice divide shows us that there may be something significant in establishing complementarity between EBP and PBE rather than treating them as mutually exclusive forms of research (Fishman et al., 2017 ). For one, EBP is not a sufficient condition for delivering research relevant to practice settings (Bower, 2003 ). While RCTs can demonstrate that an intervention works on average in a group, clinicians who are facing individual patients need to answer a different question: how can I make therapy work with this particular case ? (Cartwright & Hardie, 2012 ). Systematic case studies are ideal for filling this gap: they contain descriptions of microprocesses (e.g. patient symptoms, therapeutic relationships, therapist attitudes) in psychotherapy practice that are often overlooked in large-scale RCTs (Iwakabe & Gazzola, 2009 ). In particular, systematic case studies describing the use of specific interventions with less researched psychological conditions (e.g. childhood depression or complex post-traumatic stress disorder) can deepen practitioners’ understanding of effective clinical techniques before the results of large-scale outcome studies are disseminated.

Secondly, establishing a working relationship between systematic case studies and RCTs will contribute towards a more pragmatic understanding of validity in psychotherapy research. Indeed, the very tension and so-called trade-off between internal and external validity is based on the assumption that research methods are designed on an either/or basis; either they provide a sufficiently rigorous study design or they produce findings that can be applied to real-life practice. Jimenez-Buedo and Miller ( 2010 ) call this assumption into question: in their view, if a study is not internally valid, then ‘little, or rather nothing, can be said of the outside world’ (p. 302). In this sense, internal validity may be seen as a pre-requisite for any form of applied research and its external validity, but it need not be constrained to the quantitative approach of causality. For example, Levitt, Motulsky, Wertz, Morrow, and Ponterotto ( 2017 ) argue that, what is typically conceptualised as internal validity, is, in fact, a much broader construct, involving the assessment of how the research method (whether qualitative or quantitative) is best suited for the research goal, and whether it obtains the relevant conclusions. Similarly, Truijens, Cornelis, Desmet, and De Smet ( 2019 ) suggest that we should think about validity in a broader epistemic sense—not just in terms of psychometric measures, but also in terms of the research design, procedure, goals (research questions), approaches to inquiry (paradigms, epistemological assumptions), etc.

The overarching argument from research cited above is that all forms of research—qualitative and quantitative—can produce ‘valid evidence’ but the validity itself needs to be assessed against each specific research method and purpose. For example, RCTs are accompanied with a variety of clearly outlined appraisal tools and instruments such as CASP (Critical Appraisal Skills Programme) that are well suited for the assessment of RCT validity and their implications for EBP. Systematic case studies (or case studies more generally) currently have no appraisal tools in any discipline. The next section evaluates whether existing qualitative research appraisal tools are relevant for systematic case studies in psychotherapy and specifies the missing evaluative criteria.

The relevance of existing appraisal tools for qualitative research to systematic case studies in psychotherapy

What is a research tool.

Currently, there are several research appraisal tools, checklists and frameworks for qualitative studies. It is important to note that tools, checklists and frameworks are not equivalent to one another but actually refer to different approaches to appraising the validity of a research study. As such, it is erroneous to assume that all forms of qualitative appraisal feature the same aims and methods (Hannes et al., 2010 ; Williams et al., 2019 ).

Generally, research assessment falls into two categories: checklists and frameworks . Checklist approaches are often contrasted with quantitative research, since the focus is on assessing the internal validity of research (i.e. researcher’s independence from the study). This involves the assessment of bias in sampling, participant recruitment, data collection and analysis. Framework approaches to research appraisal, on the other hand, revolve around traditional qualitative concepts such as transparency, reflexivity, dependability and transferability (Williams et al., 2019 ). Framework approaches to appraisal are often challenging to use because they depend on the reviewer’s familiarisation and interpretation of the qualitative concepts.

Because of these different approaches, there is some ambiguity in terminology, particularly between research appraisal instruments and research appraisal tools . These terms are often used interchangeably in appraisal literature (Williams et al., 2019 ). In this paper, research appraisal tool is defined as a method-specific (i.e. it identifies a specific research method or component) form of appraisal that draws from both checklist and framework approaches. Furthermore, a research appraisal tool seeks to inform decision making in EBP or PBE paradigms and provides explicit definitions of the tool’s evaluative framework (thus minimising—but by no means eliminating—the reviewers’ interpretation of the tool). This definition will be applied to CaSE (Table ​ (Table5 5 ).

Key concept: research appraisal tool

In contrast, research appraisal instruments are generally seen as a broader form of appraisal in the sense that they may evaluate a variety of methods (i.e. they are non-method specific or they do not target a particular research component), and are aimed at checking whether the research findings and/or the study design contain specific elements (e.g. the aims of research, the rationale behind design methodology, participant recruitment strategies, etc.).

There is often an implicit difference in audience between appraisal tools and instruments. Research appraisal instruments are often aimed at researchers who want to assess the strength of their study; however, the process of appraisal may not be made explicit in the study itself (besides mentioning that the tool was used to appraise the study). Research appraisal tools are aimed at researchers who wish to explicitly demonstrate the evidential quality of the study to the readers (which is particularly common in RCTs). All forms of appraisal used in the comparative exercise below are defined as ‘tools’, even though they have different appraisal approaches and aims.

Comparing different qualitative tools

Hannes et al. ( 2010 ) identified CASP (Critical Appraisal Skills Programme-tool), JBI (Joanna Briggs Institute-tool) and ETQS (Evaluation Tool for Qualitative Studies) as the most frequently used critical appraisal tools by qualitative researchers. All three instruments are available online and are free of charge, which means that any researcher or reviewer can readily utilise CASP, JBI or ETQS evaluative frameworks to their research. Furthermore, all three instruments were developed within the context of organisational, institutional or consortium support (Tables ​ (Tables6, 6 , ​ ,7 7 and ​ and8 8 ).

CASP (Critical Appraisal Skills Programme-tool)

JBI (Joanna Briggs Institute-tool)

ETQS (Evaluation Tool for Qualitative Studies)

It is important to note that neither of the three tools is specific to systematic case studies or psychotherapy case studies (which would include not only systematic but also experimental and clinical cases). This means that using CASP, JBI or ETQS for case study appraisal may come at a cost of overlooking elements and components specific to the systematic case study method.

Based on Hannes et al. ( 2010 ) comparative study of qualitative appraisal tools as well as the different evaluation criteria explicated in CASP, JBI and ETQS evaluative frameworks, I assessed how well each of the three tools is attuned to the methodological , clinical and theoretical aspects of systematic case studies in psychotherapy. The latter components were based on case study guidelines featured in the journal of Pragmatic Case Studies in Psychotherapy as well as components commonly used by published systematic case studies across a variety of other psychotherapy journals (e.g. Psychotherapy Research , Research In Psychotherapy : Psychopathology Process And Outcome , etc.) (see Table ​ Table9 9 for detailed descriptions of each component).

Comparing the relevance of JBI (Joanna Briggs Institute), CASP (Critical Appraisal Skills Program) and ETQS (Evaluation Tool for Qualitative Studies) for appraising components specific to systematic case studies

The evaluation criteria for each tool in Table ​ Table9 9 follows Joanna Briggs Institute (JBI) ( 2017a , 2017b ); Critical Appraisal Skills Programme (CASP) ( 2018 ); and ETQS Questionnaire (first published in 2004 but revised continuously since). Table ​ Table10 10 demonstrates how each tool should be used (i.e. recommended reviewer responses to checklists and questionnaires).

Recommended reviewer responses to JBI (Joanna Briggs Institute), CASP (Critical Appraisal Skills Program) and ETQS (Evaluation Tool for Qualitative Studies)

Using CASP, JBI and ETQS for systematic case study appraisal

Although JBI, CASP and ETQS were all developed to appraise qualitative research, it is evident from the above comparison that there are significant differences between the three tools. For example, JBI and ETQS are well suited to assess researcher’s interpretations (Hannes et al. ( 2010 ) defined this as interpretive validity , a subcategory of internal validity ): the researcher’s ability to portray, understand and reflect on the research participants’ experiences, thoughts, viewpoints and intentions. JBI has an explicit requirement for participant voices to be clearly represented, whereas ETQS involves a set of questions about key characteristics of events, persons, times and settings that are relevant to the study. Furthermore, both JBI and ETQS seek to assess the researcher’s influence on the research, with ETQS particularly focusing on the evaluation of reflexivity (the researcher’s personal influence on the interpretation and collection of data). These elements are absent or addressed to a lesser extent in the CASP tool.

The appraisal of transferability of findings (what this paper previously referred to as external validity ) is addressed only by ETQS and CASP. Both tools have detailed questions about the value of research to practice and policy as well as its transferability to other populations and settings. Methodological research aspects are also extensively addressed by CASP and ETQS, but less so by JBI (which relies predominantly on congruity between research methodology and objectives without any particular assessment criteria for other data sources and/or data collection methods). Finally, the evaluation of theoretical aspects (referred to by Hannes et al. ( 2010 ) as theoretical validity ) is addressed only by JBI and ETQS; there are no assessment criteria for theoretical framework in CASP.

Given these differences, it is unsurprising that CASP, JBI and ETQS have limited relevance for systematic case studies in psychotherapy. First, it is evident that neither of the three tools has specific evaluative criteria for the clinical component of systematic case studies. Although JBI and ETQS feature some relevant questions about participants and their context, the conceptualisation of patients (and/or clients) in psychotherapy involves other kinds of data elements (e.g. diagnostic tools and questionnaires as well as therapist observations) that go beyond the usual participant data. Furthermore, much of the clinical data is intertwined with the therapist’s clinical decision-making and thinking style (Kaluzeviciute & Willemsen, 2020 ). As such, there is a need to appraise patient data and therapist interpretations not only on a separate basis, but also as two forms of knowledge that are deeply intertwined in the case narrative.

Secondly, since systematic case studies involve various forms of data, there is a need to appraise how these data converge (or how different methods complement one another in the case context) and how they can be transferred or applied in broader psychotherapy research and practice. These systematic case study components are attended to a degree by CASP (which is particularly attentive of methodological components) and ETQS (particularly specific criteria for research transferability onto policy and practice). These components are not addressed or less explicitly addressed by JBI. Overall, neither of the tools is attuned to all methodological, theoretical and clinical components of the systematic case study. Specifically, there are no clear evaluation criteria for the description of research teams (i.e. different data analysts and/or clinicians); the suitability of the systematic case study method; the description of patient’s clinical assessment; the use of other methods or data sources; the general data about therapeutic progress.

Finally, there is something to be said about the recommended reviewer responses (Table ​ (Table10). 10 ). Systematic case studies can vary significantly in their formulation and purpose. The methodological, theoretical and clinical components outlined in Table ​ Table9 9 follow guidelines made by case study journals; however, these are recommendations, not ‘set in stone’ case templates. For this reason, the straightforward checklist approaches adopted by JBI and CASP may be difficult to use for case study researchers and those reviewing case study research. The ETQS open-ended questionnaire approach suggested by Long and Godfrey ( 2004 ) enables a comprehensive, detailed and purpose-oriented assessment, suitable for the evaluation of systematic case studies. That said, there remains a challenge of ensuring that there is less space for the interpretation of evaluative criteria (Williams et al., 2019 ). The combination of checklist and framework approaches would, therefore, provide a more stable appraisal process across different reviewers.

Developing purpose-oriented evaluation criteria for systematic case studies

The starting point in developing evaluation criteria for Case Study Evaluation-tool (CaSE) is addressing the significance of pluralism in systematic case studies. Unlike RCTs, systematic case studies are pluralistic in the sense that they employ divergent practices in methodological procedures ( research process ), and they may include significantly different research aims and purpose ( the end - goal ) (Kaluzeviciute & Willemsen, 2020 ). While some systematic case studies will have an explicit intention to conceptualise and situate a single patient’s experiences and symptoms within a broader clinical population, others will focus on the exploration of phenomena as they emerge from the data. It is therefore important that CaSE is positioned within a purpose - oriented evaluative framework , suitable for the assessment of what each systematic case is good for (rather than determining an absolute measure of ‘good’ and ‘bad’ systematic case studies). This approach to evidence and appraisal is in line with the PBE paradigm. PBE emphasises the study of clinical complexities and variations through local and contingent settings (e.g. single case studies) and promotes methodological pluralism (Barkham & Mellor-Clark, 2003 ).

CaSE checklist for essential components in systematic case studies

In order to conceptualise purpose-oriented appraisal questions, we must first look at what unites and differentiates systematic case studies in psychotherapy. The commonly used theoretical, clinical and methodological systematic case study components were identified earlier in Table ​ Table9. 9 . These components will be seen as essential and common to most systematic case studies in CaSE evaluative criteria. If these essential components are missing in a systematic case study, then it may be implied there is a lack of information, which in turn diminishes the evidential quality of the case. As such, the checklist serves as a tool for checking whether a case study is, indeed, systematic (as opposed to experimental or clinical; see Iwakabe & Gazzola, 2009 for further differentiation between methodologically distinct case study types) and should be used before CaSE Purpose - based Evaluative Framework for Systematic Case Studie s (which is designed for the appraisal of different purposes common to systematic case studies).

As noted earlier in the paper, checklist approaches to appraisal are useful when evaluating the presence or absence of specific information in a research study. This approach can be used to appraise essential components in systematic case studies, as shown below. From a pragmatic point view (Levitt et al., 2017 ; Truijens et al., 2019 ), CaSE Checklist for Essential Components in Systematic Case Studies can be seen as a way to ensure the internal validity of systematic case study: the reviewer is assessing whether sufficient information is provided about the case design, procedure, approaches to inquiry, etc., and whether they are relevant to the researcher’s objectives and conclusions (Table ​ (Table11 11 ).

Case Study Evaluation-tool (CaSE) checklist for essential components in systematic case studies. Recommended responses: Yes, No, unclear or not applicable

CaSE purpose-based evaluative framework for systematic case studies

Identifying differences between systematic case studies means identifying the different purposes systematic case studies have in psychotherapy. Based on the earlier work by social scientist Yin ( 1984 , 1993 ), we can differentiate between exploratory (hypothesis generating, indicating a beginning phase of research), descriptive (particularising case data as it emerges) and representative (a case that is typical of a broader clinical population, referred to as the ‘explanatory case’ by Yin) cases.

Another increasingly significant strand of systematic case studies is transferable (aggregating and transferring case study findings) cases. These cases are based on the process of meta-synthesis (Iwakabe & Gazzola, 2009 ): by examining processes and outcomes in many different case studies dealing with similar clinical issues, researchers can identify common themes and inferences. In this way, single case studies that have relatively little impact on clinical practice, research or health care policy (in the sense that they capture psychotherapy processes rather than produce generalisable claims as in Yin’s representative case studies) can contribute to the generation of a wider knowledge base in psychotherapy (Iwakabe, 2003 , 2005 ). However, there is an ongoing issue of assessing the evidential quality of such transferable cases. According to Duncan and Sparks ( 2020 ), although meta-synthesis and meta-analysis are considered to be ‘gold standard’ for assessing interventions across disparate studies in psychotherapy, they often contain case studies with significant research limitations, inappropriate interpretations and insufficient information. It is therefore important to have a research appraisal process in place for selecting transferable case studies.

Two other types of systematic case study research include: critical (testing and/or confirming existing theories) cases, which are described as an excellent method for falsifying existing theoretical concepts and testing whether therapeutic interventions work in practice with concrete patients (Kaluzeviciute, 2021 ), and unique (going beyond the ‘typical’ cases and demonstrating deviations) cases (Merriam, 1998 ). These two systematic case study types are often seen as less valuable for psychotherapy research given that unique/falsificatory findings are difficult to generalise. But it is clear that practitioners and researchers in our field seek out context-specific data, as well as detailed information on the effectiveness of therapeutic techniques in single cases (Stiles, 2007 ) (Table ​ (Table12 12 ).

Key concept: purpose–based systematic case studies

Each purpose-based case study contributes to PBE in different ways. Representative cases provide qualitatively rich, in-depth data about a clinical phenomenon within its particular context. This offers other clinicians and researchers access to a ‘closed world’ (Mackrill & Iwakabe, 2013 ) containing a wide range of attributes about a conceptual type (e.g. clinical condition or therapeutic technique). Descriptive cases generally seek to demonstrate a realistic snapshot of therapeutic processes, including complex dynamics in therapeutic relationships, and instances of therapeutic failure (Maggio, Molgora, & Oasi, 2019 ). Data in descriptive cases should be presented in a transparent manner (e.g. if there are issues in standardising patient responses to a self-report questionnaire, this should be made explicit). Descriptive cases are commonly used in psychotherapy training and supervision. Unique cases are relevant for both clinicians and researchers: they often contain novel treatment approaches and/or introduce new diagnostic considerations about patients who deviate from the clinical population. Critical cases demonstrate the application of psychological theories ‘in action’ with particular patients; as such, they are relevant to clinicians, researchers and policymakers (Mackrill & Iwakabe, 2013 ). Exploratory cases bring new insight and observations into clinical practice and research. This is particularly useful when comparing (or introducing) different clinical approaches and techniques (Trad & Raine, 1994 ). Findings from exploratory cases often include future research suggestions. Finally, transferable cases provide one solution to the generalisation issue in psychotherapy research through the previously mentioned process of meta-synthesis. Grouped together, transferable cases can contribute to theory building and development, as well as higher levels of abstraction about a chosen area of psychotherapy research (Iwakabe & Gazzola, 2009 ).

With this plurality in mind, it is evident that CaSE has a challenging task of appraising research components that are distinct across six different types of purpose-based systematic case studies. The purpose-specific evaluative criteria in Table ​ Table13 13 was developed in close consultation with epistemological literature associated with each type of case study, including: Yin’s ( 1984 , 1993 ) work on establishing the typicality of representative cases; Duncan and Sparks’ ( 2020 ) and Iwakabe and Gazzola’s ( 2009 ) case selection criteria for meta-synthesis and meta-analysis; Stake’s ( 1995 , 2010 ) research on particularising case narratives; Merriam’s ( 1998 ) guidelines on distinctive attributes of unique case studies; Kennedy’s ( 1979 ) epistemological rules for generalising from case studies; Mahrer’s ( 1988 ) discovery oriented case study approach; and Edelson’s ( 1986 ) guidelines for rigorous hypothesis generation in case studies.

Case Study Evaluation-tool (CaSE) purpose-based evaluative framework for systematic case studies. Recommended responses: open-ended questionnaire

Research on epistemic issues in case writing (Kaluzeviciute, 2021 ) and different forms of scientific thinking in psychoanalytic case studies (Kaluzeviciute & Willemsen, 2020 ) was also utilised to identify case study components that would help improve therapist clinical decision-making and reflexivity.

For the analysis of more complex research components (e.g. the degree of therapist reflexivity), the purpose-based evaluation will utilise a framework approach, in line with comprehensive and open-ended reviewer responses in ETQS (Evaluation Tool for Qualitative Studies) (Long & Godfrey, 2004 ) (Table ​ (Table13). 13 ). That is to say, the evaluation here is not so much about the presence or absence of information (as in the checklist approach) but the degree to which the information helps the case with its unique purpose, whether it is generalisability or typicality. Therefore, although the purpose-oriented evaluation criteria below encompasses comprehensive questions at a considerable level of generality (in the sense that not all components may be required or relevant for each case study), it nevertheless seeks to engage with each type of purpose-based systematic case study on an individual basis (attending to research or clinical components that are unique to each of type of case study).

It is important to note that, as this is an introductory paper to CaSE, the evaluative framework is still preliminary: it involves some of the core questions that pertain to the nature of all six purpose-based systematic case studies. However, there is a need to develop a more comprehensive and detailed CaSE appraisal framework for each purpose-based systematic case study in the future.

Using CaSE on published systematic case studies in psychotherapy: an example

To illustrate the use of CaSE Purpose - based Evaluative Framework for Systematic Case Studies , a case study by Lunn, Daniel, and Poulsen ( 2016 ) titled ‘ Psychoanalytic Psychotherapy With a Client With Bulimia Nervosa ’ was selected from the Single Case Archive (SCA) and analysed in Table ​ Table14. 14 . Based on the core questions associated with the six purpose-based systematic case study types in Table ​ Table13(1 13 (1 to 6), the purpose of Lunn et al.’s ( 2016 ) case was identified as critical (testing an existing theoretical suggestion).

Using Case Study Evaluation-tool (CaSE): Lunn et al. ( 2016 )’s case ‘ Psychoanalytic psychotherapy with a client with bulimia nervosa ’

Sometimes, case study authors will explicitly define the purpose of their case in the form of research objectives (as was the case in Lunn et al.’s study); this helps identifying which purpose-based questions are most relevant for the evaluation of the case. However, some case studies will require comprehensive analysis in order to identify their purpose (or multiple purposes). As such, it is recommended that CaSE reviewers first assess the degree and manner in which information about the studied phenomenon, patient data, clinical discourse and research are presented before deciding on the case purpose.

Although each purpose-based systematic case study will contribute to different strands of psychotherapy (theory, practice, training, etc.) and focus on different forms of data (e.g. theory testing vs extensive clinical descriptions), the overarching aim across all systematic case studies in psychotherapy is to study local and contingent processes, such as variations in patient symptoms and complexities of the clinical setting. The comprehensive framework approach will therefore allow reviewers to assess the degree of external validity in systematic case studies (Barkham & Mellor-Clark, 2003 ). Furthermore, assessing the case against its purpose will let reviewers determine whether the case achieves its set goals (research objectives and aims). The example below shows that Lunn et al.’s ( 2016 ) case is successful in functioning as a critical case as the authors provide relevant, high-quality information about their tested therapeutic conditions.

Finally, it is also possible to use CaSE to gather specific type of systematic case studies for one’s research, practice, training, etc. For example, a CaSE reviewer might want to identify as many descriptive case studies focusing on negative therapeutic relationships as possible for their clinical supervision. The reviewer will therefore only need to refer to CaSE questions in Table ​ Table13(2) 13 (2) on descriptive cases. If the reviewed cases do not align with the questions in Table ​ Table13(2), 13 (2), then they are not suitable for the CaSE reviewer who is looking for “know-how” knowledge and detailed clinical narratives.

Concluding comments

This paper introduces a novel Case Study Evaluation-tool (CaSE) for systematic case studies in psychotherapy. Unlike most appraisal tools in EBP, CaSE is positioned within purpose-oriented evaluation criteria, in line with the PBE paradigm. CaSE enables reviewers to assess what each systematic case is good for (rather than determining an absolute measure of ‘good’ and ‘bad’ systematic case studies). In order to explicate a purpose-based evaluative framework, six different systematic case study purposes in psychotherapy have been identified: representative cases (purpose: typicality), descriptive cases (purpose: particularity), unique cases (purpose: deviation), critical cases (purpose: falsification/confirmation), exploratory cases (purpose: hypothesis generation) and transferable cases (purpose: generalisability). Each case was linked with an existing epistemological network, such as Iwakabe and Gazzola’s ( 2009 ) work on case selection criteria for meta-synthesis. The framework approach includes core questions specific to each purpose-based case study (Table 13 (1–6)). The aim is to assess the external validity and effectiveness of each case study against its set out research objectives and aims. Reviewers are required to perform a comprehensive and open-ended data analysis, as shown in the example in Table ​ Table14 14 .

Along with CaSE Purpose - based Evaluative Framework (Table ​ (Table13), 13 ), the paper also developed CaSE Checklist for Essential Components in Systematic Case Studies (Table ​ (Table12). 12 ). The checklist approach is meant to aid reviewers in assessing the presence or absence of essential case study components, such as the rationale behind choosing the case study method and description of patient’s history. If essential components are missing in a systematic case study, then it may be implied that there is a lack of information, which in turn diminishes the evidential quality of the case. Following broader definitions of validity set out by Levitt et al. ( 2017 ) and Truijens et al. ( 2019 ), it could be argued that the checklist approach allows for the assessment of (non-quantitative) internal validity in systematic case studies: does the researcher provide sufficient information about the case study design, rationale, research objectives, epistemological/philosophical paradigms, assessment procedures, data analysis, etc., to account for their research conclusions?

It is important to note that this paper is set as an introduction to CaSE; by extension, it is also set as an introduction to research evaluation and appraisal processes for case study researchers in psychotherapy. As such, it was important to provide a step-by-step epistemological rationale and process behind the development of CaSE evaluative framework and checklist. However, this also means that further research needs to be conducted in order to develop the tool. While CaSE Purpose - based Evaluative Framework involves some of the core questions that pertain to the nature of all six purpose-based systematic case studies, there is a need to develop individual and comprehensive CaSE evaluative frameworks for each of the purpose-based systematic case studies in the future. This line of research is likely to enhance CaSE target audience: clinicians interested in reviewing highly particular clinical narratives will attend to descriptive case study appraisal frameworks; researchers working with qualitative meta-synthesis will find transferable case study appraisal frameworks most relevant to their work; while teachers on psychotherapy and counselling modules may seek out unique case study appraisal frameworks.

Furthermore, although CaSE Checklist for Essential Components in Systematic Case Studies and CaSE Purpose - based Evaluative Framework for Systematic Case Studies are presented in a comprehensive, detailed manner, with definitions and examples that would enable reviewers to have a good grasp of the appraisal process, it is likely that different reviewers may have different interpretations or ideas of what might be ‘substantial’ case study data. This, in part, is due to the methodologically pluralistic nature of the case study genre itself; what is relevant for one case study may not be relevant for another, and vice-versa. To aid with the review process, future research on CaSE should include a comprehensive paper on using the tool. This paper should involve evaluation examples with all six purpose-based systematic case studies, as well as a ‘search’ exercise (using CaSE to assess the relevance of case studies for one’s research, practice, training, etc.).

Finally, further research needs to be developed on how (and, indeed, whether) systematic case studies should be reviewed with specific ‘grades’ or ‘assessments’ that go beyond the qualitative examination in Table ​ Table14. 14 . This would be particularly significant for the processes of qualitative meta-synthesis and meta-analysis. These research developments will further enhance CaSE tool, and, in turn, enable psychotherapy researchers to appraise their findings within clear, purpose-based evaluative criteria appropriate for systematic case studies.

Acknowledgments

I would like to thank Prof Jochem Willemsen (Faculty of Psychology and Educational Sciences, Université catholique de Louvain-la-Neuve), Prof Wayne Martin (School of Philosophy and Art History, University of Essex), Dr Femke Truijens (Institute of Psychology, Erasmus University Rotterdam) and the reviewers of Psicologia: Reflexão e Crítica / Psychology : Research and Review for their feedback, insight and contributions to the manuscript.

Author’s contributions

GK is the sole author of the manuscript. The author(s) read and approved the final manuscript.

Arts and Humanities Research Council (AHRC) and Consortium for Humanities and the Arts South-East England (CHASE) Doctoral Training Partnership, Award Number [AH/L50 3861/1].

Availability of data and materials

Declarations.

The authors declare that they have no competing interests.

Publisher’s Note

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

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How to Write a Case Conceptualization: 10 Examples (+ PDF)

Such understanding can be developed by reading relevant records, meeting with clients face to face, and using assessments such as a mental status examination.

As you proceed, you are forming a guiding concept of who this client is, how they became who they are, and where their personal journey might be heading.

Such a guiding concept, which will shape any needed interventions, is called a case conceptualization, and we will examine various examples in this article.

Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with detailed insight into positive Cognitive-Behavioral Therapy (CBT) and give you the tools to apply it in your therapy or coaching.

This Article Contains:

What is a case conceptualization or formulation, 4 things to include in your case formulation, a helpful example & model, 3 samples of case formulations, 6 templates and worksheets for counselors, relevant resources from positivepsychology.com, a take-home message.

In psychology and related fields, a case conceptualization summarizes the key facts and findings from an evaluation to provide guidance for recommendations.

This is typically the evaluation of an individual, although you can extend the concept of case conceptualization to summarizing findings about a group or organization.

Based on the case conceptualization, recommendations can be made to improve a client’s self-care , mental status, job performance, etc (Sperry & Sperry, 2020).

• Summary of the client’s identifying information, referral questions, and timeline of important events or factors in their life . A timeline can be especially helpful in understanding how the client’s strengths and limitations have evolved.
• Statement of the client’s core strengths . Identifying core strengths in the client’s life should help guide any recommendations, including how strengths might be used to offset limitations.
• Statement concerning a client’s limitations or weaknesses . This will also help guide any recommendations. If a weakness is worth mentioning in a case conceptualization, it is worth writing a recommendation about it.

Note: As with mental status examinations , observations in this context concerning weaknesses are not value judgments, about whether the client is a good person, etc. The observations are clinical judgments meant to guide recommendations.

• A summary of how the strengths, limitations, and other key information about a client inform diagnosis and prognosis .

You should briefly clarify how you arrived at a given diagnosis. For example, why do you believe a personality disorder is primary, rather than a major depressive disorder?

Many clinicians provide diagnoses in formal psychiatric terms, per the International Classification of Diseases (ICD-10) or Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Some clinicians will state a diagnosis in less formal terms that do not coincide exactly with ICD-10 or DSM-5 codes. What is arguably more important is that a diagnostic impression, formal or not, gives a clear sense of who the person is and the support they need to reach their goals.

Prognosis is a forecast about whether the client’s condition can be expected to improve, worsen, or remain stable. Prognosis can be difficult, as it often depends on unforeseeable factors. However, this should not keep you from offering a conservative opinion on a client’s expected course, provided treatment recommendations are followed.

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Based on the pointers for writing a case conceptualization above, an example for summarizing an adolescent case (in this instance, a counseling case for relieving depression and improving social skills) might read as follows.

Background and referral information

This is a 15-year-old Haitian–American youth, referred by his mother for concerns about self-isolation, depression, and poor social skills. He reportedly moved with his mother to the United States three years ago.

He reportedly misses his life and friends in Haiti. The mother states he has had difficulty adjusting socially in the United States, especially with peers. He has become increasingly self-isolating, appears sad and irritable, and has started to refuse to go to school.

His mother is very supportive and aware of his emotional–behavioral needs. The youth has been enrolled in a social skills group at school and has attended three sessions, with some reported benefit. He is agreeable to start individual counseling. He reportedly does well in school academically when he applies himself.

Limitations

Behavioral form completed by his mother shows elevated depression scale (T score = 80). There is a milder elevation on the inattention scale (T score = 60), which suggests depression is more acute than inattention and might drive it.

He is also elevated on a scale measuring social skills and involvement (T score = 65). Here too, it is reasonable to assume that depression is driving social isolation and difficulty relating to peers, especially since while living in Haiti, he was reportedly quite social with peers.

Diagnostic impressions, treatment guidance, prognosis

This youth’s history, presentation on interview, and results of emotional–behavioral forms suggest some difficulty with depression, likely contributing to social isolation. As he has no prior reported history of depression, this is most likely a reaction to missing his former home and difficulty adjusting to his new school and peers.

Treatments should include individual counseling with an evidence-based approach such as Cognitive-Behavioral Therapy (CBT). His counselor should consider emotional processing and social skills building as well.

Prognosis is favorable, with anticipated benefit apparent within 12 sessions of CBT.

How to write a case conceptualization: An outline

The following outline is necessarily general. It can be modified as needed, with points excluded or added, depending on the case.

• Client’s gender, age, level of education, vocational status, marital status
• Referred by whom, why, and for what type of service (e.g., testing, counseling, coaching)
• In the spirit of strengths-based assessment, consider listing the client’s strengths first, before any limitations.
• Consider the full range of positive factors supporting the client.
• Physical health
• Family support
• Financial resources
• Capacity to work
• Resilience or other positive personality traits
• Emotional stability
• Cognitive strengths, per history and testing
• The client’s limitations or relative weaknesses should be described in a way that highlights those most needing attention or treatment.
• Medical conditions affecting daily functioning
• Lack of family or other social support
• Limited financial resources
• Inability to find or hold suitable employment
• Substance abuse or dependence
• Proneness to interpersonal conflict
• Emotional–behavioral problems, including anxious or depressive symptoms
• Cognitive deficits, per history and testing
• Diagnoses that are warranted can be given in either DSM-5 or ICD-10 terms.
• There can be more than one diagnosis given. If that’s the case, consider describing these in terms of primary diagnosis, secondary diagnosis, etc.
• The primary diagnosis should best encompass the client’s key symptoms or traits, best explain their behavior, or most need treatment.
• Take care to avoid over-assigning multiple and potentially overlapping diagnoses.

When writing a case conceptualization, always keep in mind the timeline of significant events or factors in the examinee’s life.

• Decide which events or factors are significant enough to include in a case conceptualization.
• When these points are placed in a timeline, they help you understand how the person has evolved to become who they are now.
• A good timeline can also help you understand which factors in a person’s life might be causative for others. For example, if a person has suffered a frontal head injury in the past year, this might help explain their changeable moods, presence of depressive disorder, etc.

Sample #1: Conceptualization for CBT case

This is a 35-year-old Caucasian man referred by his physician for treatment of generalized anxiety.

Strengths/supports in his case include willingness to engage in treatment, high average intelligence per recent cognitive testing, supportive family, and regular physical exercise (running).

Limiting factors include relatively low stress coping skills, frequent migraines (likely stress related), and relative social isolation (partly due to some anxiety about social skills).

The client’s presentation on interview and review of medical/psychiatric records show a history of chronic worry, including frequent worries about his wife’s health and his finances. He meets criteria for DSM-5 generalized anxiety disorder. He has also described occasional panic-type episodes, which do not currently meet full criteria for panic disorder but could develop into such without preventive therapy.

Treatments should include CBT for generalized anxiety, including keeping a worry journal; regular assessment of anxiety levels with Penn State Worry Questionnaire and/or Beck Anxiety Inventory; cognitive restructuring around negative beliefs that reinforce anxiety; and practice of relaxation techniques, such as progressive muscle relaxation and diaphragmatic breathing .

Prognosis is good, given the evidence for efficacy of CBT for anxiety disorders generally (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012).

Sample #2: Conceptualization for DBT case

This 51-year-old Haitian–American woman is self-referred for depressive symptoms, including reported moods of “rage,” “sadness,” and “emptiness.” She says that many of her difficulties involve family, friends, and coworkers who regularly “disrespect” her and “plot against her behind her back.”

Her current psychiatrist has diagnosed her with personality disorder with borderline features, but she doubts the accuracy of this diagnosis.

Strengths/supports include a willingness to engage in treatment, highly developed and marketable computer programming skills, and engagement in leisure activities such as playing backgammon with friends.

Limiting factors include low stress coping skills, mild difficulties with attention and recent memory (likely due in part to depressive affect), and a tendency to self-medicate with alcohol when feeling depressed.

The client’s presentation on interview, review of medical/psychiatric records, and results of MMPI-2 personality inventory corroborate her psychiatrist’s diagnosis of borderline personality disorder.

The diagnosis is supported by a longstanding history of unstable identity, volatile personal relationships with fear of being abandoned, feelings of emptiness, reactive depressive disorder with suicidal gestures, and lack of insight into interpersonal difficulties that have resulted in her often stressed and depressive state.

Treatments should emphasize a DBT group that her psychiatrist has encouraged her to attend but to which she has not yet gone. There should also be regular individual counseling emphasizing DBT skills including mindfulness or present moment focus, building interpersonal skills, emotional regulation, and distress tolerance. There should be a counseling element for limiting alcohol use. Cognitive exercises are also recommended.

Of note, DBT is the only evidence-based treatment for borderline personality disorder (May, Richardi, & Barth, 2016). Prognosis is guardedly optimistic, provided she engages in both group and individual DBT treatments on a weekly basis, and these treatments continue without interruption for at least three months, with refresher sessions as needed.

Sample #3: Conceptualization in a family therapy case

This 45-year-old African-American woman was initially referred for individual therapy for “rapid mood swings” and a tendency to become embroiled in family conflicts. Several sessions of family therapy also appear indicated, and her psychiatrist concurs.

The client’s husband (50 years old) and son (25 years old, living with parents) were interviewed separately and together. When interviewed separately, her husband and son each indicated the client’s alcohol intake was “out of control,” and that she was consuming about six alcoholic beverages throughout the day, sometimes more.

Her husband and son each said the client was often too tired for household duties by the evening and often had rapid shifts in mood from happy to angry to “crying in her room.”

On individual interview, the client stated that her husband and son were each drinking about as much as she, that neither ever offered to help her with household duties, and that her son appeared unable to keep a job, which left him home most of the day, making demands on her for meals, etc.

On interview with the three family members, each acknowledged that the instances above were occurring at home, although father and son tended to blame most of the problems, including son’s difficulty maintaining employment, on the client and her drinking.

Strengths/supports in the family include a willingness of each member to engage in family sessions, awareness of supportive resources such as assistance for son’s job search, and a willingness by all to examine and reduce alcohol use by all family members as needed.

Limiting factors in this case include apparent tendency of all household members to drink to some excess, lack of insight by one or more family members as to how alcohol consumption is contributing to communication and other problems in the household, and a tendency by husband and son to make this client the family scapegoat.

The family dynamic can be conceptualized in this case through a DBT lens.

From this perspective, problems develop within the family when the environment is experienced by one or more members as invalidating and unsupportive. DBT skills with a nonjudgmental focus, active listening to others, reflecting each other’s feelings, and tolerance of distress in the moment should help to develop an environment that supports all family members and facilitates effective communication.

It appears that all family members in this case would benefit from engaging in the above DBT skills, to support and communicate with one another.

Prognosis is guardedly optimistic if family will engage in therapy with DBT elements for at least six sessions (with refresher sessions as needed).

Introduction to case conceptualization – Thomas Field

The following worksheets can be used for case conceptualization and planning.

• Case Conceptualization Worksheet: Individual Counseling helps counselors develop a case conceptualization for individual clients.
• Case Conceptualization Worksheet: Couples Counseling helps counselors develop a case conceptualization for couples.
• Case Conceptualization Worksheet: Family Counseling helps counselors develop a case conceptualization for families.
• Case Conceptualization and Action Plan: Individual Counseling helps clients facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
• Case Conceptualization and Action Plan: Couples Counseling helps couples facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
• Case Conceptualization and Action Plan: Family Counseling helps families facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.

17 Science-Based Ways To Apply Positive CBT

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

Created by Experts. 100% Science-based.

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

Analyzing Strengths Use in Different Life Domains can help clients understand their notable strengths and which strengths can be used to more advantage in new contexts.

Family Strength Spotting is another relevant resource. Each family member fills out a worksheet detailing notable strengths of other family members. In reviewing all worksheets, each family member can gain a greater appreciation for other members’ strengths, note common or unique strengths, and determine how best to use these combined strengths to achieve family goals.

Four Front Assessment is another resource designed to help counselors conceptualize a case based on a client’s personal and environmental strengths and weaknesses. The idea behind this tool is that environmental factors in the broad sense, such as a supportive/unsupportive family, are too often overlooked in conceptualizing a case.

If you’re looking for more science-based ways to help others through CBT, check out this collection of 17 validated positive CBT tools for practitioners. Use them to help others overcome unhelpful thoughts and feelings and develop more positive behaviors.

In helping professions, success in working with clients depends first and foremost on how well you understand them.

This understanding is crystallized in a case conceptualization.

Case conceptualization helps answer key questions. Who is this client? How did they become who they are? What supports do they need to reach their goals?

The conceptualization itself depends on gathering all pertinent data on a given case, through record review, interview, behavioral observation, questionnaires completed by the client, etc.

Once the data is assembled, the counselor, coach, or other involved professional can focus on enumerating the client’s strengths, weaknesses, and limitations.

It is also often helpful to put the client’s strengths and limitations in a timeline so you can see how they have evolved and which factors might have contributed to the emergence of others.

Based on this in-depth understanding of the client, you can then tailor specific recommendations for enhancing their strengths, overcoming their weaknesses, and reaching their particular goals.

We hope you have enjoyed this discussion of how to conceptualize cases in the helping professions and that you will find some tools for doing so useful.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

• Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research , 36 (5), 427–440.
• May, J. M., Richardi, T. M., & Barth, K. S. (2016). Dialectical behavior therapy as treatment for borderline personality disorder. The Mental Health Clinician , 6 (2), 62–67.
• Sperry, L., & Sperry, J. (2020).  Case conceptualization: Mastering this competency with ease and confidence . Routledge.

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Pragmatic Case Studies in Psychotherapy

PCSP is a peer reviewed, open-access journal and database. It provides innovative, quantitative and qualitative knowledge about psychotherapy process and outcome. PCSP is published by the National Register of Health Service Psychologists.

January, 2024 -- see our newest case, "The Commitment of a Lifetime": The Role of Emotionally Focused Couple Therapy in Strengthening Attachment Bonds and Improving Relationship Health in Later-Life Couples—The Teletherapy Case of "Alice" and "Steve."

Click on the upper left button for the “Newest Case" or the button labeled "Current."   Click on "CE Exams On Case Studies" below for an Exam on the current issue's case study and on past issues' case studies.  

The Case Studies

Autism spectrum, cognitive difficulties, medical conditions, obsessive compulsive, personality disorders, psychosis/schizophrenia, trauma/ptsd, specific features in case studies, methodology of case studies, approaches and theories in case studies, ce exams on case studies.

January 23, 2024 -- FROM THE EDITOR  

ANNOUNCING THE PUBLICATION OF OUR 67th ISSUE (Vol. 20, Module 1)  

"The Commitment of a Lifetime": The Role of Emotionally Focused Couple Therapy in Strengthening Attachment Bonds and Improving Relationship Health in Later-Life Couples --The Teletherapy Case of "Alice" and "Steve"  

*** Drew Mendelson, Rutgers University-New Brunswick, NJ    

Commentaries 

*** Karen Skean and Elisabeth Brown, Rutgers University-New Brunswick, NJ   

*** Shalonda Kelly, Rutgers University-New Brunswick, NJ 

EDITOR'S NOTE

A healthy marriage is a crucial protective factor for adapting to the challenges of late life. Emotionally Focused Couple Therapy (EFCT) for couples is an attachment-based model of psychotherapy that emphasizes here-and-now processing of emotion in a safe holding environment; enhanced understanding of the patterned interactions between self and other; and a non-pathologizing, growth-oriented approach toward couples’ difficulties.   This case study examines the benefits of EFCT for addressing issues specific to late life, including existential concerns such as aging, illness, and mortality; caregiving burdens and stress; cumulative relational trauma over the lifespan; and forgiveness and healing from emotional injuries.   Specifically, this case study involves a 20-session, teletherapy treatment of a couple named “Alice” and “Steve,” aged 74 and 75, respectively, with Steve suffering from advanced Parkinson’s Disease. The couple presented with hopelessness and resentment about their caregiving situation, unresolved traumas from early childhood fueling their relationship’s sore spots, and unprocessed grief and fears concerning losses at the end stage of life.   The EFCT-guided treatment focused on promoting transformational and corrective experiences of secure attachment bonding and was importantly successful in resolving their presenting problems.

*** For a Table of Contents and pdf links to the articles, click on the upper left button labeled "Newest Case" or the button labeled "Current."  

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9 Case Examples

• Published: August 2022
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This chapter provides three lengthy, detailed presentations of disguised real-life cases from a Brief Supportive Psychotherapy perspective, contrasting the Brief Supportive Psychotherapy approach at points with other psychotherapeutic perspectives. Each of the cases, described session-by-session, includes illustrations of therapeutic techniques, numerous patient–therapist interchanges, and serial measurement of symptomatic outcomes. A commentary following each case summarizing key strategic and technical points. The chapter aims to convey the breadth and trajectory of relatively easy and relatively difficult patient presentations and how a therapist adjusted and reacted to them.

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Psychology Case Study Examples

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Experiments are often used to help researchers understand how the human mind works. There have been many famous examples in psychology over the years. Some have shown how phenomena like memory and personality work. Others have been disproven over time. Understanding the study design, data, content, and analytical approach of case studies is important to verifying the validity of each study.

In considering case studies, researchers continuously test and reevaluate the conclusions made by past psychologists to continue offering the most up-to-date and effective care to modern clients. Prospective case studies are continually being developed based on previous findings and multiple case studies done in one area can lend credence to the findings. Learning about the famous psychology case studies can help you understand how research continues to shape what psychologists know about the human experience and mind. 

Examples of the most famous case study in psychology

Hundreds of thousands of case studies have been done in psychology, and narrowing a list of the most ground-breaking studies can be challenging. However, the following seven case studies present findings that have defied expectations, achieved positive outcomes for humanity, and launched further research into existing knowledge gaps within the niche.

Phineas Gage

The case of Phineas Gage is perhaps the  most cited study  in psychology. This famous case study showed how different areas of the brain affect personality and cognitive ability. While working as a construction foreman on a railroad, Phineas Gage was involved in an accident in which a rod was pushed through his cheek and brain. He survived, but because of the accident, both his personality and his ability to learn new skills were affected.

Although the case is frequently cited and referenced in psychology, relatively little information about Gage's life before and after the accident is known. Researchers have discovered that the last two decades of his life were spent in his original job, which may have been unlikely to have been possible if the extent of his injuries were as severe as initially believed. Still, his case was a starting point for psychology research on how memory and personality work in the brain, and it is a seminal study for that reason.

Genie the "feral child"

Although an outdated term, "feral children" referred to children raised without human interaction, often due to abuse or neglect. One famous case study of a neglected child was done with a child known as Genie. She was raised in a single bedroom with little human interaction. She never gained the cognitive ability of an average adult, even though she was found at age 13. Later in life, she regressed and stopped speaking altogether. Her case has been studied extensively by psychologists who want to understand how enculturation affects cognitive development. It's one of many cognitive psychology examples that have had an impact on this field.

Henry Molaison

The case study  of Henry Molaison has helped psychologists understand memory. It is one of the most famous case studies in neuroscience. Henry Molaison was in a childhood accident that left him with debilitating seizures. Doctors could stop the seizures by removing slivers of his brain's hippocampus, though they did not fully understand what they were doing at the time. As a result, scientists learned how important the hippocampus is to forming long-term memories. After the surgery, Molaison could no longer form long-term memories, and his short-term memory was brief. The case study started further research into memory and the brain.

Jill Price had one of a few documented cases of hyperthymesia, a term for an overactive memory that allowed her to remember such mundane things as what she had for dinner on an average day in August 20th years previously. Her  case study  was used as a jumping-off point to research how memory works and why some people have exceptional memories. 

However, through more research, it was discovered that her overall memory was not exceptional. Rather, she only remembered details of her own life. She was diagnosed with obsessive-compulsive disorder (OCD), with memories being part of her obsession. This case study is still relevant because it has helped modern psychologists understand how mental illness affects memory.

In the John/Joan  case study , a reputable sexologist tested his theory that nurture, not nature, determined gender. The case study has been cited extensively and laid the groundwork for other research into gender identity. However, the case study was not legitimate. In this study, Dr. John Money performed surgery on an infant whose genitals were damaged during circumcision. 

The boy was raised as a girl; however, he never identified as female and eventually underwent gender-affirming surgery as an adult. Because Dr. Money didn't follow up with the patient appropriately and did not report adverse findings, the case study is still often cited as successful.

Anna O. was the pseudonym given to a German woman who was one of the first to undergo psychoanalysis. Her case inspired many of the theories of Freud and other prominent psychologists of the time. It was determined at the time that Anna's symptoms of depression were eliminated through talk therapy. More recently, it has been suggested that Anna O. had another illness, such as epilepsy, from which she may have recovered during the therapy. This  case study is still cited as a reason psychologists believe that psychotherapy, or talk therapy, can be helpful to many patients. 

Victor the "wild boy" of Aveyron

Another study done on a child that had grown up without parents was done with a boy named "Victor" who had been found wandering in the wilderness and was thought to have been living alone for years. The boy could not speak, use the bathroom, or connect with others. However, through the study of his condition, he was able to learn bathroom habits, how to dress, writing, and primary language. Psychologists today speculate that he may have been autistic. 

Ethical concerns for doing a case study

When case studies are flawed through not having enough information or having the wrong information, they can be harmful. Valuable research hours and other resources can be wasted while theories are used for inappropriate treatment. Case studies can therefore cause as much harm as benefit, and psychologists are often careful about how and when they are used.

Those who are not psychologists and are interacting with studies can also practice caution. Psychologists and doctors often disagree on how case studies should be applied. In addition, people without education in psychology may struggle to know whether a case study is built on a faulty premise or misinformation. It can also be possible to generalize case studies to situations they do not apply. If you think a case study might apply to your case or that of a loved one, consider asking a therapist for guidance. 

Case studies are descriptions of real people. The individuals in the studies are studied intensively and often written about in medical journals and textbooks. While some clients may be comfortable being studied for science, others may not have consented due to the inability or lack of consent laws at the time. In addition, some subjects may not have been treated with dignity and respect. 

When considering case study content and findings from psychology, it can be helpful to think of the cases as stories of real individuals. When you strip away the science and look at the case as a whole person in a unique situation, you may get more out of the study than if you look at it as research that proves a theory. 

Therapeutic implications of a case study

Case examples are sometimes used in therapy to determine the best course of treatment. If a typical case study from psychology aligns with your situation, your therapist may use the treatment methods outlined in the study. Psychiatrists and other mental health professionals also use case examples to understand mental illness and its treatment.

Researchers have reviewed the role of case studies in counseling and psychotherapy. In one study, the authors discussed how reading case studies benefits therapists, providing a conceptual guide for clinical work and an understanding of the theory behind the practice. They also stressed the importance of teaching psychotherapy trainees to do better case study research. They encouraged practitioners to publish more case studies documenting the methods they use in their practice.

How a case study is used in counseling

If you want to meet with a psychologist, counseling may benefit you. Therapists often use theories behind popular case studies and can discuss their implications with you. In addition, you may be able to participate in case studies in your area, as psychologists and psychiatrists often perform clinical trials to understand treatments on a deeper level.

Online therapy can also be beneficial if you cannot find a therapist in your area. Through a platform like BetterHelp, you can get matched with a provider meeting your needs and choose between phone, video, or live chat sessions. When experiencing symptoms of a mental health condition, it can sometimes be hard to leave home for therapy. You can use many online therapy platforms from the comfort and safe space of your own home. 

Therapy is a personal experience; not everyone will go into it seeking the same outcomes. Keeping this in mind may ensure you get the most out of online therapy, regardless of your specific goals. If you're interested in learning more about the effectiveness of online therapy, you can look into various clinical studies that have shown it can be as effective, if not more effective, than in-person options. 

BetterHelp therapist reviews

“Amanda provides an excellent balance of warmth, accountability, and reliability. She keeps you on-topic while actively listening and providing guidance as needed. Her credentials and expertise are well applied to our sessions and I am so grateful for her.”

“She’s been amazing, helped me process my feelings and work on the things I needed to heal to grow stronger and be content with my life. She was available every day, I managed to connect with her deeply, she was supportive. I never expected to meet someone who’d have such a big positive effect on my life. I want to continue my journey with her and I trust the lessons I’ve learned from her will continue to be useful for my present and future.”

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A Study Of Social Anxiety And Perceived Social Support

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

Learn about our Editorial Process

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

Social anxiety , a common mental health concern, can be greatly influenced by an individual’s perceived social support. Those with strong, supportive relationships often report lower levels of social anxiety, as they feel more secure and accepted in social situations. Conversely, individuals who lack a robust support system may experience heightened anxiety due to feelings of isolation and fear of negative evaluation. Developing social skills and building a reliable support network can be crucial for managing social anxiety . Improving communication abilities, assertiveness, and emotional expression can help individuals navigate social interactions more confidently and effectively. Moreover, having trusted friends, family members, or a therapist to provide encouragement, validation, and a safe space to practice social skills can be invaluable in reducing anxiety and fostering a sense of belonging.

• Social anxiety is associated with lower perceived social support among both men and women.
• Communication styles mediate the relationship between social anxiety and perceived social support, but the specific communication styles involved differ by gender.
• For both men and women, lower expressiveness explains some of the link between social anxiety and lower perceived social support.
• For men, lower preciseness also mediates the relationship between social anxiety and perceived social support. For women, lower verbal aggressiveness and higher emotionality play mediating roles.
• The study has limitations like using self-report measures and a predominantly female college student sample, but provides insights into how socially anxious individuals may be able to increase perceived social support through modifying communication styles.

Social anxiety is one of the most common anxiety disorders (Kessler et al., 2012) and has been linked to lower perceived social support (Calsyn et al., 2005; Davidson et al., 1994; Torgrud et al., 2004).

While the size of one’s social network influences perceived social support, other factors like satisfaction with available support matter more (Sarason et al., 1983).

Among women in relationships, self-disclosure helps explain the social anxiety-perceived support link (Cuming & Rapee, 2010), suggesting interpersonal communication plays a role.

However, more research is needed on how communication styles impact the relationship between social anxiety and perceived support, and potential gender differences.

Previous studies found socially anxious individuals are less emotionally expressive and assertive (Davila & Beck, 2002; Turk et al., 2005).

Gender differences also exist in social anxiety, communication, and social support. Women have higher rates of social anxiety (Asher et al., 2017) and are more expressive and polite, while men are more assertive and verbally aggressive (Basow & Rubenfeld, 2003).

Women tend to provide, receive (Neff & Karney, 2005), and perceive more social support than men (Kendler et al., 2005).

Building on this research, the current study examined six communication styles as mediators between social anxiety and perceived social support among men and women.

Understanding these relationships could inform interventions to help socially anxious individuals harness communication skills to increase perceived support.

This study explored relationships between social anxiety, perceived social support, and six communication styles (expressiveness, preciseness, verbal aggressiveness, questioningness, emotionality, and impression manipulativeness) among college students.

It also examined gender differences in these variables and whether communication styles mediated the link between social anxiety and perceived social support differently for men and women.

Participants completed an online survey with measures of social anxiety, communication styles, and perceived social support. The order of the measures was randomized.

813 psychology students (233 men, 580 women) at a large southern U.S. university participated. They ranged in age from 18-30 (M=20.56 years).

The sample was 52.8% White, 16.5% Black, 19.7% Hispanic, 8% Asian, and 3.1% other ethnicities.

• Social Interaction Anxiety Scale-6 (SIAS-6) & Social Phobia Scale-6 (SPS-6): 12 items total measuring social anxiety on a 5-point scale. The SIAS-6 assesses anxiety related to social interactions, while the SPS-6 measures fear of being scrutinized during routine activities.
• Communication Styles Inventory (CSI): 96 items assessing 6 communication domains (expressiveness, preciseness, verbal aggressiveness, questioningness, emotionality, and impression manipulativeness) on a 5-point scale. Each domain consists of 4 facets measuring specific aspects of that communication style.
• Multidimensional Scale of Perceived Social Support (MSPSS): 12 items measuring perceived support from family, friends, and significant others on a 7-point scale. The scale provides a subjective assessment of the adequacy of social support from these three sources.

Statistical Analysis

Descriptive statistics, bivariate correlations, and independent t-tests compared men and women.

Multiple mediation models using PROCESS tested communication styles as mediators between social anxiety and perceived support, separately for men and women.

As hypothesized, social anxiety was associated with lower perceived social support (H1).

For both genders, social anxiety was related to lower perceived support through lower expressiveness (H2).

Social anxiety was linked to lower support through higher emotionality for women only (H3).

The mediating communication styles differed by gender:

• For men, social anxiety was associated with lower support through lower preciseness.
• For women, social anxiety was linked to lower support through lower verbal aggressiveness and higher emotionality.

This study highlights that the way socially anxious individuals communicate influences their perceptions of available support.

While prior research found self-disclosure impacted the social anxiety-perceived support link just for women (Cuming & Rapee, 2010), the current study showed that for both genders, being less expressive and contributing less to conversations explained some of the relationship.

The gender-specific mediators align with research on gender norms in communication. For men, conveying ideas precisely and substantively seems important for feeling supported and fitting masculine norms around clear, outcome-focused communication (Mulac et al., 2001).

For women, lower verbal aggressiveness or a lack of assertiveness to marshal support when needed mediated the link, perhaps reflecting expectations for women to be less direct (Palomares, 2009).

Higher emotionality also played a role for women, suggesting that socially anxious women feel their sensitivity and emotional expressiveness could burden others and reduce support.

This study extends prior work by revealing communication styles as a mechanism linking social anxiety and perceived support. It suggests socially anxious individuals could benefit from interventions targeting communication skills to bolster confidence in their ability to garner support.

Future research could incorporate third-party observations of communication and longitudinal designs to clarify causal relationships.

This study had several strengths, including:

• Explored an understudied mechanism (communication styles) in the link between social anxiety and perceived social support
• Examined gender differences
• Used well-validated measures
• Tested multiple mediators simultaneously
• Large sample size (N=813)

Limitations

This study also had several limitations, including:

• Cross-sectional design prevents conclusions about directionality and causality
• Predominantly female sample limits generalizability
• Self-report measures introduce potential for bias; no behavioral observations of communication
• College student sample may not generalize to broader population

Implications

The findings suggest that psychotherapy for social anxiety could incorporate communication skills training to help individuals develop tools to increase their perception of social support.

Increasing expressiveness may benefit both men and women. However, clinicians may need to tailor interventions by gender, for example helping men communicate ideas clearly and succinctly, assisting women with healthy assertiveness, and normalizing emotionality.

With social anxiety one of the most prevalent disorders, better understanding its interpersonal effects and the role of communication could substantially improve sufferers’ relational experiences and mental health.

However, more research in representative samples using observational methods is needed to establish causal links and inform interventions.

Primary reference

Barnett, M. D., Maciel, I. V., Johnson, D. M., & Ciepluch, I. (2021). Social anxiety and perceived social support: Gender differences and the mediating role of communication styles.  Psychological Reports ,  124 (1), 70-87. https://doi.org/10.1177/0033294119900975

Other references

Asher, M., Asnaani, A., & Aderka, I. M. (2017). Gender differences in social anxiety disorder: A review.  Clinical psychology review ,  56 , 1-12. https://doi.org/10.1016/j.cpr.2017.05.004

Calsyn, R. J., Winter, J. P., & Burger, G. K. (2005). The relationship between social anxiety and social support in adolescents: A test of competing causal models.  Adolescence ,  40 (157), 103.

Cuming, S., & Rapee, R. M. (2010). Social anxiety and self-protective communication style in close relationships.  Behaviour Research and Therapy ,  48 (2), 87-96. https://doi.org/10.1016/j.brat.2009.09.010

Davila, J., & Beck, J. G. (2002). Is social anxiety associated with impairment in close relationships? A preliminary investigation.  Behavior Therapy ,  33 (3), 427-446. https://doi.org/10.1016/S0005-7894(02)80037-5

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Keep Learning

Here are some potential discussion questions for a college class on this paper:

• How might cultural norms and values impact the relationships between social anxiety, communication styles, and perceived social support? What cultural factors would be important to consider in future research?
• What are some specific ways psychotherapy could help socially anxious individuals modify their communication to increase perceived social support? What role could assertiveness training, expressive writing, or role-playing conversations play?
• If you were designing a longitudinal study to clarify the causal links between social anxiety, communication, and perceived support, what variables would you measure at each timepoint? What would be the ideal time lag between assessments?
• The current study found that emotionality was linked to lower perceived support for socially anxious women. However, could there be contexts where emotional expressiveness helps elicit support? What factors might moderate this relationship?
• How might the increasing prevalence of digital communication impact the relationships explored in this study? Would you expect communication styles to play a smaller or larger role in linking social anxiety to perceived support in online interactions compared to face-to-face?

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• Open access
• Published: 16 May 2024

Procrastination, depression and anxiety symptoms in university students: a three-wave longitudinal study on the mediating role of perceived stress

• Anna Jochmann 1 ,
• Burkhard Gusy 1 ,
• Tino Lesener 1 &
• Christine Wolter 1  

BMC Psychology volume  12 , Article number:  276 ( 2024 ) Cite this article

Metrics details

It is generally assumed that procrastination leads to negative consequences. However, evidence for negative consequences of procrastination is still limited and it is also unclear by which mechanisms they are mediated. Therefore, the aim of our study was to examine the harmful consequences of procrastination on students’ stress and mental health. We selected the procrastination-health model as our theoretical foundation and tried to evaluate the model’s assumption that trait procrastination leads to (chronic) disease via (chronic) stress in a temporal perspective. We chose depression and anxiety symptoms as indicators for (chronic) disease and hypothesized that procrastination leads to perceived stress over time, that perceived stress leads to depression and anxiety symptoms over time, and that procrastination leads to depression and anxiety symptoms over time, mediated by perceived stress.

To examine these relationships properly, we collected longitudinal data from 392 university students at three occasions over a one-year period and analyzed the data using autoregressive time-lagged panel models.

Procrastination did lead to depression and anxiety symptoms over time. However, perceived stress was not a mediator of this effect. Procrastination did not lead to perceived stress over time, nor did perceived stress lead to depression and anxiety symptoms over time.

Conclusions

We could not confirm that trait procrastination leads to (chronic) disease via (chronic) stress, as assumed in the procrastination-health model. Nonetheless, our study demonstrated that procrastination can have a detrimental effect on mental health. Further health outcomes and possible mediators should be explored in future studies.

Peer Review reports

Introduction

“Due tomorrow? Do tomorrow.”, might be said by someone who has a tendency to postpone tasks until the last minute. But can we enjoy today knowing about the unfinished task and tomorrow’s deadline? Or do we feel guilty for postponing a task yet again? Do we get stressed out because we have little time left to complete it? Almost everyone has procrastinated at some point when it came to completing unpleasant tasks, such as mowing the lawn, doing the taxes, or preparing for exams. Some tend to procrastinate more frequently and in all areas of life, while others are less inclined to do so. Procrastination is common across a wide range of nationalities, as well as socioeconomic and educational backgrounds [ 1 ]. Over the last fifteen years, there has been a massive increase in research on procrastination [ 2 ]. Oftentimes, research focuses on better understanding the phenomenon of procrastination and finding out why someone procrastinates in order to be able to intervene. Similarly, the internet is filled with self-help guides that promise a way to overcome procrastination. But why do people seek help for their procrastination? Until now, not much research has been conducted on the negative consequences procrastination could have on health and well-being. Therefore, in the following article we examine the effect of procrastination on mental health over time and stress as a possible facilitator of this relationship on the basis of the procrastination-health model by Sirois et al. [ 3 ].

Procrastination and its negative consequences

Procrastination can be defined as the tendency to voluntarily and irrationally delay intended activities despite expecting negative consequences as a result of the delay [ 4 , 5 ]. It has been observed in a variety of groups across the lifespan, such as students, teachers, and workers [ 1 ]. For example, some students tend to regularly delay preparing for exams and writing essays until the last minute, even if this results in time pressure or lower grades. Procrastination must be distinguished from strategic delay [ 4 , 6 ]. Delaying a task is considered strategic when other tasks are more important or when more resources are needed before the task can be completed. While strategic delay is viewed as functional and adaptive, procrastination is classified as dysfunctional. Procrastination is predominantly viewed as the result of a self-regulatory failure [ 7 ]. It can be understood as a trait, that is, as a cross-situational and time-stable behavioral disposition [ 8 ]. Thus, it is assumed that procrastinators chronically delay tasks that they experience as unpleasant or difficult [ 9 ]. Approximately 20 to 30% of adults have been found to procrastinate chronically [ 10 , 11 , 12 ]. Prevalence estimates for students are similar [ 13 ]. It is believed that students do not procrastinate more often than other groups. However, it is easy to examine procrastination in students because working on study tasks requires a high degree of self-organization and time management [ 14 ].

It is generally assumed that procrastination leads to negative consequences [ 4 ]. Negative consequences are even part of the definition of procrastination. Research indicates that procrastination is linked to lower academic performance [ 15 ], health impairment (e.g., stress [ 16 ], physical symptoms [ 17 ], depression and anxiety symptoms [ 18 ]), and poor health-related behavior (e.g., heavier alcohol consumption [ 19 ]). However, most studies targeting consequences of procrastination are cross-sectional [ 4 ]. For that reason, it often remains unclear whether an examined outcome is a consequence or an antecedent of procrastination, or whether a reciprocal relationship between procrastination and the examined outcome can be assumed. Additionally, regarding negative consequences of procrastination on health, it is still largely unknown by which mechanisms they are mediated. Uncovering such mediators would be helpful in developing interventions that can prevent negative health consequences of procrastination.

The procrastination-health model

The first and only model that exclusively focuses on the effect of procrastination on health and the mediators of this effect is the procrastination-health model [ 3 , 9 , 17 ]. Sirois [ 9 ] postulates three pathways: An immediate effect of trait procrastination on (chronic) disease and two mediated pathways (see Fig.  1 ).

Adopted from the procrastination-health model by Sirois [ 9 ]

The immediate effect is not further explained. Research suggests that procrastination creates negative feelings, such as shame, guilt, regret, and anger [ 20 , 21 , 22 ]. The described feelings could have a detrimental effect on mental health [ 23 , 24 , 25 ].

The first mediated pathway leads from trait procrastination to (chronic) disease via (chronic) stress. Sirois [ 9 ] assumes that procrastination creates stress because procrastinators are constantly aware of the fact that they still have many tasks to complete. Stress activates the hypothalamic-pituitary-adrenocortical (HPA) system, increases autonomic nervous system arousal, and weakens the immune system, which in turn contributes to the development of diseases. Sirois [ 9 ] distinguishes between short-term and long-term effects of procrastination on health mediated by stress. She believes that, in the short term, single incidents of procrastination cause acute stress, which leads to acute health problems, such as infections or headaches. In the long term, chronic procrastination, as you would expect with trait procrastination, causes chronic stress, which leads to chronic diseases over time. There is some evidence in support of the stress-related pathway, particularly regarding short-term effects [ 3 , 17 , 26 , 27 , 28 ]. However, as we mentioned above, most of these studies are cross-sectional. Therefore, the causal direction of these effects remains unclear. To our knowledge, long-term effects of trait procrastination on (chronic) disease mediated by (chronic) stress have not yet been investigated.

The second mediated pathway leads from trait procrastination to (chronic) disease via poor health-related behavior. According to Sirois [ 9 ], procrastinators form lower intentions to carry out health-promoting behavior or to refrain from health-damaging behavior because they have a low self-efficacy of being able to care for their own health. In addition, they lack the far-sighted view that the effects of health-related behavior only become apparent in the long term. For the same reason, Sirois [ 9 ] believes that there are no short-term, but only long-term effects of procrastination on health mediated by poor health-related behavior. For example, an unhealthy diet leads to diabetes over time. The findings of studies examining the behavioral pathway are inconclusive [ 3 , 17 , 26 , 28 ]. Furthermore, since most of these studies are cross-sectional, they are not suitable for uncovering long-term effects of trait procrastination on (chronic) disease mediated by poor health-related behavior.

In summary, previous research on the two mediated pathways of the procrastination-health model mainly found support for the role of (chronic) stress in the relationship between trait procrastination and (chronic) disease. However, only short-term effects have been investigated so far. Moreover, longitudinal studies are needed to be able to assess the causal direction of the relationship between trait procrastination, (chronic) stress, and (chronic) disease. Consequently, our study is the first to examine long-term effects of trait procrastination on (chronic) disease mediated by (chronic) stress, using a longitudinal design. (Chronic) disease could be measured by a variety of different indicators (e.g., physical symptoms, diabetes, or coronary heart disease). We choose depression and anxiety symptoms as indicators for (chronic) disease because they signal mental health complaints before they manifest as (chronic) diseases. Additionally, depression and anxiety symptoms are two of the most common mental health complaints among students [ 29 , 30 ] and procrastination has been shown to be a significant predictor of depression and anxiety symptoms [ 18 , 31 , 32 , 33 , 34 ]. Until now, the stress-related pathway of the procrastination-health model with depression and anxiety symptoms as the health outcome has only been analyzed in one cross-sectional study that confirmed the predictions of the model [ 35 ].

The aim of our study is to evaluate some of the key assumptions of the procrastination-health model, particularly the relationships between trait procrastination, (chronic) stress, and (chronic) disease over time, surveyed in the following analysis using depression and anxiety symptoms.

In line with the key assumptions of the procrastination-health model, we postulate (see Fig.  2 ):

Procrastination leads to perceived stress over time.

Perceived stress leads to depression and anxiety symptoms over time.

Procrastination leads to depression and anxiety symptoms over time, mediated by perceived stress.

The section of the procrastination-health model we examined

Materials and methods

Our study was part of a health monitoring at a large German university Footnote 1 . Ethical approval for our study was granted by the Ethics Committee of the university’s Department of Education and Psychology. We collected the initial data in 2019. Two occasions followed, each at an interval of six months. In January 2019, we sent out 33,267 invitations to student e-mail addresses. Before beginning the survey, students provided their written informed consent to participate in our study. 3,420 students took part at the first occasion (T1; 10% response rate). Of these, 862 participated at the second (T2) and 392 at the third occasion (T3). In order to test whether dropout was selective, we compared sociodemographic and study specific characteristics (age, gender, academic semester, number of assessments/exams) as well as behavior and health-related variables (procrastination, perceived stress, depression and anxiety symptoms) between the participants of the first wave ( n  = 3,420) and those who participated three times ( n  = 392). Results from independent-samples t-tests and chi-square analysis showed no significant differences regarding sociodemographic and study specific characteristics (see Additional file 1: Table S1 and S2 ). Regarding behavior and health-related variables, independent-samples t-tests revealed a significant difference in procrastination between the two groups ( t (3,409) = 2.08, p  < .05). The mean score of procrastination was lower in the group that participated in all three waves.

The mean age of the longitudinal respondents was 24.1 years ( SD  = 5.5 years), the youngest participants were 17 years old, the oldest one was 59 years old. The majority of participants was female (74.0%), 7 participants identified neither as male nor as female (1.8%). The respondents were on average enrolled in the third year of studying ( M  = 3.9; SD  = 2.3). On average, the students worked about 31.2 h ( SD  = 14.1) per week for their studies, and an additional 8.5 h ( SD  = 8.5) for their (part-time) jobs. The average income was €851 ( SD  = 406), and 4.9% of the students had at least one child. The students were mostly enrolled in philosophy and humanities (16.5%), education and psychology (15.8%), biology, chemistry, and pharmacy (12.5%), political and social sciences (10.6%), veterinary medicine (8.9%), and mathematics and computer science (7.7%).

We only used established and well evaluated instruments for our analyses.

• Procrastination

We adopted the short form of the Procrastination Questionnaire for Students (PFS-4) [ 36 ] to measure procrastination. The PFS-4 assesses procrastination at university as a largely stable behavioral disposition across situations, that is, as a trait. The questionnaire consists of four items (e.g., I put off starting tasks until the last moment.). Each item was rated on a 5-point scale ((almost) never = 1 to (almost) always = 5) for the last two weeks. All items were averaged, with higher scores indicating a greater tendency to procrastinate. The PFS-4 has been proven to be reliable and valid, showing very high correlations with other established trait procrastination scales, for example, with the German short form of the General Procrastination Scale [ 37 , 38 ]. We also proved the scale to be one-dimensional in a factor analysis, with a Cronbach’s alpha of 0.90.

Perceived stress

The Heidelberger Stress Index (HEI-STRESS) [ 39 ] is a three-item measure of current perceived stress due to studying as well as in life in general. For the first item, respondents enter a number between 0 (not stressed at all) and 100 (completely stressed) to indicate how stressed their studies have made them feel over the last four weeks. For the second and third item, respondents rate on a 5-point scale how often they feel “stressed and tense” and as how stressful they would describe their life at the moment. We transformed the second and third item to match the range of the first item before we averaged all items into a single score with higher values indicating greater perceived stress. We proved the scale to be one-dimensional and Cronbach’s alpha for our study was 0.86.

Depression and anxiety symptoms

We used the Patient Health Questionnaire-4 (PHQ-4) [ 40 ], a short form of the Patient Health Questionnaire [ 41 ] with four items, to measure depression and anxiety symptoms. The PHQ-4 contains two items from the Patient Health Questionnaire-2 (PHQ-2) [ 42 ] and the Generalized Anxiety Disorder Scale-2 (GAD-2) [ 43 ], respectively. It is a well-established screening scale designed to assess the core criteria of major depressive disorder (PHQ-2) and generalized anxiety disorder (GAD-2) according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). However, it was shown that the GAD-2 is also appropriate for screening other anxiety disorders. According to Kroenke et al. [ 40 ], the PHQ-4 can be used to assess a person’s symptom burden and impairment. We asked the participants to rate how often they have been bothered over the last two weeks by problems, such as “Little interest or pleasure in doing things”. Response options were 0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day. Calculated as the sum of the four items, the total scores range from 0 to 12 with higher scores indicating more frequent depression and anxiety symptoms. The total scores can be categorized as none-to-minimal (0–2), mild (3–5), moderate (6–8), and severe (9–12) depression and anxiety symptoms. The PHQ-4 was shown to be reliable and valid [ 40 , 44 , 45 ]. We also proved the scale to be one-dimensional in a factor analysis, with a Cronbach’s alpha of 0.86.

Data analysis

To test our hypotheses, we performed structural equation modelling (SEM) using R (Version 4.1.1) with the package lavaan. All items were standardized ( M  = 0, SD  = 1). Due to the non-normality of some study variables and a sufficiently large sample size of N near to 400 [ 46 ], we used robust maximum likelihood estimation (MLR) for all model estimations. As recommended by Hu and Bentler [ 47 ], we assessed the models’ goodness of fit by chi-square test statistic, root mean square error of approximation (RMSEA), standardized root mean square residual (SRMR), Tucker-Lewis index (TLI), and comparative fit index (CFI). A non-significant chi-square indicates good model fit. Since chi-square is sensitive to sample size, we also evaluated fit indices less sensitive to the number of observations. RMSEA and SRMR values of 0.05 or lower as well as TLI and CFI values of 0.97 or higher indicate good model fit. RMSEA values of 0.08 or lower, SRMR values of 0.10 or lower, as well as TLI and CFI values of 0.95 or higher indicate acceptable model fit [ 48 , 49 ]. First, we conducted confirmatory factor analysis for the first occasion, defining three factors that correspond to the measures of procrastination, perceived stress, and depression and anxiety symptoms. Next, we tested for measurements invariance over time and specified the measurement model, before testing our hypotheses.

Measurement invariance over time

To test for measurement invariance over time, we defined one latent variable for each of the three occasions, corresponding to the measures of procrastination, perceived stress, and depression and anxiety symptoms, respectively. As recommended by Geiser and colleagues [ 50 ], the links between indicators and factors (i.e., factor loadings and intercepts) should be equal over measurement occasions; therefore, we added indicator specific factors. A first and least stringent step of testing measurement invariance is configural invariance (M CI ). It was examined whether the included constructs (procrastination, perceived stress, depression and anxiety symptoms) have the same pattern of free and fixed loadings over time. This means that the assignment of the indicators to the three latent factors over time is supported by the underlying data. If configural invariance was supported, restrictions for the next step of testing measurement invariance (metric or weak invariance; M MI ) were added. This means that each item contributes to the latent construct to a similar degree over time. Metric invariance was tested by constraining the factor loadings of the constructs over time. The next step of testing measurement invariance (scalar or strong invariance; M SI ) consisted of checking whether mean differences in the latent construct capture all mean differences in the shared variance of the items. Scalar invariance was tested by constraining the item intercepts over time. The constraints applied in the metric invariance model were retained [ 51 ]. For the last step of testing measurement invariance (residual or strict invariance; M RI ), the residual variables were also set equal over time. If residual invariance is supported, differences in the observed variables can exclusively be attributed to differences in the variances of the latent variables.

We used the Satorra-Bentler chi-square difference test to evaluate the superiority of a more stringent model [ 52 ]. We assumed the model with the largest number of invariance restrictions – which still has an acceptable fit and no substantial deterioration of the chi-square value – to be the final model [ 53 ]. Following previous recommendations, we considered a decrease in CFI of 0.01 and an increase in RMSEA of 0.015 as unacceptable to establish measurement invariance [ 54 ]. If a more stringent model had a significant worse chi-square value, but the model fit was still acceptable and the deterioration in model fit fell within the change criteria recommended for CFI and RMSEA values, we still considered the more stringent model to be superior.

Hypotheses testing

As recommended by Dormann et al. [ 55 ], we applied autoregressive time-lagged panel models to test our hypotheses. In the first step, we specified a model (M 0 ) that only included the stabilities of the three variables (procrastination, perceived stress, depression and anxiety symptoms) over time. In the next step (M 1 ), we added the time-lagged effects from procrastination (T1) to perceived stress (T2) and from procrastination (T2) to perceived stress (T3) as well as from perceived stress (T1) to depression and anxiety symptoms (T2) and from perceived stress (T2) to depression and anxiety symptoms (T3). Additionally, we included a direct path from procrastination (T1) to depression and anxiety symptoms (T3). If this path becomes significant, we can assume a partial mediation [ 55 ]. Otherwise, we can assume a full mediation. We compared these nested models using the Satorra-Bentler chi-square difference test and the Akaike information criterion (AIC). The chi-square difference value should either be non-significant, indicating that the proposed model including our hypotheses (M 1 ) does not have a significant worse model fit than the model including only stabilities (M 0 ), or, if significant, it should be in the direction that M 1 fits the data better than M 0 . Regarding the AIC, M 1 should have a lower value than M 0 .

Table  1 displays the means, standard deviations, internal consistencies (Cronbach’s alpha), and stabilities (correlations) of all study variables. The alpha values of procrastination, perceived stress, and depression and anxiety symptoms are classified as good (> 0.80) [ 56 ]. The correlation matrix of the manifest variables used for the analyses can be found in the Additional file 1: Table  S3 .

We observed the highest test-retest reliabilities for procrastination ( r  ≥ .74). The test-retest reliabilities for depression and anxiety symptoms ( r  ≥ .64) and for perceived stress ( r  ≥ .54) were a bit lower (see Table  1 ). The pattern of correlations shows a medium to large but positive relationship between procrastination and depression and anxiety symptoms [ 57 , 58 ]. The association between procrastination and perceived stress was small, the one between perceived stress and depression and anxiety symptoms very large (see Table  1 ).

Confirmatory factor analysis showed an acceptable to good fit (x 2 (41) = 118.618, p  < .001; SRMR = 0.042; RMSEA = 0.071; TLI = 0.95; CFI = 0.97). When testing for measurement invariance over time for each construct, the residual invariance models with indicator specific factors provided good fit to the data (M RI ; see Table  2 ), suggesting that differences in the observed variables can exclusively be attributed to differences of the latent variables. We then specified and tested the measurement model of the latent constructs prior to model testing based on the items of procrastination, perceived stress, and depression and anxiety symptoms. The measurement model fitted the data well (M M ; see Table  3 ). All items loaded solidly on their respective factors (0.791 ≤ β ≤ 0.987; p  < .001).

To test our hypotheses, we analyzed the two models described in the methods section.

The fit of the stability model (M 0 ) was acceptable (see Table  3 ). Procrastination was stable over time, with stabilities above 0.82. The stabilities of perceived stress as well as depression and anxiety symptoms were somewhat lower, ranging from 0.559 (T1 -> T2) to 0.696 (T2 -> T3) for perceived stress and from 0.713 (T2 -> T3) to 0.770 (T1 -> T2) for depression and anxiety symptoms, respectively.

The autoregressive mediation model (M 1 ) fitted the data significantly better than M 0 . The direct path from procrastination (T1) to depression and anxiety symptoms (T3) was significant (β = 0.16; p  < .001), however, none of the mediated paths (from procrastination (T1) to perceived stress (T2) and from perceived stress (T2) to depression and anxiety symptoms (T3)) proved to be substantial. Also, the time-lagged paths from perceived stress (T1) to depression and anxiety symptoms (T2) and from procrastination (T2) to perceived stress (T3) were not substantial either (see Fig.  3 ).

To examine whether the hypothesized effects would occur over a one-year period rather than a six-months period, we specified an additional model with paths from procrastination (T1) to perceived stress (T3) and from perceived stress (T1) to depression and anxiety symptoms (T3), also including the stabilities of the three constructs as in the stability model M 0 . The model showed an acceptable fit (χ 2 (486) = 831.281, p  < .001; RMSEA = 0.048; SRMR = 0.091; TLI = 0.95; CFI = 0.95), but neither of the two paths were significant.

Therefore, our hypotheses, that procrastination leads to perceived stress over time (H1) and that perceived stress leads to depression and anxiety symptoms over time (H2) must be rejected. We could only partially confirm our third hypothesis, that procrastination leads to depression and anxiety over time, mediated by perceived stress (H3), since procrastination did lead to depression and anxiety symptoms over time. However, this effect was not mediated by perceived stress.

Results of the estimated model including all hypotheses (M 1 ). Note Non-significant paths are dotted. T1 = time 1; T2 = time 2; T3 = time 3. *** p  < .001

To sum up, we tried to examine the harmful consequences of procrastination on students’ stress and mental health. Hence, we selected the procrastination-health model by Sirois [ 9 ] as a theoretical foundation and tried to evaluate some of its key assumptions in a temporal perspective. The author assumes that trait procrastination leads to (chronic) disease via (chronic) stress. We chose depression and anxiety symptoms as indicators for (chronic) disease and postulated, in line with the key assumptions of the procrastination-health model, that procrastination leads to perceived stress over time (H1), that perceived stress leads to depression and anxiety symptoms over time (H2), and that procrastination leads to depression and anxiety symptoms over time, mediated by perceived stress (H3). To examine these relationships properly, we collected longitudinal data from students at three occasions over a one-year period and analyzed the data using autoregressive time-lagged panel models. Our first and second hypotheses had to be rejected: Procrastination did not lead to perceived stress over time, and perceived stress did not lead to depression and anxiety symptoms over time. However, procrastination did lead to depression and anxiety symptoms over time – which is in line with our third hypothesis – but perceived stress was not a mediator of this effect. Therefore, we could only partially confirm our third hypothesis.

Our results contradict previous studies on the stress-related pathway of the procrastination-health model, which consistently found support for the role of (chronic) stress in the relationship between trait procrastination and (chronic) disease. Since most of these studies were cross-sectional, though, the causal direction of these effects remained uncertain. There are two longitudinal studies that confirm the stress-related pathway of the procrastination-health model [ 27 , 28 ], but both studies examined short-term effects (≤ 3 months), whereas we focused on more long-term effects. Therefore, the divergent findings may indicate that there are short-term, but no long-term effects of trait procrastination on (chronic) disease mediated by (chronic) stress.

Our results especially raise the question whether trait procrastination leads to (chronic) stress in the long term. Looking at previous longitudinal studies on the effect of procrastination on stress, the following stands out: At shorter study periods of two weeks [ 27 ] and four weeks [ 28 ], the effect of procrastination on stress appears to be present. At longer study periods of seven weeks [ 59 ], three months [ 28 ], six months, and twelve months, as in our study, the effect of procrastination on stress does not appear to be present. There is one longitudinal study in which procrastination was a significant predictor of stress symptoms nine months later [ 34 ]. The results of this study should be interpreted with caution, though, because the outbreak of the COVID-19 pandemic fell within the study period, which could have contributed to increased stress symptoms [ 60 ]. Unfortunately, Johansson et al. [ 34 ] did not report whether average stress symptoms increased during their study. In one of the two studies conducted by Fincham and May [ 59 ], the COVID-19 pandemic outbreak also fell within their seven-week study period. However, they reported that in their study, average stress symptoms did not increase from baseline to follow-up. Taken together, the findings suggest that procrastination can cause acute stress in the short term, for example during times when many tasks need to be completed, such as at the end of a semester, but that procrastination does not lead to chronic stress over time. It seems possible that students are able to recover during the semester from the stress their procrastination caused at the end of the previous semester. Because of their procrastination, they may also have more time to engage in relaxing activities, which could further mitigate the effect of procrastination on stress. Our conclusions are supported by an early and well-known longitudinal study by Tice and Baumeister [ 61 ], which compared procrastinating and non-procrastinating students with regard to their health. They found that procrastinators experienced less stress than their non-procrastinating peers at the beginning of the semester, but more at the end of the semester. Additionally, our conclusions are in line with an interview study in which university students were asked about the consequences of their procrastination [ 62 ]. The students reported that, due to their procrastination, they experience high levels of stress during periods with heavy workloads (e.g., before deadlines or exams). However, the stress does not last, instead, it is relieved immediately after these periods.

Even though research indicates, in line with the assumptions of the procrastination-health model, that stress is a risk factor for physical and mental disorders [ 63 , 64 , 65 , 66 ], perceived stress did not have a significant effect on depression and anxiety symptoms in our study. The relationship between stress and mental health is complex, as people respond to stress in many different ways. While some develop stress-related mental disorders, others experience mild psychological symptoms or no symptoms at all [ 67 ]. This can be explained with the help of vulnerability-stress models. According to vulnerability-stress models, mental illnesses emerge from an interaction of vulnerabilities (e.g., genetic factors, difficult family backgrounds, or weak coping abilities) and stress (e.g., minor or major life events or daily hassles) [ 68 , 69 ]. The stress perceived by the students in our sample may not be sufficient enough on its own, without the presence of other risk factors, to cause depression and anxiety symptoms. However, since we did not assess individual vulnerability and stress factors in our study, these considerations are mere speculation.

In our study, procrastination led to depression and anxiety symptoms over time, which is consistent with the procrastination-health model as well as previous cross-sectional and longitudinal evidence [ 18 , 21 , 31 , 32 , 33 , 34 ]. However, it is still unclear by which mechanisms this effect is mediated, as perceived stress did not prove to be a substantial mediator in our study. One possible mechanism would be that procrastination impairs affective well-being [ 70 ] and creates negative feelings, such as shame, guilt, regret, and anger [ 20 , 21 , 22 , 62 , 71 ], which in turn could lead to depression and anxiety symptoms [ 23 , 24 , 25 ]. Other potential mediators of the relationship between procrastination and depression and anxiety symptoms emerge from the behavioral pathway of the procrastination-health model, suggesting that poor health-related behaviors mediate the effect of trait procrastination on (chronic) disease. Although evidence for this is still scarce, the results of one cross-sectional study, for example, indicate that poor sleep quality might mediate the effect of procrastination on depression and anxiety symptoms [ 35 ].

In summary, we found that procrastination leads to depression and anxiety symptoms over time and that perceived stress is not a mediator of this effect. We could not show that procrastination leads to perceived stress over time, nor that perceived stress leads to depression and anxiety symptoms over time. For the most part, the relationships between procrastination, perceived stress, and depression and anxiety symptoms did not match the relationships between trait procrastination, (chronic) stress, and (chronic) disease as assumed in the procrastination-health model. Explanations for this could be that procrastination might only lead to perceived stress in the short term, for example, during preparations for end-of-semester exams, and that perceived stress may not be sufficient enough on its own, without the presence of other risk factors, to cause depression and anxiety symptoms. In conclusion, we could not confirm long-term effects of trait procrastination on (chronic) disease mediated by (chronic) stress, as assumed for the stress-related pathway of the procrastination-health model.

Limitations and suggestions for future research

In our study, we tried to draw causal conclusions about the harmful consequences of procrastination on students’ stress and mental health. However, since procrastination is a trait that cannot be manipulated experimentally, we have conducted an observational rather than an experimental study, which makes causal inferences more difficult. Nonetheless, a major strength of our study is that we used a longitudinal design with three waves. This made it possible to draw conclusions about the causal direction of the effects, as in hardly any other study targeting consequences of procrastination on health before [ 4 , 28 , 55 ]. Therefore, we strongly recommend using a similar longitudinal design in future studies on the procrastination-health model or on consequences of procrastination on health in general.

We chose a time lag of six months between each of the three measurement occasions to examine long-term effects of procrastination on depression and anxiety symptoms mediated by perceived stress. However, more than six months may be necessary for the hypothesized effects to occur [ 72 ]. The fact that the temporal stabilities of the examined constructs were moderate or high (0.559 ≤ β ≤ 0.854) [ 73 , 74 ] also suggests that the time lags may have been too short. The larger the time lag, the lower the temporal stabilities, as shown for depression and anxiety symptoms, for example [ 75 ]. High temporal stabilities make it more difficult to detect an effect that actually exists [ 76 ]. Nonetheless, Dormann and Griffin [ 77 ] recommend using shorter time lags of less than one year, even with high stabilities, because of other influential factors, such as unmeasured third variables. Therefore, our time lags of six months seem appropriate.

It should be discussed, though, whether it is possible to detect long-term effects of the stress-related pathway of the procrastination-health model within a total study period of one year. Sirois [ 9 ] distinguishes between short-term and long-term effects of procrastination on health mediated by stress, but does not address how long it might take for long-term effects to occur or when effects can be considered long-term instead of short-term. The fact that an effect of procrastination on stress is evident at shorter study periods of four weeks or less but in most cases not at longer study periods of seven weeks or more, as we mentioned earlier, could indicate that short-term effects occur within the time frame of one to three months, considering the entire stress-related pathway. Hence, it seems appropriate to assume that we have examined rather long-term effects, given our study period of six and twelve months. Nevertheless, it would be beneficial to use varying study periods in future studies, in order to be able to determine when effects can be considered long-term.

Concerning long-term effects of the stress-related pathway, Sirois [ 9 ] assumes that chronic procrastination causes chronic stress, which leads to chronic diseases over time. The term “chronic stress” refers to prolonged stress episodes associated with permanent tension. The instrument we used captures perceived stress over the last four weeks. Even though the perceived stress of the students in our sample was relatively stable (0.559 ≤ β ≤ 0.696), we do not know how much fluctuation occurred between each of the three occasions. However, there is some evidence suggesting that perceived stress is strongly associated with chronic stress [ 78 ]. Thus, it seems acceptable that we used perceived stress as an indicator for chronic stress in our study. For future studies, we still suggest the use of an instrument that can more accurately reflect chronic stress, for example, the Trier Inventory for Chronic Stress (TICS) [ 79 ].

It is also possible that the occasions were inconveniently chosen, as they all took place in a critical academic period near the end of the semester, just before the examination period began. We chose a similar period in the semester for each occasion for the sake of comparability. However, it is possible that, during this preparation periods, stress levels peaked and procrastinators procrastinated less because they had to catch up after delaying their work. This could have introduced bias to the data. Therefore, in future studies, investigation periods should be chosen that are closer to the beginning or in the middle of a semester.

Furthermore, Sirois [ 9 ] did not really explain her understanding of “chronic disease”. However, it seems clear that physical illnesses, such as diabetes or cardiovascular diseases, are meant. Depression and anxiety symptoms, which we chose as indicators for chronic disease, represent mental health complaints that do not have to be at the level of a major depressive disorder or an anxiety disorder, in terms of their quantity, intensity, or duration [ 40 ]. But they can be viewed as precursors to a major depressive disorder or an anxiety disorder. Therefore, given our study period of one year, it seems appropriate to use depression and anxiety symptoms as indicators for chronic disease. At longer study periods, we would expect these mental health complaints to manifest as mental disorders. Moreover, the procrastination-health model was originally designed to be applied to physical diseases [ 3 ]. Perhaps, the model assumptions are more applicable to physical diseases than to mental disorders. By applying parts of the model to mental health complaints, we have taken an important step towards finding out whether the model is applicable to mental disorders as well. Future studies should examine additional long-term health outcomes, both physical and psychological. This would help to determine whether trait procrastination has varying effects on different diseases over time. Furthermore, we suggest including individual vulnerability and stress factors in future studies in order to be able to analyze the effect of (chronic) stress on (chronic) diseases in a more differentiated way.

Regarding our sample, 3,420 students took part at the first occasion, but only 392 participated three times, which results in a dropout rate of 88.5%. At the second and third occasion, invitation e-mails were only sent to participants who had indicated at the previous occasion that they would be willing to participate in a repeat survey and provided their e-mail address. This is probably one of the main reasons for our high dropout rate. Other reasons could be that the students did not receive any incentives for participating in our study and that some may have graduated between the occasions. Selective dropout analysis revealed that the mean score of procrastination was lower in the group that participated in all three waves ( n  = 392) compared to the group that participated in the first wave ( n  = 3,420). One reason for this could be that those who have a higher tendency to procrastinate were more likely to procrastinate on filling out our survey at the second and third occasion. The findings of our dropout analysis should be kept in mind when interpreting our results, as lower levels of procrastination may have eliminated an effect on perceived stress or on depression and anxiety symptoms. Additionally, across all age groups in population-representative samples, the student age group reports having the best subjective health [ 80 ]. Therefore, it is possible that they are more resilient to stress and experience less impairment of well-being than other age groups. Hence, we recommend that future studies focus on other age groups as well.

It is generally assumed that procrastination leads to lower academic performance, health impairment, and poor health-related behavior. However, evidence for negative consequences of procrastination is still limited and it is also unclear by which mechanisms they are mediated. In consequence, the aim of our study was to examine the effect of procrastination on mental health over time and stress as a possible facilitator of this relationship. We selected the procrastination-health model as a theoretical foundation and used the stress-related pathway of the model, assuming that trait procrastination leads to (chronic) disease via (chronic) stress. We chose depression and anxiety symptoms as indicators for (chronic) disease and collected longitudinal data from students at three occasions over a one-year period. This allowed us to draw conclusions about the causal direction of the effects, as in hardly any other study examining consequences of procrastination on (mental) health before. Our results indicate that procrastination leads to depression and anxiety symptoms over time and that perceived stress is not a mediator of this effect. We could not show that procrastination leads to perceived stress over time, nor that perceived stress leads to depression and anxiety symptoms over time. Explanations for this could be that procrastination might only lead to perceived stress in the short term, for example, during preparations for end-of-semester exams, and that perceived stress may not be sufficient on its own, that is, without the presence of other risk factors, to cause depression and anxiety symptoms. Overall, we could not confirm long-term effects of trait procrastination on (chronic) disease mediated by (chronic) stress, as assumed for the stress-related pathway of the procrastination-health model. Our study emphasizes the importance of identifying the consequences procrastination can have on health and well-being and determining by which mechanisms they are mediated. Only then will it be possible to develop interventions that can prevent negative health consequences of procrastination. Further health outcomes and possible mediators should be explored in future studies, using a similar longitudinal design.

Data availability

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

University Health Report at Freie Universität Berlin.

Abbreviations

Comparative fit index

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

Generalized Anxiety Disorder Scale-2

Heidelberger Stress Index

Hypothalamic-pituitary-adrenocortical

Robust maximum likelihood estimation

Short form of the Procrastination Questionnaire for Students

Patient Health Questionnaire-2

Patient Health Questionnaire-4

Root mean square error of approximation

Structural equation modeling

Standardized root mean square residual

Tucker-Lewis index

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Learning together for better health using an evidence-based Learning Health System framework: a case study in stroke

• Helena Teede 1 , 2   na1 ,
• Dominique A. Cadilhac 3 , 4   na1 ,
• Tara Purvis 3 ,
• Monique F. Kilkenny 3 , 4 ,
• Bruce C.V. Campbell 4 , 5 , 6 ,
• Coralie English 7 ,
• Alison Johnson 2 ,
• Emily Callander 1 ,
• Rohan S. Grimley 8 , 9 ,
• Christopher Levi 10 ,
• Sandy Middleton 11 , 12 ,
• Kelvin Hill 13 &
• Joanne Enticott   ORCID: orcid.org/0000-0002-4480-5690 1  

BMC Medicine volume  22 , Article number:  198 ( 2024 ) Cite this article

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In the context of expanding digital health tools, the health system is ready for Learning Health System (LHS) models. These models, with proper governance and stakeholder engagement, enable the integration of digital infrastructure to provide feedback to all relevant parties including clinicians and consumers on performance against best practice standards, as well as fostering innovation and aligning healthcare with patient needs. The LHS literature primarily includes opinion or consensus-based frameworks and lacks validation or evidence of benefit. Our aim was to outline a rigorously codesigned, evidence-based LHS framework and present a national case study of an LHS-aligned national stroke program that has delivered clinical benefit.

Current core components of a LHS involve capturing evidence from communities and stakeholders (quadrant 1), integrating evidence from research findings (quadrant 2), leveraging evidence from data and practice (quadrant 3), and generating evidence from implementation (quadrant 4) for iterative system-level improvement. The Australian Stroke program was selected as the case study as it provides an exemplar of how an iterative LHS works in practice at a national level encompassing and integrating evidence from all four LHS quadrants. Using this case study, we demonstrate how to apply evidence-based processes to healthcare improvement and embed real-world research for optimising healthcare improvement. We emphasize the transition from research as an endpoint, to research as an enabler and a solution for impact in healthcare improvement.

Conclusions

The Australian Stroke program has nationally improved stroke care since 2007, showcasing the value of integrated LHS-aligned approaches for tangible impact on outcomes. This LHS case study is a practical example for other health conditions and settings to follow suit.

Peer Review reports

Internationally, health systems are facing a crisis, driven by an ageing population, increasing complexity, multi-morbidity, rapidly advancing health technology and rising costs that threaten sustainability and mandate transformation and improvement [ 1 , 2 ]. Although research has generated solutions to healthcare challenges, and the advent of big data and digital health holds great promise, entrenched siloes and poor integration of knowledge generation, knowledge implementation and healthcare delivery between stakeholders, curtails momentum towards, and consistent attainment of, evidence-and value-based care [ 3 ]. This is compounded by the short supply of research and innovation leadership within the healthcare sector, and poorly integrated and often inaccessible health data systems, which have crippled the potential to deliver on digital-driven innovation [ 4 ]. Current approaches to healthcare improvement are also often isolated with limited sustainability, scale-up and impact [ 5 ].

Evidence suggests that integration and partnership across academic and healthcare delivery stakeholders are key to progress, including those with lived experience and their families (referred to here as consumers and community), diverse disciplines (both research and clinical), policy makers and funders. Utilization of evidence from research and evidence from practice including data from routine care, supported by implementation research, are key to sustainably embedding improvement and optimising health care and outcomes. A strategy to achieve this integration is through the Learning Health System (LHS) (Fig.  1 ) [ 2 , 6 , 7 , 8 ]. Although there are numerous publications on LHS approaches [ 9 , 10 , 11 , 12 ], many focus on research perspectives and data, most do not demonstrate tangible healthcare improvement or better health outcomes. [ 6 ]

Monash Learning Health System: The Learn Together for Better Health Framework developed by Monash Partners and Monash University (from Enticott et al. 2021 [ 7 ]). Four evidence quadrants: Q1 (orange) is evidence from stakeholders; Q2 (green) is evidence from research; Q3 (light blue) is evidence from data; and, Q4 (dark blue) is evidence from implementation and healthcare improvement

In developed nations, it has been estimated that 60% of care provided aligns with the evidence base, 30% is low value and 10% is potentially harmful [ 13 ]. In some areas, clinical advances have been rapid and research and evidence have paved the way for dramatic improvement in outcomes, mandating rapid implementation of evidence into healthcare (e.g. polio and COVID-19 vaccines). However, healthcare improvement is challenging and slow [ 5 ]. Health systems are highly complex in their design, networks and interacting components, and change is difficult to enact, sustain and scale up. [ 3 ] New effective strategies are needed to meet community needs and deliver evidence-based and value-based care, which reorients care from serving the provider, services and system, towards serving community needs, based on evidence and quality. It goes beyond cost to encompass patient and provider experience, quality care and outcomes, efficiency and sustainability [ 2 , 6 ].

The costs of stroke care are expected to rise rapidly in the next decades, unless improvements in stroke care to reduce the disabling effects of strokes can be successfully developed and implemented [ 14 ]. Here, we briefly describe the Monash LHS framework (Fig.  1 ) [ 2 , 6 , 7 ] and outline an exemplar case in order to demonstrate how to apply evidence-based processes to healthcare improvement and embed real-world research for optimising healthcare. The Australian LHS exemplar in stroke care has driven nationwide improvement in stroke care since 2007.

An evidence-based Learning Health System framework

In Australia, members of this author group (HT, AJ, JE) have rigorously co-developed an evidence-based LHS framework, known simply as the Monash LHS [ 7 ]. The Monash LHS was designed to support sustainable, iterative and continuous robust benefit of improved clinical outcomes. It was created with national engagement in order to be applicable to Australian settings. Through this rigorous approach, core LHS principles and components have been established (Fig.  1 ). Evidence shows that people/workforce, culture, standards, governance and resources were all key to an effective LHS [ 2 , 6 ]. Culture is vital including trust, transparency, partnership and co-design. Key processes include legally compliant data sharing, linkage and governance, resources, and infrastructure [ 4 ]. The Monash LHS integrates disparate and often siloed stakeholders, infrastructure and expertise to ‘Learn Together for Better Health’ [ 7 ] (Fig.  1 ). This integrates (i) evidence from community and stakeholders including priority areas and outcomes; (ii) evidence from research and guidelines; (iii) evidence from practice (from data) with advanced analytics and benchmarking; and (iv) evidence from implementation science and health economics. Importantly, it starts with the problem and priorities of key stakeholders including the community, health professionals and services and creates an iterative learning system to address these. The following case study was chosen as it is an exemplar of how a Monash LHS-aligned national stroke program has delivered clinical benefit.

Australian Stroke Learning Health System

Internationally, the application of LHS approaches in stroke has resulted in improved stroke care and outcomes [ 12 ]. For example, in Canada a sustained decrease in 30-day in-hospital mortality has been found commensurate with an increase in resources to establish the multifactorial stroke system intervention for stroke treatment and prevention [ 15 ]. Arguably, with rapid advances in evidence and in the context of an ageing population with high cost and care burden and substantive impacts on quality of life, stroke is an area with a need for rapid research translation into evidence-based and value-based healthcare improvement. However, a recent systematic review found that the existing literature had few comprehensive examples of LHS adoption [ 12 ]. Although healthcare improvement systems and approaches were described, less is known about patient-clinician and stakeholder engagement, governance and culture, or embedding of data informatics into everyday practice to inform and drive improvement [ 12 ]. For example, in a recent review of quality improvement collaborations, it was found that although clinical processes in stroke care are improved, their short-term nature means there is uncertainty about sustainability and impacts on patient outcomes [ 16 ]. Table  1 provides the main features of the Australian Stroke LHS based on the four core domains and eight elements of the Learning Together for Better Health Framework described in Fig.  1 . The features are further expanded on in the following sections.

Evidence from stakeholders (LHS quadrant 1, Fig.  1 )

Engagement, partners and priorities.

Within the stroke field, there have been various support mechanisms to facilitate an LHS approach including partnership and broad stakeholder engagement that includes clinical networks and policy makers from different jurisdictions. Since 2008, the Australian Stroke Coalition has been co-led by the Stroke Foundation, a charitable consumer advocacy organisation, and Stroke Society of Australasia a professional society with membership covering academics and multidisciplinary clinician networks, that are collectively working to improve stroke care ( https://australianstrokecoalition.org.au/ ). Surveys, focus groups and workshops have been used for identifying priorities from stakeholders. Recent agreed priorities have been to improve stroke care and strengthen the voice for stroke care at a national ( https://strokefoundation.org.au/ ) and international level ( https://www.world-stroke.org/news-and-blog/news/world-stroke-organization-tackle-gaps-in-access-to-quality-stroke-care ), as well as reduce duplication amongst stakeholders. This activity is built on a foundation and culture of research and innovation embedded within the stroke ‘community of practice’. Consumers, as people with lived experience of stroke are important members of the Australian Stroke Coalition, as well as representatives from different clinical colleges. Consumers also provide critical input to a range of LHS activities via the Stroke Foundation Consumer Council, Stroke Living Guidelines committees, and the Australian Stroke Clinical Registry (AuSCR) Steering Committee (described below).

Evidence from research (LHS quadrant 2, Fig.  1 )

Advancement of the evidence for stroke interventions and synthesis into clinical guidelines.

To implement best practice, it is crucial to distil the large volume of scientific and trial literature into actionable recommendations for clinicians to use in practice [ 24 ]. The first Australian clinical guidelines for acute stroke were produced in 2003 following the increasing evidence emerging for prevention interventions (e.g. carotid endarterectomy, blood pressure lowering), acute medical treatments (intravenous thrombolysis, aspirin within 48 h of ischemic stroke), and optimised hospital management (care in dedicated stroke units by a specialised and coordinated multidisciplinary team) [ 25 ]. Importantly, a number of the innovations were developed, researched and proven effective by key opinion leaders embedded in the Australian stroke care community. In 2005, the clinical guidelines for Stroke Rehabilitation and Recovery [ 26 ] were produced, with subsequent merged guidelines periodically updated. However, the traditional process of periodic guideline updates is challenging for end users when new research can render recommendations redundant and this lack of currency erodes stakeholder trust [ 27 ]. In response to this challenge the Stroke Foundation and Cochrane Australia entered a pioneering project to produce the first electronic ‘living’ guidelines globally [ 20 ]. Major shifts in the evidence for reperfusion therapies (e.g. extended time-window intravenous thrombolysis and endovascular clot retrieval), among other advances, were able to be converted into new recommendations, approved by the Australian National Health and Medical Research Council within a few months of publication. Feedback on this process confirmed the increased use and trust in the guidelines by clinicians. The process informed other living guidelines programs, including the successful COVID-19 clinical guidelines [ 28 ].

However, best practice clinical guideline recommendations are necessary but insufficient for healthcare improvement and nesting these within an LHS with stakeholder partnership, enables implementation via a range of proven methods, including audit and feedback strategies [ 29 ].

Evidence from data and practice (LHS quadrant 3, Fig.  1 )

Data systems and benchmarking : revealing the disparities in care between health services. A national system for standardized stroke data collection was established as the National Stroke Audit program in 2007 by the Stroke Foundation [ 30 ] following various state-level programs (e.g. New South Wales Audit) [ 31 ] to identify evidence-practice gaps and prioritise improvement efforts to increase access to stroke units and other acute treatments [ 32 ]. The Audit program alternates each year between acute (commencing in 2007) and rehabilitation in-patient services (commencing in 2008). The Audit program provides a ‘deep dive’ on the majority of recommendations in the clinical guidelines whereby participating hospitals provide audits of up to 40 consecutive patient medical records and respond to a survey about organizational resources to manage stroke. In 2009, the AuSCR was established to provide information on patients managed in acute hospitals based on a small subset of quality processes of care linked to benchmarked reports of performance (Fig.  2 ) [ 33 ]. In this way, the continuous collection of high-priority processes of stroke care could be regularly collected and reviewed to guide improvement to care [ 34 ]. Plus clinical quality registry programs within Australia have shown a meaningful return on investment attributed to enhanced survival, improvements in quality of life and avoided costs of treatment or hospital stay [ 35 ].

Example performance report from the Australian Stroke Clinical Registry: average door-to-needle time in providing intravenous thrombolysis by different hospitals in 2021 [ 36 ]. Each bar in the figure represents a single hospital

The Australian Stroke Coalition endorsed the creation of an integrated technological solution for collecting data through a single portal for multiple programs in 2013. In 2015, the Stroke Foundation, AuSCR consortium, and other relevant groups cooperated to design an integrated data management platform (the Australian Stroke Data Tool) to reduce duplication of effort for hospital staff in the collection of overlapping variables in the same patients [ 19 ]. Importantly, a national data dictionary then provided the common data definitions to facilitate standardized data capture. Another important feature of AuSCR is the collection of patient-reported outcome surveys between 90 and 180 days after stroke, and annual linkage with national death records to ascertain survival status [ 33 ]. To support a LHS approach, hospitals that participate in AuSCR have access to a range of real-time performance reports. In efforts to minimize the burden of data collection in the AuSCR, interoperability approaches to import data directly from hospital or state-level managed stroke databases have been established (Fig.  3 ); however, the application has been variable and 41% of hospitals still manually enter all their data.

Current status of automated data importing solutions in the Australian Stroke Clinical Registry, 2022, with ‘ n ’ representing the number of hospitals. AuSCR, Australian Stroke Clinical Registry; AuSDaT, Australian Stroke Data Tool; API, Application Programming Interface; ICD, International Classification of Diseases; RedCAP, Research Electronic Data Capture; eMR, electronic medical records

For acute stroke care, the Australian Commission on Quality and Safety in Health Care facilitated the co-design (clinicians, academics, consumers) and publication of the national Acute Stroke Clinical Care Standard in 2015 [ 17 ], and subsequent review [ 18 ]. The indicator set for the Acute Stroke Standard then informed the expansion of the minimum dataset for AuSCR so that hospitals could routinely track their performance. The national Audit program enabled hospitals not involved in the AuSCR to assess their performance every two years against the Acute Stroke Standard. Complementing these efforts, the Stroke Foundation, working with the sector, developed the Acute and Rehabilitation Stroke Services Frameworks to outline the principles, essential elements, models of care and staffing recommendations for stroke services ( https://informme.org.au/guidelines/national-stroke-services-frameworks ). The Frameworks are intended to guide where stroke services should be developed, and monitor their uptake with the organizational survey component of the Audit program.

Evidence from implementation and healthcare improvement (LHS quadrant 4, Fig.  1 )

Research to better utilize and augment data from registries through linkage [ 37 , 38 , 39 , 40 ] and to ensure presentation of hospital or service level data are understood by clinicians has ensured advancement in the field for the Australian Stroke LHS [ 41 ]. Importantly, greater insights into whole patient journeys, before and after a stroke, can now enable exploration of value-based care. The LHS and stroke data platform have enabled focused and time-limited projects to create a better understanding of the quality of care in acute or rehabilitation settings [ 22 , 42 , 43 ]. Within stroke, all the elements of an LHS culminate into the ready availability of benchmarked performance data and support for implementation of strategies to address gaps in care.

Implementation research to grow the evidence base for effective improvement interventions has also been a key pillar in the Australian context. These include multi-component implementation interventions to achieve behaviour change for particular aspects of stroke care, [ 22 , 23 , 44 , 45 ] and real-world approaches to augmenting access to hyperacute interventions in stroke through the use of technology and telehealth [ 46 , 47 , 48 , 49 ]. The evidence from these studies feeds into the living guidelines program and the data collection systems, such as the Audit program or AuSCR, which are then amended to ensure data aligns to recommended care. For example, the use of ‘hyperacute aspirin within the first 48 h of ischemic stroke’ was modified to be ‘hyperacute antiplatelet…’ to incorporate new evidence that other medications or combinations are appropriate to use. Additionally, new datasets have been developed to align with evidence such as the Fever, Sugar, and Swallow variables [ 42 ]. Evidence on improvements in access to best practice care from the acute Audit program [ 50 ] and AuSCR is emerging [ 36 ]. For example, between 2007 and 2017, the odds of receiving intravenous thrombolysis after ischemic stroke increased by 16% 9OR 1.06 95% CI 1.13–1.18) and being managed in a stroke unit by 18% (OR 1.18 95% CI 1.17–1.20). Over this period, the median length of hospital stay for all patients decreased from 6.3 days in 2007 to 5.0 days in 2017 [ 51 ]. When considering the number of additional patients who would receive treatment in 2017 in comparison to 2007 it was estimated that without this additional treatment, over 17,000 healthy years of life would be lost in 2017 (17,786 disability-adjusted life years) [ 51 ]. There is evidence on the cost-effectiveness of different system-focussed strategies to augment treatment access for acute ischemic stroke (e.g. Victorian Stroke Telemedicine program [ 52 ] and Melbourne Mobile Stroke Unit ambulance [ 53 ]). Reciprocally, evidence from the national Rehabilitation Audit, where the LHS approach has been less complete or embedded, has shown fewer areas of healthcare improvement over time [ 51 , 54 ].

Within the field of stroke in Australia, there is indirect evidence that the collective efforts that align to establishing the components of a LHS have had an impact. Overall, the age-standardised rate of stroke events has reduced by 27% between 2001 and 2020, from 169 to 124 events per 100,000 population. Substantial declines in mortality rates have been reported since 1980. Commensurate with national clinical guidelines being updated in 2007 and the first National Stroke Audit being undertaken in 2007, the mortality rates for men (37.4 deaths per 100,000) and women (36.1 deaths per 100,0000 has declined to 23.8 and 23.9 per 100,000, respectively in 2021 [ 55 ].

Underpinning the LHS with the integration of the four quadrants of evidence from stakeholders, research and guidelines, practice and implementation, and core LHS principles have been addressed. Leadership and governance have been important, and programs have been established to augment workforce training and capacity building in best practice professional development. Medical practitioners are able to undertake courses and mentoring through the Australasian Stroke Academy ( http://www.strokeacademy.com.au/ ) while nurses (and other health professionals) can access teaching modules in stroke care from the Acute Stroke Nurses Education Network ( https://asnen.org/ ). The Association of Neurovascular Clinicians offers distance-accessible education and certification to develop stroke expertise for interdisciplinary professionals, including advanced stroke co-ordinator certification ( www.anvc.org ). Consumer initiative interventions are also used in the design of the AuSCR Public Summary Annual reports (available at https://auscr.com.au/about/annual-reports/ ) and consumer-related resources related to the Living Guidelines ( https://enableme.org.au/resources ).

The important success factors and lessons from stroke as a national exemplar LHS in Australia include leadership, culture, workforce and resources integrated with (1) established and broad partnerships across the academic-clinical sector divide and stakeholder engagement; (2) the living guidelines program; (3) national data infrastructure, including a national data dictionary that provides the common data framework to support standardized data capture; (4) various implementation strategies including benchmarking and feedback as well as engagement strategies targeting different levels of the health system; and (5) implementation and improvement research to advance stroke systems of care and reduce unwarranted variation in practice (Fig.  1 ). Priority opportunities now include the advancement of interoperability with electronic medical records as an area all clinical quality registry’s programs needs to be addressed, as well as providing more dynamic and interactive data dashboards tailored to the need of clinicians and health service executives.

There is a clear mandate to optimise healthcare improvement with big data offering major opportunities for change. However, we have lacked the approaches to capture evidence from the community and stakeholders, to integrate evidence from research, to capture and leverage data or evidence from practice and to generate and build on evidence from implementation using iterative system-level improvement. The LHS provides this opportunity and is shown to deliver impact. Here, we have outlined the process applied to generate an evidence-based LHS and provide a leading exemplar in stroke care. This highlights the value of moving from single-focus isolated approaches/initiatives to healthcare improvement and the benefit of integration to deliver demonstrable outcomes for our funders and key stakeholders — our community. This work provides insight into strategies that can both apply evidence-based processes to healthcare improvement as well as implementing evidence-based practices into care, moving beyond research as an endpoint, to research as an enabler, underpinning delivery of better healthcare.

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Abbreviations

Australian Stroke Clinical Registry

Confidence interval

• Learning Health System

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Acknowledgements

The following authors hold National Health and Medical Research Council Research Fellowships: HT (#2009326), DAC (#1154273), SM (#1196352), MFK Future Leader Research Fellowship (National Heart Foundation #105737). The Funders of this work did not have any direct role in the design of the study, its execution, analyses, interpretation of the data, or decision to submit results for publication.

Author information

Helena Teede and Dominique A. Cadilhac contributed equally.

Authors and Affiliations

Monash Centre for Health Research and Implementation, 43-51 Kanooka Grove, Clayton, VIC, Australia

Helena Teede, Emily Callander & Joanne Enticott

Monash Partners Academic Health Science Centre, 43-51 Kanooka Grove, Clayton, VIC, Australia

Helena Teede & Alison Johnson

Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 2 Monash University Research, Victorian Heart Hospital, 631 Blackburn Rd, Clayton, VIC, Australia

Dominique A. Cadilhac, Tara Purvis & Monique F. Kilkenny

Stroke Theme, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia

Dominique A. Cadilhac, Monique F. Kilkenny & Bruce C.V. Campbell

Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia

Bruce C.V. Campbell

Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia

School of Health Sciences, Heart and Stroke Program, University of Newcastle, Hunter Medical Research Institute, University Drive, Callaghan, NSW, Australia

Coralie English

School of Medicine and Dentistry, Griffith University, Birtinya, QLD, Australia

Rohan S. Grimley

Clinical Excellence Division, Queensland Health, Brisbane, Australia

John Hunter Hospital, Hunter New England Local Health District and University of Newcastle, Sydney, NSW, Australia

Christopher Levi

School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, NSW, Australia

Sandy Middleton

Nursing Research Institute, St Vincent’s Health Network Sydney and and Australian Catholic University, Sydney, NSW, Australia

Stroke Foundation, Level 7, 461 Bourke St, Melbourne, VIC, Australia

Kelvin Hill

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Contributions

HT: conception, design and initial draft, developed the theoretical formalism for learning health system framework, approved the submitted version. DAC: conception, design and initial draft, provided essential literature and case study examples, approved the submitted version. TP: revised the manuscript critically for important intellectual content, approved the submitted version. MFK: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. BC: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. CE: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. AJ: conception, design and initial draft, developed the theoretical formalism for learning health system framework, approved the submitted version. EC: revised the manuscript critically for important intellectual content, approved the submitted version. RSG: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. CL: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. SM: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. KH: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. JE: conception, design and initial draft, developed the theoretical formalism for learning health system framework, approved the submitted version. All authors read and approved the final manuscript.

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Teede, H., Cadilhac, D.A., Purvis, T. et al. Learning together for better health using an evidence-based Learning Health System framework: a case study in stroke. BMC Med 22 , 198 (2024). https://doi.org/10.1186/s12916-024-03416-w

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DOI : https://doi.org/10.1186/s12916-024-03416-w

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• High-Impact Prevention
• Case Studies
• National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention

A Promising HIP Intervention — Electronic Directly Observed Therapy for Active TB Disease

What to know.

Electronic directly observed therapy is an effective alternative to traditional DOT methods of treating TB disease. Several studies have shown it is an acceptable and cost-effective program to patients and medical personnel.

Tuberculosis overview

Tuberculosis (TB) is the leading cause of infectious disease death worldwide. The TB bacterium is spread when a person with TB disease of the lungs or throat coughs. In 2022, a total of 8,331 persons received a diagnosis for TB disease in the United States 1 .

Most TB disease can be treated by taking certain medications for 6 or more months. To be effective, patients must maintain and complete medication and treatment regimens.

Directly Observed Therapy (DOT) and Electronic Directly Observed Therapy (eDOT)

Directly observed therapy (DOT) is a key element of TB case management. DOT entails a trained observer watching the patient swallow anti-TB medications.

A majority of the population owns a mobile phone, computer, or tablet, allowing DOT to be done electronically. 2 3 One form of electronic DOT (eDOT) allows a member of the health care team to watch the patient swallow the anti-TB medications. They can do this via live or real-time video, or a recorded video submitted for later review.

Multiple studies have shown that eDOT is effective and acceptable to patients. These studies also identified potential cost savings from reduced staff time and travel expenditures for patients and medical staff. 4 5 6 7 8 9 10 11 12 13 14 15 They also found that regularly attending scheduled sessions and treatment completion with eDOT has been comparable with in-person DOT.

A study from New York City watched 61 patients on eDot and 329 on in-person DOT. It found:

• Patients maintained 95% of eDOT and 91% of in-person DOT scheduled sessions
• Treatment completion was similar (96% eDOT and 97% DOT)
• Money saved (2016 USD) from eDOT treatment ranged from $1,811 10 16 to $14,355 per patient. 14 16

Selected pilots and small case studies with cost data regarding eDOT

Suburban illinois pilot 14.

Summary: The DuPage County Health Department, Illinois, piloted an eDOT program from January 2013 to December 2014. The program enrolled 11 patients with active TB (non-multidrug resistant TB) and likely to have high adherence (i.e., stable housing).

• 9 patients used smartphones
• 2 patients used personal computers

Results: Patients received 1,083 eDOT doses with a 97% adherence rate. The eDOT program saved:

• An average of 9,499 travel miles
• 579 hours in staff time
• $144,750 and $13,159 in travel miles/expenses 16

Urban Washington State/Seattle-Tacoma Metropolitan Area Pilot 15

Summary: From 2002 to 2006, two local health jurisdictions in Pierce and Snohomish Counties, Washington, conducted a retrospective chart review of 57 patients with TB disease who used videophones for medication monitoring.

Results: Medication adherence was documented 95.6% of the time. The average patient in eDOT saved $2,449 in travel expenses compared to in-person DOT patients. 5

Medical staff saved:

• $139,576 in staff salaries, benefits, and travel costs (2016 USD) 16
• 2,994 hours of travel time
• 103,632 miles in travel

Recent studies of eDOT

An economic evaluation assessed health department and patient costs for eDOT and in-person DOT in low-, medium- and high-TB incidence settings in the United States. Among the different DOT types, both types of video DOT (live, recorded) were associated with lower patient and health department costs when compared with traditional forms of DOT. By setting, the cost of recorded eDOT was significantly lower than cost of community-based DOT in medium- and high-incidence settings. However, the cost of recorded eDOT was not too different from the community DOT in low-incidence settings. This finding demonstrates an economy of scale - when there are fewer patients to spread fixed costs, the cost per dose is higher. 17

The study found:

• 89.8% of doses were completed with eDOT compared to 87.2% of doses with in-person DOT.
• Issues affecting medication observation (scheduling issues, operating software, etc) was highest for community-based in-person DOT observations (19%), followed by live-video eDOT (10%), recorded-video eDOT (8%), and clinic-based in-person DOT (6%).
• 84% of patients preferred continuing treatment with eDOT. 18

Both types of eDOT were significantly lower than in-person DOT for medium- and high-incidence settings.

However, the cost of video DOT with recorded videos was not too different from community DOT in low-incident settings. This finding shows an economy of scale where if there are fewer patients to spread fixed costs, the cost per dose is higher.

An eDOT resource

As of 2015, 42% of TB programs surveyed used eDOT in some form with 36% planning to begin it in the next year. 9

To support TB programs, CDC published a resource for programs considering an eDOT program. The toolkit, called " Implementing an Electronic Directly Observed Therapy (eDOT) Program: A Toolkit for Tuberculosis (TB) Programs ," looks at the benefits and drawbacks of eDOT. It will help programs gain insights related to management and regulation concerns and how to use available resources.

• CDC. About AtlasPlus | National Center for HIV, Viral Hepatitis, STD, and TB Prevention | CDC . Atlanta, GA: US Department of Health and Human Services, CDC; 2022.
• World Health Organization (WHO). Digital health in the TB response: Scaling up the TB response through information and communication technologies . Geneva, Switzerland: WHO; 2014.
• World Health Organization (WHO). Digital health for the end TB Strategy: an agenda for action . Geneva, Switzerland: WHO; 2015
• Chuck C, Robinson E, Macaraig M, Alexander M, Burzynski J. Enhancing management of tuberculosis treatment with video directly observed therapy in New York City. Int J Tuberc Lung Dis 2016;20:588–93.
• Garfein RS, Collins K, Muñoz F, et al. Feasibility of tuberculosis treatment monitoring by video directly observed therapy: a binational pilot study. Int J Tuberc Lung Dis 2015;19:1057–64.
• Gassanov MA, Feldman LJ, Sebastian A, Kraguljac MJ, Rea E, Yaffe B. The use of videophone for directly observed therapy for the treatment of tuberculosis. Can J Public Health 2013;104:e272.
• Hoffman JA, Cunningham JR, Suleh AJ, et al. Mobile direct observation treatment for tuberculosis patients: a technical feasibility pilot using mobile phones in Nairobi, Kenya. Am J Prev Med 2010;39:78–80.
• Holzschuh EL, Province S, Johnson K, et al. Use of video directly observed therapy for treatment of latent tuberculosis infection—Johnson County, Kansas, 2015. MMWR Morb Mortal Wkly Rep 2017;66:387–9.
• Macaraig, M, Lobato MN, McGinnis Pilote K, Wegener D. A national survey on the use of electronic directly observed therapy for treatment of tuberculosis. J Public Health Manag Pract 2017. Epub ahead of print.
• DeMaio J, Sharma D. Tuberculosis therapy and telemedicine. Expert Opin Pharmacother 2002;3:1283–8.
• Molton JS, Pang Y, Wang Z, et al. Prospective single-arm interventional pilot study to assess a smartphone-based system for measuring and supporting adherence to medication. BMJ Open 2016;6:e014194.
• Story A, Garfein RS, Hayward A, et al. Monitoring therapy compliance of tuberculosis patients by using video-enabled electronic devices. Emerg Infect Dis 2016;22:538–40.
• Wade VA, Karnon J, Eliott JA, Hiller JE. Home videophones improve direct observation in tuberculosis treatment: a mixed methods evaluation. PLoS One 2012;7:e50155.
• Mirsaeidi M, Farshidpour M, Banks-Tripp D, Hashmi S, Kujoth C, Schraufnagel D. Video directly observed therapy for treatment of tuberculosis is patient-oriented and cost-effective. Eur Respir J 2015;46:871–4.
• Krueger K, Ruby D, Cooley P, et al. Videophone utilization as an alternative to directly observed therapy for tuberculosis. Int J Tuberc Lung Dis 2010;14:779–81.
• Bureau of Economic Analysis. Consumer spending. Table 2.3.4U. In: Price Indexes for Personal Consumption Expenditures by Major Type of Product and by Major Function . Washington, DC: US Department of Commerce; 2017.
• Beeler Asay GR, Lam CK, Stewart B, Mangan JM, Romo L, Marks SM, Morris SB, Gummo CL, Keh CE, Hill AN, Thomas A, Macaraig M, St John K, J Ampie T, Chuck C, Burzynski J. Cost of Tuberculosis Therapy Directly Observed on Video for Health Departments and Patients in New York City; San Francisco, California; and Rhode Island (2017-2018). Am J Public Health. 2020 Nov;110(11):1696-1703. doi: 10.2105/AJPH.2020.305877. Epub 2020 Sep 17. PMID: 32941064; PMCID: PMC7542290.
• Burzynski J, Mangan JM, Lam CK, et al. In-Person vs Electronic Directly Observed Therapy for Tuberculosis Treatment Adherence: A Randomized Noninferiority Trial. JAMA Netw Open. 2022;5(1):e2144210. doi:10.1001/jamanetworkopen.2021.44210

High-Impact Prevention is a cost-effective, proven, scalable public health approach that prevents new infections, saves life-years, and reduces disparities.